Australia: the healthiest country by 2020
National Preventative Health Strategy - Overview

5. Reduce inequity through targeting disadvantage

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Major health inequities exist not only between Indigenous Australians and non-Indigenous Australians, but between rich and poor, and between rural and city dwellers. Even within a city such as Melbourne, life expectancy can vary by up to six years within a matter of kilometres.

The WHO’s Commission on the Social Determinants of Health (CSDH) makes three overarching recommendations to tackle the ‘corrosive effects of inequality of life chances’:

• Improve daily living conditions, including the circumstances in which people are born, grow, live, work and age
• Tackle the inequitable distribution of power, money and resources – the structural drivers of those conditions – globally, nationally and locally
• Measure and understand the problem and assess the impact of action[38]

The poorest of the poor have the highest levels of illness and premature mortality. But poor health is not confined to those who are worst off. At all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.

The social gradient

Solely focusing on the difference in health experience at opposite ends of the social spectrum masks the graded relationship between social position and health. A recent analysis of mortality rates, and notably avoidable mortality rates, illustrates how death rates decrease progressively with increasing SES (Figure 5).



In Australia, excess body weight tends to be more prevalent among people further down the social and economic scale.[40] Analysis of the AusDiab 1999–2000 data shows a clear social gradient in the prevalence of obesity among adult women (Figure 6). A policy and programmatic focus on only the most disadvantaged, in this instance women with primary level education, would miss the equally significant health burden from obesity among women along the remainder of the education spectrum.



Understanding health inequity in terms of the social gradient in health allows us to embrace not only conditions of poverty and exclusion but social conditions that affect everyone. In doing so, policies and programs will have greater potential to reach a wider population, thereby improving the health of more people.

Social determinants of obesity, tobacco use and alcohol consumption

Of particular relevance to obesity, alcohol consumption and tobacco use is the nature of, and inequity in:

• The physical and social experiences in early life
• Access to and quality of education
• The nature of urbanisation – how cities are planned and designed – along with the liveability and sustainability of rural locations
• Transport options
• Distribution mechanisms and consumer price of food, alcohol and tobacco
• Exposure to marketing of energy dense nutrient poor (EDNP) foods, alcohol and tobacco
• The financial, psychosocial and physical conditions of working life
• The degree of social protection provided

Culture is a major social determinant of health. For Indigenous people, health status does not correlate with position in the social gradient, as for the general population. Irrespective of SES or geographical location, Aboriginality itself is associated with poor health.[41] Specific recognition of culture, as a major social determinant of Indigenous health, is important when designing preventative health programs to contribute to ‘Close the Gap’ (see below).

Structural determinants: power, money and resources

Promoting health equity through healthy weight, responsible alcohol use and no tobacco use also means tackling some of the fundamental political, economic and cultural issues that affect people’s living conditions, their daily practices and behaviour-related risks.

That means dealing with matters of governance; national economic priorities; trade arrangements; market deregulation and foreign direct investment; fiscal policy; and the degree to which policies, systems and processes are inclusionary – each issue very much related to the CSDH recommendation of tackling the unequal distribution of power, money and resources. Addressing these structural determinants of health inequity not only helps empower individuals and communities but also empowers national government and other key public sector institutions. For example, good global governance and regulatory frameworks create support for national governments to introduce policies that tackle corporate pressures such as irresponsible marketing.[42]

In light of the strong relationship between health and social disadvantage and the clustering of risk in the most vulnerable populations, the Taskforce welcomes the Australian Government’s Social Inclusion Agenda, and similar initiatives introduced at the state and territory level (such as South Australia’s Social Inclusion initiative).

The Taskforce shares the Australian Government’s vision of an inclusive society as one in which all Australians feel valued and have the opportunity to participate fully in social and economic life. Health is one of the key resources that enables participation; conversely, social exclusion can itself be a contributor and determinant of poor health.

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