Evidence on social determinants of health, health inequities and primary disease prevention and health promotion present many, currently under-utilised opportunities for Australian Government Health Ministers to genuinely be Ministers for health as well as for remedial healthcare services.
A recent article in The Conversation highlighted current evidence on systemic health inequities in Australia showing a consistent pattern whereby those lower on the scale of socioeconomic status (SES) have higher rates of premature mortality, chronic diseases including diabetes and mental illness, suicide and risk factors such as obesity and smoking. We know very well why these inequalities occur: they are largely socially produced through the effects of what are known as the social determinants of health (SDH). Well recognised SDH include material factors such as income and education; psychosocial factors such as family environment and social relationships; and environmental factors such as the commercial food and beverage environment and protections from disease pathogens. Anthropogenic climate change present a rapidly escalating threat to human health. It is the combined effects of many such determinants that shape an individual’s ‘health trajectory’ through life. Health inequities occur because structural socioeconomic inequalities mean that those higher on the SES scale are more likely to experience conditions supportive of good health, while those lower ‘down’ are more likely to experience adverse conditions. Many Aboriginal and Torres Strait Islander people have to deal with ‘general’ challenges such as poverty or inadequate housing coupled with additional challenges to health such as racism and the on-going impacts of colonisation.
Chronic ill-health and risk factors such as obesity and alcohol abuse place personal, financial and emotional burdens on individual and families who may already be struggling with day to day living costs. High rates of chronic disease create substantial social costs in lost productivity and direct costs of healthcare. The Council of Australian Governments’ National Strategic Framework for Chronic Conditions estimates that the four most costly forms of chronic disease — cardiovascular diseases, oral health, mental illness and musculoskeletal conditions — alone incurred direct health care costs of $27 billion in 2008–2009. The Mental Health Commission estimates the current direct and indirect costs of mental illness in Australia are around $60 billion.
The good news about social determinants of health is that they present multiple, cost-effective opportunities for good government and social action to prevent disease, promote health and reduce health inequities. Australia’s good performance on tobacco regulation, road safety, and food safety demonstrate the potential of such measures. The Gonski plan for education proportionate to need is a good model of public policy on a key SDH to reduce health inequities. In the health sector, our vaccination program is generally excellent, in this writer’s opinion (and as it happens is one where governments cooperate effectively, respect the science and reject conspiracy theories). Given that total spending on health policy is currently running around $160 billion a year, you would think that sensible health ministers would be seeking to extend on these good practices – and the saving in health expenditure they represent – and take every opportunity to promote health and reduce chronic disease through prudent actions on SDH and preventive actions in the primary healthcare and community health sector. You would think that but you would be wrong. One recent report estimates that only around 1.5% of Australian governments’ spending on health is dedicated to primary health promotion and disease prevention programs. Readily available policy options on SDH outside the healthcare sector to promote health, reduce disease and improve health equity are ignored or implemented in partial, ineffective and inefficient ways. Such options include poverty reduction, affordable housing, healthy urban design, public transport, community development, environmental protection and restoration, and sensible regulation on food and alcohol. Such measures would augment the achievements of Australia’s generally high-quality, universal, publically-funded healthcare services, which should be valued and celebrated.
A number of factors are plausibly implicated in this situation. The Federal-State divisions in health policy, and the lobbying power of medical professionals, create powerful political incentives for State and Territory Ministers to focus most of their attention on public hospitals. The introduction of Medicare Locals and now Primary Health Networks has been exploited by States as a reason to defund primary and community health services. The corporate food and alcohol sectors use their lobbying power and manipulate information to block regulation of their products and advertising. The Private Health Insurance industry is draining $6 billion out of the health budget every year. Neoliberal hysteria about the nanny state has cooled political willingness to support health promotion policies and programs, and led to the closure of the national preventive health agency. Politicisation of climate policy has trashed the science, licensed conspiracy theories and cultivated both political paralysis and public despair.
Whatever the cause, for now, we don’t have Ministers for Health, we have Ministers for Healthcare services.
Matthew Fisher is an artist, political philosopher and public health researcher. He works as a Senior Research Fellow with the Southgate Institute for Health, Society and Equity at Flinders University in Adelaide.