2013 vol. 37 no. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 503© 2013 The Authors. ANZJPH © 2013 Public Health Association of Australia

Editorials

doi: 10.1111/1753-6405.12165

Funding the ‘H’ in NHMRCFran Baum, Matt Fisher

Southgate Institute for Health, Society and Equity, Flinders University

Dennis TrewinFormer Australian Statistician; Chair, Policy and Advocacy Committee, Academy of the Social Sciences in Australia

Angella DuvnjakSouthgate Institute for Health, Society and Equity, Flinders University

Members of the Public Health Research Advisory Group of the Public Health Association of Australia

Introduction Pressure from a range of sources on the National Health and

Medical Research Council (NHMRC) is intensifying to increase

the funding it devotes to the social determinants of health. Most

significantly, the Senate Community Affairs Reference Committee

recommended in its report on Australia’s domestic response to

the Commission on the Social Determinants of Health that “the

NHMRC give greater emphasis in its grant allocation priorities to

research on public health and social determinants research”. 1 The

underlying message for the Council is the same as expressed by

others: you do well at funding medical research but much less well

at funding health research. The newly elected Coalition Government

is committed to research that improves the health and wellbeing of

Australians and has decided to give a $100 million boost to medical

research.2 Research on social determinants may be more cost

effective than biomedical research in addressing many health issues.

In this editorial we consider the arguments that have been advanced

to support this message and suggest some steps towards improved

research funding for social determinants of health research.

BackgroundThe NHMRC is the primary funder of health and medical research

in Australia. The bulk of its funded research tends to focus on

illness and disease rather than on health, and on individuals rather

than populations. In 2012, only 14.5% of NHMRC funding went

to public health and there is no data on how much of this was for

social determinants research.3

Over the past 10 years there have been numerous reviews and

inquiries into the nature of health and medical research in Australia,

such as the 1998 Wills Review4 and the 2004 Grant Review.5 The

2008 Nutbeam Review6 into NHMRC’s public health research

funding found that they funded very little research on the social

determinants of health specifically and under-funded public health

more generally.

Recently, the Public Health Association of Australia (PHAA),

through its Public Health Research Advisory Group (PHRAG)

and in cooperation with the Academy of Social Sciences in

Australia (ASSA), has sought to advance the case for improved

support and a more strategic approach to funding health research.

In September 2012, the PHAA and ASSA held a one-day Round

Table in Canberra,7 attended by some of Australia’s leading

health researchers, to discuss how the NHMRC could achieve the

recommendation of the Commission on the Social Determinants of

Health8 that ‘research funding bodies create a dedicated budget for

generation and global sharing of evidence on social determinants

of health and health equity, including health equity intervention

research’ (p. 186). PHAA also made submissions to the recent

Senate Committee Inquiry9 and the McKeon Strategic Review of

Health and Medical Research in Australia10,11 and to the Australian

National Preventative Health Agency consultations on their research

strategy.12 The main points from these submissions and the Round

Table, relating to the role of NHMRC, are discussed below. We are

not arguing for research funding to show that social determinants

are important. That is well known. We are arguing for research into

the systems and policy interventions that effectively address the

impacts of social determinants.

The importance of increased investment in social determinants of health research

The Commission on the Social Determinants of Health

summarised the significant body of research supporting the notion

that health outcomes are predominantly determined by social,

economic and cultural factors outside the individual and the

provision of health services.8 It also put forward the view that health

inequities are ethically untenable and can create costly demands on

health services. In all OECD countries the costs of acute treatment

services, reflecting an ever-increasing supply of new medical and

pharmaceutical therapies and increasing rates of chronic disease, are

leading governments to look for effective strategies to promote good

health and better prevent disease. The Coalition Government elected

in September 2013 has put a priority on improving population health

and wellbeing. This includes Indigenous people, for whom the focus

should be on social determinants such as education and training,

employment and housing, and combating racism. NHMRC’s central

role is to ‘build a healthy Australia’ that should include addressing

the social determinants of health across all population groups.

Despite these national priorities, the majority of NHMRC funding

for medical research until now has been directed toward biomedical

research to produce new forms of treatment for disease and the

‘health’ component focused on interventions to persuade individuals

to change their behaviour. The NHMRC funds very little research

that considers the broader factors. The current focus on high-risk

individuals and groups, and biomedical research, is less likely to

achieve improved population health and improved health equity

than attention to whole-of-population research that addresses the

social determinants of health.

The economic arguments in favour of a greater focus on social

determinants of health inequities have been made by Brown et al.13

who estimate the considerable savings to be made from welfare

payments, lost productivity and pharmaceuticals and medical

504 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2013 vol. 37 no. 6© 2013 The Authors. ANZJPH © 2013 Public Health Association of Australia

Editorials

expenditures. Thus, there are well-documented arguments to support

the view that NHMRC needs to considerably increase its investment

in research that considers what social and economic interventions

produce equitable health gain.

Where to next?The discussion at the Round Table leads us to suggest an alternative

agenda for understanding how to improve health at a population

level. This means developing a new NHMRC public health research

strategy that focuses on social determinants; reforming processes

for assessing research proposals and determining which should be

supported; increasing the proportion of funding for public health;

and providing more explicit reporting on the type of research funded

under the heading of ‘public health’.

A new NHMRC research strategy for addressing social determinants of health

A research agenda based on social determinants will require a

clear strategic direction that recognises this as a priority for NHMRC.

This emphasis is closely aligned to the new Australian Government’s

priority on improved health and wellbeing. The NHMRC would be

best able to contribute to the new national research priorities with a

stream of work labelled as ‘the social determinants of health’, where

the main focus is on the higher level ‘societal’ processes affecting

health and the distribution of health in populations rather than the

social relations and circumstances of individuals. As Starfield14 has

argued, “Equity in health, as a societal goal, will require societal

strategies that influence the evidence-based chain of mechanisms,

from those at the global and national levels through community and

social characteristics” (p. 172).

The key features of this new research agenda are provided in

Box 1. The conceptualisation should be on research that aims to

improve population health equitably, rather than on causes and

treatment of disease in individuals. It should pose and answer social

questions. For example, rather than asking how to treat young people

with depression, it would question why Australia has higher rates

of depression in young people in recent decades and what social,

cultural and economic trends have fuelled this? Most importantly, the

research agenda should be to fund intervention research to determine

what changes in society will reduce depression. Rather than asking

how we can encourage obese children to lose weight, we would ask

what social and economic factors in our community contribute to

increasing rates of childhood obesity and how can these factors be

changed, so that childhood obesity is reduced across the population.

A priority on social determinants would also fund research to track

the health consequences of policies and interventions in areas

such as housing, employment, education and urban planning. The

agenda should also place importance on research that evaluates the

interactions between health and climate change, and determines how

social and economic sustainability can be enhanced. Research on

the social determinants of health of Indigenous people is another

vital priority to determine similarities in the broader population

and distinctive social determinants, including cultural links to land

and dispossession, and those determinants that are unique to the

Indigenous peoples of Australia, especially those stemming from

Australia’s colonial history.

Overall, the balance of the new agenda should be towards research

that highlights which social and economic arrangements lead to

the most improved and equitable population health outcomes.

Social science disciplines should be recognised as having a central

contribution and the NHMRC should seek formal advice from the

ASSA to develop this research agenda. These priority areas would

need to be supported by capacity building through fellowship

programs and designated centres focused on research on assessing

interventions and policies designed to improve health through action

on social determinants. These could be developed in partnership

with State and local governments in some instances. The value

of the social determinants of health stream should be explicitly

recognised as a public good. Funding of health research on the

basis of prospects for commercialisation, disadvantages public

health research, which is less likely to produce something of a

commercial nature.15

Reformed processes for assessing and funding research

Supporting research on the social determinants of health

would require changes to grant assessment processes. A specific

grant review panel should be constituted with expertise in social

determinants including a range of social and population scientists.

Along with this there should be recognition of the diversity of

methods used in social determinants research. The Round Table

noted a tendency for certain methodologies to be privileged over

others and that social science methods in particular appear to be

under-valued by NHMRC review processes. The translational

research developments within NHMRC are welcome, but they

have a tendency to be primarily concerned with translation from

the laboratory to individual patient, rather to healthy people or

populations. Greater emphasis on social determinants of health will

require parallel expertise that focuses on translation from broad

population research to public policy.

Box 1: Key Elements of a Social Determinants of Health Research Strategy for NHMRC.

Focus on improving population health equitably rather than on causes and treatment of disease in individuals

Pose social questions

Emphasise intervention, policy and comparative research on what works to promote health including in housing, employment, education, urban planning and environmental sustainability

Include a distinct Aboriginal and Torres Strait Islander stream of work

Emphasise the importance of social science research

Recognise the importance of public good research outcomes

Include fellowships and designated centres programs that centre on the social determinants

Introduce social determinants Grant Review Panel

Provide detailed breakdown of what is funded under broad heading ‘public health research’.

2013 vol. 37 no. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 505© 2013 The Authors. ANZJPH © 2013 Public Health Association of Australia

Editorials

The Round Table stressed the importance of recognising the

value of community engagement, the skills and experience of

non-academic research partners, and expertise in research relevant

to policy and practice. It was also suggested that research agenda

setting should involve those from the diverse sectors that influence

public health including employment, housing, welfare, urban

planning and taxation policy, and should include public interest

non-government organisations.

Improved reporting on funding outcomesIt was also recommended that the NHMRC provide more detailed

reporting on what they fund under the category ‘public health

research’. In 2012, the NHMRC provided more than $850 million

to fund 1,339 separate grants. Of these, 13.8% were classified

as ‘public health’ related research, representing 14.5% of the

total expenditure.3 Within this category were research projects as

diverse as ‘The molecular epidemiology of malaria transmission

in the Solomon Islands’, ‘Brain connectivity biomarkers predict

specific memory consolidation deficits across dementia subtypes’

and ‘Understanding and addressing socioeconomic inequalities

in diet, physical activity and obesity’.3 Among those classified as

‘public health’ it is unknown how many of the grants focused on

social determinants of health as opposed to more biomedical or

genetic aspects of disease. Reporting should include the disciplinary

backgrounds of chief investigators and the more nuanced

categorising that would, for instance, allow better identification of

research that focuses on positive health distinct from that concerned

with disease.

ConclusionEnsuring the NHMRC pays much more attention to the ‘health’ in

its name needs to be a priority for the betterment of Australia’s health.

There are many ways in which attention to social determinants are

ignored in current priority setting, grant assessment and selection

process. We strongly recommend that the NHMRC takes action

in the very near future to address the recommendations from the

Senate Community Affairs Reference Committee, the Research

Round Table, and others. Doing so will ensure that our pre-eminent

health and medical research body addresses both ways to deal with

illness in individuals and, equally importantly, ways of promoting

healthy communities and health equity.

References1. Senate Community Affairs Reference Committee. Australia’s Domestic

Response to the WHO Commission on Social Determinants of Health Report ‘Closing the Gap within a Generation’. Canberra (AUST): Commonwealth of Australia; 2013

2. Benson, S. Abbott vows to cut futile research. Daily Telegraph. 2013 [cited 2013 Sep 25]: September 5. Available from: http://www.dailytelegraph.com.au/news/nsw/abbott-vows-to-cut-futile-research/story-fni0cx12-1226710934260

3. National Health and Medical Research Council. Summary of the Results of the NHMRC 2012 Grant Application Round. Canberra (AUST): NHMRC; 2013 [cited 2013 Jun 12]. Available from: http://www.nhmrc.gov.au/grants/outcomes-funding-rounds

4. Wills P. Health and Medical Research Strategic Review, the Virtuous Cycle - Working Together for Health and Medical Research. Canberra (AUST): Commonwealth Department of Health and Aged Care; 1998 [cited 2013 Jun 12]. Available from: http://www.nhmrc.gov.au/grants/outcomes-funding-rounds.

5. Grant, J. Sustaining the Virtuous Cycle for a Healthy Competitive Australia: Investment Review of Health and Medical Research. Canberra (AUST): Commonwealth Department of Health and Aged Care; 2004.

6. Nutbeam, D. Report of the Review of Public Health Research Funding in Australia. Canberra (Canberra): NHMRC, 2008.

7. Australian Academy of Social Sciences. Report on Social Determinants of Health Research Roundtable. Canberra (AUST): ASSA; 2013 [cited 2013 Nov 8]. Available from: http://www.assa.edu.au/publications/proceedings/AP42012.pdf

8. Commission on the Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva (CHE): World Health Organization; 2008.

9. Public Health Association of Australia. Submission to the Senate Community Affairs Committees’ Inquiry on Australia's Domestic Response to the World Health Organization's (WHO) Commission on Social Determinants of Health Report ‘Closing the Gap within a Generation’. Canberra (AUST): PHAA; 2012. Available from: http://goo.gl/EGZD9S

10. Public Health Research Advisory Group. Submission to the Review of Health and Medical Research in Australia. Canberra (AUST): Public Health Association of Australia; 2012

11. Public Health Research Advisory Group. McKeon Review – Comment on the Draft Consultation Paper 2012. Canberra: Public Health Association of Australia; 2012

12. Public Health Research Advisory Group. Submission to the Australian National Preventative Health Agency: National Preventative Health Research Advisory Strategy 2012-2016: Consultation Draft. Canberra: Public Health Association of Australia; 2012

13. Brown L, Thurecht L, Nepal B. The Cost of Inaction on the Social Determinants of Health, Report No.: 2. In: CHA-NATSEM Second Report on Health Inequalities. Canberra (AUST): National Centre for Social and Economic Modelling; 2012.

14. Starfield B. Are social determinants of health the same as societal determinants of health? Health Promot J Austr. 2006;17:170-3.

15. Pratt B, Loff B. Health research systems: Promoting health equity or economic competitiveness? Bull World Health Organ. 2012;90:55-62.

Correspondence to: Professor Fran Baum, Southgate Institute for Health, Society and Equity, Flinders University, GPO Box 2100, Adelaide SA 5000; e-mail: fran.baum@flinders.edu.au