It’s taken years but at last there may be some movement towards developing a national approach to action on the social determinants of health – something that is widely agreed to be essential if we are to achieve a fairer distribution of health.

In the article below, Professor Fran Baum from Flinders University and a Commissioner on the former Commission on the Social Determinants of Health, welcomes news of progress with the Senate Committee inquiry, and suggests that SA’s Health in All Policies strategy will provide a useful case study.

However, Croakey wonders if the inquiry’s terms of reference could be stronger and more explicit (some concrete implementation goals rather than the wishy washy encouraging “awareness” of the social determinants).

The terms of reference also risk framing this as health sector business when surely they should be encouraging other sectors to be at the forefront of submissions and recommendations – such as early childhood and education, local government, the community and social sectors, and business, for example. Perhaps the inquiry could be using digital participation tools to engage the wider community and civil society in developing some practical, concrete steps forward.

At least, the Committee won’t have any shortage of reading given the work that has already been done in other countries on this issue – the WHO has a wealth of resources, as does Sir Michael Marmot’s UCL Institute of Health Equity.

Some Croakey readers may also be interested in this electronic discussion platform that the WHO has established for sharing resources and enabling discussions about action on the social determinants of health.

This letter from a diverse group calling for the inquiry – including the AMA’s Dr Steve Hambleton, the CEO of Catholic Health Australia Martin Laverty, Father Frank Brennan, rural health leader Dr Jenny May and psychiatrist Professor Pat McGorry – outlines some of the history leading up to the inquiry (Australia may be a pack leader in some areas of public health policy, like tobacco control, but not when it comes to addressing this issue).

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It’s time to move beyond the focus on behavioural change

Fran Baum writes:

It is very heartening that today Senator Siewert (Chair of the Community Affairs References Committee) moved this motion in the Senate:

That the following matter be referred to the Community Affairs References Committee for inquiry and report by 27 March 2013: Australia’s domestic response to the World Health Organization’s (WHO) Commission on Social Determinants of Health report, Closing the gap within a generation, including the:

(a) Government’s response to other relevant WHO reports and declarations;

(b) impacts of the Government’s response;

(c) extent to which the Commonwealth is adopting a social determinants of health approach through:

(i) relevant Commonwealth programs and services,

(ii) the structures and activities of national health agencies, and

(iii) appropriate Commonwealth data gathering and analysis; and

(d) scope for improving awareness of social determinants of health:

(i) in the community,

(ii) within government programs, and

(iii) amongst health and community service providers.

This is dear to my heart having spent three years as a Commissioner on the Commission on the Social Determinants of Health and being disappointed that there had, to date, been no formal Australian response to the Commission’s work.

The Commission on the Social Determinants of Health (CSDH) sat from 2005-08 and made its report to the World Health Organisation in August 2008 – just shortly before the start of the global financial crisis.

When it was launched the Economist editorialised that we were “baying at the moon”.  This was despite the fact that the CSDH’s report resulted from extensive deliberation by the Commissioners at a series of meeting around the world, the research of nine knowledge networks, intensive work in a range of countries, and the systematic contribution of civil society to the process.

The final report made a series of recommendations that went to the heart of the ways in which the world internationally and within countries could organise social, economic and everyday life in order to maximise population health and health equity.

The CSDH report was aimed at a global audience and so inevitably the recommendations are broad in scope and have to be re-interpreted within each country context.

It was not surprising, perhaps, that the Howard Coalition Government did not respond to the CSDH but it was entirely surprising that neither the Rudd nor Gillard Labor Government’s did so.

Many of the recommendations of the CSDH fitted with the social inclusion strategy and the emphasis on social justice.

There was, however, less fit with the “preventive health” focus of these governments. Using this strange term for a review of Australia’s effort to promote health led to a review that focussed primarily on behavioural change strategies rather than the social determinants of unhealthy behaviours.  This has been the focus on much of the Rudd and Gillard’s health policy.

The newly established Australian National Preventive Health Agency was given constrained terms of reference. It would be great if the  Community Affairs References Committee  recommends that this agency take a far more direct role in encouraging and facilitating action on the social determinants of health.

Catholic Health have played a vital role in making the argument for more action on the social determinants. They published a book and commissioned two reports from NATSEM the “Health lies in wealth: Health inequalities in Australians of working age” and “The cost of inaction on the social determinants of health”.  Both will have played a role in bringing about the current inquiry.

It is not that we don’t have policies relevant to the social determinants in Australia. For instance, the COAG Closing the Gap initiative includes among its objectives the need for access to early childhood education, increasing reading, writing and numeracy achievements for Indigenous children, and improved year 12 completions, and sets out to halve the gap in employment outcomes between Indigenous and non-Indigenous Australians within a decade.Thus two of the most powerful determinants of health – education and employment – are central to the policy.

The national social inclusion agenda also addresses social determinants from the perspective of improving the lives of the five percent of Australians who are most disadvantaged, and considers geographical areas of extreme disadvantage and the need to involve disadvantaged people in education and employment.

However, one can see that while the Closing the Gap and the social inclusion initiatives tackle social determinants, they do this from the point of view of the most disadvantaged and don’t tackle the issue of the health gradient.

The CSDH report was clear that addressing health equity required consideration of the evidence showing that health status most often operates as a gradient across society.

The South Australian Government is also implementing its Health in All Policies strategy which provides a mechanism for tackling the broader determinants of health. This model should be closely examined by the Community Affairs References Committee .

It will be important that the Committee receives many submissions which argue the case for more systematic action on the social determinants of health.

I will be very happy if it ultimately leads to greater uptake of the CSDH’s ideas in Australia in order to reduce health inequities and make us a healthier and more equitable country.

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Further reading

2012 Overview from Commonwealth Parliamentary Library

2011 Call for a Senate inquiry (Martin Laverty) 

2010 Why we need an Australian Health and Equity Commission (Fran Baum)

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