the healthiest country by 2020
National Preventative Health Strategy –
the roadmap for action
30 June 2009
prepared by the National Preventative Health Taskforce
Australia: The Healthiest Country by 2020 –
National Preventative Health Strategy – the roadmap for action
Online ISBN: 1-74186-920-X
Publications Number: P3 -5444
(c) Commonwealth of Australia 2009
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(c) Commonwealth of Australia 2009
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NATIONAL PREVENTATIVE HEALTH TASKFORCE
The Strategy was prepared on behalf of the National Preventative Health Taskforce for the Minister for Health and Ageing, the Hon Nicola Roxon.
Professor Rob Moodie, Chair
Professor Mike Daube, Deputy Chair
Ms Kate Carnell AO
Dr Christine Connors
Dr Shaun Larkin
Dr Lyn Roberts AM
Professor Leonie Segal
Dr Linda Selvey
Professor Paul Zimmet AO
Research and writing team
Ms Meriel Schultz – Coordinator
Ms Janet Austin
Ms Tessa Letcher
Ms Yolanda Mansfield
Ms Kate Purcell
Ms Michelle Scollo
Ms Claire Tobin
Mr Brian Vandenberg
Supported by the Australian Government Department of Health and Ageing
Table of Contents
Overall table of contents ii
Chair’s foreword v
CHAPTER 1: Building preventative health in Australian communities 1
Chapter table of contents 1
Vision, purpose and call to action 3
Australia’s response to the call to action 4
The need for action 6
What we know: prevention works 11
Taking Action 13
A conceptual framework for the Strategy 28
The roadmap for prevention 32
Ensuring effective implementation 67
Conclusion: a call to action 77
Chapter References 78
CHAPTER 2: Obesity in Australia: A need for urgent action 85
Chapter table of contents 85
The case for prevention 86
Key action areas 92
Summary tables 138
Chapter references 150
CHAPTER 3: Tobacco: Towards world’s best practice in tobacco control 163
Chapter table of contents 163
The case for prevention 164
Key action areas 168
Summary tables 200
Chapter references 218
CHAPTER 4: Alcohol: Reshaping the drinking culture in Australia 233
Chapter table of contents 233
The rationale for action 234
Key action areas 239
Summary tables 266
Chapter references 275
1. Preventative Health Taskforce Terms of Reference 281
2. Preventative Health Taskforce member profiles 283
3. Formal consultations conducted by the Preventative Health Taskforce 286
4. Submissions to the Preventative Health Taskforce 288
5. Papers commissioned by the Preventative Health Taskforce 299
6. Acknowledgements 300
The National Preventative Health Taskforce was established in April 2008 and given the challenge to develop the National Preventative Health Strategy, focusing initially on obesity, tobacco and excessive consumption of alcohol. The Strategy is directed at primary prevention, and addresses all relevant arms of policy and all available points of leverage, in both the health and non-health sectors.
The Strategy is the outcome of a great deal of thinking, debate, evidence gathering and consultation across a wide range of Australians, from individuals and local communities to major organisations, corporations, NGOs and governments. This has been accompanied by international experience and evidence, as there are many countries from which we can learn a great deal.
The Taskforce acknowledges the work to date of governments at all levels, of individuals and groups leading community initiatives, of industries that want a healthier Australia, and of researchers and academics who seek to build our knowledge base.
The Taskforce has considered a rapidly growing volume of evidence, as can be witnessed in the Technical Reports and addenda available online at www.preventativehealth.org.au. Opposing and diverse views have been taken into account, and the Strategy is built on the best available evidence and experience. The Taskforce does not presume that it will not be challenged by different interest groups. Where the evidence is still developing or is hotly debated, we seek to learn by doing – to build evidence for future action.
The Taskforce invites your help in making Australia a healthier country. It is keen to hear, and to tell others, of your contribution. An online national forum for organisations, local governments, businesses and industry, community groups, families and individuals will be developed to share your commitments and plans to making Australia healthy.
The Strategy is presented with the direct intention of reaching the goal of Australia being the healthiest nation by 2020, with ambitious targets that respond to the need for urgent, comprehensive and sustained action. We have developed the strategy across three multi-year phases until 2020. Not surprisingly, many of the actions are required in the first four-year phase. The Taskforce appreciates the level of resources and the workload required to successfully implement the Strategy and reach the targets that have been set by the Council of Australian Governments. However, sitting on our hands is not an option.
National Preventative Health Taskforce
CHAPTER 1: Building preventative health in Australian communities
1. Vision, purpose and call to action 3
1.1 Making healthy choices easier choices 3
1.2 Prevention is everyone’s business 4
2. Australia’s response to the call to action 4
2.1 Feedback from consultations 4
2.2 Building on current prevention activity 4
3. The need for action 6
3.1 The burden of disease – a focus on obesity, tobacco and alcohol 6
3.2 Outcomes for Australia 10
4. What we know: prevention works 11
4.1 About prevention 11
4.2 Prevention gets results 11
5. Taking action 13
5.1 A phased approach 13
Supporting infrastructure for all phases 26
6. A conceptual framework for the Strategy 28
6.1 Influencing markets 28
6.2 Inequities in health 29
6.3 Developing effective policies 30
6.4 Investing for maximum benefit 31
7. The roadmap for prevention 32
7.1 The roadmap 32
7.2 Principles 33
7.3 Targets and indicators 33
7.4 Staging change 36
7.5 Strategic directions 38
i. Shared responsibility – developing strategic partnerships 38
ii. Act early and throughout life 41
iii. Engage communities 46
iv. Influence markets and develop connected and
coherent policies 52
v. Reduce inequity through targeting disadvantage 54
vi. Indigenous Australians – contribute to ‘Close the Gap’ 59
vii. Refocus primary health care towards prevention 62
8. Ensuring effective implementation 67
8.1 Building and sustaining infrastructure 67
8.2 National Prevention Agency 67
8.3 Social marketing 70
8.4 Data, surveillance and monitoring 71
8.5 National prevention research infrastructure 73
8.6 Workforce development 75
8.7 Future funding models for prevention 76
9. Conclusion – a call to action 77
10. References 78
CHAPTER 1: Building preventative health in Australian communities
1 Vision, purpose and call to action
This Strategy sets out a vision for Australia to be the healthiest country by 2020. To realise this vision, the Strategy provides the roadmap for a series of strategic and practical actions, to be implemented across all sectors and by all Australians between now and 2020. This is a major challenge for the nation, but the rewards will be immense in terms of lives saved, and improved health and wellbeing.
In April 2008 the Minister for Health and Ageing, the Hon Nicola Roxon MP, appointed the National Preventative Health Taskforce to develop a National Preventative Health Strategy, focusing in the first instance on obesity, tobacco and alcohol. (The terms of reference and details of membership of the Taskforce are set out in Appendices 1 and 2.)
Significant shifts towards prevention in Australia continued in 2005 driven by the Productivity Commission’s Research Report on the Economic Implications of an Ageing Australia. The Report projected future cost pressures on the healthcare system, expected as a consequence of changes to demographic ageing in Australia. In light of this projection, in 2006, the Council of Australian Governments (COAG) established the Australian Better Health Initiative (ABHI), with the aim of refocusing the health system towards promoting good health and reducing the burden of chronic disease.
The Rudd Government made a pre-election commitment in 2007, endorsing the connection between better health and economic productivity, noting the need to:
‘treat preventative healthcare as a first order economic challenge because failure to do so results in a long-term negative impact on workforce participation, productivity growth and the impact on the overall health budget.’
With the introduction of the COAG National Reform Agenda, governments identified the crucial importance of better health to economic productivity and opened the way for a new ‘whole of government’ approach to health. In particular, the recent 2009 COAG National Partnership Agreement on Preventive Health provides the largest single investment in preventive health in Australia’s history.
1.1 Making healthy choices easier choices
‘Action currently under way does not adequately reflect the magnitude of the problem. There is indeed a need for a greater sense of urgency’ (Quote from submission)
Tackling the growing personal, social and economic burden of chronic illness is imperative, especially in a country with an ageing population. Prevention is increasingly being seen as a crucial means of reducing this burden. The three priority areas for action identified by the Australian Government are:
• Reducing the growing epidemic of overweight and obese Australians
• Accelerating the decline in smoking
• Addressing the health and social harms resulting from risky drinking
Australia must significantly scale up its prevention effort in these and other areas. Making healthy choices is often difficult – and there are many barriers to action at all levels. The Strategy provides a number of priorities and actions that will help reduce these barriers and enable healthy choices to become easier. In the first instance, these actions will help people maintain or achieve a healthy weight, prevent smoking and exposure to tobacco smoke, and limit intake of alcohol to safe levels.
The Taskforce has set out a phased program which seeks to match the magnitude of the problems and the required urgency of action, while also recognising that everything cannot be done instantly. The phased approach to the Preventative Health Strategy will be challenging, but it is feasible. The extent of the problem and the benefits to be gained for the health of the community require nothing less.
1.2 Prevention is everyone’s business
‘Given the multiple social determinants of health, it is clear that a prevention agenda requires cross sectoral, multilevel interventions that extend beyond the health sector into sectors such as housing, welfare, justice, immigration, employment, agriculture, education, family and community services, Indigenous affairs and communications’ (Quote from submission)
The Strategy is for all Australians, not just governments. Throughout the Strategy, the Taskforce has identified comprehensive and staged directions that rely on mutual support between those who will benefit (individuals, families and communities) and those who can provide the infrastructure and support to enable effective action (governments, industry, the non-government and business sectors).
2 Australia’s response to the call to action
‘There are many positive changes that individuals and families can make, but if the environment in which they exist – where they work, live and play, interact and experience life – is not conducive to health, the impact of individual behaviours may be severely limited’ (Quote from submission)
In October 2008 the Taskforce released a Discussion Paper, Australia: the Healthiest Country by 2020, backed up by three Technical Reports that presented detailed international and Australian evidence about obesity, tobacco and alcohol (see www.preventativehealth.org.au).
2.1 Feedback from consultations
Formal consultations were held in 16 metropolitan and regional sites across Australia, along with many meetings and 10 roundtable discussions that aimed to understand the views of particular groups and to encourage debate on issues such as the food supply, physical activity, sport, fitness and weight loss, alcohol supply, demand and harm reduction and tobacco control. There were consultations with Indigenous Australians (including a special consultation with the National Indigenous Health Equity Council), primary healthcare providers, food and alcohol industries, the recreation, sport, fitness and weight-loss industries, and the private health insurance industry, as well as researchers, urban planners and those driving health promotion in the workplace. Consultations were also held with all state and territory governments, with representation from a wide range of portfolios (see Appendix 3).
More than 400 submissions were received from a range of individuals, organisations, associations and governments (see Appendix 4). The Taskforce also took into account submissions about prevention that had already been provided to the Australia 2020 Summit, the National Health and Hospitals Reform Commission (NHHRC) and the House of Representatives Inquiry into Obesity.
Several comprehensive papers were commissioned on topics of particular interest to the Taskforce. Information from these papers has been incorporated into the Strategy. A list of the commissioned papers and authors is at Appendix 5.
2.2 Building on current prevention activity
Prevention in health is not new. Many important preventative interventions have made a crucial contribution to improving and protecting Australia’s health over the years, and a range of valuable measures are already included in many aspects of health and other government policy. During the development of this Strategy, the Taskforce has worked in alignment with other reform processes and with other groups, including COAG through the Prevention Partnership, the NHHRC (whose expressed priorities include looking at ways of ensuring a greater emphasis on prevention across the health system), Treasury (through contribution to the Henry Review), the External Reference Group advising the National Primary Health Care Strategy, the National Indigenous Health Equity Council and the National Health Workforce Taskforce (NHWT).
The Taskforce received very positive and encouraging feedback from its consultation processes, confirming broad support for the approaches proposed in the Discussion Paper. The important themes are outlined below, and they include a range of calls for action on prevention. Such calls are in part a response to the increasingly high burden posed by chronic illnesses (such as heart disease, diabetes and some cancers), which are in large measure caused or exacerbated by lifestyle choices; for example, smoking, sedentary lifestyle and poor diet.
While the vast majority of submissions and contributions supported the approaches taken in the Discussion Paper, often seeking further and more urgent action, there were also some that disagreed or offered alternative perspectives. The Taskforce has taken account of these in developing the Strategy. There was, however, an overwhelming sense that the Strategy provides an opportunity for prevention to be at the forefront of healthcare, and that there is great anticipation of the action following its release. In developing the Strategy, the Taskforce was aware that across all the issues considered there are a wide range of views, and that there will be some differing interpretations and perspectives. The Taskforce has reached its conclusions on the basis of careful consideration of the evidence and of all the views expressed to it.
Important themes arising from consultation
• Action and leadership on preventative health is urgent and long overdue in Australia.
• A coordinated and comprehensive approach to prevention is needed, rather than the piecemeal approach adopted to date.
• Strong leadership will be needed to drive and coordinate action and achieve targets.
• Action will need strong contribution from outside as well as within the health sector, and may involve new partnerships.
• There will need to be stronger partnerships between all three tiers of government, non-government organisations, industries, the business sector and communities, as well as action by individuals and families to improve their own health.
• Action to improve health is required across a person’s lifetime, starting early in life and with an emphasis on identifying the key opportunities to influence change.
• Emphasis should be placed on the social determinants of health within the Strategy. These determinants should be linked with priorities and action.
• Achieving results will require sustained and significant investment for many years but will ultimately be cost effective and deliver benefits for individuals, families and communities as well as governments.
3 The need for action
3.1 The burden of disease – a focus on obesity, tobacco and alcohol
Obesity, tobacco and alcohol feature in the top seven preventable risk factors that influence the burden of disease (see Figure 1.1 below), with over 7% of the total burden being attributed to each of obesity and smoking, and more than 3% attributed to the harmful effects of alcohol. Along with a range of other risk factors, and accounting for their interactions, approximately 32% of Australia’s total burden of disease can be attributed to modifiable risk factors.
Keys to prevention: top seven selected risk factors and the burden of disease
Source: AIHW (adapted from Australia’s Health 2008 Table 4.1)
While the prevalence of smoking is declining (though not enough), overweight and obesity and the harmful use of alcohol are escalating. The scale and pace of efforts in all these areas must be increased.
The prevalence of overweight and obesity in Australia has been steadily increasing over the past 30 years.
If the current trends continue unabated over the next 20 years, it is estimated that nearly three-quarters of the Australian population will be overweight or obese in 2025.(4)
In only 15 years, from 1990 to 2005, the number of overweight and obese Australian adults increased by 2.8 million. Almost a quarter of Australian children are overweight or obese, an increase from an estimated 5% in the 1960s. Nearly a third of children do not meet the national physical activity guidelines. Only one-fifth of 4–8-year-olds and 5% of 14–16-year-olds meet the dietary guidelines for vegetable intake.
Recent trends indicate that the life expectancy for Australian children alive today will fall two years by the time they are 20 years old, representing life expectancy levels seen for males in 2001 and for females in 1997. This is not a legacy we should be leaving our children.
If these health threats are left unchecked, the impact on individuals and families, our healthcare systems, the economy and society more generally will be profound.
• Type 2 diabetes is projected to become the leading cause of disease burden for males and the second leading cause for females by 2023, mainly due to the expected growth in the prevalence of obesity. If this occurs, annual healthcare costs for type 2 diabetes will increase from $1.3 billion to $8 billion by 2032.
• Almost 2.9 million Australian adults smoke on a daily basis. Around half of these smokers who continue to smoke for a prolonged period will die early; half will die in middle age.
• The total quantifiable costs of smoking to the economy (including the costs associated with loss of life) were estimated at over $31 billion in 2004–05.
• There can be no cause for complacency while one-sixth of Australian adults smoke, thousands of children start smoking each year, and adult and young non-smokers alike are exposed to the dangers of passive smoking.
• The most recent national survey of drug use estimates that one in four Australians drink at a level that puts them at risk of short-term harm at least once a month. Around 10% of Australians drink at risky levels of harm in the long term. However, among young adults aged 20–29 years, the prevalence of drinking at levels for long-term risk of harm is significantly higher (16%) than among other age groups.
• The harmful consumption of alcohol causes problems for those who drink at risky levels and has repercussions across our society. Alcohol is involved in 62% of all police attendances, 73% of assaults, 77% of street offences, 40% of domestic violence incidents and 90% of late-night calls (10 pm to 2 am).
• The annual costs of harmful consumption of alcohol are huge. They consist of crime ($1.6 billion per annum), health ($1.9 billion), productivity loss in the workplace ($3.5 billion), loss of productivity in the home ($1.5 billion) and road trauma ($2.2 billion) in 2004–05.
The cost to the healthcare system alone associated with these three risk factors is in the order of almost $6 billion per year, while lost productivity is estimated to cost almost $13 billion.[8, 9]
There are further and especially important reasons for urgent action in these areas:
• ‘Close the Gap’: the burden of disease caused by obesity, tobacco and alcohol makes up a significant part of the life expectancy gap between Indigenous and non-Indigenous Australians. Similarly, a large part of the differences in health status between rich and poor Australians and between city dwellers and rural and remote Australians can be attributed to these risk factors.
• Intervening early in life is important. A relationship exists between growth and development during foetal and infant life, and health in later years. Poor nutrition, cigarette smoking and alcohol use during pregnancy can result in long-term adverse health consequences. Early life events also play a powerful role in influencing later susceptibility to chronic conditions such as obesity, cardiovascular disease and type 2 diabetes.
Since the release of the Taskforce’s Discussion Paper, many new studies have emerged, and have been reflected in updated versions of the three Technical Reports on obesity, tobacco and alcohol. Important examples are described below: