Pacific Islands Global Health Policy Memo for the Opposition Leader

Australia and the Pacific Islands have a long-standing relationship through their shared history. The isolation of the Pacific Islands first ended around the 1680’s when Spain and the Western wonderers established a presence (Department of the Parliamentary Library, 1995). From the 1800s, this presence continued to increase, and in the first half of the twentieth century all the Pacific Island nations were “colonies or protectorates of the Western powers” (Department of the Parliamentary Library, 1995). It was only during the 1960’s that the Western colonies started to loosen their control on the Pacific region (Department of the Parliamentary Library, 1995), however, Australia maintains a significant relationship and health footprint with the Pacific Islands (DFAT, 2019).

For the purposes of this memo, the Pacific Islands refers to the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Fiji, French Polynesia, Kiribati, the Marshall Islands, Nauru, New Caledonia, New Zealand, Palau, Solomon Islands, Tonga, Tuvalu, Vanuatu, and Wallis and Futuna (WHO, 2013).

Many of these countries and territories are small, isolated, and geographically dispersed with relatively small populations (Horwood et al., 2019). Due to their location, these populations are disproportionately affected by the rising sea levels and changes in weather patterns that have resulted from climate change (Horwood et al., 2019). Likewise, their location has serious consequences for the delivery and maintenance of health care, and most countries and territories within the Pacific only have basic health capacities available for their people (Horwood et al., 2019). All of the above only exacerbate the impact of the current high burden of infectious and non-communicable diseases (NCDs) (Horwood et al., 2019).

With this context in mind, this memo will provide the opposition leader with key considerations and strategies for new policies on global health in the Pacific Islands, ahead of our next Australian federal election in six months’ time. For clarities sake, this memo will have four broad sections focusing on: 1) the crucial aspects of the origins of good health in low- and middle-income countries; 2) recommendations for policies that are likely to be the most effective; 3) the tensions between addressing a) the social and political determinants of health vs. health- or health-care specific programmes, and b) upstream vs. downstream social determinants of health; and 4) any unintended consequences to be aware of.

1. The crucial aspects of the origins of good health in low- and middle-income countries (LMICs)

The WHO (2021a) defines good health as ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” It is holistic and well supported health systems that enables countries to maintain good health among their people. It has been consistently noted that the Pacific Islands are overrepresented globally in their burden of infectious diseases and NCDs (Horwood et al., 2019; The Lowey Institute, 2021).

Reflecting the geographic range of the Pacific Islands, the diversity of ranges on health indicators, and health expenditure, also vary widely. In what are coined “the best performing countries” (namely, Australia and New Zealand), life expectancy can be up to ~20 years higher and infant mortality ~15 times lower compared to their “poorest performing” counterparts (namely, Papua New Guinea and Solomon Islands) (Horwood et al., 2019). Additionally, only 4 out of the 14 countries of the Pacific Islands spend more than US$500 per capita per year on health expenditure, which still falls short of the global average of ~US$1000 per capita per year (The Lowey Institute, 2021). Proficiently functioning health systems are perhaps the most important origin of good health in LMICs, and globally, supporting people how and when they need it.

The Islands of the Pacific are significantly more exposed to the loss of disability-adjusted life years (DALYS), mainly due to metabolic diseases. Between 1980 and 2008, all genders and all populations of the Pacific Islands had the largest increase in BMI in the world (Horwood et al., 2019). In Tonga, 91% of adults are overweight and 67% are obese (Snowdon et al., 2010), and 36% and 54% of all 11-16 year-old boys and girls, respectively, are overweight or obese (Snowdon et al., 2010). In Fiji, heart disease, heart failure, stroke and hypertension are the cause of ~60% of deaths resulting from the impacts of increased BMI (Snowdon et al., 2010). In the South Pacific, Type 2 diabetes mellitus (T2DM) has the highest prevalence in the world, up to 30% among some Indigenous Pacific populations compared to ~9.4% in the United States (Horwood et al., 2019).

However, globally, the mortality and morbidity burden is substantially related to increasing rates of NCDs; all LMICs, not just the Pacific Islands, share this burden (Baird et al., 2017). The prevalence and impact of NCDs is a well-documented health, social and economic issue, and is attributed to changes in food accessibility and availability (Snowdon et al., 2010). Due to shifts in trade deals, the impacts of climate change, issues with transportation across atolls that range 5000km, and changes in agriculture and fisheries, there is a global trend of moving away from traditional diets within LMICs. As such, there is an increasing dependence on imported foods, such as rice. sugary snacks, and meat products (Snowdon et al., 2010), all of which are contributing to the increasing rates of metabolic diseases within LMICs. Improving diets, and consequently reducing the impact of NCDs and improving mental health, is a key origin of good health.

Social capital is another broad determinant of good health in LMICs. Social capital is defined as the “institutions, relationships and norms that shape up the quality and quantity of a society’s social interactions” (Agampodi, Agampodi, Glozier, and Siribaddana, 2015), and in 2005, the WHO defined social capital as both a ‘structural and intermediary determinant of health’ (Agampodi, Agampodi, Glozier, and Siribaddana, 2015). Access to resources and social influences are cited as the main link between social capital and health within LMICs, therefore we can assume that trade, supply chains, and impacts on culture and traditional ways of life, as well as well-functioning health systems, form the key origins of good health in LMICs.

2. Recommendations for policies that are likely to be the most effective

From 2008-2018, the Australian Department of Foreign Affairs and Trade (DFAT) provided $402 million in Official Development Assistance (ODA) for health programs in the Pacific (DFAT, 2019). In 2017, Australia announced it’s ‘Step Up’ commitment plan to increase engagement with countries of the Pacific Island (DFAT, 2021). In 2019-2020, Australia provided its largest ever ODA contribution to the Pacific Islands, totalling $1.4 billion of which 15.3% is to be spend on health (DFAT, 2019).

It is currently DFAT’s priority to invest in broad health systems strengthening, and demand for disease-focused health funding often comes from humanitarian pleas (DFAT, 2019). DFATs main contributions to improving health performance and outcomes in the Pacific Islands has been focused on governance, financial management, health information systems, and health services (DFAT, 2019). Whilst DFAT’s priorities are strong and on track, this memo will bring light to some specific health policies that can have a greater impact and address the current health challenges being experienced in the Pacific, as mentioned in the above section.

Health system strengthening through governance

Good health has been shown to reduce poverty levels and significantly contribute to sustained social and economic development within countries (DFAT, 2019). To achieve good functioning health systems and realise the aforementioned benefits, it is widely acknowledged that good governance plays the most critical role. In fact, the Universal Health Coverage (UHC) 2030 Platform and the ‘Health Systems Governance Collaborative’ are linked to harness and strengthen governance practices aimed at improving health system performances (Gilson, Lehmann, and Schneider, 2017).

Policy recommendation 1

• Australia’s next global health policy in the Pacific Islands should focus on achieving UHC through strengthening good governance with strategic partnerships that are country specific. This can be bolstered by:
  • Embracing the promise of the Sustainable Development Goals by leaving no one behind;
  • Recognising that health systems must be first built upon strong foundations by providing facilities, staff and equipment;
  • Learning from the past, it is important to know what has and hasn’t worked in this partnership model to strengthen local health systems.

A lifecourse approach to NCDs

In the previous section of this memo, it was outlined how NCDs have the primary responsibility for the burden of mortality and morbidity within LMICs and the Pacific. Research has shown that environmental influences starting from the early years of life can increase the risk of an individual developing an NCD later in life (Baird et al., 2017). Therefore, a lifecourse approach to preventing NCDs is recommended, where understanding the biological, behavioural and psychological processes of an individual can be used to optimise the potential for development and growth and intervene in their risk of developing an NCD in the future. This approach will also help to address the impacts of changing diets and focus on improving social capital, as mentioned in the above section of this memo.

Policy recommendation 2

• Australia’s next global health policy in the Pacific Islands should expand the emphasis on research and monitoring of early life influences that negatively impact on health and contribute to NCDs. This can be supported by:
  • Investing in research capacities that can inform the local health systems approaches;
  • Co-analyse early life influences on a country-specific level and determine their cause and impact;
  • Understand the local food systems in place, and how current trade policies impact on traditional diets;
  • Ensuring cultural traditions and relationships are not impacted in the process, and ensuring communication and support is tailored to the local health context.

3. The tensions between addressing a) the social and political determinants of health vs. health- or health-care specific programmes, and b) upstream vs. downstream social determinants of health

a) Social and political determinants of health vs. health- or health-care specific programmes

Social determinants of health include the conditions “in which people are born, grow, live, work and age”, and the systems that are in place to support the growth of a person affects their health and quality of life (Public Health Association Australia, 2021). These conditions shape the everyday lives of people and are responsible for the occurrence of health inequities. On the other hand, political determinants of health are determined by local, national and international laws (Public Health Association Australia, 2021). Analysing health impacts through the lens of political determinants highlights how competing institutions, ideologies and power groups affect health. However, the social and political determinants of health are often group together as one concept as politically progressive governments, such as Australia, tend to approve policies that aim to reduce the negative health impacts of social inequalities.

Research has shown that up to 30-55% of health outcomes are attributed to the social and political determinants of health (WHO, 2021b). In addition, sectors other than the health sector have been shown to have more of an impact on population health than the actual health sector (WHO, 2021b). Therefore, the social and political determinants of health are said to be more important to an individual’s, and populations, health and should command more attention than specific health issues.

Addressing health- or health-care specific programmes, AKA vertical programmes, refers to the delivery of health services that address a particular condition or disease, often within a specific timeframe (Oliveira-Cruz, Kurowski, and Mills, 2003). Vertical programmes are sometimes prioritised over addressing the social and political determinants of health because they are less costly, require less resources, are easier to monitor and implement, and it is often easier to secure funding and approval for specific causes (Oliveira-Cruz, Kurowski, and Mills, 2003). However, vertical programmes do not promote self-reliance within a community, do not take into consideration the variations of health issues within and between countries, and do not allow for a more holistic approach to health (Oliveira-Cruz, Kurowski, and Mills, 2003).

b) Upstream vs. downstream determinants of health

Upstream determinants of health occur at the macro level and include government policies and global forces, whereas downstream determinants of health occur at the micro level, including an individual’s genetics (Australian Medical Association, 2021). In other words, the upstream determinants of health can influence the number and severity of illnesses or diseases, but it is downstream determinants of health that are operating when a person is unwell.

For example, if a patient requires a new drug for a chronic illness, an upstream approach will address health policies to ensure timely access, whereas a downstream approach would likely see the patient administered a generic drug as it does not include factors outside of that individual. Many of the same arguments for and against upstream vs. downstream determinants of health are similar to those of the social and political determinants of health vs. health specific programmes. Similarly, the upstream approach is long, complex and costly. In contrast the downstream approach includes inequities such as access to care, resources, less than optimal health systems, and generic treatment. Whilst downstream causes are easier to identify, they do not address the underlying causes of health issues.

In the long term, it is not unreasonable to expect that health systems can be strengthened to such an extent that they address the social, political, upstream, downstream and vertical determinants of health. In other words, health systems will be integrated to such an extent that countries are self-empowered with good health governance and can remove systematic inequities within and between communities. Such an approach is often termed diagonal (Mercer et al., 2019). Effectively addressing social determinants of health and incorporating disease-specific programmes should effectively address barriers affecting access to health services and increase good health governance and will be pivotal in helping the Pacific Islands achieve UHC (DFAT, 2019).

4. Unintended consequences to be aware of

In advising on a new policy on global health in the Pacific Islands, there are a number of potential consequences to keep in mind:

1. Any reduction in funding Pacific Islands health runs the risk of increase the burden of infectious and non-communicable diseases;
2. If engagement is not strategic and around shared objectives, an inclusive and supportive environment will not come to fruition and countries may lose trust and respect for Australia;
3. Providing technical assistance will not empower self-reliance nor address the underlying causes of health issues or health system weaknesses;
4. Financial and advisory support must be responsive to the changing local context and needs due to shifts in, for example, trade and climate change;
5. Health- or health-care specific programmes have been historically unsustainable due to lapses in donor funding and support;
6. Health- or health-care specific programmes have the potential to draw resources away from the broader healthcare system to address one specific illness or disease;
7. Approaches that address the upstream or social and political determinants of health have the potential of becoming diluted by trying to address too many factors at once;

Final Note

The Australian government has the opportunity to Partner with health ministers of the Pacific Islands to better support their Healthy Islands vision and achieve UHC by 2030.

This memo would like to highlight that Australia has a long-running, respected relationship with the Pacific that it needs to uphold. Currently, the most pressing health issues faced in the Pacific Islands relate to NCDs and social capital. Strengthening health systems through increased health governance and utilising a lifecourse approach to NCDS are the two policy recommendations that will be the most effective.

Ultimately, the best approach to strengthening health systems in the Pacific Islands and achieving UHC is to co-create diagonal health approaches that systematically prioritise the social and political determinants of health and address the most pressing infectious and non-communicable diseases, and their root causes. Additionally, this must be done with respect to the local context, and a one-size-fits-all approach will not be effective.

References

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Mercer, T., Chang, A.C., Fischer, L., Gardner, A., Kerubo, I., Tran, D.N., Laktabai, J. and Pastakia, S., 2019. Mitigating the burden of diabetes in sub-saharan Africa through an integrated diagonal health systems approach. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 12, p.2261.

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