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Please note: This summary can also be downloaded in pdf format here >>

This is the first in a series of Dialogues on this topic. For information on the second Dialogue, click here >>

Comments

The Oxford Health Alliance would very much welcome your comments on this Dialogue. Please contact Professor Ruth Colagiuri with any feedback: rcolagiuri@med.usyd.edu.au.

Background

Law and Health Policy Dialogue was initiated by the Oxford Health Alliance Asia Pacific arm to begin a process of exploring the untapped potential of the law and health policy to interact to moderate determinants and vectors of chronic diseases which may be generated or exacerbated by workplace conditions or the broader physical environment. This theme is an undercurrent to the Oxford Health Alliance workstreams, which centre on:

• Developing the economic argument for preventing chronic diseases
• Urban design
• Prevention in the workplace
• Youth
• The role of industry/business in health

These streams – in particular the urban design stream – will form the central focus of the Oxford Health Alliance Global Summit, which will be held in Sydney in early 2008. The Summit’s primary objective will be to set health goals to optimise the opportunities arising from the present increase in economic wealth and minimise the unwanted and unintended consequences of this greater affluence.

The Summit will bring together influencers from public and private health, legal, business, building and transport sectors together with governments, employee unions, academics, researchers, activists and non-government organisations to construct a plan – and build a ‘coalition of the committed’ around the plan – for re-engineering the policies and practices that currently constrain efforts to reduce the burden of chronic diseases in Australia and internationally. 

Purpose of the Dialogue

As a tool for ameliorating social determinants of chronic diseases, the law will be pivotal to this process. Consequently, in late 2006, Justice Terry Sheahan was persuaded to identify and lead a small group of people with particular expertise in law, workplace health, and urban design with a view to developing an issues paper to feed into the Alliance’s 2008 Summit. 

The Law and Health Policy Dialogue was co-convened by Justice Sheahan and Associate Professor Ruth Colagiuri to commence a journey exploring ways in which the law might be used to modify and ameliorate a range of workplace and environmentally determined behaviours and health risks. Specifically the purpose of the Dialogue was to:

• enter into seminal discussion on the topic;
• develop a framework for further exploration of the issues; and
• identify a small number of people to join a working group to develop a discussion document on how health and legal policy can interact to create healthier workplace and physical environments.

The Dialogue was convened in full consciousness of the emerging international appreciation of the centrality of the role of law in promoting and protecting health, and the awareness that there are many other groups and individuals with an interest and activities in this field who need to be engaged or drawn into collaboration as the movement evolves and gathers momentum.  

Summary of the discussion

The Dialogue was held at the University of Sydney and was loosely predicated on the following discussion guide:

1. Defining and scoping the key issue/s around the interface between the law and health.
2. Identifying areas and mechanisms in which health policy can be used to shape legislation, and legal policy can feed into health,  particularly in relation to the workplace and the broader physical environment.
3. Identifying the core elements of a framework for developing a discussion paper on potential areas and pathways for legal and health policy to coalesce to create environments that inhibit chronic diseases.

1.  Scope

The discussion opened with the question: 'If a key objective of health policy is to achieve better public health outcomes then what role does the law play in developing, shaping and maintaining this with particular regard to urban environments in modern technological societies in both developed and developing countries?'

In scoping the focus of the discussion, it was agreed to retain – as the backdrop – a broad overarching acknowledgement of the role of the law in shaping societies, while keeping the remit  manageable by limiting it to the workplace and urban design rather than the wider social environment.  Discussion points included:

• The question of where does the law fit into governance, guidelines and public policy? How do we create healthy workplaces and urban spaces?
• This came with a plea to think laterally around the law and not be constrained by narrow notions of prescriptive legislation. Rather, use the law in a positive and creative way to enable health to flourish. This means considering how law might influence a range of determinants for health, as they apply specifically to the workplace, and the physical environment. Law might have a role, for example, in influencing economic policies, influencing the behaviour of businesses, in shaping the environment directly (e.g. through planning laws), as well as supporting patterns of socialisation that are health-enhancing. The goal, in each case, is to mitigate the negative impacts of the workplace and the environment upon health, and to use law as a policy tool to facilitate better health outcomes in these areas.
• The need for a focus on good policy to underpin law – social policy as well as health policy, situational objectives, urban planning, and not just Occupational Health and Safety – was affirmed  as was the need to consider differences in urban and rural health and the corporate, workplace and government policies that prevail and impact on each.
• While it was thought that a focus on urban environments is appropriate, there was a feeling that the contextual differences in developing countries and rural areas warranted specific consideration.
• The governmental jurisdictional and interdepartmental chasm was raised as being in need of attention with similar but less acute concerns being expressed with regard to corporations.

2. Mechanisms

Although the notion of applying the law to social and environmental determinants of chronic diseases is only now gaining ascendency, there were thought to be a number of areas which could be utilised and built upon:

• With regard to two overt and major proximate health risks – smoking and inappropriate nutrition – it was noted that we already have the Framework Convention on Tobacco Control supported by extensive legislation and, at the policy level, the WHO Global Strategy for Diet, Physical Activity and Health as exemplars.
• Over-regulation of the wrong kind should be avoided and we must learn to speak the language of the corporate world and put the argument in terms they can relate to: 'use the language of the hip pocket, e.g. return on investment, and cost-benefit ratios demonstrating the health and economic gains to be made where workers and companies adopt health promoting policies and practices versus those that don’t'.
• The role of the trade union movement is potentially pivotal and its engagement in shaping legal and health policy relating to the workplace and urban planning is to be strongly encouraged.
• Corporate social responsibility as it now stands is not enough. We need to redefine corporate social responsibility and use existing cross-cutting structures to get health a place at the boardroom table, e.g. (in Australia) the Institute of Company Directors Standards. 
• Governments are employers and construct or rent and remodel buildings. Pressure needs to be put on them to contribute health promoting polices, health promoting workplaces and health promoting urban design. Universities should also become exemplars of health-promoting workplaces and environments.
• We need to move outside our health ‘silo’ and reach out and engage economists – particularly macroeconomists. We also need to get more planners and urban designers involved and perhaps a representative from the Planning Institute of Australia.
• Review and make use of knowledge gleaned from other examples of changes arising from public concern and identify ways in which the law can be applied as a tool for  supporting  change: 
   – what policy development and implementation initiatives have worked?
   – how did they work and what were the pathways?
   – are additional promising models evolving?
• Health is an unmanaged risk in Australia at present. Policies and implementation strategies using incentives and disincentives can be applied, e.g. incentives such as tax deductions for corporate organisations that are proactive in this area and/or penalties such as increased premiums for failure to act.
• All models and mechanisms need to incorporate a dual top-down/bottom-up approach

3.  Towards a framework

Conceptualising the elements and intricacies of the interface between the law and health policy generated the following points:

• It may be appealing to write things down in regulation but law has more far-reaching implications: 'build a framework based on broader regulatory systems, flexible solutions and guidelines – don’t conceptualise the law in a restrictive way'. 
• Consider issues, concepts and constructs of responsibility. Whose responsibility is health – the individual, the employer, the state?  And, if it is the individual, to what extent do barriers imposed by others constrain his/her capacity to shoulder that responsibility?
• Move the environment and planning focus from noise and air pollution to nutrition, physical activity and design. Similar to Scandinavia, develop a tripartite coalition between the judiciary, industry (both business and unions) and administrative authorities.
• Move occupational health and safety from a focus on injury avoidance to a concern with general physical and mental health ensuring a strong preventative focus in relation to workplace organisation and conditions. 
• Look to frameworks and models from other countries for guidance, e.g. the European Union, Scandinavia.

Additional thoughts put forward since the Dialogue

One major theme with the physical environment is: how do we get cross-cutting structures that get health a place at the decision-making table? Can law help? Health needs more influence in the governance of the physical environment. The same might be said of ‘corporate governance’, which is usually thought of as purely a private matter for employers/corporations.

Turning to the role of employers and to the design of healthy, active workplaces: what are the environmental conditions within workplaces that might be facilitated (by laws and policies) to promote and preserve health? Note that law is only part of the puzzle: defining the role of law necessarily means working out which policies should take legal form.

Where to next?

It was felt that a certain critical mass is needed to generate the sufficient momentum to effect change. The next step should be a small working group to develop an issues paper that drills a little deeper into the possibilities and a broader reference group to review the findings as this is progressed. The wider reference group should include broader representation, in particular from the urban planning and building industries. Consideration was given as to whether economists should be represented directly or brought in via the networks of the people and organisations already involved, or who will be drawn in, with the latter option appearing the most popular. 

There was thought to be some urgency about refining and articulating a framework and a need to engage a wider stakeholder group encompassing corporations, big builders, relevant government and non government agencies and to be mindful of the different needs in developed versus developing countries. 

Since the Dialogue steps have been undertaken to broaden the discussion nationally and plans are underway to organise a second Dialogue in Melbourne. As a means of obtaining input from the international ‘community of interest’ in this area, the Dialogue Summary will be placed on the Oxford Health Alliance website and its interactive website 3four50, which can act as a vehicle for broadening the debate to an international audience both within and outside the Alliance. 

It was felt that the Law + Health Working Group should initially be primarily concerned with building the momentum for generating discussion and analytical debate. In Australia this could make use of the forthcoming elections and, on an international front, obtaining insights and inputs from other countries – notably the large and rapidly developing economies such as India and China. 

The Dialogue concluded with a strong feeling that every initiative has its time and that the time for this one is ripe. There is a sense of readiness suggesting that proposals for change may be better accepted than in the past and the Oxford Health Alliance provides an ideal platform for the dissemination and promotion of well-informed and considered strategies with the first task being  to develop a conceptual framework that appropriately balances the regulatory role of the law with it’s potential to interact with and influence health, social, fiscal and general public policy and decision-making to improve the environment for health. 

Participants

For a full list of participants, please see the full summary document here >>