Local government’s important role in public health
Globally, preventable non-communicable diseases (NCDs) are on the rise and present a serious risk to the sustainability of health care systems. The prevalence of many NCDs is due to inadequate physical activity, poor diet and social isolation and is determined by factors outside the health system, including poor land-use planning decisions that have resulted in low densities, car dependence and food deserts. Healthy urban planning therefore has significant potential to reduce the global burden of disease.
As the level of government closest to the people, Victorian local government has critical potential to enhance these social determinants of health. It has extensive interaction with its communities and germane experience of the local manifestation of contemporary health issues. It also has significant authority to manage land use and development.
Appropriately, each of Victoria’s 79 LGs is legislated under the Public Health and Wellbeing Act (2008) to prepare an evidence-based municipal public health and wellbeing plan (MPHWP). MPHWPs must be consistent with the municipal strategic statement, and either consistent or integrated with the council plan. These requirements recognise that decision-making within many, if not all of a local government’s diverse departments can beneficially influence health and as such, the legislation sends a clear message that improving public health is a primary purpose of local government.
In preparing their MPHWPs, section 26(3) of the Act requires Victorian local government to ‘have regard’ to the Victorian Public Health and Wellbeing Plan and the health priorities listed therein (Victorian Government, 2008). In the previous planning cycle, The State Plan framed priorities in terms of their downstream consequences (Zola, 1970), emphasising environmental health, communicable disease control, and lifestyle-related risk behaviors (Victorian Government, 2011b, p.4)
There are significant benefits to LG receiving guidance from the State regarding priorities. The efficiencies, obtainable from local delivery of state-wide health promotion campaigns, are a salient example. However, given LG’s unique experience of local health issues, there is also benefit in councils making their own decisions based on assessments of their communities’ health needs and the resources available (Mason, 1990). Perhaps in acknowledgement of this fact, the Act is not prescriptive regarding the extent to which local government should ‘have regard’ to State Health Plan priorities.
Consistent with this, a recent analysis of MPHWPs showed that only a third of all actions in MPHWPs targeted state government priority areas directly (Browne, unpublished, Browne et al., 2016). Instead, Victorian local government’s unique experience and agency in public health led it to focus more on gambling and the prevention of violence against women, and also to direct many more actions towards upstream determinants of health (Zola, 1970), with a particular focus on improving social cohesion and democracy, managing growth and development and enhancing leisure and cultural opportunities. Although Victorian local governments could be said to have satisfactorily fulfilled their obligations under the Act, to Victorian local government the words ‘have regard’ meant no more than they say: local governments did not ignore the state priorities and generally gave them the attention, thought and such weight as was considered appropriate. But having done that, they often concluded that the state priorities were not of sufficient significance to outweigh other considerations in accordance with their statutory function.
The Victoria state government has recently acknowledged the merit of local governments’ locally responsive and upstream approach and this has resulted in a shift of state-level priorities that is reflected in the current State Health Plan (2015-2019). Specifically, the current plan acknowledges that although councils responded to many of the priority areas of the State Health Plan, many also
. . . noted that their contributions to the health and wellbeing of their communities go beyond the priorities listed in the first plan. Additional areas included in some council plans were problem gambling, community safety, immunisation, land-use planning and family violence (Victorian Government, 2015c, p. 6).
Regarding the last of these issues, local government’s advocacy regarding the causes and consequences of family violence has also resulted in a recent amendment to the legislation. As a result of a number of submissions to the Royal Commission into Family Violence (Victorian Government, 2016), from May 2017 local governments’ leadership in tackling family violence was supported and reinforced through changes to the Act requiring MPHWPs to explicitly describe how the council would both prevent violence against women and respond to the needs of victims.
State government’s acknowledgment of local government’s priorities is a commendable response to research into MPHWPs, and suggests that the Victorian State Government increasing recognises local government’s commitment to and potential for improving health and wellbeing. However, there is also a risk that local government’s high level of organisational efficacy (Fearon et al., 2013) to improve the social determinants of health will result in increased cost shifting. Although local government is the level of government closest to the people, ultimately, its effectiveness as an agent of public health is limited and there are many health determining-policy issues that are beyond its jurisdiction. State and Commonwealth Government must therefore continue - and indeed increase efforts - to improve the socio-economic, cultural and environmental conditions that determine health (Barton and Grant, 2006, Dahlgren and Whitehead, 1991). Most importantly, State and Commonwealth Governments should actively work to ensure that all policy decisions, from taxation and trade, to the regulation of local industries, meaningfully contribute to improving health equity for all Australians.
About the Author
Geoff Browne @CubisticNevada is undertaking a PhD in local government's use of evidence in their health planning and how it organises its efforts against a social determinant of health framework. He is an academic at the University of Melbourne's School of Population and Global Health and a lecturer and tutor in the Melbourne School of Design and ACU's School of Allied Health. Prior to this Geoff worked for seven years as a senior policy analyst and professional wildfire fighter with the Victorian Environment Department and Environment Commissioner. He was a chief author of the 2008 State of the Environment report and the 2013 State Waste Policy. Geoff also has experience in local government and private practice as a sustainability consultant. It was while working for state government that Geoff became interested in the role of evidence in decision making, and the importance of community wellbeing for sustainability.
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