Javanparast Sara, Maddern Janny, Baum Fran, Freeman Toby, Lawless Angela, Labonté Ronald, Sanders David
Southgate Institute for Health, Society and Equity, Flinders University, Adelaide, Australia.
Department of Health Care Management, Flinders University, Adelaide, Australia.
Int J Health Plann Manage. 2018 Jan;33(1):e76-e88. doi: 10.1002/hpm.2413. Epub 2017 Mar 22.
INTRODUCTION/BACKGROUND: Globally, health reforms continue to be high on the health policy agenda to respond to the increasing health care costs and managing the emerging complex health conditions. Many countries have emphasised PHC to prevent high cost of hospital care and improve population health and equity. The existing tension in PHC philosophies and complexity of PHC setting make the implementation and management of these changes more difficult. This paper presents an Australian case study of PHC restructuring and how these changes have been managed from the viewpoint of practitioners and middle managers.
As part of a 5-year project, we interviewed PHC practitioners and managers of services in 7 Australian PHC services.
Our findings revealed a policy shift away from the principles of comprehensive PHC including health promotion and action on social determinants of health to one-to-one disease management during the course of study. Analysis of the process of change shows that overall, rapid, and top-down radical reforms of policies and directions were the main characteristic of changes with minimal communication with practitioners and service managers. The study showed that services with community-controlled model of governance had more autonomy to use an emergent model of change and to maintain their comprehensive PHC services.
Change is an inevitable feature of PHC systems continually trying to respond to health care demand and cost pressures. The implementation of change in complex settings such as PHC requires appropriate change management strategies to ensure that the proposed reforms are understood, accepted, and implemented successfully.
引言/背景：在全球范围内，卫生改革在卫生政策议程上仍然占据重要位置，以应对不断上涨的医疗保健成本，并应对新出现的复杂健康状况。许多国家都强调初级卫生保健，以防止医院护理成本过高，并改善人群健康和公平性。初级卫生保健理念中现有的矛盾以及初级卫生保健环境的复杂性，使得这些变革的实施和管理更加困难。本文介绍了澳大利亚初级卫生保健重组的案例研究，以及从从业者和中层管理人员的角度来看这些变革是如何进行管理的。
作为一个为期5年项目的一部分，我们采访了澳大利亚7个初级卫生保健服务机构的初级卫生保健从业者和服务管理人员。
我们的研究结果显示，在研究过程中，政策发生了转变，从包括健康促进和针对健康的社会决定因素采取行动的全面初级卫生保健原则，转向一对一的疾病管理。对变革过程的分析表明，总体而言，政策和方向的快速、自上而下的激进改革是变革的主要特征，与从业者和服务管理人员的沟通极少。研究表明，采用社区治理模式的服务机构在采用新兴变革模式和维持其全面初级卫生保健服务方面具有更大的自主权。
变革是初级卫生保健系统不断试图应对医疗保健需求和成本压力时不可避免的特征。在初级卫生保健等复杂环境中实施变革需要适当的变革管理策略，以确保所提议的改革得到理解、接受并成功实施。
