Social determinants of health….or structural determinants of poor policy

In March 2017, the Minister for Health, Ken Wyatt announced a new online public consultation portal, with the rather obtuse tag My Life My Lead, to facilitate consultations on the social determinations of health to support the next iteration of the implementation plan for the National Aboriginal and Torres Strait Islander Health Plan 2013-23 (link here).  The Minister’s media release included the following paragraph:

We will use feedback from the consultation portal to consider factors that impact on the social determinants of health like education, employment, justice, income and housing, as well as the important role cultural determinants play in supporting better health outcomes.

On 21 December 2017, the Minister released the report of the consultations undertaken since March (link here).

Seven priority areas have been identified in My Life My Lead, which will be integral to the next iteration of the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan. It will also help inform our Closing the Gap refresh agenda,” Minister Wyatt said.

The seven priorities are: 1. Culture at the centre of change 2. Success and wellbeing for health through employment 3. Foundations for a healthy life 4. Environmental health 5. Healthy living and strong communities 6. Health service access 7. Health and opportunity through education.

The full title of the report is:

My Life My Lead - Opportunities for strengthening approaches to the social determinants and cultural determinants of Indigenous health: Report on the national consultations December 2017.

The report is a useful addition to the policy dialogue on Indigenous affairs, and as the Minister noted, should be a useful contribution to the Closing the Gap refresh exercise currently underway. The Ministers reference to a ‘refresh agenda’ in his media release rather than a more neutral term was perhaps unwise, but let’s give him the benefit of the doubt on terminology.

The report is well written and succinctly lays out key data points on social determinants of health within a simple yet effective framework. The authors have done a good job in this respect, and this makes the report worth reading. Here is the link to the full report.

However, the substantive concern emerging from the report in my view is the complete disjunction between the title: ‘opportunities for strengthening approaches to the social determinants and cultural determinants of Indigenous health’, and the sections of the report on ‘next steps’ which are invariably drafted in vague or obtuse bureaucratese, designed to sound positive, but to make no commitments whatsoever (notwithstanding the heading ‘next steps’).

I refer interested readers to the first paragraph under the heading ‘What makes this approach different?’ on page 7, and point out that there is absolutely no indication of how the government intends to implement this new ‘approach’ to the social determinants of health.  Or to take up a particular hobby horse of mine, on Indigenous housing, the report spends just three paragraphs on this issue (in the section on Priority Four: Environmental Health). I reproduce the text in full below:

A lack of adequate and functional housing and overcrowding also remains a significant impediment to improving all aspects of Aboriginal and Torres Strait Islander health. In 2014-15, around one quarter of dwellings in which Aboriginal and Torres Strait Islander people resided had major structural problems.

Furthermore, in remote areas, one in six households did not have working facilities for preparing food and 15 per cent did not have facilities for washing clothes and bedding— double the rate of non-remote areas.

Despite only making up three per cent of the Australian population, one in four clients of specialist homelessness services (24 per cent) in 2015-16 were Aboriginal or Torres Strait Islander. In addition, homelessness, inadequate housing and overcrowded housing have the potential to contribute to higher rates of Aboriginal and Torres Strait Islander people in incarceration, further exacerbating the cycle of disadvantage. (page 17)

The points made are on point, but hardly comprehensive. The relevant section on Next Steps states:

Addressing the underlying environmental health conditions that contribute to poor health outcomes in many Aboriginal and Torres Strait Islander communities will lead to long term improved health, education and employment outcomes and can be achieved by:

·         Supporting safe and secure housing;

·         A national approach to environmental health; and

·         Increasing the Aboriginal and Torres Strait Islander environmental health workforce. (page 19)

There is no indication whatsoever as to how the Government intends to address the three potential actions above, and indeed, each of the identified actions are intermediate steps which if they were to be implemented may or may not be successful depending on policy design, resources, implementation capability, coordination and collaboration, and policy commitment.

In relation to housing, supporting safe and secure housing is a no brainer. Yet there is every indication (link here) that the Government is pursuing a retrograde policy of reducing support for safe and secure housing in remote regions where disadvantage is most severe.

My Life My Lead outlines succinctly in 34 pages and 62 footnotes what we already knew. Yet it provides no substantive indication about how the Government intends to address the reality that the determinants of health outcomes are in very large measure to be found in areas outside the health domain, and worse, ignores entirely the reality that government support for those external determinants of poor health are inadequate or being wound back or reduced.

The absence of any attempt to devise a programmatic link between the target problem (in this case health outcomes) and the resources available (budget appropriations) is the major flaw in this exercise in persuading us that the Government is doing something constructive.

A similar flaw already exists in the Closing the Gap construct (link here) and is likely to be regurgitated in the outcomes of the refresh exercise currently underway.

There are two broader observations emanating from this vignette of the Indigenous policy machine at work which are worth making:

First, the effectiveness of government programs and initiatives is more complex than is generally understood, and in particular, program interventions which are aimed at changing behaviour to deliver improved outcomes depend for a large part of their efficacy on the fact that the target population is positively disposed to the intentions and approaches of government. Yet the accumulated experience of disadvantaged citizens, including Indigenous citizens, is that in relation to addressing disadvantage governments are rarely serious, are focussed on rhetoric over substantive action, suffer from endemic attention deficit disorder syndrome, are incapable of sustaining positive engagement, regularly swing toward punitive policies, and are not prepared to enter into real partnerships. In these circumstances, the production of yet another report which is strong on rhetoric but weak on substance just strengthens the cynicism and low expectations disadvantaged citizens have in relation to governments.

Second, Minister Wyatt is an Aboriginal politician with deep experience in the Indigenous health sector and an undoubted commitment to improving the health outcomes of Indigenous citizens. The fact that he oversighted the production and publication of this report is an indicator of just how deep the structural impediments to good policy making are in our public policy system.  

In other words, while the focus on social determinants of poor health and the cultural determinants of improved health are steps in the right direction, it might be time to focus much more attention of the structural and political determinants of poor policy.