DOI: 10.1002/hpja.
48
EDITORIAL
Ten years on from the World Health Organization
Commission of Social Determinants of Health: Progress or
procrastination?
Ten years have passed since the release of the final report of the
World Health Organization (WHO) Commission on Social Determi-
1
nants of Health (CSDH), a landmark document that provided a
global blue-print for the health promotion community and the
stakeholders we work with. Three overarching recommendations
were outlined, improving daily living conditions; tackling the inequi-
table distribution of power, money and resources; and measuring
1
and understanding the problem and assessing the impact of action.
The extent to which progress has been, and continues to be, made
is contested. This editorial briefly reflects on what has been achieved
over the past decade—in broad terms—about action on the social
determinants of health (SDH) in Australia. We deliberately take a
balanced view by highlighting the weaknesses and strengths in what
has been achieved by governments, non-government organisations,
research institutions, peak bodies and civil society. We also reflect
on the ongoing role that the Australian Health Promotion Associa-
tion (AHPA) has played in advancing our understanding about, and
action on, the SDH.
1 | PIECEMEAL GOVERNMENT RESPONSES
TO SDH
We have a good starting point to track progress regarding the SDH.
In 2006, prior to the release of the CSDH report, Newman and col-
leagues published a policy analysis in the Health Promotion Journal of
Australia which examined the extent to which Federal, State and
Territory governments had responded to emerging concerns about
2
health inequities and SDH. The finding: most jurisdictions could
more explicitly incorporate health equity into core government and
health department strategies and initiatives.2 A decade later, Fisher
and colleagues published a similar policy analysis, suggesting that all
jurisdictions recognised evidence on SDH and expressed goals to
improve health equity.3 So although progress has been made, Fisher
et al3 also acknowledge that relatively few strategies addressed SDH
and health equity outside access to health care, and strategies were
often limited in scope. There are, of course, some notable excep-
tions. The National Male Health Policy and National Women’s Health
Policy adopted an explicit SDH focus, including a supporting docu-
4,5
ment on the topic. The National Primary Health Care Strategic
Framework also referred to health equity and the SDH and discussed
this with reference to health promotion and prevention efforts.6,7
Health Promot J Austral. 2018;29:3–7. wileyonlinelibrary.com/journal/hpja
Although there is evidence of policy progress, it has been slow and
limited in scope. Australia’s delayed response to the CSDH rein-
forces this observation. The fact that a national Senate Community
Affairs References Committee inquiry was required to unpack the
reasons for Australia’s delayed domestic response to the CSDH Final
Report was to say the least, embarrassing. The recommendations
from this inquiry were predictable—a greater policy focus should be
placed on SDH by the Australian Government, including a greater
level of accountability to the Australian Parliament.8 Yet, implemen-
tation of these recommendations has remained elusive.
Perhaps the one promising finding from the analysis by Fisher
and colleagues is that national policies on Aboriginal and Torres
Strait Islander health have made the greatest attempts to move this
agenda forward.3 We suggest that the Implementation Plan for the
National Aboriginal and Torres Strait Islander Health Plan 2013-20239
and the NHMRC’s Draft Road Map 3: A strategic framework for
improving Aboriginal and Torres Strait Islander health through research
10
are two useful illustrative examples where considerations about
SDH have been incorporated well.
Let us be frank, however—the Australian Government track
record in Indigenous affairs and attempts to improve the daily living
conditions of Aboriginal and Torres Strait Islander people, particularly
those considered most vulnerable, has been inconsistent and
frequently at odds with political discourse.
In June 2007, just prior to the release of the CSDH report, the
Australian Government embarked on the Northern Territory Emer-
gency Response (NTER—subsequently coined “the intervention”)—a
suite of measures to “protect” Aboriginal children in response to a
review to prevent and tackle child sexual abuse among Aboriginal
children. In short, the intent of the recommendations was misunder-
stood (some would argue politically manipulated), but used as the
means to embark on the NTER. The reality was that NTER involved
suspension of some parts of the Racial Discrimination Act, and ensu-
ing implementation was repeatedly deemed to breach the fundamen-
tal human and sovereign rights of Australia’s Indigenous people.11 It
was unpopular; subsequent “Closing the Gap” and “overcoming
Indigenous disadvantage” reports demonstrated such policy attempts
have largely failed to achieve meaningful outcomes for Aboriginal
and Torres Strait Islander people over the past 10 years.12,13 Fur-
thermore, there is emerging evidence that (components of) these
policies have had detrimental impact on the social and health out-
comes of Aboriginal and Torres Strait Islander people.14,15 The
© 2018 Australian Health Promotion Association | 3
4 |
Gillard Labor government replaced the NTER with the “Stronger
Futures in the Northern Territory” policy and legislation in 2011-12,
which retained many of the strategies adopted under the NTER.
More recently, the implementation of the Indigenous Advancement
Strategy (IAS)—a merging of 150 discrete Indigenous focused pro-
grammes into five mega programmes—has been heavily criticised by
the Productivity Commission and the Australian National Audit
16
Office. Generally speaking, the administration of IAS by the
Department of Prime Minister and Cabinet was deemed to be poorly
planned and executed, with multiple subsequent implementation fail-
ures noted.16 Importantly, the failure to invest appropriately in the
evaluation of Indigenous programmes, such as those funded through
the IAS, is considered to be highly problematic.17 The establishment
of an IAS evaluation framework, which acknowledges the cross-cut-
ting nature of evaluation when attempting to address SDH,18 along-
side an evaluation funding commitment, is promising. Yet, we know
it still falls short of what is required when the Aboriginal and Torres
Strait Islander Health Performance Framework indicates that 34.4%
of the health gap experienced by Aboriginal and Torres Islander peo-
ple relates to SDH.19 Clearly, progress has been slow, and the level
of investment to address SDH at scale, and with sufficient intensity,
has been sub-optimal. It appears that Aboriginal and Torres Strait
Islander people have fallen victim to what Carol Bacchi has previ-
ously referred to as the SDH “know-do” gap.20 As such, the first few
articles of this issue of the Health Promotion Journal of Australia are
dedicated to the health and wellbeing of Aboriginal and Torres Strait
Islander peoples. This marks our attempt, as Editors, to learn from
existing health promotion efforts in this space.
Unfortunately, we have seen similar patterns emerge outside of
the Indigenous affairs realm as well. Recent planning and implemen-
tation of the National Disability Insurance Scheme (NDIS) have seri-
ous potential to entrench and widen inequities faced by those with
disabilities.21 Similarly, the abhorrent treatment of asylum seekers
and refugees by the Australian Government, through inhumane pol-
icy measures—such as off-shore detention centres—marks a distinct
lack of progress in relation to principles of fairness and social justice
required to promote health equity through action on SDH. Indeed,
refugees and asylum seekers were clearly denied basic human rights
as outlined in ongoing advocacy efforts among health and medical
professionals.22 Despite significant negative media exposure and
substantial political backlash, Australian Government policy has per-
formed little to protect the basic health needs of this priority popula-
tion. This needs to change.
These observations have occurred during a period when there
has been a parallel focus on the development of a Health-in-All-Poli-
cies (HiAP) approach. This concept was spear-headed within Aus-
tralia through the collaborative work of the South Australian
Government and the World Health Organization in response to Pro-
fessor Ilona Kickbusch’s tenure as Thinker in Residence in Adelaide
23,24
in 2007. Many Australian scholars have since contributed to
publications, forums, university intensives and case studies on this
topic. Such work has positioned Australia as an international leader
in this space, with continued support from the World Health
EDITORIAL
Organization.25 Notably, a more recent focus on Sustainable Devel-
opment Goals has increasingly been aligned with HiAP approaches
emanating from Australia.25 Despite the success of the South Aus-
tralian HiAP model, it has not been adopted readily in other states
and territories across Australia. Recent public health policy scholars
have emphasised the importance of HiAP approaches, adaptive poli-
cies, intersectoral action and systems thinking to achieve action on
SDH,26–29 but also questioned the extent to which current Australian
approaches have been able to address structural health inequities.30
An over emphasis on individually focused, risk factor driven initia-
tives, has not helped in this regard.31 However, a more concerted
effort to join the dots between “action on SDH” and the adoption of
“HiAP” approaches in Australia could provide the impetus to address
issues associated with the apparent policy-practice stalemate. Health
promotion professionals are perfectly positioned to show a higher
level of accountability in this regard. We need to move beyond con-
versations that position action on SDH as being too hard, or the role
of someone else. We argue that identifying new ways of working,
driving innovative solutions and ensuring an equity lens is central to
all health-related decision-making, is best championed by health pro-
motion community. Similarly, vocal professional bodies can assist in
this regard. We briefly discuss the role that AHPA has played and
continues to play, in advancing the SDH agenda in Australia. This is
complemented by an additional editorial written by Professor Fran
Baum, a former Commissioner with the CSDH and Fellow of AHPA,
which explains the important role that empowered citizens (specifi-
cally the Peoples’ Health Movement) are contributing to further
action on SDH on the global stage.
2 | STEWARDSHIP ON SDH BY THE
AUSTRALIAN HEALTH PROMOTION
ASSOCIATION
Stewardship from within the health sector was identified as a key
enabler for change with respect to action on SDH.32 AHPA has
shown a deep commitment to assisting its members to understand
the impact and influence of SDH both prior to, and throughout, the
last decade. Indeed, the Health Promotion Journal of Australia curated
a special issue on this topic in December 2006, well before the
release of the CSDH report. Subsequent action has involved projects
and activities at state, territory and national branch levels. For exam-
ple, in 2008, the NSW Branch developed fact sheets about what we
know about particular areas for action33 and included evidence-
based summaries about the importance of early life, ecosystem sus-
tainability, education, employment, food security, healthcare system,
housing, income, social inclusion and welfare.33 Many state and terri-
tory branches of AHPA have planned and delivered professional
development opportunities about SDH over the past decade. These
have related to climate change and health; homelessness and hous-
ing; Indigenous health; food security; and strategies for promoting
health equity. These issues remain pertinent to the contemporary
health promotion context.
EDITORIAL
At a national level, AHPA has also played an active role in advo-
cacy and partnership efforts about action on the SDH, as evidenced
in a 2009 Editorial published in the Health Promotion Journal of Aus-
34
tralia, which outlined AHPA’s response to the discussion paper
released by the [then) National Preventive Health Taskforce:
To achieve outcomes that are equitable and sustainable
across populations, a broader social determinants
approach is essential to address the underlying individ-
ual, social, economic, political, cultural and environmen-
tal contexts that enable or hinder action. . .and
collaboration to ensure the conditions in which people
grow, live, go to school, work, and age are conducive to
health [34, p5]
This work laid the foundation for further advocacy efforts. In partic-
ular, AHPA was a founding partner of the Social Determinants of
Health Alliance (SDOHA) which was established in 2012. AHPA has
also made multiple submissions to various government inquiries and
consultation processes, often advocating for a stronger focus on SDH,
particularly during periods of disinvestment in health promotion.35 This
has included responses to Senate Community Affairs References
Committee Inquiry mentioned above, a response to the abolition of the
Australian National Preventive Health Agency, and multiple federal bud-
get responses advocating for a great focus on health equity. We argue
that advocacy of this nature has, and will continue to have, impact.
In addition, AHPA has ensured that multiple national conferences
have explicitly focused on health equity and SDH. Prominent
national and international keynote speakers have provided valuable
insights into SDH, ensuring the health promotion community stays
abreast of key issues, such as the implications of the Trans-Pacific
Partnership agreement and the influence of large multi-national con-
glomerates. Similarly, there have been multiple presentations at
these conferences about innovative, cost-effective and contextually
relevant programmes, policies and activities planned, implemented
and evaluated locally with community input. Sometimes these pre-
sentations have demonstrated evidence of efficacy and effectiveness
in addressing SDH, but usually they focus on process rather than
impact or outcomes, indicating that more comprehensive evaluation
work is required. There has also been an annual commitment by
AHPA to host an Indigenous health forum attached to each national
conference. AHPA has also awarded a number of Fellow and Life
Member awards to individuals that have shown leadership in relation
to SDH. These steps are small, yet significant. Continued steward-
ship of this nature is required now more than ever.
To honour this tradition, AHPA in collaboration with the new
Editorial Team of the Health Promotion Journal of Australia is already
planning to release a virtual issue about action on the SDH in Aus-
tralia. The virtual issue will be released in August 2018. This will
coincide with the AHPA National Symposium to be held in Canberra
on 23-24th August which will also have as part of its programme a
dedicated focus on the SDH.
| 5
The new Editorial Team of the Health Promotion Journal of Aus-
tralia has also deliberately refreshed the scope of the journal to
include a sharper focus on SDH. It now reads:
The journal welcomes submissions about educational,
cultural, organisational, economic and/or environmental
approaches that address health promotion issues,
advance the health promotion profession; and which
support positive system changes that benefit population
health. Manuscripts that address social and ecological
determinants of health and/or issues relating to the pro-
motion of health equity are strongly encouraged.
The Editorial Team has a strong vision to be a respected global
leader in publishing high-quality and innovative content about action
on the SDH. We very much welcome contributions of this nature.
3 | PROGRESS OR PROCRASTINATION?
What we have highlighted above demonstrates there has been
some progress in building a better understanding of what SDH
constitute. In particular, we have shown that a focus on SDH has
been more explicitly incorporated into government policies, at
both national and jurisdictional levels, over the past decade. How-
ever, we have also recognised that action on SDH has remained
limited, particularly for those priority populations that would bene-
fit most. Interestingly, similar trends in progress have been noted
globally.36 There needs to be a shift in focus from what we know
about SDH, to what we do about it. Whilst there have been
some promising in-roads between agenda setting and implementa-
tion to address SDH in Australia, further research examining this
nexus, including institutional analyses, is required.37–40 The
NHMRC Centre for Research Excellence on the Social Determi-
nants of Health Equity has started to make a solid contribution in
this regard. This has resulted in a greater focus on effective, evi-
dence-based implementation strategies—in both policy and prac-
tice domains. This work has demonstrated that policymakers,
practitioners, researchers and citizens with an interest in address-
ing the SDH need to continue to work in close partnership. State
and local actions on SDH must be complemented with national
policy to reduce the growing social and economic inequalities that
give rise to health inequities. This is central to what has previ-
ously been termed a comprehensive health promotion approach.41
We have procrastinated for too long to achieve meaningful action
on SDH. Collectively, let us make the change that we deserve
both locally and globally.
CONFLICT OF INTEREST
The authors declare that there are no conflicts of interest in connec-
tion with this article.
6 |
James Smith PhD1,2,3,4
Kalinda Griffiths PhD1,2
Jenni Judd DHSc5
Gemma Crawford MHP4,6
Heather D’Antoine MHEcon (Aboriginal Health)1
Matthew Fisher PhD7
Roxanne Bainbridge PhD5
Patrick Harris PhD2
1
Menzies School of Health Research, Casuarina, NT, Australia
2 Quarantining Welfare on School Attendance in Indigenous Commu-
University of Sydney, Sydney, NSW, Australia
3 nities. Indooroopilly: LCC Working Paper Series: 2017-22; 2017.
Charles Darwin University, Casuarina, NT, Australia
4
Australian Health Promotion Association, Adelaide, SA, Australia
5
Central Queensland University, Rockhampton, QLD, Australia
6 Canberra: Commonwealth of Australia; 2017.
Curtin University, Perth, WA, Australia
7 17. Hudson S. Mapping the Indigenous Program Funding Maze.
Flinders University, Adelaide, SA, Australia
Correspondence
James Smith, Menzies School of Health Research, Casuarina,
NT, Australia.
Email: james.smith@menzies.edu.au
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