Social Determinants and Primary Health Care

Fran Baum (with CPHC research team)

Commission on the Social Determinants of Health

• Launched 28th August 2008 by Dr. Margaret Chan, Director General, WHO in Geneva

• "Health inequity really is a matter of life and death" Margaret Chan

Basic logic: what good does it do to treat people's illnesses/addictions/send them to

gaol/ .........

then give them no choice to go back to or no control over the conditions that made them

sick/addicted/commit crime in the first place?

• “The Commission’s main finding is straightforward. The social conditions in which people are born, live, and work are the single most important determinant of good health or ill health, of a long and productive life, or a short and miserable one. ……..This ends the debate decisively. Health care is an important determinant of health. Lifestyles are important determinants of health. ….But, let me emphasize, it is factors in the social environment that determine access to health services and influence lifestyle choices in the first place”.

1978

1993

2000

2001

2008

1986

Social dimensions of health affirmed in WHO Constitution (1948), downplayed during 1950s era of disease campaigns.

Determinants re-emerge under Health for All agenda (1970s), some action in 1980s due to Ottawa Charter – eg Healthy Cities

1990s: paradigm of health as private issue dominant; some exceptions.

2000s: “step-up" and new chance for action. MDGs CMH

History: SDH & PHC

1948

2005-08 Commission on Social Determinants of Health

WHR 2008 PHC

HiAP

2005-08

Rio Declaration 2011

19th Century

19th Century History: UK, Virchow, Latin America Social Medicine

Commission on the Social Determinants of Health Final Report

“Health systems should be based on the PHC model, combining

locally organized action on the social determinants of health as well as a strengthened primary level of care, and focusing at least as much on prevention and promotion as on treatment” (CSDH, 2008).

The Commission recommends: • Publicly funded health care system • Build quality health-care services with universal coverage, focusing

on Primary Health Care. • Build and strengthen the health workforce, and expand capabilities

to act on the social determinants of health. • Educational institutions and relevant ministries make the social

determinants of health a standard and compulsory part of training of medical and health professionals

Alma Ata, 1978 The International Conference on Primary Health Care calls for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world by the year 2000.

Australian Aboriginal Community Controlled sector was represented at Alma Ata

PHC as basis of a health system • Community Participation • Multidisciplinary health care • Health Promotion and disease prevention • Appropriate technology • Equity • Social understanding of health • Emphasis on global cooperation and peace -

investment in health rather than armaments • Call for New Economic Order

A broader social and economic program for a healthier society

Australian Primary Health Care

• Parallel systems in Australia: fee-for-service GP and State government funded services, community controlled and NGOs.

• Progressive elements in Aboriginal community controlled, women’s health and community health movements from 1970s – struggle to retain progressive edge

• Shape of current reform proposals unclear • Considerable cutbacks in States and territories

PHC and health promotion programs

Comprehensive PHC

Selective PHC

Health Promotion addressing the SDH through collective action and responsibility

Behavioural Health Promotion focused on individual responsibility

Values: encourage solidarity, collective, universal, publicly funded and free at point of use

Values: more likely to encourage individualism, privatisation, health care a commodity

Clinical interventions with individuals

Current Australian PHC reform appears akin to SPHC

• Clinical/Behaviour change based • Lip service at best to social determinants • GP as main provider and others subservient rather

than as a part of democratic team • Rapid change undermines effective relationships • Community engagement not evident other than as

self-management • Community development being cut and not refunded • Potential for Medicare Locals to lead to more

comprehensive PHC but nature unclear and likely to be inconsistent in structures, focus, programs and approaches and few funds currently

Small evidence base on CPHC • Teasdale Corti project indicated

evidence mainly “slices” of activity • Women’s Health conflicts with feminist

ideology (Broom) • Australian CHC – Legge et al Best

Practice, SACHRU, case histories, reports of projects within CPHC

• Aboriginal Community controlled health services

CPHC Project • Five year project, funded by National Health & Medical Research

Council

• Study models of Comprehensive Primary Health Care (CPHC) services in South Australia and the Northern Territory

• Contribute to understanding the effectiveness of CPHC using innovative evaluation methods

• Six participating sites – 5 Adelaide (Shine & Services A, B, C, D) , 1 Alice Springs (Congress)

Methods (2010) • Six monthly audit of each site – changes in staff, activities,

funding • 68 semi-structured interviews:

– 7-15 at each site: managers, practitioners, admin – 6 Regional health service executives – 2 Departmental funders

Inc. sections on views of current health reform, space for health promotion, community development, advocacy, and action on social determinants of health

• Workshops at each site to develop program logic models

Headline findings

• Conceptualising, understanding and developing a practice in relation to social determinants is partial

• More than a place to deliver services • Advocating for access to services • Advocating for policy change • Limits to action

Findings: awareness of social determinants

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We’re one of the lowest socio economic areas in Australia, let alone in South Australia, and so we have a lack of transport, lack of cars, funding is a huge thing. We’re on the fourth generation of unemployment, we’re in an area where children care for their parents sometimes. You know, they don’t go to school because they’re worried ‘Will something happen to mum if I’m at school?’ ….So all those social determinants make a huge difference on our community.

Health worker, Service A

Findings: awareness of social determinants

I think that that’s where again it’s all interrelated for me. I think it’s just so connected in that what we see presenting at the door, and wanting assistance, is a reflection of what’s happening in society, what’s happening in terms of the social determinants of health. That is high levels of unemployment amongst Aboriginal people, the education disadvantage of Aboriginal people, the historic neglect of education in the Northern Territory for Aboriginal people.

Executive, Congress

Findings: awareness of social determinants

• Our clients have multiple issues. It could be financial, it could be housing, education, and all that can contribute to bad health in ways where if you don’t have a proper income, you're not getting proper food. I mean just not being educated, you're not going to know how to read signs, maybe not go into services because you can't even talk to the receptionist... (Worker, Service D)

Developing a practice

• We don’t just look at the medical model, we look at the whole person. Not just their medical problems, but social, economical, environmental, all those things that affect people, like education, income. So we don’t just focus on one little thing, we try and just see the whole person and the whole picture, not just a small part of it. (Aboriginal Health Worker, Congress)

Developing a practice • I think if you went and talked to someone in our clinic

out at [suburb], then they would be saying holistically there are a whole lot more problems, issues, when they see a client. Other things impact a whole lot more on their sexual health and their general health, like their drug and alcohol use, or their homelessness, or being in prison when we run the clinic at the prison (Nurse, SHine SA)

• You can’t do therapeutic counselling with someone who has no home or has got the bills piled up and can’t pay the bills. (Counsellor, Service C)

Developing a practice: groups

• The Dads’ group looks at social change about the role of the father. It encourages fathers to fight against the stereotypes of what is a father, and to encourage [them] to be more involved. (Nurse, Service C)

More than a place to deliver services

• So you can come in and have a yarn with your mates and have a shower and wash your clothes, just chill out for a while. A lot of men actually like to come in here because they said there’s no humbug here. So if they’re living in an area where there’s lots of drinking, they can’t sleep and that sort of stuff so it’s just a hassle free place. We don’t get in anyone’s face and they just come and take it easy and do what you have to do. (Manager, Congress)

More than a place to deliver services

• The office at [suburb], for example, has a resource library and coffee and internet café. So the view is, it’s a drop in centre. And also if consumer groups, community groups want to use the premises for other meetings and things like that, all of those offices are available to that. (Board member, SHine SA)

More than a place to deliver services – community garden

• It is such a great way to get people involved in something and essentially they are contributing to something that they see changes over time - growing plants and vegetables. But they are also socialising, they are also interacting with health professionals, like myself. (Worker, Service C)

Advocacy

• For individual access to a range of services (including legal. Welfare payments, women’s shelters, GPs)

• Policy advocacy to institute broader social change

Dilemmas of PHC practice • Understand SDH yet work in biomedical system • Need space for political analysis of SDH (yet

determinants are reduced to an epidemiological list of risk factors rather than seen as produced through social process)

• Advocacy no longer seen as acceptable in some services

• Causes of disadvantage are deep and complex – needs multi-sectoral approach and political commitment to justice

Advocacy: not able Significantly, you can’t. I mean that’s the reality now.

I think there are fear factors, and I think there’s probably some fairly justified fear factors along with that. And at the moment we are very much - probably more so now than I’ve ever seen - we are driven by the government around “these are the programs, this is what you deliver on, this is the way we’re going forward.”

And trying to sell that message, sometimes that doesn’t sit comfortably. But you’re unable to do that advocacy against it, because it’s seen as going against government.

Regional Executive

Limits on action on SDH • Many SDH are beyond the remit of

health sector • In South Australia HiAP is at policy

rather than PHC level • Health Department focus on chronic

disease and the behaviours that contribute to chronic disease

• Balancing treatment and disease prevention

Change in SA health sector priority

Broader community participation, it doesn’t really fit with the command and control culture, which it’s hard to overstate how much the culture has changed since I came into (name of service) four years ago, admittedly in a different role.

… The whole culture has really quite significantly changed, and it’s to a large extent around budget and around defining what is health’s business and what isn’t health’s business, and cutting off things that we can save money on. So I think the context has changed quite significantly.

Regional Executive

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Changing focus of SA health department

We don’t provide a comprehensive primary healthcare service any more.

What we are is a specialist, well, we’re heading towards being a specialist service, because we have targeted priority populations and limited service focus, and our focus these days is heading to be much more around hospital avoidance.

Regional Executive

Limits on health sector action I don’t know that we do a huge lot on the social determinants of health. I think we’re looking at symptoms more than causes. It’s probably on a higher level than we are.

[It’s through] having someone at the top end of health, somebody at the top of transport, and speaking to somebody at the top of housing, that we are designing better transport routes that people can actually get to services, and bike routes and walking things planned in, and houses - not just little boxes.

And I think that’s probably a higher kind of level than I’m ever likely to operate at.

Health worker, Service C

Limits: balancing immediate needs with prevention

• I think we’ve got to try and get a balance within our clinical services around how do we just get ourselves out of the treatment regime? This is stuff that I agonise about continuously. How do we get a balance? How do we take that preventative approach? We’re still seeing people who come through our services that have scabies. We’ve got to be able to have the capacity and the vision I think to go and work at a preventative level because it’s total preventable. 80% of what we see is totally preventable. How do you get the balance between that, knowing that, and moving beyond just clinical treatment? (Manager, Congress)

Need for broader picture

• And it just appals me that we go on concentrating on diseases when we’ve got Big Mac on every corner. It’s such a powerful lobby and nobody tackles that. We’ve spent the last probably 40 years recognising and beginning to fight the cigarettes lobby and it’s just sad that when we talk about community health, we don’t talk about where the food is and who’s getting it and why it’s actually cheaper to go to McDonalds. (Worker, SHine SA)

Ways forward: Community Management of PHC services

NGOs in study closer to CPHC Local boards of management State and national council of board

members Real tangible support for the work of board

members Come to understand and advocate for

health of their community

Ways forward: funding & co-ordination

• Move away from fee-for-service PHC to community funding model and incentives to promote health and prevent disease and recognise they are different activities

• Avoid over-burden with multiple funding streams • Direct links between PHC and health promotion

activities of governments • Use Healthy Cities model to link PHC and local

government or Victorian PCP model • Potential for Medicare Locals

More focus on dilemmas of PHC practice

• Examine the contradictions • Support for range of practice models • See community development as aspect of patient

safety (first step of safety is access) • How to link HiAP with PHC • Need for PHC to be viewed as part of broader

social justice project • Advocacy as a political activity and position of

public servants – needs to be resolved – some notion of the public good

Summary: if PHC is to respond to Social Determinants

• PHC based on well supported community management

• Social determinants basis to planning

• Linked to HiAP and local government

• Reflective practice encouraged and supported

•

Baum, 2008