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What can be done about the social determinants of health?

Three recent reports: the Australian Institute of Health and Welfare (AIHW) report on perinatal depression, Australia’s Health 2012 (produced by the AIHW) and the Council of Australian Government (COAG) Reform Council performance report on the National Healthcare Agreement (2008) have highlighted the impact of the social determinants of health. These reports demonstrate the relationship between income, health status and access to health care. They clearly show that Australians with low incomes usually have poorer health outcomes.

The AIHW report on perinatal depression shows that low income households have the highest rates of perinatal depression (14%). Perinatal depression is less likely if the mother has a high level of education attainment (bachelor or higher), is working and spoke another language than English at home.

Australia's Health 2012, while noting the difficulties associated with measuring socioeconomic status (SES), outlined the association between SES and health measures. Poorer health outcomes were generally associated with low income and other SES factors such as occupation and low education attainment.

The COAG Reform Council Report highlighted the inequity of access experienced across the health care system. One example is access to dental care - around 25% of Australians do not see a dentist due to cost, rising to 30% outside of capital cities. The 'Great Dividing Range' also signified societal divide with those living over the range usually experiencing: longer waits for GPs, higher rates of preventable disease, higher rates of preventable hospitalisation, lower rates of cancer survival and poorer access to mental health care.

These reports give further weight to what the Catholic Health Australia (CHA)-NATSEM reports on Health Inequalities have previously found. The first report, Health lies in wealth, showed the socio-economic gradient in health that exists among working aged Australians. It quantified the difference between low and high income groups; 65% of low income groups have long term health problems, compared to only 15% in high income groups. Obesity rates were three times as high among low income families. These outcomes were attributed to education level, stability of housing and employment and the size of social and family networks. Access to health services was not considered to be a significant factor.

The second CHA-NATSEM report, The Cost of inaction on the social determinants of health, calculated the potential savings to the Government if the health status of the 400 000 individuals of working age in the bottom income quintile was improved. It estimated that this would result in a reduction of 5.5 million Medicare services with a saving of around $273 million per annum. Improvements in health across all income brackets would also result in less Pharmaceutical Benefits Scheme scripts with an estimated reduction of 5.3 million in script volume. There would also be flow-on effects to savings in income and welfare support as people with poor health or who have a long-term health condition usually receive between 1.5 to 2.5 times the level of financial assistance from Government than those in good health or without chronic illness.

The evidence is compelling, but with the exception of a few countries, national governments have been slow to act. The World Health Organization (WHO) established a Commission on the Social Determinants of Health from 2005–2008 to support countries in addressing social inequities. The final report of the Commission challenged governments and WHO to achieve health equity within a generation. This commitment was reiterated in 2011 at the Rio Political Declaration on the Social Determinants of Health. The Declaration also acknowledged that more needed to be done by governments to address the unequal distribution of health resources and the social determinants of health.

Countries such as the United Kingdom, Norway and Finland have commenced implementation of programs and policies to address the structural inequalities contributing to poor health outcomes. The UK government commissioned Sir Michael Marmot in 2008 to conduct an independent review of the most effective and evidence based strategies to reduce inequalities in England. The final report Fair Society, Healthy Lives’ (2010) proposed action on six policy objectives:
  1. Give every child the best start in life
  2. Enable all children, young people and adults to maximise their capabilities and have control over their lives
  3. Create fair employment and good work for all
  4. Ensure healthy standard of living for all
  5. Create and develop healthy and sustainable places and communities
  6. Strengthen the role and impact of ill-health prevention
Recent results from the UK measuring the impact of this approach show some improvements but inequalities persist. This is not a reflection on the approach, rather, action on the social determinants of health is a long term investment and it will take some time to see results.

Despite being a member state of WHO, Australia is yet to implement a targeted response to the 2008 and 2011 WHO Declarations on the Social Determinants of health. Some state governments (for example, NSW, SA, VIC and TAS) have taken the initiative and integrated this understanding into policy development and health planning. South Australia is perhaps the most well known for its ‘Health in All Policies’ approach and an evaluation of this framework is currently being developed. The Public Health Act 1997 (TAS) requires a report on the public health status of Tasmania every five years. The most recent report (2008) reported on the interaction of the social determinants of health and health status and showed that Tasmanians in more disadvantaged circumstances had worse health and higher mortality rates than those in more advantaged socio-economic circumstances.

Fran Baum, an Australian academic and Commissioner on the Social Determinants of Health Commission, has recommended that Australia establish an Australian Health and Equity Commission to address health inequities. This would assess the health and equity impacts of a range of government policies. CHA has long advocated for a Senate Inquiry into the social determinants of health. It has also recommended that the Government adopt a ‘health in all policies' (part of WHO’s response in addressing the social determinants of health) as a means of addressing health inequities. Minister Butler has acknowledged these calls but has not endorsed their suggestions. The Senate Committee on Community Affairs will consider whether this will form part of their work program for this year.

Recent reports have added to the long standing evidence about the relationship between social inequity and health. Perhaps an Inquiry which grapples with practical aspects of addressing the social determinants of health in the Australian context might be a good place to start.