Comments on: It’s time to write the obituary for primary health care

By: Ruth Townsend

Ruth Townsend — Thu, 01 Jan 1970 10:00:00 +0000

It is fascinating to read John’s submission and to enjoy the benefit of reading Professor Baum’s reply given that they are both acknowledged experts in this area and particularly given Professor Baum’s position as Commissioner for the WHO Commission on the social determinants of health! And of course Professor Mooney and Dr Alperstein who also have expertise in the area! I wish there were more on-line discussions with contributors of your calibre!

Would it be naive to suggest that changes made to the Constitution in the 40’s regarding doctors and the inability of Government to now civially conscript them which ultimately means that we are unable to entice doctors with incentives to apply PHC principles to their practise as they do in the UK and Cuba because they essentially earn more acting as ‘private providers’ to the national system. I guess that concords with Dr Alperstein’s assessment that a motivation to adopt the PHC is somewhat lacking amongst this politically powerful group. I am however pleased to hear the federal minister speaking out about the need for change within the system and more importantly, Minister Nixon has been targeting change in that particular group. Time will tell how successful she is but we all, as academics, can continue to impress on our students, the health carers of tomorrow, the importance of adopting and applying PHC priniciples - for the health of the nation!

By: Garth Alperstein

Garth Alperstein — Thu, 01 Jan 1970 10:00:00 +0000

I agree with John MacDonald that for the moment, at this point in time, PHC is dead, but for sightly different reasons. I partially agree with his analysis for its demise. I think the main reason for its demise is because the forces for neoliberalism (individualism, private sector, market driven, and a world where the word equity either doesn’t exist, matter or has become synonymous with Communism) have been for a while, and currently still are far more powerful than the forces for equity, social justice and social democracy. Everything else follows, including the behaviours of the medical workforce. Not only have those in power embraced neoliberism, consumerism and materialism and exploited the developing world to maintain it, but so have a significant proportion of the public – the community out there. What is government saying we have to do to get us out of our current economic woes? Spend, spend, spend! Don’t save your money or pay off your debts – go out on a spend spree! And spend we did. We spent a few million more at the Melbourne Cup this year than last year, when economic times were much better. PHC is just another victim of neoliberalism.

However, I do not agree with either of John’s solutions:
Shift resources from hospitals to primary care. That will not have any effect on the ‘cause behind the cause’ (to use Michael Marmot’s phrase) of the problem. If one wanted a more sensible distribution of the pieces of the cake, rather fund more primary care with money from the military budget, or politicians’ perks budget, rather than the hospitals budget. Yes, we can be more efficient and spend less on high tech. However, that won’t result in a significant change in the expensive and less equitable two tier system we currently have. Nor will it change the basic underlying problem – the political system that has resulted in inequities.
..more to come

By: Fran Baum

Fran Baum — Thu, 01 Jan 1970 10:00:00 +0000

I understand John MacDonald’s frustration with the failure of governments to implement a truly comprehensive form of primary health care. In Australia we so often see the term “Primary Health Care” used and then find that the on-the-ground reality is GPs services with some behavioural change programs grafted on. Yet there have also been much better examples – Community Health Service in Victoria and South Australia from the 1970s-1990s provided a much stronger model. They were multidisciplinary, had community boards of management and engaged in a range of interventions including community development and social action. Similarly our Aboriginal Controlled Health services offer a great model of comprehensive PHC and show the importance of control.

The Commission on the Social Determinants of Health reported in August this year and made strong recommendations about the need for health systems that were based on comprehensive PHC and which also reached out to other sectors and ensure that they are aware of the health impact of their activities.The CSDH report was clear that effective implementation of PHC requires a sophisticated understanding of the impact of the social determinants of health. John is correct that Comprehensive Health Systems are required but more than anything we need a political commitment to the values of participation and equity and a strong recognition that health is not primarily about individual behaviours but about the ways in which organise society and the structures we establish and within which we all live our everyday lives.

By: Garth Alperstein

Garth Alperstein — Thu, 01 Jan 1970 10:00:00 +0000

Part 2:
Call it "Comprehensive Health Care Systems which would oblige medical practitioners to think beyond their preoccupation with clinical interventions and give us a lever to push for evidence of systemic linkages between prevention, promotion and curative care.” This is more like the system in Cuba where medical practitioners are responsible for the clinical care of ill health of individuals in their community, as well the overall ‘good’ health of that community. They are trained and paid to do that. It can work in Cuba, because Cuba does not have neoliberal political system. If Cuba adopted neoliberal policies, that system would die too in Cuba. In Australia we would have to nationalise the health system to do Comprehensive Health Care Systems. But that won’t occur while we worship the “neoliberal God”.
So what are the solutions? Where is there some semblance of PHC with good equitable outcomes? The closest one gets today are in countries that take equity seriously – like the social democracies of Scandinavia, state of Kerala in India, Costa Rica, Cuba and a few others.
If Australia and the rest of the developed world were to morph from a neoliberal political system into a Scandinavian style social democracy, PHC in developed countries and the rest of the world might have a chance. Short of that, I think you are right John – PHC is dead. Long live PHC.
What will the future bring? I think only Nostradamus knows that.
Garth (not a pessimist, a realist!)

By: Gavin mooney

Gavin mooney — Thu, 01 Jan 1970 10:00:00 +0000

John Macdonald is so right about the failure of Primary Health Care (PHC) but I do not think we should give it up. What is the problem in PHC is best seen through the lens of political economy - who holds the power in health care in resource allocation? The answer by and large is the medical profession who in the main want more and more resources to go to treatment within hospitals - hence the frequent calls by the profession for more and more hospital beds rather than more and more resources in PHC and the community to keep people out of hospital.

Don't give up on PHC John but rather look to changing power structures within health care. As a society we need to see the health care system as first and foremost a social institution. Interestingly in citizens' juries (with informed citizens chosen randomly, asked to act as citizens representing their community and given time to reflect) here in WA, out of six that I have been involved in not one has given priority to hospital care. They are much more interested in giving priority to equity, community care and public health.

So don't give up on PHC John - just think of it as the People's Health Care and that shift in power can get us there!