Elly Howse is a public health professional and researcher interested in how environments, systems and inequalities determine people's health.
A few years ago, a Labor activist asked me:
“What level of government has most impact on people’s health?”
I considered this question for a bit. The obvious answer is ‘federal’ – the Australian Government collects the Medicare levy to fund our world class health system; it supports the provision of subsidised and low cost medicines through the Pharmaceutical Benefits Scheme (PBS); it funds the National Immunisation Register to ensure all babies, children and adults can access free (or heavily subsidised) vaccination; and it provides funding to the states and territories for the cost of running hospitals and other essential health services. In recent years the federal government has also launched schemes such as the National Disability Insurance Scheme (NDIS) to provide decent services to Australians living with a disability. None of this should be underestimated or taken for granted.
However what’s missing in this image of health are what we call ‘the social determinants of health’. And there is no better way to see how they play out than at the state level of government.
But what do we mean when we talk about ‘the social determinants of health’? And how important is this approach in our striving for economic and social justice through state government and NSW Labor?
The social determinants of health
Almost ten years ago the World Health Organization (WHO) released a landmark report (WHO, 2008). It was the result of four years of work by an international commission of experts that looked at the broad range of social and economic factors leading to poor health and health inequalities within and across countries.
The report of the Commission stated quite bluntly that:
‘Social justice is a matter of life and death.’
It called out the fact that inequities and inequality are the biggest killers of people worldwide. It noted that governments, global organisations, and civil society needed to improve people’s daily living conditions and challenge the unequal distribution of economic and political power.
The report was a huge and influential call to action around health. Health is not something only shaped by genes and biological factors, which can be addressed through a decent, well-funded public healthcare system.
Rather, health is strongly driven by ‘the conditions in which people are born, grow, live, work, and age’ (Marmot, 2016). These are the social determinants of health: economic policies; education and training; housing; employment; urbanisation; gender equality; social exclusion and isolation; justice.
This approach to health explains why there is a social and economic gradient to health: the wealthier you are, the more likely your physical and mental health will be better. This has nothing to do with genes and there is nothing ‘natural’ about this. Poor health has everything to do with socioeconomic and political inequalities – which are created by us, including the governments we vote in.
So when I thought again about my answer to this question of impact, I realised that state and territory governments have a significant role to play in shaping and determining policies and services that can radically affect people’s health – for the better and for the worse.
I’ll outline some key areas where NSW Labor can make a monumental and cost-effective impact on the health of people in NSW: education and training; urbanisation, housing and public institutions; sexual and reproductive health and rights; and health as the core of government policies and decision-making.
Equity from the start: education and training
A well-funded public education and training system is at the heart of a healthy community and society. Early childhood education must be accessible to all, not just the very wealthy. Our children and young people need decent primary and secondary schools. Young people and adults too need a range of further education and training options for skill development. Education and training is strongly correlated with fair and just economic development; it helps people to build skills and confidence to make decisions about their lives.
In recent years, however, the NSW Government has ripped apart our public vocational and training provider TAFE. It has flip flopped on implementing the Gonski reforms to see needs-based funding actually directed to the children and schools who need it most.
When access to quality education is based on what people can pay, we know from extensive social research that the poorest, most disadvantaged and vulnerable populations lose out. Programs to combat racism, homophobia and transphobia amongst children and young people must also continue to be supported. This is why NSW Labor has to urgently reinvest public education and:
- Increase funding to TAFE to lower fees and help subsidise people, particularly from low income backgrounds and people with a disability, to gain the qualifications they need;
- Invest in the Gonski reforms to ensure the neediest schools in NSW are receiving the most support;
- Provide greater opportunities and support for new teachers to work in the public system;
- Continue to fund programs in schools such as the Safe Schools program and anti-racism programs.
Healthy places, healthy people: urbanisation, housing and public institutions
Good urban planning, smart development and affordable housing are also integral to people’s health. Nowhere is this more obvious than in Sydney, which recently reached 5 million residents and counting. Successive NSW governments have overseen a period of rapid and significant growth for the area and its satellite centres of Wollongong, Central Coast and Newcastle. Growing too are major regional centres such as Port Macquarie, Orange and Armidale. However, what’s clear is with urban growth comes inequality.
Housing affordability and the availability of community and social housing are two major challenges. Our poorest residents in Sydney are being pushed further and further out of the city centre, with no public transport or services. When people and services are pushed further apart, people’s physical health suffers. Obesity and diabetes are major health problems for NSW with geographic and economic causes. For example, the areas of greater Western Sydney are already disproportionately experiencing poor health due to lack of public transport, high levels of car reliance, and low housing density (Committee for Sydney, 2017). The state government must invest in more public and social housing – but also ensure services and public transport are developed in tandem.
Similarly public institutions – schools, universities, hospitals, libraries, parks and other essential places – need to be ones that promote health. It’s unthinkable that poor food choices are readily available and often cheaper than accessing healthier, fresh food, particularly in our low income communities in NSW. Access to nutritious food can’t be based on economics but on justice and the right to a healthy diet. Public institutions and spaces have to support this through providing healthier food offerings that are affordable to all.
Approval of new developments such as fast food outlets, bottle shops and pubs have to be informed not by the economic potential for large corporations and industries but by the potential health implications for the community. Sometimes there are trade-offs – such as the development of beautiful parklands and cycleways around Barangaroo. But NSW Labor must urgently re-centre urban development and housing with the health of the community in mind:
- Invest in more public, social and affordable housing schemes in urban centres, and ensuring that services and active transport are also developed;
- Invest in cycleways and walkability schemes in major metropolitan centres, particularly in lower income areas;
- Invest in public transport and infrastructure alongside major road projects;
- Ensure that public spaces and services offer access to low cost healthy foods and drinks;
- Include in planning legislation the consideration of the health of the community in all approval processes.
Gender equity: reproductive health and women’s rights
There is no doubt that at the heart of the social determinants of health is a commitment to justice for women. Access to reproductive and family planning services is a core component of action for gender equality. This includes access to services such as abortion.
Abortion in New South Wales, like in Queensland, remains in the Criminal Code. Access to it is only possible through a forty year old ruling and precedent that prescribes the circumstances under which abortion is not a crime. Women must have the ability to make decisions about their bodies and their lives. The control of a woman’s right to choose when and if she has children should be handed back to women – not legislators. Victorian Labor decriminalised abortion in 2008 – NSW Labor must be next.
Women’s health is also affected severely by levels of violence and abuse, particularly by intimate partners. State government needs to be funding prevention – in our schools, workplaces and communities.
NSW Labor must:
- Decriminalise abortion by removing it from the NSW Crimes Act, acknowledging that abortion is a personal decision best made by a woman in consultation with her medical professional;
- Allocate more funding for services such as refuges, emergency and long term housing options specifically for women and their children escaping violence;
- Fund evidence-based prevention programs in schools, workplaces and communities, targeting men’s attitudes towards women, sexual assault and violence.
Health equity in all policies: health in core government policies and decisions
One of the WHO Commission’s recommendations was about pursuing a ‘health equity in all policies’ approach. This was taken up with gusto by our Labor counterparts in South Australia, whose Department of Health subsequently developed a model called ‘Health in All Policies’ (HiAP) (SA Government, 2012). This is where the impact on health and equity is considered in every major government decision and policy.
Current NSW Government processes and strategies suggest that health comes as an afterthought, or something that gets in the way of economic progress and investment. What a radical rethinking it would be for a NSW Labor Government to put the health of people at the centre of all decisions and policies.
NSW Labor can and should:
- Support a ‘Health in All Policies’ approach in NSW;
- Promote the ‘joining up’ of government services to eradicate health and social inequities, borrowing best practice approaches from around the world;
- Promote the consideration of the health of people and society at the centre of all decision-making in NSW.
Moving on from the social: the ecological determinants of health
I haven’t even touched on other areas that are also hugely influential on health, such as justice and corrections, and family and children’s services. But there is one final layer to consider when it comes to health. Our health as individuals and as a collective is influenced by social, economic and political forces – and ecological and environmental forces.
Climate change is one of the most significant threats to human health and state governments have a massive role to play in how we respond to climate change. State governments can invest in and subsidise systems of transport which are based on sustainability and human movement – such as cycling and public transport. Or they can build more roads and tollways at a huge cost to human and environmental health!
Similarly, other major environmental issues such as land-clearing, the lack of protection for parks and wildlife, and coal seam gas exploration show us that what affects the natural environment affects us too. NSW Labor must lead on environmental protection and policies to help address the effects and impact of climate change. For example, through better investing in adaptation planning, and continuing schemes to support households and businesses switch to sustainable sources of energy and electricity.
Good health policy in NSW isn’t just about timely and equitable access to hospitals, services and treatment for illnesses and injuries. Equitable and effective health policy is also about making sure every person in NSW is supported by decent opportunities and services, and that every person can live in safe communities that promote the health of people and planet.
The next few years will be a pivotal time for NSW Labor to develop their ideas and policies in preparation for the 2019 election. The economic and human costs of doing nothing to address health inequalities is enormous. Doing nothing isn't an option for NSW Labor. We have to use the social determinants of health as a basis for investment in our state – and it’s absolutely in line with our core values as a social movement and parliamentary party.
This essay was published in the Australian Fabian pamphlet A New Vision for NSW: Ideas for the next NSW Labor Government.
Committee for Sydney 2017, Adding to the Dividend, Ending the Divide, Issues paper no. 4, p. 18 http://www.sydney.org.au/wp-content/uploads/2015/10/CfS-Issues-Paper-14-Adding-to-the-Dividend-Ending-the-Divide-3-1.pdf
Marmot, Sir Michael 2016, Boyer Lectures 2016: The social determinants of ill health, ABC http://www.abc.net.au/radionational/programs/breakfast/boyer-lectures-michael-marmot-social-determinants-ill-health/7636982
SA Government 2012, ‘Health in All Policies’, http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+reform/health+in+all+policies.
WHO 2008, Closing the gap in a generation: Health equity through action on the social determinants of health. Final report. Geneva: Switzerland. http://www.who.int/social_determinants/thecommission/finalreport/en/