Background: One third of all Australians live outside of its major cities. Access to health services and health outcomes are generally poorer in rural and remote areas relative to metropolitan areas. In order to improve access to services, many new programs and models of service delivery have been trialled since the first National Rural Health Strategy in 1994. Inadequate evaluation of these initiatives has resulted in failure to garner knowledge, which would facilitate the establishment of evidence-based service models, sustain and systematise them over time and facilitate transfer of successful programs. This is the first study to systematically review the available published literature describing innovative models of comprehensive primary health care (PHC) in rural and remote Australia since the development of the first National Rural Health Strategy (1993Strategy ( -2006. The study aimed to describe what health service models were reported to work, where they worked and why.

Background: Chronic illness and disability can have damaging, even catastrophic, socioeconomic effects on individuals and their households. We examined the experiences of people affected by chronic heart failure, complicated diabetes and chronic obstructive pulmonary disease to inform patient centred policy development. This paper provides a first level, qualitative understanding of the economic impact of chronic illness.

Advances in software are allowing the participatory model building approach to be extended to more sophisticated multimethod modelling that provides policy makers with more powerful tools to support the design of targeted, effective and equitable policy responses for complex health problems. Building capacity and investing in communication to promote these modelling methods, as well as documenting and evaluating their applications, will be vital to supporting uptake by policy makers.

BackgroundIn the design of public health policy, a broader understanding of risk factors for disease across the life course, and an increasing awareness of the social determinants of health, has led to the development of more comprehensive, cross-sectoral strategies to tackle complex problems. However, comprehensive strategies may not represent the most efficient or effective approach to reducing disease burden at the population level. Rather, they may act to spread finite resources less intensively over a greater number of programs and initiatives, diluting the potential impact of the investment. While analytic tools are available that use research evidence to help identify and prioritise disease risk factors for public health action, they are inadequate to support more targeted and effective policy responses for complex public health problems.DiscussionThis paper discusses the limitations of analytic tools that are commonly used to support evidence-informed policy decisions for complex problems. It proposes an alternative policy analysis tool which can integrate diverse evidence sources and provide a platform for virtual testing of policy alternatives in order to design solutions that are efficient, effective, and equitable. The case of suicide prevention in Australia is presented to demonstrate the limitations of current tools to adequately inform prevention policy and discusses the utility of the new policy analysis tool.SummaryIn contrast to popular belief, a systems approach takes a step beyond comprehensive thinking and seeks to identify where best to target public health action and resources for optimal impact. It is concerned primarily with what can be reasonably left out of strategies for prevention and can be used to explore where disinvestment may occur without adversely affecting population health (or equity). Simulation modelling used for policy analysis offers promise in being able to better operationalise research evidence to support decision making for complex problems, improve targeting of public health policy, and offers a foundation for strengthening relationships between policy makers, stakeholders, and researchers.

Primary health care in Australia has undergone 2 decades of change. Starting with a vision for a national health strategy with general practice at its core, Australia established local meso-level primary health care organizations-Divisions of General Practice-moving from focus on individual practitioners to a professional collective local voice.The article identifies how these meso-level organizations have helped the Australian primary health care system evolve by supporting the roll-out of initiatives including national practice accreditation, a focus on quality improvement, expansion of multidisciplinary teams into general practice, regional integration, information technology adoption, and improved access to care. Nevertheless, there are still challenges to ensuring equitable access and the supply and distribution of a primary care workforce, addressing the increasing rates of chronic disease and obesity, and overcoming the fragmentation of funding and accountability in the Australian system. (J Am Board Fam Med 2012;25:S18 -26.)

Successful, “innovative” primary health care (PHC) models exist that have adapted to the specific circumstances of their rural and remote context. A typology of discrete, integrated, comprehensive and outreach rural and remote services exists rather than a “one coat fits all” PHC health service model. Successful models are characterised by macro‐scale environmental enablers (supportive health policy, federal–state relations, and community readiness) and five essential service requirements (workforce organisation and supply; funding; governance, management and leadership; linkages; and infrastructure). Service sustainability depends on ensuring that key systemic service requirements are met at the local level in ways that accord with, and are supported by, the broader macro‐scale environmental enablers. Based on these principles, these model types are amenable to generalisation and evaluation in other regions.

Objective: To describe the factors and processes that facilitate or inhibit implementation, sustainability and generalisation of effective models of primary health care (PHC) service delivery in rural and remote Australia. Design: Case‐study approach, including review of relevant literature, interviews with key informants, site visits and direct observation. Thematic analysis and template analysis were used with interview transcripts. An expert reference group provided feedback and advice on policy relevance. Setting and participants: Six PHC services in small communities across rural and remote Australia were selected based on results of a previous systematic review; they reflected diverse rural and remote settings and PHC models, and the multidisciplinary nature of PHC. Sites were visited, and 55 individuals associated with the establishment and operation of these services were interviewed between July 2006 and December 2007. Results: Independent and template analysis confirmed the usefulness of a conceptual framework, which identified three key “environmental enablers” — supportive policy; federal and state/territory relations; and community readiness — and five essential service requirements — governance, management and leadership; funding; linkages; infrastructure; and workforce supply. Systematically addressing each of these factors improves effectiveness and lessens the threat to service sustainability. Conclusions: Evidence from existing effective rural and remote PHC services can inform the health care reform agenda, in Australia and other countries. The evidence highlights the need for improved governance, management and community involvement, as well as strong, visionary political leadership to achieve a more responsive and better coordinated health system which could help eliminate existing health status differentials between cities and rural areas. In Australia, establishment of a single national health system, operationalised at a regional level, would obviate much of the current inefficiency and poor coordination.

BackgroundCoordination of care is considered a key component of patient-centered health care systems, but is rarely defined or operationalised in health care policy. Continuity, an aspect of coordination, is the patient’s experience of care over time, and is often described in terms of three dimensions: information, relational and management continuity. With the current health policy focus on both the use of information technology and care coordination, this study aimed to 1) explore how information continuity supports coordination and 2) investigate conditions required to support information continuity.MethodsFour diverse Australian primary health care initiatives were purposively selected for inclusion in the study. Each has improved coordination as an aim or fundamental principle. Each organization was asked to identify practitioners, managers and decision makers who could provide insight into the use of information for care coordination to participate in the study. Using in-depth semi-structured interviews, we explored four questions covering the scope and use of information, the influence of governance, data ownership and confidentiality and the influence of financial incentives and quality improvement on information continuity and coordination. Data were thematically analyzed using NVivo 8.ResultsThe overall picture that emerged across all four cases was that whilst accessibility and continuity of information underpin effective care, they are not sufficient for coordination of care for complex conditions. Shared information reduced unnecessary repetition and provided health professionals with the opportunity to access records of care from other providers, but participants described their role in coordination in terms of the active involvement of a person in care rather than the passive availability of information. Complex issues regarding data ownership and confidentiality often hampered information sharing. Successful coordination in each case was associated with responsiveness to local rather than system level factors.ConclusionsThe availability of information is not sufficient to ensure continuity for the patient or coordination from the systems perspective. Policy directed at information continuity must give consideration to the broader ‘fit’ with management and relational continuity and provide a broad base that allows for local responsiveness in order for coordination of care to be achieved.