19 February 2016

Here's what we told the Tasmanian Government in relation to their Healthy Tasmania Community Consultation Draft

19 February 2016

A Healthy Tasmania
Department of Health and Human Services
GPO Box 125
Hobart TAS 7001

Submission on the Healthy Tasmania Community Consultation Draft

The Tasmanian Social Determinants of Health Advocacy Network (SDoHAN) appreciates this opportunity to comment on the Community Consultation Draft of the Healthy Tasmania Five Year Strategic Plan (December 2015). We commend the Tasmanian Government for taking this important step towards a healthier Tasmania.

As a Network, we support the goal of improving the health of the Tasmanian population through systems change and investment in preventive measures underpinned by evidence-informed action on the social determinants of health. We endorse the World Health Organisation’s definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Therefore, it focuses not only on reducing mortality and morbidity, but on the impact of health determinants, the economic, environmental and social conditions, on health and well-being at various stages in life.”[i]
To improve the effectiveness of the planned strategy we strongly suggest that the following elements are incorporated.

A core focus on the social determinants of health. The Consultation Draft makes minimal reference to social and environmental factors such as education, income, housing, food security, equity, climate change and social connections, and the influence these have on health outcomes.  Tasmania continues to have among the lowest health status in Australia yet is spending as much if not more on health services than are other states and territories. Clearly, continual investment in services is having little effect on the overall health of the population and there are many other reasons that lie much deeper than our health care system for our low achievements in health. The proposed health impact assessment process has the potential to recognise social factors and their effect on population health, but this process is complex, and must be well-resourced to do so. The planned commissioning model should also be strongly based within a social determinants framework.

There is a strong international evidence base which clearly demonstrates the relationship between action on social determinants and improved health outcomes (e.g. Closing the gap in a generation: Health equity through action on the social determinants of health (WHO, 2008); Evidence review: Early childhood development and the social determinants of health inequities (Moore et al 2015); Addressing the Social Determinants of Health to Reduce Tobacco-Related Disparities (Garrett et al 2015); Social Determinants of Mental Health (WHO, 2014); Health equity in Australia: A policy framework based on action on the social determinants of obesity, alcohol and tobacco (Friel, 2009).

In our submission to the Joint Select Committee Preventative Health Care Inquiry, we provided numerous examples of evidence of some of the social determinants on health in the Tasmanian context. On this note, we urge the Government, in preparing the Healthy Tasmania Five Year Strategic Plan to consider the submissions that were presented by stakeholders to this Inquiry and to engage in dialogue with the Committee as it prepares its report. The two pieces of work should be in synergy and the evidence that was presented to the Inquiry taken into consideration as part of the development process for the Government’s Strategic Plan.

 The action areas of the Ottawa Charter for Health Promotion (WHO, 1986) that include:
o   building healthy public policy
o   creating supportive environments
o   strengthening community action
o   developing personal skills
o   reorienting health services.

Focusing simply on education strategies and placing the responsibility for improving one’s health on the individual, without appreciation for the wider determinants of health and a comprehensive plan of actions, is out of step with modern thinking and evidence-based best practice.

 The concept of Proportional Universalism. We encourage the Government to become familiar with the concept of proportionate universalism and to embrace a population health approach. Proportionate universalism is the resourcing and delivering of universal services and programs at a scale and intensity proportionate to the degree of need.[ii] We would argue that the terms preventive, public, and population health should not be used interchangeably. Public health (the ‘new’ definition) and population health are about more than prevention. A comprehensive review of the literature would be useful in clarifying any misconception and provide the Government with a useful framework.

A life course approach. Government’s Strategic Plan should emphasis a life course approach to good health and wellbeing. Key stages in people’s lives have particular relevance for their health. The life course approach is about recognising the importance of these stages. The Strategic Plan should respond to key milestones in the life course including the early years, adolescence, work/social life, and ageing. Each of these phases presents important opportunities for a healthy life.

Building on relevant literature. The Consultation Draft needs to draw strong parallels with existing well-researched publications, frameworks and plans, such as Chronic diseases in Australia: Blueprint for preventive action, The Cost of Inaction on the Social Determinants of Health, Rethink Mental Health (obesity and smoking should not be considered in isolation of mental health and wellbeing, and other social determinants such as employment and income) and The World Report on Ageing and Health. We note that there is virtually no reference to Tasmania’s five-yearly State of Public Health Report (a requirement of the Public Health Act 1997) or to relevant preventative health data that demonstrates social gradients of health in Tasmania. We suggest that further research be undertaken to inform the Strategic Plan and that it be prepared in consultation with those who can identify the existing evidence-base on which it should be based.

We encourage the Government to recognise frameworks and principles such as those put forward in Chronic diseases in Australia: Blueprint for preventive action, and to base the Plan on a similar set of principles:
1. Systemic approach: focus on common risk factors and determinants, not individual diseases.
2. Evidence-based action: act now using best available evidence and continue to build evidence.
3. Tackling health inequity: work to improve and redress inequities in outcomes.
4. National agenda with local action: build commitment and innovation with local action.
5. A life course approach: intervene early and exploit prevention opportunities at all ages and across generations.
6. Shared responsibility: encourage complementary actions by all groups.
7. Responsible partnerships: avoid ceding policy influence to vested interests.[iii]

Addressing legal barriers. Legal barriers that undermine health and wellbeing outcomes for Tasmanian’s must be addressed if there is to be successful implementation of harm reduction and health promotion programs in the community. Punitive laws, policies and practices that promote stigma and discrimination against particular groups in the community (such as sex workers, people living with or affected by HIV, people who inject drugs) persist within many healthcare facilities, deterring people from seeking services, eroding trust in health systems and jeopardising implementation of and access to services. An investment approach that strengthens linkages to the Office of the Attorney General should be adopted as part of a Health in All Policies approach.

Achieving good health requires significant investment. We question what new money will be directed towards improving the health of the population. We note that current investment in preventive health is just 1.9% of the Department’s budget and dispute the statement that the “Tasmanian Government already significantly invests in prevention...” While we support ideas raised in the Consultation Draft such as health impact assessment, embedding a focus on health across government, improving health literacy and anticipatory care, these are all processes that require significant planning and investment. We thus endorse the proposal by the Heart Foundation, TasCOSS and others that the prevention budget be raised to at least 5% of the health budget (irrespective of where this money comes from).

Ongoing community consultation. We encourage the Government to include the community when preparing its Healthy Tasmania Five Year Strategic Plan – recognising communities as educators of policy-makers. [iv] We query what process the Government employed in determining the priorities identified in the discussion paper. We agree that obesity, smoking and health literacy are issues of concern but such symptoms are usually the result of more complex social problems – and this is not reflected in your Consultation Draft.

When consulting with the community, there needs to be acknowledgement that health is complicated and that language matters. As stated by World Health Organisation: “Health is not a stand-alone phenomenon with clear boundaries. Diseases and health conditions have multiple causes, including social. They are interrelated with nature and nurture, and evolve over time.”[v] This complexity is well recognised in the community. In 2015, we undertook a study where we asked members of the Tasmanian public for their thoughts about health, and specifically the way in which policy makers and researchers talk about it. In contrast to the Healthy Tasmania publication, we found that Tasmanians place a lot of emphasis on the underlying factors that contribute to good health – such as education, housing, and social connections.

We also found that the community are concerned when they are labelled as being ‘vulnerable’, ‘disadvantaged’ and being ‘targeted’. Study participants described these words as being impersonal and vilifying, contributing to stigma and blame. Participants suggested that words which reflect prejudice, that oversimplify complex relationships or that minimise history, can heighten bias and exclusion. Study participants suggested that those who use such terminology are disconnected and out of touch. 

If we want to be a healthy population, we need to bring everyone along for the ride. Defining people by their weaknesses and over-simplifying the complexities of their existence will not lead us to the end goal.

Ongoing community partnerships. We strongly urge the Government to work in partnership with stakeholders – such as community organisations, peak bodies and volunteer networks – to determine the health priorities that can make Tasmanians a healthier population. There is vast untapped knowledge and important social capital that could support the Government’s work in this area. Tapping into this knowledge, and integrating it with quality data will help give the Government a strong evidence-based Strategic Plan. 

Achieving good health requires a long term approach. We wish to raise the point that if the Government is serious about improving the health of the population, a five year timeframe is too short. This is a plan that requires long term strategic vision, with bi-partisan support. It also requires a Health in All Policies approach. As it stands, the Consultation Draft proffers much uncertainty in terms of:

·         The governance arrangements for the implementation of the Strategic Plan; how will the Government ensure accountability, transparency and inclusiveness in governance?
·        The resources that will be invested in the implementation and evaluation of the Strategic Plan.

We look forward to further engagement as the Government undertakes the process of developing the Healthy Tasmania Five Year Strategic Plan.

[i] WHO, Health at key stages of life – the life-course approach to public health, WHO, Denmark.
[ii] NHS Scotland, Proportion universalism and health inequalities, http://www.healthscotland.com/uploads/documents/24296-ProportionateUniversalismBriefing.pdf.
[iii] Willcox, S, 2015, Chronic diseases in Australia: Blueprint for preventive action, Australian Health Policy Collaboration Policy paper No. 2015-01. Melbourne: Australian Health Policy Collaboration.
[iv] Mackenzie, M et al, 2016, ‘Working-class discourses of politics, policy and health: ‘I don’t smoke; I don’t drink. The only thing wrong with me is my health’, Policy and Politics, Early Online Publication.
[v] Pourbohloul, B & Kieny M, 2011, ‘Complex systems analysis: towards holistic approaches to health systems planning and policy’, Bulletin of the WHO, 2011;89:242-242.