Management of COVID-19 in the community and the role of primary care: how the pandemic has shone light on a fragmented health system

[Extract] The Australian health care system is well regarded on the global stage in terms of the balance between investment in health care and outcomes delivered, particularly in terms of universal access, quality and safety.1 However, there is considerable fragmentation and poor coordination of care and communication between hospitals and primary care, which limits further improvement.2, 3 Geographical barriers, workforce shortages and issues relating to acceptability of services limit health care access for residents of rural, regional and remote communities, Aboriginal peoples and Torres Strait Islanders, and together with an inadequate focus on prevention, limit progress towards health equity. Australian responses to the coronavirus disease 2019 (COVID-19) pandemic through both public health responses and the acute health sector have been viewed as among the best in the world. Nevertheless, challenges in the structure, organisatIon and financing of the Australian health care system have been brought into stark relief by the evolution of responses to the pandemic

What do patients with diabetes and providers think of an innovative Australian model of remote diabetic retinopathy screening? A qualitative study

Background: Diabetic retinopathy (DR) is the commonest cause of preventable blindness in working age populations, but up to 98% of visual loss secondary to DR can be prevented with early detection and treatment. In 2012, an innovative outreach DR screening model was implemented in remote communities in a state of Australia. The aim of this study was to explore the acceptability of this unique DR screening model to patients, health professionals and other key stakeholders. Methods: This descriptive qualitative study used semi-structured interviews with patients opportunistically recruited whilst attending DR screening, and purposefully selected health care professionals either working within or impacted by the programme. Interviews were audiotaped, transcribed and analysed using NVIVO. An iterative process of thematic analysis was used following the principles of grounded theory. Results: Interviews were conducted with fourteen patients with diabetes living in three remote communities and nine health professionals or key stakeholders. Nine key themes emerged during interviews with health professionals, key stakeholders and patients: i) improved patient access to DR screening; ii) efficiency, financial implications and sustainability; iii) quality and safety; iv) multi-disciplinary diabetes care; v) training and education; vi) operational elements of service delivery; vii) communication, information sharing and linkages; viii) coordination and integration of the service and ix) suggested improvements to service delivery. Conclusions: The Remote Outreach DR Screening Service is highly acceptable to patients and health professionals. Challenges have primarily been encountered in communication and coordination of the service and further development in these areas could improve the programme's impact and sustainability in remote communities. The service is applicable to other remote communities nationally and potentially internationally

Training a fit-for-purpose rural health workforce for low- and middle-income countries (LMICs): how do drivers and enablers of rural practice intention differ between learners from LMICs and high income countries?

Equity in health outcomes for rural and remote populations in low- and middle-income countries (LMICs) is limited by a range of socio-economic, cultural and environmental determinants of health. Health professional education that is sensitive to local population needs and that attends to all elements of the rural pathway is vital to increase the proportion of the health workforce that practices in underserved rural and remote areas. The Training for Health Equity Network (THEnet) is a community-of-practice of 13 health professional education institutions with a focus on delivering socially accountable education to produce a fit-for-purpose health workforce. The THEnet Graduate Outcome Study is an international prospective cohort study with more than 6,000 learners from nine health professional schools in seven countries (including four LMICs; the Philippines, Sudan, South Africa and Nepal). Surveys of learners are administered at entry to and exit from medical school, and at years 1, 4, 7, and 10 thereafter. The association of learners' intention to practice in rural and other underserved areas, and a range of individual and institutional level variables at two time points—entry to and exit from the medical program, are examined and compared between country income settings. These findings are then triangulated with a sociocultural exploration of the structural relationships between educational and health service delivery ministries in each setting, status of postgraduate training for primary care, and current policy settings. This analysis confirmed the association of rural background with intention to practice in rural areas at both entry and exit. Intention to work abroad was greater for learners at entry, with a significant shift to an intention to work in-country for learners with entry and exit data. Learners at exit were more likely to intend a career in generalist disciplines than those at entry however lack of health policy and unclear career pathways limits the effectiveness of educational strategies in LMICs. This multi-national study of learners from medical schools with a social accountability mandate confirms that it is possible to produce a health workforce with a strong intent to practice in rural areas through attention to all aspects of the rural pathway

Practice intentions at entry to and exit from medical schools aspiring to social accountability: findings from the Training for Health Equity Network Graduate Outcome Study

Background: Understanding the impact of selection and medical education on practice intentions and eventual practice is an essential component of training a fit-for-purpose health workforce distributed according to population need. Existing evidence comes largely from high-income settings and neglects contextual factors. This paper describes the practice intentions of entry and exit cohorts of medical students across low and high income settings and the correlation of student characteristics with these intentions. Methods: The Training for Health Equity Network (THEnet) Graduate Outcome Study (GOS) is an international prospective cohort study tracking learners throughout training and ten years into practice as part of the longitudinal impact assessment described in THEnet’s Evaluation Framework. THEnet is an international community of practice of twelve medical schools with a social accountability mandate. Data presented here include cross-sectional entry and exit data obtained from different cohorts of medical students involving eight medical schools in six countries and five continents. Binary logistic regression was used to create adjusted odds ratios for associations with practice intent. Results: Findings from 3346 learners from eight THEnet medical schools in 6 countries collected between 2012 and 2016 are presented. A high proportion of study respondents at these schools come from rural and disadvantaged backgrounds and these respondents are more likely than others to express an intention to work in underserved locations after graduation at both entry and exit from medical school. After adjusting for confounding factors, rural and low income background and regional location of medical school were the most important predictors of intent to practice in a rural location. For schools in the Philippines and Africa, intention to emigrate was more likely for respondents from high income and urban backgrounds

Building blocks for social accountability: a conceptual framework to guide medical schools

Background: This paper presents a conceptual framework developed from empirical evidence, to guide medical schools aspiring towards greater social accountability. Methods: Using a multiple case study approach, seventy-five staff, students, health sector representatives and community members, associated with four medical schools, participated in semi-structured interviews. Two schools were in Australia and two were in the Philippines. These schools were selected because they were aspiring to be socially accountable. Data was collected through on-site visits, field notes and a documentary review. Abductive analysis involved both deductive and inductive iterative theming of the data both within and across cases. Results: The conceptual framework for socially accountable medical education was built from analyzing the internal and external factors influencing the selected medical schools. These factors became the building blocks that might be necessary to assist movement to social accountability. The strongest factor was the demands of the local workforce situation leading to innovative educational programs established with or without government support. The values and professional experiences of leaders, staff and health sector representatives, influenced whether the organizational culture of a school was conducive to social accountability. The wider institutional environment and policies of their universities affected this culture and the resourcing of programs. Membership of a coalition of socially accountable medical schools created a community of learning and legitimized local practice. Communities may not have recognized their own importance but they were fundamental for socially accountable practices. The bedrock of social accountability, that is, the foundation for all building blocks, is shared values and aspirations congruent with social accountability. These values and aspirations are both a philosophical understanding for innovation and a practical application at the health systems and education levels. Conclusions: While many of these building blocks are similar to those conceptualized in social accountability theory, this conceptual framework is informed by what happens in practice - empirical evidence rather than prescriptions. Consequently it is valuable in that it puts some theoretical thinking around everyday practice in specific contexts; addressing a gap in the medical education literature. The building blocks framework includes guidelines for social accountable practice that can be applied at policy, school and individual levels

Building effective governance: book review of "Health workforce governance: improved access, good regulatory practice, safer patients" by Stephanie D Short, Fiona McDonald (eds) Farnham, UK: Ashgate Publishing, 2012. ISBN: 9781409429210

[Extract] Ensuring that we produce a health workforce that is well trained, "fit for purpose", equitably distributed, and that delivers effective and safe health care is a key responsibility of all those involved in medical education, health governance and health policy making. Various health scandals have drawn the attention of the public to failures in health governance, and raised considerable doubt about the ability of the health professions (and in particular doctors) to self-regulate in a way that will protect the public

Access to contraception for remote Aboriginal and Torres Strait Islander women: necessary but not sufficient

[Extract] Comprehensive sexual and reproductive health care contributes to the autonomy of Indigenous women.\ud \ud The World Health Organization has long promoted a human rights-based view of the importance of access to sexual and reproductive health (SRH) care, including a reliable method for managing the spacing of children.¹ Globally, this is important for improving the health and development of populations and limiting population growth. In Australia, overall rates of pregnancy in teenage women have been falling, although they are stable or even increasing in some disadvantaged subgroups, such as young women from remote areas or low socio-economic status backgrounds.² Sexual activity rates among Aboriginal and Torres Strait Islander and non-Indigenous young people are broadly similar. Teenage pregnancy rates among young Indigenous women, however, are higher, and teenage birth rates are much higher, as non-Indigenous young people have greater access to and use the option of terminating a pregnancy.³,⁴\u

Fluorscent anterograde labelling of the genitofemoral nerve shows that it supplies the scrotal region before migration of the gubernaculum

The genitofemoral nerve (GFN) contains a sexually dimorphic neuropeptide transmitter, calcitonin generelated peptide (CGRP). It has been proposed that release of CGRP from the nerve may mediate testicular descent. The aim of this study was to determine the course of the GFN in order to see if CGRP-containing fibres reached the future scrotum before gubernacular migration occurs, since this arrangement would be expected if the nerve controls gubernacular migration by CGRP release. Fluorescent anterograde labelling of the cut GFN in young rats using diamidinophenyl indole (DAPI) or Fast Blue was performed to determine the distal course of the nerve. On frozen serial sections, the nerve was found running posterolateral to the developing spermatic cord in the inguinal canal, then distally on the surface of the cremaster muscle. It then turned cranially to enter the gubernaculum from its distal attachment while some branches continued past the gubernaculum to end in the skin of the future scrotum. Immunoperoxidase staining for CGRP showed labelling in all GFN fibre bundles, including those reaching the scrotum. The course of the nerve with its sexually dimorphic neurotransmitter, CGRP, suggests that the nerve may influence the direction of gubernacular migration from the groin into the scrotum