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.

A note on the decomposition of the health concentration index

In recent work, the concentration index has been widely used as a measure of income-related health inequality. The purpose of this note is to illustrate two different methods for decomposing the overall health concentration index using data collected from a Short Form (SF-36) survey of the general Australian population conducted in 1995. For simplicity, we focus on the physical functioning scale of the SF-36. Firstly we examine decomposition 'by component' by separating the concentration index for the physical functioning scale into the ten items on which it is based. The results show that the items contribute differently to the overall inequality measure, i.e. two of the items contributed 13% and 5%, respectively, to the overall measure. Second, to illustrate the 'by subgroup' method we decompose the concentration index by employment status. This involves separating the population into two groups: individuals currently in employment; and individuals not currently employed. We find that the inequality between these groups is about five times greater than the inequality within each group. These methods provide insights into the nature of inequality that can be used to inform policy design to reduce income related health inequalities. Copyright (C) 2002 John Wiley Sons, Ltd.

The evidence for better health from health assessments: A large clustered randomised controlled trial

Aim: To test the efficacy of a comprehensive health assessment using the CHAP tool in adults with an intellectual disability (ID). Method: A cluster randomised control design was used. The intervention group received the CHAP, while the control group received usual care. This tool directed carers to gather a health history, which was reviewed by the person’s general practitioner (GP) who completed a medical examination and a healthcare plan. The tool acted as an advocacy tool, a ticket-of-entry to the GPs surgery and educated the GP and the caregiver about the deficits in the healthcare of adults with ID. The healthcare of the participants was followed for one-year after intervention by the collection of data from GP and service providers’ notes. Also interviews were performed with all those involved. Results: We obtained a representative sample of  adults with ID (RR%). We found the intervention group received a significant increase in many health promotion/disease prevention activities e.g. hearing screening was  times and a Pap smear was  times more likely to have occurred in the intervention groups.We also found a trend towards earlier detection of disease. Conclusions: The CHAP process improves the provision of health screening/promotion activities and should be implemented.

Are health assessments in the community acceptable to those involved? Yes, Yes and maybe

Aim: To test the acceptability of a comprehensive health assessment program (CHAP) in adults with an intellectual disability (ID). Method: We interviewed adults with ID, their general practitioners (GPs) and caregivers (healthcare triad), before and after the intervention period as part of a clustered randomised controlled trial to test the use of the CHAP tool in adults with ID. A content and thematic analysis of these interviews will be presented. Results: We found adults with ID were unable to recall the health assessment consultation or differentiate this consultation from the usual contact with their GP. GPs and residential staff where largely supportive of the process and considered it did improve the care they could provide to AWID. They also considered that the intervention helped other members of the healthcare triad. Conclusions: The CHAP was found to be acceptable to caregivers and GPs however further work is needed to ascertain the views of adults with ID.

Are a health advocacy diary and health assessment welcomed by those who use them?

Aim: To determine acceptability of a health advocacy intervention, the Ask Diary and the comprehensive health assessment program (CHAP). Method: We performed a two by two designed randomised controlled trial of the Ask Diary and the CHAP tool in  adults with intellectual disability. Results of interviews of self-advocates and caregiver advocates, both families and paid carers, will be presented. Results: The interviews found strong support for the Ask Diary and the CHAP tool among selfadvocates and family caregivers. There was clear indication that the Ask Diary improved advocacy, aided in the organisation of health matters and was easy to use. It was reported that the health assessment resulted in benefits for the person’s health and high acceptability by carers. There was less support for the interventions where the person was supported through government services. Conclusions: Self-advocates and family caregivers welcome and use a personalised health advocacy diary and also a health assessment. However paid carers used the diary less but were supportive of the health assessment.

Assessing cost-effectiveness in mental health: family interventions for schizophrenia and related conditions

Objective: Existing evidence suggests that family interventions can be effective in reducing relapse rates in schizophrenia and related conditions. Despite this, such interventions are not routinely delivered in Australian mental health services. The objective of the current study is to investigate the incremental cost-effectiveness ratios (ICERs) of introducing three types of family interventions, namely: behavioural family management (BFM); behavioural intervention for families (BIF); and multiple family groups (MFG) into current mental health services in Australia. Method: The ICER of each of the family interventions is assessed from a health sector perspective, including the government, persons with schizophrenia and their families/carers using a standardized methodology. A two-stage approach is taken to the assessment of benefit. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted. The second stage involves application of 'second filter' criteria (including equity, strength of evidence, feasibility and acceptability to stakeholders) to results. The robustness of results is tested using multivariate probabilistic sensitivity analysis. Results: The most cost-effective intervention, in order of magnitude, is BIF (A$8000 per DALY averted), followed by MFG (A$21 000 per DALY averted) and lastly BFM (A$28 000 per DALY averted). The inclusion of time costs makes BFM more cost-effective than MFG. Variation of discount rate has no effect on conclusions. Conclusions: All three interventions are considered 'value-for-money' within an Australian context. This conclusion needs to be tempered against the methodological challenge of converting clinical outcomes into a generic economic outcome measure (DALY). Issues surrounding the feasibility of routinely implementing such interventions need to be addressed.

Assessing cost-effectiveness - Mental health: introduction to the study and methods

Objective: The Assessing Cost-Effectiveness - Mental Health (ACE-MH) study aims to assess from a health sector perspective, whether there are options for change that could improve the effectiveness and efficiency of Australia's current mental health services by directing available resources toward 'best practice' cost-effective services. Method: The use of standardized evaluation methods addresses the reservations expressed by many economists about the simplistic use of League Tables based on economic studies confounded by differences in methods, context and setting. The cost-effectiveness ratio for each intervention is calculated using economic and epidemiological data. This includes systematic reviews and randomised controlled trials for efficacy, the Australian Surveys of Mental Health and Wellbeing for current practice and a combination of trials and longitudinal studies for adherence. The cost-effectiveness ratios are presented as cost (A$) per disability-adjusted life year (DALY) saved with a 95% uncertainty interval based on Monte Carlo simulation modelling. An assessment of interventions on 'second filter' criteria ('equity', 'strength of evidence', 'feasibility' and 'acceptability to stakeholders') allows broader concepts of 'benefit' to be taken into account, as well as factors that might influence policy judgements in addition to cost-effectiveness ratios. Conclusions: The main limitation of the study is in the translation of the effect size from trials into a change in the DALY disability weight, which required the use of newly developed methods. While comparisons within disorders are valid, comparisons across disorders should be made with caution. A series of articles is planned to present the results.

Is screening for abdominal aortic aneurysm bad for your health and well-being?

Background: The purpose of the present paper was to investigate whether screening for abdominal aortic aneurysm (AAA) causes health-related quality of life to change in men or their partners. Methods: A cross-sectional case-control comparison was undertaken of men aged 65-83 years living in Perth, Western Australia, using questionnaires incorporating three validated instruments (Medical Outcomes Study Short Form-36, EuroQol EQ-5D and Hospital Anxiety and Depression Scale) as well as several independent questions about quality of life. The 2009 men who attended for ultrasound scans of the abdominal aorta completed a short prescreening questionnaire about their perception of their general health. Four hundred and ninety-eight men (157 with an AAA and 341 with a normal aorta) were sent two questionnaires for completion 12 months after screening, one for themselves and one for their partner, each being about the quality of life of the respondent. Results: Men with an AAA were more limited in performing physical activities than those with a normal aorta (t-test of means P = 0.04). After screening, men with an AAA were significantly less likely to have current pain or discomfort than those with a normal aorta (multivariate odds ratio: 0.5; 95% confidence interval (Cl): 0.3-0.9) and reported fewer visits to their doctor. The mean level of self-perceived general health increased for all men from before to after screening (from 63.4 to 65.4). Conclusions: Apart from physical functioning, screening was not associated with decreases in health and well-being. A high proportion of men rated their health over the year after screening as being either the same or improved, regardless of whether or not they were found to have an AAA.

Electronic medical records may be inadequate for improving population health status through general practice: cervical smears as a case study

Objective: To determine whether routine electronic records are an accurate source of population health data in general practice through reviewing cervical smears rates in four South Australian practices. Methods: The cervical screening rate in a purposive sample of four general practices (three rural and one urban) was obtained using an audit of medical records and a telephone follow-up. Results: The cervical screening rate using only immediately available electronic medical records indicated an overall low rate for the participating practices (44.9%). However, telephone follow-up and adjustments to the denominator indicated the real rate to be 85.7%. The offer of appointments during the telephone follow-up further improved this rate for eligible women (93.8%). Conclusions and implications: Electronic medical records may be inadequate in preventive screening in general practice, without ensuring their accuracy. Updating records by telephone or personal follow-up produces a much more accurate denominator.

Does health service utilisation vary by remoteness? South Australian population data and the Accessibility and Remoteness Index of Australia

Objective: To compare rates of self-reported use of health services between rural, remote and urban South Australians. Methods: Secondary data analysis from a population-based survey to assess health and well-being, conducted in South Australia in 2000. In all, 2,454 adults were randomly selected and interviewed using the computer-assisted telephone interview (CATI) system. We analysed health service use by Accessibility and Remoteness Index of Australia (ARIA) category. Results: There was no statistically significant difference in the median number of uses of the four types of health services studied across ARIA categories. Significantly fewer residents of highly accessible areas reported never using primary care services (14.4% vs. 22.2% in very remote areas), and significantly more reported high use ( greater than or equal to6 visits, 29.3% vs. 21.5%). Fewer residents of remote areas reported never attending hospital (65.6% vs. 73.8% in highly accessible areas). Frequency of use of mental health services was not statistically significantly different across ARIA categories. Very remote residents were more likely to spend at least one night in a public hospital (15.8%) than were residents of other areas (e.g. 5.9% for highly accessible areas). Conclusion: The self-reported frequency of use of a range of health services in South Australia was broadly similar across ARIA categories. However, use of primary care services was higher among residents of highly accessible areas and public hospital use increased with increasing remoteness. There is no evidence for systematic rural disadvantage in terms of self-reported health service utilisation in this State.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders

Background: The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. This paper presents CPGs for schizophrenia and related disorders. Over the past decade schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Australia. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. These guidelines therefore tackle only one element in the endeavour to reduce the impact of schizophrenia. They distil the current evidence-base and make recommendations based on the best available knowledge. Method: A comprehensive literature review (1990-2003) was conducted, including all Cochrane schizophrenia reviews and all relevant meta-analyses, and a number of recent international clinical practice guidelines were consulted. A series of drafts were refined by the expert committee and enhanced through a bi-national consultation process. Treatment recommendations: This guideline provides evidence-based recommendations for the management of schizophrenia by treatment type and by phase of illness. The essential features of the guidelines are: (i) Early detection and comprehensive treatment of first episode cases is a priority since the psychosocial and possibly the biological impact of illness can be minimized and outcome improved. An optimistic attitude on the part of health professionals is an essential ingredient from the outset and across all phases of illness. (ii) Comprehensive and sustained intervention should be assured during the initial 3-5 years following diagnosis since course of illness is strongly influenced by what occurs in this 'critical period'. Patients should not have to 'prove chronicity' before they gain consistent access and tenure to specialist mental health services. (iii) Antipsychotic medication is the cornerstone of treatment. These medicines have improved in quality and tolerability, yet should be used cautiously and in a more targeted manner than in the past. The treatment of choice for most patients is now the novel antipsychotic medications because of their superior tolerability and, in particular, the reduced risk of tardive dyskinesia. This is particularly so for the first episode patient where, due to superior tolerability, novel agents are the first, second and third line choice. These novel agents are nevertheless associated with potentially serious medium to long-term side-effects of their own for which patients must be carefully monitored. Conventional antipsychotic medications in low dosage may still have a role in a small proportion of patients, where there has been full remission and good tolerability; however, the indications are shrinking progressively. These principles are now accepted in most developed countries. (vi) Clozapine should be used early in the course, as soon as treatment resistance to at least two antipsychotics has been demonstrated. This usually means incomplete remission of positive symptomatology, but clozapine may also be considered where there are pervasive negative symptoms or significant or persistent suicidal risk is present. (v) Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for comorbid conditions, such as substance abuse, depression and anxiety. (vi) The social and cultural environment of people with schizophrenia is an essential arena for intervention. Adequate shelter, financial security, access to meaningful social roles and availability of social support are essential components of recovery and quality of life. (vii) Interventions should be carefully tailored to phase and stage of illness, and to gender and cultural background. (viii) Genuine involvement of consumers and relatives in service development and provision should be standard. (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no special Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved.

What is an effective health consumer? A convergent interviewing approach

This study is part of a larger project on the measurement of effective health consumers in the context of musculoskeletal illness. This complex issue involves the progressive nature of the disease, invisibility of the illness and attendant impairments, complexity of decision-making and negotiation, and urgent need to translate emergent evidence about treatment and management to patients and health professionals. We conducted indepth interviews with patients, family members, general practitioners, specialist clinicians, and health consumer advocates (N = 84) about effective consumers in this context, using a process of convergent interviewing, with convergence conducted within and across groups and countries. The initial set of themes included information seeking and adaptation, decision-making, roles of patients, GPs, and specialists and communication between them, importance of pain and impact of depression, impact of the social environment (including the invisibility of the disease and the need for a normal life), and coping strategies.

Relationships between pet ownership and health: Asking questions and passing criticisms

The literature examining purported relationships between ownership of companion animals and health is extremely heterogeneous. While much of the descriptive literature tends to support benefits of animal companionship, large scale, controlled research yields inconsistent and even contradictory findings on several issues, including associations with cardiovascular disease, mood and wellbeing. In an analysis of a large longitudinal data-set from the Australian Longitudinal Study on Women's Health, a prospective study of a nationally representative sample of more than 12,000 older women, difficulties with disentangling the effects of powerful demographic variables and age-related factors from the specific effects of pet ownership became apparent. Both cross-sectional and longitudinal analyses demonstrated that associations between mental and physical health and pet ownership as well as changes in pet ownership over time were weak and inconsistent compared to the large effects of living arrangements and other demographic variables. As sociodemographic variables relate strongly to both health and opportunities for pet ownership, this high level of confounding means it is unlikely that the impact of the specific variable of pet ownership on health can be ascertained from such studies. Rather, well-designed experimental studies, wherein the majority of such confounding variables can be held constant or at least somewhat controlled, are needed.