The first consideration of a Minister should be the health of the people.Benjamin Disraeli, British Prime Minister, 1872
There is furious agreement.
Governments, political parties and public health advocates across Australia acknowledge that chronic disease is our greatest health challenge. And rightly so. Chronic disease is responsible for 90% of all deaths and perhaps more importantly 85% of the burden of disease. The bulk of the burden is caused by relatively few disease groups, including ‘the big two’, cancer (19% of the total disease burden) and cardiovascular disease (15%).
A costly question
The social and economic carnage caused by chronic disease is correspondingly immense, with cardiovascular disease alone accounting for some $7.7 billion a year in direct health care expenditure. Tragically, much of this human and economic impact on community and government is avoidable. As the Australian Institute of Health and Welfare points out, almost one third (31%) of the entire disease burden in 2011 could have been prevented by addressing a small number of modifiable risk factors. These included tobacco use (contributing 9% of the burden), overweight and obesity combined with physical inactivity (8.9%) and alcohol use (5.1%).
Which brings us to the question at hand: If the Australian Government were to spend an additional $100 million a year to prevent chronic disease, where best would this money be spent? This was a question put to a forum in Canberra last year, and to which I give one of many possible answers below.
Before answering, we need some caveats. First, $100 million is not, in terms of the Australian Government expenditure, a particularly large sum. Australia’s new submarine project, for example, is estimated by the Defence Department to cost more than $50 billion. With a 12-boat fleet, $100 million could potentially contribute to the cost of perhaps 2.5% of a single submarine.
Second, ‘spending’ on prevention is better described as ‘investing’ in health. Many interventions can be highly cost-effective and even cost-saving.
Third, sustained and comprehensive approaches are regarded as good practice, overcoming the piecemeal and short-term approaches that were so decried by Australia’s National Preventative Health Taskforce in its 2009 report, Australia: The healthiest country by 2020.
Considering the context
Comprehensive approaches suggest a mix of complementary interventions, some cost-dominant, some cost-effective, some experimental for which the cost effectiveness still needs to be determined. Such approaches would realistically require more than an additional investment of $100 million a year. But additional spending could be easily off-set through tax measures that not only raise revenue, but have a positive public health impact as well.
Sensible, modest and long-overdue reform of alcohol taxes, as proposed by the Foundation of Alcohol Research and Education, could put an additional $2.9 billion into the Australian Government’s coffers, allowing it to fund a comprehensive package of measures while leaving funds to also undertake ‘Budget repair’.
Finally, we also need to be mindful of the broader social determinants of health. Addressing these determinants requires higher-level approaches that need to be addressed at a whole-of-government level. These are not within the scope of this paper.
Advice is at hand
So, with these caveats in mind, where should we invest our $100 million? There are plenty of sign-posts to guide us, including the excellent burden of disease work undertaken by the Australian Institute of Health and Welfare. This collection of studies utilises the Australian Bureau of Statistics first biomedical survey, the National Health Measures Survey, conducted in 2011-12 and funded by the Heart Foundation and the Department of Health and Ageing.
In addition, there are dozens of excellent ‘best buy’ summaries, including well-known work by the World Health Organization and the Australian Health Policy Collaboration’s list of key interventions to achieve Australian ’25 by 25′ non-communicable disease targets.
We also need to be informed by the studies, including the Heart Foundation’s Heart Maps work, that looks at communities and postcodes where the greatest burden lies, including regional and rural Australia, Aboriginal and Torres Strait Islanders, those with mental health challenges, culturally and linguistically diverse groups, those without secure housing and people on lower incomes.
While many mainstream programs, such as tobacco control mass media education campaigns, can have a disproportionately higher benefit among vulnerable groups, targeted programs are often additionally necessary to achieve the greatest gains.
Australia is a world leader in tobacco control, but we have made solid investments in a more targeted approach for Aboriginal and Torres Strait Islander people, with Tackling Indigenous Smoking helping to make important reductions in (still very high) smoking rates.
What can be modified?
With these approaches in mind, we should turn to the impact of various modifiable risk factors on the population. Using the AIHW Burden of Disease supplementary report of 2011, we find tobacco continues to take the greatest toll, responsible for 9.0% of the disease burden, followed by dietary risk factors (7.2%), high body mass (5.5%), alcohol use (5.0%), physical inactivity (5.0%) and high blood pressure (4.9%).
Since then, the AIHW has published an ‘enhanced analysis’ of the impact of overweight and obesity, attributing no less than 7.0% of the disease burden to this risk factor: a considerable revision.
We should be investing our modest prevention dollars to tackle these big risk factors, not just because they have an immense impact on health, but also because they cause so many different chronic conditions.
With $100 million a year to allocate on top of existing investments, the following suggestions address leading causes of the burden of disease in Australia, support evidence-based approaches, encourages new ideas and focus on areas of highest need.
Tobacco control ($30 million a year)
While Australia is a world leader in tobacco control, with credit to all major political parties over many years, investment in mass media education campaigns is sub-optimal. While Tackling Indigenous Smoking commitments are very good, it is hard to identify how much has been allocated to mass media campaigns for the broader community over the forward estimates.
Solid tobacco tax increase over the past few years should see at least a smidgen of this additional revenue allocated to improving expenditure on mass media campaigns at rates required to have a sustained impact. At least $30 million a year should be allocated to this task.
Obesity prevention campaign ($30 million a year)
With the evidence showing that overweight/obesity is having an increasing impact on health outcomes, the need for a comprehensive approach to promote healthy weight is critical.
Importantly, the public health community in 2017 reached a consensus on what a national obesity prevention strategy should look like, with the Obesity Policy Coalition coordinating the production of the Tipping the Scales report with its eight key interventions.
The investment would be more than offset by an evidence-based health levy on sugar-sweetened beverages, which could raise around $500 million a year. The measure enjoys strong public support, especially if the funds raised are ploughed back into public health.
A comprehensive approach, as proposed in the obesity prevention consensus statement, should support a strong national food reformulation and portion control program (as supported by the McKinsey Overcoming Obesity report), a clamp down on the marketing of unhealthy food and beverages to children, mandatory use of the Health Star Rating food labelling system and an active travel strategy. A mass media education campaign, along the lines of the successful LiveLighter model, is also essential.
It would take a lot more money than $30 million a year to address obesity, but while the need is great, our bucket is small.
Physical activity action plan ($30 million)
Often referred to as the ‘Cinderella’ risk factor, the importance of physical activity for health is becoming better understood by governments across the world.
With an impact similar to that of smoking (physical inactivity is estimated to cause around 14,000 deaths a year in Australia, compared to around 15,000 for smoking, according to unpublished calculations by the Heart Foundation Data and evaluations unit Evaluation Unit), the importance of getting people to move more and sit less is now better understood by decision-makers.
There are some existing and proposed initiatives in this arena that are warmly applauded.
The Turnbull Government is investing $10 million in walking – boosting the Girls Make Your Move mass media campaign and developing a new sport strategy with an emphasis on participation. Shadow Heath Minister Catherine King committed Labor to a comprehensive $90 million national physical activity action plan at the 2016 federal election. And the Greens have promoted a national walking and cycling strategy.
Walking is particularly important. It’s accessible, social and confers a surprisingly broad array of health benefits without the need for special clothing or equipment.
Where to invest the $30 million? We already have the answer. The Heart Foundation convened a national policy consensus forum at Parliament House in late 2015 that identified nine clear areas for action. These include:
- Walking and cycling through active travel
- Urban design guidance to create liveable and active cities and suburbs
- Physical activity prescription integrated into primary care
- Media campaigns to motivate Australians to move more and sit less
- School-based programs to get children moving more and community and aged care programs to keep older Australians active.
These actions are based on the Heart Foundation’s Blueprint for an Active Australia, the Toronto Charter and the International Society for Physical Activity and Health’s Investments that Work for Physical Activity.
Again, much more than $30 million is needed, but it will make a big difference to addressing a risk factor that WHO notes is estimated to be the main cause for approximately 21-25% of breast and colon cancer, 27% of diabetes and 30% of coronary heart disease.
Public health research $5 million
This is a very specific investment in research that would focus on how to implement policies across governments that would specifically benefit vulnerable communities. It’s a modest additional investment that potentially can have a big impact on equity.
Building better approaches to public health funding ($5 million)
Importantly, the Prevention 1st Preventive Health report canvasses the idea that “the choice of funding mechanism is an important determinant of the overall efficiency of the prevention spend”.
It notes that the UK has a relatively robust model for identifying priorities for prevention spending and assessing its program impact.
“England stands alone in the countries we examined as having institutional structures in place both for assessing the cost-effectiveness for preventative interventions (through NICE) and for monitoring the effectiveness of spending on prevention through Public Health England’s public health outcomes framework,” the report states.
This final $5 million should be allocated to help point the way to a more robust funding and monitoring mechanism for public health in Australia that can also steer the way to greater certainty, transparency and sustainability of public health funding.
Together, these modest additional public health investments should make a significant contribution to reducing premature death and suffering from our leading killers while helping all Australians lead longer, healthier, happier and more productive lives.