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 Determinants of Health (CSDH),1 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 inequitable distribution of power, money and resources; and measuring and understanding the problem and assessing the impact of action.1 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 Association (AHPA) has played in advancing our understanding about, and action on, the 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 colleagues 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 health inequities and SDH.2 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 exceptions. The National Male Health Policy and National Women's Health Policy adopted an explicit SDH focus, including a supporting document on the topic.4, 5 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 Although there is evidence of policy progress, it has been slow and limited in scope. Australia's delayed response to the CSDH reinforces 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, implementation 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 Emergency 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 misunderstood (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 ensuing implementation was repeatedly deemed to breach the fundamental 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 Furthermore, there is emerging evidence that (components of) these policies have had detrimental impact on the social and health outcomes of Aboriginal and Torres Strait Islander people.14, 15 The 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 programmes into five mega programmes—has been heavily criticised by the Productivity Commission and the Australian National Audit Office.16 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 failures 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-cutting nature of evaluation when attempting to address SDH,18 alongside 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 people 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 previously 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 implementation of the National Disability Insurance Scheme (NDIS) have serious 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 policy 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 performed little to protect the basic health needs of this priority population. 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-Policies (HiAP) approach. This concept was spear-headed within Australia through the collaborative work of the South Australian Government and the World Health Organization in response to Professor Ilona Kickbusch's tenure as Thinker in Residence in Adelaide in 2007.23, 24 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 Organization.25 Notably, a more recent focus on Sustainable Development Goals has increasingly been aligned with HiAP approaches emanating from Australia.25 Despite the success of the South Australian 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 policies, 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 initiatives, 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 conversations 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 promotion 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 (specifically the Peoples’ Health Movement) are contributing to further action on SDH on the global stage. 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 example, 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 sustainability, education, employment, food security, healthcare system, housing, income, social inclusion and welfare.33 Many state and territory 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 housing; Indigenous health; food security; and strategies for promoting health equity. These issues remain pertinent to the contemporary health promotion context. To achieve outcomes that are equitable and sustainable across populations, a broader social determinants approach is essential to address the underlying individual, social, economic, political, cultural and environmental 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 particular, 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 budget 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 conglomerates. 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 presentations 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 stewardship 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 Australia. 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. 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 promotion 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. 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. However, we have also recognised that action on SDH has remained limited, particularly for those priority populations that would benefit 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 implementation 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 Determinants of Health Equity has started to make a solid contribution in this regard. This has resulted in a greater focus on effective, evidence-based implementation strategies—in both policy and practice domains. This work has demonstrated that policymakers, practitioners, researchers and citizens with an interest in addressing 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 previously 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. The authors declare that there are no conflicts of interest in connection with this article.