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

Abstract

BackgroundThe 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.MethodsSixty-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.ResultsWhile 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.ConclusionsThe 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.

Revisiting the ability of Australian primary healthcare services to respond to health inequity

“…As an NGO they haddid, however, have some flexibility not available to the state-managed services the ability to provide services outside the scope of the service agreement, giving them some flexibility not available to the state-managed services. The more positive findings for the community controlled and non-government organisations accord with our findings of strengths for these two models in other aspects of CPHC as well, such as health promotion, action on the social determinants of health, and community participation Baum et al, 2013;Freeman et al, 2014). These findings support literature indicating more comprehensive models of PHC only achieve traction outside the mainstream health system (Hurley et al, 2010).…”

“…Improving health care access and reducing health inequities are key objectives of CPHC (Baum, 2007;World Health Organization, 1978) and require a broad range of strategies enabling actions on social determinants of health inequity (Baum et al, 2013; Commission on Social Determinants of Health, 2008), and enhancing equity of access (Freeman et al, 2011;Thiede et al, 2007). These strategies require funding, organisational and policy support, which are vulnerable to changes in fiscal and political environments (Hanratty et al, 2007;Jolley et al, 2014).…”

Factors shaping intersectoral action in primary health care services

“…In contrast, workers in state-managed services were taking IAH within less supportive organisational environment, and the constraints to their political agency from their role as public servants had increased as the priorities of the Department of Health had shifted away from health promotion. 30 This research offers a largely historical review as health promotion work has recently largely been removed from South Australian health services.…”

“…These included an Aboriginal community controlled organisation, Central Australian Aboriginal Congress, a non-government agency, the Sexual Health information networking and education SA Inc (SHine SA), and four South Australian state-government-managed services anonymised as Services A, C, D, and E. 30 Service B withdrew from the study prior to the research reported here and was replaced by Service E. Such turnover was expected as the project spanned five years at a time of considerable change and reorganisation of PHC within Australia. Service labels were maintained for consistency across the project research papers.…”

Theory vs Practice: Should Primary Care Practice Take on Social Determinants of Health Now? No.

“…Published literature on the topic is mostly theoretical or commentary, with the very few studies in small and atypical practice settings. [2][3][4][5][6][7][8][9][10] The article by DeVoe and colleagues in this issue of Annals recommends a very reasonable approach of collecting community and patient data before taking individual patient and panel actions and then adding automated supports. 11 Before we ask practices to take on these tasks, however, we need much more evidence that it is both feasible and effective.…”