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					“Why Aren’t Simple Cost-Effective
  Solutions Implemented More
  Widely? - Housing for Health”

                  Paul Pholeros
               Partner, Healthabitat


       5th National Rural Health Conference
   Adelaide, South Australia, 14-17th March 1999
                   Proceedings
            5 th NATIONAL RURAL HEALTH CONFERENCE
  “Why Aren't Simple Cost-Effective Solutions
Implemented More Widely? – Housing for Health”

                                      Paul Pholeros


BRIEF SUMMARY OF UWANKARA POLYANYKU KANYINTJAKU (UPK)
AND HOUSING FOR HEALTH: THE CONNECTION BETWEEN
ENVIRONMENT AND HEALTH
Aims
To stop people getting sick by improving the living environment, beginning with
the household living area.
Priority
Life threatening safety issues first then the nine Healthy Living Practices as
developed for UPK.
Method
•     assume need exists and secure funding for fix work before commencing any project;
•     detailed assessment and testing of over 240 simple, describable parts of the living
      environment that affect health.

Fix
•     immediate fix at survey ($2-20) on entry to the living area;
•     three hour trade fix ($50-200) / house; and
•     two month upgrade fix ($4-10K) / house.

After the Housing for Health project
Major follow up action (major new housing or upgrade, water, waste, power ie
Health Infrastructure Priority Project Scheme (HIPP) or National Aboriginal
Health Strategy (NAHS) projects)
Local community involvement at all levels
•     invitation to start the work (project management);
•     work teams (fix work and liaison with residents of each house);
•     when upgrade work continues (fix work and liaison with residents of each house); and
•     future projects ( ongoing assessment, project management, fix work and liaison with
      residents).
                        5 th NATIONAL RURAL HEALTH CONFERENCE
WHY AREN'T SIMPLE COST-EFFECTIVE SOLUTIONS IMPLEMENTED
MORE WIDELY?
The problem
Re-defining need. Resources are put into surveys to define large need, (ie the
Minister needs to know - how much repair is needed?) rather than fixing small
health hardware items.
Local, State and national surveys have defined need, in very general terms only,
over the last 20 years. For example:
•   the toyota survey: a slow drive by of community housing recording roof colour, wall material,
    and state of the windows;
•   ask the people about the state of their house/health on the doorstep or at the community
    office; and
•   developing '$ X billion' housing need figure.

Usually there have been no resources or minimal resources at best to act on the
outcome of the surveys.
Action
•   assume need will exist;
•   begin a project by finding resources to fix the problems when they are found; and
•   no survey (of any sort) without (some form of) service immediately.

The problem
The environmental health work needed to achieve sustained, improvement of
the living environment (ie making sure water is getting to a house and a drain is
getting waste water safely out of the house and yard) involves a wide range of
people, skills and work areas and is not sexy
The large teams of (largely Aboriginal) people, who I am proud to have worked
with on Housing for Health projects over 12 years, are usually not speaking at
conferences in capital cities.
They are doing the tedious, dirty and often dangerous day-in, day-out work that
ensures the most basic services for health (health hardware) are functioning.
They are often mopping up the mistakes of a more highly paid professional
working on policy issues in a capital city.
Action
•   make fixing a tap, drain and toilet important, and try to reward the fixers;
•   use the people who keep the health hardware working in the policy arena (developing
    housing guidelines, structuring Environmental Health Worker training courses).

But it will be important to know if these large projects are Health Infrastructure
Priority Projects or Infrastructure Priority Projects. That is, is there likely to be a
positive health outcome?
          5 th NATIONAL RURAL HEALTH CONFERENCE
Did the projects improve the quantity and quality of functioning health hardware
available to any community or simply build useful infrastructure (tanks, pumps,
pipelines, sewers, roads, dams, new houses and upgrade houses)? The
measure of this improvement will probably be in terms of working taps, hot water,
drains etc.
Action
•   keep a clear health priority rather than building / infrastructure focus; and
•   whilst I would strongly support large budget projects such as HIPP and NAHS, there is a
    strong need to test for the ability to wash children before and after the intervention and NOT
    just record the total $’s spent;
•   ensure functioning health hardware becomes the surrogate measure of health, rather than
    having to prove health gain repeatedly in small under resourced communities.

The problem
A strong perception that improvement in housing or health is impossible. An
often-unstated belief that all positive change is impossible may have the greatest
negative effect on future progress.
Constant re-defining of huge need in the face of minimal resources loses public
sympathy, makes bureaucracy nervous to commit more resources, workers
directly involved in the area feel powerless and, most importantly, leaves
Aboriginal and Islander people living in poor conditions.
Action
Focus on improving the function of basic health hardware first, and make small
changes.
It always strikes me that this detailed work makes total sense to the Aboriginal
people who live in these communities. To have a working shower, toilet, and a
place to cook a meal are significant things in their lives. The closer to Canberra
you get the focus on these details becomes dwarfed by larger more complex
policy decisions. Both are needed not one or the other.
Major improvements in both living environment and health are possible by
tackling small, often seemingly insignificant details.
Over 12 years of documented work in remote area communities shows that
Aboriginal people are not the culprits.
With active primary health care services and better initial design/construction of
the living environment, the ongoing maintenance needed to sustain a healthy
living environment is reduced to a point where it can largely be managed by local
Aboriginal people.
Change is possible and it should start today.
                                                           5 th NATIONAL RURAL HEALTH CONFERENCE
Figure 1#
                                     Comparison of the performance of basic Health
                                     Hardware in 3 communities: remote, rural and suburban

                                    100

                                     90
     Percentage of houses working




                                     80

                                     70
                                                                                                         Rural Community near
                                     60                                                                  country town 24 houses

                                     50                                                                  Sub-urban Community
                                                                                                         major city 35 houses
                                     40

                                     30                                                                  Remote Area 2hrs flight
                                                                                                         to regional centre 98
                                     20                                                                  houses
                                     10

                                         0
                                                 Safe       Ablitiy to   Working   Removal     Store
                                              electrical    Shower /      toilet     of all   prepare
                                               system         wash                  waste     and cook
                                                                                                food
                                                                          Items


Figure 2

                                                Improvement in the Health Hardware in 3
                                                        communities 1996-1999
                          100

                                    90

                                    80
                                                                                                         Rural Community Before
                                    70
                                                                                                         Rural Community After
                                    60

                                    50                                                                   Remote Tropical Before

                                    40                                                                   Remote Tropical After

                                    30
                                                                                                         Remote Desert Before
                                    20
                                                                                                         Remote Desert After
                                    10

                                     0
                                                Safe       Ablitiy to    Working   Removal     Store
                                             electrical    Shower /       toilet     of all   prepare
                                              system         wash                   waste     and cook
                                                                                                food

				
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