social determinants of health advocacy network...2015); social determinants of mental health (who,...

Social Determinants of Health Advocacy Network

A Healthy Tasmania

Department of Health and Human Services

GPO Box 125

Hobart TAS 7001

Submission on the Healthy

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).

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

evidence-informed action on the social determinants of health.

Health Organisation’s definition of health

social well-being and not merely the absence of disease or infirmity. Therefor

not only on reducing mortality and morbidity, but on the impact of health determinants,

the economic, environmental and social conditions, on health and well

stages in life.”i


Department of Health and Human Services

Healthy Tasmania Community Consultation Draft


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.


investment in preventive measures underpinn

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

being and not merely the absence of disease or infirmity. Therefor


the economic, environmental and social conditions, on health and well

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19 February 2016

Tasmania Community Consultation Draft


on the Community Consultation Draft of the Healthy Tasmania

We commend the Tasmanian Government for


underpinned by

We endorse the World

as “a state of complete physical, mental and

being and not merely the absence of disease or infirmity. Therefore, it focuses


the economic, environmental and social conditions, on health and well-being at various

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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.

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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.

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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.

• 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

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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.

• 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).

We have attached the Network’s previously developed key actions that we

consider are needed to achieve real gains in Tasmanians’ health now and into the

future.

We look forward to further engagement as the Government undertakes the process

of developing the Healthy Tasmania Five Year Strategic Plan.

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Attachments:

• Social Determinants of Health Advocacy Network, 2015, Supporting Tasmanians to

be the healthiest population in Australia by 2025 (SDoHAN Key Messages 2015).

This submission was prepared on behalf of members of the Social Determinants of Health

Advocacy Network, Tasmania by:

• Morven Andrews

• Miriam Vandenberg

19 February 2016

For further information please contact:

Co-convenor, Social Determinants of Health Advocacy Network (Tasmania)

℡ Miriam Vandenberg - 0400 480 908

� [email protected]

� PO Box 23, Margate, Tasmania 7000

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.

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