Something very big is missing from the proposed overhaul of our health system, writes Professor Boyd Swinburn.
The long-awaited Simpson review of our health sector makes a powerful call to refocus the system on creating better health outcomes through prevention.
But something very big is missing. The focus is on the healthcare institutions themselves, like the Ministry of Health, district health boards and the Health Promotion Agency – their structures, roles and accountabilities. These are very important organisations; they need to be as strong as possible, and the review provides an excellent platform for this national discussion.
But as the review notes, these health services contribute to only about 20% of our health outcomes, and only about 10% of health equity outcomes. Health equity is about eliminating the current unfair differences in health outcomes across ethnicities and income levels in New Zealand. So what determines the other 80-90% of our health and health equity, and what can the health systems do to influence that?
The societal systems outside our hospitals and GP surgeries that are the real shapers of our health – the food, transport, education, taxation, employment, housing, urban development, trade, justice and welfare systems. If the health system is to be the champion for better population health, it must engage with these other societal systems to help them reorient more towards health. Otherwise we are missing the big picture.
In particular, the commercial sector selling unhealthy products has a massive impact on our health. About one third of our ill health and premature death is caused by just three commercial products – tobacco, alcohol and unhealthy food. Over 300,000 healthy life years are lost every year because successive governments have bowed to industry pressure and not implemented the policies, regulations, laws and taxes needed to curtail this huge toll of lost population health.
Every time a new report arrives from WHO, the Law Commission or a government inquiry, the proposed actions – which would be very effective, especially for reducing harm from alcohol and ultra-processed food – are squashed by the power those industry lobbies have over government actions. The scales are heavily tipped towards commercial profits over community health interests.
I chair the Health Coalition Aotearoa, which is dedicated to reducing the harm from tobacco, alcohol and unhealthy food. Unfortunately, there are no recommendations in the Simpson report to help us achieve this goal. The report focused on many of the ways the healthcare services can improve our health status within their 20% contribution to our overall health status, but not on the wider societal determinants that contribute the 80%.
However, the health system can still affect the wider societal systems – either directly, by leading on policies, or indirectly, by influencing the shape of policies led by other areas of government, the so-called health-in-all-policies approach.
The first direct approach means the Ministry of Health develops policies to reduce the harm from clearly unhealthy products, policies including marketing restrictions, reducing access, regulating the product content, warning labels, and pricing policies such as taxes, levies or minimum prices. These policies are all recommended in some form for tobacco, alcohol and unhealthy foods by WHO and other expert groups, but only weakly implemented in New Zealand.
This phenomenon of weak progress despite widely agreed, evidence-based recommendations is called policy inertia. It is the result of strong industry opposition, a lack of government willingness to stand up to industry, and unheard voices from the people and communities who are suffering the consequences of the harmful products. It is true that an influential health minister who battles long and hard for strong health policies can overcome this policy inertia, but such ministers are very rare indeed. The other way to redress the power imbalance over contested policies is to proactively bring the community and expert voices to the policy development table in Wellington, while at the same time excluding the commercial voices because of their serious conflicts of interest.
The Simpson review recommended the reinstatement of a public health advisory committee, but recognised this won’t be enough to create sufficient demand for policy action. It noted that a strong, coordinated network across community groups, NGOs and public health experts was “fundamental for a healthy democracy and a smart system”. The review was silent, however, on which government agency would be responsible. This key insight into what is needed for health gains was not translated into a recommendation and will fall through the cracks if it’s left up to the Ministry of Health, which has a poor track record on sector engagement for policy development.
The second, indirect approach of including health in all policies means that one of the health agencies needs to work with other government agencies to help them ensure health is considered in their policy development. This sometimes happens – for example, the Ministry of Health is working with the Ministry of Education to make sure the free lunches now being provided in some high-disadvantage schools are healthy lunches.
However, the Ministry of Health has no organised system of health impact assessments for policies and programmes in other parts of government. For example, when the government reinserted the four wellbeings (social, economic, environmental and cultural) that the National government removed from the Local Government Act, an opportunity was lost to fortify the legislation so councils and communities could have more say over the healthiness of their local environments. KFC recently backtracked on its plans to add yet another fast food outlet in Ōtara, which is already drowning in junk food. However, if it had decided to push ahead, Auckland Council would not have had a legal leg to stand on to block it.
The Simpson review has laid down the platform for debate and the 80% question needs to be answered: which authoritative body on population health will have the specific roles of supporting better policy-making, both within the Ministry of Health and across other ministries, so that societal systems are better oriented towards health?
Within healthcare itself, there is a finite budget with which to maximise its influence over its 20% slice of health status. The current health budget allocates only about 2% for public health and population prevention measures. Ask anyone from a health economist to a person in the street what it should be and you will get a much higher number. So why is our investment so heavily weighted in favour of treatment versus prevention? On the treatment side of the pressure for resources are the loud and articulate demands from patients and front-line doctors for funding the latest, expensive cancer drug, more hip operations or more hospital beds. On the prevention side are the silent voices of unvaccinated children, or people struggling under their burdens of diabetes or alcohol dependence or lung cancer that society says is their own fault.
The Simpson report clearly calls for population health and health equity to be brought back onto centre stage, where it must be if we are to make health gains. This is what the 2000 legislation that created DHBs also tried to do, but, as it always does, the pressure for personal health services, often to treat the complications of preventable disease, pushes population health prevention backstage. If we want that to change, the next government will need to enact all the Simpson report recommendations, including the far stronger role outlined for the Māori health authority, currently buried on page 173 as an “alternative plan”.
However, if we’re serious about improving health, we will need to focus on the 80% of health determined by societal systems, especially the current commercial drivers of ill health.
Boyd Swinburn is a professor of population nutrition and global health at the University of Auckland, chair of the Health Coalition Aotearoa and a board member of the Health Promotion Agency (Te Hiringa Hauora). The views expressed are personal and do not represent the University of Auckland, the Health Coalition Aotearoa or Health Promotion Agency.