Striving towards integrated people-centred health services: reflections on the Australian experience.

Health systems around the world are under continuing pressure for reform. Health system reform involves both content and process. Content deals with changes to the structures of the health system; process deals with the strategies of change. In this paper, we reflect on the development of the Australian healthcare system and draw out lessons regarding both structural and developmental principles. We review the historical development and functional performance of a range of 'programmes' which comprise the Australian health system. We use WHO's 2016 'framework on integrated people-centred health services' as a standard against which to evaluate the performance of the different programmes. A model of health system development featuring incremental change, windows of opportunity and policy coherence is used to frame some lessons from the Australian experience regarding reform strategy. Several of the programmes reviewed can be shown to have contributed positively to integrated and people-centred services. However, there have also been significant shortfalls in performance. The successes and the shortfalls of the programmes reviewed reflect both their histories and their contemporary context. Structural principles emerging from this review include the policy leverage available under single payer purchasing and on the other hand the fragmenting effects of privatisation and marketisation. Lessons regarding strategies of reform include cultivating 'reform readiness' across all of the locations and levels where opportunities for change may emerge while cultivating system wide coherence through a shared vision of how the system as a whole should develop.

The potential for multi-disciplinary primary health care services to take action on the social determinants of health: actions and constraints.

BACKGROUND: The Commission on the Social Determinants of Health and the World Health Organization have called for action to address the social determinants of health. This paper considers the extent to which primary health care services in Australia are able to respond to this call. We report on interview data from an empirical study of primary health care centres in Adelaide and Alice Springs, Australia. METHODS: Sixty-eight interviews were held with staff and managers at six case study primary health care services, regional health executives, and departmental funders to explore how their work responded to the social determinants of health and the dilemmas in doing so. The six case study sites included an Aboriginal Community Controlled Organisation, a sexual health non-government organisation, and four services funded and managed by the South Australian government. RESULTS: While respondents varied in the extent to which they exhibited an understanding of social determinants most were reflexive about the constraints on their ability to take action. Services' responses to social determinants included delivering services in a way that takes account of the limitations individuals face from their life circumstances, and physical spaces in the primary health care services being designed to do more than simply deliver services to individuals. The services also undertake advocacy for policies that create healthier communities but note barriers to them doing this work. Our findings suggest that primary health care workers are required to transverse "dilemmatic space" in their work. CONCLUSIONS: The absence of systematic supportive policy, frameworks and structure means that it is hard for PHC services to act on the Commission on the Social Determinants of Health's recommendations. Our study does, however, provide evidence of the potential for PHC services to be more responsive to social determinants given more support and by building alliances with communities and social movements. Further research on the value of community control of PHC services and the types of policy, resource and managerial environments that support action on social determinants is warranted by this study's findings.

Evaluating health policy capacity: Learning from international and Australian experience.

BACKGROUND: The health sector in Australia faces major challenges that include an ageing population, spiralling health care costs, continuing poor Aboriginal health, and emerging threats to public health. At the same time, the environment for policy-making is becoming increasingly complex. In this context, strong policy capacity - broadly understood as the capacity of government to make "intelligent choices" between policy options - is essential if governments and societies are to address the continuing and emerging problems effectively. RESULTS: This paper explores the question: "What are the factors that contribute to policy capacity in the health sector?" In the absence of health sector-specific research on this topic, a review of Australian and international public sector policy capacity research was undertaken. Studies from the United Kingdom, Canada, New Zealand and Australia were analysed to identify common themes in the research findings. This paper discusses these policy capacity studies in relation to context, models and methods for policy capacity research, elements of policy capacity and recommendations for building capacity. CONCLUSION: Based on this analysis, the paper discusses the organisational and individual factors that are likely to contribute to health policy capacity, highlights the need for further research in the health sector and points to some of the conceptual and methodological issues that need to be taken into consideration in such research.

Micro macro integration: reframing primary healthcare practice and community development in health

The idea of micro macro integration (MMI) provides a useful framework for thinking about primary healthcare (PHC) and community development in health (CD). PHC and CD are important strategies for addressing the structural determinants of health. They are each based on a powerful logic and have significant body of support. However, while exemplary, even inspiring, instances of practice are common, attempts to replicate models of good practice (or 'scale up') often flounder. As frameworks for analysing this paradox, both PHC and CD have limitations, partly because they are overburdened with different and conflicting meanings. This paper explores an alternative framework based on a common aspiration of both PHC and CD: to effect change at both the micro level (meeting the immediate health needs of individuals, families and communities) and also at the macro level (of political, economic and social structures). The MMI framework assumes that health issues can be analysed at different levels of scale and of term (from the micro to the macro); that objectives and strategies can be conceived at these different levels; and that a coherent programme of activities can be conceived and implemented which addresses both the immediate and local problems and the larger scale and longer term phenomena that reproduce those patterns of need. The idea of MMI is less ambitious than either PHC or CD but (partly because of this) has value as a framework for analysing barriers to good practice (AU)

Describing Chinese hospital activity with diagnosis related groups (DRGs). A case study in Chengdu.

OBJECTIVE: To examine the applicability of an Australian casemix classification system to the description of Chinese hospital activity. DESIGN: A total of 161,478 inpatient episodes from three Chengdu hospitals with demographic, diagnosis, procedure and billing data for the year 1998/1999, 1999/2000 and 2000/2001 were grouped using the Australian refined-diagnosis related groups (AR-DRGs) (version 4.0) grouper. MAIN OUTCOME MEASURES: Reduction in variance (R2) and coefficient of variation (CV). RESULTS: Untrimmed reduction in variance (R2) was 0.12 and 0.17 for length of stay (LOS) and cost respectively. After trimming, R2 values were 0.45 and 0.59 for length of stay and cost respectively. CONCLUSIONS: The Australian refined DRGs provide a good basis for developing a Chinese grouper.