National Strategic Framework For Chronic Conditions PDF

National
Strategic
Framework
for Chronic Conditions
All Australians live healthier lives
through effective prevention and
management of chronic conditions.
COAG
J2865 - 11643 National Strategic Framework for Chronic Conditions_PRESS.indd 1 24/4/17 2:42 pm
National Strategic Framework for Chronic Conditions
Copyright
© Australian Health Ministers’ Advisory Council 2017
This publication is copyright, no part may be reproduced by any process except in accordance with the provisions
of the Copyright Act 1968 (Cth).
This publication was prepared under the auspices of the Australian Health Ministers’ Advisory Council.
Enquiries about the content of this publication should be directed to the Australian Government Department
of Health (www.health.gov.au).
ISBN: 978-1-76007-287-2
Online ISBN: 978-1-76007-288-9
Publications approval number: 11643
Suggested Citation:
Australian Health Ministers’ Advisory Council, 2017, National Strategic Framework for Chronic Conditions.
Australian Government. Canberra.
Foreword
The National Strategic Framework for Chronic Conditions is the result of extensive collaboration between
the Commonwealth, and all state and territory, governments under the Australian Health Ministers’
Advisory Council. It presents the agreed high level guidance that will allow us all to work towards the delivery
of a more effective and coordinated national response to chronic conditions. Our commitment is to improve
the health and wellbeing of Australians, and to deliver a sustainable health system that is responsive
to the increasing burden of chronic conditions in Australia.
Chronic conditions are becoming increasingly common due to our ageing population, as well as our
changing lifestyles. The increasing prevalence of chronic conditions, combined with their long-term and
persistent nature, and their impact on quality of life and overall health, is placing unprecedented pressure
on individuals, families, our communities and the health system.
Our new approach recognises that there are often similar underlying principles for the prevention and management
of many chronic conditions. As such, this Framework moves away from a disease-specific focus and better
considers shared health determinants, risk factors and multimorbidities across a broad range of chronic conditions.
The Framework is the outcome of thorough consultation with a broad spectrum of stakeholders, including state
and territory governments, peak bodies, non-government organisations, clinical experts, health professionals,
academics, researchers, industry, consumer representatives and community members, including people with
chronic conditions, their carers and families.
The Framework builds on existing work and is an important tool to enhance activities already underway and to guide
the development of new and innovative policies and approaches. It embraces a systemic, person-centred approach
which values the coordinated and collective influence of partnerships to jointly establish a strong foundation for
all Australians to experience optimal health outcomes today, and in the years to come.
The Framework provides the platform to achieve the Vision that “all Australians live healthier lives through effective
prevention and management of chronic conditions”.
The Hon Jill Hennessy MP

Chair
COAG Health Council
Acknowledgements
Many individuals and organisations have given their time and expertise to the development of this National Strategic
Framework for Chronic Conditions. The Commonwealth and all state and territory governments would like to thank
organisations and individuals who provided feedback through an online public consultation in 2016, as well as those
who participated in the scoping and national targeted consultation workshops during 2015.
Jurisdictional Working Group

The Framework has been developed through the Australian Health Ministers’ Advisory Council’s Community
Care and Population Health Principal Committee, with valued input from a Jurisdictional Working Group.
The Working Group provided advice on all aspects of the development of the Framework. Membership comprised
a Commonwealth Chair and members from each jurisdiction, as well as a representative from New Zealand and
the National Aboriginal and Torres Strait Islander Health Standing Committee.
Expert Advice
Advice from a range of experts was also sought throughout the development of the Framework, in particular
relating to chronic conditions, their risk factors, the outcomes and measurability.
2 National Strategic Framework for Chronic Conditions
Contents
Part 1: Setting the scene 4 Objective 2: Provide efficient, effective and
appropriate care to support people with
Introduction 5
chronic conditions to optimise quality of life 29
Chronic Conditions Defined 6
Strategic Priority Area 2.1: Active engagement 31
Purpose 6
Strategic Priority Area 2.2: Continuity of care 33
Audience 6
Strategic Priority Area 2.3:
Timeframe 6 Accessible health services 35
About the Framework 6 Strategic Priority Area 2.4: Information sharing 37
The Challenge of Chronic Conditions 9 Strategic Priority Area 2.5: Supportive systems 39
Current Status and Impact of Chronic Conditions 9 Objective 2 — Measuring Success 40
The Cost of Chronic Conditions 10 Objective 3: Target priority populations 42

International and National Challenges 10 Strategic Priority Area 3.1:
Prevention and Management 10 Aboriginal and Torres Strait Islander health 44
Priority Populations 11 Strategic Priority Area 3.2:

Action and empowerment 46
Determinants of Health 12
Objective 3 — Measuring Success 48
Part 2: The Framework 13

Part 3: Future work 50
The National Strategic Framework
for Chronic Conditions 14 Focus on the Future 51
Vision 14 Further Work 51
Principles 14 Ongoing Review 52
Enablers 14
Partners 15 Appendix: WHO Targets and Indicators 53
Objectives 15
Strategic Priority Areas 15 References 55
Outcomes 16 Commissioned Work 59
Measuring Progress 16
Objective 1: Focus on prevention

for a healthier Australia 17
Strategic Priority Area 1.1: Promote health
and reduce risk 19
Strategic Priority Area 1.2: Partnerships for health 21
Strategic Priority Area 1.3: Critical life stages 22
Strategic Priority Area 1.4: Timely and appropriate
detection and intervention 24
Objective 1 — Measuring Success 26
National Strategic Framework for Chronic Conditions 3
Part
PART1:1:
Setting the scene
Part 1 explores the impact of chronic
conditions in Australia and outlines
the approach
the approach of the Framework.
Introduction
Chronic conditions are the leading cause of illness, By reducing the impact of chronic conditions,
disability and death in Australia1. Tackling chronic there is more to be gained than building an
conditions and their causes is the biggest challenge economically viable and sustainable health system.
facing Australia’s health system2. Along with our Reducing the physical, psychological, social
ageing population, increasing consumer expectations and financial impacts of chronic conditions
and the high cost of pharmaceuticals and treatments, will improve quality of life and enhance
ever-increasing rates of chronic conditions are health outcomes for individuals, families
putting unprecedented strains upon individuals, and communities. Furthermore, the inequitable
communities and the health system. burden of chronic conditions and the higher
prevalence of risk factors in priority populations,
Over the past 40 years, the burden of disease in
particularly amongst Aboriginal and Torres
Australia has shifted away from infectious diseases
Strait Islander people, must be acknowledged3.
and injury, well suited to an episodic care model,
Greater emphasis towards identifying and supporting
towards chronic conditions requiring attention to
these populations is needed to reduce the impact of,
prevention activities and coordinated management.
and the risk of developing, chronic conditions.
Chronic conditions are occurring earlier in life
and Australians may live for longer with complex Similar to Australia, other countries face the challenge
care needs. This means individuals require more of the increasing prevalence of chronic conditions.
services from a range of providers across the health To address this, the World Health Organization
system over extended periods of time. Change must (WHO) has developed a Global Action Plan for the
occur to deliver a sustainable health system that Prevention and Control of Noncommunicable Diseases
responds more effectively to chronic conditions. 2013–20204. The Global Action Plan aims to reduce
the burden of noncommunicable diseases by 2025,
A focus on prevention can significantly reduce the
through a set of nine global targets and 25 indicators5
volume and severity of chronic conditions and provide
(refer to Appendix). As a member state of the WHO,
long-term cost savings and better health outcomes.
Australia has an international commitment to
Strategies to effectively manage chronic conditions
address noncommunicable diseases in line with
are equally important, to minimise multimorbidities,
the Global Action Plan. International and national
complications and associated disabilities and to
experience indicates a multisectoral response is
optimise quality of life.
most effective and should involve governments
at all levels, non-government and private sectors,
communities and individuals. The National Strategic
Framework for Chronic Conditions (the Framework)
supports Australia’s international commitments
and provides national guidance for a multisectoral
response in the prevention and management of
chronic conditions.
Chronic Conditions Defined Purpose
Various terminology is used to describe chronic The Framework supersedes the National Chronic
health conditions, including ‘chronic diseases’, Disease Strategy 20056 and associated National Service
‘noncommunicable diseases’, and ‘long-term Improvement Frameworks7, 8, 9, 10, 11 as the overarching
health conditions’. In the Framework, the use of policy for the prevention and management of chronic
the term ‘chronic conditions’ encompasses a broad conditions in Australia. It provides guidance for
range of chronic and complex health conditions across the development and implementation of policies,
the spectrum of illness, including mental illness, strategies, actions and services to address chronic
trauma, disability and genetic disorders. conditions and improve health outcomes.
This broad definition is intended to move the
While the Framework is primarily health focused,
focus away from a disease-specific approach.
it recognises that the health sector must take
The Framework only uses the term ‘chronic disease’
a leadership role, where appropriate, to foster advocacy,
when referencing disease-specific data.
engagement and partnering with external sectors
International policy from the WHO to achieve its Vision. Relevant external sectors may
relating to chronic conditions focuses include environment, housing, education, employment,
primarily on noncommunicable diseases. transport and social services.
However, both communicable and noncommunicable
diseases can become chronic and the origins of Audience
chronic conditions are varied and complex. The Framework is directed at decision and policy
Chronic conditions: makers at national, state and local levels. It is a useful
resource for governments, the non-government sector,
• have complex and multiple causes;
stakeholder organisations, local health
• may affect individuals either alone or service providers, private providers, industry
as comorbidities; and communities that advocate, and provide care
• usually have a gradual onset, although they and education, for people with chronic conditions
can have sudden onset and acute stages; and their carers and families.
• occur across the life cycle, although they
become more prevalent with older age; Timeframe
• can compromise quality of life and The timeframe of the Framework is eight years
create limitations and disability; (2017–2025), with a review proposed every three years.
• are long-term and persistent, and often lead
About the Framework
to a gradual deterioration of health and loss
of independence; and The Framework is the overarching policy document
for chronic conditions that sets the direction and
• while not usually immediately life threatening,
outcomes to achieve the Vision that “all Australians
are the most common and leading cause of
live healthier lives through effective prevention and
premature mortality.
management of chronic conditions”.
This definition is consistent with the definition Working within the guidance of the Framework will
of noncommunicable diseases used by the WHO, contribute to the long-term sustainability of Australia’s
without referring to specific disease groups. health system and reduce the impact of, and provide
better care for people with, chronic conditions.
Figure 1 illustrates the relationship between
the components of the Framework and depicts the
essential elements that interact to guide policies,
strategies, actions and services.
National
Figure 1: Concept map Strategic Framework
of the National Strategic for Chronic
Framework Conditions
Partners
• Government (at all levels) • Non-Government Organisations • Private Sector and Industry
• Researchers and Academics • Communities • Individuals
Principles
E qu
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c he En a b l e r s
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on
SPA 1.1: Promote tr a L

je c
ll a
rs
health and reduce risk l ia

Ob
ea
Pe
bo
de
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rs
SPA 1.2: SPA 1.3: Critical SPA 1.4: Timely
t io
h ip
n&
Partnerships life stages and appropriate
for health detection and
P ar
intervention
gy
tn e r
olon
O bj
ship s
Tech
il i t y
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Vision
S u s t a in a b
ve 2: P
All Australians live SPA 2.1: Active
healthier lives through
Research
engagement
r o v i d e ef f i c i e n t
w i t h c h r o n i c co f e c t i v
effective prevention
and management SPA 2.2:
a ti o n s
SPA 3.1: of chronic conditions. Continuity

Aboriginal of care
and Torres Strait
p op ul
A cc e s s
Islander health SPA 2.3:
cy
,
n
Accessible
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d
ty
iter a
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SPA 3.2:
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Action and
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SPA 2.4:
tp
empowerment
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Information
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Ta
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3:
SPA 2.5:
ib i
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s
Supportive
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ti ri
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at a l i t y
at
ec
systems
sp
ec
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H e al th
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a r en Accounta
bilit y & Tr ansp
Policies, Strategies, Actions and Services
Outcomes and Indicators

Monitor progress toward meeting the Objectives
SPA = Strategic Priority Area
The Framework: National action is required to strengthen Australia’s
• moves away from a disease-specific approach; approach to reducing the impact of chronic conditions.
A national approach should be coordinated and needs
• identifies the key principles for the effective
to accommodate the variable policy environments
prevention and management of chronic conditions;
in Australia, including the range of perspectives and
• supports a stronger emphasis on coordinated care practices that are supported by current evidence and
across the health sector; existing state, national and international policies.
• acknowledges and builds on work already in place There are many existing national and state-based
that supports chronic conditions; strategies and actions that target chronic conditions
• complements state-based, national and (refer to Figure 2). The Framework does not replace
international policy for chronic conditions; current policies or strategies, but provides guidance
• accommodates existing and new strategies and to enhance current disease-specific policies and
policies without changing the responsibilities of develop new and innovative approaches to address
the Australian or state and territory governments; chronic conditions.
• acknowledges the important role that the health
sector may take as a leader and advocate in working
with other sectors to address the social, economic
and environmental determinants of health; and
• provides flexibility to accommodate future and
emerging priorities and allows for innovative
solutions for the prevention and management
of chronic conditions.
Figure 2: Relationship between the Framework and other health and chronic conditions policies and programs
Chronic Conditions Policies Other Relevant Health Policies and Programs*
International chronic conditions policies International

e.g. WHO Global Action Plan for the Prevention
health policies
and Control of Noncommunicable Diseases 2013–2020
National chronic conditions policies National National health

e.g. National Strategic Framework health policies programs &
for Chronic Conditions (this Framework) e.g. National Aboriginal infrastructure
Health Care Homes: Reform of the Primary Health Care System and Torres Strait Islander e.g. Medicare Benefits
Health Plan 2013–2023; Scheme; Pharmaceutical
National Mental Health Benefits Scheme;
Commission’s Review Primary Health
National policies Networks;
for specific My Health Record
chronic conditions
e.g. Australian
National Diabetes
Strategy 2016–2020; State-based chronic State-based State-based
National Mental conditions policies & regional & regional
Health Strategy e.g. ACT Chronic Conditions health policies health programs
Strategy: Improving Care and e.g. WA Aboriginal & infrastructure
Support 2013–2018; Health and Wellbeing e.g. Primary Health
NT Chronic Conditions Framework 2015–2030; Networks; Hospitals;
Prevention and Management NSW Health Community-controlled
Strategy 2010–2020 Framework for health services
Women’s Health 2013,
My Health,
Queensland’s future:
Advancing Health 2026
State or regional State or regional

based policies based chronic
for specific conditions policies
chronic conditions for specific sectors
or populations *These are policies and programs at the international,
national, state and territory and local levels that provide
the setting in which chronic conditions policies operate.
The Challenge of Chronic Conditions
Current Status and Impact of Chronic Conditions The Primary Health Care Advisory Group’s
Chronic conditions are threatening to overwhelm December 2015 report to the Australian
Australia’s health budget, the capacity of health Government on: Better Outcomes for People with
services and the health workforce. They remain Chronic and Complex Health Conditions18 states that
the predominant cause of illness, premature “Our current health system is not optimally set up to
mortality and health system utilisation; in fact effectively manage long-term conditions.” The report
most of the burden of disease in Australia in 2011 also reveals that patients often experience:
was from chronic diseases, with approximately • a fragmented system, with providers and services
66 per cent, or two-thirds, of the total burden working in isolation from each other rather than
of disease resulting from five disease groups as a team;
— cancer, cardiovascular diseases, mental and • uncoordinated care;
substance use disorders, musculoskeletal conditions
• difficulty finding services they need;
and injuries12. Changing lifestyles, an ageing population,
improvements in managing infections, changing • at times, service duplication; at other times,
consumer expectations and finite resources are absent or delayed services;
all contributing to the impact of chronic conditions • a low uptake of digital health and other health
on Australia’s economy and population, now and technology by providers to overcome these barriers;
into the future. • difficulty in accessing services due to lack
The term ‘chronic conditions’ refers to a broad of mobility and transport, plus language,
range of often complex health conditions; financial and remoteness barriers; and
therefore overall prevalence is difficult to quantify. • feelings of disempowerment, frustration
Current evidence indicates: and disengagement.
• In 2014–2015, more than 50 per cent of Australians
The report highlights the need to strengthen
reported having at least one chronic condition,
primary health care, particularly to better manage
and 1 in 4 (23 per cent) reported having two
the large numbers of patients with multiple
or more chronic conditions13.
chronic conditions. Considerable change is
• The likelihood of having one or more chronic under way through ongoing national reforms
conditions increases with age14, and in Australia’s to deliver a more sustainable, person-centred
ageing population there is a corresponding health system. This includes, pharmacy and medicine
increase in multimorbidities. price reforms; the Healthier Medicare Initiative,
• Almost 1 in 3 Australians (29 per cent) aged particularly Health Care Homes — Reform of
65 and over reported having three or more Primary Health Care System; the establishment of
chronic diseases, compared with just 2.4 per cent Primary Health Networks; the redevelopment of the
of those aged under 4515. My Health Record; landmark mental health reforms;
• Having more than one chronic condition is associated reforms to improve aged care services; and the
with worse health outcomes, more complex disease National Medical Training Advisory Network project.
management and increased health costs16. These reforms are supported through Schedule 2 of
• Premature mortality (that is, deaths among people the Heads of Agreement between the Commonwealth
aged less than 75 years) from chronic disease and the States and Territories on Public Hospital
accounted for 83 per cent (over four out of five) Funding (April 2016).
of all premature deaths in Australia in 200717.
The Cost of Chronic Conditions Dialogue on strengthening international cooperation
People with chronic conditions use health services on noncommunicable diseases recognises:
and medicines frequently and over extended periods • the significant socio-economic impact of
of time — a pattern exacerbated by the presence noncommunicable diseases;
of multimorbidities. Consequently, chronic conditions • the massive disconnect between the scale and
are associated with high health care expenditure. complexity of the problem and the lack of resources
Health care costs are expected to rise with the dedicated to tackle it;
increasing prevalence of chronic conditions, • that even more important than increasing resources
escalating treatment costs, costs of medications is the necessity of getting national policies right,
and increasing demand for services. in particular those beyond the health sector; and
Most information regarding the economic impact • the potential for noncommunicable diseases to
of chronic conditions in Australia is sourced from be integrated into other development programs
disease-specific data that focuses on a select through strategic partnerships, including the role
group of chronic conditions. Estimates based on of information and communications technology in
disease-specific allocated health care expenditure empowering individuals to manage their own health.
indicate that the four most costly disease groups
are chronic — cardiovascular diseases, oral health, Australia faces similar challenges to other
mental illness and musculoskeletal conditions — economically developed countries in relation to
incurring direct health care costs of $27 billion in chronic conditions. Unbalanced diets heavy with
2008–2009 (36 per cent of allocated health expenditure)19. unhealthy (high fat, high sugar, high salt content)
Taking into account the broad definition of chronic foods, physical inactivity and sedentary behaviour,
conditions used in the Framework, it is likely that the prolonged burden of tobacco-related disease and
the true economic burden of chronic conditions is alcohol-related harm are common characteristics.
considerably greater than can be demonstrated Improved health care that supports people to live
with available data. Most expenditure is longer with chronic conditions places extended and
associated with admitted patient hospital services, intensive demands on the health system along with
out-of-hospital services, medications and social and economic burdens on individuals, families,
dental services20. Additionally, the economic communities and economies. There is increasing
impact of chronic conditions would be greater if international recognition that preventive measures
non-health sector costs, such as residential care are an essential means of reducing this burden23.
and lost productivity from compromised health,
illness and death, were considered21.
Prevention and Management
The focus of Australia’s health system has been
Chronic conditions are also associated with on treating illness rather than on preventing it.
non-economic costs, including personal, Focusing attention toward prevention activities,
social and community costs such as loss of while continuing to ensure chronic conditions are
independence, social isolation, discrimination, well managed, will provide better health, social
stigma, and potential disability and aged care impacts. and economic outcomes for all Australians.
These factors can have lasting impacts through
reduction in quality of life and lost opportunities that The prevention and management of chronic
extend beyond individuals to their carers and families, conditions in Australia is evolving. The increasing
and to future generations. burden of chronic conditions, both nationally
and internationally, is placing greater demands on
International and National Challenges existing traditional arrangements. Australia must
The escalating burden of chronic conditions is a adopt a consistent and integrated approach to
global health issue. The WHO’s Global Action Plan the effective prevention and management of
for the Prevention and Control of Noncommunicable chronic conditions to improve health outcomes
Diseases 2013–202022 follows on from commitments for all Australians and to ease the pressure on
made by Heads of State and Government. The Global the health system.
Action Plan recognises the primary role and Objectives 1 and 2 of the Framework explore the
responsibility of governments in responding to prevention and management of chronic conditions
the challenge of noncommunicable diseases and in more detail.
the important role of international cooperation
and solidarity to support national efforts.
Priority Populations The Framework is designed to be used for all Australians.
Priority populations are those that are negatively Objective 3 sets out targeted information and outcomes
impacted by chronic conditions more than the specific to priority populations. However, Objectives 1
general population. This is demonstrated by and 2 also apply to priority populations and should be
a higher prevalence of chronic conditions and considered in tandem to inform policies, strategies,
a greater burden of disease in these populations actions and services to meet the needs of all
resulting in inequitable health outcomes. priority populations.
Priority populations include, but are not limited to: Aboriginal and Torres Strait Islander Health
Aboriginal and Torres Strait Islander people;
people from culturally and linguistically In 2008, the Council of Australian Governments agreed
diverse backgrounds; older Australians; carers of to targets to address disadvantage experienced
people with chronic conditions; people experiencing by Aboriginal and Torres Strait Islander people —
socio-economic disadvantage; people living in remote, the Closing the Gap initiative. One of the targets
or rural and regional locations; people with disability; identified was to close the life expectancy gap
people with mental illness; and people who are, or have between Aboriginal and Torres Strait Islander people
been, incarcerated. Targeted guidance to better support and non-Indigenous Australians within a generation
priority populations is explored in Objective 3. (by 2031)29. The Implementation Plan for the National
Aboriginal and Torres Strait Islander Health Plan
Examples of the prevalence of chronic conditions 2013–202330 builds on the Closing the Gap approach
in some priority populations include: and recognises the importance of social and cultural
• In 2014–15, 87 per cent of older Australians determinants of health. The Implementation Plan
(people aged 65 years and over) reported having at identifies health-specific strategies and actions,
least one chronic condition (compared with 50 per cent including those that address chronic conditions,
in the general population), and 60 per cent reported to improve health outcomes for Aboriginal and
having two or more chronic conditions (compared with Torres Strait Islander people31.
25 per cent in the general population)24. The overall burden of disease for Aboriginal and
• In 2011–12, Australians aged under 65 with severe Torres Strait Islander people is more than twice that
or profound disability had a higher prevalence of for non-Indigenous Australians, of which a large
long-term health conditions. They were also 3.3 proportion is due to chronic conditions32.
times as likely to have three or more long-term health • In 2012–13, two-thirds (67 per cent) of Aboriginal
conditions as people without disability (74 per cent and Torres Strait Islander people reported having
compared with 23 per cent)25. at least one chronic health condition, and one-third
• Mental health conditions affect, and are (33 per cent) reported having three or more chronic
affected by, other chronic conditions: they can health conditions33.
be a precursor or consequence of a chronic • Aboriginal people experience much earlier onset of
condition, or the result of the interactions a number of chronic diseases, in some cases up to
between common risk factors and comorbidities26. 20 years earlier than non-Indigenous Australians 34.
• Australians living in rural areas experience poorer • In 2012–13, 36 per cent of Aboriginal and Torres
health outcomes such as higher mortality rates Strait Islander people had some form of disability,
associated with chronic disease, a higher prevalence which is one-and-a-half times the rate experienced
of mental illness, more potentially avoidable by non-Indigenous Australians35.
hospitalisations and higher rates of injury than
those living in cities27. • In 2012–13, 29 per cent of Aboriginal and Torres Strait
Islander people rated their health as ‘fair’ or ‘poor’
Further, Australia has long had geographic challenges which is more than double the non-Indigenous rate
in health care delivery in a way that few Organisation of 14 per cent36.
for Economic Co-operation and Development (OECD) • In 2010–2012, the average life expectancy of
countries have experienced. This is compounded by Aboriginal and Torres Strait Islander people
maldistribution in the workforce28. Barriers experienced was approximately 10 years less than that of
by people living in remote communities can include: non-Indigenous Australians37.
limited access to services; transport; limited opportunities • Chronic disease accounts for around three
for education and work; and difficulties in accessing quarters of the gap in mortality rates between
affordable nutritious food. These disadvantages Aboriginal and Torres Strait Islander people and
perpetuate socio-economic disadvantage and non-Indigenous Australians38.
existing health conditions.
Determinants of Health • Individual characteristics — for example,
The determinants of health are many and varied, sex, genetics and physical or mental determinants 40.
they interact to raise or lower the health status
of individuals and populations. They operate at The factors within each of these categories and
every life stage — maternal and infancy, childhood, their interactions influence knowledge, attitudes
adolescence, adulthood and older age — both to and beliefs; social norms and expectations;
immediately influence health and as a foundation and means and opportunities — which can
for future health39. The determinants of health ultimately impact health (refer to Figure 3).
can have cumulative effects over the course of While some determinants of health sit within the
a lifetime and across generations. For example, realm of the health sector, there are many that fall
children who experience disadvantage are more likely outside the boundaries of health. The WHO recognises
to have poor educational outcomes, thus influencing that influencing public policies in sectors outside
employment opportunities, socio-economic status of health which tackle the determinants of health,
and health in adult life, and this can contribute to will enable health systems to respond more effectively
intergenerational disadvantage. and equitably to the health care needs of people with
The determinants of health fall into four main categories: chronic conditions41. With this in mind, it is important
that the health sector does not work in isolation from
• Physical environment — for example, housing, other sectors and services. The Framework takes the
sanitation and the natural and built environments; approach of promoting, where practical, the benefits
• Social environment — for example, education, of partnerships and coordinated efforts within and
employment, political structures, relationships outside of the health sector to minimise the impacts of
and culture; the determinants of health and positively influence the
• Economic factors — for example, income, health of all Australians. A united approach to achieve
expenditure and affordability; and change is a shared responsibility.
Figure 3: Influence of the Determinants of Health
Determinants of Health
Social Physical Economic Individual
Environment Environment Factors Characteristics
Individual and Societal Features

Knowledge, Social Norms Means and Opportunity
Attitudes and Beliefs and Expectations (Individual/Community)
(Individual/Cultural)
Psychological, Safety
Behaviours and Biomedical Factors
Tobacco use, alcohol consumption,
Stress, risk taking, work health & safety,
physical activity, dietary behaviour,
birth weight, body weight, blood pressure,
use of illicit drugs, sexual practices, vaccination
blood cholesterol, glucose tolerance
Health
Diagram adapted from the Australia Institute of Health and Welfare

(AIHW 2014, Australia’s Health 2014. Australia’s Health series no. 14. Cat no. AUS 178. Canberra; AIHW).
Part 2:
The Framework
Part 2 sets out the Vision,
Objectives and Aspirational
Outcomes of the Framework.
13
The National Strategic Framework
Vision Enablers
All Australians live healthier lives through effective Seven specific Enablers have been identified that
prevention and management of chronic conditions. will assist in achieving the Vision of the Framework.
Appropriate use of the Enablers will give effect to
Principles successful policies, strategies, actions and services
Eight guiding Principles have been identified to that will support people with, or at risk of developing,
enable the successful prevention and management of chronic conditions.
chronic conditions for all Australians. The Principles The Enablers comprise:
should be clearly evident in the planning, design and
• Governance and leadership — supports
implementation of policies, strategies, actions and
evidence-based shared decision-making and
services aimed at preventing and/or managing all
encourages collaboration to enhance health
chronic conditions.
system performance.
The Principles are: • Health workforce — a suitably trained, resourced
• Equity — all Australians receive safe, and distributed workforce is supported to work to
high-quality health care irrespective of its full scope of practice and is responsive to change.
background or personal circumstance. • Health literacy — people are supported to
• Collaboration and partnerships — identify linkages understand information about health and
and act upon opportunities to cooperate and partner health care, to apply that information to their lives
responsibly to achieve greater impacts than can and to use it to make decisions and take actions
occur in isolation. relating to their health.
• Access — high standard, appropriate support and • Research — quality health research accompanied
services are available, accessible, equitable and by the translation of research into practice and
affordable for all Australians. knowledge exchange strengthens the evidence
• Evidence-based — rigorous, relevant and current base and improves health outcomes.
evidence informs best practice and strengthens the • Data and information — the use of consistent,
knowledge base to effectively prevent and manage quality data and real-time data sharing enables
chronic conditions. monitoring and quality improvement to achieve
• Person-centred approaches — the health system better health outcomes.
is shaped to recognise and value the needs • Technology — supports more effective and
of individuals, their carers and their families, accessible prevention and management strategies
to provide holistic care and support. and offers avenues for new and improved
• Sustainability — strategic planning and responsible technologically driven initiatives.
management of resources delivers long-term • Resources — adequate allocation,
improved health outcomes. appropriate distribution and efficient use
• Accountability and transparency — decisions of resources, including funding, to address
and responsibilities are clear and accountable, identified health needs over the long-term.
and achieve best value with public resources.
• Shared responsibility — all parties understand,
accept and fulfil their roles and responsibilities
to ensure enhanced health outcomes for
all Australians.
Partners Objectives
The effective prevention and management of The Vision is supported by the following
chronic conditions is strongly influenced by the three Objectives:
contributions made by a wide range of Partners. 1. Focus on prevention for a healthier Australia.
Partners in the prevention and management of
2. Provide efficient, effective and appropriate care
chronic conditions include:
to support people with chronic conditions to
• individuals, carers and families optimise quality of life.
• communities 3. Target priority populations.
• all levels of government
• non-government organisations Strategic Priority Areas
• the public and private health sectors, including all Strategic Priority Areas have been identified
health care providers and private health insurers under each Objective as shown in Tables 1, 2 and 3.
These are the core priority areas where Partners
• industry
should focus attention to achieve each of
• researchers and academics the Objectives. Partners can readily identify, plan and
implement their own policies, strategies, actions
All Partners have shared responsibility for health and services against the Strategic Priority Areas.
outcomes according to their role and capacity within
the health care system. Greater cooperation between
Partners can lead to more successful individual and
system outcomes.
Table 1: Strategic Priority Areas for Objective 1
Objective 1: Focus on prevention for a healthier Australia

Strategic Priority Area 1.1 Promote health and reduce risk
Strategic Priority Area 1.2 Partnerships for health
Strategic Priority Area 1.3 Critical life stages
Strategic Priority Area 1.4 Timely and appropriate detection and intervention
Objective 2: Provide efficient, effective and appropriate care to support people

with chronic conditions to optimise quality of life
Strategic Priority Area 2.1 Active engagement
Strategic Priority Area 2.2 Continuity of care
Strategic Priority Area 2.3 Accessible health services
Strategic Priority Area 2.4 Information sharing
Strategic Priority Area 2.5 Supportive systems
Objective 3: Target priority populations

Strategic Priority Area 3.1 Aboriginal and Torres Strait Islander health
Strategic Priority Area 3.2 Action and empowerment
Outcomes Measuring Progress
Outcomes are described for each Strategic Progress should be measured at various levels
Priority Area. They describe the result of actions, and is the responsibility of all Partners. Each layer
rather than the actions required, to allow flexibility of the Framework — the Objectives, the Strategic
for Partners to develop and implement their Priority Areas and the Outcomes — contributes
own strategies, policies, actions and services to achieving its Vision — “All Australians live healthier
within the boundaries of their specific health lives through effective prevention and management of
responsibilities and governing authorities. chronic conditions”.
A phased outcome approach has been used to Due to the complexities associated with the
recognise that a continuum of progress is required prevention and management of chronic conditions
to meet each Objective. It is acknowledged that there is no single indicator to determine the impact
relevant Partners will be at different stages along of the Framework. Rather, a description of what
this continuum; therefore, timeframes for the success will look like, and example indicators,
achievement of each outcome have not been specified. have been included at the Objective level. The example
indicators may not be a comprehensive list, but are
Phase 1 Outcomes are intended to be achieved
provided to demonstrate the information currently
in the short-term, whereas Phase 2 Outcomes
available to monitor the impact of collective action.
build upon the Phase 1 Outcomes and represent
In addition, Partners should monitor their
long-term achievements.
own strategies, policies, actions or services to
Aspirational Outcomes outline the ambitious ensure that these activities are contributing to the
long-term results that would be seen if collective Outcomes described in each Strategic Priority Area.
action was successful against each of the Phase 1
More robust and relevant data and information
and Phase 2 Outcomes. The Aspirational Outcomes
may become available in the future. Partners should
are offered to stretch responses and to foster
take these opportunities to review and refine the
innovative and creative solutions to meet the
measures they use to track and monitor progress
challenges of the burden of chronic conditions
against the Framework.
in Australia.
Objective 1:
Focus on prevention
for a healthier Australia
What success will look like:
1. The proportion of Australians living with preventable chronic conditions
or associated risk factors is reduced.
2. Australia meets the voluntary global targets outlined in the WHO Global Action Plan
for the Prevention and Control of Noncommunicable Diseases 2013–202042.
3. Australians with chronic conditions, or associated risk factors,
develop them later in life and receive timely interventions to achieve optimal health outcomes.
Prevention is key to improving the health of There are multiple risk factors and health
all Australians, reducing health related expenditure determinants that contribute to the development
and ensuring a sustainable health system. of chronic conditions. However, chronic conditions
Changing lifestyles, characterised by poor diet often share common behavioural risk factors,
and nutrition, physical inactivity, the harmful biomedical risk factors and social determinants,
consumption of alcohol and tobacco use, and an with a small number of risk factors accounting
ageing population, all contribute to the current burden for much of the morbidity and mortality attributed
of chronic conditions which is placing increasing to chronic conditions. The Australian Burden of
demands on the health system and the economy Disease Study: impact and causes of illness and death
more broadly. Prevention generates long-term in Australia 201145 identified that almost one-third
health and economic benefits, delivers the greatest of the burden of disease in Australia in 2011 could
improvement in health outcomes and improves be prevented by eliminating exposure to risk
the health of future generations 43. factors such as tobacco use, high body mass,
harmful use of alcohol, physical inactivity and high
Health promotion and prevention activities
blood pressure46. Further, the burden of disease
which encourage healthy environments,
experienced by priority populations, for example
communities and behaviours can:
those living in remote locations or those experiencing
• lessen predisposing factors for chronic socio-economic disadvantage, is greater than for
conditions through improved environmental and Australians residing in major cities, or with increasing
social conditions, and reduce the development socio-economic status, respectively47. This highlights
of behavioural and biomedical risk factors the significant potential to target common preventable
(primordial prevention); risk factors and determinants of health as an effective
• prevent the occurrence, or delay the onset, approach to reducing the burden associated with
of chronic conditions (primary prevention); chronic conditions.
• minimise or prevent disease progression in people Nevertheless, not all chronic conditions can be
with chronic conditions (secondary prevention); prevented through action to address risk factors and
• reduce the risk of developing additional determinants of health. However, preventive action
chronic conditions, complications and/or can foster protective factors, such as good nutrition
associated disabilities (tertiary prevention); and regular physical activity, which can contribute
• support improved quality of life; and to greatly improved health outcomes for people
• reduce demand on the health care system44. with non-preventable chronic conditions 48.
The multiple and complex interaction of risk factors • take place in different settings — childcare centres
and determinants for chronic conditions means and schools, workplaces and the urban environment,
that prevention must be considered from a range as well as more traditional health service locations;
of different perspectives. Preventive action can: and
• occur at different points along the continuum of • be undertaken by individuals, families,
disease progression — in healthy populations; in community organisations, employers, private
those recognised as being at an increased risk of health insurers, non-government organisations,
developing chronic conditions; and in individuals industry and different sectors and levels
displaying early signs of a chronic condition or of government.
those experiencing long-term and persistent
chronic conditions; Action to prevent chronic conditions is
• occur across the life course — from conception a shared responsibility. The complex nature
and birth, for infants, throughout childhood, of chronic conditions, combined with the need to
adolescence, adulthood and into older age; create positive sustainable change for individuals,
families, communities, governments and the economy
requires an inclusive, multi-faceted approach whereby
all Partners respond to the challenges in a cooperative
and responsible manner.
The Strategic Priority Areas and Aspirational
Outcomes in this Objective are outlined in Table 4.
Table 4: Strategic Priority Areas and Aspirational Outcomes for Objective 1

Strategic Priority Areas Aspirational Outcomes
1.1 A
ustralians live healthy lifestyles with reduced risk of developing
1.1: P
romote health and reduce risk
chronic conditions.
1.2 Responsible partnerships promote health and reduce risk factors
1.2: Partnerships for health
for chronic conditions.
1.3 A
ustralians maintain good health and healthy behaviours
1.3: Critical life stages
through times of developmental, social or environmental change.
1.4: Timely and appropriate 1.4 Timely and appropriate detection and intervention reduces the risk
detection and intervention of chronic conditions and/or disease severity.
Strategic Priority Area 1.1: • Non-modifiable risk factors — these comprise
Promote health and reduce risk individual physical and psychological components.
Health promotion activities encourage a — Examples include age, sex, genetics or
healthy lifestyle, reduce health risk factors intergenerational influences.
and are an important element in preventing • Physical environment determinants — these comprise
chronic conditions and helping people both the natural and built environment, can impact
to improve quality of life and live longer. health in a subtle or obvious manner and can occur
Health promotion focuses on a broad range of over the short or the long-term.
social and environmental strategies, rather than — Examples include UV exposure, air pollution,
on individual behaviour change49. It encourages urban environment, or geographic location.
healthy communities and environments by • Social and economic determinants — these can
increasing the capacity of people, communities, be difficult for individuals to control, however they
organisations and governments to positively influence the way in which people live their lives54.
influence health. Health promotion is the process — Examples include beliefs, customs and culture,
of empowering people to increase control over their education and employment status.
health and its determinants, thereby improving
their health50, 51. An effective approach to Risk factors are often discussed individually;
promoting health recognises the relationship and however in practice they do not operate in isolation
interaction between health related behaviours — they often coexist and interact with one another.
and the environments in which people live52. Many chronic conditions share common risk factors
and determinants, and are often risk factors for
A diverse range of factors influence the health each other.
and wellbeing of the Australian population.
These factors are attributes, characteristics or Risk factors for chronic conditions should
exposures that increase the likelihood of a person be addressed through a coordinated suite of
developing a disease or health disorder 53. evidence-based interventions targeted across
They can be categorised as follows: the spectrum from individual to population
level approaches over a sustained period
• Behavioural risk factors — these are the most
of time55. A cohesive approach to promoting
common risk factors for many chronic conditions.
health and preventing chronic conditions should
As such, they are often a major focus for
empower individuals and their families to make
prevention strategies and interventions.
healthy choices, facilitate local leadership
— Examples include smoking, poor diet and
and encourage wider societal responsibility to
nutrition, harmful consumption of alcohol,
address the broader factors that influence health56.
physical inactivity and/or cognitive inactivity.
• Biomedical risk factors — these relate to the While in some circumstances the evidence may
condition, state or function of the body that be limited, the evidence that does exist shows that
contributes to the development of chronic conditions. the greatest impact is likely to come from a broad
The effects of a single biomedical risk factor can be range of actions which occur across multiple
intensified when additional biomedical risk factors and different settings, sectors, age groups and
or behavioural risk factors are present. life stages57. A comprehensive approach to promoting
— Examples include high blood pressure, high blood health and reducing risk factors allows action to be
cholesterol, overweight or obesity, impaired taken at the social and cultural level and in the physical
glucose tolerance, stress, mental illness, locations in which people undertake daily activities,
trauma, or illness (communicable disease). and in which environmental, organisational and
personal factors interact to influence health
and wellbeing58.
Policies, strategies, actions and services developed
under this Strategic Priority Area by relevant
Partners should aim to achieve the Outcomes
outlined in Table 5.
Table 5: Strategic Priority Area 1.1 Outcomes
Strategic Priority Area 1.1: Promote health and reduce risk
Phase 1 Outcomes Phase 2 Outcomes Aspirational Outcome

Consistent and coordinated health Australians make healthier 1.1 Australians live healthy
promotion positively influences choices and change behaviour lifestyles with reduced risk of
healthy behaviour choices. to reduce their risk of developing developing chronic conditions.
chronic conditions.
Targeted health messages and
education meet community needs. Increased population health literacy
in chronic conditions prevention,
Health and non-health sectors
risk factor identification and
and settings promote the risks
healthy behaviours.
and protective factors for
chronic conditions. The evidence base strengthens
prevention policy and action.
People navigate and use health
information to meet their needs. Innovative solutions,
including diagnostic technology,
Risk factors are identified early
support risk factor identification
and acted on appropriately.
and reduction.
Individuals and communities are
All Partners contribute to creating
motivated and skilled to positively
health promoting environments.
modify behaviour.
Fiscal and regulatory levers are
The health workforce is adequately
used, where considered appropriate,
equipped to deliver holistic action
to incentivise healthy behaviours.
to prevent and manage the risk
factors for chronic conditions.
At risk people and populations
receive evidence-based
targeted interventions.
Research builds the evidence
base around effective
preventive health measures.
Data collection and sharing
improves identification and
management of risk factors.
Strategic Priority Area 1.2: • the sharing of responsibility and expertise;
Partnerships for health • enhanced cooperation and understanding
The physical, mental and social health of Australians within and across sectors;
can be positively or negatively influenced by the • an extended breadth and reach
physical and social environments in which people live, of communication and action;
learn, work and play. The complexity and diversity • more efficient resourcing and reduced duplication;
of these influences means that the prevention
• sustained, multi-faceted and strategic approaches
of chronic conditions not only relies on activities
that meet the needs of identified populations; and
undertaken within the health sector, but on action
across a wide range of social, economic, political, • mutual benefits for partners.
cultural and environmental determinants of health59.
A comprehensive approach to prevention is benefited Within the health sector, partnerships can drive
by establishing responsible partnerships and consistent and coordinated national and local
sharing responsibility to facilitate positive cultural prevention strategies. Beyond the health sector,
change and to make the healthy choices become the leadership from the health sector to advocate,
easy choices. With this in mind, the settings for health engage and collaborate with partners can
promotion and prevention activities should be varied: enhance efforts to establish and maintain
covering geographic locations, including cities, evidence-based multi-pronged prevention
towns or urban spaces; using organisational structures approaches that meet local requirements,
such as childcare centres, schools, workplaces or including the needs of priority populations.
hospitals; through event-based activities delivered With this in mind, effective existing partnerships
at festivals or sporting events; or social media and should be consolidated and strengthened, and new
online communication. and responsible partnership opportunities explored.
Strong, cooperative and productive Policies, strategies, actions and services developed
partnerships between governments at all levels, under this Strategic Priority Area by relevant Partners
non-government organisations, the private sector, should aim to achieve the Outcomes outlined in Table 6.
industry, researchers and academics, communities,
and individuals, carers and families, are crucial
to successfully preventing chronic conditions
and supporting those with chronic conditions.
When responsible and effective partnerships
are developed, the benefits can exceed those
achieved when action is taken in isolation.
Effective partnerships are characterised by:
Strategic Priority Area 1.2: Partnerships for health

Partners collaborate and build on Partnerships promote healthy 1.2 Responsible partnerships
common goals to create health local environments and settings, promote health and reduce risk
promoting environments. and encourage healthy behaviours. factors for chronic conditions.
Clear governance and Responsible partnerships that
leadership supports responsible promote population health and
decision-making processes foster healthy environments are
between partners. evaluated and recognised as
best practice.
Investment in prevention strategies
engages multiple partners Regulatory and legislative
wherever practical. changes are introduced
where considered appropriate.
Consistent and robust data
collection and sharing occurs New, non-traditional and
between relevant partners responsible partnerships evolve.
to promote health.
Strategic Priority Area 1.3: Critical life stages • the transition for young people from
There are critical periods throughout life where dependent children to independent adults,
exposure to risk factors and determinants of in particular relating to education and
health can independently and interactively impact on career path decisions, employment and
long-term health outcomes. The adverse impact of risk financial decisions, relationships with family
factors for chronic conditions can have a cumulative and peers, exposure to alcohol and drugs,
impact on the health outcomes of individuals as they and susceptibility to mental illness and
age and can also be transferred to future generations. behavioural risk factors, including smoking,
Targeting policies, strategies, actions and services alcohol use and physical inactivity;
at different stages of life, key transition points • support for young people when they transition
and developmentally sensitive stages can prevent from paediatric to adult health services;
or minimise the impact of, chronic conditions, • the health and wellbeing of adults of working
positively influencing health outcomes age to facilitate engagement in economic
throughout life and for successive generations. and social activities;
A comprehensive life course approach to • critical transition points such as retirement
prevent chronic conditions and improve health or bereavement, which can be a catalyst
and wellbeing considers relevant age-related for deteriorating health and wellbeing,
and developmental circumstances, as well as particularly for older Australians;
transition points, significant events and risk factors • the influence of environmental and
that may occur across the lifespan. Examples include: socio-economic factors, carer responsibilities,
• maternal health and nutrition to give children an disability, and the development of risk factors and/or
optimal start in life and to reduce infant mortality; unhealthy habits on future health outcomes; and
• the impact of breastfeeding, nutrition, • the risk of developing a chronic condition for future
weight gain and socio-economic factors on physical, generations due to genetic and epigenetic factors.
cognitive and mental development throughout
infancy and childhood; Targeting opportunities to tackle chronic conditions at
• the health and development of children, critical life stages, including through action to address
which may in turn enhance educational outcomes, risk factors and improve the determinants of health,
facilitate healthy lifestyles and reduce the risk can positively influence individual and population
of mental illness and other chronic conditions; health outcomes both now and into the future.
under this Strategic Priority Area by relevant Partners
should aim to achieve the Outcomes outlined in Table 7.
Strategic Priority Area 1.3: Critical life stages

Prevention opportunities Longitudinal monitoring and 1.3 Australians maintain good
target life stages: research is used to determine health and healthy behaviours
• maternal health (in utero); the life-long effects of preventive through times of developmental,
interventions delivered social or environmental change.
• children (0–5 and 5–12 years);
to young Australians.
• young people
(13–17 and 18–24 years); Australians receive appropriate
prevention measures at any stage
• adults (25–64 years); and
of life.
• older people (65 years and older).
Research drives new approaches
Preventive action is directed at that improve health and quality
critical life transition points. of life across the life course.
The health workforce provides
support for antenatal, postnatal
and early life to reduce risk factors
for chronic conditions.
Interventions target multiple
settings (such as general
practices, schools, workplaces
families and communities),
using multiple strategies,
covering a range of
behavioural risk factors.
Research better identifies the
critical age points for focused
prevention interventions to
prevent and/or reduce risk
of chronic conditions.
Evidence base strengthened
around critical life stages to reduce
life-long risk of chronic conditions
and intergenerational risk.
Strategic Priority Area 1.4: Timely and • utilisation of opportunities to improve individuals’
appropriate detection and intervention understanding of their condition;
Timely and appropriate detection and intervention for • supporting individuals who wish to actively
chronic conditions involves identifying and planning participate in the management of their
action for people with, or at risk of developing, chronic conditions and/or associated risk factors
a chronic condition. The concept of ‘timely and to develop the necessary skills and resources
appropriate’ detection and intervention, aims to avoid: for self-management;
over-diagnosis; over-medicalisation; unnecessary, • fewer avoidable hospitalisations;
intrusive and costly procedures; inaccurate • improved health outcomes for people
or inconclusive test results; and high financial with chronic conditions; and
outlay for individuals and families.
• improved quality of life.
The detection of chronic conditions requires the
identification of, and appropriate monitoring for: The detection of chronic conditions can occur through
• risk factors linked to the development of a variety of settings, including in general practice,
chronic conditions, in particular behavioural pharmacies, fitness and recreation centres and
or biomedical risk factors; through community events. Detection can be
opportunistic or targeted in nature, including through
• the development of signs or symptoms commonly
the implementation of evidence-informed screening
associated with chronic conditions; and
for average risk population groups, as well as groups
• the emergence of complications associated identified as being at increased risk of developing
with existing chronic conditions. chronic conditions60 — for example, Aboriginal and
Torres Strait Islander people or those with a genetic
Individuals and health care providers play an
predisposition for a particular chronic condition61.
important role in the detection and intervention
for chronic conditions and their risk factors. An integrated approach to detecting and managing
Detection is enhanced when both individuals chronic conditions moves away from the detection
and health care providers are able to recognise of specific chronic conditions and recognises the
risk factors, signs or symptoms and to then interaction between chronic conditions and their
implement the most suitable follow up processes. risk factors. Integrated risk assessments or integrated
health checks are important tools that identify an
The benefits of timely and appropriate detection,
individual’s risk across a range of chronic conditions.
paired with appropriate follow up, include:
These tools should be combined with suitable
• improved detection and management of people follow-up processes or diagnostics to ensure timely
at increased risk of developing a chronic condition; detection and intervention for people identified as being
• delayed progression and more effective at increased risk. Communication and coordination
treatment or management of chronic conditions; between and within health care services, and with
• reduced risk of developing additional individuals, will enhance the effectiveness of chronic
chronic conditions, complications and/or conditions’ risk assessment, detection and intervention.
associated disabilities; Policies, strategies, actions and services developed
under this Strategic Priority Area by relevant Partners
should aim to achieve the Outcomes outlined in Table 8.
Strategic Priority Area 1.4: Timely and appropriate detection and intervention

Health checks, integrated risk Innovative and improved methods 1.4 Timely and appropriate
assessments and evidence-based of detection and integrated risk detection and intervention
screening programs are promoted assessment are developed. reduces the risk of
and utilised in various settings. chronic conditions and/or
Technology supports individuals
disease severity.
People recognise their risk of to identify their own risk for chronic
developing a chronic condition conditions and prompts appropriate
and have the necessary skills action and/or follow-up.
to take appropriate action.
Enhanced quality and accuracy of
Health workforce delivers detection methods are achieved.
comprehensive health checks,
Appropriate intervention reduces
referral pathways, evidence-based
disease severity and associated
screening and genetic counselling
complications and disabilities.
as appropriate.
Information sharing and
appropriate follow-up or referrals
occur between health care providers
across settings and sectors.
Objective 1 — Measuring Success
Table 9: Example Indicators to measure progress against Objective 1

1. The proportion of Australians living with preventable chronic conditions or associated risk factors is reduced.
Example Indicator Relevant Agency
Strategic
Priority Area
(SPA)
Morbidity and mortality
Incidence of heart attacks SPA 1.1 AIHW
Incidence of selected cancers SPA 1.1 AIHW
Prevalence of cardiovascular disease, cancers, diabetes
SPA 1.1 ABS, AIHW
or chronic respiratory diseases, by age group
Prevalence rate for mental illness SPA 1.1 Health, ABS
High/Very high levels of psychological distress, by age group SPA 1.1 ABS
Non-fatal burden of disease (Years Lost due to Disability — YLD) SPA 1.1 AIHW*
Fatal burden of disease (Years of Life Lost — YLL) SPA 1.1 AIHW*
Unconditional probability of dying between ages 30–70 years from
SPA 1.1 AIHW
cardiovascular disease, cancers, diabetes or chronic respiratory diseases
Alcohol-related morbidity and mortality among adolescents and adults SPA 1.1 AIHW
Risk factors
Low income SPA 1.1 ABS
Education attainment SPA 1.1 ABS
Unemployment SPA 1.1 ABS
Alcohol consumption per capita SPA 1.1 ABS
Single occasion and lifetime risky drinking, by age group SPA 1.1, 1.3 AIHW, ABS
Insufficient physical activity, by age group SPA 1.1, 1.3 ABS
Salt intake per capita SPA 1.1 ABS*
Daily smoking, by age group SPA 1.1, 1.3 AIHW, ABS
Raised blood pressure, by age group SPA 1.1, 1.3 ABS
Raised blood glucose levels (including diabetes), by age group SPA 1.1, 1.3 ABS*
Overweight/obese, by age group SPA 1.1, 1.3 ABS
Energy intake from discretionary foods, by age group SPA 1.1, 1.3 ABS*
Inadequate fruit and/or vegetable consumption, by age group SPA 1.1, 1.3 ABS
Raised total cholesterol, by age group SPA 1.1, 1.3 ABS*
Absolute cardiovascular risk, ages 45–74 years SPA 1.1 NHF, ABS*
Table 9: Example Indicators to measure progress against Objective 1 (continued)

2. Australia meets the voluntary global targets outlined in the WHO Global Action Plan for the Prevention and
Control of Noncommunicable Diseases 2013–2020.
Strategic
Priority Area
(SPA)
Unconditional probability of dying between ages 30–70 years from
SPA 1.1 AIHW
cardiovascular disease, cancers, diabetes or chronic respiratory diseases
Incidence of selected cancers SPA 1.1 AIHW
Alcohol consumption per capita SPA 1.1 ABS
Alcohol-related morbidity and mortality among adolescents and adults SPA 1.1 AIHW
Salt intake per capita SPA 1.1 ABS*
Immunisation rates among children SPA 1.3 Health
Screening rates for breast, cervical and bowel cancer SPA 1.4 AIHW
Eligible persons receiving drug therapy and counselling
SPA 1.1, 1.4 ABS*
to prevent heart attacks and stroke

3. Australians with chronic conditions, or associated risk factors, develop them later in life
and receive timely interventions to achieve optimal health outcomes.
Strategic
Priority Area
(SPA)
Smoking during pregnancy SPA 1.3 AIHW
Low birth weight SPA 1.3 AIHW
Exclusive breastfeeding SPA 1.3 AIHW*
Children exposed to tobacco smoke in the home SPA 1.3 AIHW
Children with developmental health checks SPA 1.3 Health**
Immunisation rates among children SPA 1.3 Health
Consultation with health professional for long-term condition
SPA 1.4 ABS
in last 12 months
Annual health assessment for older people SPA 1.4 Health
Dentist visit in last 12 months SPA 1.4 AIHW
Screening rates for breast, cervical and bowel cancer SPA 1.4 AIHW
Diagnostic assessment rate for breast, cervical and bowel cancer
(proportion of population with positive screening test and follow-up SPA 1.4 AIHW
diagnostic assessment)
Time between positive screen and diagnostic assessment
SPA 1.4 AIHW
— breast, cervical and bowel cancer
* Data not routinely available

** Indicator comprehensiveness issues
ABS — Australian Bureau of Statistics
AIHW — Australian Institute of Health and Welfare
Health — Commonwealth Department of Health
NHF — National Heart Foundation
Objective 2:
Provide efficient, effective and
appropriate care to support people with
chronic conditions to optimise quality of life
1. Australians with chronic conditions receive coordinated, person-centred and appropriate care.
2. Australians experience fewer complications, multimorbidities
or disabilities associated with chronic conditions.
3. Fewer Australians die prematurely due to specific chronic conditions.
All Australians are entitled to efficient, effective Effective and appropriate care improves overall
and appropriate quality health care. People with health and social outcomes for people with
chronic conditions may have multimorbidities with chronic conditions, and their carers and families.
varying levels of complexity; require increased,
People with chronic conditions often require joined-up
ongoing access to a range of services and
and coordinated health care which can be complex and
self-management support; and are likely to
traverse a range of different health care providers,
be on multiple pharmacotherapies. Without effective
settings and sectors. Establishing collaborative and
support these people often experience poor health
trusting relationships across health sectors will:
and reduced quality of life. Actively engaging
provide the foundation for improved communication;
people in their own health care (with appropriate
strengthen continuity of care; and facilitate
involvement of carers and families) empowers people
information sharing. An adequately equipped and
to take greater control in managing their health and
trained health workforce is essential to provide
optimising their quality of life.
care that is of a high standard to those who need it,
Provision of clinically appropriate, when they need it, in a way that meets individual needs.
evidence-based, safe and accessible health
Addressing risk factors and providing the right
care for people with chronic conditions can:
support at early onset of a chronic condition will
• slow disease progression; also contribute to long-term management strategies
• help to prevent and delay the onset of by helping to slow disease progression and reducing
additional chronic conditions, complications, the risk of developing additional chronic conditions,
and associated disabilities; complications and associated disabilities. Objective 1
• improve health and wellbeing; and addresses these interrelated issues.
• enhance quality of life. The Strategic Priority Areas and Aspirational

2.1 People with chronic conditions, and their carers and families,
2.1: Active engagement
are central to, and have an informed role in, their care management.
2.2 Australians receive consistent, holistic, coordinated care across
2.2: Continuity of care
the health system to manage their chronic conditions.
2.3 People with chronic conditions have equitable access
2.3: Accessible health services
to quality health care.
2.4 Effective sharing of consistent, relevant and secure health information
2.4: Information sharing
and data improves service delivery performance and health outcomes.
2.5 Systems work together to better meet the needs of people
2.5: Supportive systems
with chronic conditions.
Strategic Priority Area 2.1: Active engagement Active engagement is more than just effective
Active engagement embodies a person-centred self-management. Active engagement in the
approach that puts people at the centre of their decision-making process is especially important for
own health care and empowers them to play people with complex care needs and limited capacity
an informed role according to their interest for self-management, so they can work in partnership
and abilities. People with chronic conditions with health professionals to gain more control over
should not manage their health in isolation, nor be their health.
expected to play a passive role. Wherever possible, The more advanced stages of chronic conditions
individuals should be actively engaged in shared can be associated with disability and impaired
decision-making processes, with care partnerships decision-making capability. For some people,
created between individuals and their health care advance care planning in the early stages
providers, carers, families and communities of chronic conditions can greatly improve
as appropriate. quality of life by encouraging individuals
Chronic conditions have a range of potential impacts to make informed decisions about matters
on a person’s individual circumstances, including such as palliative care and end-of-life care,
broader social, emotional and economic effects62. and plan appropriately for the future.
Actively engaging individuals allows personal Empowering individuals to make informed decisions
factors to be considered — such as home, about their health and wellbeing builds confidence and
family and work life, education, psychosocial factors, understanding that enables action to maximise their
constraints caused by their condition, and economic health outcomes and maintain optimal quality of life
and community contribution. Effectively engaging at any stage of illness66.
people in the management of their chronic
conditions empowers individuals to: Active engagement necessitates a health
workforce with strong capabilities in effective
• improve their knowledge about their condition; communication techniques, proficiency in the
• set goals appropriate to their health use of technology, and willingness to embrace
and social needs and values; new and emerging technologies, to support
• involve their carers and families in individuals accordingly. The health workforce is
care planning as appropriate; a critical partner in delivering health information,
• discuss treatment preferences; and education and services to people who have varying
levels of health literacy. Digital technology and
• set individual quality of life goals.
telehealth have great potential to enable people
to take more control over their health and support
Improving health literacy is essential to activating
person-centred care and self-management
people in their own health care63. Decisions
where used appropriately67.
and behaviours required to improve health and
wellbeing are often undertaken on a daily basis by Policies, strategies, actions and services developed
people themselves: effective self-management is under this Strategic Priority Area by relevant
a key part of optimal care for chronic conditions. Partners should aim to achieve the Outcomes
Health literacy is critical to empowerment and affects outlined in Table 11.
a person’s capacity to make good decisions about their
health and health care and take appropriate action64, 65.
Strategic Priority Area 2.1: Active engagement

The health workforce supports People have better health literacy 2.1 People with chronic conditions,
delivery of information and services and improved confidence to and their carers and
to people who have varying levels partner in the management families, are central to,
of health literacy. of their chronic conditions. and have an informed role in,
their care management.
People have sufficient and relevant Quality of life for people with
information and support to learn chronic conditions is enhanced
more about their chronic condition through effective care
and its management. management strategies.
Individuals, carers and families The health workforce has
have access to resources and strong capabilities in effective
information to better navigate communication techniques.
the health system.
People with chronic conditions
Individuals, carers and families are participate in advance care
active in the management of chronic planning as appropriate.
conditions as recognised and
People’s capacity for active
valued members of the care team.
self-management is improved.
Personalised goal setting and
care planning enhance social,
economic and community
engagement and improve
quality of life.
Integrated care plans are
developed in partnership with
individuals (and carers and families),
and implemented and
reviewed through a flexible
team-based approach.
People with chronic conditions are
educated about the benefits of,
and encouraged to consider,
advance care planning.
Innovative care models
support uptake of referrals
and active self-management.
Better self-management
and active engagement is
supported by technology.
The health workforce is proficient
in the use of technology to
support active engagement.
Strategic Priority Area 2.2: Continuity of care Transition points across the health system often
Continuity of care is concerned with how an act as a barrier to continuity of care. Health
individual’s health care is connected over time68. care transition points occur across the lifespan,
Continuity of care covers: and between health care providers and services
such as: acute to primary care and aged care;
• an individual’s experience of the health system
maternity to community-based care; paediatric to
and relationship with an identified care provider
adult health services; and day-to-day health provider
(relational continuity); and
transitions such as shift changes, admission,
• the consistency of care and continuity of information referral or discharge. These transition points are
to ensure that individuals have seamless and timely often difficult for people to navigate. Making these
access to the full range of services they require transitions navigable and as seamless as possible
across the health system (informational and minimises handover risk, avoids duplication
management continuity)69. and treatment delays, and ensures the provision
of high-quality, consistent care71.
For people with chronic conditions, health needs
can rarely be met by a sole practitioner. As such, A greater emphasis on coordinating care can
a stronger focus is required on coordination of improve people’s health and wellbeing, and result
care and integration where possible. in a better individual experience of the health system.
However, not all people with a chronic condition
Australia’s health system has tended to operate will benefit from coordinated care72. For example,
as a disparate set of service sectors rather than individuals who are largely high functioning with
an integrated service system. Services have not little reduction in quality of life are unlikely to expect
always been well aligned to support the ongoing or receive much value from coordinated care.
and multidisciplinary care required for managing Resources should therefore be targeted to
the increasing number of people living with individuals who stand to gain the most benefit
chronic conditions. Communication barriers from coordinated care, including those who:
can also exist between the various health sectors,
• are not well linked into health and community services;
limiting the connectivity required for continuity of care.
• lack knowledge of their condition;
Integrated care involves the provision of seamless,
• have mental health or lifestyle risk factors
effective and efficient care that responds to the
and lack motivation to change behaviour; or
breadth of a person’s health needs, across physical
and mental health, in partnership with the individual, • have poorly controlled chronic conditions
their carers and families70. For people with or multiple chronic conditions.
chronic conditions, services are frequently required
from multiple health care providers, across disciplines Coordinated care should also be offered to people
and across different service sectors. There is an who have had previous hospital admissions or
increasing need to build strong partnerships within have potential to improve self-management73.
the health system and across health sectors such as: Achieving continuity of care across the
primary, community and acute care; specialist health system requires concentrated
and generalist care; mental health, aged care, effort at the system level and strong
and disability services; as well as public, private partnerships to deliver the changes required.
and not-for-profit providers. All relevant parts of the Management and care for people with chronic
system must work to facilitate better integration or conditions requires coordination, flexible service
coordination of services to enhance health service delivery and team-based care. This should be
delivery that is centred on the needs of the individual. underpinned by a well-resourced health workforce
Innovative solutions, technology and new models of with capacity to communicate effectively across
care should be harnessed to successfully sectors and to work in flexible team-based
respond to this challenge. care arrangements. Appropriate leadership,
commitment and innovation will strengthen the
health system’s capacity to achieve coordinated
and integrated service delivery.
The most effective strategies and initiatives to achieve Continuity of care and accessibility are
continuity of care and improve health outcomes implicitly intertwined: inaccessible health services
are multi-faceted and include: can be a barrier to achieving continuity of care.
• communication and support for providers Accessible health services are addressed in
and individuals; Strategic Priority Area 2.3 (Accessible health services).
• structural arrangements to support integration
to improve continuity of care may also contribute
and enable care coordination for people within
towards achieving Outcomes in Priority Area 2.3
and between different health services; and
(Accessible health services), and vice versa.
• strong relationships and establishment of
trust between the different components Policies, strategies, actions and services developed
of the health sector74. under this Strategic Priority Area by relevant
Strategic Priority Area 2.2: Continuity of Care

People with multiple chronic Transitions between services 2.2 Australians receive consistent,
conditions or complex care and across health care settings holistic and coordinated
needs are supported to navigate are smooth for people with care across the health
and access coordinated care chronic conditions. system to manage
across multiple health settings their chronic conditions.
Health services deliver
and services.
well-coordinated and
Effective transfer, discharge holistic care to people
and referral pathways exist with chronic conditions.
between health care services.
Health service planning addresses
Systems support the effective gaps and fragmentation in the
use of, and communication about, health system at the national
advance care plans, particularly and local levels.
during care transitions.
Continuity of care is enhanced by
Innovative funding and care improved technological capabilities.
models enhance coordination
Safe, high-quality and consistent
and flexible team-based care
systems and processes
on an ongoing basis.
improve continuity of care
The health workforce works in and health outcomes.
flexible multidisciplinary teams
to address single or multiple
chronic conditions.
Clinical care provided
across the health system
reflects evidence-based
best practice guidelines.
Effective communication
pathways are established within
and across health services,
settings and sectors.
Technology enhances secure
communication and coordination
between multidisciplinary care
providers and with patients.
Strategic Priority Area 2.3: The health sector can advocate and partner
Accessible health services responsibly with other sectors and partners
Accessible health services are those that are where possible to:
physically available, affordable, appropriate • identify how to better align health and other support
and acceptable75. Access can be limited by physical services to assist people with chronic conditions;
and economic barriers as well as cultural or • work in partnership to improve affordability and
individual factors including lack of knowledge accessibility of health services; and
about what, where and how to access health services. • provide innovative service delivery options.
Adequate distribution of the health workforce
and services underpins accessible and timely provision Telehealth and digital technology also have
of high-quality health care across the health system. the potential to improve access to health care,
In 2009, the National Health and Hospitals Reform improve the quality of health care delivery, and reduce
Commission found that fragmentation in the health health care costs. These tools offer opportunities to
system leads to uneven access to services and quality enhance access for people where physical access
of care76. People with chronic conditions should receive is limited, and can be harnessed to provide flexible,
the right care, at the right time, in the right place, accessible health services that are responsive to
by the right team. They need equitable access to individual needs. This may include utilising non
a range of health services across a variety of settings face-to-face services where clinically appropriate
and often require flexibility in service provision to allow — enabled by telephone, videoconferencing or
quality, culturally safe and appropriate care that meets other digital health platforms. Used effectively and
the needs of the individual, when it is most needed. appropriately, technology can improve communication
and information sharing and enhance collaboration
To date, this has required navigation of a complex across health settings and services.
health system requiring a strong understanding of
care requirements and providers, which can result However, technology may be a barrier to access for
in access barriers. Improving people’s access to people if they lack the skills or infrastructure to use
relevant health information and their capacity to use it it appropriately. The health workforce is a critical
effectively will improve individual health literacy and partner in using technology to improve access.
assist individuals to better navigate the health system. A skilled workforce proficient in the use of
e-technologies, effective communication and in
There are various barriers to accessing providing information and services to people who
health care. People with chronic conditions have varying levels of health literacy will help to
can experience cost barriers associated with overcome barriers and facilitate improved access
managing single or multiple chronic conditions, to health services.
multiple pharmacotherapies, and accessing
a range of health services, including those Inaccessible health services can negatively impact
for which there is little or no rebate available. continuity of care. Policies, strategies, actions and
Accessing some services may require travel, services developed to achieve Outcomes in Strategic
accommodation or other support services and Priority Area 2.2 (Continuity of care) may contribute
can result in additional out-of-pocket expenses. towards achieving Outcomes in Strategic Priority
In some cases, physical access may not Area 2.3 (Accessible health services), and vice versa.
be feasible and out-of-hospital or at-home Policies, strategies, actions and services
service delivery methods may be required, developed under this Strategic Priority Area
particularly for palliative care services. by relevant Partners should aim to achieve
the Outcomes outlined in Table 13.
Strategic Priority Area 2.3: Accessible health services

Information about how, who, where People easily navigate the health 2.3 People with chronic conditions
and when to access health services system through a range of have equitable access to quality
is readily available and provided to innovative options. health care.
people in a timely manner through
Access barriers are addressed
a range of formats and settings.
through needs identification,
Technology broadens access advocacy and appropriate
to health services, including coordinated action.
appropriate use of telehealth
Funding and incentives take into
and digital health options.
account addressing access barriers.
The health workforce is
suitably trained, resourced and
distributed to meet identified need.
The health workforce is skilled
in the use of technology and in
effective communication that is
appropriate to health literacy levels.
The health workforce works
to its full scope of practice.
Innovative and flexible service
options enhance access to health
information and services.
Innovation drives cost-effective
delivery of health care services
and prescribing of medicines.
Strategic Priority Area 2.4: Information sharing Enabling health professionals from all
Sharing quality, accessible information about the sectors to share and act upon a wider range
health system’s performance and the health of of readily accessible health information,
Australians can improve monitoring, reduce waste paired with clinical support to use it for data
and duplication of effort, build the evidence and/or research purposes, can have a positive
base and improve the safety and quality of care. impact on the quality and safety of clinical care.
Access to quality information informs prevention Continuous quality improvement processes and
and management of chronic conditions, and allows review of performance procedures individually,
priority populations to be readily identified and or as part of a team, makes provision of care safer
effectively supported. and more effective. Engaging people with chronic
conditions in the ongoing monitoring, measurement
Collection, linkage and sharing of consistent, and evaluation of health service performance to
reliable and de-identified data provides information support continuous quality improvement will ensure
about the health of Australians and the impact a better patient experience of the health system
of chronic conditions. National data sources and better health outcomes78. Sharing information
are beneficial as they provide information at will provide the basis for implementing changes
the population level; state and territory level to improve the quality, safety, and appropriate
information helps to identify health needs and delivery of health care.
complements national data; and regional and local
data enables better understanding of the needs of Access to appropriate technological infrastructure
local communities and the extent to which available can enhance information sharing. A universal
services meet these needs. Integrating data sources health record (such as the My Health Record)
by data linkage will help to provide a more complete has the potential to facilitate secure, real-time sharing
picture and maximise the utility of information, of health information. A continuing and stronger
allowing data collected once to be used multiple focus is required to facilitate broader sharing of
times by many partners. information between all health workforce sectors.
Access to health data in a timely, comprehensive Privacy laws can be a barrier to sharing
and routine manner also enables researchers to health information. Mechanisms that provide
generate new information and knowledge to improve people with the choice to consent to their
the quality of care, support new and innovative information being used to improve policy, services,
solutions and identify successful, clinically safe and their own health care, and the use of de-identified
strategies to better prevent, treat or manage data in population, state and local level planning help
chronic conditions. Translating this evidence into overcome this barrier.
practice can be challenging, as various barriers Policies, strategies, actions and services developed
to this process often leads to a gap between under this Strategic Priority Area by relevant Partners
the knowledge produced and what happens at should aim to achieve the Outcomes outlined in
the policy, strategy, action and service level. A number Table 14.
of knowledge exchange and translation models exist
which can facilitate information flow to the right
people in a useable format, and help to influence
evidence-based decision-making and policy77.
Strategic Priority Area 2.4: Information sharing

Effective data sharing occurs A connected health system has 2.4 Effective sharing of consistent,
across health settings, services timely and secure access to accurate relevant, secure health
and sectors, such as acute health information and data. information and data improves
and primary care settings, service delivery performance
Real-time, secure data sharing
aged care, disability and and health outcomes.
occurs across the health
mental health services.
system and between partners
A universal electronic health as appropriate.
record (My Health Record) is used to
Quality, transparent data
securely share health information
and research findings are
between health care providers.
readily available and drive
The health workforce uses health new evidence-based solutions.
information to inform quality
Research findings inform new
improvement processes and
solutions to service delivery
service delivery options.
that respond to changing
People with chronic conditions population needs.
understand the need for data
sharing and are asked to give
informed consent.
Consistent data collection
meaningfully informs the design,
innovation and continuous quality
improvement of services and policy
at national and local levels.
Relevant and robust research,
including real-life research,
knowledge exchange and
translation, occurs to strengthen
the evidence base, inform
policy development and
support innovative solutions.
Care plans (including advance
care plans) and relevant medical
records are securely shared
between all health sectors
and the aged care sector.
Technology enhances the
collection of relevant data and
information to support continuous
quality improvement and better
service planning.
Strategic Priority Area 2.5: Supportive systems People with chronic conditions often require support
The current health system in Australia is largely based from services beyond the health sector such as
on an acute model of care and is not well structured to disability and social services, and infrastructure
deliver optimal care for people with chronic conditions. support (physical and technological).
With an increasing number of people with chronic Consultation between relevant partners and
conditions and multimorbidities, it is becoming more people with chronic conditions is essential
important that health infrastructure and services to identify who, where, what and how support
are designed to better support the needs of people is needed, and to design, plan, and implement
with chronic conditions. innovative solutions to optimise the ways in
which services support population health.
Current health reforms are already going some This requires long-term plans, collaborative
way to implement the change required to enable the partnerships across sectors, coordinated action
health system to respond more effectively to chronic at the local, state and national levels, and strong
conditions and their complications. Proposed new governance arrangements to ensure that funders,
models of primary health care, workforce reform, providers, communities and individuals are
innovative funding models, incentive payments, engaged in the process and in ongoing evaluation.
mental health reform, aged care reform,
and reforms to Medicare, are some of the more Wherever possible, the health sector should
recent developments. Sustained efforts within the engage relevant partners from within and beyond
health sector are required to better provide supportive the health sector, working within the boundaries
systems and innovative models of care to support of current political directions and organisational
people with chronic conditions in a coordinated and governance arrangements. Building leadership skills
patient-centred way. However, creating systems in appropriate representatives, including across
that better support people with chronic conditions local networks and at the non-government
is not necessarily the responsibility of the health organisation level, will help strengthen capacity
sector alone. for cross-sector engagement, and will assist the
health sector to advocate for broader systemic
change to better support the needs of people
Strategic Priority Area 2.5: Supportive systems

The health sector identifies Health services collaborate 2.5 Systems work together to better
where and how people with with external support services meet the needs of people with
chronic conditions could be to better support people chronic conditions.
better supported. with chronic conditions and
reduce access barriers.
Coordinated action reduces
duplication and improves The health sector advocates and
efficacy of health services. works collaboratively with external
sectors to influence planning
Continued commitment to health
and delivery of services.
reforms that aim to more effectively
respond to chronic conditions. Innovative services and funding
models better support people
Collaborative research partnerships
examine cross-sectoral issues and
inform evidence-based responses.

1. Australians with chronic conditions receive coordinated, person-centred and appropriate care.
Strategic
Priority Area
(SPA)
Health literacy SPA 2.1 ABS*
Patient experience SPA 2.1, 2.2 ABS
People with (i) asthma, (ii) diabetes, (iii) mental illness with a care plan SPA 2.1, 2.2 ABS**
Chronic Disease Management Medicare Items
SPA 2.2 Health
(GPMP Item 721 and TCA Item 723)
Efficient management of diabetes SPA 2.2 ABS*
Community follow-up after psychiatric discharge SPA 2.2 AIHW
Waiting times for (i) GPs, (ii) public dentistry, (iii) elective surgery,
SPA 2.3 AIHW, ABS
(iv) emergency
Cancer care pathway — cancer care waiting times SPA 2.3 AIHW
Eligible persons receiving drug therapy and counselling
SPA 2.3 ABS*
to prevent heart attacks and stroke
Hospital procedures, by region SPA 2.3 AIHW
Potentially preventable hospitalisations for chronic conditions SPA 2.3 AIHW
Bulk-billing for non-referred (GP) attendances SPA 2.3 Health
Out-of-pocket medical expenditure SPA 2.3 AIHW
Unmet need for medical, dental care due to cost SPA 2.3 ABS
GP, nursing, public dentist availability by region SPA 2.3 Health
GP practices in the Practice Incentives Program (PIP) using computers
SPA 2.4 Health
for clinical purposes
Uptake of My Health Record SPA 2.4 Health


2. Australians experience fewer complications, multimorbidities or disabilities associated with chronic conditions.
Strategic
Priority Area
(SPA)
Unplanned hospital readmissions for chronic conditions SPA 2.3 AIHW
Prevalence of chronic condition multimorbidities SPA 2.3 ABS
Chronic conditions among people with disability SPA 2.3 ABS


3. Fewer Australians die prematurely due to specific chronic conditions.
Strategic
Priority Area
(SPA)
Potentially avoidable deaths SPA 2.3 AIHW, ABS
Potential Years of Life Lost (PYLL) from chronic conditions SPA 2.3 AIHW
* Data not routinely available.

** Indicator comprehensiveness issues.
Objective 3:
Target priority populations
1. Priority populations have reduced risk of developing chronic conditions.
2. Priority populations experience fewer complications, multimorbidities
or disabilities associated with chronic conditions.
3. Aboriginal and Torres Strait Islander people have reduced risk of developing chronic conditions
and those with chronic conditions have an improved life expectancy.
Chronic conditions impact all Australians, The prevention and management approaches
but some populations are disproportionally outlined in Objective 1 and 2 apply equally
affected due to a complex interaction between for priority populations as they do for
the physical environment, social and cultural the wider population. However, given the
determinants and biomedical and behavioural disproportionate burden of chronic conditions
risk factors. This is demonstrated by a higher experienced by priority populations, targeted action is
prevalence of chronic conditions and a greater essential to ensure that they receive access to quality,
burden of disease in these populations, resulting in safe health care and relevant information. The health
inequitable health outcomes. Due to the disparity system at all levels must be responsive to the specific
in health outcomes, equal focus is not sufficient: needs of priority populations to effectively address
greater investment and sustained efforts are chronic conditions by providing:
required to positively advantage priority populations • culturally safe and appropriate services;
and overcome current inequities in health outcomes.
• accessible health services that are effective,
Priority populations include, but are not limited to: high-quality and affordable; and
• Aboriginal and Torres Strait Islander people; • flexible service options.
• people from culturally and linguistically
diverse backgrounds; The planning and delivery of health services
should recognise the diversity of people
• older Australians;
in Australia and the range of requirements
• carers of people with chronic conditions; for urban, regional, rural and remote locations.
• people experiencing socio-economic disadvantage;
• people living in remote, or rural and
regional locations;
• people with disability;
• people with mental illness; and
• people who are, or have been incarcerated.
A range of issues that specifically focus on Aboriginal
and Torres Strait Islander people are provided
under Strategic Priority Area 3.1 (Aboriginal and
Torres Strait Islander health). Strategic Priority
Area 3.2 (Action and empowerment) establishes key
outcomes to guide policies, strategies, actions and
services to address health inequities and empower
all priority populations. As such, Strategic Priority
Area 3.2 (Action and empowerment) is inclusive
of all priority populations.
The Strategic Priority Areas and Aspirational

3.1: Aboriginal and Torres Strait 3.1 The disparity in health outcomes due to chronic conditions between
Islander health Aboriginal and Torres Strait Islander people and non-Indigenous
Australians is reduced.
3.2: Action and empowerment 3.2 Community empowerment and targeted action improves local and
population health outcomes for priority populations at risk of, or with,
chronic conditions.
Strategic Priority Area 3.1: • are flexible to meet local needs and are
Aboriginal and Torres Strait Islander health provided at a local level as appropriate to minimise
In 2008, the Council of Australian Governments the need for people to move away from family
agreed to a set of targets to address the disadvantage and community; and
experienced by Aboriginal and Torres Strait • include Aboriginal and Torres Strait Islander people
Islander people — the Closing the Gap initiative. as part of the health care team wherever possible.
One of the targets identified was to close the gap in
life expectancy between Aboriginal and Torres Strait To improve the cultural competence of the
Islander people and non-Indigenous Australians health workforce, action is needed to increase the
within a generation (by 2031)79. The Implementation number of Aboriginal and Torres Strait Islander
Plan for the National Aboriginal and Torres Strait people in the health workforce. The current number
Islander Health Plan 2013–2023 builds on the Closing of Aboriginal and Torres Strait Islander people
the Gap approach through identified strategies and represented in the health workforce does not
actions and recognises the importance of social reflect the need of the population and potentially
and cultural determinants of health. contributes to reduced access to health services 84.
In addition, to enhance health service delivery
Since 2008, the health of Aboriginal and Torres Strait for Aboriginal and Torres Strait Islander people,
Islander people has slowly improved with positive a greater focus on culture within health care education
progress toward the Closing the Gap targets, but there is needed to improve the cultural competency of
are still significant gains to be made. Continued effort the health workforce.
to close the gap in life expectancy between Aboriginal
and Torres Strait Islander people and non-Indigenous Responsible partnerships combined with
Australians by 2031 and achieve equitable health strong community leadership and advocacy will
outcomes remains a critical goal80. optimise access, quality and sustainability of culturally
safe and appropriate health services to address
Chronic conditions are the leading cause of the chronic conditions. Engaging and collaborating with
health gap between Aboriginal and Torres Strait Aboriginal and Torres Strait Islander communities,
Islander people and non-Indigenous Australians 81. community Elders and leaders, the community
Aboriginal and Torres Strait Islander people controlled sector, health professionals, and peak
experience a greater burden of chronic conditions bodies representing Aboriginal and Torres Strait
and they tend to develop them earlier in life82. Islander people encourages active, individual and
Action to prevent and manage chronic conditions family participation. This inclusive approach will also
and their risk factors must occur across the life contribute to the identification of community health
course to increase life expectancy for Aboriginal and needs and the development and implementation
Torres Strait Islander people, reduce the occurrence of locally responsive and appropriate services.
of multimorbidities and improve health outcomes
now and for future generations. Strategic Priority Supporting Aboriginal and Torres Strait Islander
Area 3.1 (Aboriginal and Torres Strait Islander health) people to self-identify to the health sector as being of
complements the range of current activity underway Aboriginal and Torres Strait descent will help to better
by specifically focusing on improving health inform evidence-based health policy. By improving
outcomes relating to chronic conditions. data collection processes across the health system,
a more complete picture of Aboriginal and Torres
The concept of health for Aboriginal and Torres Strait Strait Islander health can be gained85. Accurate and
Islander people is holistic, with culture, land and reliable information about Aboriginal and Torres
spirituality playing a key role83. To improve health Strait Islander peoples’ health allows stronger
outcomes for Aboriginal and Torres Strait Islander understanding of where and how these can be more
people with, or at risk of chronic conditions, health effectively supported to prevent and appropriately
care services must be culturally safe and appropriate. manage chronic conditions.
Culturally safe and appropriate services for
Aboriginal and Torres Strait Islander people: Policies, strategies, actions and services developed
• are provided by a culturally competent workforce,
who communicate respectfully and are able to
establish good relationships;
Strategic Priority Area 3.1: Aboriginal and Torres Strait Islander health

Aboriginal and Torres Strait Individuals, carers and families 3.1 The disparity in health
Islander people engage with participate in the management of outcomes due to chronic
culturally appropriate health chronic conditions as recognised conditions between Aboriginal
promotion activities. and valued members of the and Torres Strait Islander
care team. people and non-Indigenous
Culturally appropriate
Australians is reduced.
information and interventions Aboriginal and Torres Strait
reduce Aboriginal and Torres Islander people are consulted and
Strait Islander peoples’ risk active in health research specific
of developing a chronic condition. to their cultural and/or population
health needs.
Aboriginal and Torres Strait
Islander people access The health workforce actively
culturally safe, high-quality works to meet the current and
and appropriate health future health needs of Aboriginal
and wellbeing services. and Torres Strait Islander people.
Personalised goal setting and Improved data collection better
care planning enhances social supports Aboriginal and Torres
and community engagement and Strait Islander health outcomes.
improves quality of life for Aboriginal
and Torres Strait Islander people.
Islander people partner in, and lead,
the planning, design, evaluation and
implementation of locally responsive
and culturally appropriate services.
Aboriginal and Torres Strait Islander
Elders and community leaders
are recognised, valued and engaged
to positively influence health and
wellbeing outcomes.
Aboriginal Community Controlled
Health Organisations are leaders
in the prevention and management
of chronic conditions for Aboriginal
Mainstream health services
are inclusive, accessible,
and understand and respect
the cultural values of Aboriginal
The capability of the health
workforce is enhanced to meet
current and future needs of
Islander people.
Strategic Priority Area 3.2: Targeted action should also aim to facilitate individual,
Action and empowerment community and population empowerment.
People within priority populations have a higher Empowerment is the process by which people gain
risk of developing a chronic condition, and they are control over the factors and decisions that shape their
also more likely to experience inequitable access lives and can lead to an improvement in the health
to health services, more rapid progression of their status of an individual, community and population87.
chronic condition and have higher rates of associated Empowerment is achieved through communication
hospitalisation and death86. Targeted action through and consultation and implies community
population level and community level approaches, ownership and action88.
as well as empowering individuals, communities and Communities have an important role in identifying
populations, will also positively advantage priority local health needs for community members
populations and improve health equity. with chronic conditions, particularly for those in
Approaches for targeted action should be based on priority populations, and in providing leadership
the shared characteristics of a population, or consider and support to ensure that these needs are met.
geographical communities who share common values Communities can be empowered to deliver
and health needs. Actions to improve health outcomes locally responsive health care services that are
for priority populations should: culturally safe, of high-quality and readily accessible
to meet the specific needs of their community.
• provide high-quality, safe health care services and
appropriate health information to more effectively Investment in community empowerment builds
meet specific health needs, including addressing greater community resilience and ownership,
health literacy; influences the environment to promote healthy
• improve screening and timely detection for those behaviour, allows individuals to increase control
at high risk of developing chronic conditions; over the factors that influence their health, and leads
to sustained improvements in health outcomes.
• be supported by an appropriately distributed
health workforce who understand different Policies, strategies, actions and services developed
populations’ values, beliefs and priorities and who under this Strategic Priority Area by relevant
work effectively in cross-cultural and social settings; Partners should aim to achieve the Outcomes
• be provided at a local level, as appropriate, outlined in Table 19.
to minimise the need for people to move away
from their family and community; and
• engage individuals as active participants
in the prevention and management of
their chronic conditions.
Strategic Priority Area 3.2: Action and empowerment

Interventions reduce the risk of Locally responsive health services 3.2 Community empowerment
developing a chronic condition for people with chronic conditions and targeted action improves
in priority populations. are accessible to communities. local and population health
outcomes for priority
Health information and education Flexible service delivery and care
populations at risk of, or with,
enables self-management where teams are available to areas and
chronic conditions.
appropriate and encourages populations with the greatest
engagement with health services. access barriers.
Community partnerships Research informs innovative
contribute to the planning, design, solutions to community health
evaluation and implementation of service delivery needs.
locally responsive and culturally
The health workforce effectively
appropriate services.
engages with diverse communities
The health workforce delivers in a culturally appropriate manner.
appropriate information and
Research provides
services to people who have
evidence-based solutions
varying levels of health literacy.
to specific community needs.
Services are delivered in a culturally
safe way involving people from the
same cultural background.
Local champions foster
health and wellbeing.
Information and technology
better supports local needs.

1. Priority populations have reduced risk of developing chronic conditions.
Strategic
Priority Area
(SPA)
Low income SPA 3.1, 3.2 ABS
Education attainment SPA 3.1, 3.2 ABS
Unemployment SPA 3.1, 3.2 ABS
Single occasion and lifetime risky drinking SPA 3.1, 3.2 AIHW, ABS
Insufficient physical activity SPA 3.1, 3.2 ABS
Daily smoking SPA 3.1, 3.2 AIHW, ABS
Raised blood pressure SPA 3.1, 3.2 ABS
Raised blood glucose levels (including diabetes) SPA 3.1, 3.2 ABS*
Overweight/obesity SPA 3.1, 3.2 ABS
Inadequate fruit and/or vegetable consumption SPA 3.1, 3.2 ABS
Raised total cholesterol SPA 3.1, 3.2 ABS*

2. Priority populations experience fewer complications, multimorbidities or disabilities associated
Strategic
Priority Area
(SPA)
Unplanned hospital readmissions for chronic conditions SPA 3.2 AIHW
Prevalence of chronic condition multimorbidities SPA 3.2 ABS
Chronic conditions among people with disability SPA 3.2 ABS

3. Aboriginal and Torres Strait Islander people have reduced risk of developing chronic conditions
and those with chronic conditions have an improved life expectancy.
Strategic
Priority Area
(SPA)
Low income SPA 3.1, 3.2 ABS
Education attainment SPA 3.1, 3.2 ABS
Unemployment SPA 3.1, 3.2 ABS
Access to functional housing with utilities SPA 3.1, 3.2 ABS
Single occasion and lifetime risky drinking SPA 3.1, 3.2 AIHW, ABS
Insufficient physical activity SPA 3.1, 3.2 ABS
Daily smoking SPA 3.1, 3.2 ABS
Drug and other substance use including inhalants SPA 3.1, 3.2 AIHW
Raised blood pressure SPA 3.1, 3.2 ABS
Raised blood glucose levels (including diabetes) SPA 3.1, 3.2 ABS*
Overweight/obese SPA 3.1, 3.2 ABS
Inadequate fruit and/or vegetable consumption SPA 3.1, 3.2 ABS
Raised total cholesterol SPA 3.1, 3.2 ABS*
Early detection and early treatment for Aboriginal
SPA 3.1 Health
and Torres Strait Islander people
Indigenous persons who did not access health services when needed SPA 3.1 ABS
Proportion of services with cultural safety policies or processes in place SPA 3.1 AIHW
Employed health practitioners, by Indigenous status SPA 3.1 AIHW
Proportion of Indigenous primary health care services accredited SPA 3.1 AIHW
* Data not routinely available.

Part
PART3:1:
Setting
Future work
the scene
Part 13 explores
outlines future
the impact
directions
of chronic
conditions
for further in Australia
work and outlines
and ongoing review.
the approach of the Framework.
50
Focus on the Future
The Framework’s primary role is to provide high level As an initial step, the Framework provides
guidance to support the planning and development a description of what success will look like,
of specific policies, strategies, actions and services and example indicators, at the Objective level.
so that all Australians may live healthier lives Where possible, these are based upon existing
through effective prevention and management of indicators that are measurable and where data
chronic conditions. The Framework establishes the are available. Where data are not routinely available
policy context and evidence-based strategic priority to support measures, these have been highlighted.
areas where action is required to meet the three
It is recognised that there is a need to create
overarching Objectives. The outcome focused
accountability to ensure prevention and management
approach of the Framework provides high level
actions are successfully implemented and
direction and identifies where opportunities might
that progress is reported in a consistent way.
be taken by Partners to achieve the best outcomes
Partners should seize the opportunity to develop
to prevent and/or manage chronic conditions.
their own organisational reporting processes
The increasing burden of chronic conditions in to monitor their progress in achieving results
Australia demands immediate action from across in relevant areas.
the health sector to address chronic conditions to
In recognition of the core role that the Australian
maximise health outcomes and optimise the quality
and state and territory governments have
of life of the population. Implementing policies,
across the health system, formalised reporting
strategies, actions and services to meet the
on progress towards the Objectives of the
outcomes identified through the Framework
Framework is anticipated at the national and
requires the combined response of all Partners.
state level (refer to Figure 4). Further work will be
Partners, including governments at all levels,
undertaken to develop a reporting mechanism that will
non-government organisations, industry and
build on existing work and available data and underpin
public and private health sectors, should establish
Australia’s international reporting commitments.
the areas where they can deliver and/or influence
action according to the remit of organisational Future work will be undertaken in collaboration
charters and governance direction. Action must with states and territories, and relevant experts,
start now and responsibility rests with all Partners. resulting in a companion document to support
the Framework. Once developed, the reporting
Further Work mechanism will be publicly available and used by
Several complementary actions are planned to all jurisdictions, including the Australian Government,
maximise the utility of the Framework. The call for reporting purposes at regular intervals for the life
throughout the consultations undertaken to inform of the Framework. Other Partners will be encouraged
the development of the Framework has been to refer to the document in monitoring their individual
strong in recommending that a nationally agreed progress and to review the way they track and
set of performance measures be developed to evaluate their activities against the Framework.
allow activity and achievements to be monitored
in a consistent manner. These measures should,
where possible, align with Australia’s international
reporting requirements for the WHO Global Action
Plan for the Prevention and Control of Noncommunicable
Diseases 2013–202089.
Figure 4: Monitoring and Reporting Cycle
Monitoring
Policies, Strategies, Actions and Services
and
Reporting Outcomes and Indicators
Ongoing Review the review of the Framework will be managed
The Framework will remain a living document that in a collaborative way, involving Partners,
will continue to be refined to meet changing needs, experts and all jurisdictions. Figure 5 sets out the
environments and emerging evidence. ongoing review and monitoring of the Framework.
The Framework will be reviewed every three years, Through an ongoing, shared commitment,

and informed by achievements against the Objectives. positive change can be achieved for people at risk of,
In recognition of the successful consultative process or with, chronic conditions. Improving health
through which the Framework was developed, outcomes for all Australians requires
a united approach.
Figure 5: Monitoring and Reviewing the Framework
Partners
• Government (at all levels) • Non-Government Organisations • Private Sector and Industry
• Researchers and Academics • Communities • Individuals
Principles
E qu
s it y
c he En a b l e r s
oa
pr
ap Go
r ed ce
s
ention for a h v er
nt ur on p r ev e na
so o c u s a l t hie nc
Re F
e
1: rA e&
-c
e u
Co
v
on
t i SPA 1.1: Promote s tr L

c a
ll a
rs
bj e health and reduce risk l ia
ea
Pe
bo
O
de
ra
rs
SPA 1.2: SPA 1.3: Critical SPA 1.4: Timely
t io
h ip
n&
Partnerships life stages and appropriate
for health detection and
P ar
intervention
gy
tn e r
o lo
n
O bj
ship s
Tech
il i t y
e c ti
Vision
S u s t a in a b
ve 2: P
All Australians live SPA 2.1: Active
healthier lives through engagement Research
r o v i d e ef f i c i
Triennial
w i th c h r o n
effective prevention
and management SPA 2.2:
Review
ion s
SPA 3.1: of chronic conditions. Continuity

Aboriginal
op ul at
of care
and Torres Strait
i c
A cc e s s
e
Islander health
c
n
SPA 2.3:
o
t
it y p
cy
,
n d i t ti v e a
Accessible
ef f e
iter a
SPA 3.2: health services

ion
io r
Action and
pr
th L
st da
empowerment SPA 2.4:

o
et
Information
al
o
g
n
pt pro
r
He
sharing
l it y
Ta
im p
p
is
3:
SPA 2.5:
i
e
sib
ve
qu
Supportive
Da
i ri
on
ct at a l i t y
systems
ta
p
je ec
a r of l i f e
es
Ob
&
In
r
fo et
d
os
Ev
re
rm up p
id
ha
at or t p
e
S io n e o p le nc
e-
e ba
rc se
r k fo Wo
d
H e al th
cy
a r en Accounta
bilit y & Tr ansp
Monitoring Policies, Strategies, Actions and Services

and
Reporting Outcomes and Indicators
SPA = Strategic Priority Area
Appendix: WHO Targets and Indicators
Image from the World Health Organization (WHO) — World Health Organization (WHO). Noncommunicable Disease
Global Monitoring Framework — Ensuring progress on noncommunicable diseases in countries [Internet].
Geneva, Switzerland: WHO; Available from: http://www.who.int/nmh/global_monitoring_framework/gmf1_large.jpg?ua=1
Image from the World Health Organization (WHO) — World Health Organization (WHO). Noncommunicable Disease
Global Monitoring Framework — Ensuring progress on noncommunicable diseases in countries [Internet].
Geneva, Switzerland: WHO; Available from: http://www.who.int/nmh/global_monitoring_framework/gmf2_large.jpg?ua=1
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National

National Strategic Framework for Chronic Conditions

The Hon Jill Hennessy MP

National Strategic Framework for Chronic Conditions

Jurisdictional Working Group

2 National Strategic Framework for Chronic Conditions

Current Status and Impact of Chronic Conditions 9 Objective 2 — Measuring Success 40

The Cost of Chronic Conditions 10 Objective 3: Target priority populations 42

Priority Populations 11 Strategic Priority Area 3.2:

Part 2: The Framework 13

Vision 14 Further Work 51

Principles 14 Ongoing Review 52

Outcomes 16 Commissioned Work 59

Objective 1: Focus on prevention

National Strategic Framework for Chronic Conditions 3

National Strategic Framework for Chronic Conditions 5

6 National Strategic Framework for Chronic Conditions

SPA 1.1: Promote tr a L

health and reduce risk l ia

SPA 3.1: of chronic conditions. Continuity

Policies, Strategies, Actions and Services

Outcomes and Indicators

National Strategic Framework for Chronic Conditions 7

Chronic Conditions Policies Other Relevant Health Policies and Programs*

International chronic conditions policies International

National chronic conditions policies National National health

State or regional State or regional

8 National Strategic Framework for Chronic Conditions

National Strategic Framework for Chronic Conditions 9

10 National Strategic Framework for Chronic Conditions

National Strategic Framework for Chronic Conditions 11

Figure 3: Influence of the Determinants of Health

Individual and Societal Features

Diagram adapted from the Australia Institute of Health and Welfare

12 National Strategic Framework for Chronic Conditions

14 National Strategic Framework for Chronic Conditions

Table 1: Strategic Priority Areas for Objective 1

Objective 1: Focus on prevention for a healthier Australia

Table 2: Strategic Priority Areas for Objective 2

Objective 2: Provide efficient, effective and appropriate care to support people

Table 3: Strategic Priority Areas for Objective 3

Objective 3: Target priority populations

National Strategic Framework for Chronic Conditions 15

16 National Strategic Framework for Chronic Conditions

National Strategic Framework for Chronic Conditions 17

Table 4: Strategic Priority Areas and Aspirational Outcomes for Objective 1

Objective 1: Focus on prevention for a healthier Australia

18 National Strategic Framework for Chronic Conditions

National Strategic Framework for Chronic Conditions 19

Strategic Priority Area 1.1: Promote health and reduce risk

Phase 1 Outcomes Phase 2 Outcomes Aspirational Outcome

20 National Strategic Framework for Chronic Conditions

Strategic Priority Area 1.2: Partnerships for health

Phase 1 Outcomes Phase 2 Outcomes Aspirational Outcome

National Strategic Framework for Chronic Conditions 21

22 National Strategic Framework for Chronic Conditions

Strategic Priority Area 1.3: Critical life stages