Replacing the clockwork model of medicine

Loneliness and negative effects on mental health as trade-offs of the policy response to COVID-19

This note introduces a framework incorporating multiple sources of evidence into the response to COVID-19 to overcome the neglect of social and psychological causes of illness. By using the example of psychological research on loneliness and its effects on physical and mental health with particular focus on aging and disability, I seek to open further inquiry into how relevant psychological and social aspects of health can be addressed at policy level.

Strife of Interests: Constraints on integrated and co-ordinated comprehensive PHC in Australia

The 1978 World Health Organisation Alma Ata Declaration on Primary Health Care (PHC) emphasised a comprehensive view which stressed the importance of cure, prevention, promotion and rehabilitation delivered in a way that involved local communities and considered a social, economic and political perspective on health. Despite this, selective approaches have dominated. This paper asks why this has been the case in Australia through a multi-method study of regional PHC organisations. Interviews with senior policy players, focus groups with non-government organisations and document analysis inform an institutional and power analysis of PHC. The findings indicate that there are different interests competing for attention in PHC but that medical perspectives prove the most powerful and are reinforced by the actors, ideas and institutions that shape PHC. Community perspectives which stress lived experience and social perspectives on health are marginal concerns in the implementation of PHC. The other important interest is that of a neo-liberal perspective on health policy which stresses cost-containment, close measurement of activity and fragmented contracting out of services. This perspective is not compatible with a social determinants of health perspective and can also conflict with a medical view. The result of the interplay between competing interests and the distribution of power is a selective PHC system that is not likely to change without radical shifts in power and perspectives.

The potential for multi-disciplinary primary health care services to take action on the social determinants of health: actions and constraints

BACKGROUND

The Commission on the Social Determinants of Health and the World Health Organization have called for action to address the social determinants of health. This paper considers the extent to which primary health care services in Australia are able to respond to this call. We report on interview data from an empirical study of primary health care centres in Adelaide and Alice Springs, Australia.

METHODS

Sixty-eight interviews were held with staff and managers at six case study primary health care services, regional health executives, and departmental funders to explore how their work responded to the social determinants of health and the dilemmas in doing so. The six case study sites included an Aboriginal Community Controlled Organisation, a sexual health non-government organisation, and four services funded and managed by the South Australian government.

RESULTS

While respondents varied in the extent to which they exhibited an understanding of social determinants most were reflexive about the constraints on their ability to take action. Services' responses to social determinants included delivering services in a way that takes account of the limitations individuals face from their life circumstances, and physical spaces in the primary health care services being designed to do more than simply deliver services to individuals. The services also undertake advocacy for policies that create healthier communities but note barriers to them doing this work. Our findings suggest that primary health care workers are required to transverse "dilemmatic space" in their work.

CONCLUSIONS

The absence of systematic supportive policy, frameworks and structure means that it is hard for PHC services to act on the Commission on the Social Determinants of Health's recommendations. Our study does, however, provide evidence of the potential for PHC services to be more responsive to social determinants given more support and by building alliances with communities and social movements. Further research on the value of community control of PHC services and the types of policy, resource and managerial environments that support action on social determinants is warranted by this study's findings.