Beyond social determinants of health

In 2024, the Australian Government published an unusually large number of responses (23), to House of Representatives’ health related inquiries; however, only eight of these responses actually included a response to recommendations outlined in the reports. The remaining 15 inquiries were all met with the same response, ‘Given the passage of time since this report was tabled… a substantive Government response is no longer appropriate’. So, what were these costly inquiries and reports that the Australian Government deemed no longer pertinent to Australian people’s health and wellbeing? Disappointingly, but not surprisingly, 10 of these reports relate to or directly speak to the largest drivers of Australia’s burden of disease – social determinants of health.

Twenty years ago in a groundbreaking Social Justice Report, Aboriginal and Torres Strait Islander Social Justice Commissioner Professor Tom Calma AO (Kungarakan, Iwaidja) called for a human rights-based approach to achieving equality of health status and life expectation within a generation for Aboriginal and Torres Strait Islander peoples. Calma outlined an intersectional holistic approach of addressing systemic discrimination and cultural-social-political determinants of health, enabled by effective partnership with Aboriginal and Torres Strait Islander peoples and shared decision-making.¹ This report, followed by the groundswell of the 2007 grassroots Close the Gap Campaign heavily influenced the 2008 National Indigenous Reform Agreement (known as Closing the Gap Agreement). Concurrently, the National Health and Hospital Reform Commission (NHHRC), tasked with formulating a long-term health reform plan for Australia, outlined 123 recommendations, including 7 specific to addressing Indigenous health inequity. All recommendations were accepted, supported, or noted, and mostly implemented, except one. The one recommendation not supported by government was the recommendation to establish an independent National Aboriginal and Torres Strait Islander Health Authority.²

Internationally, the 2008 World Health Organization’s (WHO) Commission on Social Determinants of Health report echoed Calma’s call for health equity, imploring all governments to address the growing global health inequity within a generation through improvement of social determinants of health, as well as tackling inequitable distribution of power, money and resources and by acknowledging inequity through data and evaluation.³ A senate inquiry was held to inform an Australian response, with recommendations for the Australian Government to adopt the WHO Report and commit to addressing the social determinants of health in the Australian context.⁴ These expert recommendations, alongside several other inquiries into obesity, tobacco industry, childhood rheumatic heart disease, rural health and out-of-pocket costs of healthcare, remain shelved and formally or appropriately unacknowledged.

The 2009 NHHRC echoed the WHO’s call for action to address social determinants of health as foundational to a national approach to preventative health.⁵ Within its scope, the NHRRC recommended the establishment of the Australian National Preventative Health Agency which was enacted in 2011; however, following an election commitment to ‘reduce the size of government and to ensure government services are as efficient and well-targeted as possible’,⁶ 2014 saw the Coalition government abolish the Australian National Preventative Health Agency after only 3 years of operation. Despite the 2021 National Preventative Health Strategy and overwhelming evidence of social and economic benefits, Australia continues to undervalue and underspend within preventative health, spending less than one-third of Canada and less than half of what the UK spends per person. The Grattan Institute describes this policy inaction as the perfect storm of short-termism, opposition from vested interest and the challenge of coordinated action.⁷ With the recent announcement of an Australian Centre for Disease Control came hope for a single authority to take responsibility and drive strategic action in addressing the social determinants of health. These calls echoing the same recommendation made by the ignored social determinants of health senate inquiry report 10 years earlier. Aboriginal and Torres Strait Islander peoples are unfortunately familiar to the blatant ignorance of our expertise, inaction in the face of overwhelming evidence, deliberate dismantling of carefully conceived governance structures and under investment in long term solutions by successive governments, particularly when it comes to our health and wellbeing. Uncle Tom Calma outlined a clear framework and approach in 2005, which was ignored with the original 2008 Closing the Gap Agreement. In 2020 we saw a glimmer with the Priority Reforms firmly placed within the updated National Agreement on Closing the Gap. For first time, an intergovernmental agreement was informed by community consultation through partnership with the Coalition of the Aboriginal and Torres Strait Islander Peak Organisations. Yet despite this partnership, the 2024 Productivity Commission’s Closing the Gap Report⁸ clearly outlines pervasive government inaction, particularly around shared decision-making and data-sharing. In 2025, as another National Health Reform Agreement is negotiated, once again a tiny glimmer re-emerges that the NHRRC’s recommendation for Independent Aboriginal and Torres Strait Islander Health Authority may be heeded.

While the fight and advocacy for better health for Aboriginal and Torres Strait Islander peoples is not the same, neither is it that different to those advocating for long term investment in the health and wellbeing of all Australians through preventive measures. The failure of successive governments to move beyond short-termism, the failure to partner and relinquish power in decision-making and data to the people most informed on the issues is the real struggle of Australia’s health system – the political determinant.

Political determinants of health are not just the struggle and success of Aboriginal and Torres Strait Islander peoples to assert their sovereignty and right to self-determination within a settler-colonial system. Political determinants of health ‘involve the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance health equity or exacerbate health inequities’ (p. 1).⁹

Twenty years ago, Uncle Tom Calma’s Social Justice Report provided a path forward not just for addressing inequity of Aboriginal and Torres Strait Islander peoples health and wellbeing, but for all Australians. We must acknowledge health and wellbeing as a human right, address the discrimination and inequity of the health system with a holistic approach and ensure a long-term commitment with power and decision sharing by governments with empowered communities.