Writing in The Age earlier this month, Professor Rob Moodie gave the Australian Federal Government a failing grade for its efforts in non-communicable disease prevention. According to Professor Moodie, Australia’s preventive health agenda ‘is in serious trouble’ and ‘there’s a grave risk of it disappearing altogether.’
Professor Moodie’s assessment draws upon a recent report from the Mitchell Institute of Health and Education Policy at Victoria University, authored by Sharon Wilcox. This report maps out the social, economic and health costs of chronic diseases to the Australian community, and identifies evidence on the cost-effectiveness of interventions to prevent chronic disease (a second report identifies strategic priorities for taking action in preventive health). This blog post uses the Mitchell Institute’s report as the basis for an assessment of Australia’s progress in NCD prevention, focusing on the Federal Government’s response to the World Health Organisation’s (WHO) Global Action Plan for the Prevention and Control of NCDs, and the government’s response to the report of the National Preventive Health Taskforce in 2009.
The Global Action Plan for the Prevention and Control of NCDs 2013-2020
In September 2011 the United Nations devoted a high level summit to NCDs, which led to the adoption of the Political Declaration on the Prevention and Control of Non-Communicable Diseases. In 2012 the WHO set the global target of a 25% reduction in premature NCD mortality by 2025 (the ’25×25′ goal), and a year later it adopted the Global Action Plan for the Prevention and Control of NCDs 2013-2020. The Global Action Plan provides a road map and menu of policy options for states and other actors to reduce the burden of NCDs. It also sets out a global monitoring framework, including nine voluntary global targets and 25 indicators for tracking progress towards achieving the voluntary targets, with reporting due in 2015 and 2020. The action plan anticipates that states will develop policies and set national targets for chronic disease prevention, and monitor their progress against agreed indicators.
The National Preventative Health Taskforce
In 2008 the Federal Labor Government established the National Preventive Health Taskforce (NPHT), and charged it with developing strategies to tackle the health challenges posed by tobacco, alcohol, and obesity. Following a process of consultation and review, the Taskforce released its final report in September 2009, entitled Australia: The Healthiest Country by 2020. The report comprised five documents, and put forward 136 recommendations and 35 areas for action, focusing on preventive measures for tackling obesity, tobacco and alcohol, as well as developing critical prevention infrastructure.
The Taskforce set four main goals for prevention by 2020, and identified seven strategic directions for effective implementation of its recommendations, including shared responsibility between different government and non-government actors; engaging communities; influencing markets and developing connected and coherent policy; reducing inequality; ‘closing the gap’ for Indigenous Australians and refocusing primary care towards prevention.
The Taskforce proposed action that encouraged individuals to adopt healthy lifestyles, but also targeted the social, cultural, and economic environments that shape individual choices on tobacco, alcohol, and unhealthy food consumption. Using a phased approach, the report recommended the introduction of a range of measures to reshape unhealthy environments, including: interpretive food labelling on packaged foods and fast-food restaurant menus; restricting food advertising to children; expanding restrictions on tobacco promotion and mandating plain packaging; protecting young people from exposure to alcohol advertising, and introducing a minimum floor price for alcoholic beverages.
In 2010 the Federal Government released its response to the Taskforce’s report, called Taking Preventive Action: A Response to Australia: The Healthiest Country by 2020. The government addressed 68 of the Taskforce’s recommendations, and considered a further 49. The government identified 15 recommendations as the responsibility of state and territory governments, and stated that four other recommendations were not consistent with government policy. The final sections of this post discuss the government’s response to the NPHT’s recommendations for specific initiatives related to obesity, tobacco and alcohol.
In relation to preventative health infrastructure, the government had established the National Partnership Agreement (NPA) on Preventive Health prior to the release of the Taskforce’s final report, to which it allocated $872.1 million for investment in prevention initiatives, including community-based programs and local policies that support healthy eating and physical activity. States and territories also agreed to report on progress in reducing the prevalence of unhealthy weight, smoking, physical inactivity and poor nutrition through the NPA.
The government established the Australian National Preventive Health Agency (ANPHA) in response to the NPHT’s report, an independent statutory authority that was to coordinate the government’s response to the report of the NPHT, and which was funded through the NPA. The work of the ANPHA included monitoring and evaluating national prevention policies and programs; advising COAG on national priorities and options for preventative health; administering national programs, and facilitating national partnerships, and advising on national infrastructure for surveillance, monitoring, research and evaluation.
Australia’s 2014 report on implementation of the Global Action Plan
Australia is a signatory to the WHO’s Global Action Plan on NCD Prevention, and made submissions contributing to its development. Australia also provided information in 2010 and 2014 on its capacity to address chronic diseases.
In 2014, Australia self-assessed its capacity to respond to chronic diseases as relatively strong, on the basis that it had a national systems response to NCDs, an operational NCD unit within the Department of Health, and a multisectoral national policy on NDCs, accompanied by policies on specific NCD risk factors – the harmful use of alcohol, physical inactivity, unhealthy diets, and tobacco use. However, the government indicated that it did not have an NCD surveillance and monitoring system to enable reporting against the nine global NCD targets.
The Mitchell report concludes that there is a lack of comprehensive, public reporting on how well Australia is tackling NCDs. Australia has established targets and indicators in line with its commitments under the Global Action Plan, via the NPA on Preventive Health and the National Health Performance Authority’s Performance and Accountability Framework. The latter identifies indicators against which the performance of public hospitals and primary health care organisations are measured, some of which relate to the risk factors for NCDs. However, together these amount to a relatively narrow suite of indicators. Despite the Global Action Plan including measurable targets for six key risk factors, Australian indicators focus on smoking, physical activity, body weight and the consumption of fruits and vegetables, excluding targets for tackling harmful alcohol use, reducing salt intake, and blood pressure.
The NPA on Preventive Health required states and territories to provide reports outlining performance against benchmarks as at 30 June 2013 and 31 December 2014, but there was no requirement for the reports to be made public, thus significantly reducing the accountability of the targets, according to the Mitchell Institute report. The COAG Reform Council had responsibility for monitoring the performance of various national partnership agreements in Australia, but it did not publish any analyses of progress under the NPA on Preventive Health. The Council’s final report on the National Healthcare Agreement described data for two of the performance benchmarks in the NPA, noting that smoking rates had fallen significantly, but not sufficiently to meet the benchmark of reducing smoking rates to 10% by 2019. The report also mentioned that there was no significant change in the proportion of adults or children at a healthy body weight between 2007-08 and 2011-2012.
Two steps forward and one step back: rescinding prevention funding and abolishing infrastructure
Australia’s capacity to address NCDs is critically impaired by reforms under the Federal Abbot Liberal Government, which has dismantled prevention infrastructure introduced by the previous Labor government in response to the report of the NPHT, and it has also rescinded funding for prevention initiatives. In its 2014-15 Budget, the government indicated that it would:
- Abolish the COAG Reform Council;
- Abolish the ANPHA; and
- Cease funding the NPA on Preventive Health
These changes mean the loss of $386 million in funding for various prevention agreements made between the Federal Government and the states, and imply that there is no longer dedicated, specific national funding for the prevention of chronic disease. The status and commitment of governments to targets under the NPA on Preventive Health is now uncertain, and the abolition of the NPA and the ANPHA remove key mechanisms for coordinating state and Federal Government action on preventive health. The abolition of the ANPHA and the COAG Reform Council also critically impairs national monitoring and reporting on targets for the prevention of chronic diseases.
The Mitchell report notes other limitations in the Federal Government’s response to prevention, including the absence of a comprehensive, coordinated policy framework for prevention, and a lack of current estimates or recent trend data on the morbidity and mortality rates associated with chronic diseases (although it notes that there has been some investment in new research and expanded datasets, including the expansion of the Australian Health Survey in 2011-12 to include additional data on nutrition, physical activity and biomedical measures).
A failure to take action on many of the NPHT’s recommendations
The Federal Government has failed to act on many of the recommendations for prevention initiatives from the NPHT in relation to reducing obesity, tobacco use and excessive alcohol consumption, which were meant to accompany the expansion of government infrastructure for prevention. There were some promising first steps following the Taskforce’s report, including an increase of 25% in tobacco excise from April 2010; harmonising tax rates for alcopops with other spirit-based drinks, and the introduction of tobacco plain packaging laws, which took effect in 2012. However, many of the NPHT’s other recommendations have not been implemented, including greater restrictions on promoting alcohol at times or locations where young people are likely to be exposed to such promotions, and the introduction of health impact assessments by governments across all policies.
My own research, undertaken together with Professor Roger Magnusson, shows that where the government has acted on the NPHT’s recommendations, it has often chosen the weakest regulatory option available. The Federal Government encouraged the food industry to create its own voluntary codes on marketing food to children, despite the Taskforce recommending legislation that banned unhealthy food promotions before 9pm on television. The government supported a voluntary ‘health star rating system’ for food labelling, giving in to industry lobbying against the traffic light labelling system proposed by health advocates. Through the Food and Health Dialogue the government has established a platform for voluntary collaboration between industry, government and public health organisations on a program of product reformulation, which, although promising, lacks transparency and accountability.
The government remains committed to industry engagement and voluntary action, despite evidence that such initiatives produce very limited improvements at best, and that many such programs lack the design features of successful voluntary programs.
Where to from here?
The Federal Government’s inaction on NCDs is frustrating, because much of this burden of death and disease is preventable, and often at relatively little cost. The risk factors for NCDs are well known, and the WHO has identified series of “best buys” for tackling NCDs, i.e. effective, feasible policies that are affordable for most countries. Australian research has also evaluated the cost-effectiveness of a suite of preventive measures, and has identified promising opportunities for action, including increasing taxes on alcohol and tobacco by 30%, taxing unhealthy foods by an additional 10%, and mandatory limits for the salt content of processed food.
Many of these measures require legislative or regulatory reform in order to be implemented by government. Legislative change aimed at NCD prevention is often put into the ‘too hard’ basket in Australia, with even those supporting public health reforms claiming that it can’t be done. But many countries are experimenting with novel legislative and regulatory measures to address NCDs, including mandatory limits on the salt content of processed foods in South Africa, co-regulatory restrictions on junk food marketing to children in the United Kingdom, and a one peso per litre tax on soft drink in Mexico.
These examples show that strong government intervention to prevent NCDs is not outside the realm of possibility, and that Australia is fast becoming a ‘laggard’ in NCD prevention, despite its world-class track record in tobacco control. Future blog posts will further explore Australia’s efforts in chronic disease prevention, and identify avenues for action, including novel forms of regulation aimed at promoting healthy lifestyles, and legal mechanisms for strengthening existing voluntary initiatives favored by the Federal Government.