The George Institute for Global Health, University of Sydney, Sydney, Australia.
BMC Health Serv Res. 2012 Oct 28;12:369. doi: 10.1186/1472-6963-12-369.
Australian federal and jurisdictional governments are implementing ambitious policy initiatives intended to improve health care access and outcomes for Aboriginal and Torres Strait Islander people. In this qualitative study we explored Aboriginal Medical Service (AMS) staff views on factors needed to improve chronic care systems and assessed their relevance to the new policy environment.
Two theories informed the study: (1) 'candidacy', which explores "the ways in which people's eligibility for care is jointly negotiated between individuals and health services"; and (2) kanyini or 'holding', a Central Australian philosophy which describes the principle and obligations of nurturing and protecting others. A structured health systems assessment, locally adapted from Chronic Care Model domains, was administered via group interviews with 37 health staff in six AMSs and one government Indigenous-led health service. Data were thematically analysed.
Staff emphasised AMS health care was different to private general practices. Consistent with kanyini, community governance and leadership, community representation among staff, and commitment to community development were important organisational features to retain and nurture both staff and patients. This was undermined, however, by constant fear of government funding for AMSs being withheld. Staff resourcing, information systems and high-level leadership were perceived to be key drivers of health care quality. On-site specialist services, managed by AMS staff, were considered an enabling strategy to increase specialist access. Candidacy theory suggests the above factors influence whether a service is 'tractable' and 'navigable' to its users. Staff also described entrenched patient discrimination in hospitals and the need to expend considerable effort to reinstate care. This suggests that Aboriginal and Torres Strait Islander people are still constructed as 'non-ideal users' and are denied from being 'held' by hospital staff.
Some new policy initiatives (workforce capacity strengthening, improving chronic care delivery systems and increasing specialist access) have potential to address barriers highlighted in this study. Few of these initiatives, however, capitalise on the unique mechanisms by which AMSs 'hold' their users and enhance their candidacy to health care. Kanyini and candidacy are promising and complementary theories for conceptualising health care access and provide a potential framework for improving systems of care.
澳大利亚联邦和州政府正在实施雄心勃勃的政策举措，旨在改善原住民和托雷斯海峡岛民的医疗保健获取和结果。在这项定性研究中，我们探讨了原住民医疗服务（AMS）工作人员对改善慢性病护理系统所需因素的看法，并评估了这些因素与新政策环境的相关性。
有两个理论为这项研究提供了信息：（1）“候选资格”，它探讨了“个人和医疗服务机构共同协商人们获得护理的资格的方式”；（2）kanyini 或“持有”，这是一种澳大利亚中部的哲学，描述了培育和保护他人的原则和义务。通过在六个 AMS 和一个政府主导的原住民健康服务机构中进行小组访谈，对经过当地改编的慢性病护理模型领域的结构化健康系统评估进行了管理。对数据进行了主题分析。
工作人员强调，AMS 的医疗保健与私人全科医生不同。与 kanyini 一致，社区治理和领导力、员工中的社区代表以及对社区发展的承诺是保留和培育员工和患者的重要组织特征。然而，他们经常担心 AMS 的政府资金被扣留，这破坏了这些特征。工作人员的资源、信息系统和高级领导层被认为是提高医疗保健质量的关键驱动因素。由 AMS 工作人员管理的现场专科服务被认为是增加专科医生可及性的一项可行策略。候选资格理论表明，上述因素会影响服务是否对其用户“可处理”和“可导航”。工作人员还描述了在医院中根深蒂固的患者歧视，以及需要花费大量精力来恢复护理。这表明，原住民和托雷斯海峡岛民仍然被构建为“非理想用户”，并被医院工作人员拒绝“持有”。
一些新的政策举措（增强劳动力能力、改善慢性病护理提供系统和增加专科医生的可及性）有可能解决本研究中强调的障碍。然而，这些举措很少利用 AMS 机构“持有”其用户并增强他们对医疗保健的候选资格的独特机制。kanyini 和候选资格是概念化医疗保健获取的有前途和互补的理论，并为改善护理系统提供了一个潜在框架。
