PUBH1382 Australian Health Care System
Week 4 (Section A): Primary healthcare & Public
Health
INSTRUCTORS: Mervyn Jackson & Amy Loughman
Learning objectives
1. Distinguish between primary care and primary health care in terms of:
a. Profit versus not for profit
b. Bio-medical versus social models of health
c. Major principles of health care
d. Levels of prevention
2. Evaluate the impact/effectiveness of community health and community-based
services in Australia
3. In relation to public health, outline social determinants of health
4. In relation to public health, outline the concept of population health and equity
5. Differentiate the responsibilities for public and population health by the three major
levels of government: Federal; State/territory; and, Local.
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Notes
1. Primary care vs Primary healthcare
Primary care has been around since the 1920’s. It is the traditional reactive model of health
care – it react to or focuses on the treatment of a presenting illness. That is, patients
become ill and then seek traditional health care from GPs, public hospital emergency
depts., rehabilitation centres, dentists, nurses, pharmacists, physiotherapists, occupational
therapists, chiropractors, osteopaths, dieticians and psychologists.
Primary health care was first discussed in 1978 at International Conference of Primary
Health Care. Primary health care is the current model of proactive, community-based
health care delivery. These services focus efforts on addressing the social, economic and
environmental disadvantages that lead to health inequality. Some of these services include:
community health services, aboriginal health services, women’s health services, mental
health and youth health services.
Profit vs not for profit
Primary care services are profit based. Professionals working in primary care either are
privately employed and charge fees (this includes Medicare payments) or work for
organizations who pay them a salary.
Primary health care organizations are not-for-profit, are funded through the public system
and provide services to the community without charging fees. These services primarily
focus on prevention of future health problems.
Models of health
Primary care is based on the traditional bio-medical model of health, which emphasizes the
role of diseases in creating illness and the treatment of diseases (and their symptoms) to
regain health. The model focuses on the immediate cause of illness [smoking, obesity, etc]
and does not look beyond this factor.
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Primary health care is based on the (bio-psychosocial or) social models of health. That is,
health is determined by biological factors (including disease) but also by the psychological,
environmental, economic and political determinants. Hence, poverty, lack of education, lack
of safe drinking water, etc all contribute to the quality of life and health of a person.
Primary health care refers to the social determinants of health which is equated to the
unequal distribution of social and economic conditions that correlate [and probably cause]
inequitable distribution of health and disease [for instance, indigenous Australians are
amongst the poorest and politically disadvantaged in Australian society and have a life
expectancy of 15 years less than the average non-indigenous citizen.
With the escalating costs of the traditional (medical – hospital) treatment of illness, many
reformers advocate a shift in focus to preventive healthcare – a system based on equity
and fairness within the Australian community. That is, instigating community health
programs that target the causes of illness (modern polluted environments, poor diets, low
levels of exercise, lack of sleep, stressful lives, etc) rather than ignoring these unhealthy
life-styles until chronic diseases (cancers, heart disease, strokes, diabetes) occur and then
spending millions of dollars treating conditions that significantly decrease quality of life.
It is important for the reader not to confuse primary health care (the social model focussing
on prevention) with primary care (the biomedical model focussing on treating illness).
Major principles of health care
Primary care focus on four major principles
1. All diseases/illness have a biological cause (note this also includes mental illness)
2. All treatments have biological basis (either surgical or pharmacological)
3. Health professionals have the expertise to diagnose and treat the whole range of
illnesses
4. The patient has no (or only a minor) role in their treatment
Primary health care also have four major tenets
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1. Health is a fundamental human right and everyone should have equal access to a
safe environment and quality health care
2. Existing inequalities in health status are caused by social, economic and political
disadvantage
3. There needs to be reduced reliance on traditional professional (primary) care, a shift
from urban hospitals to community-based settings and a commitment to overcome
social-environmental inequality
4. Health care should be conceived not as an isolated, short-term intervention, but as a
long-term process of creating healthy environments (see “Closing the Gap” initiatives
within indigenous Australian communities)
Levels of prevention
Primary care professionals traditionally focus on the treatment of specific illnesses that are
presented at their practice (a focus on illness). Currently, primary care has begun to focus
on tertiary and secondary prevention. In tertiary prevention, primary care treatment
extends health care to ensuring rehabilitation, prevention of further complications and an
overall improvement in quality of life (eg, for someone with a chronic illness). As part of the
shift toward primary health care, primary care professional are involved in screening at risk
individuals and implementing early intervention programs to prevent future health
complications.
Primary health care professionals are involved in all levels of prevention. Their primary
focus is on primary prevention or ensuring the social, economic and environmental
conditions lead to a well population and an overall increase in quality of life. At the
secondary prevention level, they identify at risk populations and try to ensure that there
are special programs to minimize the onset of health problem in that population. Finally,
within primary prevention, they target people with existing health problems and try to
ensure that they have appropriate primary care and enough social support and community
infrastructure to improve their quality of life.
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https://www.hsc.com.my/heart-stroke-prevention.php
http://networkingfutures.com/photographymhx/social-determinants-of-health-model
If you accept the social determinants of health approach, there are bio-psychosocial layers
of health influences. Each of these levels can now be matched with levels of prevention –
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for instance, while the biological factors [heredity, etc] need targeted primary prevention,
many [universal] prevention programs can be targeted at socio-economic, cultural and
environmental inequities within Australia.
2. Impact of Community health services in Australia
Community Health Programs (CHP) were established in the 1970s by the Whitlam Labour
Government. These were based on the social model of health and had a strong focus on
equity and community input and participation. CHPs were strong advocates for community
health priorities but faced intense competition from the medical profession and its primary
care priorities. CHPs were comprised of multidisciplinary teams providing low cost services
such as counselling and housing services. The CHP ceased to exist by 1981 when the Fraser
Liberal government withdrew its support.
Community health services (CHS) was established in 1983 by the Hawke Labour
government. Community health centres were established in low socio-economic areas of
Victoria and South Australia. These centres used new models of service delivery that met
the needs of the community, but still promoted the social model of care. Services that were
established included district nursing, women’s health services, youth services, community
mental health services and community allied health services. Drug and alcohol services also
became predominant, however, in more recent years these have become specialised
services. Note, some of these services have specialist indigenous health teams while others
work with local Aboriginal Community Health organizations.
Community health has become integral as chronic disease increases and early intervention
programs become more prevalent. The focus has become about empowering the
individual through education to support self-management of chronic illness and aid people
who are disadvantaged within the community. Nowadays, health promotion and
community development programs are readily funded and supported by government. The
focus of Australian health care is beginning to shift from treatment and management of
disease to prevention and curative methods in an attempt to improve overall health
outcomes.
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However, these services face issues such as lack of support from modern medical
institutions (hospitals and the medical profession) and lack of funding support from
governments. This lack of on-going funding support arises for two reasons:
1. Competition for limited funding from primary care treatments and disease
management services
2. Challenges associated with demonstrating cost-benefit effectiveness
Primary care services have their funding tied to activities such as services provided via the
Medicare Benefit Schedule and the case-mix funding with number of hospital separations.
The cost-benefit effectiveness of such services can be readily determined. However,
community health and community-based services are primary health care services that
provide free services to the community. The impact of these services and their contribution
to future improved health of the whole community are hard to evaluate.
Public health in Australia
Public health focuses on preventing disease and injury, prolonging life and promoting
health through the organized efforts of the whole community. Public health is about
healthy populations and the quality of people’s lives and wellbeing as well as the
reorientation of health systems towards health rather than illness. The economic drivers
for public health are about reducing costs of illness and treatment by prevention,
promotion and protection of the public’s health, and to maintain a healthy workforce.
We all need public health, and it needs to be provided in the most efficient and effective
ways. While public health is primarily a public sector government activity, delivery of some
activities is reliant on sound relationships between governments at all levels, universities
and research institutes, as well as with the private sector, such as general practice.
As a nation, Australia has been ranked as being very effective in the quality of public
services, the quality of the civil service and the degree of its independence from political
pressures, the quality of policy formulation and implementation, and the credibility of the
government's commitment to such policies.
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Some successful programs
http://www.cancerinstitute.org.au/cancer-in-nsw/cancer-presentation-slides/cancer-preven
tion
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http://www.cancerinstitute.org.au/cancer-in-nsw/cancer-presentation-slides/cancer-statistics-slides
Improvement needed
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http://www.cancerinstitute.org.au/cancer-in-nsw/cancer-presentation-slides/cancer-prevention-slides
http://rcvman.blogspot.com.au/2010_09_01_archive.html
3. Social determinants of health
The term ‘social determinants of health’ refers to the living conditions in which a population
lives and works, but for the most part are out of their control. These social factors
determine the health outcomes of the population. The social determinants of health not
only impact on health outcomes, but shape how individuals within the community behave,
live, work and participate in leisure activities. There are four major social determinants of
health. These are social factors, economic factors, political factors and environmental
factors. The social determinants of health are shaped by what has come to be known as
‘the new public health’ in the 21st century that describes the need for strong economic and
political powers to control disease and illness and shape the environments and social
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situations individuals live in. It aims to promote equality and address inequalities in health
within a nation by addressing these determinants of health, in turn reducing the burden of
cost for the public health care system.
View the following video on social determinants of health:
http://s.vid.ly/embeded.html?link=c6h8x2&autoplay=false&fullscreen=yes¤tTime=11
0.3512356&volume=0.6&mute=false&state=play
Thus the key difference between the models is that the social determinants of health
model focuses on the factors external to the individual [economic and social environment
factors], while the medical model locates the problem within the individual [genetic factors,
risky behaviours].
http://www.paho.org/saludenlasamericas/index.php?option=com_content&view=article&id=58&Itemid
=55&lang=en
4. Population health and equity
The term ‘population health’ refers to a system that shapes how we view the overall health
of a population and why some populations are healthier than others. Population health
shapes policy development within health care, as well as determining where funds within
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the health care system should be allocated and what research needs to be conducted to
produce the best evidence for positive health outcomes.
Population health focuses on areas of health care such as access, but focus on broader
socioeconomic situations such as socioeconomic environments such as income,
employment status, education level, gender, culture, race and available social supports,
physical environments such as metro or rural living and sanitation, and social norms that
are seen as influencing behaviour in our society.
The population health approach benefits society by integrating health care systems,
increasing economic growth and productivity and strengthening social cohesion and citizen
engagement. Interesting, social and economic inequalities in societies lead to community
disintegration and a negative impact on overall population health. The following diagram
indicates that the more homogeneous a nation is (Japan and Scandinavian nations) the
higher life expectancy compared to nations with significant socio-economic inequalities (eg
USA – even though this is the highest overall wealth). This reduction in life expectancy could
be due to inequality of access to affordable health care, high percentage of poverty with
poor quality lifestyles and/or disintegration of society leading to increased homicides and
suicides.
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http://inequality.org/inequality-health/
There are two population-based health strategies.
1. a “high risk” strategy that targets individuals within a population that are seen as
being most at risk of poor health outcomes such as indigenous people, pregnant
women, overweight people or smokers
2. a “population” strategy that focuses on determinants that affect the overall health of
the population such as childhood immunization of infectious diseases such as small
pox, rubella, poliomyelitis, etc
5. Government responsibilities for public and population health
Division of public health funding is determined by the National Public Health Expenditure
Project. The amounts of funding that certain programs receive are measured against nine
types of population issues. These are communicable disease control, selected health
promotion services, vaccination, environmental health, food standards and hygiene, breast,
cervical and other cancer screening programs, illicit and unsafe drug use prevention,
research into public health and administration – mainly for the Public Health Outcome
Funding Agreements (PHOFA).
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http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129547594
According to Australian Institute of Health and Welfare 2014 report Australia’s health 2014,
Australia spent 9.5% of its gross domestic product (GDP) on health in 2011-2012 (most
recent data published). The various avenues of spending are outlined in the diagram
below.
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The focus of government is to reduce costs and the overall burden of the health
expenditure debt on the economy of Australia. The federal government seeks to do this by
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encouraging privatisation; however, this can have impacts on the health outcomes of lower
socio-economic families.
The responsibility of the Federal Government is funding and organising schemes such as
Medicare and the Pharmaceutical Benefit Scheme (PBS). In relation to public health, the
Federal Government is responsible for funding family planning services, blood donation
services, food safety, anti-violence programs and some specifically nationwide targeted
programs. The Federal Government is also responsible for national priorities that change
periodically in response to local and international health programs. Previously known as
the National Health Priorities (NHPs), in 2016 this program became the National Strategic
Framework for Chronic Conditions. It is designed to provide a national approach to guide
planning, design and delivery of policies, strategies, actions and services to reduce the
impact of chronic conditions in Australia. Plans and programs are funded and implemented
through the Federal Government to address this public health concerns such as Active
Australia programs, tobacco legislation, the ‘Slip Slop Slap’ campaign and programs
promoting prevention and early intervention for mental health.
The responsibility of the state and territory governments is funding and managing schemes
such as immunisation and vaccination, and managing disease outbreaks. State and
territory governments are also in charge of managing public health issues such as
emergencies like flooding and bushfires. Each state and territory government contributes
to health promotion, maternal and child health programs, dental health programs and
school health programs. Health promotion funding is prioritised to key areas of concern
such as tobacco related harm, reproductive health, environmental safety, food security,
nutrition, physical activity and mental health.
The responsibility of local government is funding and management at a community level.
This can involve legislation, safe food handling regulation, waste disposal, environmental
hazards, land planning, community public spaces such as roads, footpaths, parks and
drains, and provision and funding of community services such as aged care and youth
services. Community programs such as meals on wheels, in-home private caring and
council services such as cleaning and maintenance are also funded and operated by local
government. Local government is directly related to public health, as most aspects of
management are health promotion focussed and are concerned with the health and
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wellbeing of the local people.
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