CHAPTER 9 Public health in Australia
Public health is the art and science of preventing disease and injury, prolonging life and promoting health through the organised efforts of society. Public health focuses on the broad determinants of health and the conditions of life where people live, work and play. The drivers for public health are both philosophical and economic. Philosophically, the values for public health are based on notions of health for all, social justice, and equity. Public health is about healthy populations and the quality of people’s lives and wellbeing as well as the reorientation of health systems towards health rather than illness. The economic drivers for public health are about reducing costs of illness and treatment by prevention, promotion and protection of the public’s health.
Over the last 150 years, progressive shifts in public health thinking have been observed (see Baum 2002b). Public health is informed by a wide range of disciplines including traditional disciplines of medicine, epidemiology and biostatistics as well as economics, social sciences, political science, psychology, environmental health, and health promotion.
The world-views of the various disciplines involved in public health have more recently been influenced by contemporary social-ecology/equity debates, and since the early 21st century, ‘new public health’ is increasingly influenced by the evidence emerging about the social, economic, political, and environmental determinants of health (Baum 2002b). The new public health is therefore a socio–political movement that argues the need for social and political action to control disease and improve the health of populations. Its proponents see the need for action on social and economic environments to improve the public’s health and to reduce health inequalities where these are avoidable, and especially where they are unjust or unfair (Marmot 2006).
The social determinants of health are the social conditions in which people live and work, and they represent a significant shift in thinking about how to resolve issues of health inequity and disadvantage (Marmot 2006). Collectively, the social determinants of health are now recognised as the best predictors of health — the causal pathways both for individuals and populations. The evidence that has been systematically collected and analysed demonstrates how pathways through societal, political, environmental and economic determinants translate into illness and disease. The social conditions and settings in which people live their lives influence not just how people behave, but have a direct impact on the health of individuals, communities and populations. Some of these issues were raised in Chapter 2.
Population health is an approach used within public health systems — a framework for thinking about why some populations are healthier than others, as well as the policy development, research and resource allocation that flow from it (Young 1998). A narrow view of population health is that ‘population health rests largely on shaping the distribution of risk in a population so that fewer people are exposed to risky situations’ (Berkman & Melchior 2006: 55).
A broader view of population health is that it describes both a level of analysis about risk exposure, the health outcomes of whole populations, or sub-populations, and the distribution of outcomes across those various populations (e.g. youth, children, refugees, older people) (Kindig 2007). Population health is increasingly concerned with studies and programs addressing health determinants (Berkman & Melchior 2006; Kindig 2007).
So, population health can be narrowly defined in terms of risks and associated health outcomes, but there is support for broader conceptualisation of population health as encompassing the multiple determinants of such health outcomes, however these outcomes are measured. These determinants include: access to health care and public health interventions; socioeconomic environments including income, education, employment, social support, gender and culture; physical environments including urban design, clean air and water; genetics or biology; and individual and group behaviours including social norms for particular groups (Kindig 2007).
the outcomes of benefits of a population health approach extend beyond improved population health outcomes to include sustainable and integrated health systems, increased national growth and productivity, and strengthened social cohesion and citizen engagement.
Geoffrey Rose, now regarded as a classic thinker and researcher about public and population health, posed a key question for public health: ‘Why are some people healthy and others not?’ (Rose 1981, 1992, 2001). To answer that question, he said (Rose 1992: 62):
In order to grasp the principles of public health, one must understand that society is not merely a collection of individuals but is also a collectivity, and the behavior (sic) and health of its individual members are profoundly influenced by its collective characteristics and social norms. Given time, these collective and societal characteristics can be changed either by the behavior (sic) of individuals, such as opinion formers and health educators, or by the mass effects of changes in the economy, the environment, or technical developments. The efforts of individuals are only likely to be effective when they are working with the societal trends.
Both high-risk and population strategies have been developed to influence the distribution of illness across the population. A high-risk strategy is one that targets the right patient at high risk of developing a more serious condition, such as pregnant women or overweight men who are smokers. The population strategy is one that attempts to control the determinants of incidence, and thus to shift the distribution of exposure across the whole population. This gives rise to the prevention paradox, which is that a large number of people at small risk may give rise to more cases than the small number who are at high risk, which is to say that ‘a preventive measure that brings large benefits to the community offers little to each participating individual’. In other words, many people must take precautions in order to prevent illness in only a few, such as immunisation.
In theory, population health work should take account of the patterns of health determinants, and policies and interventions that link outcomes with determinants. But in reality, only a narrow range of determinants are considered in population health work by governments which focus on relationships between patterns of illness and disease in relation to socioeconomic factors and, to a lesser extent, racial and ethnic group differences. Good population health requires intersectoral approaches to programs and a focus on the needs of those with disadvantaged health status, aiming to reduce health and social inequities.
Typically, both public health and population health strategies are more ‘upstream’ than medical treatment services, which are classified primarily as ‘downstream’. Upstream strategies are focused on social and environmental change, and health-promoting policies and practices. Figure 9.1 illustrates downstream–upstream causal pathways towards the development of disease and illness.
Other chapters (1, 2, 10, 11, 12, 13) discuss the higher incidence of poor health among socio-economically disadvantaged groups and problems of inequity. Public health places emphasis on high quality, universal programs such as immunisation, maternal and infant health, and cancer screening programs that are available to the whole population. As health inequities increase, a balance needs to be found for targeted programs that are tailored to meet specific needs of vulnerable populations and groups.
Public health in Australia receives 1.7% of the total recurrent Commonwealth allocation from the health budget (AIHW 2004c: 239). This share of the health budget was under pressure in the early 1990s, but from 1996 has been protected in joint Commonwealth and state/territory programs (Healy, Sharman & Lokuge 2006). Estimating the actual funding for public health across all jurisdictions would be a complex matter because they all have public health responsibilities, while the definitions of what is or is not a public program makes estimates even more difficult, so the 1.7% is not an estimate of all expenditure on public health. Nonetheless, there are strong arguments, based on increasing evidence, that expenditure on public health should be increased given emerging disease threats and their global significance.
Arguably, the low ceiling on public health expenditure can be attributed to debates about the role of government in the lives of the public, and therefore, their role in public health. New public management (see Introduction to this book) has seen trends in the role of government in health care to minimise government roles to one of a contract manager seeking accountability for outputs, as well as greater involvement of markets and competitive forces to ‘reform’ health care, including public health, as governments look to reduce expenditure and increase end-user costs. We have seen the privatisation of housing, water and transport, food, food safety, hospitals and medical care all of which have public health impacts, especially on the health of the poorest. When interests of private industry dominate, public health interests can be suppressed.
Public health, which seeks prevention and capacity building for the long-term with social objectives, including access and equity, is vulnerable to cutbacks as health is increasingly considered a marketplace commodity, or the demands of hospital waiting lists become politically embarrassing for governments. One of the tensions for public health is the extent to which governments are prepared to allow the allocation of public expenditure for public health to be allocated to the private sector. Privatised health care systems emphasise technological solutions to public health problems but technological solutions usually do not increase the capacity of government infrastructure for public health or invest in social infrastructure. This is illustrated by the emphasis on immunisation and downstream narrowly focused prevention when public health is contracted to medical practitioners working in private practice. Economic growth without social investment can bring four ‘D’s: deprivation, disruption, death and disease.