We know that the social and environmental conditions in which we live can significantly affect our health. Yet, social determinants of health are rarely the focus in our initial contact with health and care systems about a health issue. These contacts often occur too late – when people are already sick and in crisis – and the focus is too often on treatment and triage rather than prevention.
We have achieved increased life expectancy and improved health outcomes globally, but appear to have reached a point of diminishing returns. Countries continue to spend more on healthcare every year1 as a modern health crisis featuring chronic diseases escalates, fuelled by societal factors and individual behaviours2. Indeed, the impact of social determinants of health on healthcare costs is beginning to outweigh the impact of health factors alone.
Research suggests that clinical care can address only 20 per cent of a person’s overall health and wellbeing; the greatest gains, especially for those at highest risk of poor health, come from action on their social determinants of health3.
The time has come to focus on earlier prevention and address these influential factors.
Although in this series of articles we talk about the social determinants of ‘health’, we know that these same social determinants have an impact on many different aspects of life. Here, we are considering the health outcomes that are influenced and can be improved, likewise, we can also consider the housing outcomes, or the education outcomes of the people and their families.
Australia’s efforts to address social determinants of health began decades ago4 and have achieved critical outcomes in areas such as childhood vaccinations, compulsory seatbelts, screening for bowel and breast cancer, tobacco legislation and gun control. Some initiatives have had success; however, progress overall has been patchy and not implemented at the appropriate scale, often due to the challenges of Australia’s federated governance and funding model, disconnected datasets, short-term political focus and poor health literacy.
Advocacy on social determinants of health has struggled to secure the broad policy changes envisaged in key documents by the World Health Organization’s Commission on Social Determinants of Health5.
The findings of a new global survey by PwC’s Health Research Institute, outlined in Action required: the urgency of addressing social determinants of health, tell us that the social determinants of health have particular effects on Australians.6 Relative to other nationalities surveyed, more Australians selfreported poor health (14 per cent vs 9 per cent) and reported visiting a healthcare provider in the last 12 months (90 per cent vs 83 per cent).7 However, Australians interviewed for this research were likely to believe that individuals themselves are responsible for their own social determinants of health (52 per cent vs 41 per cent in other countries) and were less likely to discuss these determinants with their healthcare provider (44 per cent vs 36 per cent)8.
More broadly, Australians surveyed were also less likely than other nationalities to use or access support from social services (28 per cent of Australians vs 41 per cent in other countries). Australians also identified mental health and a lack of sleep to be among the chief barriers to a healthy lifestyle.9
Health disparities between the better and less off are well documented. The contrast between Australia’s Aboriginal and Torres Strait Islander peoples and their non-Indigenous counterparts on all health statistics remain stark,10 with an estimated gap of approximately 17 years between Indigenous and non-Indigenous life expectancy.11 In addition to this, socio-economic disadvantage, associated with chronic stress, increases vulnerability to high-risk health behaviour and chronic disease. For example, the 20 per cent of Australians residing in the lowest socio-economic areas are 1.6 times more likely than the 20 per cent in the highest socio-economic areas to have two or more chronic health conditions, such as heart disease and diabetes.12
These health inequalities demonstrate that social determinants of health have complicated feedback effects that can compound and entrench disadvantage. Advocates argue that a lack of education limits employment and life opportunities, leading to income constraints that often translate to hardship and reduced access to healthcare and nutritious food. Hardship induces stress and poor mental health, which in turn leads to dysfunctional coping patterns involving substance abuse and overconsumption of unhealthy foods.
Failure to address social determinants of health – and by extension chronic disease – will have enormous social and economic consequences. Today, a third of Australia’s disease burden is caused by factors that are preventable, such as smoking, excessive alcohol consumption and insufficient exercise.13 Clinical treatment alone is no longer sufficient for effective healthcare. Healthcare providers will prescribe drugs to patients, only to watch them grow more ill – not because of treatment failure – but because of the broader social factors of diet, sleep, mental health, work and exercise.
Take obesity as an example. Among Organisation for Economic Co-operation and Development (OECD) member countries in 2018, Australia had the eighth highest proportion of adult population who are overweight: roughly 63 per cent of our adults were either overweight or obese, accounting for seven per cent of Australia’s total disease burden.14 The prevalence of obesity in our country has nearly tripled since 1975; in a three-year period alone (2014–2017) there has been a 10 per cent increase.15 Given its known links to a slew of chronic health problems (including high blood pressure, diabetes, high cholesterol, cancer and sleep disorders), obesity – if unaddressed – will eventually overwhelm our health system.
The broader economic implications of failing to address social determinants are significant. According to the Australian Institute of Health and Welfare, Australians with chronic disease took an average 0.48 days off work due to illness, compared with 0.25 days by those without chronic disease. The overall loss to the workforce associated with chronic diseases amounts to around half a million person-years.16
Conversely, taking action will lower costs for individuals and the public purse. A study cited in Australia’s Health estimates that if action were taken on social determinants to close the health gap between the most and least disadvantaged Australians, half a million people could be spared chronic illness: this translates to $2.3 billion in annual hospital costs saved and 5.3 million pharmaceutical benefits scheme prescriptions reduced.17 The OECD estimates that if there is a 10 per cent increase in healthier lifestyles, Australians will gain 2.6 months of life expectancy.18
The costs of inaction are inescapable. Much is at stake, and relies on us starting to think innovatively and more radically about how we may address those societal issues with tangible health impacts. All stakeholders (governments, health systems and users) have a role to play.
However, the solution lies not simply in spending more money. What is required is a multifaceted and nuanced approach, as shown in the case of Japan. Despite having the world’s oldest population by country (26.7 per cent of its population are aged 65 and over),19 Japan spends a similar proportion of its GDP on healthcare (10.9 per cent)20 to that of Australia (10.3 per cent GDP),21 possibly and partly explained by the fact that only 25 per cent of its population are obese (note that their per capita sugar consumption is 17.2 kg compared to Australia at 49.2 kg).22 Therefore, the solution is not solely in more health funding; the social and behavioural factors at play require multi-pronged strategies.
What constitutes social determinants of health is widely acknowledged, as is the need for effective action.
Current initiatives, here and overseas, point the way. The US is employing technology such as NowPow,23 which optimises analytics to screen patients for social determinants of health and connects them to relevant local resources to address those issues. This strategy employs a whole person care model across whole communities. According to the data in the global PwC report, Australians are less likely than other nationalities to use technology to support their health care, and are less likely to interact with or access social services. The potential for technology-based approaches to engage health consumers has yet to be fully explored.
As governments demand evidence-based outcomes for the money they are spending, forward-thinking leaders need to seize the opportunity to influence social determinants of health to produce better outcomes for all. Stakeholders in our health system need to build collective will, collaborate and establish a coherent framework that addresses social determinants of health. Non-traditional health partners, including those with expertise in data analytics and technology as well as those communities at higher risk, need to be brought into the fold to ensure that programs are grounded in the reality of people’s lives and work.
Already, examples of the whole person care model to enact proactive change – not driven by governments but by other players – have achieved impressive results. For instance, UnitedHealthcare in the US invested US$400 million in affordable housing to mitigate health problems associated with homelessness. They built over 4,500 homes as of March 2019, with early success: in one state, UnitedHealthcare registered a 50 per cent drop in total cost of health care for members enrolled in its housing program.24
Our report, Action required: the urgency of addressing social determinants of health, suggests five bold steps that healthcare systems and governments can take to address social determinants of health and tackle health inequalities in Australia.
Effective change will only come from a combined cross-industry effort, led by a convener who can help bring partners across the system together to demonstrate the long-term benefits for each stakeholder of preventing – not just managing – illness.
Governments or community organisations could act as the convener, driving the communication and narrative to bring multiple organisations and actors together. From a government perspective, a key challenge is to maintain this effort through election cycles and changes of government – particularly important given the differing political cycles across Australia.
However, it is important that such an approach is not perceived as a ‘nanny state’ approach. Instead, collaboration within and across sectors is required (see Figure 1). Research to identify those champions in the communities and/or organisations who are respected by target groups should be undertaken, so that their buy-in may be secured.
Figure 1: Cross- and within-sectoral collaboration to address social determinants of health
There are strong examples in Australia of working together to combine health and non-health initiatives to positively benefit communities. NSW Health’s Housing for Health program assessed and repaired or replaced health hardware so that houses for Aboriginal communities are safe and can support healthy living. The program has been shown to significantly reduce rates of hospital activity for infectious diseases (the rates among those in the program were 40 per cent lower than for the rest of the rural NSW Indigenous population, where the program was not implemented).25
Once coalitions are built, the partners in the coalition must harmonise the various workplaces with different missions, incentives and perspectives so that common goals can be achieved. Health consumers can rightly expect that their care is integrated and seamless. However, approximately one-third of the respondents in PwC’s global survey indicated that there was scope for healthcare and social services to be better connected.
Predictive analytics can be used to consider both individual behaviour and population behavioural trends. While not ignoring those who are diagnosed with chronic illness, by identifying the early warning signs, people at risk of chronic disease can be assisted to avert the condition through behavioural science, machine learning and simulation modelling. Feasibility studies of such initiatives will enable us to identify those areas and communities to target so that less time and money are wasted chasing ineffective interventions.
New Zealand, for example, applied data analytics to develop a ‘social investment’ approach that identifies those groups to target with earlier interventions, to improve overall wellbeing and reduce the need for social welfare programs over their lifetime.26 Similarly, the Australian Priority Investment Approach to Welfare uses actuarial analysis to estimate overall future lifetime welfare costs, leading to better investments earlier in a person’s life to improve quality of life and employment prospects, while reducing government costs of future healthcare.27
Strategies that target social determinants of health must be grounded in the way people live and work. Retailers, technology providers, home health workers and educators could provide new pathways through which to engage consumers. Bringing others, particularly individuals who are the target of policy efforts on the journey is important: as outlined earlier, Australians surveyed in PwC’s research are more inclined than their overseas counterparts to believe that they alone must manage their particular social determinants of health. Attention must be paid to the real-world situation of the community being targeted; for example, tackling obesity in Sydney’s Inner West may require a very different approach to that in Perth with more cyclical economies and therefore more transient population. What works for one may not work for the other.
Some Australian community service providers are already applying this approach. For example, cohealth, a large community health service provider in Victoria, works with atrisk groups during extreme weather events. It recognises the need to address climate change as a health threat, conducting service checks on homeless people, public housing residents and people with mental illness during heatwaves to ensure they can take steps to stay safe.28
The success of any social determinant of health strategy ultimately depends on the response of the targeted community. Those carrying out the intervention must have local credibility and knowledge to work in the area so that trust among the target cohort can be built.
Successful intervention campaigns that target social determinants of health are exercises in continuous improvement in which experience, data and insights are gathered and fed back into the system. Feedback reveals where partners need to improve capabilities for identified social determinants of health or strengthen particular processes, and enables the refinement of strategies.
Technology can play a further role in the delivery of some of these initiatives, especially when combined with big data; for example, Lucina Health in the US employed artificial intelligence to reduce pre-term births by 13 per cent.29 Our regular use of smart phones makes them ideal delivery points for sharing information that people can engage with, such as the self-management Gateway diabetes app developed by Western Sydney Diabetes to enable sufferers to self-educate, monitor and manage their illness.30
We are faced with a genuine crisis of chronic diseases, and it is no longer feasible to expect that clinical care alone can solve the challenge of our increasing healthcare burden. It is apparent that health services are disproportionately relied upon to manage health problems having social causes, against a backdrop of an 11 per cent year-on-year increase in emergency department activity.31
It is critical that leaders understand the serious consequences of not addressing social determinants of health. By investing earlier in strategies that target social determinants of health, such as helping people with housing, promoting exercise behaviour and providing mental health support and better access to affordable treatment, governments and health systems stand to save money in the long term and, more importantly, improve health outcomes for all.
1 The Business Research Company 2019, Healthcare global market opportunities and strategies to 2022, accessed 10 July 2019, https://www.researchandmarkets.com/reports/4787550/healthcare-global-market-opportunities-and
2 OECD 2017, Health at a glance 2017 – OECD indicators, accessed 15 July 2019, https://www.oecd.org/els/health-systems/Health-at-a-Glance-2017-Chartset.pdf
3 PwC US 2018, The case for intervening upstream: why addressing social determinants of health is the right thing to do, for your mission and your business, accessed 15 August 2019, https://www.pwc.com/us/en/industries/health-services/case-for-intervening-upstream.html
4 Turrell G et al. 1999, Socioeconomic determinants of health: towards a national research program and a policy and intervention agenda, accessed 30 August 2019, https://eprints.qut.edu.au/585/
5 2008, Closing the gap in a generation: health equity through action on the social determinants of health. Final report, accessed 15 September 2019, https://www.who.int/social_determinants/thecommission/finalreport/en/
6 The survey was conducted across eight countries (Australia, China, Germany, India, Japan, UAE, UK and US).
7 PwC Global 2019, Action required: the urgency of addressing social determinants of health, accessed 15 August 2019, https://www.pwc.com/gx/en/industries/healthcare/publications/social-determinants-of-health.html
8 The survey found that, relative to respondents in other countries, Australian respondents were approximately 20 per cent less likely to have discussed social, economic, behavioural and/or environmental factors with their healthcare providers. See PwC Global, 2019, Action required: The urgency of addressing social determinants of health, accessed 15 September 2019, https://www.pwc.com/gx/en/industries/healthcare/publications/social-determinants-of-health.html
9 PwC Global 2019, Action required: the urgency of addressing social determinants of health, accessed 15 August 2019], https://www.pwc.com/gx/en/industries/healthcare/publications/social-determinants-of-health.html
10 For example, the 2001 unemployment rate among Indigenous Australians was 20 per cent – three times higher than that for non-Indigenous Australians. See Australian Bureau of Statistics 2001, Population characteristics, Aboriginal and Torres Strait Islander Peoples, 2001, cat. no. 4713.0, ABS, Canberra.
11 Trewin D & Madden R (Australian Bureau of Statistics and the Australian Institute of Health and Welfare) 2005, The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples 2005, cat. no. 4704.0, accessed 15 September 2019, https://www.aihw.gov.au/reports/indigenous-health-welfare/health-welfare-australias-indigenous-peoples-2005/contents/table-of-contents
12 Australian Institute of Health and Welfare, Australia’s health 2016, accessed 22 September 2019], https://www.aihw.gov.au/reports/australias-health/australias-health-2016/contents/determinants
13 Australian Institute of Health and Welfare, Australia’s health 2016, accessed 22 September 2019], https://www.aihw.gov.au/reports/australias-health/australias-health-2016/contents/determinants
14 Australian Institute of Health and Welfare, Overweight and obesity: an interactive insight, accessed 20 July 2019, https://www.aihw.gov.au/reports/overweight-obesity/overweight-and-obesity-an-interactive-insight/contents/time-trends
15 World Health Organization 2018, ‘Obesity and overweight’, accessed 15 September 2019, https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
16 Australian Institute of Health and Welfare 2009, Chronic disease and participation in work, accessed 22 September 2019, https://www.aihw.gov.au/reports/chronic-disease/chronic-disease-participation-work/contents/summary
17 Australian Institute of Health and Welfare 2018, Australia’s health 2018, p.181, accessed 15 September 2019, https://www.aihw.gov.au/getmedia/7c42913d-295f-4bc9-9c24-4e44eff4a04a/aihw-aus-221.pdf
18 OECD 2017, ‘Chapter 2 What has driven life expectancy gains in recent decades? A cross-country analysis of OECD member states’, in Health at a glance 2017, accessed 5 October 2019, https://www.oecd-ilibrary.org/docserver/health_glance-2017-5-en.pdf?expires=1573189496&id=id&accname=guest&checksum=6C3D5C06B4BFBD9FF7151AFED100F6FD
19 World Population Review 2019, ‘Japan 2019’, accessed 20 July 2019, http://worldpopulationreview.com/countries/japan-population/
20 The World Bank 2019, ‘Current health expenditure’, accessed 18 July 2019, https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS
21 Australian Institute of Health and Welfare, ‘2.2 How much does Australia spend on health care?’ in Australia’s health 2018, accessed 15 September 2019, https://www.aihw.gov.au/getmedia/941d2d8b-68e0-4883-a0c0-138d43dba1b0/aihw-aus-221-chapter-2-2.pdf.aspx
22 Malmö University n.d., ‘Sugar consumption WPRO’, accessed 25 July 2019, https://www.mah.se/CAPP/Globalsugar/Sugar-Global-Data/Sugar-Consumption-WPRO/
23 NowPow 2019, NowPow website, accessed 10 October 2019, https://www.nowpow.com/
24 LaRock Z 2019, ‘UnitedHealthcare and the AMA are developing new billing codes for social determinants of health’, Business Insider, April 4, accessed 15 September 2019, https://www.businessinsider.com/unitedhealthcare-ama-social-determinants-of-health-project-2019-4/?r=AU&IR=T
25 NSW Health 2019, ‘Housing for health’, accessed 15 September 2019, https://www.health.nsw.gov.au/environment/aboriginal/Pages/housing-for-health.aspx
26 New Zealand Government, Social Investment Agency 2019, Social Investment Agency website, accessed October 2019, https://sia.govt.nz/
27 Australian Government, Department of Social Services 2018, ‘Australian Priority Investment approach to welfare’, accessed 10 October 2019, https://www.dss.gov.au/review-of-australias-welfare-system/australian-priority-investment-approach-to-welfare
28 cohealth 2017, Cohealth report 2017: creating connections, accessed 22 September 2019, https://www.cohealth.org.au/wp-content/uploads/2017/11/cohealth-report-2017.pdf
29 Barber G 2019, ‘How AI and data-crunching can reduce preterm births’, Wired, 26 March, accessed 22 September 2019, https://www.wired.com/story/how-we-reproduce-premature/
30 Western Sydney Diabetes 2019, ‘Western Sydney Diabetes Gateway’, accessed 25 September 2019, https://www.westernsydneydiabetes.com.au/framework-for-change/enhanced-management/western-sydney-diabetes-gateway
31 Australian Institute of Health and Welfare 2018, Emergency department care 2017–18: Australian hospital statistics, Health Services Series No. 89, accessed 15 September 2019, https://www.aihw.gov.au/getmedia/9ca4c770-3c3b-42fe-b071-3d758711c23a/aihw-hse-216.pdf
National Health & Wellbeing Leader, NSW, PwC Australia
Tel: +61 409 984 935
Manager, PwC Australia
Tel: +61 02 8266 0000