Effect of removing user fees on attendance for curative and preventive primary health care services in rural South Africa

User fees are used to recover costs and discourage unnecessary attendance at primary care clinics in many developing countries. In South Africa, user fees for children aged under 6 yea rs and pregnant women were removed in 1994, and in 1997 all user fees at all primary health care clinics were abolished. The intention of these policy changes was to improve access to health services for previously disadvantaged communities. We investigated the impact of these changes on clinic attendance patterns in Hlabisa health district. Average quarterly new registrations and total attendances for preventive services (antenatal care, immunization, growth monitoring) and curative services (treatment of ailments) at a mobile primary health care unit were studied from 1992 to 1998. Regression analysis was undertaken to assess whether trends were statistically significant. There was a sustained increase in new registrations (P = 0.0001) and total attendances (P = 0.0001)for curative services, and a fall in new registrations (P = 0.01) and total attendances for immunization and growth monitoring (P = 0.0002) over the study period. The upturn in demand for curative services started at the time of the first policy change. The decreases in antenatal registrations (P = 0.07) and attendances (P = 0.09) were not statistically significant The number of new registrations for immunization and growth monitoring increased following the first policy change but declined thereafter. We found no evidence that the second policy change influenced underlying trends. The removal of user fees improved access to curative services but this may have happened at the expense of some preventive services. Governments should remain vigilant about the effects of new health policies in order to ensure that objectives are being met.

Perceived need for mental health care: influences of diagnosis, demography and disability

Background. Recent major epidemiological studies have adopted increasingly multidimensional approaches to assessment. Several of these have included some assessment of perceived need for mental health care. The Australian National Survey of Mental Health and Wellbeing, conducted in 1997, included a particularly detailed examination of this construct, with an instrument with demonstrated reliability and validity. Methods. A clustered probability sample of 10641 Australians responded to the field questionnaire for this survey, including questions on perceived need either where there had been service utilization, or where a disorder was detected by administration of sections of the Composite International Diagnostic Interview. The confidentialized unit record file generated from the survey was analysed for determinants of perceived need. Results. Perceived need is increased in females, in people in the middle years of adulthood, and in those who have affective disorders or co-morbidity. Effects of diagnosis and disability can account for most of the differences in gender specific rates. With correction for these effects through regression, there is less perceived need for social interventions and possibly more for counselling in females; disability is confirmed as strongly positively associated with perceived need, as are the presence of affective disorders or co-morbidity. Conclusions. The findings of this study underscore the imperative for mental health services to be attentive and responsive to consumer perceived need. The substantial majority of people who are significantly disabled by mental health problems are among those who see themselves as having such needs.

Health for all beyond 2000: the demise of the Alma-Ata Declaration and primary health care in developing countries

Access to basic health services was affirmed as a fundamental human right in the Declaration of Alma-Ata in 1978. The model formally adopted for providing healthcare services was primary health care (PHC), which involved universal, community-based preventive and curative services, with substantial community involvement. PHC,did not achieve its goals for several reasons, including the refusal of experts and politicians in developed countries to accept the principle that communities should plan and implement their own heathcare services. Changes in economic philosophy led to the replacement of PHC by Health Sector Reform, based on market forces and the economic benefits of better health. It is time to abandon economic ideology and determine the methods that will provide access to basic healthcare services for all people.

'You can criticise because you care': Identification, constructiveness, and the intergroup sensitivity effect

Group criticisms judged to be reasonable in the mouth of an ingroup member are aggressively rejected when they stem from an outgroup member (the intergroup sensitivity effect). Mediational analyses suggest that this phenomenon is underpinned by an attributional bias; criticisms from insiders are more likely to be perceived as being motivated for constructive reasons than are criticisms from outsiders, thus arousing lower levels of defensiveness. But what if group members were to receive information that called into question the ingroup critic's commitment to the group? For example, if the ingroup critic was known to be a low identifier with their group, or used language to suggest that they were psychologically distancing themselves from their group, we might expect that ingroup critics will be downgraded as strongly as outgroup critics. Furthermore, it might be possible for people to turn an outgroup criticism into an ingroup criticism by making salient their shared identity at the superordinate level. Three experiments are described that provide support for each of these propositions.

Dual C3a/C5a receptor agonism by a C5a C-terminal analogue decapeptide

No abstract

'You can criticise because you care': How attributions affect responses to ingroup and outgroup critics

There are times when people feel compelled to stand up and articulate their group's shortcomings, an act that carries with it enormous social risks. Indeed, a mechanistic reading of social identity theory might lead one to believe that ingroup critics are doomed to face hostility because they are attacking a fundamental part of people's self-concept. But often ingroup critics are doing more than attacking their group — they are trying to incite positive change. Criticism is the cornerstone of protest, and it is difficult to imagine how a group can be reinvigorated, reinvented, or reformed without some process of critical self-reflection. Thus, although the ingroup critic might create tension within the group, it is possible that internal criticism could be seen by other group members as beneficial in terms of promoting positive change and stimulating innovation, creativity, and flexibility in decision making. In this talk I examine the 'identity rules' that ingroup critics need to follow to avoid defensiveness, and look at empirical evidence of how factors such as language, the intergroup context, and choice of audience shape people's attributions regarding criticism and their subsequent evaluations of critics.

Improving access to evidence-based mental health care: general practitioners and allied health professionals collaborate

This study evaluated whether projects conducted through the Access to Allied Health Services component of the Australian Better Outcomes in Mental Health Care initiative are improving access to evidence-based, non-pharmacological therapies for people with depression and anxiety. Synthesising data from the first 29 projects funded through the initiative, the study found that the models utilised in the projects have evolved over time. The projects have achieved a high level uptake; at a conservative estimate, 710 GPs and 160 allied health professionals (AHPs) have provided care to 3,476 consumers. The majority of these consumers have depression (77%) and/or anxiety disorders (55%); many are low income earners (57%); and a number have not previously accessed mental health care (40%). The projects have delivered 8,678 sessions of high quality care to these consumers, most commonly providing CBT-based cognitive and behavioural interventions (55% and 41%, respectively). In general, GPs, AHPs and consumers are sanguine about the projects, and have reported positive consumer outcomes. However, as with any new initiative, there are some practical and professional issues that need to be addressed. The projects are improving access to evidence-based, non-pharmacological therapies. The continuation and expansion of the initiative should be a priority.

Quality of diabetes care and coronary heart disease absolute risk in patients with type 2 diabetes mellitus in Australian general practice

Objective: To examine the quality of diabetes care and prevention of cardiovascular disease (CVD) in Australian general practice patients with type 2 diabetes and to investigate its relationship with coronary heart disease absolute risk (CHDAR). Methods: A total of 3286 patient records were extracted from registers of patients with type 2 diabetes held by 16 divisions of general practice (250 practices) across Australia for the year 2002. CHDAR was estimated using the United Kingdom Prospective Diabetes Study algorithm with higher CHDAR set at a 10 year risk of >15%. Multivariate multilevel logistic regression investigated the association between CHDAR and diabetes care. Results: 47.9% of diabetic patient records had glycosylated haemoglobin (HbA1c) >7%, 87.6% had total cholesterol >= 4.0 mmol/l, and 73.8% had blood pressure (BP) >= 130/85 mm Hg. 57.6% of patients were at a higher CHDAR, 76.8% of whom were not on lipid modifying medication and 66.2% were not on antihypertensive medication. After adjusting for clustering at the general practice level and age, lipid modifying medication was negatively related to CHDAR (odds ratio (OR) 0.84) and total cholesterol. Antihypertensive medication was positively related to systolic BP but negatively related to CHDAR (OR 0.88). Referral to ophthalmologists/optometrists and attendance at other health professionals were not related to CHDAR. Conclusions: At the time of the study the diabetes and CVD preventive care in Australian general practice was suboptimal, even after a number of national initiatives. The Australian Pharmaceutical Benefits Scheme (PBS) guidelines need to be modified to improve CVD preventive care in patients with type 2 diabetes.

Biologically active conformer of the effector region of human C5a and modulatory effects of N-terminal receptor binding determinants on activity

A conformationally biased decapeptide agonist of human C5a (C5a(65-74)Y65,F67,P69,P71,D-Ala73 or YSFKPMPLaR) was used as a functional probe of the C5a receptor (C5aR) in order to understand the conformational features in the C-terminal effector region of C5a that are important for C5aR binding and signal transduction. YSFKPMPLaR was a potent, full agonist of C5a, but at higher concentrations had a superefficacious effect compared to the natural factor. The maximal efficacy of this analogue was 216 +/- 56% that of C5a in stimulating the release of beta-glucuronidase from human neutrophils. C5aR activation and binding curves both occurred in the same concentration range with YSFKPMPLaR, characteristics not observed with natural C5a or more conformationally flexible C-terminal agonists. YSFKPMPLaR was then used as a C-terminal effector template onto which was synthesized various C5aR binding determinants from the N-terminal core domain of the natural factor. In general, the presence of N-terminal binding determinants had little effect on either potency or binding affinity when the C-terminal effector region was presented to the C5aR in this biologically active conformation. However, one peptide, C5a(12-20)-Ahx-YSFKPMPLaR, expressed a 100-fold increase in affinity for the neutrophil C5aR and a 6-fold increase in potency relative to YSFKPMPLaR. These analyses showed that the peptides used in this study have up to 25% of the potency of C5a in human fetal artery and up to 5% of the activity of C5a in the PMN enzyme release assay.