Some Canadian lessons on primary health care reform; and facing up to dilemmas of public health advocacy
What can Australian primary health care reform learn from the Canadian experience?
What are some of the rarely-discussed dilemmas faced by health campaigners when they engage in advocacy?
These questions are addressed in the latest articles profiled by theÂ Primary Health Care Research & Information Service.
Lessons from Albertaâ€™s primary care networks for Medicare Locals
Dr Jodie Oliver-Baxter writes:
The challenge for primary care worldwide is to improve access (especially in rural or remote regions), manage chronic diseases, foster multidisciplinary teams, and develop further links between primary care and hospitals.
Medicare Locals could consider learning from the Primary Care Networks (PCN) established in Alberta in 2005, given our similar health system structures, according to the authors of a recent article in The Medical Journal of Australia.
PCNs are organisations of practices. They do not enrol patients, nor do they run practices. Nominal capitation funding ($50 per patient) is allocated to the network based on patients registered at practices within the PCN; in Canada it is desirable that patients are registered with a practitioner but they are not penalised for visiting other practices.
PCNs are required to submit business plans to the provincial provider organisation responsible for the flow of funding, Alberta Health Services.
These plans are to detail how capitation funding will be spent; there is flexibility in the structure and content of these reports to allow for local variation in priority setting.
Medicare Locals could learn from three portable mechanisms of PCNs.
1. Capitation Funding enables the PCN to know how much they can expect and can plan and budget accordingly.
2. A dual board system as the governance structure of PCNs reflects both practitioner autonomy and the need for accountability. This is formalised by two decision making forums – the practitioners board (â€˜little boardâ€™) and the PCN board (â€˜big boardâ€™).
The Big Board includes members representing the funding organisations providing a direct link to senior local provincial leaders who are responsible for wider health issues.
3. The last lesson from PCNs is to take an evolutionary approach allowing time for phase-in. This means the system is not imposed on any practitioners or practices and allows sceptics to evaluate benefits of local cooperation.
Evaluation is mentioned in this article but there is little formal evaluation, which reflects a broader lack of clear direction for PCNs; this partly stems from the autonomy granted to PCNs in setting priorities to allow for flexibility to respond to local needs.
This is a weakness but also a strength of the network.
â€¢ Suchowersky, A., O. Suchowersky, et al. (2012). “Can Alberta’s primary care networks provide any lessons for Medicare Locals?” Medical Journal of Australia 196(1): 27-28.
If you like the topic, you might also like this article from the eBulletin’sÂ October 4th edition.
Dealing with dilemmas in health campaigning
Â Dr Melissa Raven writes:
Robust debates are common in the public health arena. Recent controversies include plain packaging for cigarettes, routine circumcision of baby boys, whether or not GPs should screen for prostate cancer and how they should respond to obese children and their parents.
A new article, ‘Dealing with dilemmas in health campaigning’, published in Health Promotion International by University of Wollongong Professor Brian Martin, divides research on scientific controversies into four categories.
The first is a ‘positivist approach’ that assumes dominant mainstream scientific views are correct and opponents’ views are wrong, and analyses reasons for opposition.
The second category is a ‘group politics approach’, which looks at the activities of government entities, corporations, citizens’ groups and other participants in debates.
The ‘constructivist approach’ is a third category that analyses the social construction of claims on both sides of a debate, using a sociological perspective.
Lastly, a ‘social structural approach’ uses concepts such as class, gender, the state and professional status to analyse participants and alliances in debates.
These approaches are useful for analysing debates, but they do not offer health campaigners much direction about how to act. There has been very little research on campaigning tactics with most research on controversies focusing on the issue, not on the processes of debate and advocacy.
In fact, there has been ‘continuing neglect of advocacy as a serious, funded priority even among many public health institutions’, according to University of Sydney Professor Simon Chapman, a leading campaigner against the tobacco industry Â (p. xiii).
Martin discusses six dilemmas that health campaigners face when they engage in advocacy. These dilemmas, which are rarely openly discussed, are whether or not to engage in these strategies:
1. Acknowledging shortcomings of their position, e.g. acknowledging that vaccines can cause adverse reactions.
2. Advocating for more research, which could strengthen their position, but could also weaken it.
3. Acknowledging vested interests, e.g. disclosing pharmaceutical industry funding.
4. Publicly debating opponents and issues, which can provide an opportunity to demonstrate the weaknesses in opponents’ positions, but can also seem to give legitimacy to opponents.
5. Attacking opponents, which can weaken their willingness and capacity to continue advocating their position, but may also be perceived as unfair.
6. Criticising radical flanks (people who engage in extreme action) on their own side, e.g. some anti-tobacco campaigners disapproved of BUGAUP activists who defaced cigarette billboards in the 1980s.
Martin discusses the pros and cons of these strategies, concluding that there are no simple answers to these dilemmas. Choices in either direction can be supported by both ethical principles and pragmatism.
However, he notes that some controversies are ‘incredibly bitter and may seem never ending’, and he suggests that it may be better to be open and honest and engage respectfully with opponents rather than just focusing on winning the current debate.
Declaration: Melissa Raven is a member of Healthy Skepticism. Brian Martin supervised her PhD thesis.
Martin, B. (2012). “Dealing with dilemmas in health campaigning.” Health Promotion International. doi:10.1093/heapro/das052
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