Data, surveillance and monitoring

• Implement and extend the National Health Risk Survey Program, funded under the COAG Agreement on Preventive Health

• Comprehensive national surveillance systems for obesity, tobacco and alcohol are essential tools for the purposes of collecting and managing relevant datasets, monitoring progress against specified targets and reporting trend information over time. To be effective, these systems should have the capacity to:

• 
  Collect and report against behavioural, environmental and biomedical risk factors relevant to obesity, tobacco and alcohol
  
• 
  Expand and incorporate newly identified and/or revised indicators into datasets as required and appropriate
  
• 
  Become permanent systems of data collection undertaken at predetermined regular intervals
  
• 
  Provide representative data for the whole of population and also populations of interest (for example, Indigenous, children and adolescents, disadvantaged)
  
• 
  Complement and build upon other existing data collection and monitoring mechanisms as required and appropriate
  

• Establish:

• 
  A National Strategic Framework for preventative health research
  
• 
  A preventative health strategic research fund
  
• 
  A national preventative health research register
  

• 
  Partner with community interventions in the region they serve, with NGOs and other collaborators
  
• 
  Have a national specialty role (for example, in obesity, tobacco or alcohol, school settings or disadvantaged populations)
  
• 
  Have a workforce development role in education, research and intervention practice
  

• NPA to oversee as a matter of priority a national audit of the prevention workforce outlined in the 2008–09 COAG Agreement on Preventive Health; strategy arising from the audit to be brought to AHMC for implementation

• Ensure prevention becomes an important part of the work of Health Workforce Australia Agency

Future funding models for prevention

• NPA to investigate and provide advice in regard to the potential development of a funding framework for prevention, both within and external to the health sector

6. A conceptual framework for the Strategy

The purpose of the Strategy is to improve the health, wellbeing and life expectancy of Australians, and to remedy disadvantage in health status. Within this context, the components of the Strategy are based on the following four rationales:

• Influencing markets

• Inequities in health

• Developing effective policies

• Investing for maximum benefit

Later in this chapter, these concepts are applied to the strategic directions put forward by the Taskforce.

‘In a political economy that measures progress in terns of growth and consumption there are many underlying environmental, social and political determinants. In this context the introduction of policy and regulatory interventions is essential to make real impact’ (Quote from submission)

6.1 Influencing markets

Food, physical activity, alcohol and tobacco are all consumables trading in our market system. When markets work efficiently, and consumers and producers act with full information, markets contribute significantly to community wellbeing. However, markets are imperfect and do not always produce optimal outcomes from a societal point of view.

For example, markets often under-provide the information consumers need in order to make healthy choices. When individuals have imperfect information about their own health, the range of choices available to them and the expected impact of particular lifestyle choices on their health, they may fail to act in the best interests of themselves or society.

Understanding how to adopt a healthy lifestyle is compromised by the complexity of the relationship between lifestyle behaviours and health, and an economic and social environment that promotes unhealthy choices. Efficient markets rely on a rational consumer able to critically evaluate information and weigh up, for instance, current pleasure and possible consequences. Alcohol, food and smoking are particularly vulnerable to compulsive choices and alcohol and tobacco can be addictive; in addition, alcohol directly affects capacity for rational decision making. Children and teenagers require special consideration, given their under-developed abilities to weigh the consequences of their behaviour.

Where imperfect information, the absence of rational decision making and negative externalities exist, there is a strong case for corrective action to be taken.

The Taskforce has considered the economic arguments with regard to these issues carefully and systematically, and has taken account of research evidence regarding the relative influence of market, government and individual actions on behaviours that have demonstrated adverse health outcomes. Further, it has considered the weight of views and arguments presented in the submissions and received from the community and in consultative forums.

Based on the above, it is the Taskforce’s view that there are areas in which an imperfect market does in fact exist and which warrant corrective action – largely but not only through government action – if desired improvements in health are to be achieved. These areas are those identified as most clearly distorting consumption; for example, any form of marketing in the case of tobacco, and in the case of alcohol and obesity, marketing promotions aimed at children or adolescents that portray unhealthy choices as socially desirable.

However, in recommending measures that impose constraints on marketplace activity, it is the intention wherever possible to find ways in which both the private and social good can be served by shifting consumption in particular markets from less healthy to more healthy consumption patterns (see responsive regulation below).

6.2 Inequities in health

Australians’ concern with fairness in relation to preventative health, together with their concern for the suffering of others, demands actions to support equity of access to the means to lead a healthy life. This suggests, for instance, policies that promote access for all to nutritious food, physical activity, clean water and adequate housing. It also supports the provision of culturally relevant and accessible preventative health services (including minimal co-payments) that discriminate in favour of high-risk groups and those in poorer health.

At the system level, providing equity of access is the major argument for funding primary and community care according to a needs-adjusted capitation formula. A predominant fee-for-service payment system results in highest Medicare Benefits Schedule spend in regions with the highest SES and higher levels of health. It is also an argument for strengthening universal health cover and reconsidering policies not consistent with equity.

We know that health is a major indicator of inequity. If you want to judge how affluent a suburb is, you could check its tax returns – or you could look at its medical records. Rates of diabetes, of heart disease, early deaths, infant mortality, how many teeth a person has left – all are clear markers of socio-economic status. …In three areas – prevention, workforce, and the provision of health services by both public and private providers – a confused combination of government regulation and badly designed markets can hamper our ability to deliver the healthcare that people deserve. Which means health inequalities are becoming entrenched in our community.[26]

In formulating its recommendations, the Taskforce has been particularly concerned with the need to address the unequal distribution of health and risk in Australia. In this, the Taskforce’s views are firmly in alignment with other contemporary developments in Australia and internationally, including:

• The NHHRC, which identified ‘Facing inequities: recognise and tackle the causes and impacts of health inequities’ as one of four major themes in its Interim Report

• The targets and priorities set out under the COAG ‘Close the Gap’ objective to address Indigenous disadvantage, which include both health, such as life expectancy and child mortality, and ‘social determinants’ targets, such as education and employment

• The Australian Government’s Social Inclusion Agenda, and similar initiatives introduced at the state level (such as South Australia’s Social Inclusion initiative)

• The Report of the WHO Commission on the Social Determinants of Health

‘To support a health promoting society, broad structural reform is required not only within the health system but to address the structures, environments and institutions that influence and impact on the health of the population and the individual’ (Quote from submission)

As submissions and consultations noted, to date much of Australia’s prevention policy has been ad hoc, and has been developed to suit single rather than multiple issues managed by single departments rather than coordinated between government portfolios. The combined effect – while sometimes reflecting policies that are consistent with the objectives of the agency and portfolio but not necessarily in the interest of the wider society – has been to distort the health service mix, reduce the efficiency of the health system and to have favoured some medical and pharmaceutical services over lifestyle and community-based initiatives.

Policy failure within health and the wider economy provides an important rationale for the Strategy’s components. To be effective, prevention policy needs to maintain a balance across a comprehensive and complex set of approaches and settings, avoid cost shifting between levels of government, and encourage cross-sectoral initiatives that allow flexibility in supply. The introduction of new policies must be accompanied by quality assurance and accountability mechanisms. Appropriate responses will often include regulatory or system level initiatives.

• The differential funding arrangements across governmental and departmental budget silos. This is far from the ideal of a level playing field in which all services can compete equally for resources, regardless of modality, setting, stage of disease or delivery mode.

• The lack of accountability and quality assurance mechanisms for preventative health.

Reform options are set out by the NHHRC,[27] in various commissioned papers for the NHHRC and for this Taskforce, as well as in the wider health services literature. Some components of health reform have emerged, such as enrolled populations and electronic patient records. Health reform issues, especially for primary healthcare, are covered later in this chapter, although it is recognised that some of these issues are being addressed by other initiatives such as the Primary Health Care Strategy.

Examples of ways to address health impacts from non-health policy can include the introduction of health impact assessments in all policy development (for example, in urban planning, school education or transport), and the development of partnership models such as the Health in All Policies approach described below.

EXAMPLE: THE HEALTH IN ALL POLICIES APPROACH (HIAP) The South Australian Strategic Plan provides the framework for the HiAP approach. In 2007, through the Adelaide Thinkers in Residence program, Professor Ilona Kickbusch developed a proposal for integrated policies and strategies around the broad theme of ‘Healthy Societies’. High-level commitment from both the central government agency (the Department of Premier and Cabinet) and the Health Department was obtained.[28] • Obesity was one of the areas included in the HiAP plan, building on the existing partnerships between the Department of Health with: • Primary Industries and Resources of South Australia (PIRSA) through encouraging fruit and vegetable consumption • Department of Transport, Energy and infrastructure (DTEI) through support of active transport • Department of Education and Children’s Services (DECS) through the Right Bite school canteen program • Department of Environment and Heritage (DEH) through the Healthy Parks Healthy People program • Recreation and Sport through Be Active workplaces[29]

6.4 Investing for maximum benefit

The fourth rationale for selecting components of the Strategy is that of minimising opportunity cost – that is, the opportunities and benefits missed because of activities that have not been funded. This requires the redirection of resources away from cost-ineffective to more cost-effective interventions. Put simply, resources should be allocated where they yield the greatest benefit per unit cost. The approach taken by the Taskforce has been to work wherever possible from a well-researched evidence base – and where the evidence is not yet clear, to build evidence to inform future cost-effective investment in prevention activity.

7. The roadmap for prevention

The roadmap for action outlines the themes, targets and strategic directions that will bring about the results we seek.

Figure 1.3:

Roadmap



7.2 Principles

The principles underpinning the Strategy have been identified from evidence from the research literature, and confirmed through consultations and submissions to the Taskforce. In this first National Preventative Health Strategy, these principles guide action in relation to obesity, tobacco and alcohol, but they can also be used for other prevention issues such as mental health promotion or the prevention of injury or blood-borne viruses.

• Maximising community wellbeing – by building a roadmap with staged approaches for strategic prevention across the whole of life, in a variety of settings and for a wide range of population groups.

• Working together – with individuals, families, communities, health professionals, industry, employers and governments to build prevention in Australian communities.

• Addressing health equity – through recognition and response to the causes and effects of health inequity, especially for Indigenous people.

• Ensuring effective implementation – through a strong infrastructure that supports individuals and communities in making and sustaining healthy choices.

The Taskforce has set four key targets. By 2020 Australia will:

These targets are consistent with those of the COAG National Partnership Agreement on Preventive Health and the National Healthcare Agreement performance targets, which include:

• Increase the proportion of children and adults meeting national guidelines for healthy body weight by 3 percentage points within 10 years

• Increase the proportion of children and adults meeting national guidelines for healthy eating and physical activity by 15% within six years

• Help assure Australian children of a healthy start to life, including through promoting positive parenting and supportive communities, and with an emphasis on the new

In addition to these targets and aligned with the COAG outcome measures, the Taskforce has developed a number of interim targets and performance measures for each of the topic areas, which are set out in the relevant chapters.

It is necessary to strengthen Australia’s capacity to effectively monitor, evaluate and build evidence around preventative health. A number of ambitious targets relating to overweight and obesity, alcohol and tobacco have been set by this Strategy, and Australians will need to know how effective our preventative health programs are and whether we are on track to meet these targets.

The Strategy has been designed to focus on implementation, measurement and accountability – a cyclical approach of ‘do, measure, report – do, measure, report’. The development of a robust performance framework to underpin the Strategy and inform its implementation is therefore a priority. Progress will be monitored at three levels:

• Health status and outcomes

• Determinants of health

• Program and systems performance

Changes in health outcomes and determinants of health are the long-term measures of the success of this strategy. However, these indicators are most reliably measured over several years at the population level, and changes cannot easily be attributed to specific program elements. Complementing these longer term measures are the shorter term program and system-level performance indicators more closely related to the specific priority actions and programs. These program and system performance measures are summarised in the tables within this strategy. In addition, indicators relevant to enabling infrastructure for prevention will also be developed and monitored.

PERFORMANCE INDICATORS FOR OBESITY, TOBACCO AND ALCOHOL PREVENTION

Health outcome measures (all to be reported by Indigenous status) Deaths attributable to tobacco, alcohol, overweight and obesity Hospital separations for tobacco, alcohol, overweight and obesity

Determinants of health measures (all to be reported by Indigenous status and by index of relative social disadvantage of place of residence) Proportion of adults who are daily smokers Proportion of adult smokers who have attempted to quit in last year or who intend to quit in next three months Proportion of children who smoke at least weekly or monthly and proportion who have smoked at least 100 cigarettes Proportion of adults and children who live in a home where anyone smokes indoors Proportion of adults and children at risk of long-term harm from alcohol Proportion of adults and children at risk of short-term harm from alcohol at least once a month Proportion of adults and children overweight or obese Proportion of adults and children eating sufficient daily serves of fruit and vegetables Proportion of adults insufficiently physically active to obtain a health benefit Proportion of people walking, cycling or using public transport to travel to work or school Proportion of babies breastfed for six months or more

Program and system performance measures (reporting by Indigenous status and by index or relative social disadvantage as appropriate) These measures are summarised in the tables within the obesity, tobacco and alcohol chapters. They include but are not limited to the following measures: Knowledge, attitudes and awareness of risks associated with tobacco use, risk drinking and overweight and obesity Recall of social marketing campaigns for obesity, tobacco and alcohol Proportion of Australian population not covered by legislative restrictions on promotion and use of tobacco and alcohol that operate at state and territory level Proportions of overweight or obese people, smokers or people at risk of short- or long-term harm from alcohol receiving brief interventions in primary healthcare settings Children’s exposure to advertisements for EDNP food and beverages Food price disparity in rural and remote areas Number and proportion of state and municipal plans that include steps to tackle obesity Number and proportion of schools with comprehensive programs in place that support healthy eating and physical activity Number and proportion of workplaces that have comprehensive programs in place to support healthy living Proportion of retailers breaching tobacco-related legislation Number of instances where tobacco products are being promoted Price of cigarettes (recommended retail price, average price paid by consumers and price in comparison to average weekly earnings) Proportion of smokers surveyed who report purchase of illicit tobacco products and proportion of children who report that they have been able to purchase tobacco products from retail outlets Alcohol outlet density by city/town and region Taxation incentives for the production and consumption of low alcohol products Systems and practices to proactively police licensed venues, events and harms Expenditure on research and evaluation relating to the control of alcohol, tobacco and overweight and obesity in Indigenous and other disadvantaged communities

Enabling infrastructure measures These may include indicators relevant to workforce, investment in social marketing campaigns and investment in prevention research including understanding of social determinants of health behaviour, modelling of health impact policy options and evaluation of programs. They would also include measures relevant to the development of partnerships and engagement/participation of stakeholders with the Strategy.