Lesson 20 · Actions to promote and improve health
The Sustainable Development Goals II: SDG 10 and SDG 11, and how the goals interlock
SDG 10 and SDG 11 are the two goals that describe, almost exactly, the two mechanisms this module has been documenting since Lesson 1: health follows a social gradient, and health follows where you live. Between them they cover most of what determines whether a person in an Australian community is well.
Think about the suburb or town you know best. Without naming a single health service, list four features of the place itself that make it easier or harder to be healthy there.
Then mark which of your four a local council could change, and which it could not.
- Describe SDG 10: Reduced Inequalities and explain why inequality itself affects health.
- Describe SDG 11: Sustainable Cities and Communities and how the built environment produces health.
- Explain how all four goals interlock, which is what the “key features” dot point is ultimately for.
- Explain why a strategy addressing only one goal tends to underperform.
- Apply the four goals to an Australian community, in preparation for the final two lessons.
- Inequality — a difference in outcome or opportunity between groups. Inequity — a difference that is avoidable, unnecessary and unfair.
- Social gradient — health improving stepwise with social and economic position, at every step, not only at the bottom.
- Relative inequality — the size of the gap between groups, as distinct from the absolute level of the worst-off group.
- Discrimination — unequal treatment on the basis of a characteristic; a health determinant through stress, exclusion and reduced access.
- Built environment — the human-made surroundings people live in: housing, streets, transport, parks, shops and services.
- Walkability — how easily daily destinations can be reached on foot; one of the most studied built-environment influences on health.
- Green space — parks and vegetation, associated with physical activity, lower heat exposure and better mental health.
- Urban heat island — built-up areas retaining more heat than surrounding areas, which matters increasingly as heat events increase.
- Housing security — having housing that is affordable, adequate and stable; among the strongest single determinants of health.
What it covers. Reducing inequality within and among countries. Its targets include raising the income of the poorest faster than the average; promoting the social, economic and political inclusion of everyone regardless of age, sex, disability, race, ethnicity, origin, religion or economic status; eliminating discriminatory laws and practices; adopting policies that progressively achieve greater equality; improving regulation of global financial systems; and enabling safe and orderly migration.
Why inequality is a health issue in its own right. This is the part worth understanding, because it goes beyond “poor people have worse health”.
- The social gradient is stepwise, not a cliff. Health improves at every step up the social ladder. That means it is not only poverty that damages health; relative position does too, at all levels. A gradient cannot be explained by material deprivation alone, because people in the middle are not materially deprived.
- Relative position has direct effects. Chronic stress from low control, insecurity and status, and the physiological consequences of sustained stress, are part of the mechanism.
- Inequality shapes the environment everyone lives in. Highly unequal places tend to have weaker shared services and lower trust, which affects everyone in them and not only the poorest.
- Discrimination is a determinant. Racism, ableism, ageism and other forms of exclusion act on health through stress, through reduced access, and through service experiences that discourage return — the acceptability gate from Lesson 8.
- Absolute and relative improvement can diverge. The worst-off group can improve while the gap widens, if better-off groups improve faster. That is the Lesson 2 pattern, and SDG 10 is the goal that names it as a problem rather than treating it as an accounting curiosity.
SDG 10 is the goal that says the gap itself matters, not just the level of the worst-off. That is the difference between a target that can be met by lifting everyone slightly and one that requires the distance to close.
Quick check: The social gradient in health is stepwise rather than a cliff. The most important implication is that:
What it covers. Making cities and human settlements inclusive, safe, resilient and sustainable. Its targets include adequate, safe and affordable housing; safe, affordable and accessible transport with attention to the needs of women, children, people with disability and older people; inclusive and sustainable urbanisation and participatory planning; protection of cultural and natural heritage; reducing deaths and losses from disasters; reducing the environmental impact of cities including air quality and waste; and universal access to safe, inclusive and accessible green and public spaces.
Why this is the most directly health-shaping goal of the four. It changes the conditions people live in every day, without requiring anyone to make a decision about their health.
- Housing. Affordable, adequate and stable housing is among the strongest determinants of health there is. Crowding transmits infection, cold and damp cause respiratory illness, heat kills, insecurity produces chronic stress, and unaffordable housing takes money from food and medicine.
- Transport. Whether a person can reach work, school, food and healthcare without a car determines access and determines daily activity. It matters most for older people, people with disability, young people and low-income households.
- Walkability and design. Places where daily destinations are reachable on foot produce more physical activity than any exhortation to exercise. Activity built into the day beats activity that requires a decision.
- Green and public space. Associated with physical activity, better mental health and social connection, and it reduces heat — which is a rising cause of illness and death.
- Air quality and environment. Air pollution affects respiratory and cardiovascular health, and it is unevenly distributed: poorer areas are more often near major roads and industry.
- Safety and disaster resilience. Injury, and the health effects of fire and flood, including sustained mental health effects.
- Food environment. What is available, affordable and nearby shapes diet more reliably than nutrition information does.
The built environment is the only health intervention that works while people are not thinking about their health. That is why it reaches the people whom information-based approaches reach least, and why it is the most equitable form of prevention available.
And it is the goal most within reach of local government — which matters, because Lesson 9 established that local government's health role is largely exercised through exactly these decisions.
True or false: Built-environment changes are among the most equitable forms of prevention, because they improve health without requiring a person to have the time, money or information to act.
Indivisibility is the claim; this card is the evidence. Take a single change and follow it through all four goals.
A community builds affordable, well-insulated housing near a school and a transport line.
- SDG 11. Adequate, affordable housing; accessible transport; a walkable neighbourhood. The direct goal.
- SDG 3. Less crowding and fewer respiratory infections; less heat and cold exposure; more incidental activity; reduced stress from housing insecurity; and better access to health services on the transport line.
- SDG 4. Stable housing near a school means fewer school changes and better attendance, and a child with a quiet, warm place to study learns more. Housing instability is one of the strongest predictors of interrupted schooling.
- SDG 10. Affordable housing near services reduces the cost of living for lower-income households and reduces the spatial concentration of disadvantage, which is one of the main ways inequality becomes self-sustaining.
Now run it the other way, because indivisibility works in both directions. A community's affordable housing is built on the edge of town with no transport. Housing is provided, and the residents cannot reach work, school, shops or the clinic without a car many of them do not have. SDG 11's housing target is met and its transport target is not, and the result is worse for health than not building at all in that location — because the disadvantage is now concentrated and fixed in place for decades.
This is what indivisibility means operationally: a strategy that meets one target while ignoring the ones it depends on can produce a worse outcome than doing nothing. The goals are not a menu, and partial implementation is not partial success.
Fill the gaps. The human-made surroundings people live in — housing, streets, transport, parks and shops — are called the environment. Built-up areas retaining more heat than the land around them create an urban heat .
Universality means these apply here. Where do they bite?
SDG 10 in Australia.
- The persistent gaps this module has documented: between Aboriginal and Torres Strait Islander Peoples and other Australians, by socioeconomic position, by remoteness, and for people with disability.
- The social gradient runs through the whole population and is visible in almost every health measure in the course.
- Discrimination as a health determinant, acting through stress, access and the acceptability of services.
- Absolute improvement with a persisting or widening gap — the exact pattern from Lesson 2, and the pattern SDG 10 exists to name.
SDG 11 in Australia.
- Housing affordability and security, and the concentration of affordable housing in areas with the fewest services.
- Car dependence in outer suburban and regional areas, which reduces incidental activity and makes access dependent on owning and running a car.
- Unequal distribution of green space and tree canopy, so heat exposure falls hardest on lower-income suburbs — a case where climate and inequality compound.
- Accessibility of transport and public space for older people and people with disability, which determines whether the functional ability from Lesson 7 can be exercised.
- Disaster resilience, as fire, flood and heat events increase.
- Remote communities, where housing, water, food supply and transport are simultaneously the hardest and the most consequential.
Notice that almost every item on the second list is a decision made outside the health system, mostly by state and local government, and mostly for reasons that had nothing to do with health.
Two truths and a lie. One of these statements is false. Find it.
The next two lessons apply the goals to a community, so this card sets up the method.
- Start with the health issue, not with the goals. Identify what is actually wrong in the community, then find which goals bear on it. Starting from the goals produces a plan that fits the framework and not the place.
- Ask which goal each determinant belongs to. This is how you find the actions available outside the health system, which is where most of the leverage is.
- Check the dependencies. For any action, ask which other goals it needs in order to work. The housing-without-transport example is the warning.
- Apply leave no one behind. Ask who in the community would be missed by the action, and whether the plan improves the average while leaving a group behind.
- Decide what you would measure. Against a target, disaggregated by group, over a stated period. Without this, an evaluation is an opinion.
The four goals are most useful as a checklist against narrowness. Their function is to stop a community's health plan being a list of health services, when most of what determines its health is housing, income, education and the street outside.
Activities · trace the connections
For each action, name every one of the four goals it touches, and describe the health mechanism for at least two of them.
A council plants street trees and installs shade and seating along a main shopping street.
A regional town extends its bus service to run in the evening and on weekends.
A program repairs and insulates housing in a remote community and reduces crowding.
A workplace policy eliminating discriminatory hiring practices against people with disability.
Match each goal to the health mechanism most characteristic of it.
- SDG 3
- SDG 4
- SDG 10
- SDG 11
- Access to services and medicines without financial hardship
- Health literacy, income security and control, passed to the next generation
- The social gradient, discrimination, and gaps that persist while averages improve
- Housing, transport, walkability, green space and heat
Using the four features you listed in card 01, audit the community you know best against SDG 10 and SDG 11.
Name three things that support health and three that work against it. For each of the three problems, say which level of government or which organisation could change it, and identify the one you would act on first — giving the reason in terms of who it would reach rather than how big it is.
Lock it in. In one sentence, explain why meeting one Sustainable Development Goal target while ignoring the ones it depends on can produce a worse outcome than doing nothing.
Analyse how the Sustainable Development Goals interact to improve the health status of a community.
Analyse asks for the parts and their relationships, and the stem's word is interact. Describing four goals in sequence is the failure mode here.
Plan: identify the components, state the constraint linking them, relate them across a situation, then draw the implication.
Four goals bear on community health: SDG 3 acting on health services and outcomes directly, SDG 4 on education, SDG 10 on inequality, and SDG 11 on the built environment. Each targets a different determinant, and none acts on health alone.
They are linked because the determinants they target are themselves causally connected. Education raises employment and income; income determines housing and nutrition; housing and neighbourhood determine exposure; and inequality governs how all of these are distributed. Progress on any one therefore changes the conditions under which the others operate, so the goals cannot be pursued independently even when they are funded separately.
In a community with poor health outcomes the interaction is visible in both directions. A new health service under SDG 3 raises attendance only if transport under SDG 11 makes it reachable and health literacy under SDG 4 makes its purpose understood; conversely, improving school completion raises income and housing quality, which lowers the demand on that health service without any health intervention at all.
The limiting case demonstrates the dependency: a fully funded clinic in a community without transport, income or trust produces almost no improvement in health status, which shows that SDG 3 is not sufficient on its own and that the binding constraint in any given community may lie under a different goal entirely.
It follows that improving a community's health status requires identifying which determinant is currently binding rather than applying all four goals uniformly, because effort directed at a determinant that is not the constraint produces little change.
Four goals bear on community health — SDG 3 on health services and outcomes, SDG 4 on education, SDG 10 on inequality and SDG 11 on the built environment — each targeting a different determinant and none acting on health alone. They are linked because those determinants are causally connected: education raises employment and income, income determines housing and nutrition, housing and neighbourhood determine exposure, and inequality governs how all of these are distributed, so progress on any one changes the conditions under which the others operate and the goals cannot be pursued independently even when funded separately. In a community with poor health outcomes the interaction runs both ways: a new health service under SDG 3 raises attendance only if transport under SDG 11 makes it reachable and health literacy under SDG 4 makes its purpose understood, while conversely improving school completion raises income and housing quality and lowers demand on that service without any health intervention at all. The limiting case demonstrates the dependency — a fully funded clinic in a community without transport, income or trust produces almost no improvement in health status — which shows SDG 3 is not sufficient alone and that the binding constraint in a given community may lie under a different goal entirely. It follows that improving a community's health status requires identifying which determinant is currently binding rather than applying all four goals uniformly, because effort directed at a determinant that is not the constraint produces little change.
Explain why strategies drawn from one community's experience may not transfer directly to another.
Explain asks for the mechanism of failure. The question assumes transfer is difficult and asks you to say why, so asserting that communities differ is not yet an answer.
Plan: name the principle, build linked pairs identifying what does not travel, then answer the question directly.
A strategy works through a mechanism operating in a specific context, and it is the mechanism rather than the activity that produces the result. Transfer fails when the activity is copied while the conditions the mechanism depended on are absent.
The binding determinant differs between communities, so a strategy that succeeded by relieving the constraint in one place may target a determinant that was never limiting in another, which means the same effort produces a much smaller change.
Many strategies work through existing trust, leadership and community organisation, so where those structures are absent or where the delivering agency is not trusted, the identical program achieves lower participation, which removes the exposure the effect depended on.
Programs are also sensitive to scale and to the surrounding services they assume, so a strategy relying on a nearby hospital, reliable transport or a stable workforce will underperform where those are unavailable, even though nothing about the program itself has changed.
Strategies therefore transfer as principles rather than as packages: what should be carried across is the mechanism and the evidence about the conditions it requires, with the activity redesigned for the receiving community — which is why the syllabus asks what lessons can be drawn rather than what programs can be copied.
A strategy works through a mechanism operating in a specific context, and it is the mechanism rather than the activity that produces the result, so transfer fails when the activity is copied while the conditions the mechanism depended on are absent. The binding determinant differs between communities, so a strategy that succeeded by relieving the constraint in one place may target a determinant that was never limiting in another, and the same effort produces a much smaller change. Many strategies also work through existing trust, leadership and community organisation, so where those structures are absent, or where the delivering agency is not trusted, an identical program achieves lower participation and the exposure the effect depended on is lost. Programs are further sensitive to scale and to the surrounding services they assume, so one relying on a nearby hospital, reliable transport or a stable workforce will underperform where those are unavailable, even though nothing about the program has changed. Strategies therefore transfer as principles rather than as packages: what should be carried across is the mechanism and the evidence about the conditions it requires, with the activity redesigned for the receiving community — which is why the syllabus asks what lessons can be drawn rather than what programs can be copied.
Return to card 01. You listed four features of a place that make it easier or harder to be healthy, and marked which a council could change. Count them: in most communities, more of the four are within local government's reach than people expect — which is the practical meaning of SDG 11 for an Australian community.
Multiple choice · 5 questions
MC 1. SDG 10 is described as making the gap itself matter. The practical consequence is that a target is not met by:
- A. lifting everyone slightly while the distance between groups stays the same
- B. improving the outcomes of the worst-off group
- C. reducing discrimination in employment
- D. reporting outcomes by population group
MC 2. Which is the strongest reason built-environment change is an equitable form of prevention?
- A. It is always the cheapest option available
- B. It improves health without requiring a person to have the time, money or information to act
- C. It produces measurable results within one year
- D. It applies only in low-income areas
MC 3. Affordable housing is built on the edge of a town with no transport service. The most likely health consequence is that:
- A. residents' health improves because housing is the strongest determinant
- B. disadvantage is concentrated and fixed in place, with access to work, school and services reduced
- C. the SDG 11 targets are fully met
- D. the effect on health is neutral
MC 4. Unequal distribution of tree canopy and green space in Australian cities matters for health mainly because:
- A. green space has no measurable health effect
- B. heat exposure and its health effects fall hardest on lower-income areas
- C. parks are used only by higher-income residents
- D. tree canopy affects air quality but not temperature
MC 5. When applying the Sustainable Development Goals to a community, the recommended starting point is:
- A. the list of goals, working outward to find matching problems
- B. the health issue actually present in the community, then finding which goals bear on it
- C. the goal with the most available funding
- D. the goal the community has previously reported against
Short answer · exam style
SA 1. Understand Band 4 Describe SDG 10 and SDG 11, and explain one way each contributes to health. (4 marks)
SA 2. Analyse Band 5 Explain why inequality itself, and not only poverty, affects health outcomes. (5 marks)
SA 3. Evaluate Band 6 Using a specific action, explain how SDGs 3, 4, 10 and 11 interlock, and evaluate what this means for how a community should plan to improve its health. (6 marks)
📖 Comprehensive answers (click to reveal)
Multiple choice: 1 → A. 2 → B. 3 → B. 4 → B. 5 → B.
Activity 1 model answers: 1 → SDG 11 principally, with SDG 3 and SDG 10. Mechanisms: shade reduces heat exposure, which is a rising cause of illness and death; seating and shade make the street usable by older people and people with limited mobility, which converts capacity into functional ability and supports incidental activity. 2 → SDG 11, SDG 10, SDG 3 and SDG 4. Mechanisms: evening and weekend transport gives access to work, education and services to households without a car, which is the affordability and accessibility gates from Lesson 8; it reduces the concentration of disadvantage that follows from immobility. 3 → SDG 11, SDG 3 and SDG 10, and SDG 4 through the study environment. Mechanisms: reduced crowding lowers transmission of the infections that become chronic disease, as in Lesson 2; insulation reduces heat and cold exposure; secure adequate housing reduces stress and supports schooling. 4 → SDG 10 principally, with SDG 3. Mechanisms: employment raises income and security and reduces the stress of exclusion; removing discrimination also improves the acceptability of services and institutions to the group affected.
SA 1 (4 marks): SDG 10 described as reducing inequality within and among countries, including income, inclusion regardless of characteristic, and elimination of discriminatory laws and practices [1], with a health contribution explained — for example, that reducing the social gradient improves health at every level, or that reducing discrimination removes a determinant acting through stress and access [1]. SDG 11 described as inclusive, safe, resilient and sustainable cities and communities, covering housing, transport, public space, air quality and disaster resilience [1], with a health contribution explained — for example, that walkable neighbourhoods produce activity without requiring a decision, or that adequate housing reduces infection, heat and cold exposure and stress [1].
SA 2 (5 marks): The social gradient described as stepwise: health improves at every step up, not only at the bottom [1]. The inference drawn: material deprivation alone cannot explain a gradient that continues among people who are not deprived [1]. Mechanisms explained [2]: chronic stress from low control, insecurity and relative position; weaker shared services and lower trust in highly unequal places, affecting everyone; and discrimination acting through stress, access and the acceptability of services. The absolute-versus-relative point for the fifth mark [1]: the worst-off group can improve while the gap widens, which is why SDG 10 makes the gap itself a target rather than only the level of the worst-off.
SA 3 (6 marks): A specific action chosen and its effect traced through all four goals with a mechanism for each [3]. The reverse case used: the same action implemented partially — for example, housing without transport — meeting one target while failing the ones it depends on, and producing a worse outcome than not acting in that location because disadvantage becomes concentrated and fixed [2]. Evaluation of what follows for community planning [1]: start from the health issue rather than the framework, check the dependencies of each action, apply leave no one behind by asking who would be missed, and decide in advance what will be measured and disaggregated — because partial implementation is not partial success, and the goals are most useful as a check against a plan that is nothing but a list of health services.
You now have all four goals and, more importantly, the reason they are taught together. The two diagrams — the education–health loop from Lesson 19 and the whole-versus-partial action here — are the two ways indivisibility shows up in practice.
The final two lessons put this to work: first by examining what other communities have actually done and what transfers, then by building and judging a strategy for a community of your own.
Mark lesson as complete
Tick when you've finished the practice and review.