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Changing Government Process to Improve the Social Determinants of Health

Brad CrammondMonash University

Gemma CareyANU

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Social Determinants

‣ We all know that many of the determinants of health fall outside the health sector

The obvious bit

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Government Policy

‣ The approach of SDH has been to ask government to intervene in these non-health areas and make them healthier

“…action is required across all the social determinants of health and needs to involve all central and local government departments as well as the third and private sectors. Action taken by the Department of Health and the NHS alone will not reduce health inequalities.”

Fair Society, Healthy Lives (the Marmot Review)

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Process-based Interventions

‣ The SDH response has been to lobby for changes in government process which build health considerations into non-health sector decision making

Joined-Up Government: Public Health Style

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Non-Health Sector

‣ Non-Health departments have been resistant to this imposition of tasks and responsibilities

The Less Obvious Bit

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Two Prominent Processes

The ‘Fairness Agenda’

Health in all Policies

‣ First set out in the Marmot Review

‣ Calls for ‘robust political leadership’ from ‘the Secretary of State for Health with an explicit cross-government remit to deliver on health inequalities.’

‣ Introduce a ‘health equity impact assessment’ to which all departments are subject.

‣ Was not implemented by the UK government to which the Marmot Review was addressed

‣ Described as a practical implementation of the principles set out in the Ottawa Charter on Health Promotion

‣ Aims to make healthier government policy

‣ To be achieved by the enforcement of a ‘Health Lens Analysis’ on all policy

‣ Currently running in South Australia

‣ Has newly commenced in France

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Joined Up Government

‣ Term was coined by the Blair government.

‣ Emerged as an attempt to deal with ‘wicked problems’

• By which they mean the difficult social problems which implicate many government departments

In the Public Policy Literature

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What We Did

‣ Searched the Public Policy literature for all empirical evaluations of joined-up government

The Obligatory Methods Slide

Search Terms

‣ joined-up government

‣ joined-up governance

‣ whole of government

Databases

‣ Expanded Academic

‣ Academic Complete

‣ JSTOR

‣ Web of Science

‣ Science Direct

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PRISMA DiagramIt must be true because it’s in a flow chart

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What We Found

‣ Joined-Up Government is most effective when:

• It targets multiple levels of operation

• Is both top down and bottom up

• Has decentralised control

• Is designed to fit both purpose and context

• Has a range of instruments which can be fitted to specific functions

Summary of Results

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How Does SDH Stack Up?Operational Level

‣ Target Multiple Levels:

‣ Strategic Government

‣ Managerial

‣ Practitioner

‣ Community

HiAP

‣ Managerial

Fairness Agenda

‣ Strategic Government

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How Does SDH Stack Up?Context

Top Down&

Bottom Up

Decentralised Control

Design for purpose

AND context

Top Down only

HiAP Fairness Agenda

Top Down only

CentralisedControl

CentralisedControl

Embed health in all policies(only purpose)

Promote equity in health(only purpose)

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How Does SDH Stack Up?Instruments and their Functions

‣ Fulfil a range of functions depending upon objectives:

‣ Governance and Structure

‣ Managerial changes

‣ Adjust systems, processes and finances

‣ Cultural and institutional changes

HiAP

‣ Interdepartmental Committee

‣ Improve relationship between departments

‣ Introduce Health Lens Analysis (HLA)

‣ Hoped to arise through application of HLA

Fairness Agenda

‣ Interdepartmental teams

– none –

‣ Health Equity Impact Assessment

‣ Political leadership to create cultural change

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How Does SDH Stack Up?

Not particularly well

Summary

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How Can We Improve?SDH approaches to government need to relinquish control and promote public involvement

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Questions?