Social

As we digest the results of the Federal election the Social Determinants of Health Alliance (SDOHA) vows to maintain its commitment to working towards a healthy Australia for everyone.

Prime Minister Scott Morrison in his victory speech pledged that he would work on policies that ‘will keep Australians together’. With demonisation of people on the basis of race, religion, gender, sexuality and income level all too common in the election campaign, and recent years, SDOHA urges the Prime Minister to deliver on this commitment.

We know that the biggest drivers of health outcomes are the conditions in which people are born, grow, live, work and play. Investing in them is good for society, for the economy and for people’s physical and mental health.

Reducing poverty, addressing racism, stigma and discrimination, ensuring secure and affordable housing for everyone, ensuring health care is accessible to everyone, acting on climate change and improving education and employment will create the environment that promotes good health and reduces health inequities. Regrettably, none of these policies featured in the Government election platform.

SDOHA recognises that the election result means we need to redouble our efforts to achieve a healthy, equitable and compassionate Australia.

Some positive gains have come out of the campaigning and efforts of many individuals and organisations in the lead up the election, and over many years. The urgent need for an increase in the Newstart Allowance now has majority public support. The majority of voters want more action on climate change. And the connections between climate change and health are much better understood.

We also know that many more understand the fundamental importance of the social determinants of health. A number of health bodies spoke of them in their campaigning, and the social services sector knows that health is inseparable from other aspects of individual and community wellbeing.

But there is no denying that the election of the Morrison government means there is much work for us to do to safeguard everyone’s wellbeing– particularly those experiencing disadvantage and marginalisation – our communities, and the very land we live on.

The Social Determinants of Health Alliance is determined to prosecute the need for action on key issues fundamental to improving the health and wellbeing of all Australians, particularly those on low income.

Climate change is threatening people’s homes, livelihoods, health and cost of living. It disproportionately impacts on people experiencing disadvantage who have less money, choice and power to adapt in response.

Self-determination is fundamental to good health and wellbeing. Until there is a meaningful response to the Uluru statement, including a treaty, the health of First Nations peoples will continue to lag that of the rest of the country.

Raising the rate of the Newstart Allowance is a first essential step to reduce poverty. We know that those on the lowest incomes not only struggle to make ends meet but also have the poorest health. We will not improve the health of all Australians until we raise the incomes of the poorest.

The stable, affordable housing so essential to good health is out of reach for an increasing number of Australians. Real plans to increase the supply of affordable housing, and to reduce homelessness, are needed as a matter of urgency to ensure that everyone has a safe roof over their head.

The Morrison government has made much of its plan to reduce taxes, including for those on higher incomes. This poses a serious risk to our revenue base well in to the future. Funding for the essential services the community relies on – health care, schools, child care, aged care and disability services – will suffer in the future, and health inequities will worsen.

The Social Determinants of Health Alliance calls on the Morrison Government to work collaboratively with all sectors of the community to address these matters to ensure Australia is healthy and inclusive for everyone.

Key Points

• The budget does nothing to reduce health inequities.
• The people in most need receive the least in the 2019-20 Federal Budget.
• Tax cuts will remove vital revenue from the system well into the future. Our ability to pay for essential services such as health care and education will be at risk.
• Lack of action now on social determinants of health will have substantial costs on the health and wellbeing of Australians into the future.

Analysis

‘Investing in the conditions in which people are born, grow, live, work and play is good for society, for the economy 
and for people’s physical and mental health.’ Professor Sharon Friel

• Our health reflects the environments we live in – our physical, cultural, economic and environmental circumstances.This is the single most important determinant of health. 
• The relationship between income and health is clear – those with lowest incomes have the poorest health. 
• Reducing poverty, addressing racism, stigma and discrimination, ensuring secure and affordable housing for everyone, ensuring health care is accessible to everyone, acting on climate change and improving education and employment will create the environment that promotes good health and reduces health inequities.
• The 2019-20 Federal Budget fails to address any of these social determinants of health.
• Tax cuts reduce Australia’s revenue base well into the future. Funding for the essential services the community relies on – health care, schools, child care, age care and disability services – will suffer in the future. Health inequities will worsen.

Measures addressing the Social Determinants of Health

Measures that would improve health equity through addressing the social determinants of health were completely absent in the Budget:

• Reducing poverty
• No increase to the woefully inadequate level of Newstart Allowance, despite widespread. support for an urgent increase of $75 per week. 
• No increases to other pensions and benefits. 
• Housing
• Nothing to respond to or reduce homelessness. 
• Very little investment in social or affordable housing. 
• Tax cuts
• Biggest benefits flow to those on higher incomes – who have less need for them. People on the lowest incomes – who don’t earn enough income to pay tax – will receive no benefit from the tax cuts.
• People on $200,000 will get over $224 a week. 
• People on $50,000 will get $23 a week. 
• People on $25,000 (on pensions) get a one-off payment of $75 (equivalent to $1.40pw).
• People on $15,000 (on Newstart) get a one-off payment of $75 (post Budget announcement). 
• Energy Assistance Payment  
• The one-off payment of $75 will do little to offset rapidly increasing costs of living for those on the lowest incomes. 
• Employment
• No plans to reduce unemployment, particularly for long term unemployed. 
• Rural/remote
• Limited provisions aimed at the addressing the health disadvantages of living outside major cities. There is $62m to train doctors in rural general practice and money for specific programs in particular regional and rural areas.  
• Climate change
• Nothing to address the health impacts of climate change 
• Reactions to the Climate Solutions Package are skeptical that it won’t produce significant emissions reductions 
• No specific plans to respond to and reduce racism and discrimination  
• Education and early childhood 
• 15 hours of 4-year-old preschool extended for two years, including $1.4m to increase preschool attendance rates of disadvantaged and Indigenous children.  
• No changes to school education funding.  
• $525.3m over five years to improve the VET system, including up to 80,000 new apprenticeships. However, commentary indicates this is simply returning some investment into the sector that had been cut in recent years. 

Public health measures

There’s also little joy in public health measures that would improve the health of people on the lowest incomes.

• Lifting freeze on Medicare rebates for diagnostic imaging and GP services could reduce out of pocket costs. 

This article appeared in the Health Advocate published by AHHA in August 2015

By Fiona Armstrong

Executive Director

Climate and Health Alliance

Back in 2012, the Australia arm of a newly established global network of green and healthy hospitals was established in Australia.

Environmental health expert Dr Peter Orris, senior advisor to Health Care without Harm, was in Sydney to launch the initiative, at the inaugural Think Tank on Greening the Health Care Sector, now an annual event co-hosted by Climate and Health Alliance and the Australian Healthcare and Hospitals Association.

The Global Green and Healthy Hospitals network was then made up of member institutions representing the interests of around 4,000 hospitals and health services; now, with the commencement of an online platform to support this virtual community, membership of the global network has grown to over 12,500 hospitals and health centres. This dynamic community of people and institutions is working together in a giant and dynamic global collaboration to share knowledge, skills, tools, and resources to build a global best practice in sustainability in healthcare, and accelerate the transition of health care to low carbon operations.

Starting from just a handful of members a few years ago, the Pacific region (Australia and New Zealand) now has over 150 hospitals and health services from across Australia and New Zealand as part of the network. We hope to dramatically grow the participation of Australian and New Zealand hospitals and health services in coming years, and see the lessons from this region as potentially cutting edge sustainable healthcare practices.

Our innovative workforce, coupled with the growing realisation among health service leaders and managers regarding cost savings and reputational benefits, is likely to see greater investment in efforts to realise these gains, offering Australia and Zealand the chance to be world leaders.

We already have amazing work being done: Austin Health in Victoria has implemented a comprehensive environmental management strategy, with initiatives underway across several facilities to improve energy efficiency, limit waste, reduce water use, and create green outdoor healing spaces, among other things. Specific gains include the diversion of tonnes of food waste from landfill and almost 20% of all waste now being recycled. Mater Health Services in Queensland has saved almost $1 million and around 400 tonnes of carbon emissions in one year with smarter electricity contracts and energy efficiency. They have also implemented important staff engagement campaigns to encourage participation into pro environmental behaviours. St Vincent’s Health Australia has reduced energy consumption in one of its largest hospitals by 30%, and plans to invest in further efficiencies to reduce total energy consumption by 30-40%.

Across the Tasman, Counties Manukau Health (CM Health) are recycling paper, glass and electronic waste, cutting carbon emissions and organising car-pooling for staff. CM Health has saved over $100,000 so far through their waste reduction program, and reduced their carbon footprint by 4% every year since 2012, and are the first Australasian participant in 2020 Health Care Climate Challenge – a new campaign launched in May to encourage hospitals across the world to set their own emissions reduction targets - to reduce their carbon footprint and protect public health from climate change.

Other participants in the 2020 Challenge include Gundersen Health System (USA), Hospital Albert Einstein and Hospital Sirio Libanes (Brazil), Dignity Health Care (USA), Kaiser Permanente (USA), NHS Sustainable Development Unit (England), Virginia Mason Health System (USA), Western Cape Government Health (South Africa), and Yonsei University Health System (South Korea). And the group continues to grow. Several of the initial participants, such as Kaiser Permanente, Yonsei University Health and the NHS have already committed to reduce their greenhouse gas emissions by 30% or more by 2020. All have also pledged to encourage public policy, economic development, and investment strategies that move their societies away from fossil fuel dependency and toward healthy energy alternatives.

While the Challenge offers incentives through the spirit of competition and recognition of achievements through awards, the ethic of the Global Green and Healthy Hospitals network is really all about collaboration. It is an inspiring demonstration of an emerging global trend towards cooperation, rather than competition; of sharing, rather than secrecy; with an emphasis on community, rather than individuals.

As we wrestle with the challenges of a resource-constrained, climate changed world, this kind of cooperation can enable us to build on our strengths, support others, and in doing so build trust, resilience, respect, understanding, and power, while boosting quality of care, realising financial savings and ensuring public health and environmental protections.

It is also the case that cooperation is fun, and personally rewarding – through my own involvement I’ve seen people inspired, friendships develop, ambitions realised and then renewed through this relentlessly positive and supportive network. When people of shared passion (and for many, concern about our future is a deep and profound passion) come together, change is not only possible, but from our experience, it becomes exponential and, we hope, unstoppable.

For more information about CAHA, visit www.caha.org.au; about Global Green and Healthy Hospitals visit: www.greenhospitals.net and about the 2020 Health Care Climate Challenge, visit: http://greenhospitals.net/en/2020hcccpledge/

The following blog post has also been published on CEIPSblog and has been republished with the author's permission: "Systems science - the new way of thinking?"

Posted: August 19, 2015 | Author: CEIPSblogger | Filed under: Knowledge Exchange, Prevention, Systems Thinking

 Rebecca Zosel, Public Health Consultant

Systems science – the new way of thinking?

In the fourth of the CEIPS Seminar Series on Tuesday 23 June, Dr Therese Riley, Senior Research Fellow, explored two questions about quality in systems science in her presentation: ‘How do we know our systems science is any good?’

The complete post can be found at https://ceipsblog.wordpress.com/2015/08/19/systems-science-the-new-way-of-thinking/

The following blog post has also been published on CEIPSblog and has been republished with the author's permission:  Evaluating public health interventions:  an urban regeneration case study

Posted: July 8, 2015 | Author: CEIPSblogger | Filed under: Evaluation, Knowledge Exchange, Prevention, Systems Thinking
Rebecca Zosel, Public Health Consultant

Evaluating public health interventions: an urban regeneration case study

The third of the CEIPS Seminar Series was delivered by Dr Lyndal Bond, Principal Research Officer on Tuesday 26 May: ‘GoWell: the challenges of evaluating urban regeneration as a population health intervention’. The seminar explored the challenges of evaluating complex public health interventions, using an urban regeneration program in Glasglow, Scotland as a case study.

 CEIPS Seminar 3 two

Despite our understanding that the environments where we live, work and play impacts our health, surprisingly, there is little robust evidence to test the policy assumption that housing-led regeneration improves health and wellbeing and reduces health inequalities. This limited evidence base is partly due to the challenges of evaluating regeneration programs.

Launched in 2005, GoWell is a longitudinal research and learning program investigating the impacts of investment in housing and neighbourhood regeneration in Glasgow on the health and wellbeing of individuals, families and communities. GoWell seeks to improve the evidence base by telling us which kinds of improvements lead to the biggest benefits in health and wellbeing, and which may cause unexpected problems; what initiatives have been found to improve health; and how people’s lives are affected by regeneration initiatives (i.e. the ways in which health behaviours and potentially life-enhancing activities such as seeking employment or engaging in voluntary activities are affected by housing and neighbourhood improvements). As part of the evaluation, GoWell will monitor the effects of regeneration policy on area-based health and social inequalities across Glasgow.[1]

The regeneration program is being undertaken across the city of Glasgow, a city known as ‘the sick man of Europe’. GoWell focuses on the 15 most deprived areas with the highest rates of premature mortality in the UK. In these areas, the majority (80-90%) of the population are social renters (the equivalent to public housing), who bear a disproportionate burden of the city’s ill health and poverty. In 2003 before the regeneration program commenced, the condition of social housing in Glasgow was appalling, with 70% of homes non-compliant with Scottish Housing Quality Standards due to damp and mould, and insufficient heating.

The large-scale regeneration program involves over 75,000 homes and £1.4 billion over 10 years to be invested in:

• Housing improvements
• Transformational regeneration (demolition of high-rise blocks and replacement with lower-rise flats and houses)
• Neighborhood renewal
• Resident relocation
• Mixed tenure (mixed income) communities
• Community engagement and empowerment
• Social regeneration (community services).

CEIPS Seminar 3 one

Lyndal spoke of a number of challenges associated with evaluating the large scale regeneration program and of GoWell’s responses to the challenges. Two overall factors emerged from her presentation as critical to successfully evaluating complex public health interventions.

1)  Flexible and responsive evaluation plans are critical to success

 Complex public health interventions are indeed that – complex. Lyndal spoke of a situation familiar to most of us working in public health– the challenges of working with multiple partners within a dynamic and ever-changing context. The emerging and changing nature of interventions. The reality of not having control over everything. The changing political context which influences priorities and agendas. Difficulties in defining boundaries and identifying who receives the intervention. The practical and ethical challenges of finding a control group or randomly allocating at a population level. The list goes on.

 The GoWell case study was a good reminder: because of the complex, contextual and dynamic nature of public health interventions, we need evaluation plans that are flexible and responsive – with a good dose of pragmatism.

 2)  A comprehensive evaluation that captures multiple methods and outcomes is required

 Public health interventions are notoriously hard to evaluate, and this is especially true of interventions that tackle the social determinants of health. Like many upstream determinants of health targeted by public health, regeneration strategies are not always amenable to quantification, demonstrable causal pathways or short-term outcomes. Lyndal emphasised the need for comprehensive evaluations that are characterised by multiplicity – evaluations that capture multiple outcomes at multiple levels, use multiple methods and collect multiple data sources.

 As a ten-year research and learning program, GoWell has long-term funding from several stakeholders which enables a comprehensive evaluation to be undertaken. Not all interventions are so well resourced however it is interesting to note GoWell’s multitudinous approach to evaluation.

GoWell uses primary and routine data to capture multiple outcomes at multiple levels:

Individual

· Physical health·

Mental health·

GoWell uses primary and routine data to capture multiple outcomes at multiple levels:

Individual

· Physical health

· Mental health

· Health behaviours

· Social networks

· Social support

· Safety and trust

· Participation

· Perceptions

· Employment and SES

Community

· Social interaction

· Collective action

· Empowerment

· Community cohesion

· Community sustainability

· Neighborhood changes

City

· Population change and movement

· Perceptions of areas

· Relative performance of neighborhoods, e.g.

o Turnover

o Tenure mix

o Health details

o Health outcomes

Multiple evaluation methods are used by GoWell including:

- Community health and wellbeing survey (repeat cross-sectional every 2-3 years)

- Longitudinal studies of out movers and remainers

- Ecological monitoring (city and country wide changes to health)

-  Environmental audits (capturing change at the neighborhood level)

-  Qualitative studies

   -  Study of governance, empowerment and participation

   -  Experience of demolition and relocation

   -  Practitioners and policy makers (mapping policy expectations of regeneration)

   -  Evaluations of social regeneration activities (e.g. youth diversionary schemes, local employability schemes)

Further, GoWell data is linked with other data:

   -  Hospital and general practice linkage for GoWell survey participants

   -  Mapping crime statistics in GoWell areas

   -  Mapping food outlets (relating to snacking/diet)

   - Education outcome data (impact of regeneration and tenure mix on education outcomes?)

It’s refreshing to see an example of large-scale change with a long-term, comprehensive evaluation to accompany it. This is consistent with CEIPS’ evaluation agenda which aims to build our understanding of systems-change and how to apply the science of systems thinking to population health improvement. GoWell is building the evidence base for complex public health interventions and importantly, helping policy makers to be more explicit and realistic about what regeneration might achieve.

For more information on GoWell visit: www.gowellonline.com

Rebecca Zosel is a public health practitioner, advocate and consultant. She tweets at @rzosel.

[1] GoWell, 2015 www.gowellonline.com

The following blog post has also been published on CEIPSblog and has been republished with the author's permission:

Using a systems approach to tackle obesity: insights from the UK

Posted: April 2, 2015 | Author: CEIPSblogger | Filed under: Uncategorized |Leave a comment

 Rebecca Zosel, Public Health Consultant

CEIPS launched their new seminar series with a bang on 17 March 2015, attracting a large crowd to the inaugural seminar by Dr Denise Goodwin: Is it possible to take a systems approach in obesity prevention? Findings from the Healthy Towns program in England.

The multidisciplinary crowd of policy makers, practitioners and researchers who gathered to hear Dr Goodwin speak were not disappointed. From her unique vantage point as part of the team evaluating the Healthy Towns program, Denise shared insights from the UK relevant to local obesity prevention efforts, the use of systems approaches to prevention, and Victoria’s own prevention initiative, Healthy Together Victoria.

Healthy Towns program

The English context in which the Healthy Towns program was borne parallels our own: a treatment-oriented health care system facing pressure from rising demands and untenable costs. The program itself also has similarities to Healthy Together Victoria; both prevention initiatives are underpinned by a systems approach with concentrated, community-level effort in certain areas.

A number of events in the UK led to the establishment of Healthy Towns, including a call to develop a comprehensive strategy to tackle obesity (Health Select Committee of the House of Commons, 2004), release of the Foresight report ‘Tackling obesities: Future Choices’, and a cross-government obesity strategy ‘Healthy Weight, Healthy Lives’. All of these advocated the need for systemic change at multiple levels and multiple sectors across the life-span.

Healthy Towns was conceived as a way to take a systems approach to tackling the obesogenic environment. With £30 million funding, nine towns across England were involved in developing, implementing and evaluating programs to tackle the environmental determinants of diet and physical activity.

Dr Denise Goodwin presented the findings of the Healthy Towns process evaluation, a qualitative stakeholder interview study (n=72). The evaluation generated some interesting insights which seem to indicate a failure in the execution of a systems approach, rather than a failure of a systems approach per se.

The takeout messages from Denise’s presentation:

We need to develop a shared understanding of systems approaches.

The lack of shared understanding of systems approaches in the Healthy Towns program was evident in the towns’ reliance on more ‘traditional’, risk-factor based approaches to program delivery. Mis-understanding was compounded by vague government tender documents and the provision of guidance on linear, structured, hierarchical ‘delivery chain’ approaches that are completely at odds with a systems approach.

Systems science has been used in fields such as engineering, organisational learning & economics for some time, yet is relatively new to public health. There are different interpretations about systems approaches including views that it is no different from existing public health practice. It is critical that we find a way to describe systems thinking that resonates with policy makers, researchers and practitioners alike. This will help all of us working in public health to buy into systems thinking, and sell it to decision makers and funders.

Systems approaches can be hard to implement; tools and guidance are required.

There was a clear disconnect between what was theorised as a systems approach and how it was translated into practice in the Healthy Towns program. It was also clear that a wide range of barriers and enablers impacted on the towns’ ability to implement a systems approach. Although a systems approach has a strong theoretical basis, it requires a clear set of tools and guidance to implement, alongside a commitment to build workforce capacity and develop systems thinkers and leaders.

The innovation: evidence paradox – Is it ever really safe to fail?

The Healthy Towns program was conceived as a formative, learning program, set up to generate evidence on environmental approaches to prevention. The expectation to innovate and build the evidence base resulted in some tensions related to the use of accountability frameworks (i.e. reporting requirements, pre-identified outcomes). The accountability framework did not fit with a systems approach, as it suggested that specific outcomes are the consequence of specific processes and inputs, ignoring the unpredictability of systems change, its non-linearity and the likelihood of unintended outcomes.

“The government on the one hand they were saying ‘Look, be very creative, be very exploratory, be very developmental, let’s learn lessons from all of this’, yeah that was one of their angles which was great, we were very much in favour of that. However, on the other side the same people were saying ‘Look we want it all tied down in great detail, you know in the old style in terms of inputs, processes, outputs and stuff’ and that didn’t really match up too well.” Program Manager

Pressure to produce certain outcomes (in too short a timeframe) acted as a disincentive to exploring innovative new strategies, where the benefits might be greater but the risk of failure is quite high. In effect, the accountability framework perpetuated conservative practices, and was at odds with the program’s imperative to innovate.

In our economically stringent climate characterised by change, competition and complexity, public health is grappling to balance best practice (evidence-based) and innovation (evidence-generating). One participant mooted a 70:30 split. There is no magic formula, however it is clear that the world is changing and public health needs to respond. We must continue to do what we know works, whilst developing truly innovative approaches to prevention. In order to do this, we need to be comfortable with failure and have accountability frameworks in place to reflect this

A comprehensive and sustained approach to tackling obesity is required.

Those of us working in public health know all too well that change is best achieved using a comprehensive multi-pronged approach, and it is heartening to see this evident in initiatives such as Healthy Together Victoria. Public health also needs sustained effort and investment.

The Healthy Towns program was funded for a period of two years and five months, which was seen by local stakeholders as too short and reflective of ‘quick fix’ political expectations; those at the national level thought it long enough. We know from experience in tobacco control and skin cancer prevention that achieving sustained population level change requires a comprehensive and sustained approach. This is particularly pertinent to note at a time when Australian politics are volatile and prevention continues to be afforded a low priority and experience fluctuating commitment, as demonstrated by the recent termination of the National Partnership Agreement on Preventive Health.

Finally, obesity has been a national health priority area since 2008 which begs the question: where is Australia’s national obesity prevention strategy?

Rebecca Zosel is a public health practitioner, advocate and consultant. Follow her on Twitter at @rzosel.

Healthy Towns program reading:

• Goodwin et al. How can planning add value to obesity prevention programmes? Planning and planners in the Healthy Towns programme in England (2014) Health & Place 30 120-126
• Sautkina et al. Lost in translation? Theory, policy and practice in systems-based environmental approaches to obesity prevention in the Healthy Towns programme in England (2014) Health & Place 29 60-66
• Goodwin et al. The role and status of evidence and innovation in the Healthy Towns programme in England: qualitative stakeholder interview study (2013) JECH 67 106-112
• Ogilvie et al. An evaluability assessment framework for complex public health interventions: five questions for researchers, funders and policymakers (2011) The Millbank Quarterly 86 206-215.

Author:  David Swift - QUT Student Master of Social Work

The McClure proposal will hit young people with disability under 35, putting them into the labour market and or work experience or most likely, keep them in education or training for longer. In the proposal a simplified income support system is proposed. Pages 33-35 of the report provide a profile of people with disability and key relationships to carers as informal support. Here I propose to examine the construction of the McClure report from the perspective of my wheelchair, that is people with disability, focusing on the options asserted by the proposal, together with language and imagery and the use of budget figures.

According to the McClure Report (2014, 46-47), the 2014-15 Federal Budget announced that for certain Disability Support Pension recipients aged under 35 years, the Government will introduce compulsory work-focused activities, such as work experience or education and training, to help increase their chances of finding and keeping a job.

A targeted review will be undertaken of Disability Support Pension recipients aged under-35 years who originally accessed the payment under different rules between 2008 and 2011. Work capacity will be reassessed against the current impairment tables and people with disability and will be provided with the support needed to allow them to develop their work capacity via the current Disability Employment Service (DES) network which is under is stress and under-performing now. This will force young people with a disability to access employment services sooner at a time when it may be important for them have the opportunity to develop independent living skills and develop social networks to take them into adult life.

Thankfully, people with disability who have severe and profound incapacity will stay on the Disability Support Pension. Current expenditure on the Disability Support Pension: $18,414,990.00. Current population on Disability Support Pension:821,738 (p184).

For the purpose of this paper I also included people supported by Pharmaceutical Allowance, $609,062.00 expenses in 2012 (p141), as people with mental illnesses and the ageing population require the support of daily medication which enables this group to participate in the labor market. However, getting adequate support for people with mental illness remains a challenge and it is not clear where mental health services sit within the NDIS.

Both McClure and the NDIS objectives match with stated objectives of employment of people with disability. McClure cautiously recognizes the hidden costs of disability such as transport, which is also reflected in NDIS support. Suitable accommodation, ideally universally designed houses are been called for by NDIS which will be a determining factor toward employment outcomes for people with disability and their independent living in local communities. It is difficult to get a job with no fixed address for your tax and employer records, correction, virtually impossible!

The language and imagery of devalued roles is revealed in McClure’s construction. McClure still ascribes to well-known images of people with disability as “menace” and “burden”, as McClure’s language suggests “risks”, “control” and needing “income management” and viewing some people as “burdens of charity”. This is emphasised by the language of mutual obligation and the need for reassessment. It also suggests a Risk of longer term dependence for both the carer and disability pension recipient on budget costs.

It is also important to recognise the social good of non-economic social role for people with profound disability while continuing to work towards inclusion of all people with disability in our social and and economic spheres of life.

By Isabel Ross (Volunteer Swaziland Women’s Organisation)

The start of 2014 has been one of heartache and joy, intense activity and reflection. Just after New Year, my colleague at Gone Rural bomake and I were back at work, implementing the second element of our Safe Sisters project, funded by the US Embassy in Swaziland. We were joined by 43 of our dedicated Peer Educators.

The Safe Sisters project holds a special place for me. It is a project that has been designed wholly and solely around community-identified need. Back in 2012, when I coordinated the organisation-wide needs assessment, I asked a lot of questions about issues that I, the government, and donors, felt were relevant - HIV, income, education etc. It wasn’t until we conducted the participatory focus groups that the most important issue of all was revealed, an issue that I had completely missed - grief.

The impact of the HIV epidemic in Swaziland cannot be overstated. Add to that the extraordinarily high rates of abuse, and it’s not surprising that these focus groups ended in tears. Yet, in Swaziland, when you are so poor that you live a hand-to-mouth existence, you cannot afford to take the time to mourn. When all those around you are experiencing the same devastation, it would be too selfish to ask for help. When abuse and death has become so normalised, the whole idea of it requiring special attention seems incongruous.

The aim of Safe Sisters is to create a safe space for rural community members to grieve. The plan was to equip our peer educators with the skills to provide basic crisis and grief counselling, and to support survivors to access more specialised care if required. In most cases, this would be the only psychosocial support available in Swaziland’s rural communities AND it would be accessible at any time, at no cost.

Teaching someone to be a counsellor is not a simple affair. In Australia, a four year tertiary degree is the minimum requirement so we did not expect anything extraordinary from our well-intentioned mothers and grandmothers (and one man). They spent five days learning about the signs of human trafficking, the cycle of abuse, the importance of asking “Are you okay?”, and the basic steps to help those that aren’t. It was practical and powerful, with each participant putting themselves and their own personal stories out there. A part of me wishes that I could have understood more (it was all in siSwati), but after sitting in the corner trying to fight back tears from the few translated stories of rape, incest, neglect and death, it’s probably a good thing I didn’t.

It wasn’t all doom and gloom, though. When the facilitators came to me, beaming from ear to ear and exclaiming, “These women have achieved the extraordinary”, I have to admit I felt a bit like a proud mother. When one of the women stood and declared her thanks to God because “before, I thought I was helping by judging. Now I know that I shouldn’t judge. I should listen”, it was my turn to beam from ear to ear. By the end of the week, there was no illusion that the peer counsellors were now psychosocial experts, but there was a new and very deep sense of optimism. As Tanele put it, “It’s like they’re not leaving here with new knowledge. They’re leaving with a new way of thinking”. Only time will tell the impact of this project in the community, and by then I will be long gone. My feeling, though, is that the change we’ve already witnessed among these participants is value enough.

By  – Isabel Ross (Volunteer with Swaziland Women’s Organisation)

Kutimela (meaning ‘self-reliance’ is one of the most beautifully designed programs I’ve ever seen. I can say that without bias because it wasn’t designed by me. In fact, it is based on a model called WORTH developed by Pact International, and has been run in a range of countries across the globe.

Kutimela’s basic premise is that of a village microfinance scheme....with a difference. Women form themselves into groups of between 15-25 people. They set the parameters for their saving group: how often to meet, minimum regular deposit, savings conditions, selection of a committee etc., and their first contribution goes toward purchasing the savings box, keys and all the books needed to operate the group so that there is no external financial input required. Members also nominate and vote on someone from the region to act as an Empowerment Worker (EW). In this way, the entire process is run by the group members themselves.

EWs attend each group’s meeting and are trained by our Project Officer to provide training to the groups around financial management, entrepreneurship, calculating profit and loss, strategic advantage etc. In this way, the Kutimela group acts as a saving scheme, a lending scheme (which provides a second source of income through dividends), as well as a platform for literacy and business education.

As participants settle into the program, experience tells us that the women capitalise on the power of the group to discuss and identify solutions to local social issues, such as abuse and HIV prevention. Many groups also agree to contribute a proportion of their savings for charitable purposes, and to cover the costs of the EW and external facilitators to support the group beyond the initial training period. With the business training under their belt, groups have also gone on to facilitate the formation and training of additional groups in their communities, making it an entirely sustainable system with big potential for growth.

WORTH was first introduced into Swaziland in 2011 through Save The Children and Swaziland Action Group Against Abuse (SWAGAA). Thanks to a small grant from Swazi Kids, my organisation - Gone Rural boMake - began running it in late 2012. After just 3 months, our participants from 11 groups had managed to save E13,000 ($1,450). However, this is just the beginning.

Last year, TechnoServe did an evaluation of the WORTH groups operating under Save The Children and SWAGAA. The study found that 21% of participants started a new microenterprise due to WORTH, and 73% of members took loans to help them build their business further. In addition, women were able to keep money aside for needs such as school fees, while 55% of groups contributed to a fund to support Orphans and Vulnerable Children with schooling and food. A number of groups went on to launch new groups in their community.

With this amazing financial support from the EU and Swaziland’s Microprojects, Gone Rural boMake is partnering with Save The Children Swaziland to expand the number of Kutimela groups to 200, allowing 3,000-5,000 women AND youth to regularly save money and receive training in microfinance and business administration. If 20% of these participants form a new enterprise, that’s somewhere between 750 – 1,250 women or youth earning an income in a country where almost half of the nation’s rural people are unemployed.

If we look at this in a broader sense, we know that Gone Rural artisans take care of an average of six dependents each. As women provide most of the protective elements of the social structure in Swaziland, taking responsibility for ensuring children are able to attend school and are safe and fed, Kutimela has the potential to improve the lives of up to 30,000 people. That’s a lot of beneficiaries for one little program. Now can you understand why I’m so excited?

by Dr Gemma Carey

If you work in the community sector, you may have noticed the term “social determinants of health” creeping into conversation. The term comes from public health, and is rapidly gaining attention both internationally and here in Australia.

“Social determinants of health” is simply another name for the social problems that the community sector works to fix, such as housing, income insecurity, education and disadvantage.

Public health research has shown that these social issues are the primary cause behind health problems like cardiovascular disease, diabetes and obesity. This means that poor health is the result of social conditions that can’t be addressed by the health care system.

Interest in the social determinants has increased dramatically in the last year. 2013 saw the establishment of the Australian Social Determinants of Health Alliance and the Senate Inquiry into the Social Determinants of Health.

But what does the rise of the social determinants of health mean for the community sector?

The realisation that social issues create poor health brings a wider range of sectors and professionals to the table on issues of social disadvantage. With this also comes knowledge, expertise and resources.

Public health has an impressive history of public advocacy and policy change based on ground-breaking research. As Professor Robert Douglas reported on the Conversation, a recent public health study revealed that poverty has a greater impact on child development that the use of cocaine during pregnancy. This type of research packs a serious punch when it comes to advocating for social policy change.

In 2010, social determinants of health advocate Sir Michael Marmot released the Strategic Review of Health Inequalities in the UK. This report is one of the most comprehensive compilations of evidence on the effects of disadvantage on health and wellbeing ever created. Referred to as “ideology with evidence”, it is a must-read for the community sector.

Health is also the number one area of government spending, making up 19% of the budget. In comparison, welfare spending (including services delivered by the community sector and cash payments like Newstart) makes up just 0.004% of the government’s budget. Linking health to welfare and disadvantage creates new opportunities for resources and policy change.

Are there any risks for the sector?

Public health is undoubtedly a powerful ally. However, the rise of the social determinants of health also poses a number of risks for the sector.

Over the last few decades we have seen “health” expand to encompass an ever-growing number of social issues. The social determinants of health mean that all social issues are now the domain of health.

The community sector needs to be careful that it is not displaced by health advocates and practitioners. If health were to “take over” social determinants work, valuable knowledge from the community sector could be lost. Already, 36 of the 49 members of the Social Determinants of Health Alliance are health-based organisations.

While public health and the community sector now agree on the problem, this does not mean they agree on the solution. Social determinants of health researchers bring new evidence and fresh arguments to debates about social disadvantage, but they do not have the answers.

At the moment, public health professionals are advocating for “Health in All Policies”. This initiative is aimed at getting policy-makers to think about health when designing and implementing policy, and to avoid policies that will have negative impacts on health.

This seems reasonable on the surface, but will policy-makers in transport or employment care about health? Isn’t it rather presumptuous to think that health should trump other equally deserving issues? Social problems might impact health, but this doesn’t mean a health focus is the best way to fix them.

Public health and the community sector also work on different levels. Social determinants of health researchers tend to use statistical data to model the impact of issues – such as income – on the health of the population. However, this data has little direct relevance to the real lives of the individuals the community sector works with. This means that public health advocates are chasing major changes in policy without understanding how individuals can overcome social problems and improve their health.

What can the sector do?

In order to capitalise on what the social determinants of health offers, and minimise the threats, the sector needs to engage.

This means reading the research (such as the Review of Health Inequalities), engaging with public health researchers and joining the Social Determinants of Health Alliance.

By doing this, the community sector can help build vital links between population-based evidence and individual experiences of disadvantage.

Dr Gemma Carey is an Australian researcher with an interest in health equity and the social determinants of health. A paper she has co-authored, Help or hindrance? The social services sectors and the social determinants of health, is currently in press.