National health reform needs strategic investment in health services research

With new funding for the National Health and Medical Research Council (NHMRC) to provide an evidence base for policy and practice reform, it is timely to revisit Australia's recent experiences with health services research and policy development. We provide a broad review of the contribution of Australian health services research to the development of health policy over the past 20 years. We conclude that three preconditions are necessary to influence policy: political will; sustained funding to encourage methodological rigour and build decision makers' confidence; and the development of sufficient capacity and skills.     

Oral health in North Carolina: innovations, opportunities, and challenges

Dental disease can have negative and lasting effects on overall health and quality of life. The Institute of Medicine of the National Academy of Sciences reported last year that close to 5 million children in the United States did not receive needed care in 2008 because of costs. Increasing use of dental care has been selected by the U.S. Department of Health and Human Services as one of a small number of national leading health indicators, designating it as a national priority. Innovative initiatives have been undertaken in North Carolina to promote oral health, and there have been improvements in the state. For example, both the use of dental services among children and their oral health status are improving. Yet persistent and difficult challenges remain, such as ensuring an adequate workforce for the future, improving oral health literacy, maintaining existing programs, and resolving disparities in oral health and lifetime access to preventive and treatment services for all North Carolinians. This issue brief reviews some oral health initiatives and their outcomes--with a focus on youth. Commentaries in the policy forum also focus on access to oral health care; assessing, educating, and building the dental workforce; new practice models and trends; insurance innovation; and patients with special needs.     

A new EPOC in Australian health research

Contributing to health services research, implementation and effective health policy-making.     

Access to health care for ethnic minority populations

This paper reviews the research evidence on access to health care by ethnic minority populations, and discusses what might need to be done to improve access to services. Research on the process of care, and the quality of care received, is considered as well as studies examining uptake of services. Changes in legal context are increasing the pressure on healthcare organisations to examine and adapt their services to ensure equitable access. Examples presented include a new UK population cancer screening programme. The main challenges for clinicians, managers, and policy makers in ensuring equitable access are discussed.     

Socioeconomic determinants of health in Australia: policy responses and intervention options

Tackling socioeconomic health inequalities represents one of Australia's most challenging public health issues. Research has demonstrated that the role of physicians and other health professionals, as advocates for change in the delivery of health services, public health policy and other community-wide initiatives, is extremely important in reducing mortality and improving health outcomes. Multilevel actions to reduce health inequalities should include changes to macrolevel social and economic policies; improving living and working conditions; strengthening communities for health; improving behavioural risk factors; empowering individuals and strengthening their social networks; and improving responses from the healthcare system and associated treatment services. Australia has yet to develop a coordinated and integrated approach to addressing health disparities; however, previously successful public health interventions addressing other health issues are good starting points.     

A six-minute video-clip to ponder the values fostered by health technology

As part of our research team''s knowledge transfer and exchange (KTE) initiatives, we developed a six-minute video-clip to enable productive deliberations among technology developers, clinicians and patient representatives. This video-clip summarises in plain language the valuable goals and features that are embedded in health technology and raises questions regarding the direction that should be taken by health care innovations. The use of such video-clips creates unique opportunities for face-to-face deliberations by enabling participants to interact and debate policy issues that are pivotal to the sustainability of health care systems. In our experience, we found that audiovisual-elicitation-based KTE initiatives can fill an important communication gap among key stakeholders: pondering, from a health care system perspective, why and how certain kinds of medical technologies bring a more valuable response to health care needs when compared to others.     

Life in a time of uncertainty: optimising the health and wellbeing of young Australians

Perceptions of young people's health and wellbeing vary greatly, reflecting differences between disciplines, ideologies and generations. Young people are resilient, adaptable and doing well but, at the same time, are experiencing increased rates of important mental and physical health problems. While some of the contradictions in the evidence can be explained--for example, between measures of life satisfaction and happiness and indicators of psychosocial health--tensions between perspectives remain. We describe briefly a project involving cross-disciplinary synthesis that sought to gain a better understanding of the points of convergence and divergence in the commentaries and evidence on young people's wellbeing in Australia. The project suggests that, if young people's situation is to be optimised, there needs to be greater focus in both research and policy on: the "big picture" of the social changes reshaping life today; total health and wellbeing, not just ill health; the "mainstream" of youth, not only those young people who are marginalised and at-risk; and social and cultural resources that are as important to wellbeing as material and economic resources.     

Maintaining an agenda for children: the role of data in linking policy, politics and outcomes

There is growing recognition in Australia of the importance of early childhood to later health and wellbeing, with developments such as the National Agenda for Early Childhood and the National Public Health Action Plan for Children. To sustain a policy agenda for children and improve long-term outcomes, we need timely, comprehensive and accurate indicators and data on child health, development and wellbeing. Building this evidence requires a national monitoring and surveillance system that involves more than aggregating or linking existing data. Steps to building a national system are: to agree on key indicators of child health, development and wellbeing for regular reporting, to research a comprehensive set of indicators for each domain and ascertain data gaps, and to ensure development and coordination of data relevant to policy-making.     

Training Synergies Between Medical Informatics and Health Services Research: Successes and Challenges

Stanford''s two decades of success in linking medical informatics and health services research in both training and investigational activities reflects advantageous geography and history as well as natural synergies in the two areas. Health services research and medical informatics at Stanford have long shared a quantitative, analytic orientation, along with linked administration, curriculum, and clinical activities. Both the medical informatics and the health services research curricula draw on diverse course offerings throughout the university, and both the training and research overlap in such areas as outcomes research, large database analysis, and decision analysis/decision support. The Stanford experience suggests that successful integration of programs in medical informatics and health services research requires areas of overlapping or synergistic interest and activity among the involved faculty and, hence, in time, among the students. This is enhanced by a mixture of casual and structured contact among students from both disciplines, including social interactions. The challenges to integration are how to overcome any geographic separation that may exist in a given institution; the proper management of relationships with those sub-areas of medical informatics that have less overlap with health services research; and the need to determine how best to exploit opportunities for collaboration that naturally occur.Training in medical informatics and health services research has been closely linked at Stanford University for almost two decades. Although the close linkage was deliberate, it was facilitated by historical circumstances, in particular the common academic structures in which both programs arose. In this paper, we describe some of that rationale and history, identifying the areas of overlap that we have pursued in coordinating the training opportunities for graduate students and fellows in both areas of study. As we shall note, the synergies have been great, and in some cases trainees have collaborated closely on research while also taking some of the same courses. We believe that these interactions can be a model for the design of training programs that encourage scholarly interactions between medical informatics and health services research. Although our initial charge was to describe both the successes and failures in integrating the programs, we found that we could not identify any outright failures and that it would be better to delineate the complexities and challenges that we have faced in bringing together these two disciplines.     

EBM and the health of Indigenous Australians

Implementing evidence-based medicine (EBM) in primary healthcare for Indigenous people will usually involve increasing services, particularly those for chronic conditions. As shown by the example of diabetes care, there are significant organisational, educational, economic, cultural and structural barriers to implementing EBM in many Indigenous communities. Many of these barriers could be reduced by better-organised service delivery systems at the community level, greater numbers of Indigenous health professionals and greater advocacy for healthy public policy by health services. There is evidence that delivering evidence-based primary healthcare, particularly for chronic diseases, can improve health outcomes in Indigenous communities. There is a need for more investment in strategies to implement EBM and evidence-based public health in Indigenous settings.     

Service functions of private community health stations in China: A comparison analysis with government-sponsored community health stations

In China, with the restructuring of health care system moving forward, private community health facilities have been playing a complementary but increasingly important role in providing public health and basic medical care services in urban areas. However, only limited evidence is available concerning the service functions of private community health facilities in China. The aim of this study was to explore the functions of private community health stations (PCHSs) to provide evidence-based recommendations for policy-making and practice in the development of urban community health services systems. A total of 818 PCHSs and 4320 government-sponsored community health stations (GCHSs) located in 28 cities of China were investigated in 2008. The percentages of stations that provided health services and the annual workload per community health worker (CHW) were compared between the two types of institutions. The results showed that the percentages of PCHSs providing public health services were significantly higher than those of GCHSs (P<0.05); but no significant differences were found in the percentages of basic medical services providing between PCHSs and GCHSs (P>0.05). The annual workloads of all the public health services and basic medical services per CHW in PCHSs were lighter than those in GCHSs (P<0.05), except for resident health records establishment and health education materials distribution (P>0.05). At present, the GCHSs are still the mainstream in urban China, which will last for a long period in future. However, our findings showed that the annual workloads of CHWs in PCHSs were no heavier than those in GCHSs, and the PCHSs were willing to provide public health services. In view of current inadequacy of health resources in China, it is feasible to further develop PCHSs under the guidance of the government, given that PCHSs can perform the basic functions of community health services, which is useful for the formation of public-private partnerships (PPP) and the improvement of community health services.     

Initiatives to improve access to behavioral health services in the Veterans Affairs Health System

In response to veterans' needs in the context of recent deployments, the Veterans Affairs (VA) health system has increased the number of its facilities and caregivers and has pioneered changes in policy and programs. We review significant recent initiatives to improve access to behavioral health services in the VA health system.     

Basic amenities and health in urban India

We have examined the findings from various studies and corroborated other evidence that the large and continuous increase in India's urban population, and the concomitant growth of the population residing in slums and shanty towns, has resulted in over-straining of infrastructure and a deterioration in public health. Inadequate civic amenities, lack of purchasing power, and lack of knowledge and awareness among the urban poor have resulted in urban poverty which is very different from its rural counterpart. While a few policies have specifically targeted the urban poor, these have been neither sufficient nor effective. Also, the deteriorating health status of urban people needs urgent attention because many of the recent health problems can take an epidemic form if neglected. A resurgence of malaria, dengue and tuberculosis indicates that much of the poor health emanates from a lack of basic amenities such as sanitation, clean water and housing, coupled with a lack of awareness about the need to take precautionary measures against preventable and infectious diseases. To tackle these problems effectively, it is important for policy-makers to recognize that certain groups are more susceptible to ill health than others; they are vulnerable to the severe impact of illnesses and also the likely sources of infection for the population at large. There is an urgent need for research on the factors that prevent the urban poor from availing the services provided to them. It is possible that this is due to the lack of awareness-generating policies which should accompany any supply-side policies such as the provision of basic facilities (e.g. Sulabh Sauchalaya). To reduce the private costs as well as the negative externalities of ill health, it may be necessary to target such populations by cost-effective strategies based on holistic research on all the factors that determine well-being.     

Nailing health planks into the foreign policy platform: the Canadian experience

Foreign policy, especially trade policy, can have dramatic but rarely considered effects on public health. International human rights covenants oblige governments to scrutinise their foreign policy, including trade policy, for its impact on the progressive realisation of the right to health. Health is both a means and an end of development policy, but government investments in health are inadequate to reduce health disparities within and between nations. Few donor countries provide the agreed target of 0.7% of gross national income for development aid or toward reaching the Millennium Development Goals. The progressive liberalisation requirement of the General Agreement on Trade in Services (GATS), if applied to commitments in health care, education, and water and sanitation services, may conflict with the progressive realisation obligation of the right to health. Alternatives to regulating trade in such essential services are proposed in this article.     

健康中国视角下公共卫生学科建设与发展的思考

“健康中国”政策的实施与公共卫生密不可分，而国民健康水平的提高、健康危险因素的控制及健康服务能力的提升等各方面需要依托于医学院校公共卫生与预防医学专业的人才培养和学科建设。当前我国公共卫生学科建设和发展存在一定的滞后性和局限性，如公共卫生学术队伍和学科方向的非专业性，公共卫生教学科研与实践的割裂，公共卫生专业能力欠缺与人员规模不足，以及与经济发展不匹配的卫生应急和法律体系等。因此推进健康中国的建设应当推进公共卫生学科的交叉融合，强化卫生应急教学和实践，完善以预防为主的卫生应急和动态监测体系，使公共卫生学科兼具科学性和时代性。     

Core and comprehensive health care services: 4. Economic issues.

This article reviews the economic dimensions of the CMA's decision-making framework on core and comprehensive services. The framework was developed in a policy context characterized by three government objectives: reduction, reallocation and reassignment of health care resources. One economic-evaluation tool for the determination of core services is cost-effectiveness analysis. Some of the critical demand-side and supply-side considerations include the perceived value of medical services, the availability of private insurance and the supply of health care providers. The article concludes that shifting services to the private sector should not be viewed as a panacea for reducing the costs and improving the economic efficiency of the health care system, or for increasing patient access to, or the cost-effectiveness of high-quality care.     

Beyond the numbers: Papua New Guinean perspectives on the major health conditions and programs of the country

How members of the community perceive and respond to diseases and health problems are important variables to take into account when planning interventions and priorities in a health system. This paper summarizes some qualitative research undertaken in 2001 and 2002 in Papua New Guinea as part of the formative research for health promotion activity development for immunization, maternal health, tuberculosis and malaria services. It provides some highlights of the health beliefs and health-seeking behaviours amongst a range of urban and rural populations in a range of provinces in Papua New Guinea (PNG), and across a range of age groups including young adults. The findings reinforce that these health-related issues are seen by most of the population as important, although maternal health lags behind, especially in male respondents' perspectives. However, how they respond varies often with the planned health system interventions, and these differences need to be understood and addressed in order to increase the acceptability and efficiency of health services in PNG.     

A meeting of minds: interdisciplinary research in the health sciences in Canada

Brought together by the newly formed Canadian Academy of Health Sciences (CAHS), recognized national leaders in the 6 health sciences disciplines consider the environment for conducting interdisciplinary health research (IDHR) in Canada. Based on first-hand knowledge and thoughtful reflection, the authors argue that although much progress has been made in support of IDHR in Canada, the practical experience of researchers does not always bear this out. This article examines government, industry and academia to identify the cultural and structural characteristics that demand, promote or prevent IDHR in each sector. At its heart is the question, How can universities best support and enhance IDHR, not only for the benefit of science, but also to meet the growing needs of industry and government for intellectual capital?

Focusing on the predominant health sciences disciplines, the authors define IDHR as a team of researchers, solidly grounded in their respective disciplines, who come together around an important and challenging health issue, the research question for which is determined by a shared understanding in an interactive and iterative process. In addition, they suggest that IDHR is directly linked to translational research, which is the application of basic science to clinical practice and the generation of scientific questions through clinical observation.

This analysis of academic, industry and government sectors is not intended to offer rigorous data on the current state of IDHR in Canada. Rather, the goal is to stimulate research-policy dialogue by suggesting a number of immediate measures that can help promote IDHR in Canada.

Recommended measures to support IDHR are aimed at better resourcing and recognition (by universities and granting agencies), along with novel approaches to training, such as government- and industry-based studentships. In addition, we recommend that professional organizations reconsider their policies on publication and governance. Although intended to maintain professional scopes of practice, these policies also serve to entrench disciplinary boundaries in research.

We conclude by suggesting a number of research questions for a more rigorous assessment of the climate for IDHR in Canada. We call for an inventory and comparative analysis of academic centres, institutes and consortiums in Canada that strive to facilitate IDHR; an examination of the impact of professional organizations on health research, and on IDHR in particular; and a systematic review of research training opportunities that promote IDHR, with a view to identifying and replicating proven models.

     

Rediscovering university teaching hospitals for Australia

Partnership between research and health services has a long history in other countries, but has been relatively recent in Australia, with several models arising in the 1960s and 1970s as research-based specialties developed. Since the implementation of Medibank, which became Medicare, Australian Health Care Agreements have been primarily crafted on the basis of transactional numbers, ignoring the need for links with teaching and research and the need to implement new developments. Education and research have been seen as the responsibility of the federal government, and hospitals are progressively less recognised or funded for these functions by the states. Australia's teaching hospitals are in danger of falling seriously behind those in other countries and losing their capacity to monitor quality, to innovate and to branch into new strategies in partnership with primary care services. We should look at initiatives in other countries such as the United Kingdom and Canada, which are making big strides in tackling similar issues. University hospitals hold the key, if appropriately linked with other services. The current Australian Health Care Agreements are on hold. A new agency is needed to support clinical and service-related research, with a new structure and track for federal government funding, and providing oversight of research and development, of clinical governance and quality of outcomes in health care, linked with new strategies for prevention and treatment. A component of the foreshadowed additional federal government funding for health should be sequestered to set up such an agency.     

Complementary health care services: a survey of general practitioners' views.

OBJECTIVE: To determine the referral practices, perceived usefulness, knowledge, prior training and desire for training of general practitioners (GPs) in Quebec with regard to complementary health care services such as acupuncture, chiropractic and hypnosis. DESIGN: Cross-sectional mail survey. SETTING: Province of Quebec. PARTICIPANTS: Random sample of 200 GPs. Of the 146 who responded, 25 were excluded because they were no longer in practice; this left 121 (83%). OUTCOME MEASURES: Self-reported referral practices for complementary health care services, perceived usefulness and self-assessed knowledge of such services, and prior training and desire for training in these services. RESULTS: Sixty percent (72/121) of the GPs knew at least one practitioner of a complementary health care service for referral; 59% (70/119) reported referring patients to physicians who practise such services and 68% (80/118) to nonmedical practitioners. At least one of the three services studied were regarded as having some use by 83% (101/121). Overall, self-reported knowledge was poor: the proportions of GPs who reported knowing a lot about acupuncture, chiropractic and hypnosis were 11% (13/121), 10% (12/121) and 8% (10/121) respectively. Prior training was also lacking: only 8% (9/118) of the GPs had received previous training in acupuncture, 2% (2/111) in chiropractic and 3% (3/103) in hypnosis. In all, 48% (57/118) indicated that they would like further training in at least one of the services studied, and 13% (16/121) indicated that they currently provided one service. CONCLUSIONS: Referral of patients by GPs to practitioners of complementary health care services is common in Quebec. Although self-assessed knowledge about such services is relatively poor, interest in learning more about them is high. These findings identify a demand for future educational initiatives.