ADDRESSING THE SOCIAL DETERMINANTS OF DISADVANTAGE
Many of these underlying social determinants can be influenced by effective public policies and locally coordinated community action.
Having a grocery stores that sells affordable fresh foods may help people make healthier choices in the foods they eat. Better quality housing can provide healthier places to live and may reduce the prevalence of conditions such as childhood asthma.
There is substantial research and evidence on programs and initiatives that help to reduce, or even reverse, the impact of social determinants on disadvantage and inequity in our communities.
Despite this knowledge, we continue to see increasing rates of obesity, mental illness, alcohol related harm and incarceration certain disadvantaged communities and groups.
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In 2017, the Deloitte Center for Health Solutions surveyed nearly 300 health system leaders and found that while 80 percent were committed to establishing and developing processes to systematically address the social determinants of disadvantage that lead to poor health outcomes, "the activity was ad hoc, and gaps remained in connecting initiatives that improve health outcomes or reduce costs".
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One of the challenges in Australia is the complexity of government. It is often difficult for centralised governments to work with communities to identify the drivers of disadvantage.
Australia's federated system of government, involving three tiers with sometimes overlapping responsibilities, can lead to a disconnect between community (which has the expertise to understand the drivers of poor health, lower educational attainment or incarceration) and government-delivered human, health and community services that deliver the majority of programs designed to address the SDOD.
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In the field of health, the South Australian government has attempted to address this through the adoption of a 'Health in All Policies' approach which makes SDOH a core responsibility of all agencies of government, supported by a coordinating committee situated in the Premier's Department.
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However, more work needs to be done to engage communities in identifying and solving their own unique challenges, and connecting communities with the resources and authority to do so.
The proportionate impact of context on health outcomes
Too often, projects and initiatives to address the social determinants of disadvantage are poorly connected to broader public health prevention, crime reduction and educational attainment strategies or attuned to the specific circumstances of local communities and groups. This can result in limited resources being poorly utilised, and programs and initiatives competing with each other unnecessarily to achieve the same broad goals.
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One way to think about the issue is to ask: "who is the 'owner' of the problem?". Invariably, the owner of a problem is the people most affected by it - the local community or group. They have the most to gain, or lose, in how the issue is addressed. They also have the greatest expertise in the potential causes of problems and how their community, or group, is likely to work together to solve the problem effectively.
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The role of government in this framework is to establish consistent and standardised programs to address the social determinants of disadvantage, and then to empower local communities and groups with the resources and authority to define the strategies to address them.
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The question therefore is not whether a problem like food security, for example, is owned by one or more agencies of government, but rather which agency of government is best equipped to provide leadership in helping local communities or groups to resolve their problem at the local level. In determining which agencies of government is the most appropriate mentor and support for local communities and groups, the following questions might be useful:
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Who has the local and internal governmental credibility, influence, resources, skills, expertise, processes and networks to best help a community or group to address a need? and
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Who has the local capacity and positive productive relationships on-the-ground within a community or group to partner and design a solution the community will embrace as its own?
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In many cases, the answer may lie outside government.