All posts by Bret Hart

My wicked problem is bigger than yours!

The fact that health costs will consume the entire State Government budget in less than 25 years is a wicked problem* that precipitated the South Australian (SA) Government to explore a new approach to improving the health and wellbeing of the population.

Climate change might be an even bigger wicked problem, but the unsustainable growth in health care costs is a more urgent threat.

It is likely to be even more immediate than indicated in the graph below as forecasts of health costs tend to follow previous trends in costs of treating diseases only. For example, the trend in decline in cardiovascular disease rates would reduce costs but the (yet another) wicked problem of obesity is yet to make its large presence fully felt with the weight of chronic diseases that it induces. Thus progress in one area is likely to be overwhelmed by costly health problems elsewhere.


Total state budget compared to health sector expenditure Source: Department of the Premier and Cabinet, South Australia


Moreover, energy costs, the negative influence of economic turmoil, and the injuries and deaths from extreme weather events are rarely considered in forward estimates of health care costs as they are hard to predict.

Nevertheless the SA Government considered that there was enough troubling evidence to explore a new approach to improving the health and wellbeing of the population. Informing this approach was the realisation that this wicked problem can only be tackled with the collaboration of other agencies that influence the determinants of health.#

This approach, coined ‘Health in All Policies” (HiAP) was incorporated into the latest European Health Strategy and is progressively being implemented by all member countries of the European Union.

In a nutshell the HiAP approach actively encourages all government agencies to incorporate health, well-being and equity impacts in their policies and plans. In South Australia it is not just a nice idea, but is a commitment by all heads of department spelt out in the State’s Strategic Plan. Having the Premiers’ endorsement and support was critical in SA becoming recognised as a leader in adopting the HiAP approach.

SA invited internationally renowned public health, health promotion and global health expert, Professor Kickbusch to be the 2007 Adelaide Thinker in Residence. Professor Kickbusch recommended that SA adopt Health in All Policies as it, “… provides an opportunity for government agencies to work together to try to improve the health of the population through addressing the Social Determinants of Health (SDH) and helps to create a cost effective, sustainable health system.” 

This ultimately led to the establishment of a HiAP Unit within the SA Health Department.

HiAP Summer School in Adelaide

In 2010, the World Health Organization (WHO) and the Government of South Australia co-convened an international meeting on HiAP, where the need for new skills and competencies in public health were discussed and documented in the Adelaide Statement on HiAP. As a result of this need, the first HiAP international Summer School was held over five days between 28th Nov – 2nd Dec this year.

About 40 people attended from India, Latvia, Afghanistan, England, Holland, PNG, USA, Egypt, Malaysia, Canada, Mongolia, Northern Ireland, Armenia, and Australian States and Territories apart from Victoria and the ACT.

The evidence has yet to emerge that the HiAP approach will fulfil the objective of creating a cost effective, sustainable health system. The often-cited study of the North Karelia Project in Finland is held up as an exempla of HiAP1,2 but there has been a tendency to attempt replication of elements of the North Karelia project, without due consideration of the unique population and setting being targeted leading to an undermining of the success of community based health promotion.3

Meanwhile there is clear evidence that investment in the early years is cost effective4 and yet the expenditure on health, education, income support and social services increases with age in inverse proportion to the potential for long term benefit as shown in the diagram below.

Update 5/4/12: diagram inserted

With most of the developed world likely to be following the example of the US in expending about a third of all health care resources in the last year of life,5 the HiAP approach will need to do more than invite other agencies to tackle the SDH.  

Even if the HiAP approach drives an agenda that enables the population to reach its maximum health potential, this good work will be undone if the planet becomes uninhabitable. Also the prospect of death and injury from extreme weather events associated with dangerous climate change necessitates HiAP to enhance not only the SDH but also the determinants of ecological health. It would make no sense to establish a separate ecological HiAP as the determinants of ecological health, like the SDH, all lie outside health care services (apart from the fact that health care services contribute to resource depletion and pollution). Also the SDH agenda should incorporate a key message (number 6) from Prof Sir Michael Marmot’s UK review, ‘Fair Society Health Lives’6 as follows;

“Economic growth is not the most important measure of our country’s success. The fair distribution of health, well-being and sustainability are important social goals. Tackling social inequalities in health and tackling climate change must go together.”

This call meshes well with recent developments on sustainable economics, as for example explained by Dr Phil Lawn on this site.

In this vein, the SA publication edited by Kickbusch and Bucket entitled ‘Implementing Health in All Policies Adelaide 2010’7 points out that, “…few nations have adopted measures that integrate economic, social and health indicators and acknowledge their fundamental connections. Indeed, an unquestioning dedication to economic growth per se by governments and mass media has been critiqued as part of the problem, contributing to widening equity gaps, dangerous climate change, and mental and social health problems. In response to these challenges, a number of broader measures of national progress have been developed. These are characterised by combining a range of indicators that span various sectors and are well suited to monitoring the progress of a HiAP approach. Already, in South Australia, the SA Strategic Plan provides an example of the sort of development agenda that could dovetail effectively with such alternative indicators.”

South Australia’s endeavours would be facilitated if healthy public policy was implemented at a national level by adopting the HiAP approach but with a refinement to prioritise interventions that have evidence for long term health gain rather than short term politically expedient returns on investment.* Also the HiAP approach would be more effective if the community demanded it as their right.


 1.        Puska P. Health in all policies. The European Journal of Public Health. 2007;17(4):328.

2.         Puska P, Tuomilehto J, Nissinen A, Salonen J. Ten Years of the North Karelia project. Acta Medica Scandinavica. 1985 Jan 12;218(S701):66–71.

3.         McLaren L, Ghali LM, Lorenzetti D, Rock M. Out of context? Translating evidence from the North Karelia project over place and time. Health Education Research. 2007 Jun 1;22(3):414–24.

4.         Heckman J, Carneiro P. Human Capital Policy. National Bureau of Economic Research Working Paper Series [Internet]. 2003;No. 9495. Available from:

5.         Hogan C, Lunney J, Gabel J, Lynn J. Medicare Beneficiaries: Costs Of Care In The Last Year Of Life. Health Affairs. 2001 Jul 1;20(4):188–95.

6.         Marmot MG, Allen J, Goldblatt P, Boyce T, McNeish D, Grady M, et al. Fair society, healthy lives: Strategic review of health inequalities in England post-2010. 2010 Feb 7 [cited 2011 Dec 13];Available from:

7.         SAPO — South Australian Policy Online [Internet]. [cited 2011 Dec 13];Available from:


* A wicked problem is one that is difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognize. Moreover, because of complex interdependencies the effort to solve one aspect of a wicked problem may reveal or create other problems.

# This approach is in distinct contrast to Western Australia that some years ago realised that health care costs were unsustainable. In response to the crisis, all health department activity was prioritised according to meeting the criteria of “immediate threats to life.” This facilitated a sweeping range of funding cuts and reorganisations.


* State and Territory Health Directors General and Exec. Directors were invited to Adelaide on the first business day following the Summer School to meet with Prof Ilona Kickbusch, the HiAP Unit and Australian Government representatives to discuss the implications of the Rio Summit on the SDH in October. Update 4/4/2012: Someone did attend from Victoria. Victoria and Western Australia declined the invite. 

Who cares about cleaner living?

Some of you may know of the story related by the famous psychiatrist specialising in death and dying, the late Dr Elizabeth Kübler-Ross. She described how she had noticed that some of her patients in her hospital in Chicago were happier and more at peace on certain days. She discovered that this coincided with the days that an uneducated elderly black cleaning lady sat on their beds, occasionally held their hands and chatted and laughed with the patients. In particular there was one dying lady on oxygen who was in pain and in denial about her impending death who expressed concern to the cleaner that plugging in the vacuum cleaner might spark an explosion. The astute cleaner recognised this worry as a call for help with her fear of dying and seized the moment to explore her thanatophobia.

Kübler-Ross approached the cleaning lady and asked “What are you doing with my patients”? The cleaning lady, thinking she had done the wrong thing and might be sacked, could hardly utter a word but eventually revealed that she had endured poverty and tragedy for most of life, especially the death of her three year old son whilst awaiting treatment for pneumonia. The cleaner explained that “…dying patients are just like old acquaintances to me, and I’m not afraid to touch them, talk with them, and to offer them hope.”

This event occurred around the time that Kübler-Ross advertised for an Assistant. She received about 5000 applications including professionals with higher academic credentials and qualifications than herself. But she offered the position to the cleaner who had demonstrated the empathic skills she was looking for. 

What a different story it would have been today if the practices of employers of cleaners today were being used then at the Chicago Hospital. For example a ‘wand’ that might be magic to management has become the bane of the lives of some cleaners in Victoria. This was one of many issues revealed in a report by the Uniting Care Creative Ministries Network.

A wand is a gadget that some cleaners have to use to send a signal to a receiver to indicate the starting and finishing the cleaning of an area. At the end of the shift a computer analyses the information and indicates the number of areas cleaned. Kübler-Ross’s cleaner would have probably been sacked having scored badly as she was distracted from her cleaning by going the extra mile by responding to a human need. The survey of 380 cleaners working in Victorian shopping centres by the staff of United Voice  from April to August 2011 revealed that nowadays they have to more than focus on their core business as they are under increasing pressure to perform as a consequence of outsourcing. As one cleaner explained “they underquoted everything when they bought the shopping centre contract”. As reflected in the title of the report ‘Cutting Corners’, the more contract cleaning companies compete within the tender specifications that are set within the narrow economic parameters of the shopping centre owners, the more they contribute to the ever increasing pressures on their staff. 57% of those surveyed felt stressed about their workload. The report refers to studies that link working under these conditions is unhealthy so there is a price paid by the workers for adopting this widespread practice of outsourcing. A brief scan of the literature reveals that several studies refer to the efficiency gains with refuse collection (Boyne 1998) but there seem to be few studies showing that competitive tendering is more financially efficient when applied more widely. In one review it was made clear that in the UK the motivation for compulsory competitive tendering was not based on evidence but the political ideology of the Thatcher government and its privatisation agenda (Hodge 1999).

For the cleaners surveyed in Victoria this ideology that has become the norm has resulted in, “… minimum labour standards, labour cost-cutting, and increased workloads to protect and enhance the profits of property owners/ managers and cleaning contractors [that is] is a failure of corporate social responsibility. It puts too many cleaners’ health and safety at risk, contributes to tension and conflict in their families, provides an inadequate wage for today’s cost of living, and is flirting with public health and safety.”

The report indicates that the pay for a level one cleaning service employee, the level at which most shopping centre cleaners is employed, is $629.50 per week, according to the Cleaning Services Award (2010). This is significantly lower than the updated poverty line for 2011, which, “inclusive of housing costs, … is $835.30 per week for a family comprising two adults, one of whom is working, and two dependent children.”

Whilst the effects of work stress are referred to in the report, another relevant and famous study is of Whitehall Civil Servants by expatriate Professor Sir Michael Marmot (Marmot et al. 1991). He found a strong association between grade levels of civil servant employment and mortality rates from a range of causes. Men in the lowest grades had a mortality rate three times higher than that of men in the highest grade. It is important to note that none of the civil servants were living below the poverty line implying that the mortality rate would be even higher. Living below the poverty line accounts for some of the following results from the survey with long term health consequences as intimated from Marmot’s research. Over half the cleaners reported the following financial difficulties: 64% can’t afford to visit the dentist, 56% have had trouble paying for groceries, 53% have experienced difficulty with rent or mortgage repayments, 53% sometimes have trouble paying medical expenses and 53% can’t afford to buy a house.

It is not surprising that a report that is compiled by a religious organisation will make recommendations based on breach’s of religious social ethics but it is likely that similar suggestions would emanate from a health impact assessment of the work practices that have led to the results of the survey.  For example from the 1891 Encyclical of Pope Leo XIII on Capital and Labor “…It is neither just nor human so to grind men (and women) down with excessive labour as to stupefy their minds and wear out their bodies”  and “justice, therefore, demands … that they who contribute so largely to the advantage of the community may themselves share in the benefits which they create….”

Unfortunately this report reveals that the trickle down theory – as expressed by the economist John Kenneth Galbraith by saying “if you feed enough oats to the horse, some will pass through to feed the sparrows” – is just rhetoric. It is ironic that the trickle down effect has been demonstrated not to work in facilities that have been described as the temples of consumption where it is argued that the consumption of material goods has taken on near-sacred values. Perhaps this accounts for the pride that some cleaners get from making the customer (worshiper) experience a satisfying (spiritual) one. Viewing this with a pseudo-health rather than non-secular lens, the ‘disease’ that is being described is ‘affluenza’ which is more prevalent than the infectious diseases that the cleaners may be preventing by their efforts. The status-fuelled affluenza epidemic occurring within the ‘temples’ may exaggerate the feeling of inferiority as people “cannot keep up with the Jones”, but more concerning is to learn of the rude or abusive behaviour from managers or supervisors that occurred towards about a quarter of the cleaners surveyed.

Hopefully this report and the Clean Start: Fair Deal for Cleaners campaign will address the issues for cleaners working in Victorian Shopping Centres and set a precedent for the rest of Australia to follow. It will help give a voice to those who have been meek in their demands. So to end on a non-secular note “Blessed are the meek: for they shall inherit the earth” (Matthew 5:5) and this is not unrelated to the fact that the author of Blessed Unrest, Paul Hawkin is speaking at the UWA Summer School. Perhaps he will inform us of an unprecedented movement to help counter the Affluenza epidemic (as well as global warming) that has helped create this injustice experienced by cleaners in the first place.


Boyne, G.A., 1998. Competitive Tendering In Local Government: A Review Of Theory And Evidence. Public Administration, 76(4), pp.695-712.

Hodge, G.A., 1999. Competitive Tendering and Contracting out: Rhetoric or Reality? Public Productivity & Management Review, 22(4), pp.455-469.

Marmot, M.G. et al., 1991. Health inequalities among British civil servants: the Whitehall II study. The Lancet, 337(8754), pp.1387-1393.