cohealth welcomes the development of this Strategy. We recommend strengthening it by more strongly articulating actions to address the social determinants of health, including racism and discrimination, climate change and poverty and inequality. We argue that working in partnerships with communities is essential for developing effective preventative health measures and needs greater emphasis in the Strategy.
The sections and questions below are from the National Preventative Health Strategy consultation. More information is provided in the National Preventative Health Strategy Consultation Paper website.
“The Strategy will be designed to improve the health of all Australians at all stages of life, through early intervention, better information, targeting risk factors and addressing the broader causes of health and wellbeing. The Strategy will include targets for each aim, so that we can monitor our progress in improving the health of all Australians.
cohealth is one of Victoria’s largest community health services, with almost 1,000 staff working at 30 sites across nine local government areas in Melbourne’s CBD, northern and western suburbs. An additional 15 sites have been established to provide care and testing in response to COVID-19. Our mission is to improve health and wellbeing for all, and to tackle inequality and inequity in partnership with people and their communities. As a primary health service, cohealth provides integrated medical, dental, allied health, mental health and community support services. cohealth delivers programs promoting community health and wellbeing and involves communities in identifying needs and developing responses.
cohealth’s service delivery model prioritises people who experience social disadvantage and are consequently marginalised from mainstream health and other services – such as people who have multiple health conditions, have a disability or mental illness, experience homelessness and unstable housing, Aboriginal and Torres Strait Islanders, refugees and asylum seekers, people who use alcohol and other drugs, recently released prisoner, LGBTIQ+ communities and children in out of home care.
cohealth has extensive experience in the areas of preventative health and health promotion. Our Prevention Team contributes to the delivery of the Victorian Health and Wellbeing Plan by developing, in collaboration with communities, programs that focus on improving gender equity and addressing race-based discrimination. Across the organisation, promoting good health is a fundamental lens to all our interactions with clients and communities.
cohealth welcomes the high-level aims of the National Preventative Health Strategy (‘the Strategy’), which will allow for health inequalities to be addressed and provide a commitment for increased investment in prevention. Embedding preventative health in the health system is critical to improving the nation’s health outcomes.
However, this vision will only be achieved if the Strategy articulates and more clearly drives action to address the social determinants of health. cohealth recommends the addition of the aim of ‘reducing health inequities through addressing the social determinants of health’.
With this addition, cohealth supports the proposed aims, and provides the following feedback:
cohealth recommends the following additions to the goals:
Addressing the Social Determinants of Health
It is positive to see that the consultation paper acknowledges that ‘the impact of poor health is experienced unevenly in Australian communities’ and notes the ‘close relationship between people’s health and the circumstances in which people grow, live, work and age’. These circumstances – and the structural conditions in society which lead to unequal living conditions and affect the chances of a healthy life – are known as the social determinants of health and are a major contributor to health inequities. According to the World Health Organisation (WHO), the social conditions in which people are born, live and work are the single most important determinant of good health or ill health. They include factors such as income, Aboriginal and Torres Strait Islander status, identity, gender, housing, food security, employment conditions, where you live, the urban environment and experiences of stigma, discrimination and marginalisation. Ecological and commercial determinants also have a significant impact on health and wellbeing. It is vital that the social, ecological and commercial determinants of health are identified as a clear Strategy gaol, and actions to address them are articulated, particularly:
Racism and discrimination
There is now substantial evidence that racism has many harmful health impacts.
Mental health impacts of racism include conditions such as psychological distress, depression, anxiety, post-traumatic stress disorder and psychosis, while physical health effects include cardiovascular disease, hypertension, adult-onset asthma, cancer and accelerated biological ageing. Racially motivated assaults have both physical and mental health consequences. There is now also evidence that maternal exposure to racism has harmful effects on a foetus that impact child development.
More broadly, systemic racism serves to maintain or exacerbate the unequal distribution of opportunity across ethnic groups through the way our systems and services are structured and delivered. As a result, people may not seek the support and services they need and are entitled to. Racism reduces access to employment, housing and education, resulting in low socio-economic status, and as socio-economic status declines, so does mental and physical health.
The Strategy makes reference to ‘changing weather patterns’ and air quality, however climate change, the greatest health emergency facing our planet is not mentioned. The WHO has described climate change as the defining issue for public health in the 21st century, and as such cohealth is deeply concerned that it is not included in the Strategy. Climate change affects health in many ways: directly by the increased intensity and frequency of extreme weather events, such as prolonged heatwaves, floods and bushfires; and indirectly through worsening air quality, changes in the spread of infectious and vector-borne diseases, risks to food safety and drinking water quality, and effects on mental health.
These impacts are disproportionately greater for marginalised and vulnerable communities.
The extreme weather events of the summer of 2019/20 – bushfires and lengthy drought – followed by the COVID-19 pandemic will exact a huge toll on physical and mental health and should serve as a warning that urgent action is required to reduce the threats posed by climate change and to adapt to these threats.
cohealth strongly recommends that climate change be included in the Strategy.
Poverty and income inequality
The relationship between health and income is well established, and generally, the higher a person’s socioeconomic position, the better their health. People who are the most socio-economically disadvantaged are twice as likely to have a long-term health condition as the most affluent Australians. Those who are poor are also twice as likely to suffer from chronic illnesses and will die on average three years earlier than the wealthiest.
Low socio-economic status is a key underlying factor common to almost all people experiencing health disadvantage and lies at the heart of health inequality. The impacts of low income are exacerbated by expensive, insecure and poor quality housing, insecure employment, unemployment and underemployment; and location that is removed from services, jobs and health services. Poverty can be both a determinant and a consequence of poor physical and mental health.
With more than one in eight Australian adults and more than one in six children living in poverty, and significant inequality, it is essential to address this underlying driver of poor health if we are to improve the health of the nation.
In order to achieve this goal cohealth recommends adopting a Health in All Policies framework.
The Health in All Policies (HiAP) Framework is defined by the World Health Organisation as ‘an approach to policy-making that places “health” as a key decision-making factor in all areas of policy, by systematically taking into account the health and health-system implications of policy decisions, by seeking synergies between policy portfolios, and by avoiding harmful health impacts, in order to improve population health and health equity.’
The COVID-19 pandemic has emphasised how health, wellbeing and all other areas of life and the economy are integrally connected. Responses to the pandemic, by all levels of government, have recognised this connection and worked together to protect community health – in effect, using a HiAP approach.
At the same time, the pandemic has highlighted faults in our economic and social structures that fail to account for health and wellbeing impact, rather focussing on narrow economic outcomes. The disastrous consequences of poorly paid, insecure work in the aged care sector is a glaring example of this. Adopting a HiAP approach would ensure the impact of policies such as these would be considered in policy processes, and maximise the Nation’s health into the future.
To achieve this goal cohealth recommends that the central role of communities in driving prevention activities be strengthened in the Strategy. Grass roots communities have a sound understanding of the needs of their members, and of the best mechanisms for engaging them in prevention planning and approaches.
As the COVID-19 experience has demonstrated, all too often communities are not engaged in preventative health activities or are included too late, and the critical insights they provide not utilised until conventional approaches have not had the expected outcome. For example, in Melbourne the hard lock-down of nine high rise housing towers failed to include community leaders from the beginning. As a result, residents experienced the lock down as traumatic, with many unable to acquire their basic food, medications or health care. Some of these worst impacts may have been avoided or mitigated with community leaders had been more involved in the planning.
Learnings from this experience have informed the development of a pro-active model of place-based integrated primary health care and engagement that has subsequently been rolled out to other high-rise housing estates across Melbourne. Developed in partnership with local communities and leaders, cohealth and other community health services to respond to communities’ needs, key features of this model include:
As a result of adopting this integrated approach that actively engages local communities, COVID-19 outbreaks at other high-rise towers have been prevented.
The involvement of community health services has been central to this success. Victorian community health services are unique in Australia, although by being managed by, and responsive to, their local community they share commonalities with Aboriginal Community Controlled Health Organisations. Based in local communities, community health services provide primary care and social support services that respond to local needs. Working from a social model of health, they recognise the critical influence of the social determinants of health on the health and wellbeing of individuals, families and communities and seek to address these. Victorian community health services have a deliberate focus on key groups of people: those who are socially or economically disadvantaged, experience poorer health outcomes and have complex health needs or limited access to appropriate health care.
Employing bi-cultural workers is another key to the success of the high-rise response model, and builds on the cohealth has been undertaking in this area for a number of years. Bi-cultural workers are employed to use their cultural knowledge, language skills, lived experience and community connections; and to work with both people whom they share a lived experience and mainstream organisations. They elevate community voices, advocate for their needs, co-design and deliver programs, share information and facilitate cultural safety. As such, they provide a vital cultural bridge between mainstream services and their communities, ensuring both greater engagement with communities, and improved delivery of services to diverse communities.
In response to COVID-19, many of the bicultural workers have produced videos that deliver translated public health advice in culturally specific ways to communities that might otherwise miss out on the information. These resources have been a vital complement to government health messaging and support broader efforts to eliminate community infection.
However, too often the employment of bi-cultural workers has not been funded. Appropriate investment is required in approaches that support the involvement of communities in effective prevention work.
The small number of positive COVID-19 cases in Aboriginal and Torres Strait Islander communities across the country is testament to the work these communities have done ensuring that health information and supports are delivered in culturally appropriate and sensitive ways, and by trusted members of the community. It is critical that prevention activities are undertaken in partnership with communities in order to achieve positive health outcomes.
Creating a more effective and integrated prevention system will also require:
At the same time, health organisations have a key role to play in ensuring that their services are provided in a way that supports health literacy eg through reducing the complexity of services and ensuring staff are trained and supported in providing health information in ways that promote health literacy.
At the same time, to improve health, action needs to be taken across sectors, not just in the health system. As discussed in our response to earlier questions cohealth advocates a Health in All Policies approach, along with urgent action to address the social determinants of health, such as poverty, inequality, lack of housing, climate change and racism and discrimination. If the Strategy fails to address these determinants, and focusses only on the health sector, the actions will fail to deliver the health gains Australia needs, and the goal that those with the poorest health have the greatest gains will not be achieved.
Reorienting the health system needs to be accompanied by reforming health system funding so that it focusses on achieving outcomes, rather than outputs.
The Consultation Paper also refers to the need that ‘Real, perceived or potential conflicts of interest must be acknowledged and managed.’ cohealth recommends that this wording be strengthened to reflect the need to reduce the unhealthy influence corporate vested interests (such as junk food, alcohol, tobacco, sugar and coal) have exercised for too long and which undermine preventative health policy aimed at preventing illness and promoting health and wellbeing.
cohealth supports the need for an increased, long term sustainable funding mechanism, and recommends identifying a benchmark proportion of health spending to be invested in prevention to ensure that the real value of investment in prevention is maintained over time.
The needs of those who experience the greatest disadvantage and health inequity must be prioritised in all focus areas. Universal health promotion activities generally provide greater benefits to those who already have greater resources – thereby exacerbating health inequalities. The greatest health gains will be made by focusing prevention actions on groups experiencing disadvantage. As such, a clear equity lens needs to be included for all focus areas.
Critical focus areas that are missing from this list, and which need to be included, are mental health and oral health. Preventative work in these areas will have significant health gains.
As we have recommended earlier, it is critical that comprehensive work to address the social determinants of health – through reducing poverty and inequality, tackling racism and discrimination and acting on climate change – is undertaken to improve health outcomes across all stages of life.
The Strategy needs to include targets, responsibilities and timelines to drive accountability for achieving the aims and outcomes.