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.

Supporting holistic care for patients with tuberculosis in a remote Indigenous community: a case report.

CONTEXT: Tuberculosis (TB) is a serious infectious disease with high rates of morbidity and mortality if left untreated. In Australia, TB has been virtually eradicated in non-Indigenous Australian-born populations but in remote Aboriginal and/or Torres Strait Islander communities TB presents a rare but significant public health issue. Remote health services are most likely to encounter patients with suspected and confirmed TB diagnosis but may be unprepared for supporting someone with this disease and the complexities of balancing public health risk with patient autonomy. ISSUE: This case study will outline the process for diagnosis and treatment of a TB patient in a remote Cape York community. This case involved significant delay in diagnosis and required several strategies to achieve successful disease eradication. The process of treatment, however, had a significant effect on the patient's physical health, and social and emotional wellbeing. LESSONS LEARNED: This case highlights the importance of early collaboration between medical, nursing, Indigenous health worker and allied health services and the importance of technology such as electronic information records to support opportunistic access to diagnostic services and treatment. The enactment of the TB protocol should include discussions about the consequences of any restrictions of movement, employment or social/community roles. Identifying alternative opportunities to engage in meaningful roles may reduce the impact the disease has on a patient's quality of life.

Ethnicity and Health: Experience with an Urban Mapuche Health Program from the Perspective of Key Actors.

This article explores the relationships and tensions between ethnicity and health, describing the perspectives of various social actors on a Mapuche clinic in the context of a national health program. A qualitative methodology was used to carry out this case study of the Mapuche clinic "La Ruka," located in an urban area of the Metropolitan Region of Chile. The study analyzes the narratives of traditional health practitioners (including a machi, lawentuchefe, lonko, and intercultural facilitator), consumers, conventional healthcare professionals, and local health authorities and community leaders who share a physical, political, and symbolic space around the Mapuche health experience. The systemization of experiences method was applied to the data, acquired through nonparticipant observation, individual interviews, and focus groups. The results suggest that this healthcare experience is highly valued by its protagonists. However, there is a tension surrounding cultural diversity programs that recognize non-Western approaches to healing, such as indigenous practices. This study examines the health-related, cultural, and political tensions involved in projecting indigenous traditions into a homogenizing space such as healthcare in a multicultural neoliberalism system.

Implementation of Liver Cancer Education Among Health Care Providers and Community Coalitions in the Cherokee Nation.

INTRODUCTION: The Cherokee Nation Comprehensive Cancer Control Program collaborated with the Cherokee Nation Hepatitis C Virus (HCV) Elimination Program within Cherokee Nation's Health Services to plan and implement activities to increase knowledge and awareness of liver cancer prevention among health care providers and the Cherokee Nation community. From August 2017 to April 2018, the 2 programs implemented liver cancer prevention interventions that focused on education of health care providers and community members. We used descriptive statistics to analyze data collected from a brief, retrospective pre-post survey for each intervention. We assessed overall awareness and knowledge of liver cancer and ability and intention to address it on a scale of 1 to 5. Project Extension for Community Healthcare Outcomes didactic sessions resulted in a 1.1-point improvement, provider education workshops resulted in a 1.4-point improvement, and presentations at community coalition meetings resulted in a 1.7-point improvement. Our study shows that HCV interventions can be used by public health and medical professionals interested in controlling HCV and related diseases such as liver cancer.

Implementation of midwifery continuity of care models for Indigenous women in Australia: Perspectives and reflections for the United Kingdom.

Maternity models that provide midwifery continuity of care have been established to increase access to appropriate services for Indigenous Australian women. Understanding the development and implementation of continuity models for Indigenous women in Australia provides useful insights for the development and implementation of similar models in other contexts such as those for vulnerable and socially disadvantaged women living in the United Kingdom. To ensure better health outcomes for mothers and babies, it is crucial to promote culturally competent and safe public health models in which midwives work collaboratively with the multidisciplinary team.

Core competencies acquired in indigenous training of traditional health practitioners in Kwazulu-Natal.

INTRODUCTION: Despite the recognition of Traditional Medicine systems as a critical component of health care by the WHO and the African Union, its integration into the health care mainstream remains very subdued in South Africa. This is partly due to the lack of empirical data pertinent to traditional healer training that could inform the accreditation process. OBJECTIVE: To determine core competencies acquired by Traditional Health Practitioners (THP) of KwaZulu-Natal Province, South Africa during their apprenticeship. MATERIALS AND METHODS: Purposeful, convenient and snowballing sampling and the sequential data collection methods of questionnaires, journaling and focus groups was used to collect data from the THP tutors and their trainees in rural, peri-urban and urban areas of eThekwini and uThungulu Districts of Kwa Zulu Natal (KZN). RESULTS: Eleven core competencies were identified: consultation, diagnoses, holistic patient care and treatment, integrative and holistic healing, application of healing procedures and cultural rituals, spiritual development, ethical competencies, problem solving, herbalism, ancestral knowledge and end of life care. CONCLUSION: The apprenticeship of THPs in KZN is based on eleven core competencies. These competencies are fundamental pillars for critical health care provided by THPs and are crucial for setting standards for the accreditation of traditional training in South Africa if the THP Act 22 of 2007 is to achieve its purpose of providing for the management of and control over the registration, training and conduct of the practitioners. Hence, the appointed interim THP Council should include the identified competencies when articulating bases for accreditation of the training and assessments.

"In Their Own Voice"-Incorporating Underlying Social Determinants into Aboriginal Health Promotion Programs.

Despite growing acknowledgement of the socially determined nature of health disparities among Aboriginal people, how to respond to this within health promotion programs can be challenging. The legacy of Australia's assimilation policies have left profound consequences, including social marginalisation, limited educational opportunities, normalisation of premature death, and entrenched trauma. These social determinants, in conjunction with a reluctance to trust authorities, create barriers to accessing healthcare services for the prevention, treatment, and rehabilitation of chronic disease. The Heart Health program is a culturally sensitive cardiac rehabilitation program run at the local Aboriginal Medical Service in Perth, Western Australia that has since moved beyond cardiac education to provide a holistic approach to chronic disease management. A participatory action research framework was used to explore Heart Health participant and service provider perspectives on the barriers, enablers, and critical success factors to program participation and behaviour change. Thematic analysis of interview transcripts was undertaken, and through yarning (Aboriginal storytelling) sessions, many participants made unprompted reference to the impacts of white settlement, discrimination, and the forced fracturing of Aboriginal families, which have been explored in this paper reiterating the need for a social determinants lens to be taken when planning and implementing Aboriginal health promotion programs.

Advancing Indigenous primary health care policy in Alberta, Canada.

For Indigenous people worldwide, accessing Primary Health Care (PHC) services responsive to socio-cultural realities is challenging, with institutional inequities in healthcare and jurisdictional barriers encumbering patients, providers, and decision-makers. In the Canadian province of Alberta, appropriate Indigenous health promotion, disease prevention, and primary care health services are needed, though policy reform is hindered by complex networks and competing interests between: federal/provincial funders; reserve/urban contexts; medical/allied health professional priorities; and three Treaty territories each structuring fiduciary responsibilities of the Canadian government. In 2015, the Truth and Reconciliation Commission (TRC) of Canada released a final report from over six years spent considering impacts of the country's history of Indian residential schools, which for more than a century forcibly removed thousands of children from their families and communities. The TRC directed 94 calls to action to all levels of society, including health systems, to address an historical legacy of cultural assimilationism against Indigenous peoples. To address TRC calls that Indigenous health disparities be recognized as resulting from previous government policies, and to integrate Indigenous leadership and perspectives into health systems, PHC decision-makers, practitioners, and scholars in the province of Alberta brought together stakeholders from across Canada. The gathering detailed here explored Indigenous PHC models from other Canadian provinces to collaboratively build relationships for policy reform and identify opportunities for PHC innovations within Alberta.

Culturally Relevant Palliative and End-of-Life Care for U.S. Indigenous Populations: An Integrative Review.

PURPOSE: American Indians/Alaska Natives (AIs/ANs) have higher rates of chronic illness and lack access to palliative/end-of-life (EOL) care. This integrative review ascertained the state of the science on culturally acceptable palliative/EOL care options for Indigenous persons in the United States. DESIGN: Databases searched: CINAHL, PubMed/MEDLINE, SocINDEX, PsycINFO, PsycARTICLES, ERIC, Health Source: Nursing/Academic Edition, and EBSCO Discovery Service 1880s-Present. Key terms used: palliative care, EOL care, and AI/AN. INCLUSION CRITERIA: peer-reviewed articles published in English. Findings/Results: Twenty-nine articles were identified, 17 remained that described culturally specific palliative/EOL care for AIs/ANs. Synthesis revealed four themes: Communication, Cultural Awareness/Sensitivity, Community Guidance for Palliative/EOL Care Programs, Barriers and two subthemes: Trust/Respect and Mistrust. DISCUSSION/CONCLUSION: Limitations are lack of research funding, geographic isolation, and stringent government requirements. Palliative/EOL care must draw on a different set of skills that honor care beyond cure provided in a culturally sensitive manner.

Impact of policy support on uptake of evidence-based continuous quality improvement activities and the quality of care for Indigenous Australians: a comparative case study.

OBJECTIVES: To examine the impact of state/territory policy support on (1) uptake of evidence-based continuous quality improvement (CQI) activities and (2) quality of care for Indigenous Australians. DESIGN: Mixed-method comparative case study methodology, drawing on quality-of-care audit data, documentary evidence of policies and strategies and the experience and insights of stakeholders involved in relevant CQI programmes. We use multilevel linear regression to analyse jurisdictional differences in quality of care. SETTING: Indigenous primary healthcare services across five states/territories of Australia. PARTICIPANTS: 175 Indigenous primary healthcare services. INTERVENTIONS: A range of national and state/territory policy and infrastructure initiatives to support CQI, including support for applied research. PRIMARY AND SECONDARY OUTCOME MEASURES: (i) Trends in the consistent uptake of evidence-based CQI tools available through a research-based CQI initiative (the Audit and Best Practice in Chronic Disease programme) and (ii) quality of care (as reflected in adherence to best practice guidelines). RESULTS: Progressive uptake of evidence-based CQI activities and steady improvements or maintenance of high-quality care occurred where there was long-term policy and infrastructure support for CQI. Where support was provided but not sustained there was a rapid rise and subsequent fall in relevant CQI activities. CONCLUSIONS: Health authorities should ensure consistent and sustained policy and infrastructure support for CQI to enable wide-scale and ongoing improvement in quality of care and, subsequently, health outcomes. It is not sufficient for improvement initiatives to rely on local service managers and clinicians, as their efforts are strongly mediated by higher system-level influences.

Cardiac care for Indigenous Australians: practical considerations from a clinical perspective.

Indigenous Australians have a much high burden of cardiovascular disease, which occurs at an earlier age than in the non-Indigenous population. Comorbidities such as diabetes are common. Early diagnosis of ischaemic heart disease may be difficult because of barriers such as distance to medical centres, communication problems and family and cultural responsibilities. Disparities in cardiac care between Indigenous and non-Indigenous populations are well documented, with examples including reduced angiography and revascularisation rates in Indigenous patients. Indigenous patients can have poor health literacy and need careful explanation of procedures, with the assistance of Aboriginal health workers, visual aids and family members. Acute rheumatic fever and chronic rheumatic heart disease remain ongoing health problems in Indigenous communities, especially in remote areas. Ambulatory care of Indigenous Australians with chronic cardiovascular disease is challenging. It requires well supported health care systems, including Aboriginal health workers and cardiac nurse coordinators to case-manage patients. A holistic approach to care, with attention directed towards both cardiac and non-cardiac comorbidities, is crucial for optimal management of cardiovascular disease in Indigenous Australians. Multidisciplinary care, involving an empowered and supported primary care team working together with specialists through outreach services or telehealth, is important for patients who are at high clinical risk and those living in remote areas. Indigenous Australians deserve the same level of evidence-based cardiovascular health care and access to care as non-Indigenous Australians.

Pilot Testing an Intervention on Cultural Safety and Indigenous Health in a Canadian Occupational Therapy Curriculum.

First-year Canadian occupational therapy students (n=27) rated their knowledge of and cultural/emotional responses to cultural safety and Indigenous health prior to and following an educational intervention led by a trained Indigenous educator. At post-intervention, students were also asked to comment on their learning experience. Pilot data of 40% of the class were analyzed using nonparametric approaches proposed by Koller and colleagues; qualitative data were explored using conventional methods. The majority of participant ratings reflected a perceived increase in knowledge and cultural/emotional responses, indicative of positive change following intervention. Student comments about their learning were in keeping with the positive findings. Although our sample size was small and our study examined perceived knowledge acquisition, preliminary results were consistent with related literature.

Engaging with complexity to improve the health of indigenous people: a call for the use of systems thinking to tackle health inequity.

The 400 million indigenous people worldwide represent a wealth of linguistic and cultural diversity, as well as traditional knowledge and sustainable practices that are invaluable resources for human development. However, indigenous people remain on the margins of society in high, middle and low-income countries, and they bear a disproportionate burden of poverty, disease, and mortality compared to the general population. These inequalities have persisted, and in some countries have even worsened, despite the overall improvements in health indicators in relation to the 15-year push to meet the Millennium Development Goals. As we enter the Sustainable Development Goals (SDGs) era, there is growing consensus that efforts to achieve Universal Health Coverage (UHC) and promote sustainable development should be guided by the moral imperative to improve equity. To achieve this, we need to move beyond the reductionist tendency to frame indigenous health as a problem of poor health indicators to be solved through targeted service delivery tactics and move towards holistic, integrated approaches that address the causes of inequalities both inside and outside the health sector. To meet the challenge of engaging with the conditions underlying inequalities and promoting transformational change, equity-oriented research and practice in the field of indigenous health requires: engaging power, context-adapted strategies to improve service delivery, and mobilizing networks of collective action. The application of systems thinking approaches offers a pathway for the evolution of equity-oriented research and practice in collaborative, politically informed and mutually enhancing efforts to understand and transform the systems that generate and reproduce inequities in indigenous health. These approaches hold the potential to strengthen practice through the development of more nuanced, context-sensitive strategies for redressing power imbalances, reshaping the service delivery environment and fostering the dynamics of collective action for political reform.

Two approaches, one problem: Cultural constructions of type II diabetes in an indigenous community in Yucatán, Mexico.

The emerging epidemic of obesity and type II diabetes in Mexico has recently propelled the nation into the public health spotlight. In the state of Yucatán, the experience of diabetes is greatly impacted by two cultural constructions of disease. In this setting, elements of Yucatec Mayan health practices as well as the biomedical model affect the approach to type II diabetes. Both frameworks offer unique understandings of the etiology of diabetes and recommend different ways to manage the condition. Based on in-depth and semi-structured interviews with both community members and clinicians, the present study seeks to understand how diabetes is understood and treated in indigenous settings in rural Yucatán. We explore the context in which community members navigate between locally available healthcare options, choose one over the other, or incorporate strategies from both into their diabetes care regimens. The tension between indigenous community members and their biomedical healthcare providers, the changing food environment of this community, and the persistence of traditional gender constructions affect the management of type II diabetes and its associated symptoms.

A network approach to policy framing: A case study of the National Aboriginal and Torres Strait Islander Health Plan.

Aboriginal health policy in Australia represents a unique policy subsystem comprising a diverse network of Aboriginal-specific and "mainstream" organisations, often with competing interests. This paper describes the network structure of organisations attempting to influence national Aboriginal health policy and examines how the different subgroups within the network approached the policy discourse. Public submissions made as part of a policy development process for the National Aboriginal and Torres Strait Islander Health Plan were analysed using a novel combination of network analysis and qualitative framing analysis. Other organisational actors in the network in each submission were identified, and relationships between them determined; these were used to generate a network map depicting the ties between actors. A qualitative framing analysis was undertaken, using inductive coding of the policy discourses in the submissions. The frames were overlaid with the network map to identify the relationship between the structure of the network and the way in which organisations framed Aboriginal health problems. Aboriginal organisations were central to the network and strongly connected with each other. The network consisted of several densely connected subgroups, whose central nodes were closely connected to one another. Each subgroup deployed a particular policy frame, with a frame of "system dysfunction" also adopted by all but one subgroup. Analysis of submissions revealed that many of the stakeholders in Aboriginal health policy actors are connected to one another. These connections help to drive the policy discourse. The combination of network and framing analysis illuminates competing interests within a network, and can assist advocacy organisations to identify which network members are most influential.

Developing community-driven quality improvement initiatives to enhance chronic disease care in Indigenous communities in Canada: the FORGE AHEAD program protocol.

BACKGROUND: Given the dramatic rise and impact of chronic diseases and gaps in care in Indigenous peoples in Canada, a shift from the dominant episodic and responsive healthcare model most common in First Nations communities to one that places emphasis on proactive prevention and chronic disease management is urgently needed. METHODS: The Transformation of Indigenous Primary Healthcare Delivery (FORGE AHEAD) Program partners with 11 First Nations communities across six provinces in Canada to develop and evaluate community-driven quality improvement (QI) initiatives to enhance chronic disease care. FORGE AHEAD is a 5-year research program (2013-2017) that utilizes a pre-post mixed-methods observational design rooted in participatory research principles to work with communities in developing culturally relevant innovations and improved access to available services. This intensive program incorporates a series of 10 inter-related and progressive program activities designed to foster community-driven initiatives with type 2 diabetes mellitus as the action disease. Preparatory activities include a national community profile survey, best practice and policy literature review, and readiness tool development. Community-level intervention activities include community and clinical readiness consultations, development of a diabetes registry and surveillance system, and QI activities. With a focus on capacity building, all community-level activities are driven by trained community members who champion QI initiatives in their community. Program wrap-up activities include readiness tool validation, cost-analysis and process evaluation. In collaboration with Health Canada and the Aboriginal Diabetes Initiative, scale-up toolkits will be developed in order to build on lessons-learned, tools and methods, and to fuel sustainability and spread of successful innovations. DISCUSSION: The outcomes of this research program, its related cost and the subsequent policy recommendations, will have the potential to significantly affect future policy decisions pertaining to chronic disease care in First Nations communities in Canada. TRIAL REGISTRATION: Current ClinicalTrial.gov protocol ID NCT02234973 . Date of Registration: July 30, 2014.