APHCRI Conversations was a regular program of presentations held at the Department of Health to facilitate exchange between APHCRI Network researchers and Department policymakers. Topics are developed jointly with the Department of Health and involve a range of speakers from APHCRI, including CRE invited experts, CRE Chief Investigators and stream project Chief Investigator

Humphreys, John S

Lyle, David

McGrail, Matthew

Perkins, David

Wakerman, John

The Australian National University

CENTRE OF RESEARCH EXCELLENCE  IN RURAL AND REMOTE PRIMARY HEALTH CARE Broken Hill University Department of Rural Health Access & equity in the provision of primary health care services in rural and remote Australia  Presentation to the Department of Health & Ageing, Canberra 23 November 2011  John S. Humphreys, John Wakerman, David Perkins,  David Lyle & Matthew McGrail Today’s presentation 1. Background to the CRE 2. Aims, rationale and outcomes 3. Research streams & methodology 4. Research capacity building strategy 5. Knowledge transfer and exchange strategy  2 1. Background to the CRE 3 APHCRI CREs • 5 CREs in Primary Health Care Research now funded http://www.anu.edu.au/aphcri/Spokes_Research_Program/2010_COE.php • CRE on Access and Equity in Rural and Remote Primary Health Care http://www.crerrphc.org.au   4 The CRE team John Humphreys John Wakerman David Perkins Matthew McGrail Melissa Lindeman David Lyle Leigh Kinsman Tim Carey Helen Cameron Penny Buykx Steve Guthridge Deb Russell Yuejen Zhao Lisa Lavey Mike Jones Plus International Experts Plus 4 PhDs and 3 Postdoctoral Fellows Broken Hill University Department of Rural Health 5 Background to CRE research • Rural health status demonstrably poorer • Evidence of problems in accessing care at times of need for residents of small isolated communities • Acute workforce shortage and problems of recruitment & retention • Problems most acute for residents of small isolated communities 6 Previous APHCRI research • a systematic review of PHC models in small rural and remote communities • detailed investigation of implementation, sustainability & generalisability of PHC models • a systematic review examining the link between workforce retention and professional development • studies analysing costs and benchmarks related to turnover and retention 7 So what?  We know a lot about ‘inputs’ Contexts Inputs enable PHC delivery Outputs (products and services) Immediate (direct) outcomes Intermediate (indirect) outcomes Final outcomes Geographic, socio-economic, cultural, policy contexts; population characteristics & community readiness   Funding arrangements Infrastructure/linkages Workforce Governance & public participation Leadership & management PHC products and services: volume, distribution (who gets how much of what types of services), type (eg. health, prevention, disease prevention, curative, rehabilitative, supportive, palliative, referrals) & qualities (ie responsive, comprehensive, continuity, coordination, interpersonal communication & technical effectiveness) Maintain or improve work life of PHC workforce Increased knowledge about health and health care among the population Reduced risk, duration and effects of acute and episodic health conditions Reduced risk and effects of continuing health conditions Appropriateness of place and provider Health care system efficiency Acceptability Health care system equity Sustainable health care system Improve and/or maintain functioning, resilience and health for individuals Improved level and distribution of population health and wellness Pre-requisites for sustainable PHC services PHC Effectiveness Population health & clinical activities and decisions 8 2. Aims, rationale & outcomes of the CRE program 9 Three broad aims  Stream 1: Develop a better understanding and improved measure of access to primary health care  Stream 2: Develop an evaluation framework for monitoring impact of PHC services on access & equity of health outcomes in rural and remote Australia  Stream 3: Develop and evaluate appropriate sustainable PHC service models in priority health areas 10 Starting assumptions & key questions • Good health is a basic right of all Australians • Health & wellbeing is a function of access to society’s scarce resources • Health care is not in unlimited supply or ubiquitously available – So:  What health services should be available?  To whom should they be provided?  Who should provide them and how?  How should they be paid for?  How do we monitor their impact on health? 11 Health equity in rural and remote areas – what the evidence shows • Health inequities exist across the PHC continuum • Equity worse in rural and remote areas and parallels socio-economic disadvantage • Specific rural and remote access issues:  Services used less and care less affordable  Lack of a usual source of care affects continuity of care  Lack of transport and shortage of health workers create barriers to receiving care 12 What is equity in health? “the absence of systematic differences in one or more aspects of health status across socially, demographically, or geographically defined population groups” (Starfield 2001) • Vertical – preferential treatment for those with greater health needs (allocative decisions) • Horizontal – equivalent treatment for equivalent needs (distributive decisions)  13 Why primary health care services? Figure 1: Monthly Prevalence Estimates of Illness in the Community and the Roles of Physicians, Hospitals, and University Medical Centres in the Provision of Medical Care (White et al.,1961, NEJM) Primary health care makes a greater contribution to reducing health inequities in modern societies (Starfield, 2011) 1000 750 250 9 5 1 Adult population at risk Adults reporting one or more illnesses or injuries per month Adults consulting a physician one or more times per month Adult patients admitted to a hospital per month Adult patients referred to another physician per month Adult patients referred to a university medical centre per month 14 Expected CRE outcomes • Relevant & timely evidence-based policy research • Stakeholder participation in research/policy development • Knowledge transfer & exchange • Research capacity building 15 3.   Research streams and methodology 16 Stream 1 – Measuring access to PHC Background: • Goal of optimal access to primary health care and equity of health outcomes for rural and remote Australians • Existing resource allocation schema deficient Key policy issues: • What data items are best for monitoring access to PHC service provision in rural and remote areas? • What are the outcome implications of these decisions? Output: • A more appropriate ‘index of access’ to PHC services than just ‘rurality’ of ‘remoteness’ 17 Different criteria have different optimal locations A B C D E F G H I J K L M Maximum Demand Maximum Cover Maximum Equity Minimum Cost Community 18 • Equality  Equal service for equal payment?  Equal input per capita/areas?  Equal outcomes?  Equal satisfaction of demand? • Service availability & utilisation • Equity  Horizontal or Vertical • Need  Normative  Expressed  Felt  Comparative 19 Current Different access criteria result in different eligibility for resources Past 1. Expand index of access nationally  2. Expand to other PHC providers (GPs, Nurses, Allied Health) 3. Update index using current data, empirical data, latest methodologies 4. Academic evaluation using validation & sensitivity assessment 5. Policy evaluation using local experts & testing against policy issues Stream 1 activity  Measuring access to PHC 21 Stream 1 activity: Measuring access to PHC outputs • Improved measure of access to guide more equitable resource allocation for the provision of PHC in rural and remote areas • A mechanism for modelling the geographical impact of alternative measures of allocation criteria • A data repository and national resource for post-graduate research training and advice to policy-makers 22 Stream 1: Stakeholders • Government policy-makers – eg: workforce recruitment and retention incentive decision tools • Service providers and funders – eg: program initiatives such as PIP, community services  • Health services – eg: workforce retention incentives • Health care workers – eligibility for support and ability to deliver accessible care • Health consumers – eligibility for support, accessible and available care, and equity of health outcomes Background • Many rural and remote communities lack access to effective & sustainable PHC services. Key policy issues: • What PHC services do communities of different sizes and locations require? • What indicators and benchmarks should be used to monitor service performance? • What are appropriate models of community participation in PHC? Outputs • A comprehensive evaluation framework with benchmarks  23 Stream 2 An evaluation framework for PHC service access and equity Stream 2: Research design & methodology Mixed methods (systematic reviews, Delphi group, empirical data) to: • Review sentinel indicators and data availability for PHC services • Establish service performance benchmarks appropriate to context • Develop a robust evaluation framework for monitoring PHC service performance, quality & sustainability 24 Stream 2: Outputs • Overall funding benchmarks for rural & remote contexts • Human and physical resources, multi-disciplinary staffing mix, and supports required to provide an adequate level of PHC service • Document different mechanisms of community participation optimised for context - eg: ACCHOs • Evaluation & monitoring framework for PHC services 25 Stream 3:   To evaluate sustainable PHC models Background: • Metropolitan PHC models do not fit rural remote settings • Few rural remote PHC models have been evaluated Key policy issues: • What service models will best ensure access and equity to mental health, aged care and comprehensive PHC in rural and remote Australia? Output: • Evidence-based evaluation showing what models work well to provide effective sustainable PHC. 27 Stream 3: Research question • Can we achieve greater distributional equity with alternative PHC health care models and providers (with a focus on mental health and aged care)?  Stream 3: Research design & methodology • Undertake comprehensive evaluations of ‘what models work best where and why’ • Mixed methods – questionnaires, interviews, direct observation, service utilisation data – further development of the ‘Elmore framework’ • Undertaking collaborative research with PHC providers in private, public and voluntary sectors – including the Royal Flying Doctor Service, Western Australia Country Health Services 28 • Evidence to show how various PHC service models work to increase access, equity, quality of care • Robust, field-tested evaluation framework across rural & remote PHC including mental health and community services Stream 3 outputs 29 4. Capacity building program  30 Research Capacity Building Goal:  Grow the research capacity of the next generation of rural and remote health researchers with the necessary methods and technical skills for PHC services research.  This will be achieved by: • growing our own – 4 PhDs, 3 post-doctoral fellows, research succession planning, Indigenous research capacity, extending research culture through collaborations • extending the range of research training - reducing researcher isolation, increasing researcher access to support and training, linking research with stakeholders and end users 32 • PhD Boot Camp • Introductory research methods short courses • Advanced research methods short courses • Shared supervision/external supervisors • Writing workshops/weeks • Research seminar program • Selected conferences • Research scholars as educators Research Capacity Building 5. Knowledge transfer & exchange strategy 33 Better evidence to inform PHC service provision Example: What is the impact of health policies & incentives in improving access to PHC services and on health equity? Pathways leading to inequity Selected program responses Outcomes 1. Environmental • geographical access • social access • living conditions 2. Socio-economic 3. Policy • workforce measures • distribution of services • financing arrangements • broad social and economic policies • Access initiatives • Educational initiatives • Workforce initiatives • Indigenous initiatives • Service provision initiatives • Financing initiatives • Regional development initiatives ? 34 Knowledge transfer outcomes Comprehensive strategy: • Strengthened relationships with consumers & policymakers • Increased capacity and research literacy of policymakers & practitioners • Highly accessed dedicated website • Peer-reviewed academic papers • Conference presentations • Evaluation of impact describing strengthened evidence-informed policy & practice  35 Measuring research impact 36 Broad area of impact Specific areas of impact Key audience Stakeholders Evidence Research ‘Advancing knowledge’ New knowledge Capacity building  Researchers, educators, media      Populated using indicators of both ‘producer push’ and ‘user pull’ Policy ‘Informing decision making’  Evidence base to inform decision-making Policy makers, politicians, professional bodies  Services ‘Improving health & health systems’ Evidence-based practice -  quality, safety, efficiency, effectiveness Managers, health workforce, consumers Society ‘Creating broad social & economic benefit’ Health literacy, behaviour, & status Consumers Expected CRE outcomes • Knowledge dissemination, transfer and exchange • Extensive research capacity building • Stakeholder participation in research/policy development • Relevant and timely evidence to guide policy and practice • Index of Access • Indicators & benchmarks • Evaluation framework  37 Conclusion • Equity necessarily requires inequalities, but those deriving from policies of positive discrimination based on sound evidence & not market forces • The CRE already making excellent progress in building up the evidence base for the provision of accessible and effective rural & remote PHC services • Ongoing challenges include: – the inherent difficulty of operationalising equity – establishing appropriate rigorous evaluation methodologies – getting access to data – engaging end-users with the research process 38 

Access & equity in the provision of primary health care services in rural and remote Australia

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