"Never mind the logic, give me the numbers": former Australian health ministers' perspectives on the social determinants of health

Abstract

The articulation of strong evidence and moral arguments about the importance of social determinants of health (SDH) and health equity has not led to commensurate action to address them. Policy windows open when, simultaneously, an issue is recognised as a problem, policy formulation and refinement happens and the political will for action is present. We report on qualitative interviews with 20 former Australian Federal, State or Territory health ministers conducted between September 2011 and January 2012 concerning their views about how and why the windows of policy opportunity on the SDH did or did not open during their tenure. Almost all ex-health ministers were aware of the existence of health inequalities and SDH but their complexity meant that this awareness rarely crystalised into a clear problem other than as a focus on high needs groups, especially Aboriginal people. Formulation of policies about SDH was assisted by cross-portfolio structures, policy entrepreneurs, and evidence from reviews and reports. It was hindered by the complexity of SDH policy, the dominance of medical power and paradigms and the weakness of the policy community advocating for SDH. The political stream was enabling when the general ideological climate was supportive of redistributive policies, the health care sector was not perceived to be in crisis, there was support for action from the head of government and cabinet colleagues, and no opposition from powerful lobby groups. There have been instances of Australian health policy which addressed the SDH over the past twenty five years but they are rare and the windows of opportunity that made them possible did not stay open for long.