Southgate Institute for Health, Society and Equity/Flinders University, Adelaide, Australia.
School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada.
BMC Public Health. 2018 Mar 20;18(1):383. doi: 10.1186/s12889-018-5273-4.
Worldwide, there are competing norms driving health system changes and reorganisation. One such norm is that of health systems' responsibilities for population health as distinct from a focus on clinical services. In this paper we report on a case study of population health planning in Australian primary health care (PHC) organisations (Medicare Locals, 2011-2015). Drawing on institutional theory, we describe how institutional forces, ideas and actors shaped such planning.
We reviewed the planning documents of the 61 Medicare Locals and rated population health activities in each Medicare Local. We also conducted an online survey and 50 interviews with Medicare Local senior staff, and an interview and focus group with Federal Department of Health staff.
Despite policy emphasis on population health, Medicare Locals reported higher levels of effort and capacity in providing clinical services. Health promotion and social determinants of health activities were undertaken on an ad hoc basis. Regulatory conditions imposed by the federal government including funding priorities and time schedules, were the predominant forces constraining population health planning. In some Medicare Locals, this was in conflict with the normative values and what Medicare Locals felt ought to be done. The alignment between the governmental and the cultural-cognitive forces of a narrow biomedical approach privileged clinical practice and ascribed less legitimacy to action on social determinants of health. Our study also shed light on the range of PHC actors and how their agency influenced Medicare Locals' performance in population health. The presence of senior staff or community boards with a strong commitment to population health were important in directing action towards population health and equity.
There are numerous institutional, normative and cultural factors influencing population health planning. The experience of Australian Medicare Locals highlights the difficulties of planning in such a way that the impact of the social determinants on health and health equity are taken into account. The policy environment favours a focus on clinical services to the detriment of health promotion informed by a social determinants focus.
在全球范围内，有各种规范推动着卫生系统的变革和重组。其中一个规范是卫生系统对人群健康的责任，而不是专注于临床服务。本文报告了澳大利亚基层医疗保健组织（医疗保险地方机构，2011-2015 年）进行人口健康规划的案例研究。本文运用制度理论，描述了制度力量、观念和行为者如何塑造这种规划。
我们回顾了 61 个医疗保险地方机构的规划文件，并对每个医疗保险地方机构的人口健康活动进行了评级。我们还对医疗保险地方机构的高级职员进行了在线调查和 50 次访谈，并对联邦卫生部的职员进行了访谈和焦点小组讨论。
尽管政策强调人口健康，但医疗保险地方机构报告称，在提供临床服务方面投入的精力和能力更高。健康促进和社会决定因素的健康活动是临时进行的。联邦政府施加的监管条件，包括资金优先事项和时间表，是限制人口健康规划的主要力量。在一些医疗保险地方机构中，这与规范价值和医疗保险地方机构认为应该做的事情相冲突。政府和狭隘的生物医学方法的文化认知力量之间的一致性使临床实践得到重视，而对社会决定因素的健康行动赋予较少的合法性。我们的研究还揭示了基层医疗保健的各种行为者及其机构的范围，以及他们的行为如何影响医疗保险地方机构在人口健康方面的表现。拥有强烈关注人口健康的高级职员或社区委员会，对将行动导向人口健康和公平具有重要意义。
有许多制度、规范和文化因素影响人口健康规划。澳大利亚医疗保险地方机构的经验突出表明，要以考虑社会决定因素对健康和健康公平的影响的方式进行规划存在困难。政策环境有利于以牺牲以社会决定因素为重点的健康促进为代价，专注于临床服务。
