Social Determinants of Health Research Forum

Yesterday I attended the Social Determinants of Health Research Forum, hosted by the Social Determinants of Health Alliance. SDOHA is a collaboration of like-minded organisations from the areas of health, social services and public policy established to work with governments to reduce health inequities in Australia. The event was hosted by Michael Moore, former ACT politician, CEO of the Public Health Association of Australia, and Adjunct Professor of the University of Canberra.

Speakers included:

1. Professor Sharon Friel – Professor of Health Equity, National Centre for Epidemiology and Population Health, Australian National University, and Director of the Menzies Centre for Health Policy, Sydney University – TOPIC: A global framework for research on the social determinants of health
2. Professor Mike Salvaris – Professorial Research Fellow, Deakin University, and Board Member of the Australian National Development Index – TOPIC: The Australian National Development Index (ANDI)
3. Dr Gemma Carey – Research Fellow, National Centre for Epidemiology and Population Health, Australian National University and Mr. Bradley Crammond – Lecturer, Monash University – TOPIC: Social Determinants of Health and Public Policy
4. Ms Mary Guthrie, General Manager, Lowitja Institute – TOPIC: Progress with the Establishment and Activities of the Health System Coalition in Support of Constitutional Recognition of Aboriginal and Torres Strait Islander Peoples

A global framework for research on the social determinants of health

Professor Spiel highlighted two questions that research into social determinants of health (SDH) should cover: 1. Illumination – what and where are the inequities, 2. Causation – what are the causes of these inequities (often socially and politically produced). The spheres in which health inequities operate and intersect include the health care system, living and working conditions, and power, money and resources. Research has already demonstrated that social spending saves health and lives, but how can this research be translated into action?

Professor Spiel argues that research can be used to inform or shape the policy cycle, it can lead to social innovation and, with investment in the art and science of advocacy and communication, it can shape public discourse. What is needed is a diversity of knowledge across sectors and disciplines, weaved together by complex systems thinking in order to find the most effective ‘tipping points’ that lead to change. These issues needs to be segmented (packaged) according to target audiences for more effective communication. Funders for research need to be flooded with proposals, SDH advocates need to sit on grant selection committees and on an individual level, every person involved in SDH advocacy or research needs to ensure they are across as much research on the subject as possible, i.e. read every article that you come across.

The Australian National Development Index (ANDI)

Dr. Salvaris explained the purpose of the Australian National Development Index (ANDI) was to determine what kind of future/country we wanted and how this would be measured. The process of developing ANDI would take place over the next 3-4 years and is based on the Canadian Index of Wellbeing. It comprises of twelve domains, each of which will have 12 indicators for measurement that will be adjusted after an extensive public consultation and research process. For the moment they are:

• Children and young people’s wellbeing
• Community and regional life
• Culture, recreation and leisure
• Governance and democracy
• Economic life and prosperity
• Education, knowledge and creativity
• Environment and sustainability
• Justice, fairness and human rights
• Health
• Indigenous wellbeing
• Work and work-life balance
• Subjective wellbeing and life satisfaction

The aim is to engage the Australian community and involve 500,000 Australians in this project in order to develop a holistic and integrated approach to measuring wellbeing, which accurately depict what matters to Australians and what kind of Australia we all aspire to live in. It also aims to spark a national conversation and mobilise knowledge about these issues. The project is finalising its funding and plans to launch public participation and consultation campaigns via mass media, social media and smaller research projects in the next six months.

Dr. Salvaris argued that the current measurement for progress, Gross Domestic Product (GDP), is not an accurate reflection of the actual progress of a nation. In fact, research clearly indicates that high GDP does not equate to progress relating to higher levels of health or wellbeing, the US is a very clear example. Measuring the progress of a nation by its GDP actually equates life to shopping. ANDI is spearheading a new and more inclusive method of measuring progress and joins a global movement towards measuring progress through levels of wellbeing.

Social Determinants of Health and Public Policy

Dr. Carey spoke about research conducted by herself and Mr. Crammond (downloadable on the SDOHA home page), which explored the relationship between changes being sought by SDH advocates, and the types of methods used, and whether they are suited to the existing Australian political context. Politicians and policy makers across diverse portfolios within government, as well as private sector and not-for-profit lobbyists engaged in political agenda setting and policy action, were interviewed.

The research found that participants were aware of social determinants of health evidence but were not in a position to tackle the large-scale social changes being advocated due to structural limitations, such as departmental silos, risk-management and credit seeking (a problem with government bureaucracy that has been recognised and discussed since the time of the Romans). Much of the discourse about social determinants of health require whole-of-government change, but this is beyond the government’s sense of its own capacity.

It was also discovered that policy makers are not focused on the evidence base nor do they develop policy according to evidence, but rather, moral and ethical arguments sit at the core of public policy. In order to engage policy makers in developing policy in support of SDH, advocates need to work within the political and policy structures, i.e. target discussions within the remit of specific departments and gain political commitment through building community demand for change.

Dr. Carey also recommended that SDH advocates abandon the current linear evidence-based policy approaches in favour of a dialogic approach that embraces philosophical and moral reasoning in the first instance, supported by evidence. She also argued that the scale of the proposed solutions should not exceed the government’s sense of its capacity to act and that momentum for change should be built in the community. In summary, what is need for effective policy development is a targeted, solutions-focused approach that engages with ideological reasoning.

Mr. Crammond followed up with a presentation on research he conducted with Dr. Carey on public health interventions for joined up government. ‘Joined up government (JUP)’ also known as ‘whole of government’ approaches have been used by governments to tackle ‘wicked’ (complex and interwoven) public and social policy issues, involving multiple government departments. The ‘fairness’ agenda, highlighted in the Marmot Review, is aimed at the strategic government level and is broadly focused on more equitable policy making across government departments.

The ‘Health in All Policies (HiAP)‘ approach, first promoted by the Ottawa Health Promotion Charter (WHO, 1986) and currently in effect in South Australia, involves a specific focus on health across all government departments. However, both approaches have problems associated with all top-down and centralised approaches, involving the persistence of departmental silos, risk-management and credit-taking/giving.

SDH advocacy requires the efforts of collaborative research, across sectors and specialties, including administration and policy research, in order to identify and implement critical elements of the policy and political architecture required to deliver strategic interventions for policy change.

Health system coalition in support of Constitutional recognition of Aboriginal and Torres Strait Islander peoples

Ms. Mary Guthrie provided a presentation on the importance of constitutional recognition of Aboriginal and Torres Strait Islander peoples on their health and wellbeing. She highlighted that the Constitution was written over 100 years ago within the doctrine of ‘terra nullius’ and does not make mention of Australia’s Indigenous peoples except to discriminate. For example, until the 1967 Referendum, Indigenous Australians were excluded from even being counted in the tally of citizens under section 127 of the Constitution and it still says under Section 25 that the States can ban people from voting based on their race.

An Expert Panel – which included Indigenous and community leaders, constitutional experts and parliamentarians – consulted extensively across the nation and reported to the Prime Minister in January 2012.

It recommended that Australians should vote in a referendum to:

• Remove Section 25 – which says the States can ban people from voting based on their race;
• Remove section 51(xxvi) – which can be used to pass laws that discriminate against people based on their race;
• Insert a new section 51A – to recognise Aboriginal and Torres Strait Islander peoples and to preserve the Australian Government’s ability to pass laws for the benefit of Aboriginal and Torres Strait Islander peoples;
• Insert a new section 116A, banning racial discrimination by government; and
• Insert a new section 127A, recognising Aboriginal and Torres Strait Islander languages were this country’s first tongues, while confirming that English is Australia’s national language.

The Parliament has now appointed a Joint Select Committee on Constitutional Recognition of Aboriginal and Torres Strait Islander peoples to finalise the words that would form the amendment to the Constitution. It will be chaired by the two Indigenous members of the Commonwealth Parliament, with Mr Ken Wyatt MP as the Chair and Senator Nova Peris as the Deputy Chair.

The Government has also promised to establish a special committee including individuals outside the Parliament to progress constitutional recognition. This committee will also include representatives from Aboriginal and Torres Strait Islander communities.

The Government also announced in December 2013 that the draft wording will be finalised by the end of 2014.

Ms. Guthrie explained the Health System Coalition had been established by the Lowitja Institute in partnership with Close the Gap to raise awareness and public support for constitutional recognition in the lead up to a referendum. Ms. Guthrie was happy to report that the coalition membership has expanded significantly (unfortunately I did not note how many organisations). Michael Moore noted that the Public Health Association of Australia was a member and that the Social Determinants of Health Alliance would vote on membership to the coalition at its Annual General meeting immediately following the forum.

This forum provided valuable information on the benefits, needs and areas for improvement in research on SDH. I am particularly interested in the ANDI project and I will keep up to date on its progress, as well as on the progress of constitutional recognition for Aboriginal and Torres Strait Islander peoples.

For more specific information click on the appropriate links above. The video of the event will be provided on the SDOHA website shortly.