The Australian government has proposed a new reform of primary health care. The reform was prompted, among other things, by the pressures on the Australian national public health insurance—Medicare—including the increasing cost to patients for visits to general practitioners (GPs).
A Strengthening Medicare Taskforce has recommended funding more multi-disciplinary care through nurses, psychologists, physiotherapists, speech pathologists, and other allied health professionals. This would be a welcome addition, but is basically continuing the existing services, which are based on a selective view of primary health care, focused on treating ill health in individuals.
A root reform in order
But a more root-and-branch reform of our primary health care system is required. That reform could learn many lessons from the past. In 1973, a Community Health Program led to the establishment of community health centers and services in many communities in Australia. These were established to offer clinical services, although they didn’t always have GPs. They were multidisciplinary, understood the power of the social determinants of health, and offered group programs and community development initiatives. In contrast to the equity issues identified in the recent article in The Lancet, community health has had equity at its heart, striving to reach those with the most need.
The federal funding from the 1970s didn’t last for long. Some Australian states continued to fund the services that had been established, and they have led to progressive experiments in primary health care. In Victoria, community health services still exist and offer a much more comprehensive suite of services than private GPs. They also have a strong social justice flavor in their operations. Despite their value, they are viewed as residual services for people in disadvantaged situations, not a whole-of-community option. Mainly, primary health care in Australia remains dominated by primary medical care.
Researchers at Stretton Health Equity have been researching community health services in Australia for many years and reflected on the reasons why they have failed to flourish. Comprehensive primary health care is only likely when the political ideology of a country is focused on promoting people’s health over private profits. Australia embraced neoliberalism in the 1980s and both major parties have supported this approach since. This has meant a program of privatization of previously public services and tax cuts, which mean that comprehensive primary health care can’t be funded adequately.
The existence of community health services has been opposed by most sections of the medical profession, which is primarily committed to fee-for-service medicine, and which emphasize GP control and leadership, as is illustrated in the Lancet article. Many community health services have been managed by people from a variety of professional backgrounds. The end result is that the health system continues to be a “strife of interests,” where professional power and private profit is constraining scope for more comprehensive, equity-oriented models.
Building upon existing models
At the same time, the community health sector in Australia has been the only part of the health system that has ever recognized the power of the social determinants of health and based its operations on a social model of health. The sector has recognized that the health system should have a mandate to advocate on behalf of the community for change to macro-determinants and take full account of their impact on patients’ health.
There is one bright star in the complex constellation of the Australian health system: the nationwide network of 142 Aboriginal community-controlled health organizations (ACCHOs). ACCHOs offer comprehensive primary health care services, run by a largely elected board of management comprising people from the local community. They provide well-coordinated health services that are curative, preventive, and promotive. They work with their communities to advocate for self-determination in all aspects of life, including for health policies such as alcohol control and access to social determinants such as good quality housing. Many were established from community movements from the 1960s onwards. The main constraint is that their funding comes from the government in a variety of forms, with multiple accountability requirements. However, their value and effectiveness are being recognized. Their peak body—the National Aboriginal Community Controlled Health Organisation—is a highly effective advocacy organization.
Community-controlled primary health care services in Australia should run along the lines of the ACCHOs, making sure that all Australians have access to quality primary health care. That’s currently a pipe dream, as the politics of neoliberalism and medical dominance continue to dictate the type of health services, rather than the needs of communities.
Fran Baum (@baumfran) is an activist in the People’s Health Movement and health expert working on issues related to health equity and social and commercial determinants of health.
Toby Freeman (@drtobyfreeman) researches health equity and comprehensive primary health care, and has been an active contributor to the People’s Health Movement.
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