Dealing with the big picture in Australia



Public health challenges cannot be tackled by departments of health alone. Matthew Heath reports on how the state government of South Australia is taking a new approach.

"Health is not just about providing doctors and nurses," says April Lawrie-Smith, executive director of the Aboriginal Health Division in the South Australian Department of Health. "It's about having running water, a good transport system and technology. People need to have proper housing, safe roads and fresh food that they can afford."

The health of Australia's indigenous people is often held up as an example of the stark inequities that exist within this prosperous country of more than 22 million people, with Aboriginal men dying an average of 12 years younger than other Australian males. "The whole environment where a person lives, from where you are born to where you die, affects your health outcomes. Aboriginal people have been saying this for years," says Mary Buckskin, chief executive officer of the Aboriginal Health Council of South Australia. According to a report published in July by the Australian Institute of Health and Welfare, indigenous children are up to three times more likely to be born with low weight and to die as infants or from injury, than the rest of the Australian population.



These health inequities are not confined to Aboriginal people. The report found that children living in Australia's lowest socioeconomic groups are 70% more likely to be overweight or obese and 60% more likely to have dental decay than those living at the opposite end of the spectrum.

Improving health, particularly of people from disadvantaged communities, requires action on several fronts. As Buckskin puts it: "If you don't deal with the big picture, then you won't improve health. Without [inter-departmental dialogue] you are not going to be able to have long-term, sustained improvements." According to Buckskin, in the past, funding for Aboriginal health was too narrowly focused on just providing health services. "We would be dealing with housing and welfare issues and we would be constantly told 'you shouldn't be doing that, that is not your core business' but, unless you identify those problems and deal with them, you are not going to improve health outcomes for the individual."



For Rüdiger Krech, director of Ethics, Equity, Trade and Human Rights at the World Health Organization (WHO), it is essential that government policy-makers from different sectors work together. "Public health is often influenced by policy drawn up by government departments outside the health ministry," he says. "When the ministry of transport decides to build roads rather than developing a public transport system, there are implications for health." It would make sense for the ministers of transport and health to discuss the implications before starting the work but often this does not happen. Transport ministry agendas do not always dovetail with those of the ministry of health, and executives are under pressure to meet their own targets.

These are the kind of barriers that the South Australian government is trying to overcome with a new approach that brings together policy-makers from departments such as agriculture, education, housing and transport, to improve health while achieving their own goals. The approach is the result of the government's collaboration with public health expert, Ilona Kickbusch, who proposed that South Australia apply the concept of Health in All Policies, already well established in Canada and Finland, to tackle its health problems. This way of working encourages all government sectors to consider the health impacts of their policies. In South Australia, policy-makers are putting this concept into practice by applying what they call a "health lens analysis" to the work of other departments. So far six projects with strong potential impact on health have been through this process. For example, one such project is aimed to help migrants settle into Australian society and another is intended to help parents support their children's learning and literacy. "While these may not seem like pertinent issues to health right now, we might be able to prevent problems down the track," says Carmel Williams, manager of the Health in All Policies unit in South Australia's Department of Health.

The first step in the "health lens" analysis is to bring together the parties involved to decide where exactly to point the health lens. "We work with our colleagues in the relevant departments to define the problem from their perspective," Williams says. "We don't come in with a pre-determined health perspective. It's truly a partnership. We develop a joint understanding of the problem." Williams is the first to admit that the conversations are not always easy. "We often don't know anything about their area at all, but what we bring is an understanding of health determinants," she says.

According to WHO's Krech, it is important to apply the health lens in the early stages of policy formation. Buckskin agrees that one of the biggest frustrations with policy development is the lack of consultation in the early stages. "[Government ministers and civil servants] develop policies behind closed doors. But unless you engage at the beginning on all levels, the programmes you get out at the end don't work," she says.



What difference has this "health lens" approach made for the policymakers themselves? Wendy Golder, manager of the Digital Bridge Unit within the Department of Further Education, Employment, Science and Technology, worked closely on the digital technology project that recommended a strategy to expand access to the internet and provide community-based computer training for disadvantaged socioeconomic groups. The project's research found that, in addition to improving employment, education and networking opportunities, the internet is also an important source of preventive health information and support.

Even though her department was already working on expanding internet access to many communities, Golder believes that framing the broadband project as beneficial to health and receiving endorsement from the Department of Health gave it additional momentum. She also says that participating in the health lens analysis forced her to think differently about the problem. "I had to keep coming back to the social determinants of health – the link between digital technology and health," she says. "People feel included when they are connected to other people. That's the starting point for improving health."

Lareen Newman, of the Southgate Institute for Health, Society and Equity at Flinders University, who worked closely on the project, concurs: "We talked to people about [how internet access improved] employment, education, housing opportunities, social connection. If you have internet access, you can apply online for education courses, you can buy things for your business and save money, you can bank online." These are the factors that can make a big difference to a person's social and economic situation, the so-called social determinants of health.



"The evidence is very clear that there is a whole suite of things needed to support people to minimize their risk factors and improve their health and wellbeing," says Williams. "It is much easier for someone to minimize health risk factors if they have a decent income and if they have a decent education."

According to Williams, this crosssectoral process of policy development and implementation usually results in improved equity. "We don't explicitly set out to address equity issues with our colleagues. But most of the time we are able to address them through the process," she says. According to Williams, the new approach to health has changed the way the state's policy-makers think. "People now have a better understanding of how health and wellbeing is affected by their policy decisions. They see they can contribute to health outcomes at the same time as achieving their goals. It doesn't have to be competitive. They are starting to take that thinking and questioning to their next policy problem and we don't have to be there. It is beginning to have a life of its own."

World Health Organization Genebra - Genebra - Switzerland