Eliminating disparities in health: the Howard government’s challenge

Australia is a country of comparative wealth, in which the vast majority of its residents, and the communities in which they live, are well off and complacent, limited in their enthusiasms for change. Yet, Australian is experiencing widening scales of health, social and economic inequalities, with increasing homelessness, rising rates of children living in poverty, abuse of illicit drugs, alcohol, suicide and endemic levels of poor mental health and mental illness. The immediate challenge for the Howard Government is to provide the leadership necessary to use and improve our knowledge of the social determinants of health and the inequalities they create, in order to reverse these alarming trends.

The evidence is unequivocal that those who occupy the lower levels of the socio-economic hierarchy have significantly worse health outcomes. The relationship between health and low socio-economic status is reflected at every stage of the life-course, from birth to old age, for physical and psychosocial conditions. Morbidity and mortality rates in adult life are more likely to result from the experiences of socio-economic inequality especially in childhood. The importance of healthy early childhood development is increasingly recognized, with the value of investment in parenting and services for children especially education, is being recognised. Parental poverty and exposure to unhealthy environments (eg smoking; low levels of literacy; nutrition; emotional support) are known to reduce a child’s life chances. Poverty has the consequence of mental exhaustion and depression that reduce parents’ opportunities for engagement and stimulation of their children and can be disruptive to emotional attachment and later support. Good quality, appropriate education is a key intervention in what can otherwise become a lifelong accumulation of less than optimal physical and social experiences that leads to poorer adult health.

In Australia, there are child health effects of social inequalities across environmental determinants such as education, nutrition, and access to physical activity opportunities. Funding cuts to public education and response of schools to funding shortages is having an impact on the access of low-income families to education. A social gradient in diet quality contributes to health inequalities. Targeted interventions in the antenatal period, infancy and childhood and parenting skills programs, are increasingly recognized for their potential to support healthier families. These are also though to be important in order to counteract cumulative impact of environmental, psychosocial and behavioural factors occurring over many decades that may begin in infancy, if not before and contribute for example, to high rates of heart disease in unskilled, low income population groups, especially males.

We recognise that good health is intimately tied to quality of life – adequate income, housing, employment, transport and education are all key factors in health. These are the issues of public health. New models of service development are needed to address problems such as the impact of corporatised general practice on the cost of the MBS, the lack of services for rural, remote and outer urban areas, and the proclivity of the health system for late-stage, high technology, high cost curative care. A new style primary health care approach that goes beyond general medical practice can offer solutions to these problems.

Medicare, of course, is fundamental in giving access for all Australians to medical and hospital care. It needs strengthening. But medical systems alone cannot ensure health development in the population. Broader social and preventive programs are needed as well. Suggested strategies include:

1. Hold a health colloqium to propose a more equitable way of spending current health and social resources. This would necessarily include both non-government and government organisations. The inclusion on non-government organisations should be a signal from the Minister that she is seeking a more open and direct dialogue with the non-government sector that sees input from this sector not as confrontational but rather as a legitimate alternative voice/perspective.
2. Establish a National Primary Health Care Strategy, that clearly includes states and territories, the community health sector, general practice, and community and consumer organisations. There is currently a program called Primary Health Care Research, Evaluation and Development but it focuses narrowly on general practice university departments. An R&D program for multidisciplinary primary health care generally is needed. Australia needs a National Innovations in Primary Health Care Program, that would fund and field test innovative service development models in primary health care (especially new models of collaboration between general practice and the community health sector and opportunities to advance population health
   goals through primary health care).
3. Conduct an up-to-date systematic appraisal of the community health sector in Australia and establish dialogue/negotiation structures with the States and Territories to begin Commonwealth/State collaboration on this issue. Ensure extensive consultation with the community health sector, NGO’s and community and consumer organisations.
4. The Government should develop and implement health assessment tools that each of the bureaucracies must use as part of their policy and program decision-making. This may be best accomplished by setting up an independent ‘Health and Wellbeing Impact Assessment Research Centre’ to evaluate the impact of all proposed policies before they are implemented. Health Impact Assessments should be made compulsory for all new policy initiatives and program assessments, across all government sectors, not just the health sector.
5. List public health and health inequalities for discussion by Australian Health Ministers and the Premier’s meetings. This will raise awareness, share knowledge and establish commitment to reducing health inequalities.

Chief Medical Officer’s reports, national and State/Territory, provide a suitable chapter on inequalities from this time on to provide baseline information, results of policies and programs and future work plans.

Clearly, these issues cannot be tackled by the Commonwealth alone. The Minister for Health and Ageing will need to provide significant leadership in this area, both with the Ministers for health and the various social services at a State/Territory level and with non-government organisations. While the Commonwealth has, in conjunction with the States and Territories, put in place an effective mechanism in the National Public Health Partnership, the NPHP has not been used to best advantage. To become a more effective mechanism for handling public health issues and particularly inequalities in health, the NPHP needs to:

• consult on the development of, and publish and widely disseminate its work-plans;
• report on outcomes at regional, State/Territory and national levels; and,
• incorporate the non-government sector in its deliberations in a meaningful way (rather than isolate non-government organisations in an advisory group).

Work within the NPHP alone will not be sufficient to bring significant priority and appropriate coordination at a State/Territory level to these issues. The Commonwealth must enforce a policy and program commitment by the States/Territories for community based health care and community development services that introduce new approaches for intractable problems. Primary health care funding, currently targeted to the general practice sector, should be directed into a multi-disciplinary approach with a brief to reach the most vulnerable populations. Strategies to address inequalities must be inter-sectoral and inter-governmental and be adopted as an immediate focus of CoAG and the NPHP.

Direct funding of programs is not the only action available to the Government to improve the health of all Australians. Sound research provides the basis for good policy development and underpins every action and plan. We need scientific evaluations of a wide variety of issues (eg what we eat, what’s harmful in our environment and how we protect ourselves from these things). For research to be fostered, it needs to be well directed and there needs to be a reserve funds for this specific purpose. To that end it is suggested that the Government:

• ensure that the NHMRC have a dedicated "reducing inequalities’ research program;
• ensure that the NHMRC Primary Health Care funding is multidisciplinary rather than for general practice alone; and,
• move money from the health insurance rebate scheme to fund early childhood development, and a dental health program (at least for the elderly and other vulnerable groups).

With awareness and knowledge about what creates disparities and what works to eliminate them, the Commonwealth Government, can through its leadership, spearhead a reduction in health inequalities. It can provide the goals, the specific objectives, the means, the evaluations and most of all the integrated effort across all sectors that is necessary to a commitment to reduce health inequalities.