England has had the Marmot Review, which was commissioned to help shape a policy response to the landmark 2008 report from the WHO’s Commission on the Social Determinants of Health (CSDH).
Australia, so far as Croakey knows, has shown no such initiative. Why? And what could we be doing to help redress health inequities?
These are some of the questions that have been addressed below by Professor Fran Baum, professor of public health from Flinders University, who was one of the Commissioners on the CSDH. She writes:
“I spent three years (2005-08) working closely with Professor Sir Michael Marmot when I was a Commissioner on the Commission on the Social Determinants of Health which he chaired. I wasn’t surprised then to read his hard hitting review Fairer Society, Healthy Lives (also known as the Marmot Review) which makes the point forcefully that if we want a healthier and more equitable society then we have to focus society’s attention on the underlying causes of ill-health and act on the social and economic determinants of health.
If the Marmot Review’s recommendations are implemented in the UK, then there will be greater investment in education, especially for young children, urban planning that supports healthy lifestyles and is kind to the environment, experimentation with models of local governance, re-engineering of work so that it is supportive of good heath, more progressive taxation and new forms of national accounting that measure how happy and satisfied people are and the extent to which a nation’s way of life is sustainable. The Marmot Review also notes that the evidence is accumulating to show that societies that distribute their resources more equally tend to be healthier.
The Marmot Review has taken the recommendations of the international Commission on the Social Determinants of Health’s report Closing the Gap in a Generation: Health Equity through action on the social determinants of health, and applied them to the UK and provided a vision of how the UK can be healthier.
I had a mixed response to reading the Marmot Review. On the one hand I was glad to see how our Commission’s report translated to a developed country context and very much enjoyed the depth of evidence and support for an approach to health that tackles the underlying determinants.
Another part of me felt a sharp pang of regret that no Australian equivalent of the Marmot Review has been commissioned by the current Government and that I had failed in my mission to ensure that the CSDH’s report was acted on by Australia.
Since the CSDH report, there has been no shortage of reviews of the health system. The trouble is that these have really been reviews of the illness system and none of their reports have offered a progressive alternative to business as usual in the health sector but rather suggested some tinkering with the way we currently organize health services in response to illness.
Thus the National Health and Hospital Reform Commission final report “A Healthier Future for All Australians” just considered reform within hospitals and primary health care and while it contained the odd mention of social determinants of health, did nothing to lay out a comprehensive plan of action for tackling them.
More disappointingly the National Preventative Health Taskforce had terms of reference that focused on tobacco, obesity and alcohol and forced the attention of the Taskforce to mainly downstream factors that contribute to the epidemic of chronic disease. Most of its recommendations relate directly to changing lifestyles and pay only limited attention to changing the underlying social and economic factors that account for people’s unhealthy food, exercise, smoking and alcohol habits.
By contrast, the Marmot Review really went way beyond the tip of the iceberg and showed that the way we plan our cities, market food and alcohol and design our transport systems all are complicit in unhealthy lifestyles.
Thus in Australia when we have turned our attention to “health” what we have really meant is illness and how we cope with it. This is of course important but it leave open the question of how to we promote positive health and well-being and ensure that it extends throughout our community far more fairly than at present.
There is one area where I think the Australian government’s response may hold more promise and that is the COAG commitment to closing the health gap between Indigenous and non-Indigenous Australians which is currently about 17 years of life expectancy. This initiative is attracting significant funding and there is some evidence that the social determinants of health including housing, employment and education are being addressed.
The one glaring gap here from the CSDH’s and Marmot Review agenda is that the various interventions (including the notorious Northern Territory Intervention) are not heeding the strong evidence that improvement in health and well-being is generally dependent on forms of intervention that increase peoples’ control and result in them feeling empowered. Compulsory quarantining of welfare payments does not fit this bill and if the Nobel-prize winning economist Amartya Sen among others, is correct, having control and power to decide your own destiny are essential to development efforts.
Aside from an Australian Government finally paying serious attention to improving Indigenous health, we need to ponder why successive Australians governments have paid so little attention to health inequities and certainly a lot less than Europe does. The data are clear and show that economically better off Australians do better than their less well-off counterparts in terms of life expectancy, rates of most diseases and behaviours that affect health. The differences are systematic and the evidence is stacking up to suggest it is the underlying causes that create these systematic differences.
I think two reasons account for this. The first is that Australians still like to hang on to the idea that we are a classless society or certainly one where class counts less than in Europe. Acknowledging health inequities requires acknowledging class and entrenched privilege.
Secondly, I think there is a strong vein of individualism running through the policy discourses of both major parties. By this I mean that explanations of inequity tend towards looking at the personal lifestyles and habits of the groups that suffer the worse health and finding that they are to blame for their health status. There are examples of from both the last two health ministers’ (Tony Abbott and Nicola Roxan) speeches that they easily revert to this position and see that chronic disease could be reduced if only people would eat the right food or exercise enough.
It is rare for an Australian health minister to give a speech that shows a sophisticated understanding of the underlying determinants of health and health inequities.
We are now in an election year and I would love one of the major parties to develop a platform based on tackling the underlying causes of ill-health and health inequities.
This would require real acknowledgement of the inequalities that exist both between Indigenous and non-Indigenous Australians and also between Australians of different socio-economic classes.
You are much more likely to live longer if you are born to a better off family and you receive better education and then occupy a white collar job. As the Marmot Review points out some societies do much better in terms of distribution of health than Australia does and there would be much to learn from international comparisons. Progressive social and economic policies can do much to reduce the gradient in health.
If I was advising the current Federal Government I would recommend that we establish a Standing Commission (much like the Australian Competition and Consumer Commission – the ACCC) with a brief to work across government to establish and monitor mechanisms to encourage action in all government departments on the determinants of overall population health and to reduce inequities.
This Commission would have a specific brief to look beyond behavioral explanations of health inequities and consider the underlying factors that perpetuate inequity. This Commission (let’s call it the Australian Health and Equity Commission) could build on the work of the CSDH, the UK Marmot Review and the work of the European Union on its Health in All Policies program. This latter program is being implemented by the South Australian Government and is demonstrating that with careful implementation health can be promoted by in all areas of government including urban planning, digital technology, water provision and education.
The Australian Health and Equity Commission would develop health and equity impact assessments to consider a range of government policies. This Commission would also work with the existing Social Inclusion Board to determine its role in reducing health inequities. The Commission would also be tasked with selecting and choosing new measures by which to judge our progress as a society – measures that are directly concerned with health, happiness, well-being and sustainability.
My other advice to the Federal Government would be to establish local healthy and sustainable community projects to link State Government departments and local government in dynamic partnerships that would involve citizens in how to plan and develop local areas in a way that promotes health, equity and sustainability. The World Health Organisation’s Healthy Cities program provides an ideal model that could be expanded to include consideration of environmental sustainability.
What the CSDH report and the Marmot Review do so well is to knock on the head any simplistic idea that our health status reflects our individual determination to be healthy. They both show that health and its distribution are the result of how we organize our political, economic and society affairs.
One of the crucial raison d’etre of having a democratic government is to organize those affairs so that all Australians can enjoy the best possible health and lifestyle in as fair a manner as possible.
So when will we see an Australian response to the increasing evidence on the power of social determinants to shape our health and well-being?”
• Fran Baum is Director of the Southgate Institute of Health, Society and Equity at Flinders University
• Stay tuned. Croakey hopes to run a series of articles on these issues in coming days….
Yes – and congratulations!
But where do we find an outlet for systems-based, evidence-driven (and note that I have a very wide conceptualisation of evidence!) and community-oriented critiques of the current stale status quo which would support politicians appropriately?
Both the peer-reviewed public health as well as health promotion academic journals are either too mainstream or too marginal, and an outlet like ‘Arena’ is decidedly too fringe/esoteric. Isn’t it time to be more sophisticated?
This must be one of the most sensible articles about health I’ve read. I think some of the reasons the Government hasn’t done what the UK has done in terms of setting up a review of the WHO SDH ‘Closing the Gap in a Generation’ report is that firstly, they probably haven’t been alerted to the significance of the report, secondly, they probably wouldn’t have much of a clue as to how they should go about translating its recommendations for action, and thirdly Australia doesn’t have a Michael Marmot.
However, given these short commings, the evidence is becomming clearer that as a nation, to effectively address chronic diseases like CVD. obesity and diabetes, we need to go beyond sctraching the surface and advising the obvious – that people should be more physcally active and eat healthy diets. We need to address the deeper underlying socioeconomic, cultural and political landscape that creates the conditions and barriers preventing people being physically active and having access to healthy foods.
I share Baum’s concern about the functiion of the proposed multi-million dollar Preventative Health Agency. I fear it might turn out to be a ‘surface scratcher’, dealing only with social marketing messages around lifestyle and paying lip service to the underlying social determinants of lifestyle. However, rather than adding yet another Federal ‘Commission’ as Baum suggests, broadening the scope of the proposed Preventative Health Agency to do the things suggested by Baum might meet the requirements. These would include a ‘health in all polices’ and ‘equity based health impact assessment’ of all levels of government policy and planning as well as linkages to critical areas of social policy like the social inclusion agenda. This would give the Agency a social determinants of health focus rather than what appears to be its raison d’etre – a lifestyles social marketing one.
Our health system needs to put as much effort into health creation and development as it does into health protection. We know a lot about illness prevention and treatment – which is good, but not a lot about health creation and sustainability – which is not so good. We need a proper balance in the system between the two and there is no better time politically to do it than now. We have a chance to get the health system right but only if we focus on the right things and that must include equity and social justice as starting points.
C’mon – change our system?
Sheesh “prevention” in Oz is built on a solid foundation of printing pamphlets, posters and TV campaigns with little coloured ribbons or wrist bands, while employing tertiary educated well paid professionals to tut tut, sneer and do some finger waving at the great unwashed.
It is almost time to hear the Rudd Government’s ‘grand plan’ for addressing the problems of our health system. This is after a ‘root and branch’ analysis of the system, an analysis which left out the rather large branch of the private health insurance and private hospital industries.
As pointed out by Fran Baum, social determinants get a mention in speeches from the Minister analysing the issues which confront the system, in the Commission’s report, and in the Preventive Health Taskforce report. Neither of the reports however, suggest any way of addressing the social determinants. It is unlikely that the Government will either.
Along with all the reasons mentioned above to explain the Government’s reluctance to do so, I think there is another reason. It is that politicians don’t really believe in a socially inclusive society. Instead, the best intentioned of them are busy targeting gross inequity and ignoring Government supported structures which produce inequity. In the health system both major parties support the Howard Government’s PHI rebate and the Extended Medicare Safety Net. There is another major structural barrier to equity however. It is the fee for service Medicare rebate system with unlimited copayments. It sets the scene for geographical and financial inequity which no number of targeted programs will ever overcome. Thirty percent of sick Australians report doing without health care because of cost according to repeated surveys by the Commonwealth Fund. What is needed is regional needs based funding empoyering local communities to make decisions about how such funds are spent. This requires data on health needs and current health spending. It would set the scene for addressing those social determinants which are able to be at least partially addressed at the local level.
But successive government responses of targeted programs and safety nets attempt to address gross inequity. They are not aimed at equity. They are charity. No one is against charity and it makes the givers feel good. Rather than being socally inclusive however, such charity is socially exclusive. Witness the doctors’ surgery “Oh, you’re on a health care card are you, ok , we can reduce the fee for you”. Not really empowering. It also avoids the real issues of structural adjustments.
The same applies to our socially exclusive education system.
But the really threatening issue is that of income inequality. We are in the wrong half of rich countries in terms of income inequality ie we are more unequal than the majority. Income inequality correlates with multiple measures of health and well being. But to address it the politicians would have to adjust the tax system to more heavily tax the rich. Are they even interested in discussing it? Perhaps the PHI rebate debate is the first sign of that but I doubt it. The Henry tax review had equity as one of its terms of reference, but how far was he interested in taking it? We will eventually find out.
Most Australians however, might be quite happy to see a more equitable tax system and better income redistribution if it were sold as leading to a more healthy and safe society. I suspect the politicians, even the few who are aware of the evidence on social determinants, are not really interested in dispensing anything more than charity unless and until the evidence is in their faces and enough of the public are asking the right questions for it to be a possible political winner.
doctors reform society
Well said Fran. It seems that COAG initiates new activity these days. How do we get this on their agenda?
Others might be interested in earlier posts:
If Australia took any notice of the Marmot Review…
Will today’s health ministers meeting tackle health inequalities?