Competitive health policies and community health

Since 1992 there have been fundamental changes in health care policy in Victoria, Australia, as the state government moves to competitive market models of service delivery and the measurement of service provision through output based funding. The introduction of competitive relationships to the public health system has had a major impact in the primary health care sector, particularly on community health centres. Most community health centres in Victoria have traditionally been semi-independent agencies controlled by community based committees of management. Such policies have had huge implications for the management and organisation of these agencies, as they have led to different patterns of service delivery and different models of management practice, often devaluing traditional philosophical perspectives of 'primary health care practice'. Although many agencies have embraced change as providing opportunities for growth and development and to have more influence in the provision of mainstream public health care, primary health care models of practice should be supported for their intrinsic and increasing value.     

Primary health services at district level in South Africa: a critique of the primary health care approach

Background

The rhetoric of primary health care philosophy in the district health system is widely cited as a fundamental component of the health transformation process in post-apartheid South Africa. Despite South Africa??s progress and attempts at implementing primary health care, various factors still limit its success.

Discussion

Inconsistencies and poor understanding of primary care and primary health care raises unrealistic expectations in service delivery and health outcomes, and blame is apportioned when expectations are not met. It is important for all health practitioners to consider the contextual influences on health and ill-health and to recognise the role of the underlying determinants of ill-health, namely, social, economic and environmental influences. The primary health care approach provides a strong framework for this delivery but it is not widely applied. There is a need for renewed political and policy commitments toward quality primary health care delivery, re-orientation of health care workers, integration of primary health care activities into other community-based development, improved management skills and effective coordination at all levels of the health system. There should also be optimal capacity building, and skills development in problem-solving, communication, networking and community participation.

Summary

A well-functioning district health system is required for the re-engineering of primary health care. This strategy requires a strong leadership, a strengthening of the current district heath system and a greater emphasis on health promotion, prevention, and community participation and empowerment.     

Case study of the integration of a local health department and a community health center.

As rural communities struggle to sustain health services locally, innovative alternatives to traditional programs are being developed. A significant adaptation is the rural health network or alliance that links local health departments and community health centers. The authors describe how a rural local health department and community health center, the core organizations in publicly sponsored primary care, came to share a building and administrative and service activities. Both the details of this alliance and its development are examined. The case history reveals that circumstance and State involvement were the catalysts for service integration, more so than the need for or the benefits of the arrangement. The closure of a county-owned hospital created a situation in which State officials were able to broker a cooperative agreement between the two agencies. This case study suggests two hypotheses: that need for integrated services alone may not be sufficient to catalyze the development of primary care alliances and that strong policy support may override any local and internal resistance to integration.     

Pioneers, paediatricians and public health: the evolution of community child health services, Clifton, Nottingham 1983–1999

Since 1976 developments in the training and services provided by general practitioners and community paediatricians have led to a series of changes in clinical services provided for children in the community. A series of studies carried out in the Clifton area of Nottingham from 1983 to 1999 illustrate this. A changing pattern of service delivery is reported in which clinical medical officers provided a largely primary care service in 1983 developing into a paediatric secondary care service in the next decade with the primary health care team having taken over the role of child health surveillance. The community services in the 1990s were taking over the investigation and management of paediatric problems previously seen in the hospital outpatient clinic. The studies illustrate the advantages of locally based services in terms of ease of parental access and consultation between the primary health care team and specialist children's services.     

Health policy and the coloring of an American male crisis: a perspective on community-based health services

Health services at the community level are organized and financed in such a way that men need access but encounter barriers to care such as poor service design, lack of insurance, and the absence of health literacy. Community health delivery systems may not be appropriate, effective, fit, or able to meet the needs they are charged to fill. Community-based health services, including health departments, are underfunded, understaffed, and unable to carry out their mission in a way that protects the health of the community. The current design for funding and delivering health care services excludes poor men, particularly men of color. Improving the health of men requires modifications in the way health care is financed, delivered, and managed.     

Primary health care: a preferred health service delivery option for women

It is well known that gender is a determinant of health, but less understood is whether differences in health status attributable to gender can be mitigated through the implementation of primary health care. Primary health care, notably distinct from primary care, refers to a wide-ranging approach to the delivery of a comprehensive variety of health services. This article traces the similarities between primary health care and women-centred care from their overlapping philosophical foundations to the similar health, social, and economic benefits of both approaches. It is argued that investments in primary health care positively impact women's health, and, as such, should be a preferred option for the delivery of women's community health services. Several models of health service delivery that operate in accordance with principles of primary health care and also address the key tenets of women's-centred care are examined and their merits are compared. The article also identifies the major impediments to the adoption of both primary health care and women's-centred care approaches.     

Community health: integration of primary care and public health competencies. SESPAS report 2010

Primary care and public health have run on parallel tracks with scarce points of contact or coordination in community action to improve the population's health. If community health is defined as the "health of individuals and groups in a defined community, determined by the interaction of personal and familial factors and by the socioeconomic-cultural and physical environments" and of community intervention is defined as local action to improve community health, primary care and public health are the key players to implement this aim. However, their actions should take into account other local actors, including the population. The inclusion of community health as an objective of the health system highlights the need to achieve more coordinated and comprehensive action, and to introduce advances in several areas, which include training for health professionals, contracts to service providers, systems for defining service portfolios, and organizational aspects of services.     

社区卫生服务中心参与医养结合服务现状研究

目的:分析社区卫生服务中心通过不同方式参与医养结合服务的主要做法,为社区卫生服务中心参与医养结合服务提供建议。方法:采取目的抽样法,在东、中、西部各选取开展医养结合服务且具有代表性的上海市、武汉市、重庆市共6家社区卫生服务中心进行现场调查。运用主题框架分析法对资料进行分析。结果:调研地区社区卫生服务中心参与医养结合服务主要包括社区卫生服务中心参与居家养老、社区养老、养老机构养老以及社区卫生服务中心提供养老服务等。每个调研地区社区卫生服务中心参与不同种类医养结合服务的服务对象、主体、方式和内容均有所不同。目前社区卫生服务中心参与医养结合尚缺乏统一的行业标准,部门间仍需要进一步协同,社区卫生服务中心参与医养结合服务的程度有限。结论:顶层设计需要考虑到社区卫生服务中心辖区居民的需求以及机构服务能力,制定老年人统一照护需求评估标准,确定社区卫生服务中心提供服务的内容与对象,同时加强信息化建设,提高社区卫生服务中心的服务效率。     

Quality and customers: A planning approach to the future of mental health services in a health maintenance organization

Mental health service delivery is both a health care and business arrangement, and is accordingly impacted by national changes in both areas. HMO mental health services in the current health reform zeitgeist are being called on to provide more efficient, comprehensive integrated care. A planning effort is presented which is organized around (1) a quality improvement effort aimed at understanding who are the “customers” (patient, medical community, mental health staff, and client employer) and what they need and (2) coordination and integration with the HMO larger organizational plan and efforts. The unique benefits of staff model HMOs are discussed relative to mental health service.     

Innovative rural and remote primary health care models: What do we know and what are the research priorities?

This paper examines the literature pertaining to 'innovative' primary health care models in rural and remote areas in order to identify areas where knowledge is lacking and describes future research priorities. Although a number of reviews have identified successful primary health care models and synthesised principles that help to understand why they are successful, there is generally a dearth of rigorously collected information regarding rural and remote health service delivery. The evidence base that supports the superiority of any one model or models in a given context is thin because of the lack of systematic, policy-informing evaluation of primary care innovations. The paper identifies the need for more rigorous health services evaluation information, including examination of optimal financing systems, the optimal range and mix of providers, and supports for team practice, appropriate community participation mechanisms, improved health information systems and relevant performance indicators.     

Involving communities in health service planning in primary care

Recent health service policy in the United Kingdom has emphasized the need to involve local people in health service planning. This paper will describe how local communities were involved in the development of Primary Care Resource Centres. These centres are designed to provide a base for the delivery of a range of health, social welfare and information services within a community setting. Four centres in the process of being developed in one region were selected for in-depth study. The main method of data collection consisted of semi-structured interviews with key “stakeholders”, namely purchasers and providers of primary health care, social care providers, hospital outreach staff and local community and voluntary group workers (Weiss 1983). This paper examines how the health service organizations developing the centres involved local communities in planning them and the obstacles and difficulties encountered. The paper suggests lessons that can be learned for future community involvement in the planning of local health services.     

School health in the wilderness

Concern is expressed for the school health service which has been overlooked in the current controversy about child health services. Reference is made to a study of health services in 15 primary schools in London in demonstrating the objectives and the value of the school health service. The study also shows the need for a combination of preventive and therapeutic roles on the part of doctors practising primary child health care, and for community child health services (which include health services in schools) to be planned as supplementary rather than complementary to the family doctor services.     

An international approach to community health care for older adults

Worldwide population ageing, concomitant increases in disability rates, and changes in family health care systems require an examination of current service delivery to optimize use of societal resources in the future. This article examines a community health care approach suggested by research conducted by the World Health Organization Kobe Centre for Health Development (WKC). The WKC approach, which uses a cross-national perspective, envisions a community health care system that integrates health and social services and spans health promotion, primary care, and long-term care. Prototypical approaches for organizing community health care include communal, marketplace, case management, and managed care. The ramifications of these approaches are examined from the perspectives of the older adult, the family, and formal service providers.     

发展中国家的医疗卫生服务体系

考察了发展中国家的卫生筹资和服务提供体系,并认为发展中国家需要扩大医疗保障覆盖面,需要重新关注初级卫生保健和公共卫生,只有这样才能不断完善其卫生体系。     

The health corner: a community-based nursing model to maximize access to primary care.

America spends more than $700 billion per year on a health care system that is unparalleled in the technological advances it produces, yet many Americans do not receive the basic health care they need. Access to obtaining these health services can be affected by economic, structural, or personal barriers. This paper describes a primary health care delivery that addresses the specific health concerns of a neighborhood. The model forges a partnership with the community while developing collaborative relationships with area health providers. Targeted health services are offered in a community-based, nurse-managed site. Clients receive the basic health services they need, local providers expand their client base with "satellite locations," and the major medical institutions receive more appropriate referrals and have less unnecessary use of the emergency rooms.     

Collaborating while competing? The sustainability of community-based integrated care initiatives through a health partnership

Background  

To improve health-care delivery, care providers must base their services on community health needs and create a seamless continuum of care in which these needs can be met. Though, it is not obvious that providers apply this vision. Experiments with regulated competition in the health systems of many industrialized countries trigger providers to optimize individual organizational goals rather than improve population health from a community perspective. Thus, a tension exists between the need to collaborate and the need to compete. Despite or because of this tension, community health partnerships are being promoted, and this should enforce a needs-based and integrated care delivery.     

District health systems in a neoliberal world: a review of five key policy areas

District health systems, comprising primary health care and first referral hospitals, are key to the delivery of basic health services in developing countries. They should be prioritized in resource allocation and in the building of management and service capacity. The relegation in the World Health Report 2000 of primary health care to a 'second generation' reform--to be superseded by third generation reforms with a market orientation--flows from an analysis that is historically flawed and ideologically biased. Primary health care has struggled against economic crisis and adjustment and a neoliberal ideology often averse to its principles. To ascribe failures of primary health care to a weakness in policy design, when the political economy has starved it of resources, is to blame the victim. Improvement in the working and living conditions of health workers is a precondition for the effective delivery of public health services. A multidimensional programme of health worker rehabilitation should be developed as the foundation for health service recovery. District health systems can and should be financed (at least mainly) from public funds. Although in certain situations user fees have improved the quality and increased the utilization of primary care services, direct charges deter health care use by the poor and can result in further impoverishment. Direct user fees should be replaced progressively by increased public finance and, where possible, by prepayment schemes based on principles of social health insurance with public subsidization. Priority setting should be driven mainly by the objective to achieve equity in health and wellbeing outcomes. Cost effectiveness should enter into the selection of treatments for people (productive efficiency), but not into the selection of people for treatment (allocative efficiency). Decentralization is likely to be advantageous in most health systems, although the exact form(s) should be selected with care and implementation should be phased in after adequate preparation. The public health service should usually play the lead provider role in district health systems, but non-government providers can be contracted if needed. There is little or no evidence to support proactive privatization, marketization or provider competition. Democratization of political and popular involvement in health enhances the benefits of decentralization and community participation. Integrated district health systems are the means by which specific health programmes can best be delivered in the context of overall health care needs. International assistance should address communicable disease control priorities in ways that strengthen local health systems and do not undermine them. The Global Fund to Fight AIDS, Tuberculosis and Malaria should not repeat the mistakes of the mass campaigns of past decades. In particular, it should not set programme targets that are driven by an international agenda and which are achievable only at the cost of an adverse impact on sustainable health systems. Above all the targets must not retard the development of the district health systems so badly needed by the rural poor.     

Study protocol: national research partnership to improve primary health care performance and outcomes for Indigenous peoples

Background

Strengthening primary health care is critical to reducing health inequity between Indigenous and non-Indigenous Australians. The Audit and Best practice for Chronic Disease Extension (ABCDE) project has facilitated the implementation of modern Continuous Quality Improvement (CQI) approaches in Indigenous community health care centres across Australia. The project demonstrated improvements in health centre systems, delivery of primary care services and in patient intermediate outcomes. It has also highlighted substantial variation in quality of care. Through a partnership between academic researchers, service providers and policy makers, we are now implementing a study which aims to 1) explore the factors associated with variation in clinical performance; 2) examine specific strategies that have been effective in improving primary care clinical performance; and 3) work with health service staff, management and policy makers to enhance the effective implementation of successful strategies.

Methods/Design

The study will be conducted in Indigenous community health centres from at least six States/Territories (Northern Territory, Western Australia, New South Wales, South Australia, Queensland and Victoria) over a five year period. A research hub will be established in each region to support collection and reporting of quantitative and qualitative clinical and health centre system performance data, to investigate factors affecting variation in quality of care and to facilitate effective translation of research evidence into policy and practice. The project is supported by a web-based information system, providing automated analysis and reporting of clinical care performance to health centre staff and management.

Discussion

By linking researchers directly to users of research (service providers, managers and policy makers), the partnership is well placed to generate new knowledge on effective strategies for improving the quality of primary health care and fostering effective and efficient exchange and use of data and information among service providers and policy makers to achieve evidence-based resource allocation, service planning, system development, and improvements of service delivery and Indigenous health outcomes.     

Community health screening programs for African-Americans and the medical anthropologist

Community health screening programs were originally designed: to stimulate change in family and community knowledge and behavior relating to the prevention of disease; to inform the use of available health resources; and to improve the environmental, economic, and educational factors related to health. Since their inception, however, community health screening programs have primarily used conventional approaches to health improvement for the African-American community. That is, the need is not merely for the provision of more preventative and curative health services or the distribution of services to passive recipients, but for the active involvement of local populations in ways which will preserve or repattern their knowledge, attitudes and motivation concerning major health care issues. Health care professionals such as the clinicians need to expand their biopsychosocial model to include specific sociocultural data concerning African-American health care seeking pattern. Collaborative efforts of this type will therefore enable health care professionals to design future community health screening programs for the African-American community that are practical and culturally-oriented.     

Managing change in the era of health reform: organized delivery systems of public health.

As U.S. Medicaid managed care programs proliferate, it appears that traditional clinical training and practice often provide insufficient preparation for physicians to meet the care requirements of Medicaid beneficiaries adequately. State and local health departments have extensive experience with this population's need for preventive care, social support services, care coordination, and referral. Organized delivery systems of managed care can merge the expertise of primary care practitioners, public health professionals, and other community resources to deliver comprehensive care. Although the described model includes Medicaid as the payer, it would remain viable should Medicaid be terminated and universal coverage enacted.