Capacity building for integrated health care at the local level

Aims & Rationale/Objectives
Taking a capacity building approach to research and evaluation within the context of a federally funded national program challenges the traditional paradigms of both research and evaluation. The objective of this approach was to foster attitudes and behaviours of reflection, critical inquiry and collaborative action amongst participants responsible for health care integration activities.

Methods
A series of workshops focusing on different elements of health care integration was conducted. Each workshop offered skill development in research and evaluation methods relevant to the participants' clinical practise. The workshops were multidisciplinary and cross-sectoral in order to promote discussion about shared patient care issues.

Principal Findings
Participatory action research facilitated by external agents can build the capacity of participants to identify and make changes that improve health care integration at local levels. A capacity building approach to research and evaluation can mediate tensions between top-down initiatives and on-the-ground practitioners.

Discussion
A capacity building approach was crucial to the success of this project particularly as the project proposal was developed at the corporate level. The workshops played an important role in engaging the participants and fostering the development of solutions for locally identified clinical issues. The opportunities for discussion with other health care service providers were both readily embraced and appreciated by the participants. The networks formed during the workshops are likely to be vital in sustaining integration efforts.

Implications
Education sessions such as the workshops held within this project ensure that health care integration remains on the agenda of the relevant organisations. These workshops fostered a continuous quality improvement approach whilst focusing on the skills required and the systemic barriers to achieving health care integration. The success of these workshops is evidence that the need and desire for shared education opportunities exists and the interdisciplinary focus is a powerful tool for developing an appreciation of the cultures within disciplines as well as linkages.

Using project evaluation to build capacity for integrated health care at local levels

Capacity-building evaluation featuring multidisciplinary cross-agency workshops fostered continuous quality improvement, while focusing on skills required and systemic barriers to health care integration between GPs and a regional hospital.

A cost-based equity weight for use in the economic evaluation of primary health care interventions: case study of the Australian Indigenous population

Background : Efficiency and equity are both important policy objectives in resource allocation. The discipline of health economics has traditionally focused on maximising efficiency, however addressing inequities in health also requires consideration. Methods to incorporate equity within economic evaluation techniques range from qualitative judgements to quantitative outcomes-based equity weights. Yet, due to definitional uncertainties and other inherent limitations, no method has been universally adopted to date. This paper proposes an alternative cost-based equity weight for use in the economic evaluation of interventions delivered from primary health care services.

Methods : Equity is defined in terms of 'access' to health services, with the vertical equity objective to achieve 'equitable access for unequal need'. Using the Australian Indigenous population as an illustrative case study, the magnitude of the equity weight is constructed using the ratio of the costs of providing specific interventions via Indigenous primary health care services compared with the costs of the same interventions delivered via mainstream services. Applying this weight to the costs of subsequent interventions deflates the costs of provision via Indigenous health services, and thus makes comparisons with mainstream more equitable when applied during economic evaluation.

Results : Based on achieving 'equitable access', existing measures of health inequity are suitable for establishing 'need', however the magnitude of health inequity is not necessarily proportional to the magnitude of resources required to redress it. Rather, equitable access may be better measured using appropriate methods of health service delivery for the target group. 'Equity of access' also suggests a focus on the processes of providing equitable health care rather than on outcomes, and therefore supports application of equity weights to the cost side rather than the outcomes side of the economic equation.

Conclusion : Cost-based weights have the potential to provide a pragmatic method of equity weight construction which is both understandable to policy makers and sensitive to the needs of target groups. It could improve the evidence base for resource allocation decisions, and be generalised to other disadvantaged groups who share similar concepts of equity. Development of this decision-making tool represents a potentially important avenue for further health economics research.

An exploration of the notion and nature of the construct of cultural safety and its applicability to the Australian health care context

Cultural safety has been promoted by its New Zealand proponents as an effective process for managing cultural risk in health care and improving the cultural responsiveness of mainstream health services when delivering care to culturally diverse populations. Its effectiveness in this regard has not, however, been comprehensively investigated. A key purpose of this study was to explore and describe what is known and understood about the notion of cultural safety and its possible application to and in Australian health care domains. Findings from the study indicate that the notion of cultural safety is conceptually problematic, poorly understood, and underresearched and, unless substantially revised, cannot be meaningfully applied to the cultural context of Australia.

What's needed to increase research capacity in rural primary health care

The aim of this study is to identify ways to build research capacity within primary health. A consultation was undertaken in late 2004 using a combination of a one-page survey and a guided meeting format, in a primary health setting in rural NSW. Most (81.3%) of the 134 individuals consulted were part of an Area Health Service, with 12.7% from non-government settings. Most (80.6%) were clinicians, with a third (31.5%) nurses, 8.3% in medicine, and the remainder from a range of allied health professions. Eleven organisations were represented. The main  outcome measures were identification of support needs, processes to enhance research engagement, and barriers and enablers to clinicians’ research  involvement. The results showed that popular delivery modes for research training and support were courses and “one-to- one” advice. Writing topics were generally more popular than others. Common barriers were time and technology issues. A key enabler was a discipline-specific focus. This is one of few rural Australian  consultations on research needs in primary health conducted with a diverse  range of clinicians at the clinician level. It will direct future research capacity  building efforts towards maximising face-to-face discipline specific options and  minimising technology use.

Lesbian parents negotiating the health care system in Australia

Twenty Australian lesbian-parented families were interviewed in multigenerational family groups about the interface between their public and private worlds. Experiences of the health care bureaucracy were difficult, whereas many participants found individual providers to be approachable and caring. Three strategies were used for disclosure of their sexual orientation to health care providers: private, proud, and passive. Influences on the strategy used included family formation, role of the non-birth parent, geographic location, and expected continuity of care. Parents displayed a high degree of thoughtful planning in utilizing their preferred disclosure strategy in order to optimize safety, particularly for their children.

Healthy markets - healthy people/ : reforming health care in Cambodia

Health care reform has been described as a global epidemic. This thesis deals with nature and experience of health care reform in developing countries. Increasing privatisation, economic transition, and structural adjustment have provided the context for health system changes. Different approaches to reform have been developed by international organisations such as the World Bank, WHO and UNICEF. What has driven national health care reforms? Are such policies really appropriate to developing countries? Has a consensus now emerged in relation to international health policy? Has a new health care ‘model’ appeared? The study of health care reform in Cambodia is a timely opportunity to investigate the implementation of health care reform under extreme conditions. These conditions include a legacy of genocide, long-term conflict, political isolation, and economic transition. This case study uses both qualitative and quantitative methods and multiple sources of data to analyse the reform program. The study reinforces the conclusion that, under conditions of extreme poverty, market based reforms are likely to have limited positive impact. Rather, understanding the cultural conditions that determine demand, delivering health care of a satisfactory quality, providing appropriate incentives for health practitioners, and supporting services with adequate public funding are the prerequisites for improved service delivery and utilisation. Cambodia's strategy of integrated district health service development and universal population coverage may provide an instructive example of reform. Emerging policy issues identified by this case study include the fundamental role of equity in service provision, the influence of the social determinants of health and illness and interest in the appropriate use of evidence in international health policy-making.

Geelong community's priorities and expectations of public health care

Abstract This thesis set out to achieve the following objectives: (1) To identify the priorities and expectations that the Geelong community has of its public health care system. (2) To determine if there is a common view on the attributes of a just health system. (3) To consider a method of utilising the data in the determination of health care priority setting in Barwon Health. (4) To determine a model of community participation which enables ongoing input into the decision making processes of Barwon Health. The methodology involved a combination of qualitative and quantitative research. The qualitative work involved the use of focus groups that were conducted with 64 members of the Geelong community. The issues raised informed the development of the interview schedule that was the basis of the quantitative study, which surveyed a representative sample of 400 members of the Geelong community. Prior to reporting on this work, the areas of distributive justice, scarcity and community participation in health care were considered. The research found that timely access to public hospitals, emergency care and aged care services were the major priorities; for many people, the cost was less relevant than a quality service. Shorter waiting times and increased staffing levels were strongly supported. Increased taxes were nominated as the best means of financing the health system they sought. Community based services were less relevant than hospital services but health education was supported. An egalitarian approach to resource distribution was favoured although the community was prepared to discriminate in favour of younger people and against older people. There was strong support for the community to be involved in decision making in the public health care system through surveys or focus groups but very little support was given to priorities being determined by politicians, administrators and to a lesser extent, medical professionals.