1 Changing Government Process to Improve the Social Determinants of Health Brad Crammond Monash University Gemma Carey ANU

Social Determinants ‣ We all know that many of the determinants of health fall outside the health sector 2 The obvious bit

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) 3

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 4 Joined-Up Government: Public Health Style

Non-Health Sector 5 ‣ Non-Health departments have been resistant to this imposition of tasks and responsibilities The Less Obvious Bit

Two Prominent Processes 6 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

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 7 In the Public Policy Literature

What We Did ‣ Searched the Public Policy literature for all empirical evaluations of joined-up government 8 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

PRISMA Diagram 9 It must be true because it’s in a flow chart

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 10 Summary of Results

How Does SDH Stack Up? 11 Operational Level ‣ Target Multiple Levels: ‣ Strategic Government ‣ Managerial ‣ Practitioner ‣ Community HiAP ‣ Managerial Fairness Agenda ‣ Strategic Government

How Does SDH Stack Up? 12 Context Top Down & Bottom Up Decentralised Control Design for purpose AND context Top Down only HiAP Fairness Agenda Top Down only Centralised Control Embed health in all policies (only purpose) Promote equity in health (only purpose)

How Does SDH Stack Up? 13 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

How Does SDH Stack Up? Not particularly well 14 Summary

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

16 Questions?