Third sector primary care for vulnerable populations.

This paper aims to describe and explain the development of third sector primary care organisations in New Zealand. The third sector is the non-government, non-profit sector. International literature suggests that this sector fulfils an important role in democratic societies with market-based economies, providing services otherwise neglected by the government and private for-profit sectors. Third sector organisations provided a range of social services throughout New Zealand's colonial history. However, it was not until the 1980s that third sector organisations providing comprehensive primary medical and related services started having a significant presence in New Zealand. In 1994 a range of union health centres, tribally based Mäori health providers, and community-based primary care providers established a formal network -- Health Care Aotearoa. While not representing all third sector primary care providers in New Zealand, Health Care Aotearoa was the best-developed example of a grouping of third sector primary care organisations. Member organisations served populations that were largely non-European and lived in deprived areas, and tended to adopt population approaches to funding and provision of services. The development of Health Care Aotearoa has been consistent with international experience of third sector involvement -- there were perceived "failures" in government policies for funding primary care and private sector responses to these policies, resulting in lack of universal funding and provision of primary care and continuing patient co-payments. The principal policy implication concerns the role of the third sector in providing primary care services for vulnerable populations as a partial alternative to universal funding and provision of primary care. Such an alternative may be convenient for proponents of reduced state involvement in funding and provision of health care, but may not be desirable from the point of view of equity and social cohesion insofar as the role of the welfare state is diminished.

The community services card: does it make a difference to pharmaceutical utilisation?

AIMS: To estimate the utilisation rate, and amount of state subsidy of prescription items per head by age, sex and community Services Card (CSC) for the year ended June 1999. METHODS: Data from a market research company (IMS Health), Health Benefits Limited, Statistics New Zealand and Work and Income New Zealand were used to calculate average per head per year pharmaceutical utilisation rate and subsidy cost for CSC holders and non-holders. RESULTS: For both sexes, and for all age groups, CSC-holders tended to use more prescription items per head and incur higher subsidy cost than non-holders. The standardised CSC utilisation rate was 2.6 times the non-CSC rate. For children, average per-item subsidy cost for CSC-holders was lower than for non-holders; the reverse was true for adults. CONCLUSION: CSC holders had higher pharmaceutical utilisation rates than non-holders at a national level (but not necessarily at a local level). If non-uptake of cards and health status were taken into account, however, it is possible that pharmaceutical utilisation rates were suboptimal amongst those most in need of services. Analyses are urgently required to examine prescribing patterns at a regional level.

The first sunrise: an experience of cultural immersion and community health needs assessment by undergraduate medical students in New Zealand.

CONTEXT: Cultural factors in health and illness, and an awareness of community health needs analysis, are important issues for medical education. Both have received relatively little recognition in the medical education literature. This paper describes the development of an educational attachment to remote predominantly Maori rural communities in New Zealand. The twin purposes of the programme were to encourage students to adopt broad public health approaches in assessing the health needs of defined communities, and to increase their awareness of the importance of cultural issues. METHODS: During a one week attachment, 51 students from the Wellington School of Medicine were hosted in six small communities in the East Cape region of New Zealand. Students gained an insight into the health needs of the communities and were encouraged to challenge their own attitudes, assumptions and thinking regarding the determinants of health and the importance of cultural factors in health and illness. The programme included both health needs assessment and cultural immersion. Students made visits with primary health care professionals and were also introduced to Maori history and cultural protocol, and participated in diverse activities ranging from the preparation of traditional medicines to performing their own songs in concert. CONCLUSIONS: The students evaluated the course extremely highly. Attachments of this sort provide an opportunity for students to appreciate how cultural values have an impact on health care, and how they also make the teaching and learning of topics such as community health needs analysis an enjoyable and dynamic experience.

Third sector primary health care in New Zealand.

AIMS: To describe key organisational characteristics of selected third sector (non-profit and non-government) primary health care organisations. METHODS: Data were collected, in 1997 and 1998, from 15 third sector primary care organisations that were members of a network of third sector primary care providers, Health Care Aotearoa (HCA). Data were collected by face-to-face interviews of managers and key informants using a semi-structured interview schedule, and from practice computer information systems. RESULTS: Overall the populations served were young: only 4% of patients were aged 65 years or older, and the ethnicity profile was highly atypical, with 21.8% European, 36% Maori, 22.7% Pacific Island, 12% other, and 7.5% not stated. Community services card holding rates were higher than recorded in other studies, and registered patients tended to live in highly deprived areas. HCA organisations had high patient to doctor ratios, in general over 2000:1, and there were significant differences in management structures between HCA practices and more traditional general practice. CONCLUSIONS: Third sector organisations provide services for populations that are disadvantaged in many respects. It is likely that New Zealand will continue to develop a diverse range of primary care organisational arrangements. Effort is now required to measure quality and effectiveness of services provided by different primary care organisations serving comparable populations.

Socioeconomic deprivation and ethnicity are both important for anti-tobacco health promotion.

The aim of the study was to explore the relative importance of socioeconomic deprivation and ethnicity for smoking in New Zealand in order to assist with the design and evaluation of health promotion programs. Smoking data were derived from the 1996 census. Socioeconomic deprivation was measured using the NZDep96 index of socioeconomic deprivation for small areas, which combines nine variables from the 1996 census. There was a strong and consistent relationship between area-level socioeconomic deprivation and the proportion of regular smokers. In all age-groups, at each level of deprivation, Maöri smoked more than the "European and Other" ethnic group. The findings of this study support the view that effective tobacco control activities should address ethnic differences in smoking behavior as well as socioeconomic deprivation, and must operate at the levels of populations, places and environments, as well as individuals.

Deprivation and sudden infant death syndrome.

This research uses a case-control study to examine the relationship between deprivation of area of residence and incidence of sudden infant death syndrome (SIDS) in New Zealand. Three hundred sixteen cases and 1221 controls were elicited with geocodable addresses. Infants living in the most deprived areas had a 5.9- (95%CI = 2.9, 12.2) fold increased risk of SIDS compared with those infants living in the least deprived areas. After adjusting for individual-level factors there was no remaining area-level effect. Nearly 27% of control infants lived in the two lowest deciles of deprivation, and almost half of SIDS deaths occurred in these areas. Incidence of SIDS is strongly associated with both deprivation of area of residence and individual socioeconomic factors. This indicates the importance of reaching parents in deprived areas, however, given that approximately 50% of SIDS deaths occurred in areas other than the two most deprived, we recommend that SIDS health messages be delivered to the general population.

Utilisation rates in capitated primary care centres serving low income populations.

AIM: To measure utilisation rates in capitated primary care organisations serving low income populations with low or zero co-payments, and to examine the relationship between utilisation rates and organisation, age group, sex, ethnicity, community services card (CSC) holding rates, high use health card (HUHC) holding rates and deprivation of area of residence (NZDep96). METHODS: Data were collected during 1997/98, from eleven primary care organisations. Utilisation data were collected from practice computer information systems. RESULTS: 53.9% of registered patients were recorded as having consulted in a twelve-month period. Utilisation rates for doctor, nurse and midwife combined were higher amongst the young, elderly, and CSC holders. For males, they were higher amongst those living in the most socioeconomically deprived areas, but not for females. Utilisation rates were highest amongst the 'other' ethnic group, and lowest in the Pacific Island ethnic group. Organisation, age group, sex, ethnicity, CSC, HUHC and NZDep96 were independently predictive of total utilisation. CONCLUSIONS: Utilisation rates in capitated practices tended to be lower than those in fee-for-service practices. If equitable needs-based capitation funding formulas are to be developed, utilisation data from capitated practices in a range of cultural and socioeconomic settings is urgently required.

Socioeconomic inequalities in health: how big is the problem and what can be done?

Socioeconomic factors shape the working day for many doctors in New Zealand. The occurrence and severity of most common conditions confronting doctors in day-to-day practice are linked to the socioeconomic conditions in which patients live and work. Poorer people are likely to have worse health than wealthier people; but it is also becoming clearer that it is not just the absolute level of poverty that affects people's health, but also the distribution of material resources in society. This article highlights important aspects of our current knowledge concerning the effects of socioeconomic factors on health, and makes practical suggestions for day-to-day practice. An essential first step is to identify and characterise the socioeconomic characteristics of patients. Information routinely collected by many general practitioners can be used to characterise the socioeconomic circumstances of individual patients and the practice population as a whole. Doctors can then take action at three levels to mitigate the risks associated with these socioeconomic factors: at a broad social level; at a community and practice level; and at an individual level.

Asthma prevalence and deprivation: a small area analysis.

STUDY OBJECTIVE: To investigate the relation between the prevalence of asthma symptoms in adults and deprivation in the area of residence. DESIGN: Two complementary surveys carried out between 1991-1993 yielding adult asthma symptom prevalence throughout New Zealand. Deprivation is measured by the NZDep91 index of deprivation for small areas. SETTING: New Zealand. PARTICIPANTS: A random sample of 25,042 adults aged 20-50 years. MAIN RESULTS: After controlling for possible confounding by age, gender, and ethnicity, the 12 month period prevalence rates of asthma in this representative sample of New Zealand adults are significantly higher in the three most deprived area categories than in the least deprived (tenth) category. The prevalence ratio for the most deprived category compared with the least deprived category is 1.29 with 95% confidence intervals (CI) 1.14, 1.47. There is a linear increase in asthma prevalence with increasing area deprivation (chi 2(1) = 32.20, p < 0.001). Independently, the rates are also 1.41 (95% CI 1.29, 1.54) times higher among Maori and 1.29 (95% CI 1.10, 1.52) times higher among the Pacific Island group than among the remaining, mostly European, respondents. CONCLUSIONS: The relation between asthma in adults and area deprivation is unlikely to be attributable to study biases or confounding. Further work should examine the possible role of modifiable deprivation factors in this relation.

General practitioner funding policy: from where to whither?

Six public policy objectives relating to general practitioner (GP) funding since 1938 have been identified. They concern national health insurance, rural GP shortages, care for the poor, health promotion, cost effectiveness and community control. Each of these objectives is examined in turn, focusing on the extent to which each has been met. In all cases past policies have been, at best, only partially successful in meeting their objectives and have required little in the way of dismantling prior to the introduction of new GP funding initiatives subsequent to 1993. Theoretical principles relating to the development of efficient and coherent public policy are discussed. New Zealand policy relating to funding of GP services has rarely conformed to such principles. There is an emerging consensus between social democrats and libertarians that targeted programmes for the poor is the equitable and efficient way to proceed. A key policy decision concerns the balance between planned primary care services for low income groups and more traditional market style arrangements for others.

NZDep91: A New Zealand index of deprivation.

In New Zealand, existing area-based indices of deprivation were inadequate because of lack of theoretical underpinning and use of comparatively large areas resulting in masking of variation within them. There is growing demand for small area based indices of deprivation for the purposes of resource allocation, research, and community advocacy. This paper describes a new Census-based index of deprivation based on the smallest possible geographical areas using existing Census boundaries. The index uses deprivation variables selected according to established theory, and derived from the 1991 New Zealand Census. Ten age and gender standardised variables were combined using principal components analysis. Each variable is a standardised proportion of people in a small area with a lack of a defined material or social resource. Age/gender standardisation is important to avoid confounding and to improve the performance of indices in resource allocation formulae. The index correlates highly with mortality, hospital discharges, lung cancer registrations and childhood immunisation status.

Comparison of provision and need for publicly-funded personal health services.

AIM: To determine whether health services have been purchased equitably according to population needs at the territorial local authority (TLA) level. METHODS: The project involved the mapping of different categories of personal health service expenditure onto TLA areas. The measure used to compare provision and need was the ratio of observed to expected expenditure. Need beyond weighted populations by age, sex, and ethnicity or community services card status was measured using standardised mortality ratios. RESULTS: The analysis did not suggest that the inverse care law was operating at the level of TLAs. There was no systematic bias against equity. However there is a good deal of scatter in the plots, some of which will be accounted for by data quality problems, and some of which is possibly due to inequitable purchasing. CONCLUSIONS: The inverse care law does not appear to be operating at the level of TLA. The methods piloted in this study represent a useful way of analysing and presenting information on resource allocation. Deficiencies in data quality limit the strength of conclusions which can be drawn from this project. More specific observations could be made if the methods used here were applied to smaller areas, and data quality issues were addressed.

New Zealand policy strategies concerning the funding of general practitioner care.

The evolution of New Zealand health policy concerning general practitioner care suggests six major goals: (1) providing GP services universally at zero or very low user charges, (2) increasing the proportion of GPs in rural and sparsely populated areas, (3) increasing the proportion of primary care going to low-income populations, (4) increasing the effectiveness of primary care in promoting health, (5) lowering the cost of primary care provision, and (6) giving patient-consumers (with particular emphasis on Maori) more control over the environments in which primary services are provided. Policy packages have lacked analytical coherence, however, with the consequence that only some of the goals have been effectively promoted at any point in time. The particular policies promoted have varied over time depending on the political party in power, and on the international climate of opinion concerning the prioritising of goals. The current view is that the most significant shift in New Zealand health policy orientation occurred during 1992-1994, with the emphasis on managed competition strategies and increased reliance on user charges. The 1992-1994 policy reforms also reflect a long-standing orientation in New Zealand of attempting to separate the care of the poor from that of everyone else, and of providing care for the poor by the state in a paternalistic context, and the care for the non-poor in market arrangements that reflect the preferences of patients.

Evaluation of an otitis media with effusion screening pilot programme.

AIM: To evaluate an otitis media with effusion (OME) pilot screening programme carried out in a low socioeconomic status population. METHODS: The evaluation methodology involved a literature review, key informant interviews and evaluation of the programme according to standard screening criteria. Operational analysis was carried out in which inputs, outputs and costs were analysed. RESULTS: 731 children were screened. The proportion of the target population screened was 91.2%. Forty nine point seven percent (363) of children tested had bilateral OME on at least one occasion, of whom 25.3% (92) were referred to otorhinolaryngology (ORL). The average cost of screening each child was $46.10, of detecting a case of bilateral OME $92.85, and of detecting a case requiring referral $117.03. CONCLUSIONS: The programme demonstrated that a low socioeconomic status population can be successfully screened; that the high rate of spontaneous resolution of OME should be taken into account when designing screening protocols; that screening has significant impact on secondary services; and, screening is likely to have other benefits arising from more frequent contact with children and parents. The operational success of the pilot gives no indication, however, concerning the long term outcomes of tympanometry screening. The authors conclude that further research is required to establish the long term benefits of OME screening, and resource requirements.

Iron deficiency anaemia in infants.

AIM: To determine the prevalence of iron deficiency anaemia in infants presenting to their general practitioner in a socially deprived, ethnically mixed suburb. METHODS: A total of 43 infants between 6 and 36 months of age were tested for iron deficiency anaemia. The blood tests were collected opportunistically over a 10 month period. Infants with other than trivial illness were excluded. Parents of infants with evidence of iron deficiency were offered dietary counselling, and infants with iron deficiency anaemia were treated with oral iron therapy. Follow up blood tests for iron deficient infants were performed after approximately three months of treatment with oral iron therapy. RESULTS: 42% (18) of infants tested were Pacific Island, 35% (15) were Maori, 16% (7) were European and 7% (3) belonged to other ethnic groups. 23.2% (10) of those tested had iron deficiency anaemia (haemoglobin less than 110 g/L and mean cell volume less than 70 fL). Six of the 10 were followed up and all six found to have improved haematological indices following oral iron therapy. CONCLUSION: Given the known adverse effects of iron deficiency anaemia in infancy primary health care providers in socially disadvantaged areas should consider screening all infants for iron deficiency anaemia.