Bottleneck co-ownership as a regulatory alternative

This paper proposes a regulatory mechanism for vertically related industries in which the upstream “bottleneck” segment faces significant returns to scale while other (downstream) segments may be more competitive. In the proposed mechanism, the ownership of the upstream firm is allocated to downstream firms in proportion to their shares of input purchases. This mechanism, while preserving downstream competition, partially internalizes the benefits of exploiting economies of scale resulting from an increase in downstream output. We show that this mechanism is more efficient than a disintegrated market structure in which the upstream natural monopoly bottleneck sets a price equal to average cost.Regulation, vertically related industries, co-ownership

Child protection outcomes of the Australian Nurse Family Partnership Program for Aboriginal infants and their mothers in Central Australia

© 2018 Segal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background The Nurse Family Partnership Program developed in the USA, designed to improve mother and infant/child outcomes, has reported lower rates of child protection system involvement. The study tested the hypothesis that an adapted Nurse Family Partnership Program implemented in an Aboriginal community in Central Australia (the FPP) would improve Child Protection outcomes. Methods This was a retrospective and prospective cohort study drawing on linked administrative data, including birth registry, primary health care client information system, FPP program data, and child protection data. Participants were children of women eligible for the FPP program (an exposed and a control group of women, eligible but not referred) live-born between 1/3/2009 (program commencement) and 31/12/2015. Child protection data covered all reports, investigations, substantiations and out-of-home care placements from the time of the child’s birth to 31/12/2016. Generalised linear modelling was used to estimate the relative risk (RR) of involvement with child protection and type of involvement (report, investigation, substantiation, out-of-home-care placement) among FPP and control children. Results FPP mothers (n = 291) were on average younger, were more likely to be first-time mothers and experiencing housing instability than control mothers (n = 563). Among younger mothers 20 years, FPP children had statistically significantly lower rates of involvement with child protection (ARRreport = 0.49, 95% CI: 0.29 to 0.82; ARRinvestigation = 0.34, 95% CI: 0.19 to 0.64; ARRsubstantiation = 0.45, 95% CI: 0.21 to 0.96) and experience fewer days in care (ARR = 0.10, 95% CI: 0.02 to 0.48). Among children of first-time mothers, FPP children also had statistically significantly lower rates of involvement with child protection (ARRreport = 0.50, 95% CI: 0.30 to 0.83; ARRinvestigation = 0.36, 95% CI: 0.19 to 0.67; ARRsubstantiation = 0.38, 95% CI: 0.18 to 0.80) and fewer days in care (ARR = 0.06, 95% CI: 0.01 to 0.27). Conclusion Study results suggest a modified Nurse Family Partnership delivered by an Indigenous community-controlled organisation may have reduced child protection system involvement in a highly vulnerable First Nations population, especially in younger or first-time mothers. Testing these results with an RCT design is desirable

Case Study of an Aboriginal Community-Controlled Health Service in Australia: Universal, Rights-Based, Publicly Funded Comprehensive Primary Health Care in Action

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.Universal health coverage provides a framework to achieve health services coverage but does not articulate the model of care desired. Comprehensive primary health care includes promotive, preventive, curative, and rehabilitative interventions and health equity and health as a human right as central goals. In Australia, Aboriginal community-controlled health services have pioneered comprehensive primary health care since their inception in the early 1970s. Our five-year project on comprehensive primary health care in Australia partnered with six services, including one Aboriginal community-controlled health service, the Central Australian Aboriginal Congress. Our findings revealed more impressive outcomes in several areas—multidisciplinary work, community participation, cultural respect and accessibility strategies, preventive and promotive work, and advocacy and intersectoral collaboration on social determinants of health—at the Aboriginal community-controlled health service compared to the other participating South Australian services (state-managed and nongovernmental ones). Because of these strengths, the Central Australian Aboriginal Congress’s community-controlled model of comprehensive primary health care deserves attention as a promising form of implementation of universal health coverage by articulating a model of care based on health as a human right that pursues the goal of health equity

Lymphadenopathy after Initiating HAART in an HIV-positive Patient with Kaposi's Sarcoma: a Case of Multicentric Castleman's Disease

We present the case of a 33-year-old lady who was diagnosed with disseminated Kaposi’s sarcoma and HIV infection. The patient improved on highly active antiretroviral therapy (HAART), however, nine days into treatment, she became febrile and dyspnoeic and developed tender cervical and axillary lymphadenopathy. Despite treatment for suspected sepsis and immune reconstitution, she died in intensive care. Lymph node biopsies revealed coexistent Castleman’s disease and Kaposi’s sarcoma. Initiation of HAART can be rarely associated with unmasking and rapid progression of Castleman’s disease, a phenomenon called immune reconstitution. Urgent investigation and treatment with agents such as steroids and cytotoxic drugs can be life-saving

Health promotion in Australian multi-disciplinary primary health care services: case studies from South Australia and the Northern Territory

This paper reports on the health promotion and disease prevention conducted at Australian multi-disciplinary primary health care (PHC) services and considers the ways in which the organizational environment affects the extent and type of health promotion and disease prevention activity. The study involves five PHC services in Adelaide and one in Alice Springs. Four are managed by a state health department and two by boards of governance. The study is based on an audit of activities and on 68 interviews conducted with staff. All the sites undertake health promotion and recognize its importance but all report that this activity is under constant pressure resulting from the need to provide services to people who have health problems. We also found an increased focus on chronic disease management and prevention which prioritized individuals and behavioural change strategies rather than addressing social determinants affecting whole communities. There was little health promotion work that reflected a salutogenic approach to the creation of health. Most activity falls under three types: parenting and child development, chronic disease prevention and mental health. Only the non-government organizations reported advocacy on broader policy issues. Health reform and consequent reorganizations were seen to reduce the ability of some services to undertake health promotion. The paper concludes that PHC in Australia plays an important role in disease prevention, but that there is considerable scope to increase the amount of community-based health promotion which focuses on a salutogenic view of health and which engages in community partnerships.This work was supported by the National Health and Medical Research Council (grant number 535041), an Australian Research Council Federation Fellowship (to F.B.) and the Canada Research Chair program (to R.L.)

Completeness and Incompleteness of Synchronous Kleene Algebra

Synchronous Kleene algebra (SKA), an extension of Kleene algebra (KA), was proposed by Prisacariu as a tool for reasoning about programs that may execute synchronously, i.e., in lock-step. We provide a countermodel witnessing that the axioms of SKA are incomplete w.r.t. its language semantics, by exploiting a lack of interaction between the synchronous product operator and the Kleene star. We then propose an alternative set of axioms for SKA, based on Salomaa's axiomatisation of regular languages, and show that these provide a sound and complete characterisation w.r.t. the original language semantics.Comment: Accepted at MPC 201

Telehealth in remote Australia : a supplementary tool or an alternative model of care replacing face-to-face consultations?

Background: The COVID-19 pandemic increased the use of telehealth consultations by telephone and video around the world. While telehealth can improve access to primary health care, there are significant gaps in our understanding about how, when and to what extent telehealth should be used. This paper explores the perspectives of health care staff on the key elements relating to the effective use of telehealth for patients living in remote Australia. Methods: Between February 2020 and October 2021, interviews and discussion groups were conducted with 248 clinic staff from 20 different remote communities across northern Australia. Interview coding followed an inductive approach. Thematic analysis was used to group codes into common themes. Results: Reduced need to travel for telehealth consultations was perceived to benefit both health providers and patients. Telehealth functioned best when there was a pre-established relationship between the patient and the health care provider and with patients who had good knowledge of their personal health, spoke English and had access to and familiarity with digital technology. On the other hand, telehealth was thought to be resource intensive, increasing remote clinic staff workload as most patients needed clinic staff to facilitate the telehealth session and complete background administrative work to support the consultation and an interpreter for translation services. Clinic staff universally emphasised that telehealth is a useful supplementary tool, and not a stand-alone service model replacing face-to-face interactions. Conclusion: Telehealth has the potential to improve access to healthcare in remote areas if complemented with adequate face-to-face services. Careful workforce planning is required while introducing telehealth into clinics that already face high staff shortages. Digital infrastructure with reliable internet connections with sufficient speed and latency need to be available at affordable prices in remote communities to make full use of telehealth consultations. Training and employment of local Aboriginal staff as digital navigators could ensure a culturally safe clinical environment for telehealth consultations and promote the effective use of telehealth services among community members

Perspectives of primary health care staff on the implementation of a sexual health quality improvement program: A qualitative study in remote aboriginal communities in Australia

Background: Young people living in remote Australian Aboriginal communities experience high rates of sexually transmissible infections (STIs). STRIVE (STIs in Remote communities, ImproVed and Enhanced primary care) was a cluster randomised control trial of a sexual health continuous quality improvement (CQI) program. As part of the trial, qualitative research was conducted to explore staff perceptions of the CQI components, their normalisation and integration into routine practice, and the factors which influenced these processes. Methods: In-depth semi-structured interviews were conducted with 41 clinical staff at 22 remote community clinics during 2011-2013. Normalisation process theory was used to frame the analysis of interview data and to provide insights into enablers and barriers to the integration and normalisation of the CQI program and its six specific components. Results: Of the CQI components, participants reported that the clinical data reports had the highest degree of integration and normalisation. Action plan setting, the Systems Assessment Tool, and the STRIVE coordinator role, were perceived as adding value to the program, but were less readily integrated or normalised. The remaining two components (dedicated funding for health promotion and service incentive payments) were seen as least relevant. Our analysis also highlighted factors which enabled greater integration of the CQI components. These included familiarity with CQI tools, increased accountability of health centre staff and the translation of the CQI program into guideline-driven care. The analysis also identified barriers, including high staff turnover, limited time involved in the program and competing clinical demands and programs. Conclusions: Across all of the CQI components, the clinical data reports had the highest degree of integration and normalisation. The action plans, systems assessment tool and the STRIVE coordinator role all complemented the data reports and allowed these components to be translated directly into clinical activity. To ensure their uptake, CQI programs must acknowledge local clinical guidelines, be compatible with translation into clinical activity and have managerial support. Sexual health CQI needs to align with other CQI activities, engage staff and promote accountability through the provision of clinic specific data and regular face-to-face meetings. Trial registration: Australian and New Zealand Clinical Trials Registry ACTRN12610000358044. Registered 6/05/2010. Prospectively Registered

Bottleneck co-ownership as a regulatory alternative

This paper proposes a regulatory mechanism for vertically related industries in which the upstream “bottleneck” segment faces significant returns to scale while other (downstream) segments may be more competitive. In the proposed mechanism, the ownership of the upstream firm is allocated to downstream firms in proportion to their shares of input purchases. This mechanism, while preserving downstream competition, partially internalizes the benefits of exploiting economies of scale resulting from an increase in downstream output. We show that this mechanism is more efficient than a disintegrated market structure in which the upstream natural monopoly bottleneck sets a price equal to average cost

Strategies to improve control of sexually transmissible infections in remote Australian Aboriginal communities: a stepped-wedge, cluster-randomised trial

BACKGROUND: Remote Australian Aboriginal communities have among the highest diagnosed rates of sexually transmissible infections (STIs) in the world. We did a trial to assess whether continuous improvement strategies related to sexual health could reduce infection rates. METHODS: In this stepped-wedge, cluster-randomised trial (STIs in remote communities: improved and enhanced primary health care [STRIVE]), we recruited primary health-care centres serving Aboriginal communities in remote areas of Australia. Communities were eligible to participate if they were classified as very remote, had a population predominantly of Aboriginal people, and only had one primary health-care centre serving the population. The health-care centres were grouped into clusters on the basis of geographical proximity to each other, population size, and Aboriginal cultural ties including language connections. Clusters were randomly assigned into three blocks (year 1, year 2, and year 3 clusters) using a computer-generated randomisation algorithm, with minimisation to balance geographical region, population size, and baseline STI testing level. Each year for 3 years, one block of clusters was transitioned into the intervention phase, while those not transitioned continued usual care (control clusters). The intervention phase comprised cycles of reviewing clinical data and modifying systems to support improved STI clinical practice. All investigators and participants were unmasked to the intervention. Primary endpoints were community prevalence and testing coverage in residents aged 16–34 years for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis . We used Poisson regression analyses on the final dataset and compared STI prevalences and testing coverage between control and intervention clusters. All analyses were by intention to treat and models were adjusted for time as an independent covariate in overall analyses. This study was registered with the Australia and New Zealand Clinical Trials Registry, ACTRN12610000358044. FINDINGS: Between April, 2010, and April, 2011, we recruited 68 primary care centres and grouped them into 24 clusters, which were randomly assigned into year 1 clusters (estimated population aged 16–34 years, n=11 286), year 2 clusters (n=10 288), or year 3 clusters (n=13 304). One primary health-care centre withdrew from the study due to restricted capacity to participate. We detected no difference in the relative prevalence of STIs between intervention and control clusters (adjusted relative risk [RR] 0·97, 95% CI 0·84–1·12; p=0·66). However, testing coverage was substantially higher in intervention clusters (22%) than in control clusters (16%; RR 1·38; 95% CI 1·15–1·65; p=0·0006). INTERPRETATION: Our intervention increased STI testing coverage but did not have an effect on prevalence. Additional interventions that will provide increased access to both testing and treatment are required to reduce persistently high prevalences of STIs in remote communities.James Ward, Rebecca J Guy, Alice R Rumbold, Skye McGregor, Handan Wand, Hamish McManus, Amalie Dyda, Linda Garton, Belinda Hengel, Bronwyn J Silver, Debbie Taylor-Thomson, Janet Knox, Basil Donovan, Matthew Law, Lisa Maher, Christopher K Fairley, Steven Skov, Nathan Ryder, Elizabeth Moore, Jacqueline Mein, Carole Reeve, Donna Ah Chee, John Boffa and John M Kaldo