Chronic Disease Prevention Policy development in Australia
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Australia's health system needs to better connect the dots in a number of areas. Our work looks at connections between Australian chronic disease targets and indicators, WHO targets and indicators, and national progress.
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Chronic Disease Prevention Policy development in Australia
- 1. ACCOUNTABILITY AND CHRONIC DISEASES: MAKING IT MATTER Maximilian de Courten Director, Centre for Chronic Disease Victoria University Penny Tolhurst (Former) Manager, Chronic Disease Program, AHPC 21 June 2016 AHPA
- 2. Summary - 1 What is the aim of your project? • to develop Australian chronic disease targets and indicators through an innovative national approach, and to develop a related report card suite. What are the challenges for such? • The burden of chronic diseases is a major public policy challenge, yet prevention has failed to gain consistent traction and funding • Australia often takes a disease-specific approach, missing opportunities to address multiple risk factors and a broader burden of disease. • In prevention, there is a tendency to implement individual behavioural interventions rather than policy initiatives for tackling inequalities in health with a broad social determinants (upstream) approach
- 3. Summary - 2 What are you doing? • The AHPC auspiced a process whereby working groups reviewed the suitability of the WHO 25x25 targets and indicators. Volunteering Public Health experts worked in groups to tailor or develop for Australia targets and indicators. Strict declaration of interests was adhered to. What are the outcomes? • A set of nine targets and 34 indicators is proposed, with further indicators to be added when data sources are available. • Work is underway on report cards drawing on the targets and indicators, for audiences including both the community and health policy/health professionals.
- 4. Targets and Indicators on chronic disease Accountability for chronic disease AHPC Mission To progress a national policy agenda for the prevention of chronic diseases that improves population health and wellbeing in Australia AHPC VISION To reduce the incidence and impact of chronic diseases through population-based interventions
- 5. AHPC VISION To reduce the incidence and impact of chronic diseases through population-based interventions 1. Systemic approach: focus on common risk factors & determinants, not individual diseases 2. Evidence-based action: act now using best available evidence, continue to build evidence 3. Tackling health inequity: work to improve and redress inequities in outcomes 4. National agenda with local actions: build collective impact through community action 5. A life course approach: intervene early and exploit prevention opportunities at all ages 6. Shared responsibility: encourage complementary actions by all groups 7. Responsible partnerships: avoid ceding policy influence to vested interests Driving health behaviours & healthy environments Creating accountability for action & monitoring progress Generating community support for action on prevention 1. Healthier diets 2. Making smoking history 3. ↑ physical activity 4. ↓ harmful use alcohol 5. Better mental health 6. ↓ biomedical risk factors 7. Tackle social determinants of health 1. Aus implementation of WHO 25x25 target 2. Independent progress report cards 3. Nationally focussed accountability agency 4. State-based success challenges 1. Community data and attitudes 2. Chronic disease local action communities 3. Social media and smart technologies Increased economic participation & productivity More liveable and socially connected communities A healthy future for our children Improved health status for all populations PARTNERS: Parents and families, community groups, educational institutions, local governments, health services, private health insurers, employers and business associations, sporting associations, non-government organisations, the media and advertising industry, Commonwealth and State governments OUTCOMES UNDERPINNING PRINCIPLES STRATEGIC PRIORITIES ACTION AREAS
- 6. (ANPHA. State of Preventive Health 2013. Report to the Australian Government Minister for Health. Canberra)
- 8. WHO Global Action Plan
- 9. Australia’s Targets & Indicators for NCDs • Seven working groups (morbidity/high risk, alcohol, physical inactivity, salt, tobacco, diabetes & obesity, mental illness) • Started with, but not limited to, the WHO 25 x 25 and WHO Global Mental Health Plan T&I • Selected indicators based on criteria from AIHW • Each group produced a chapter that forms the basis for a larger report • Development of related report card is underway
- 10. November 2015
- 11. PROPOSED AUSTRALIAN TARGETS 25% reduction in overall mortality from CVD, cancer, chronic respiratory diseases & diabetes 25% reduction in the overall mortality from CVD & diabetes 25% reduction in the overall mortality from chronic respiratory diseases Elimination of asthma deaths in adults aged <65 25% reduction in the overall mortality from cancer Reduction in the national suicide rate by 10% by 2023 At least 10% relative reduction in harmful use of alcohol, with regard to: • Per capita consumption; and • Heavy episodic drinking; and • Alcohol-related morbidity and mortality A 10% relative reduction in insufficient physical activity A 30% relative reduction intake of salt/sodium A 30% relative reduction in current tobacco use in 14+ years Reduce smoking rates of adults with mental illness by 30% by 2020 A 25% relative reduction in prevalence of raised blood pressure Halt the rise in obesity Halt the rise in new diabetes
- 12. CD Baseline Report Using publicly available Australian data relevant to the 25x25: • Identifies gaps • Outlines trends where possible 0 2 4 6 8 10 12 2001 2004-05 2007-08 2011-12 2015-16 2019-20 2023-24 %Proportion Year Prevalence of Hypertensive Disease (age 18+) 18+ (Age-standardised) 2010 Baseline WHO Target 9.0% 6.8% 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 2001 2004-05 2007-08 2011-12 2015-16 2019-20 2023-24 %Proportion Year Prevalence of Diabetes Mellitus (age 18+) All Ages (Age-standardised) 2010 Baseline and WHO Target 3.8%
- 13. Baseline In 2011/12: • 4.6 million Australian adults had high blood pressure. Of these, more than two thirds had uncontrolled or unmanaged high blood pressure representing 3.1 million adult Australians. • For every four people with diabetes, there was another person with diabetes, who did not self- report the condition.
- 14. “It is not that there is not enough data, not enough information and not enough knowledge as a basis for addressing the prevention and control of NCD. The problem has been how to raise the issue to a high enough level in the political agenda and maintain it there, as without that there will be no material progress.” Sir George Alleyne, 2011 Prevention
- 15. Data Sources • Lack of national commitment to regular health surveillance (including biomedical measures) • The Australian Health Survey (AHS) has provided the best data we have had (2011/13) • No commitment to repeating the AHS • How can we identify trends, or respond to issues?
- 16. Who is Accountable for Prevention?
- 17. Who is Accountable for Prevention? • New strategies to improve responsibility sharing and the acceptance of accountability for health are needed. • This is complicated by the fact that disease risk factors such as alcohol misuse, physical inactivity, poor nutrition and smoking, lie outside the typical remit of the health system • The rise and burden of chronic disease is actually everyone's responsibility, with varied roles to play
- 19. Whose Responsibility? • Historically, Australian governments have not been required to answer for their performance in relation to prevention of chronic diseases • There is no regular comprehensive reporting against national chronic disease prevention targets • Targets that were in place (through COAG National Partnership Agreements or ANPHA) have been lost. ANPHA, for example, had a goal of halting and reversing the rise in overweight and obesity by 2020, and reducing the prevalence of daily smoking from 17.4% to 10% by 2020
- 20. Universal Policies drift towards interventions in individuals Re: Lifestyle drift… Whether or not a social problem remains in the social sphere (and is therefore seen as an area for government intervention) or an individual problem (subject to individual responsibility) is dependent on the power dynamics between the people experiencing the problem and the broader social order… Malbon, E, Pescud, M, Baker, P. Crammond,B. Carey,G. “Whose problem is it anyway? Transforming the public health narrative to stem the tide of “lifestyle drift”. Croakey. March 7,2016.
- 21. Promoting accountability Chronic diseases prevention for Australia: Statement of commitment Regular report card
- 22. Public Health Report Card Examples
- 23. Turning up the heat – Report Cards Groups hold government to account for progress (+ or -): • AMA Public Hospitals Report Card – annual report since 2007 • National Stroke Foundation –reports on compliance with stroke care guidelines • National Alliance for Action on Alcohol – policy scorecard Key features • Independent, non-partisan • Explicit targets • Measuring progress against solutions • Ongoing and regular public reporting
- 24. Preview: July 2016 #AusHealthTracker Follow us on Twitter @AHPC_VU
- 25. Strategies 1. Gain political commitment by building community support 2. Gain central agency commitment by building the economic case 3. Work with others from the sector to establish a clear message 4. Find and use policy windows 5. Acknowledge good policy and leadership 6. Find partners outside the typical health/hospital system to create change in SDOH
- 27. The 3% movement?
- 28. Public Health Message • Australia's health system needs to better connect the dots in a number of areas. Our work looks at connections between Australian chronic disease targets and indicators, WHO targets and indicators, and national progress. • Historically in Australia, governments have not been required to answer for their performance in relation to prevention of chronic diseases • Accountability through targets, indicators, and a report card, is a way of making prevention matter, and casting a spotlight on this critical issue, and extending the responsibility to all of us.
- 29. ACCOUNTABILITY AND CHRONIC DISEASES: MAKING IT MATTER Thank you! Website: www.ahpc.org.au Twitter:@AHPC_VU Contact: maximilian.decourten@vu.edu.au
- 30. Chronic disease prevention for Australia: Statement of commitment Arthritis and Osteoporosis Victoria Catholic Health Australia National Stroke Foundation Australia and New Zealand Obesity Society Centre of Excellence in Intervention and Prevention Science NCDFREE Australian Centre for Health Research Charles Perkins Centre, University of Sydney Network of Alcohol and other Drugs Agencies Australian Dental Association Chronic Illness Alliance Networking Health Victoria Australian Disease Management Association CLAN Obesity Australia Australian Federation of AIDS Organisations Cohealth Overcoming Multiple Sclerosis Australian Health Care Reform Alliance CRANAplus People’s Health Movement OZ Australian Health Promotion Association Deakin University Public Health Association of Australia Australian Healthcare and Hospitals Association Diabetes Australia Royal Flying Doctor Service Australian Psychological Society Foundation for Alcohol Research and Education School of Medicine, University of Notre Dame Australian Women’s Health Network Health West Partnership Services for Australian Rural and Remote Allied Health Baker IDI Heart and Diabetes Institute Inner North West Primary Care Partnership Better Health Plan for the West Kidney Health Australia Social Determinants of Health Alliance Brimbank City Council Lowitja Institute South Australian Health and Medical Research Institute Cabrini Institute Mental Health Australia The Telethon Kids Institute Cancer Council Australia National Heart Foundation Victoria University National Rural Health Alliance Victorian Health Promotion Foundation YMCA
Editor's Notes
- Presentation at the 2016 Australian Health Promotion Association conference in Perth – 21 June 2016 Hello my name is Maximilian de Courten and I am presenting on behalf of myself and colleagues. The Australian Health Policy Collaboration was founded at Victoria University in 2013. Our mission is to contribute to the development of public policy and its practice, and to improve health outcomes through evidenced based research, particularly for socioeconomically disadvantaged Australians.
- AHPC was created, in part, in response to growing chronic disease burden in Australia – CD now affect 1 in 2 Australians. The vision To reduce the incidence and impact of chronic diseases through population-based interventions Today I will talk to you about our work in creating accountability for action and monitoring progress.
- So…how is Australia tracking for progress on chronic disease? A 2013 snap shot demonstrates how we are going compared to some OECD countries Key: Blue bottle = Alcohol consumed Litres per capita (15+ years) Cig = Proportion of pop (15+ years) daily smokers Green man = Proportion of adults that are obese
- Because of this global burden, the WHO Global Action Plan for the Prevention and Control of Noncommunicable Disease. The World Health Assembly endorsed the WHO Global Action Plan in May 2013. The Global Action Plan provides Member States, international partners and WHO with a road map and menu of policy options which, when implemented collectively between 2013 and 2020, will contribute to progress on 9 global NCD targets to be attained in 2025, including a 25% relative reduction in premature mortality from NCDs by 2025.
- We, at the AHPC at Victoria University, embarked on a collaborative process to develop or tailor national chronic disease targets and indicators for Australia. We have used a short, sharp process in which we tried to involve the key experts around the country. People have been great in their willingness to be involved. In some topic areas there was much better data, and in some a lot of work had already been done. For example….It was possible to draw on work that has been done in the Active Healthy Kids Australia Report Card on Physical Activity for Children and Young People. For overall activity levels, unfortunately, Australian kids got a D-. 19% of Australians aged 5-17 years and 15% of Australians aged 12-17 years, meet the recommended Australian physical activity guidelines of accumulating at least 60 minutes of MVPA every day of the week. In the area of mental illness, there was work from the National Mental Health Commission and the National Survey of People living with Psychosis to draw on. There were some really interesting discussions about what the targets and indicators should be. So overall, the seven working groups found that we had some challenges ahead to improve prevention of chronic disease across Australia. In November we met to draw the work back together, which resulted in…
- The launch of this technical paper
- The proposed Australian targets included in the report are listed here in the table. And we also added to extra targets, not reflected in this slide: Age-standardised ave. total cholesterol levels for adults & percent with total cholesterol ≥ 5.0 mmol/L Improve employment rates of adults with mental illness & participation rates of young people with mental illness in education & employment, halving the employment & education gap by 2025
- The AHPC prepared a baseline report which is available on our website as well as the report from the working groups. It looks at the data we have readily available, and how Australia is travelling, against the WHO 25 x 25. The WHO is working against a 2010 baseline, which is the redline that you can see. The vertical blue line shows 2010 One of the nine targets it to halt the rise in diabetes and obesity. Another is a 25% relative reduction in the prevalence of hypertension. Achievement of either of these targets is looking rather dubious. We used this report as a way of promoting discussion about the right targets for Australia. With regard to obesity, for example, the target is halt the rise in obesity. Is that the best we can aim for? Do we want to actually turn it around? Should we have a target for children (New Zealand is promoting this)? It is interesting to see the different views that people have. Our alcohol group, for example, has included injury as an alcohol related harm. At one level it is obvious, but it is a different approach to WHO.
- Prevention needs to get some traction, if we are to have a healthier society and a more sustainable health system. The argument that there isn’t enough evidence for prevention does not wash: we know from the Assessing Cost-Effectiveness (ACE) prevention study, for example, that there are effective and cost effective interventions available now. The World Health Organization (WHO) has estimated that at least 80 per cent of all heart disease, stroke and diabetes cases, and 40 per cent of all cancers, are preventable. The (ACE) Prevention study provides a treasure trove of Australian evidence, amassed over five years, on more than 150 preventive health interventions. It provides: evidence on the interventions that have the largest population health impact (through reducing the burden of disease); a ranking of interventions on their cost-effectiveness (including whether they result in cost savings to the health system); and evidence on how to combine and sequence preventive interventions for important health priority areas to achieve the greatest ‘bang for buck’. Examples of population-based preventive interventions that are strongly cost-effective include tax increases on tobacco (30 per cent), alcohol (30 per cent) and unhealthy foods (10 per cent), as well as mandatory salt limits on processed foods. Together, these four interventions would result in 650,000 fewer years lived with a disability for the Australian population and generate $6 billion of net savings to the health system. In a climate of concern about health system sustainability, why aren’t we taking action on prevention? There is compelling evidence that addressing the risk factors associated with chronic disease is an efficient use of government funds.
- One of the challenges to measuring progress on prevention is the lack of national commitment to regular health surveillance
- Some of the difficult things we have encountered and expect to encounter with this work… WHO IS ACCOUNTABLE? New strategies to improve responsibility sharing and the acceptance of accountability for health are needed. But this is complicated by the fact that disease risk factors such as alcohol misuse, physical inactivity, poor nutrition and smoking, lie outside the typical remit of the health system. The rise and burden of chronic disease is actually everyone's responsibility, with varied roles to play.
- Some of the difficult things we have encountered and expect to encounter with this work… WHO IS ACCOUNTABLE? New strategies to improve responsibility sharing and the acceptance of accountability for health are needed. But this is complicated by the fact that disease risk factors such as alcohol misuse, physical inactivity, poor nutrition and smoking, lie outside the typical remit of the health system. The rise and burden of chronic disease is actually everyone's responsibility, with varied roles to play.
- THIS WAS OUR METHOD – (kind of) Accountability framework adapted from Kraak and colleagues, applied to healthy food environments. It can also be applied by NGOs and health policy think tanks – like the AHPC - to chronic diseases more broadly. Source: Swinburn et al (2015). The first step of the accountability cycle described by Swinburn et al (2015) is assessment. This requires measurement of progress towards agreed goals. Working with others, the AHPC seeks to establish a set of targets and indicators, linked but not restricted to the WHO 25 x 25. The second step of the accountability framework is communication, and involves wide dissemination of progress made by governments in the implementation and meeting of targets set in national and international plans for action against chronic diseases. It also involves sharing evidence on the implementation of recommended actions to meet the targets. The third step of the accountability cycle is enforcement. This step involves affected stakeholders acknowledging achievements and sanctioning poor performance of other stakeholders. Swinburn argues that this step is often the weakest component of the accountability framework (2015). The strongest accountability lever for the government to hold the private sector to account is via legal mechanisms. The fourth step of the accountability framework is making improvements. It involves changes in policies and practices by governments, industry and consumers.
- Targets that were in place (through COAG National Partnership Agreements or ANPHA) have been lost. ANPHA, for example, had a goal of halting and reversing the rise in overweight and obesity by 2020, and reducing the prevalence of daily smoking among adults from 17.4% to 10% or lower by 2020.
- Need to attack myths re Nanny State etc From Croakey: While policy ambitions start upstream at a broad population level, they soon “drift” downstream, becoming targeted at individual actions and responsibilities. This is sometimes referred to as the ‘lifestyle drift’ phenomena – where initial policy commitments that begin as universal become targeted at individuals during implementation. Consider for example the many programs aimed at reducing obesity. The broadest goal of these programs is often to reduce population-level obesity but, over time, they become social marketing campaigns to encourage physical activity and healthy eating for individuals. These types of behaviourist intervention do not (in isolation) have the power to change any of the driving social determinants of obesity. Lifestyle drift refers to both: - policy initiatives for tackling ‘inequalities in health that start off with a broad social determinants (upstream) approach but drift downstream to largely individual lifestyle factors’, and; - a general tendency to implement individual behavioural interventions.
- The Australian Health Policy Collaboration continues to lead this national project to develop and implement chronic disease targets and indicators based on the WHO noncommunicable disease targets. To date 46 public health organisations, many of them are here in the room, have signed up to the Chronic diseases prevention for Australia: Statement of commitment to establish a platform for national chronic disease targets. They were there at the beginning and the will be there to help launch and disseminate the report card in July 2016. If any of you are interested in this work please contact us and come along in July to the launch to help progress our collaborative efforts for improvements in this election year.
- We have learned from others and collaborated with many so we acknowledge the many other NGOs and public health groups are playing important accountability and awareness raising roles, such as Prevention 1st, INFORMAS, the global NCD Scorecard.
- Next steps in Targets and Indicators work….report card!
- Launching July 5th – the report cards: 1) Australia’s Health Tracker, 2) Australia’s Adult Health Tracker & 3) Australia’s Children and Young People Health Tracker will be made available on our website (ahpc.org.au) on July 5th Follow us on Twitter for all the latest on our July 5th forum, Chronic Diseases in Australia: Action and Accountability. Our official hashtag we will be using is #AusHealthTracker – we have been tweeting using this hashtag already AHPC invited Professor MacGregor to Australia as the key note speaker at the forum to speak on his success in achieving policy changes to reduce population salt intake and his recent work on a sugar tax in the UK. For more details please visit our website
- Ensure messaging is accessible to community and resonate with their needs Commitment from Health departments still absolute vital – major allies Sing from the same song sheet Like the election year! Encourage and work with Food industry and retail, television regulation, parks and leisure, town planning and urban design, banks and business – these are the major players in preventative health – along with primary health care – and we need to work with them to tackle risk factors
- BUT Some of the opportunities…. Citizens responsibility and action is not dead! For example, the occupy movement – demonstrates civil society resistance and power.
- Australia has one of the lowest levels of investment in prevention in the Western world, a shocking 1.5 per cent of the national health budget. Could there be a 3% movement in reaction to the dismal 1.5% ????? Australians have and do protest, participate in online campaigns and have supported action on tobacco control. So…people can and do take responsibility for population health and this needs to be encouraged, supported and recognised by the public health community
- 50+ signatories and more
- Photo montage of publication covers: The chronic diseases policy program – top row and 3rd on second row – a policy forum report Beyond the fragments – downloaded 717 times in 2016; targets and indicators 719; Funding models – 428 Investing in women’s mental health – 56 – published less than a fortnight ago