Why Community Health Systems Have Not Flourished in High Income Countries: What the Australian Experience Tells Us

Document Type : Original Article

Authors

Southgate Institute for Health, Society and Equity, Flinders University, Adelaide, SA, Australia

Abstract

Background 
Despite the value of community health systems, they have not flourished in high income countries and there are no system-wide examples in high income countries where community health is regarded as the mainstream model. Those that do exist in Australia, Canada, the United States and the United Kingdom provide examples of comprehensive primary healthcare (PHC) but are marginal to bio-medical primary medical care. The aim of this paper is to examine the factors that account for the absence of strong community health systems in high income countries, using Australia as an example.
 

Methods 
Data are drawn from two Australian PHC studies led by the authors. One examined seven case studies of community health services over a five-year period which saw considerable health system change. The second examined regional PHC organisations. We conducted new analysis using the ‘three I’s’ framework (interests, institutions, ideas) to examine why community health systems have not flourished in high-income countries.
 

Results 
The elements of the community health services that provide insights on how they could become the basis of an effective community health system are: a focus on equity and accessibility, effective community participation/control; multidisciplinary teamwork; and strategies from care to health promotion. Key barriers identified were: when general practitioners (GPs) were seen to lead rather than be part of a team; funding models that encourage curative services rather than disease prevention and health promotion; and professional and medical dominance so that community voices are drowned out.
 

Conclusion 
Our study of the community health system in Australia indicates that instituting such a system in high income countries will require systematic ideological, political and institutional change to shift the overarching government policy environment, and health sector policies and practices towards a social model of health which allows community control, and multidisciplinary service provision.

Keywords


  1. Baum FE, Bégin M, Houweling TA, Taylor S. Changes not for the fainthearted: reorienting health care systems toward health equity through action on the social determinants of health. Am J Public Health. 2009;99(11):1967-1974. doi:10.2105/ajph.2008.154856
  2. Baum FE, Legge DG, Freeman T, Lawless A, Labonté R, Jolley GM. The potential for multi-disciplinary primary health care services to take action on the social determinants of health: actions and constraints. BMC Public Health. 2013;13:460. doi:10.1186/1471-2458-13-460
  3. Baum F, Ziersch A, Freeman T, Javanparast S, Henderson J, Mackean T. Strife of Interests: constraints on integrated and co-ordinated comprehensive PHC in Australia. Soc Sci Med. 2020;248:112824. doi:10.1016/j.socscimed.2020.112824
  4. World Health Organization (WHO). Declaration of Alma-Ata, International Conference on Primary Health Care, USSR, 6-12 September. Alma Ata: WHO;1978.
  5. WHO, UNICEF. Declaration of Astana. Astana, Khazakstan: World Health Organization; 2018.
  6. Walsh JA, Warren KS. Selective primary health care: an interim strategy for disease control in developing countries. N Engl J Med. 1979;301(18):967-974. doi:10.1056/nejm197911013011804
  7. Baum F, Fry D, Lennie I. Community Health Policy and practice in Australia. Sydney: Pluto Press; 1992.
  8. Milio N. Next steps in community health policy: matching rhetoric and reality. Community Health Stud. 1983;7(2):185-192. doi:10.1111/j.1753-6405.1983.tb00411.x
  9. Milio N. The political anatomy of community health policy in Australia, 1972-1982. Politics (Syd). 1984;19(2):18-33. doi:10.1080/00323268408401918
  10. Lawless A, Freeman T, Bentley M, Baum F, Jolley G. Developing a good practice model to evaluate the effectiveness of comprehensive primary health care in local communities. BMC Fam Pract. 2014;15:99. doi:10.1186/1471-2296-15-99
  11. Anaf J, Baum F, Freeman T, et al. Factors shaping intersectoral action in primary health care services. Aust N Z J Public Health. 2014;38(6):553-559. doi:10.1111/1753-6405.12284
  12. Baum F, Freeman T, Sanders D, Labonté R, Lawless A, Javanparast S. Comprehensive primary health care under neo-liberalism in Australia. Soc Sci Med. 2016;168:43-52. doi:10.1016/j.socscimed.2016.09.005
  13. Freeman T, Baum F, Javanparast S, Labonté R, Lawless A, Barton E. The contribution of group work to the goals of comprehensive primary health care. Health Promot J Austr. 2021;32(1):126-136. doi:10.1002/hpja.323
  14. Freeman T, Baum F, Lawless A, et al. Revisiting the ability of Australian primary healthcare services to respond to health inequity. Aust J Prim Health. 2016;22(4):332-338. doi:10.1071/py14180
  15. Freeman T, Baum F, Lawless A, et al. Reaching those with the greatest need: how Australian primary health care service managers, practitioners and funders understand and respond to health inequity. Aust J Prim Health. 2011;17(4):355-361. doi:10.1071/py11033
  16. Freeman T, Baum FE, Jolley GM, et al. Service providers' views of community participation at six Australian primary healthcare services: scope for empowerment and challenges to implementation. Int J Health Plann Manage. 2016;31(1):E1-21. doi:10.1002/hpm.2253
  17. Javanparast S, Maddern J, Baum F, et al. Change management in an environment of ongoing primary health care system reform: a case study of Australian primary health care services. Int J Health Plann Manage. 2018;33(1):e76-e88. doi:10.1002/hpm.2413
  18. Javanparast S, Baum F, Freeman T, Ziersch A, Henderson J, Mackean T. Collaborative population health planning between Australian primary health care organisations and local government: lost opportunity. Aust N Z J Public Health. 2019;43(1):68-74. doi:10.1111/1753-6405.12834
  19. Javanparast S, Freeman T, Baum F, et al. How institutional forces, ideas and actors shaped population health planning in Australian regional primary health care organisations. BMC Public Health. 2018;18(1):383. doi:10.1186/s12889-018-5273-4
  20. Freeman T, Javanparast S, Baum F, Ziersch A, Mackean T. A framework for regional primary health care to organise actions to address health inequities. Int J Public Health. 2018;63(5):567-575. doi:10.1007/s00038-018-1083-9
  21. Ziersch A, Freeman T, Javanparast S, Mackean T, Baum F. Regional primary health care organisations and migrant and refugee health: the importance of prioritisation, funding, collaboration and engagement. Aust N Z J Public Health. 2020;44(2):152-159. doi:10.1111/1753-6405.12965
  22. Australian Government. Medicare Locals: Guidelines for the Establishment and Initial Operation of Medicare Locals & Information for Applicants Wishing to Apply for Funding to Establish a Medicare Local. Canberra, ACT: Australian Government; 2011.
  23. Australian Government Department of Health. PHN Program Performance and Quality Framework. Canberra, ACT: Australian Government Department of Health; 2018.
  24. Hall PA. The role of interests, institutions, and ideas in the comparative political economy of the industrialized nations. In: Lichbach I, Zuckerman AS, eds. Comparative Politics: Rationality, Culture, and Structure. Cambridge: Cambridge University Press; 1997:174-207.
  25. Katikireddi SV, Smith KE, Stuckler D, McKee M. Devolution of power, revolution in public health? J Public Health (Oxf). 2017;39(2):241-247. doi:10.1093/pubmed/fdw031
  26. Schram A. When evidence isn’t enough: Ideological, institutional, and interest-based constraints on achieving trade and health policy coherence. Glob Soc Policy. 2018;18(1):62-80. doi:10.1177/1468018117744153
  27. Milsom P, Smith R, Baker P, Walls H. Corporate power and the international trade regime preventing progressive policy action on non-communicable diseases: a realist review. Health Policy Plan. 2020. doi:10.1093/heapol/czaa148
  28. Sax S. A Strife of Interests: Politics and Policies in Australian Health Services. Sydney: George Allan & Unwin; 1984.
  29. Legge D, Wilson G, Butler P, Wright M, McBride T, Attewell R. Best practice in primary health care. Aust J Prim Health. 1996;2(1):22-26. doi:10.1071/py96004
  30. Labonté R, Packer C. Summary of comprehensive primary health care findings from the structured literature review. In: Labonté R, Sanders D, Packer C, Schaay N, eds. Revitalising Health for All: Case Studies of the Struggle for Comprehensive Primary Health Care. Toronto, Canada: University of Toronto Press; 2017:27.
  31. Labonté R, Sanders D, Packer C, Schaay N. Revitalising Health for All: Case Studies of the Struggle for Comprehensive Primary Health Care. Toronto, Canada: University of Toronto Press; 2017.
  32. Baum F, Freeman T, Lawless A, Jolley G. Community development--improving patient safety by enhancing the use of health services. Aust Fam Physician. 2012;41(6):424-428.
  33. Freeman T, Javanparast S, Baum F, Ziersch A, Mackean T. A framework for regional primary health care to organise actions to address health inequities. Int J Public Health. 2018;63(5):567-575. doi:10.1007/s00038-018-1083-9
  34. Henderson J, Javanparast S, MacKean T, Freeman T, Baum F, Ziersch A. Commissioning and equity in primary care in Australia: views from Primary Health Networks. Health Soc Care Community. 2018;26(1):80-89. doi:10.1111/hsc.12464
  35. Bentley M, Freeman T, Baum F, Javanparast S. Interprofessional teamwork in comprehensive primary healthcare services: findings from a mixed methods study. J Interprof Care. 2018;32(3):274-283. doi:10.1080/13561820.2017.1401986
  36. Horvath J. Review of Medicare Locals. Canberra, ACT: Report to the Minister for Health and Minister for Sport; 2014.
  37. Freeman T, Baum F, Lawless A, et al. Case study of an aboriginal community-controlled health service in Australia: universal, rights-based, publicly funded comprehensive primary health care in action. Health Hum Rights. 2016;18(2):93-108.
  38. Dwyer J, Martini A, Brown C, et al. The Road Is Made by Walking: Towards a Better Primary Health Care System for Australia’s First Peoples. Carlton South, VIC: The Lowitja Institute; 2015.
  39. McCann W. Review of Non-Hospital Based Services. Adelaide: Office of Public Employment and Review; 2012.
  40. Duckett S, Willcox S. The Australian Health Care System. 4th ed. South Melbourne, VIC: Oxford University Press; 2011.
  41. Freeman T, Baum F, Labonté R, Javanparast S, Lawless A. Primary health care reform, dilemmatic space and risk of burnout among health workers. Health (London). 2018;22(3):277-297. doi:10.1177/1363459317693404
  42. Hall PA. The role of interests, institutions, and ideas in the comparative political economy of the industrialized nations. In: Lichbach I, Zuckerman AS, eds. Comparative Politics: Rationality, Culuture and Structure. Cambridge: Cambridge University Press; 1997:174-207.
  43. Germov J. Managerialism in the Australian public health sector: towards the hyper-rationalisation of professional bureaucracies. Sociol Health Illn. 2005;27(6):738-758. doi:10.1111/j.1467-9566.2005.00472.x
  44. Global Health Watch. Global Health Watch 4. London, UK: Zed Books; 2014.
  45. Labonté R. The austerity agenda: how did we get here and where do we go next? Crit Public Health. 2012;22(3):257-265. doi:10.1080/09581596.2012.687508
  46. Miller C, Orchard L. Australian Public Policy: Progressive Ideas in the Neoliberal Ascendency. Bristol, UK: Policy Press; 2014.
  47. Oritz I, Cummins M. The Age of Austerity: A Review of Public Expenditures and Adjustment Measures in 181 Countries. New York, NY: Initiative for Policy Dialogue and the South Centre; 2013.
  48. Jolley G, Lawless A, Hurley C. Framework and tools for planning and evaluating community participation, collaborative partnerships and equity in health promotion. Health Promot J Austr. 2008;19(2):152-157. doi:10.1071/he08152
  49. Davis M. Neoliberalism, the culture wards and public policy. In: Miller C, Orchard L, eds. Australian Public Policy: Progressive Ideas in the Neoliberal Ascendency. Bristol, UK: Policy Press; 2014.
  50. Baum F. Governing for Health: Advancing Health and Equity through Policy and Advocacy. New York: Oxford University Press; 2019.
  51. Korten D. Change the Story, Change the Future: A Living Economy for a Living Earth. Oakland, CA: Berrett-Koehler Publishers; 2015.
  52. Lefkowitz B. Community Health Centres: A Movement and the People Who Made It Happen. Piscataway, NJ: Rutgers University Press; 2007.
  53. South Australian Health Commission. A Social Health Strategy for South Australia. Adelaide, SA: South Australian Health Commission; 1988.
  54. Lowell R. Localising Human Services: A History of Local Government Human Services in Victoria. Melbourne, VIC: Australian Scholarly Publishing; 2005.
  55. National Aboriginal Community Controlled Health Organisation. https://www.naccho.org.au/. Accessed June 26, 2020.
  56. Kleinert S, Horton R. From universal health coverage to right care for health. Lancet. 2017;390(10090):101-102. doi:10.1016/s0140-6736(16)32588-0
  57. Jureidini J, McHenry LB. The Illusion of Evidence-Based Medicine. Adelaide: Wakefield Press; 2020.
  58. Illich I. Medical Nemesis. London: Caldar and Boyars; 1975.
  59. Tesoriero F. Community development and health promotion. In: Baum F, ed. Health for All: The South Australian Experience. Adelaide: Wakefield Press; 1995:268-280.
  60. Expert Panel on Effective Ways of Investing in Health. Task Shifting and Health System Design. Luxembourg: European Union; 2019.
  61. Javanparast S, Windle A, Freeman T, Baum F. Community health worker programs to improve healthcare access and equity: are they only relevant to low- and middle-income countries? Int J Health Policy Manag. 2018;7(10):943-954. doi:10.15171/ijhpm.2018.53
  62. Scott K, Beckham SW, Gross M, et al. What do we know about community-based health worker programs? a systematic review of existing reviews on community health workers. Hum Resour Health. 2018;16(1):39. doi:10.1186/s12960-018-0304-x
  63. Johnson CD, Noyes J, Haines A, et al. Learning from the Brazilian community health worker model in North Wales. Global Health. 2013;9:25. doi:10.1186/1744-8603-9-25