Challenges for Medicare and universal health care in Australia since 2000.

OBJECTIVES: To identify the financing and policy challenges for Medicare and universal health care in Australia, as well as opportunities for whole-of-system strengthening. STUDY DESIGN: Review of publications on Medicare, the Pharmaceutical Benefits Scheme, and the universal health care system in Australia published 1 January 2000 - 14 August 2021 that reported quantitative or qualitative research or data analyses, and of opinion articles, debates, commentaries, editorials, perspectives, and news reports on the Australian health care system published 1 January 2015 - 14 August 2021. Program-, intervention- or provider-specific articles, and publications regarding groups not fully covered by Medicare (eg, asylum seekers, prisoners) were excluded. DATA SOURCES: MEDLINE Complete, the Health Policy Reference Centre, and Global Health databases (all via EBSCO); the Analysis & Policy Observatory, the Australian Indigenous HealthInfoNet, the Australian Public Affairs Information Service, Google, Google Scholar, and the Organisation for Economic Co-operation and Development (OECD) websites. RESULTS: The problems covered by the 76 articles included in our review could be grouped under seven major themes: fragmentation of health care and lack of integrated health financing, access of Aboriginal and Torres Strait Islander people to health services and essential medications, reform proposals for the Pharmaceutical Benefits Scheme, the burden of out-of-pocket costs, inequity, public subsidies for private health insurance, and other challenges for the Australian universal health care system. CONCLUSIONS: A number of challenges threaten the sustainability and equity of the universal health care system in Australia. As the piecemeal reforms of the past twenty years have been inadequate for meeting these challenges, more effective, coordinated approaches are needed to improve and secure the universality of public health care in Australia.

Effectiveness, cost effectiveness, acceptability and implementation barriers/enablers of chronic kidney disease management programs for Indigenous people in Australia, New Zealand and Canada: a systematic review of mixed evidence.

BACKGROUND: Indigenous peoples in Australia, New Zealand and Canada carry a greater burden of chronic kidney disease (CKD) than the general populations in each country, and this burden is predicted to increase. Given the human and economic cost of dialysis, understanding how to better manage CKD at earlier stages of disease progression is an important priority for practitioners and policy-makers. A systematic review of mixed evidence was undertaken to examine the evidence relating to the effectivness, cost-effectiveness and acceptability of chronic kidney disease management programs designed for Indigenous people, as well as barriers and enablers of implementation of such programs. METHODS: Published and unpublished studies reporting quantitative and qualitative data on health sector-led management programs and models of care explicitly designed to manage, slow progression or otherwise improve the lives of Indigenous people with CKD published between 2000 and 2014 were considered for inclusion. Data on clinical effectiveness, ability to self-manage, quality of life, acceptability, cost and cost-benefit, barriers and enablers of implementation were of interest. Quantitative data was summarized in narrative and tabular form and qualitative data was synthesized using the Joanna Briggs Institute meta-aggregation approach. RESULTS: Ten studies were included. Six studies provided evidence of clinical effectiveness of CKD programs designed for Indigenous people, two provided evidence of cost and cost-effectiveness of a CKD program, and two provided qualitative evidence of barriers and enablers of implementation of effective and/or acceptable CKD management programs. Common features of effective and acceptable programs were integration within existing services, nurse-led care, intensive follow-up, provision of culturally-appropriate education, governance structures supporting community ownership, robust clinical systems supporting communication and a central role for Indigenous Health Workers. CONCLUSIONS: Given the human cost of dialysis and the growing population of people living with CKD, there is an urgent need to draw lessons from the available evidence from this and other sources, including studies in the broader population, to better serve this population with programs that address the barriers to receiving high-quality care and improve quality of life.

Economic evaluation of Indigenous health worker management of poorly controlled type 2 diabetes in north Queensland.

OBJECTIVE: To conduct an economic evaluation of intensive management by Indigenous health workers (IHWs) of Indigenous adults with poorly controlled type 2 diabetes in rural and remote north Queensland. DESIGN: Cost-consequence analysis alongside a cluster randomised controlled trial of an intervention delivered between 1 March 2012 and 5 September 2013. SETTING: Twelve primary health care services in rural and remote north Queensland communities with predominantly Indigenous populations. PARTICIPANTS: Indigenous adults with poorly controlled type 2 diabetes (HbA1c ≥ 69 mmol/mol) and at least one comorbidity (87 people in six IHW-supported communities (IHW-S); 106 in six usual care (UC) communities). MAIN OUTCOME MEASURES: Per person cost of the intervention; differential changes in mean HbA1c levels, percentage with extremely poor HbA1c level control, quality of life, disease progression, and number of hospitalisations. RESULTS: The mean cost of the 18-month intervention trial was $10 060 per person ($6706 per year). The intervention was associated with a non-significantly greater reduction in mean HbA1c levels in the IHW-S group (-10.1 mmol/mol v -5.4 mmol/mol in the UC group; P = 0.17), a significant reduction in the proportion with extremely poor diabetes control (HbA1c ≥ 102 mmol/mol; P = 0.002), and a sub-significant differential reduction in hospitalisation rates for type 2 diabetes as primary diagnosis (-0.09 admissions/person/year; P = 0.06), with a net reduction in mean annual hospital costs of $646/person (P = 0.07). Quality of life utility scores declined in both groups (between-group difference, P = 0.62). Rates of disease progression were high in both groups (between-group difference, P = 0.73). CONCLUSION: Relative to the high cost of the intervention, the IHW-S model as implemented is probably a poor investment. Incremental cost-effectiveness might be improved by a higher caseload per IHW, a longer evaluation time frame, and improved service integration. Further approaches to improving chronic disease outcomes in this very unwell population need to be explored, including holistic approaches that address the complex psychosocial, pathophysiological and environmental problems of highly disadvantaged populations. TRIAL REGISTRATION: ANZCTR12610000812099.

Beyond the Biomedical Paradigm: The Formation and Development of Indigenous Community-Controlled Health Organizations in Australia.

This article describes the formation and development of Aboriginal Community-Controlled Health Services in Australia, with emphasis on the Redfern Aboriginal Medical Service in Sydney. These organizations were established in the 1970s by Indigenous Australians who were excluded from and denied access to mainstream health services. The aim of this research was to explore notions of Indigenous agency against a historical backdrop of dispossession, colonialism, and racism. Aboriginal Community-Controlled Health Services act as a primary source of healthcare for many Indigenous communities in rural and urban areas. This study examined their philosophy of healthcare, the range of services provided, their problems with state bureaucracies and government funding bodies, and the imposition of managerialist techniques and strategies on their governance. Essentially, these organizations transcend individualistic, biomedical, and bureaucratic paradigms of health services by conceptualizing and responding to Indigenous health needs at a grassroots level and in a broad social and political context. They are based on a social model of health.

Does Australia have the appropriate health reform agenda to close the gap in Indigenous health?

This paper provides an analysis of the national Indigenous reform strategy - known as Closing the Gap - in the context of broader health system reforms underway to assess whether current attempts at addressing Indigenous disadvantage are likely to be successful. Drawing upon economic theory and empirical evidence, the paper analyses key structural features necessary for securing system performance gains capable of reducing health disparities. Conceptual and empirical attention is given to the features of comprehensive primary healthcare, which encompasses the social determinants impacting on Indigenous health. An important structural prerequisite for securing genuine improvements in health outcomes is the unifying of all funding and policy responsibilities for comprehensive primary healthcare for Indigenous Australians within a single jurisdictional framework. This would provide the basis for implementing several key mutually reinforcing components necessary for enhancing primary healthcare system performance. The announcement to introduce a long-term health equality plan in partnership with Aboriginal people represents a promising development and may provide the window of opportunity needed for implementing structural reforms to primary healthcare. WHAT IS KNOWN ABOUT THE TOPIC? Notwithstanding the intention of previous policies, considerable health disparity exists between Indigenous and non-Indigenous Australians. Australia has now embarked on its most ambitious national Indigenous health reform strategy, but there has been little academic analysis of whether such reforms are capable of eliminating health disadvantage for Aboriginal people.WHAT DOES THE PAPER ADD? This paper provides a critical analysis of Indigenous health reforms to assess whether such policy initiatives are likely to be successful and outlines key structural changes to primary healthcare system arrangements that are necessary to secure genuine system performance gains and improve health outcomes for Indigenous Australians.WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? For policymakers, the need to establish genuine partnership and engagement between Aboriginal people and the Australian government in pursuing a national Indigenous reform agenda is of critical importance. The establishment of the National Congress of Australia's First Peoples provides the opportunity for policy makers to give special status to Indigenous Australians in health policy development and create the institutional breakthrough necessary for effecting primary healthcare system change.

The quest for equity in Latin America: a comparative analysis of the health care reforms in Brazil and Colombia.

INTRODUCTION: Brazil and Colombia have pursued extensive reforms of their health care systems in the last couple of decades. The purported goals of such reforms were to improve access, increase efficiency and reduce health inequities. Notwithstanding their common goals, each country sought a very different pathway to achieve them. While Brazil attempted to reestablish a greater level of State control through a public national health system, Colombia embraced market competition under an employer-based social insurance scheme. This work thus aims to shed some light onto why they pursued divergent strategies and what that has meant in terms of health outcomes. METHODS: A critical review of the literature concerning equity frameworks, as well as the health care reforms in Brazil and Colombia was conducted. Then, the shortfall inequality values of crude mortality rate, infant mortality rate, under-five mortality rate, and life expectancy for the period 1960-2005 were calculated for both countries. Subsequently, bivariate and multivariate linear regression analyses were performed and controlled for possibly confounding factors. RESULTS: When controlling for the underlying historical time trend, both countries appear to have experienced a deceleration of the pace of improvements in the years following the reforms, for all the variables analyzed. In the case of Colombia, some of the previous gains in under-five mortality rate and crude mortality rate were, in fact, reversed. CONCLUSIONS: Neither reform seems to have had a decisive positive impact on the health outcomes analyzed for the defined time period of this research. This, in turn, may be a consequence of both internal characteristics of the respective reforms and external factors beyond the direct control of health reformers. Among the internal characteristics: underfunding, unbridled decentralization and inequitable access to care seem to have been the main constraints. Conversely, international economic adversities, high levels of rural and urban violence, along with entrenched income inequalities seem to have accounted for the highest burden among external factors.

Funding models for outreach ophthalmology services.

BACKGROUND: This paper aims to describe funding models used and compare the effects of funding models for remuneration on clinical activity and cost-effectiveness in outreach eye services in Australia. DESIGN: Cross-sectional case study based in remote outreach ophthalmology services in Australia. PARTICIPANTS: Key stake-holders from eye services in nine outreach regions participated in the study. METHODS: Semistructured interviews were conducted to perform a qualitative assessment of outreach eye services' funding mechanisms. Records of clinical activity were used to statistically compare funding models. MAIN OUTCOME MEASURES: Workforce availability (supply of ophthalmologists), costs of services, clinical activity (surgery and clinic consultation rates) and waiting times. RESULTS: The supply of ophthalmologists (full-time equivalence) to all remote regions was below the national average (up to 19 times lower). Cataract surgery rates were also below national averages (up to 10 times lower). Fee-for-service funding significantly increased clinical activity. There were also trends to shorter waiting times and lower costs per attendance. CONCLUSIONS: For outreach ophthalmology services, the funding model used for clinician reimbursement may influence the efficiency and costs of the services. Fee-for-service funding models, safety-net funding options or differential funding/incentives need further exploration to ensure isolated disadvantaged areas prone to poor patient attendance are not neglected. In order for outreach eye health services to be sustainable, remuneration rates need to be comparable to those for urban practice.

A decade of NHMRC People Support expenditure in review: is support for Indigenous health research increasing?

OBJECTIVE: To investigate National Health and Medical Research Council (NHMRC) support over the decade to 2006 for researchers studying Indigenous health and researchers who self-identified as Indigenous. DESIGN AND SETTING: Review of data on all recipients of People Support awards and Capacity Building Grants in Population Health Research who were researching Indigenous health or who self-identified as Indigenous between 1996 and 2006. MAIN OUTCOME MEASURES: Annual People Support and Capacity Building grants and expenditure, by broad research area, state or territory, administering institution, and Indigenous status (as self-identified by award recipients in their applications). RESULTS: Between 1996 and 2006, 134 People Support awards were made to researchers studying Indigenous health; of these, 27 (20%) were to researchers who self-identified as Aboriginal or Torres Strait Islander. In 2006, about 2.9% of the annual expenditure on all People Support funding was for Indigenous health research, representing a doubling in the proportion of funds since 2001. There was no increase in the number of self-identified Indigenous researchers funded under People Support, but Capacity Building Grants increased the number of people from Indigenous backgrounds supported by the NHMRC, with funds allocated to 36 Indigenous researchers from 2002 to 2006, compared with 14 funded by People Support during the same period. CONCLUSIONS: Funding to support Indigenous health research through the People Support scheme has increased since the NHMRC adopted policy changes in 2002, but it has not reached the targeted expenditure of at least 5% of agency allocations. The Capacity Building Grants have been a more effective vehicle for funding researchers from Indigenous backgrounds.

Facilitating complementary inputs and scoping economies in the joint supply of health and environmental services in Aboriginal central Australia.

Two concerns of national relevance in central Australia are the continuing decline in Aboriginal health status relative to the rest of the Australian population, and the loss of environmental services. We draw on literature from a number of disciplines to show that not only are these two concerns interrelated but that dealing with them is inextricably connected through consideration of the psychosocial determinants of health. Involvement by Aboriginal people in land management can promote the joint supply of environmental and health services. We show that Aboriginal control of land management can result in economies through the joint supply of environmental and health services. However, because Aboriginal people derive little benefit from the provision of public goods generated through land management, they have little incentive to provide a socially optimal supply of these goods. The policy issue for government is the selection of the appropriate policy tools to facilitate the involvement of Aboriginal people in land management and the optimal supply of health and environmental services. The cost-effectiveness plane is used to provide a simple framework to guide the selection of an appropriate policy tool.

"Mutual" obligation in Indigenous health: can shared responsibility agreements be truly mutual?

Shared responsibility agreements between the Australian Government and Indigenous communities are based on a concept of mutual obligation but have overtones of paternalism and imposition. The nature and extent of choice in any such agreements need to be established.

An holistic economic evaluation of an Aboriginal community-controlled midwifery programme in Western Sydney.

OBJECTIVES: To conduct an holistic economic evaluation of an Aboriginal community (Daruk)-controlled midwifery service in Western Sydney. METHODS: The study estimated direct programme costs and downstream savings to the health sector. Measures of antenatal attendance and perinatal outcome were compared between Aboriginal women with and without experiences of the antenatal programme through examination of antenatal clinic records and the New South Wales Midwives Data Collection for the period 1991-1996. Qualitative outcomes were analysed through interviews and focus groups. RESULTS: The net cost to the health sector was estimated to be $A1200 per client. Compared with Aboriginal women who received antenatal care in two conventional settings, there were no statistically significant differences in birthweight and perinatal survival. Gestational age at first visit was lower (17.2 vs 21.2 and 19.9 weeks), mean number of antenatal visits was higher (10.5 vs 5.5 and 9.5) and attendance for routine antenatal tests was better (94% vs 71% and 84%). Aboriginal clients were strongly positive about their experience of the Daruk service in terms of relationship and trust, accessibility, flexibility, provision of clear and appropriate information, continuity of care, empowerment and family-centred care. CONCLUSIONS: Net per client costs to the health service were modest. Quantitative evidence of improved antenatal outcomes was limited, but qualitative evaluation suggested the service was strongly valued. The outcomes examined in this study were broader than those used in conventional forms of economic evaluation and this enabled identification and analysis of more diverse sources of value from this programme.

Type 2 diabetes and children in Aboriginal communities: the array of factors that shape health and access to health care.

The human costs of unrestrained development on our traditional territory, whether in the form of massive hydroelectric development or irresponsible forestry operations, are no surprise for us. Diabetes has followed the destruction of our traditional way of life and the imposition of a welfare economy. Now we see that one in seven pregnant Cree women is sick with this disease, and our children are being born high risk or actually sick.

Contemporary management issues for Aboriginal Community Controlled Health Services.

Aboriginal Community Controlled Health Services face particular management issues as they adjust to the dominant Western paradigm of managerialism and the market model of health service provision. Their cultural orientation leads to distinctive organisational features which both advantage and disadvantages them in this environment. The holistic model of health used and community control enable the delivery of integrated, culturally appropriate health care. However, effective community control is difficult to achieve. Services may benefit from partnerships with collaborators such as hospitals, regional health services and university departments of rural health if the partnerships are based on mutual respect and ensure that community control is retained.

The health transition, global modernity and the crisis of traditional medicine: the Tibetan case.

The epidemiologic and demographic consequences of the health transition, coupled with worldwide pressures for health care reform according to neoliberal tenets, will create new opportunities, and well as new problems, for organized systems of indigenous medicine. Spiraling costs of biomedically-based health care, coupled with an increasing global burden of chronic, degenerative diseases and mental disorder, will produce significant incentives for the expansion of indigenous alternatives. Yet this expansion will be accompanied by pressures to rationalize and modernize health care services according to the structurally dominant scientific paradigm. Without concerted effort to maintain native epistemologies, indigenous medical systems face an inevitable slide into narrow herbal traditions and a loss of those elements of diagnosis and therapy which may be the most valuable and effective. Analyzing the case of Tibetan medicine and other Asian medical systems, I show how this process occurs and how it is resisted. I conclude by discussing the policy dimensions of this problem.