Australia’s health: being accountable for prevention

Stronger policy and a comprehensive approach to prevention is a good investment

The global action plan of the World Health Organization (WHO) for preventing and controlling non-communicable diseases1 aims to substantially reduce the burden of premature mortality caused by cancer, diabetes, cardiovascular disease and chronic lung disease by 2025, through action on nine targets measured by 25 indicators of performance.1 As a member state of the WHO, Australia is committed to the global action plan. However, we argue that the Australian government devotes insufficient attention to health policy, funding and program implementation for effective prevention. In this article, we review Australia’s progress against national non-communicable disease (NCD) targets set in 2009, and suggest that a more comprehensive approach is required.

NCDs are responsible for nine out of ten deaths in Australia, and often reduce people’s quality of life and ability to function. Tackling the growing personal, social and national economic impact of NCDs (also referred to as chronic diseases) is imperative, particularly in a country with an ageing population. Some population groups, such as Indigenous Australians and socio-economically disadvantaged people, are affected more than others.

Many NCDs share common, preventable risk factors such as smoking, harmful alcohol use, poor nutrition and physical inactivity. They contribute to biomedical risk factors such as obesity, hypertension and high cholesterol levels. Modifiable risk factors account for a substantial proportion of the burden of disease in Australia, with, for example, high body mass and physical inactivity explaining 60% of the health loss associated with type 2 diabetes.2 Seventy per cent of mortality from cardiovascular disease in Australia has been attributed to high blood pressure, high cholesterol levels and physical inactivity.3

Preventive health efforts

Effective prevention can improve health and reduce pressure on clinical services. Australia has had some outstanding successes in areas such as smoking, road trauma and heart disease. However, we lack a sustained, comprehensive and strategic approach to prevention, together with adequate funding, coordination and monitoring. In the 2013–14 financial year, spending on public health (which includes prevention activities) was only 1.53% of total recurrent health spending, and this proportion is declining.4 This places Australia out of step with similar countries. The Organisation for Economic Co-operation and Development reported in 2011 that Australia’s spending on prevention and public health as a share of total recurrent health spending was 2.0%, much less than in New Zealand (6.4%), Finland (6.1%) and Canada (5.9%).5

Health goals and targets can provide important foci for action. The National Preventative Health Taskforce was established in 2008 to develop a National Preventative Health Strategy (NPHS). The NPHS focused on obesity, tobacco and alcohol, and set a number of targets for prevention. Also in 2009, the Council of Australian Governments (COAG) National Partnership Agreement on Preventive Health (NPAPH) set a number of complementary targets.

In addition to targets, the NPHS outlined actions, including 32 alcohol-specific actions and 27 obesity-specific actions. A review of progress against the alcohol-specific actions in 2013 by the Foundation for Alcohol Research and Education found that four actions had been completed, 18 were progressing, and no progress had been made against ten actions.6 With respect to the obesity actions, a similar recent analysis by the Obesity Policy Coalition found that of these three had been completed, 17 were progressing and no progress had been made against seven (Jane Martin, Obesity Policy Coalition, personal communication).

The recommendations of the NPHS included establishing the Australian National Preventive Health Agency, which was set up in 2011, but abolished in June 2014. The NPAPH was also abolished in 2014, which resulted in the removal of $374 million of funding to the states. In the context of substantial policy change, and disinvestment in prevention, it is timely to review the progress made against the NPHS and NPAPH goals. This review is shown in the Box.

What needs to change?

With the exception of tobacco control, the data suggest there is little or no progress being made in preventing and controlling risk factors for chronic diseases in Australia.

Failure to make progress in relation to poor nutrition, physical inactivity and harmful alcohol use is linked to a failure of implementation. Expert advice about these risk factors has been sought and obtained by many governments, but implementation of expert recommendations has often been lacking.

Despite government concern about the sustainability of the health system, Australia is not currently investing significantly in disease prevention. Assessment of progress against national goals and targets from 2009 suggests that Australia is failing to take adequate steps to reduce these modifiable risk factors, although some progress is being made with Indigenous child health.

Our country is a global leader in tobacco control, and this has generated considerable benefits for the population, health system, and economy. A comprehensive approach, including taxation to make tobacco products more expensive, media campaigns, regulation of tobacco products and targeted interventions for vulnerable groups has contributed to the reduction in smoking. Sustained bi-partisan commitment has been important to our success in tobacco control.

The reduction in the prevalence of smoking in Australia has occurred in the face of considerable opposition from tobacco companies. Progressive undermining of evidence-based policy by unhealthy commodity industries,13 and weakening of public health approaches to chronic disease prevention is common in Australia and other countries.14

Comprehensive and courageous approaches to other risk factors, such as poor nutrition, physical inactivity and alcohol would significantly benefit the health of Australians. Evidence-based interventions, including taxation, media campaigns, regulation of unhealthy products and targeted interventions could reduce the chronic disease burden in this country,15 and hence the pressure on our health system. Often, these are also the most cost-effective interventions, and a number are cost-saving. Improving diet and nutrition presents a different set of challenges than do single-risk-factor problems such as smoking or excessive salt intake. However, it is important that diet and nutrition are tackled, given that most Australian adults are overweight or obese, and (unlike England and the United States) rates have continued to rise in Australia.16 All interventions, and their impact on NCDs and risk factors, should be rigorously evaluated.

Continuity and progressive change towards improved health are important. Taking on the problems of tobacco and the road toll has involved many governments implementing a range of actions over decades. Many of the states and territories are active in the area of preventive health, and the federal government is currently developing a National Strategic Framework for Chronic Conditions. The COAG Community Care and Population Health Principal Committee may provide a forum where a preventive health agenda can again be taken forward.

Conclusion

Australia invests less in prevention than do other comparable countries, and our investment is declining. The burden of NCDs is high; more than seven million Australians are living with a chronic condition, and we are failing to meet most of the national targets set by COAG and the NPHS in 2009.

NCDs have a high personal, social and national economic impact. If we seek to achieve significant reductions in the burden of chronic disease in Australia, sustained, comprehensive and courageous approaches are required.