Primary Health Care in Australia PDF

Primary Health Care in the Australian Context Primary Health care (PHC) embodies a philosophy or approach to health care that acknowledges health as a fundamental right, as well as an individual and shared responsibility.5 Primary care and primary health care are interconnected in a comprehensive fr...

Primary Health Care in the Australian Context Primary Health care (PHC) embodies a philosophy or approach to health care that acknowledges health as a fundamental right, as well as an individual and shared responsibility.5 Primary care and primary health care are interconnected in a comprehensive framework encompassing treatment, disease management, and consideration of social determinants affecting health and illness, as depicted in the figure below: This illustration highlights primary care as a more specific instance of care compared to the broader scope of services offered by a primary health care team. However, it is widely acknowledged as best practice for integrated primary care centers to deliver a range of services. Easy access to primary care can ensure that health problems are dealt with (Willis, Reynolds, & Rudge, 2020)6 early in the progression of a disease. PHC is the first point of contact with the health care system for people (Guzys et al., 2021). Alarmingly however, there is a nation wide tendency for people to present to their local hospital’s emergency department for non-urgent care. Primary health care is a social model of health and a framework for thinking about health. Within this framework, improvements in health and wellbeing are achieved by addressing the social and environmental determinants of health, in tandem with biological and medical factors. Underpinning and supporting this conceptual framework is the Alma Ata declaration and the World Health Organization definition of health: ‘Health is a complete state of physical, mental and social wellbeing, not merely the absence of disease or infirmity’ (WHO,1986, p. 1). Elements of Primary Health Care PHC incorporates many facets of health care. A framework can be applied to the provision of health care in any country taking into account the elements outlined below:7 Education concerning current local health problems and methods of preventing and controlling them; Promotion of adequate local food supply and nutrition; Provision of an adequate and safe water supply and basic sanitation; Maternal and child health care (including family planning); Immunisation against the major infectious diseases; Prevention and control of locally endemic diseases, for example, hypertension; Appropriate treatment of common diseases and injuries, for example, common accidents in the home; and Provision of essential drugs to people in the community. Primary Care Primary care (PC) is distinct from Primary health care (PHC) in that it is the first point of entry into the health system. PC provides personfocused, integrated, coordinated care over time, typically, in Australia and New Zealand, in a general practice or PHC clinic. PC therefore represents an important aspect of care provided within the health sector. PHC is intersectoral which means that, in addition to the health sector, care is planned in collaboration with the many sectors that impact on health and aspects of community life. These include agriculture, and the food industry, education, housing, employment, public works and transportation, communications, natural resources and other sectors. The8 combination of PC and PHC can help make services more accessible and tailored to community needs (McMurray, Munns & Clendon, 2019). Primary health care gained prominence more than 40 years ago, in 1978 in the “Declaration of Alma Ata”. Click on the image to view the declaration. The declaration encouraged decision-makers to address issues early in the progression of illness. Primary health care is described as a comprehensive approach to health involving society as whole, aiming to achieve optimal health and well-being for everyone by addressing their needs at various stages of health—from promoting good health and preventing diseases to providing treatment, rehabilitation, and palliative care, all while ensuring accessibility within people's daily environments commonly known as the determinants of health (WHO, 1978).9 The Alma Ata further describes the principles of primary health care in the context of social model of health as below: The three most significant principles of PHC from the Declaration of Alma Ata was: (Willis, Reynolds, & Rudge, 2020) (Willis, Reynolds, & Rudge, 2020)10 Although primary care services are crucial within primary health care, they represent only a part of its scope. Primary health care goes beyond mere service provision, emphasizing fairness, patient-centered care, and decentralized services. The Alma Ata declaration notably shifted focus towards prevention and health promotion, rejecting the notion of a dichotomy between services and broader health goals. Instead, it advocated for an integrated approach where preventive measures are integral to care, and direct care and health promotion are viewed as part of a continuous spectrum of health provision (WHO, 1978). In Australia, PHC is provided through a range of services such as general practitioners (GPs), community health services, Aboriginal health services, women’s health services, mental health and youth health services or early childhood centres, aged care by public or private service providers and services for marginalised groups such as those for homeless people, illicit drug use and refugees. Nursing care, midwifery, pharmacy, dentistry, and allied health care are also examples of primary care services (AIHW, n.d). Most of these services are generally publicly funded and operate on the social model of health that considers fundamental elements of PHC such as equity of access and affordability (Willis, Reynolds, & Rudge, 2020). The image below indicates uptake of PHC services in the year 2021-2022. AIHW, n.d11 Module lecture - Video – What is primary health care? (World Health Organization, 2018) Module lecture - Video – Primary health care throughout our life Ctrl+Click to play (World Health Organization, 2018)12 Think about: What are the current major health problems in your country and how is the government attempting to provide education about such problems? What strategies is your country implementing to promote adequate local food supply and nutrition? What strategies are in place in your country to provide adequate services for Maternal and Child Health Care (including family planning)? Outline the immunisation schedule for the major infectious diseases in your country. Choose one disease or injury that commonly presents in your work place or community. To what degree do you think essential drugs are available to people in the community within your country? The World Health Organization (WHO)13 Click on the image to visit WHO’s website The World Health Organization aims to build a better, healthier future for people all over the world. WHO came into force on 7th April 1948 – a date now celebrated every year by World Health Day. Working with 194 Member States, across six regions, WHO has more than 7000 people working in 150 country offices, in six regional offices and at their headquarters in Geneva, Switzerland, and their primary role is to direct and coordinate international health within the United Nations system. Their main areas of work are health systems; health through the life-course; noncommunicable and communicable diseases; preparedness; surveillance and response; and corporate services. Concepts of Health and Wellness Developing an understanding of Primary Health Care (PHC) requires an exploration of the concepts of health and wellness and how they are situated culturally, socially and professionally. This understanding of health is fundamental to the provision of PHC. A number of questions are relevant to gain an understanding about the concept of health and wellness. What does health mean?14 What is optimal health? What factors endanger or contribute to wellness? How does lifestyle impact on a person's health status? What strategies can be employed to promote health? People have different perceptions of health and it is important to realise that because a person does not perceive health as you do, it does not mean that they are wrong, and you are right. Although health is widely accepted as desirable, the exact nature of health is often an ambiguous and elusive concept. There are many definitions of, or ways that individuals and communities perceive health. The WHO (1986, p. 1) defines health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”. In addition, the Declaration of Alma-Ata (WHO, 1978) states that health is also “a fundamental human right” and “a world-wide social goal”. In Australia, the Australian Institute for Health and Welfare (AIHW), (2008) notes a shift in emphasis of how health is measured, from a previous (almost exclusive) focus on ill health to a more encompassing definition that acknowledges the social and personal contexts of people and communities in relation to health. Much health data includes morbidity and mortality rate information which enables ease of measurement and comparison within a limited context. However, the AIHW notes that such data should be understood within a more comprehensive and inclusive definition of health and wellbeing which includes: social wellbeing economic wellbeing environmental wellbeing life satisfaction15 spiritual or existential wellbeing. Health and definitions of health and illness are culturally defined and relate to a society's cultural patterns. Health and illness are also socially distributed, and it becomes possible to anticipate poor health status of populations based in part on their social circumstances. Many health sociologists identify class, gender, ethnicity, rurality as the influential factors that impact on health inequality (Wright & Perry, 2010; AIHW, 2016). Globally, it is acknowledged that those who live in poverty have the worst health outcomes, bear the largest burden of disease and have the shortest lifespans. Life expectancy measures how many years on average a person can expect to live, if current death rates do not change. The term ‘health expectancy’ is used to describe, within a person’s life expectancy, the expected years spent in various health states, such as years with disability. Whether Australians have more years living free of disability as the overall life expectancy is lengthening has important implications for population health and wellbeing and for Australia’s health and long-term care systems (AIHW, 2018).16 Definition of health The following are examples of key findings from the Australian Institute of Health and Welfare: International health data comparisons, (2018).17 For full report, click on the above information box18 Integrated Models of Care Integrated care is often contraposed to fragmented and episodic care, and it is used synonymously to terms like coordinated care and seamless care, among others. However, there is no unifying definition or common conceptual understanding of integrated care. In effect, the perspectives that construct the concept are likely to be shaped by views and expectations of various stakeholders in the health system (Fig. 1). Figure 1: Perspectives shaping integrated care 1. A process-based definition used by many national governments in order to understand the different components of integrated care. “Integration is a coherent set of methods and models on the funding, administrative, organizational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors. The goal of these methods and models is to enhance quality of care and quality of life, consumer satisfaction and system efficiency for people by cutting across multiple services, providers and settings. Where the result of such multi-pronged efforts to promote19 integration leads to benefits for people, the outcome can be called integrated care”. 2. A user-led definition that supports a defining narrative and purpose for integrated care strategies at all levels of the system. “My care is planned with people who work together to understand me and my carer(s), put me in control, coordinate and deliver services to achieve my best outcomes” 3. A health system-based definition as used by WHO Regional Office for Europe. “Integrated health services delivery is defined as an approach to strengthen people-centred health systems through the promotion of the comprehensive delivery of quality services across the life-course, designed according to the multidimensional needs of the population and the individual and delivered by a coordinated multidisciplinary team of providers working across settings and levels of care. It should be effectively managed to ensure optimal outcomes and the appropriate use of resources based on the best available evidence, with feedback loops to continuously improve performance and to tackle upstream causes of ill health and to promote well-being through intersectoral and multisectoral actions”. History and origins of Primary Health Care Throughout history, health concerns have been a feature of the lives of everyday people. From the health measures of the public baths of Rome to present day immunisation programs it is clear that humans have long been aware of the links between good health, and quality of life and longevity.20 Within the modern era, and prior to the First Assembly of the World Health Organization (WHO) in 1948, health concerns were primarily the responsibility of individual nations, with further delegation of responsibility to regions and areas. WHO, a specialised agency within the United Nations (UN), introduced the idea of considering health as a global issue, and brought nations and experts together to devise policies which could improve health outcomes globally. The first attempt of the WHO to address health issues on a global scale was referred to as the Basic Health Strategy (BHS). This strategy focussed on restructuring the health care system to support priority activities at a primary level, responding to the most urgent health needs of countries and communities. Until this time, most existing health care systems were largely modelled on the Western medical system, which provided an emphasis on curing disease rather than preventing it or promoting a positive state of health. The high financial costs involved in operating and maintaining such a system meant that it was clearly inappropriate for many developing countries, where the annual per capita expenditure on health was, and continues to be, substantially inadequate in terms of meeting the health care needs of populations. In health care terms, the Western health care system spread rapidly throughout the world, sometimes almost obliterating pre-existing and co-21 existing health care systems with their accompanying philosophies and value systems. Sometimes this expansion was built on an historical colonial experience, as in Africa and India and other countries within Asia; but it is also clear that non-colonised countries often adopted Western medical systems in an attempt to modernise and embrace progress or under pressure from funding bodies to conform to their expectations. The effects of globalisation of the world economy, including advances in communication technology, contributed to the promotion and acceptance of Western health systems throughout the world. There was, and remains, an assumption by many that this model of health care contains within itself the answer to all the health problems of the present day. Just as WHO publicly questioned some aspects of this model in the 1970s, so today there is a need for a similar but even stronger critique. It is not only that Western health care systems have failed to meet the needs of developing countries; there is also increasing evidence of their inability to meet the needs of many people in developed countries. There is an in-built optimism within the philosophy of Western health care systems that presents an image of technological and scientific progress rolling back the tide of disease. The powerful symbols of this advance are the institutions of care, especially hospitals, staffed by scientifically trained personnel implementing therapeutic systems with increasingly sophisticated technologies, engaged in screening for, and dealing with disease and illness. Problems that emerge or failures of the system are often attributed to under-funding of these institutions and their research interests, rather than any flaw in the system itself.22 From the early 1970s a change in thinking about health occurred globally. Three factors can be seen as being pivotal in this change: 1. A separation of “health” as distinct from “health care” – a willingness to acknowledge that factors outside of the health care system (such as sanitation, water and nutrition) were often more important than medicine to the health of populations. This was not a novel idea as scholars had previously drawn attention to the connection between illnesses and their social origins. 2. The relative failure of the BHS (Basic Health Strategy), with high mortality and morbidity rates persisting in many countries, and resources still disproportionately channelled to medical care for urban minorities, especially the wealthy (Segall, 1983). 3. The success of some practical experiences, particularly those of China (barefoot doctors) and Cuba, where community participation, combined with political change, led to substantial improvements in health (Segall, 1983). Primary Health Care (PHC) developed out of a response by the World Health Organization (WHO) to the disparities in health status both within and between countries.23 The critique of the medical model, the failure of health care systems to address health issues in developing countries, as well as increasing incidence rates of chronic conditions and diseases of affluence in developed countries, provided a background to a conference hosted jointly by WHO and the United Nations Children’s Fund (UNICEF) at AlmaAta (previously known as Almaty in modern day Kazakhstan) in the former USSR in 1978. This conference was the beginning of the PHC movement whereby WHO declared that health is a basic right of all people. In 1977 WHO adopted the goal of Health for All by the Year 2000 (HFA) which meant that by the year 2000, all people in the world should attain a level of health where they were capable of working productively and participating in the social life and community in which they lived. Embodied in this goal was the notion that people ought to attain the highest possible level of health in order for them to lead a socially and economically productive life. In 1978, at the Alma-Ata Conference, WHO declared that PHC was a key strategy by which to meet the goal of HFA by the Year 2000 (WHO, 1978). Click to watch a brief video on the Declaration of Alma Ata24 Click on the above information box if you would like to read more about Primary Health Care The concept of HFA did not mean that illness and disability will cease to exist in the world, but that people have a right and responsibility to participate in the decisions that shape their lives in terms of health. The primary document arising from this international conference – The Declaration of Alma-Ata – has come to be seen as the manifesto of PHC. The commitment of signatory countries to the Declaration was constantly reaffirmed in the intervening years following 1978 and more recently at meetings convened by the WHO. PHC remains the central strategy for the achievement of Health for All in the 21st Century. The Declaration of Alma-Ata (WHO, 1978) strongly and clearly denounced inequalities in health status pointing to a failure of existing national health services at that time to meet the needs of their populations and25 insufficiently addressing the issue of equity. This critique is as valid today as it was at its inception in 1978. Considered within an historical perspective, the Alma-Ata Conference can be seen as an attempt to endorse efforts to practice health care in more holistic ways, while questioning the assumptions of Western style health care systems which were undergoing a period of rapid expansion. The phenomenon of globalisation has been the subject of considerable scrutiny in recent years due to its dramatic impact on health and health systems world-wide. The Declaration of Alma-Ata (WHO, 1978) stressed the reciprocal links between health and economic and social development. Thus, it does not suggest that a good health system is simply a matter of social justice, but that an active concern for equity and social justice makes good sense for the economic and social well-being of countries. PHC can be understood partly through comparison with the dominant Western model of health. The Western model of health, which is biomedical in approach, has dominated health discourse globally for at least the past two centuries (Baum, 2008; Macdonald, 2000). This model is mechanistic in that it views the body as a machine comprised of component parts, and it is predicated on the notion that health exists in the absence of disease or infirmity. As indicated in the following table, this model does not consider the social, spiritual and psychological contexts of people’s lives, and ignores issues related to equity and social justice which are most often the primary cause of illness and disease. The main focus of the Western medical model is the implementation of medical interventions where control is exerted and maintained by medical professionals. Issues such as access to education, appropriate housing, nutritious food and clean water supplies are not explicitly considered within the context of medical interventions.26 At the Alma-Ata Conference in 1978, PHC was defined as: "... essential health care made universally accessible to families and individuals in the community by means acceptable to them through their full participation and at a cost that the community and country can afford..." (WHO, 1978, p. 2). ‘Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death. We watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others. A girl born today can expect to live for more than 80 years if she is born in some countries – but less than 45 years if she is born in others (WHO, 2008). Within countries there are dramatic differences in health that are closely linked with degrees of social disadvantage. Differences of this magnitude, within and between countries, simply should never happen. These inequities in health, avoidable health inequalities, arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces. Social and economic policies have a determining impact on whether a child can grow and develop to its full potential and live a flourishing life, or whether its life will be blighted. Increasingly the nature of the health27 problems rich and poor countries have to solve are converging. The development of a society, rich or poor, can be judged by the quality of its population’s health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill-health. Primary Health Care in the Global Context Primary health care is a prominent feature of the health care systems in many places, especially in developing countries where healthcare resources are often scarce and, populations face numerous health challenges. Various health programs use the principles and elements of PHC to underpin their service provision. Through the establishment of essential services, emphasis on prevention, and community-centered approach, PHC plays a significant role in the promotion of health equity and improving overall population health outcomes. The utilisation of community health workers (CHW), expansion of nursing roles in the PHC setting, traditional birth attendants and, training volunteer health workers have been successful in reducing the burden of disease within a given population. (Jirojwong & Liamputtong, 2015). These health workers are tasked with many roles such as data collection, health education, providing low cost health services and, family planning. An example of CHW reducing the burden of disease can be demonstrated through the COBIN trial in Nepal. This randomised control trial showed that the use of female CHW was successful in reducing high blood pressure in adults without hypertension in the general population (Neupane et al., 2018). In India, the “Accredited Social Health Activist (ASHA) program was found to be successful in connecting marginalised community to maternity health services. The ASHA program predominantly recruited women from local villages to provide and promote maternal and child health, family28 planning services and provide education on disease prevention. Their cultural sensitivity and linguistic proficiency enabled effective communication, leading to increased utilisation of healthcare services and improved health outcomes among marginalised populations (Agarwal, et al., 2019). Cuba has also demonstrated that despite economic difficulties, the health of its people can thrive due to PHC model that is both effective and sustainable. The essence of their success is based on focus on early intervention than late or end stage disease treatment-which is usually the case with developed nations. Cuba has successfully managed to increase life expectancy and decrease child mortality in the last several decades (Rao & Pilot, 2014). There are many examples of grassroot projects around the world that have helped improve health outcomes for some of the most vulnerable populations. However, despite these efforts and acknowledgement that health is a fundamental human right, with PHC being pivotal to delivering health care, this vision remains unfulfilled in much of the world (Rao & Pilot, 2014). According to the WHO (2008), many countries have started to favour health programmes that focus on individual priorities such as malaria and tuberculosis. This prioritisation whilst being important and successful have resulted in the fragmentation of care with emphasis on care delivery offered in hospitals and specialist centres. Rao and Pilot (2014) assert that the evidence unequivocally illustrates the unsuitability of a hospital-oriented healthcare delivery model to fulfill the objectives set forth by Alma Ata. Strong primary health care can reduce unnecessary use of more expensive health care resources and improve health system efficiency.29 Think about: What health programs have you heard of that has shown to be successful in improving health outcomes in developing or developed countries? What do you think are the benefits of primary care? How does primary care bridge health inequity gap? The Australian Healthcare System The Australian healthcare system is a mixed public-private system that provides universal access to healthcare services for its citizens and30 permanent residents. It is funded and regulated by the federal, state, and territory governments. The components of the AHS is discussed below. Medicare Medicare is Australia's publicly-funded health insurance scheme that provides access to medical services and treatment for eligible individuals. It is financed by a combination of general taxation, Medicare levy, and Medicare levy surcharge. The scheme covers a range of healthcare services, including doctor consultations, hospital treatments, and diagnostic tests (Department of Health, 2021). According to AIHW (2023), in 2021–22, there were around 270 million Medicare-subsidised primary care services in Australia, including, but not limited to: GP attendances (189 million) allied health attendances (25 million) services provided by nurses, midwives and Aboriginal health workers (4.1 million) (AIHW 2022a). AIHW (2023) states that in 2021–22:31 Females (92%) were more likely to see a GP than males (87%) and received more Medicare-subsidised GP services per person (8.3, compared with 6.3 for males). The number of Medicare-subsidised GP services per person increased with age and was highest for those aged 80 and over (18.6 services per person). A higher proportion of people living in metropolitan Primary Health Network (PHN) areas had a Medicare-subsidised GP attendance after hours (20%), compared with regional PHN areas (10%) (AIHW 2022a). Barriers to GP services were reported to be due to GP service cost, service availability and waiting times (AIHW, 2023). It was reported that in 2021–22: 25% of people delayed seeing a GP for reasons such as service availability or waiting time. This was an increase from 2020–21 (21%). 23% of people felt they waited longer than acceptable for a GP appointment (ABS 2022). 3.5% of people who needed to see a GP delayed or did not see a GP due to cost. This was an increase from 2020–21 (2.4%). 3.9% of people with a long-term health condition who needed to see a GP delayed or did not see a GP due to cost. This was higher than for those without a long-term health condition (3.0%) and higher in regional remote areas compared to those in major cities (5% and 3.1%, respectively).32 The Pharmaceutical Benefits Scheme The Pharmaceutical Benefits Scheme (PBS) is another publicly-funded program that subsidizes the cost of prescription medications for eligible individuals. The scheme aims to make essential medicines more affordable for patients and to reduce the burden of healthcare costs on individuals and families (Department of Health, 2021). Private health insurance33 Private health insurance is also available in Australia, and it covers services not covered by Medicare or PBS, such as elective surgeries, dental care, and physiotherapy. The private health insurance system is regulated by the federal government and offers a range of policies with different levels of coverage and cost (Department of Health, 2021). Primary Health Networks Primary healthcare networks (PHNs) were established in Australia in 2015 as part of the government's healthcare reform agenda. PHNs are designed to improve the integration and coordination of primary healthcare services across Australia by working with general practitioners, allied health professionals, and other healthcare providers to identify local health needs and develop solutions to meet those needs (Department of Health, 2021). PHNs are funded by the Australian Government Department of Health and operate across 31 regions in Australia (Department of Health, 2021). The PHNs are responsible for planning and commissioning primary healthcare34 services based on the specific health needs of their region, as well as supporting healthcare providers to improve the quality and safety of care. One of the key roles of PHNs is to support the implementation of digital health initiatives to improve healthcare coordination and communication between healthcare providers (Department of Health, 2021). They also play a significant role in promoting preventative health initiatives, such as immunizations, mental health, and chronic disease management programs. You can view the PHN website here and navigate to the PHC you are a part of a resident of Australia. https://www.health.gov.au/our-work/phn/your-local-PHN/NSW-PHNs Public Hospitals Public hospitals in Australia are primarily funded by the state and territory governments and provide free emergency care and inpatient treatment for all Australians. Private hospitals, on the other hand, are largely funded35 by private health insurers and offer elective surgeries, rehabilitation, and other non-emergency services. The three levels of government The three levels of government in Australia - federal, state/territory and local- all have roles in funding, regulating, and delivering healthcare services. The federal government is responsible for funding and regulating Medicare and PBS, as well as providing funding for public hospitals. The state and territory governments are responsible for managing and funding their own public hospital systems and other health services, such as community health and mental health services.36 Healthcare Spending In terms of spending, the Australian government invests a significant amount of money into healthcare each year. The federal government's spending on health was approximately 20% of its total expenditure in the 2021-22 budget, with most of this funding going towards Medicare, PBS, and public hospitals. State and territory governments also allocate a significant proportion of their budgets to health services. An estimated 202.5 billion dollars was spent on health goods and services in the year 2019 to 2020. In 2020–21, approximately one-third of all health spending in Australia was for primary care ($73.4 billion) (AIHW 2022b). Of this: $13.2 billion was for unreferred medical services (mainly general practice) $12.5 billion was for subsidised pharmaceuticals $12.2 billion was for other medications. It is predicted that 105.8 billion will be spent on healthcare in 2022-2023 (AIHW, 2021). The high expensditure in 2019 and 2020 could be atrributed to the effects of Covid19 pandemic. However with an ageing population, the healthcare expenditure will continue to rise.