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.