The question at the core of this Review is simple: what is the evidence that primary health care services have positively changed Aboriginal and Torres Strait Islander health status? However, attempting an answer to this brings into focus two logically prior questions.
- Is there evidence that health systems in general improve the health of populations? Common sense says that the way to better health lies through better health systems. However, Thomas McKeown’s theories in the 1970s, and the powerful evidence of the importance of the social determinants of health more recently, have significantly challenged such a simple view. These theories are of particular relevance in the Aboriginal and Torres Strait Islander policy field, which has also seen tendencies to reduce ‘better health’ to a matter of ‘better infrastructure’ (for example housing, water quality and sanitation), and to see health services as irrelevant or marginal to the process of building healthier communities.
- More particularly, is there evidence about the extent to which primary health care services contribute to any such improvements? In particular, if there is no strong evidence to support the contention that primary health care improves ‘mainstream’ population health, it would be unwarranted to expect the evidence to show such a pattern in Aboriginal and Torres Strait Islander communities.
... the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work ... the first element of a continuing health care process.5
This is necessary to capture the available research literature to answer the question asked. Of course any positive results from studies using a narrower definition of primary health care will understate the population health gain possible through a more comprehensive model.
As far as we are aware there has been no comprehensive attempt in the field of primary health care policy in Australia to stand back in this way and look in the broadest manner possible at the relationship between the provision of primary health care and the health of populations. However, answering these questions is necessary to set the theoretical and evidentiary foundations from which we can looks at the more specific questions regarding Indigenous health and primary health care in Australia, as follows.
- Is there evidence that the health of Indigenous populations, both here in Australia and overseas, has improved? This question goes to the heart of any scepticism about the possibility of improvements in Aboriginal and Torres Strait Islander health. It also raises questions about absolute versus relative improvements in health status – for example, there may be positive changes in life expectancy for Indigenous peoples, but if these are the same or even less than improvements of mainstream life expectancy, the life expectancy gap will stay the same or widen.
- To what extent can health services in general and primary health care services in particular be credited with such improvements? It has become one of the truisms of Aboriginal health policy that many of the social determinants of ill health – poverty, poor education, poor housing, lack of nutrition, lack of meaningful employment – lie outside of the health sector itself. To what extent, then, are any health improvements among Indigenous peoples attributable to the social determinants, and what evidence is there for health systems and primary health care making significant contributions?
- What particular aspects of primary health care services are effective? The evidence is pointing more and more to certain key interventions as being the most critical for long-term improvements – for example, early childhood development, maternal health, chronic disease prevention and management, and social and emotional well-being. If this is the case, there is obviously a strong argument for including these as essential parts of the comprehensive primary health care model. We will consider some of the structural and organisational aspects of primary health care here – for example, the importance of local community involvement and control.
Chapter 3 will turn the focus to the health of Indigenous peoples both overseas and in Australia at a national or at least jurisdictional level, looking at how their health has changed and whether health systems including primary health care can be said to have contributed.
Chapter 4 will narrow the focus to a number of local case studies of primary health care services in Aboriginal and Torres Strait Islander communities, and seek to draw lessons about their effectiveness.
5 World Health Organization (1978) Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978. http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf