Comprehensive and integrated primary care is well documented in the research literature as providing the most cost-effective and equitable mechanism for preventing and managing chronic disease. Yet despite a growing body of research supporting this form of care, it often appears to be put in the ‘too hard’ basket of governments and policy makers.
This is particularly strange given that we already have a large number of successful examples of this form of care around the country in the form of Aboriginal Community Controlled Health Organisations (ACCHOs). As NACCHO Char Justin Mohammed outlined in the previous post, ACCHO’s have played an essential role in achieving improvements in the health status of Indigenous people.
There is a great deal that the mainstream health sector could learn from ACCHOs and yet this knowledge transfer does not appear to be occurring. The reasons for this, along with a broad range of other issues, were discussed at a recent Research Symposium held at the Southgate Institute for Health, Society and Equity, Flinders University.
Racism, cultural cringe, and a dominant private sector paradigm were suggested by participant and ‘critical friend’ Tony McBride as reasons why the broader health sector has not learnt as much as it could from ACCHOs.
In the following piece, Professor Fran Baum and Dr Toby Freeman, from the Southgate Institute for Health, Society and Equity, Flinders University Adelaide, report on this issue and the broader findings of the Symposium. They write:
The ‘Primary Health Care and Healthy Communities: Models, Practices, Policies, and Politics’ symposium was held in Adelaide on Friday 21st March 2014. This event was part of an NHMRC funded research project ‘Evaluating the effectiveness of comprehensive primary health care in local communities’ being conducted at the Southgate Institute for Health Society and Equity at Flinders University The aim of the symposium was to feed back some of the key emerging findings from the study, and to engage primary health care practitioners and policy makers in debate and discussion about the implications of these findings for primary health care policy and practice.
The research was conducted in partnership with six primary health care services: four South Australian state governmentmanaged and funded services, including an Aboriginal Health Team, a sexual health non-government organisation -SHine SA -and a community controlled health service in the Northern Territory -Central Australian Aboriginal Congress Aboriginal Corporation. The research team and the service staff developed program logic models depicting the ways in which services worked, how their operating environment and wider context influenced their work, activities, and intended outcomes. The research team then conducted evaluation methods at each service to evaluate comprehensiveness, including surveys and interviews with staff and clients, documenting patient journeys for diabetes and for depression, and collecting indicator data.
We found that the participating South Australian state government managed and funded services had moved away from an approach to primary health care that included health promotion and action on social determinants to one emphasising solely clinical work over the five years of the project (2009-2013). A Review of Non-Hospital Based Services in 2013 led to cuts to health promotion roles at the state managed services, including community programs such as Community Foodies a grass roots program to work with local people on improving food choices. The result is that in South Australia the primary health care system now focuses largely on out of hospital treatment for people with chronic conditions such as diabetes. This approach will do nothing to stem the tide of chronic disease in the future or to maintain a healthy community. The move towards selective primary health care was justified on cost saving grounds. But as many participants in the research noted, the changes to the services are likely to increase costs to the health system over the longer term.
Shine SA was found to have maintained a broader brief, despite a narrowing service agreement, and continued to engage in intersectoral collaboration and health promoting activities.
Our international visitor at the Symposium, Professor David Sanders (University of the Western Cape, South Africa) reminded the audience that the struggle between comprehensive primary health care and more selective approaches has been played out in many settings internationally and that the South Australian experience was far from unique. He commented that it was unfortunate that South Australia had withdrawn from more comprehensive primary health care especially given that it has previously had a good international reputation for the health promotion work done.
The Symposium participants heard details of the successes of the community controlled service in the research, Central Australian Aboriginal Congress, which had preserved its comprehensive approach to primary health care. The CEO of Congress, Donna Ah Chee, provided examples of its community participation (e.g. through their board of management), collaboration with other sectors on the social determinants of health, and collaborative advocacy efforts to build supportive environments for health. This example of a comprehensive service with a community controlled board was supplemented by other data presented by Prof. Ronald Labonté, University of Ottawa, Prof. David Sanders, University of the Western Cape, and Dr. David Scrimgeour, Aboriginal Health Council of South Australia, that suggested that community control of primary health care services is associated with more comprehensive services that act more on the social determinants of their community’s health.
A panel posing the question whether the community controlled model, with its suggested benefits, was applicable to the wider population concluded that it was. Many attendees also endorsed this proposal, and debated how such a model could be implemented. Implementation questions concern how such services should be funded, and whether there will be resistance to non-professional control of health services. Consultant and primary health care and community health expert Tony McBride acted as a “critical friend” for the symposium, reflecting on and challenging the findings, and placing them in a wider context. He proposed a number of reasons why we haven’t been learning from the strengths of Aboriginal community controlled organisations, including racism, cultural cringe, and a dominant private sector paradigm.
Despite these challenges, the research presented suggests there could be great benefits from community control including more equitable health services in which the circumstances of people’s lives are taken into account in service delivery and through programs to prevent ill health and promote health.
The symposium program, with links to presentations, can be found at: http://bit.ly/CPHCAdelaide and information on the wider project can be found at http://bit.ly/CPHC2014. Tweets from the conference can be viewed by searching for the hashtag #cphc2014.
The symposium was supported by funding from a National Health and Medical Research Council project grant, and a Lowitja Institute (http://www.lowitja.org.au/) knowledge exchange grant.