If Australia really wants to get serious about making health part of all policies, then we could look to the example that has been set in Thailand.
That was one of the messages delivered to a recent national primary health care conference in Adelaide by Dr Rhonda Galbally, Deputy Chair of the National Disability Insurance Scheme Advisory Council, and International Chair of the Review Board Thai Health Promotion Foundation, and Chair of the Royal Women’s Hospital.
ThaiHealth, the national equivalent to a combination of the Victorian Health Promotion Foundation and the Australian National Preventive Health Agency (ANPHA), provides a governance structure for health in all policies (HiAP), according to Dr Galbally. Its Board has representation from economic and fiscal, education, agriculture, transport and health sectors, and is chaired by the Prime Minister.
Dr Galbally says ThaiHealth has built its entire strategy around a HiAP approach. Its work in communications and media led to it establishing the first public broadcasting station in Thailand with major health literacy content and courses to educate journalists in health literacy.
In education policy, ThaiHealth has established a Quality Education Foundation to promote literacy and education of disadvantaged communities.
Dr Galbally suggested ANPHA could play a more proactive role in developing whole of government policy to improve the health status of Australia’s population.
She also revealed that “when I tried to place HiAP into the first strategic plan for ANPHA, I was told to take it out because the health could not tell other departments/sectors what to do.” (Croakey comment: This quote clearly deserves to be followed by several !!!)
She also made some suggestions for how Medicare Locals could foster health in all policies approaches, including auditing the provision of cheap, quality fruit and vegetables then collaborating to improve supply.
Dr Galbally also recommended the PolicyLink website and and its health impact tools.
Below are the notes for her speech.
Achieving Health in All Policies
Rhonda Galbally writes:
Health in All Policies (HiAP) is not a new concept. In fact it is ancient. It was known in Roman times that health is not a product of medicine and medical treatment.
There are signs to this day on Roman walls (in Latin of course), ancient Roman ordinances, with dire punishments for anyone found emptying pots of sewerage into the streets. Romans knew that health was a product of sewerage policy.
We know today that the success or failure of even what seems like a straightforward health policy, such as the mass immunization of children in developing nations, is directly related to the literacy rates of women. In fact, we know that health status of the whole population in developing countries is directly related to the education status of women.
So if we are really on about increasing health status, then the question really has to change from Health in All Policies – is it achievable, to Health in All Policies must be achievable at national, state and local levels.
And our clear aim is to improve health status – to improve the health and wellbeing of the population across Australia This means from a primary care/ Medicare Local perspective, to improve the health and wellbeing of the local community.
While managing and coordinating treatment equitably and accessibly is a very important part of the brief – this is not the aspect of the work of Medicare Locals that will actually improve health and wellbeing.
The work of improving health and wellbeing is the space where primary care intersects with prevention and health promotion. It is prevention and health promotion that will improve the health status of communities. The aim is not only to add years to life, but to also add healthy years to life.
And improving health status of populations is simply not possible without achieving HiAP. This is because it is policy outside the health sector that actually impacts directly on the population’s health and wellbeing.
Take the example of an ageing population, so relevant to Minister Mark Butler and to Australia’s economic future, where a healthy ‘grey’ population could have a major beneficial impact on our economy. Or as is more likely at present, where it will have a detrimental effect on the economy because of epidemic rates of chronic diseases such as CVD, stroke, diabetes, mental illness and alcohol related conditions.
We know that disability and death are the inevitable outcomes of the natural process of aging. Age 85 and over 90% of people are disabled and at some point everyone dies.
Yet despite being disabled by old age (or any other cause), people can improve health and wellbeing by lowering the chance of stroke, heart disease, depression, and even postponing the early onset of dementia through the lowering of risk behaviours. (Berkman LF, Syme SL. Social networks, host resistance and mortality: a nine-year follow-up of Alameda County residents. American Journal of Epidemiology, 1979, 109:186–204).
Improving social connectedness
We know that risk behaviours are lowered with social connectedness. So the health promotion question becomes one of how to promote social connectedness to improve health and wellbeing of older citizens?
So how is social connectedness promoted as a strategy to improve health and wellbeing of older citizens? One answer was outlined by Robert Putnam, who proposed that the health promotion action is the strengthening of community infrastructure such as bowls and bridge clubs for older people to join. (Bowling Alone: The Collapse and Revival of American Community, Robert D. Putnam. New York: Simon & Schuster, 2000).
This means that Health In All Policy into practice at the local level might encompass working with local government to undertake audits of the number of local community organisations that older people can join, to audit transport systems to ensure they can get there, to audit building access to ensure they can get in, to audit local government programs that encourage older people to join up.
This local audit work would collect essential data to use for partnering local governments to develop granting programs for community groups, stipulating that a percentage of older people must be included in all community activities funded; it might involve developing policy and programs to reach out to older people to connect them up.
And the same HiAP approach could be taken for any population group from a community with a young family demographic bulge, to a multicultural community.
As well, social epidemiology must be developed in Australia to measure the impact of HiAP and the programmatic interventions that come from policy.
Social epi would show the relationship between prevention of stroke, heart disease, mental illness in relation to the strength and depth of social engagement. It is essential that the capacity for such measurement is developed for application at state and national levels – social epidemiology is one of the core tools necessary for measuring the impact of HiAPs on risk behaviours and ultimately on disease profile.
The older people and social connectedness example is just one of thousands of examples illustrating the importance of social determinants of health; and social determinants are outside the health sector. Social determinants of course include education status and employment status.
Being unemployed is a serious health risk, but just as important is that being out of control at work is also a serious risk for CVD.
Marmot’s famous Whitehall study showed us what we know full well, that those workers at the bottom of the pile in the workplace such as the cleaners – will have the highest risk of CVD, stroke and diabetes by a multiplication of 5 times the risk. But the new important information from the Whitehall study was something we didn’t know – that a sense of control over the work process halves the risk of CVD. (Marmot MG et al. Contribution of job control and other risk rehabilitation factors to social variations in coronary heart disease incidence. Lancet, 1997, 350:235–239).
We know that homelessness, and poor housing, including inaccessible housing that prevents old or disabled people from leaving the house, are social determinants of health that requires health considerations in housing policy.
We know that homelessness and secure housing with safe water and other amenities, such as schools, community services, police stations and health centres are social determinants of health or ill health if they are lacking.
I have already mentioned that living in isolation from neighborhood networks – where communities do not have enough accessible, inclusive sports or arts and cultural clubs is a social determinant of health and the solution requires health considerations in community infrastructure policy. (Wilkinson, R.G., Pickett, K.E. (2006) Income inequality and population health: a review and explanation of the evidence. Soc Sci Med 62: 1768-1784. 10.1016/j.socscimed.2005.08.036).
As are communities where clubs won’t let disabled children join, or neighborhood houses that won’t let mentally ill people join. The breadth, depth and accessibility and inclusiveness of this community infrastructure varies enormously from postcode to postcode and it is all part of an important social determinant of health that Medicare locals can do something about, as long as they are taking a HiAP approach.
Clean unpolluted environments relate to transport systems. The adequacy of urban planning and public (non car-based), accessible transport systems that promote walking and wheeling are social determinants of health requiring health considerations in transport policy at national, state and importantly at local level.
Workplaces that are safe and healthy – including mentally healthy, without bullying or harassment and with low levels of stress – all of this is part of the social determinants of health requiring health considerations in workplace relations’ policy.
Addressing social determinants of health, in turn addresses health inequalities. Addressing social determinants requires HiAP.
Despite its solid background, where data around the world has shown that health status cannot improve without HiAP, it is a politically challenging strategy that requires deliberate effort.
Determinants of health, their measurement and related methodological questions are demanding questions that must be developed by collaboration, rather than by Medicare Locals and health departments at state or national levels acting alone.
HiAP is based on the fact that we know that other sectors and other players – both government and non-government, are responsible for the risk factors of the major diseases.
HiAP shifts the emphasis from a focus on individual lifestyles and single diseases, to that of structural reform that makes healthy behaviour possible.
For example, it could be seen as an expensive folly to pour resources into social marketing campaigns where people are exhorted to eat healthier foods or exercise – when at the local level junk food is cheap and fruit and vegetables are expensive. When low fat cuts of meat are expensive and high saturated fat meats are cheap. When alcohol is cheap and available into the early hours or twenty-four hours. When there is no public transport system and no walking or wheeling paths so cars are the only alternative.
This is not to say that a HiAP approach denies the value of health education and social marketing – but we now know that imposing social marketing messages, without any community ownership of the messages, means that communities are out of control – one of Marmot’s identified major risk factors for CVD and now stroke and diabetes. (Syme, S. L., 2003, Social Determinants of Health: The community as an empowered partner, preventing chronic disease. 2004 January; 1(1): A02.)
So HiAP goes beyond the boundaries of the health sector. It addresses all policies such as transport, housing, the environment, education, fiscal policies, tax policies, trade policies and economic policies.
A policy with a negative consequence for health status of the population will put an extra burden on the economy and health care systems. Compensating for negative consequences of a policy turns out to be costly for the entire economy – such as keeping the price of alcohol low leading to increasing treatment for the morbidity from alcohol related injury and illness.
The history of upfront acknowledgement and attention to HiAP was heralded by the World Health Organisation’s (WHO) Alma Ata declaration of Health for All in 1978 – where it was made clear that health for all would not be achieved with only the health sector at the table.
That health is a function of its determinants means that improving health is directly influenced through policies and interventions in a wide range of policy settings. The health promotion movement that took off in the 80’s reinforced this, where the term Healthy Public Policy was a key plank of the 1986 first international health promotion conference that set out the Ottawa Charter. In the Adelaide Declaration in 1988 WHO spelled out the need for health in all policies.
Health promotion and disease prevention infrastructure was then established as a world first in Victoria in 1988 with the Victorian Health Promotion Foundation (VicHealth) with legislation that required an intersectoral board drawn from local government, sports, arts and health sectors.
This model was replicated and improved on in other countries – so that for instance, the ThaiHealth Board has representation from economic and fiscal, education, agriculture, transport and health sectors, chaired by the Prime Minister.
This seniority in leadership of the governance structure of ThaiHealth is in recognition that health status will only be improved from policy in many sectors and that governance with all sectors driven by the Prime Minister is more likely to gain traction. ThaiHealth Ten year Review, World Bank, WHO, Rockefeller Foundation, February 2013
Barriers of the biomedical era
Despite all of the robust HiAP work through the late part of the twentieth century, now in the twenty first century, HiAP is probably more difficult than ever to promote and achieve.
We are now in the biomedical era – with enormous focus on genetic engineering, with its hopes for new medicines and new medical interventions to prevent and cure – and ultimately to improve health status.
Biomedical hope for the improvement of health status is the main health game, as evidenced by the multi billion industries and the comparatively tiny budget for primary healthcare and health promotion.
Yet biomedicine must be considered in the light of epigenetics with the relatively new findings that the expression of genes can be changed from the impact of environmental factors.
One of the most important life stages for the expression of genes to be changed is at birth and throughout the first years of life, where it has been shown that the quality and depth of attachment of the mother (or primary caregiver) can actually alter the expression of the genes of the baby to prevent future mental illness, obesity and middle aged onset of stroke, heart disease and diabetes.
So in this sense, paid parental leave, family and parenting support services, grief and counseling services if the baby is born with a disability, workplace childcare, community supports – all of these policies that promote attachment of mothers and babies will increase health status by preventing chronic diseases – from babyhood to old age. And this knowledge requires us to pay attention to the development of policies in sectors complementary to the health system itself – although the health system should also be promoting attachment in ante and postnatal care.
A second twenty-first century barrier to HiAP, particularly in areas such as trade, tax and pricing policy is the global financial crisis (GF). Despite the fact that Australia has so far done very well in riding out this northern hemisphere disaster, the GFC creates an environment protective of industry from health considerations.
Ironically the deregulation of the banking and finance sector is universally considered to be the genesis of the GFC.
Yet increasing the floor price of alcohol, apart from alcopops where Australia is a leader, taxing saturated fat and taxing sugar seems near impossible. As well, even giving effect to the banning advertising of junk food in children’s television time seems too hard, as is the labeling of food with a traffic light approach as was recommended by the Blewit Review of food labeling. However, the cost to the economy of obesity and alcohol related disorders have been well documented. This illustrates the importance of HiAP and at the same time the difficulty in achieving economic, tax and trade policies that would have major impact at national and state levels.
HiAP at national level means having major impact on agricultural policy, on trade policy, on taxation policy – as well as education, family and community and of course disability where the National Disability Insurance Scheme will have a major beneficial impact on health status of people with a disability and their families and carers.
In the tobacco area the federal government has established world HiAP leadership with its taxation, legislation with plain packaging policies.
The governance and tools for advancing HiAP at national, level, includes the relatively newly established Australian National Preventative Health Agency (ANPHA) with its intersectoral board and heroic attempts to focus on HiAP in a difficult climate.
Indeed when I tried to place HiAP into the first strategic plan for ANPHA, I was told to take it out because the health could not tell other departments/sectors what to do.
I found this to be an odd response to my proposed HiAP approach, which I believe in itself justifies an independent statutory authority as an appropriate mechanism to govern the development of whole of government policy to improve the health status of Australia’s population. This is because unless this ensures strong interaction with government policy outside the health sector, then health status will not be advanced.
ANPHA is therefore an appropriate governance mechanism to achieve HiAP, as the health department itself in most countries and states would find it hard to negotiate a health impact lens across other department’s policies.
In this regard the notion of a health lens morphing more formally into a Health Impact Assessment would be a useful piece of work for ANPHA to consider.
However, the application of a health impact assessment on strategically selected policy would require ANPHA to increase its own strategic impact, although it is early days for the birth of this new organisation into a difficult budgetary environment.
At state level we have the great example of South Australia with its HiAP unit as the governance structure in the Premiers Department. This is a valuable indication of the seriousness with which SA has been approaching HiAP, where the interface with all departments and policy development is led by the Premier.
In Thailand, the governance structure for HiAP is ThaiHealth, the national equivalent to a combination of the Victorian Health Promotion Foundation and ANPHA. The major difference is that ThaiHealth is well resourced to lead the HiAP strategy with major resources from a percentage of the tobacco and alcohol levy.
ThaiHealth has built its entire strategy around a HiAP approach. Its work in communications and media led to it establishing the first public broadcasting station in Thailand with major health literacy content and courses to educate journalists in health literacy.
In education policy ThaiHealth has established a Quality Education Foundation to promote literacy and education of disadvantaged communities. In the area of trade, tax and fiscal policy, ThaiHealth has had a major impact on alcohol pricing, banning alcohol from sports and cultural events.
And so to primary health care at local level and specifically to Medicare Locals where a HiAP approach must be built in from the beginning. Intersectoral governance of Medicare Locals is essential for the development of intersectoral HiAP policy strategy.
This must contribute to the Medicare Locals engagement with developing the policies at local level that will impact on, for example, planning permission for the building of new junk food outlets near schools or opportunities to restrict opening hours for liquor outlets or for audits and development of accessible inclusive community infrastructure, especially in disadvantaged communities where it is likely to be sparser and weaker – focusing on whatever the local demographic would indicate.
How can Medicare Locals, after auditing the provision of cheap, quality fruit and vegetables then collaborate to improve supply?
How can Medicare Locals encourage local government policy towards bike, walking and wheelchair paths? How can Medicare Locals consider the rates of unemployment and solutions and the quality of education for disadvantaged children and youth?
Have a look at www.policylink.org and download some health impact tools for local level HiAP development.
The policy questions at Medicare Local level are full of rich opportunities. Tackling these strategically with intersectoral boards is the challenge.
At the end of the day though, if we don’t take on board HiAP we are not going to take account of the reality of social determinants of health and health inequalities and we are not going to improve the health status of our populations.
After all, if we consider the improvement of health status first from an economic perspective, the health of the population is the major factor both contributing to economic growth. If we add to that the innate value of improving the wellbeing of the communities in which we live, then implementing HiAP is essential.