Comprehensive primary health care and social determinants as top priorities

Compared with other countries, Australia does very well in terms of health. We rank second in terms of life expectancy, reflecting our level of education, housing and living standards. We have a health system many envy — based on universal public health insurance. And yet, there is room for improvement.

Evidence suggests that more equal societies are healthier.1 An explicit goal of the next Australian federal government, therefore, should be reducing health inequities. To achieve this, vastly improved coordination of primary health care (PHC) services is needed. In addition, the new government’s agenda should prioritise action to improve the social determinants of health.2 By improving community health overall, our continually increasing and economically unsustainable health care costs that are excessively focused on hospital care will be reduced.

The World Health Organization has stated that health systems should be built on the basis of a strong, comprehensive PHC system.3,4 Such a system needs to cure disease, provide rehabilitation, prevent disease and promote health. For the past 20 years, Australian governments have been instituting reforms to achieve this. But the task is made difficult by lack of coordination between fee-for-service general practice, which provides episodic care, and parallel services offered by state and territory governments, such as community health services that provide multidisciplinary curative (eg, diabetes management), rehabilitative (diabetes self-care), preventive (exercise groups and promoting healthy eating) and promotive (lobbying to restrict the sale of high-fat and high-sugar foods) services. The origins of the latter services go back to the Whitlam government’s Community Health Program,5 and, despite uneven development, these services have offered comprehensive PHC services as recommended by the WHO.3,4 The Rudd–Gillard health reforms aimed to produce improved coordination of PHC services through Medicare Locals, created to assume responsibility for regional coordination and planning. It is too early to comment on their effectiveness. However, a new government would do well to build on these structures and to use the federal–state health care agreements to ensure that all states and territories do not abandon disease prevention and health promotion, as Queensland and South Australia appear to have done. The new government should also institute formal trials of community-managed community health centres that enrol general practice patients (rather than offering fee-for-service), offer a range of allied health services, run support groups (for people with chronic disease, mental illness and people coping with issues such as domestic violence) and promote health, including through community development. The existing network of Aboriginal community-controlled health services should be strengthened and new services established with increased funding and more supportive governance models. A well coordinated PHC sector would contribute to reducing health inequities by increasing access to health care for Indigenous people living in remote areas and people living on low incomes.

The second priority of an incoming government should be responding to the social determinants of health. The Senate Community Affairs References Committee has emphasised the importance to Australia of prioritising social determinants.6 The response should be systematic, whole-of-government and based on health in all policies (HiAP).7 An HiAP approach has been trialled in a number of countries and in South Australia.8 Its aim is to hold all government sectors accountable for their health impact and for determining how negative impacts can be minimised and positive ones maximised; for example, urban planning would be done in a way that encourages physical activity and social connectivity, and food supply would be regulated to reduce fat and sugar content in diets. An incoming government should ask the Department of the Prime Minister and Cabinet to take responsibility by ensuring that all departments are conscious of their health impact and take measures to maximise health. This will have a far greater impact on health than health care services are able to have.