Seize the opportunity: prioritise comprehensive primary healthcare reform

Red and white 'road closed' sign on a road, in front of other barriers. Blue sky in background.

Introduction by Croakey: System-wide and comprehensive primary healthcare reform is “needed to bring together an increasingly fragmented system, where the most disadvantaged struggle to get the care they need, when they need it”, according to public health practitioner and Masters of Global Health student Lauren Richardson.

In a submission to the Public Health Association of Australia’s Student Think Tank competition, Richardson calls on governments to show strong political commitment and leadership to reduce inequalities in accessing healthcare.

The National Public Health Student Think Tank Competition run by the Public Health Association of Australia is a chance for students to showcase their innovation and enthusiasm for the field of public health.

Students were invited to submit a written response of no more than 750 words to address the following prompt: In light of the recent Federal election, what key public health policy should the Australian government be implementing to ensure a healthier, fairer & more sustainable future for young people in Australia?

Croakey is publishing a series of edited Think Tank submissions – see other articles in the series here.

Lauren Richardson writes:

Health Ministers face many demands from many competing interests, and this has led to health policy being driven in ways that often are not in the best interests of the community, patients’ and taxpayers.

The election of a new Federal Government with a commitment to policy development and implementation brings an opportunity to rewrite the history of health reform and prioritise efforts to increase Australians’ access to comprehensive Primary Health Care (PHC).

Reforming Australia’s PHC model is not only important for ensuring a healthier, fairer and more sustainable future for Australian youth, but essential in achieving the Sustainable Development Goals (SDGs) by 2030.

System-wide reform is needed to bring together an increasingly fragmented system, where the most disadvantaged struggle to get the care they need, when they need it. There is no one silver bullet, and the next reform must take hold.

So often reform and public debate is focused on general practice rather than the multi-disciplinary PHC model required to deliver good health care. Whilst GPs deliver the majority of PHC in Australia, comprehensive PHC involves much more than this.

The Aboriginal Community Controlled Health Organisation (ACCHO) sector provides exemplars of good, comprehensive PHC. Aboriginal communities have successfully initiated and led the delivery of holistic, and culturally appropriate PHC through a team-based workforce model.

We must focus our attention to good PHC models of care like this and scale up what works.

But this is not an easy sell compared to new hospitals, or ‘quick fix’ approaches that are costly, and don’t address the root cause of the problem.

Australia’s healthcare system

Despite evidence that largely publicly funded healthcare is more equitable, efficient and cost-effective, a mixed public and private system is being pursued across Australia.

This is problematic because public health prevention and promotion interventions generally attract less funding and are not well placed to drive the system as they should. Thus, Australia’s current PHC model does not meet the needs of the population, nor the care providers.

Instead, PHC is undermined by disjointed healthcare funding, inadequate government expenditure for PHC, high out-of-pocket (OOP) costs, and variable, low-quality care, which is not patient-centred, and does not address the social determinants of health.

It’s for these reasons the most recent Grattan Institute report has called for major changes to Medicare to support Australia’s growing need for chronic disease prevention and management.

In fact, service users are incentivised to bypass primary care altogether, and seek secondary specialist care. This is costly for service users and governments, in turn exacerbating inequities, depriving PHC of adequate funding, and threatening the ability to reach agreed global health goals and priorities.

A global priority

Comprehensive PHC is recognised as the exemplar for the provision of health services and necessary public health functions, including non-communicable disease management.

PHC is the first point of contact with essential health services, delivered outside acute settings, designed to support and improve people’s health and wellbeing through accessible, affordable, and appropriate care throughout the life course.

PHC also engages with the wider determinants of health, including advocating for the community’s needs, and empowering individuals, families and communities to take charge of their own health.

It encompasses health promotion, disease prevention, treatment, rehabilitation, palliative care and more. This strategy also ensures that health care is delivered in a way that is centred on people’s needs and respects their preferences.

However, strong political and commercial interests are a barrier to implementation of comprehensive PHC, and must first be overcome for successful implementation.

Commercial determinants of health are driven by private sector activities. They influence the social, physical and cultural environments through business actions and societal engagements. For example, through supply chains, labour conditions, product design and packaging, research funding, lobbying and promotion of unhealthy choices.

Commercial determinants of health impact a range of health outcomes including obesity, diabetes, cardiovascular disease, cancer, and mental health. Young people are especially at risk. Unhealthy commodities exacerbate economic, social and racial inequities.

The World Health Organization says PHC is the most inclusive, equitable and cost-effective way to achieve universal health coverage. It is also key to strengthening the resilience of health systems to prepare for, respond to and recover from shocks and crises.

Thus, good PHC decreases the need for secondary or specialist care and avoidable emergency department admissions and hospitalisations, and drives high-performing, resilient health systems, underpinning universal health coverage (UHC).

We know that successful PHC increases equity, promotes good health, and reduces disease risk, whilst simultaneously limiting the financial burden of health care for service users, and government expenditure. This in turn contributes to improved health outcomes, and reduced medication use and mortality rates.

To address the cumulative effect of how health has changed over time, a multisector, coordinated comprehensive PHC delivery is vital.

In Australia, geographical inequalities in healthcare are worsening despite significant medical advancements, highlighting that the way healthcare is financed plays a critical role in the availability, accessibility, quality, and equality of health services.

Calls to action

Reversing this complex and perpetuating cycle is a challenging task, but a necessary one to achieve a healthier, fairer and more sustainable future for Australian youth.

There are strong ethical and economic motivations to finance PHC. A strong PHC model of care is critical to improving health outcomes and overall health system efficiency.

Governments must carefully regulate taxation and subsidies to create an environment where healthy choices are easy choices. For example, pooling health funds, allocating resources equitably to the public health system, and adopting a partial capitation payment model (for example, bundled payments per patient with some fee-for-service) are some actions that may help create easier choices.

Economic theory indicates this would incentivise service providers to favour the delivery of integrated, preventative care over prolonged durations, whilst receiving financial rewards for providing timely, safe, high-quality care.

However, adequate funding alone is not enough to support a comprehensive PHC model.

Given the political nature of the allocation of these funds, strong political commitment is required to achieve patient-centred PHC financing to reduce inequalities in accessing services across the life course.

Likewise, strong political leadership is required to tackle the commercial determinants of health, in the face of predictable resistance by powerful vested interests such as companies that profit from the sale of harmful products, like ultra-processed foods and beverages, alcohol and tobacco.

Future generations are depending on it.

Lauren Richardson is a public health practitioner working in health policy at the Victorian Department of Health. She is currently completing a Master of Global Health at University of New South Wales, and has a health services research background focusing on digital health and implementation in clinical settings.

Lauren was recently appointed as Chief Executive Officer of the not-for-profit organisation, Community Health Advancement and Student Engagement (CHASE), and is a passionate advocate for health equity by empowering and enabling healthy communities using evidence-based public health practice and principles.

Lauren is a co-author on the Grattan Institute report on strengthening general practice. The views in this story are her own and may not reflect the views of the Grattan Institute.


This article was first published by Croakey News (Editor: Alison Barrett, Author: Lauren Richardson) and has been republished with permission. Read the original here.



Image: Nick Fewings/Unsplash

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