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1.  Remunerating private psychiatrists for participating in case conferences 
Background
On 1 November 2000, a series of new item numbers was added to the Medicare Benefits Schedule, which allowed for case conferences between physicians (including psychiatrists) and other multidisciplinary providers. On 1 November 2002, an additional set of numbers was added, designed especially for use by psychiatrists. This paper reports the findings of an evaluation of these item numbers.
Results
The uptake of the item numbers in the three years post their introduction was low to moderate at best. Eighty nine psychiatrists rendered 479 case conferences at a cost to the Health Insurance Commission of $70,584. Psychiatrists who have used the item numbers are generally positive about them, as are consumers. Psychiatrists who have not used them have generally not done so because of a lack of knowledge, rather than direct opposition. The use of the item numbers is increasing over time, perhaps as psychiatrists become more aware of their existence and of their utility in maximising quality of care.
Conclusion
The case conferencing item numbers have potential, but as yet this potential is not being realised. Some small changes to the conditions associated with the use of the item numbers could assist their uptake.
doi:10.1186/1743-8462-2-33
PMCID: PMC1343565  PMID: 16359557
2.  Impact of standalone and embedded telephone triage systems on after hours primary medical care service utilisation and mix in Australia 
Background
The Australian government sponsored five local trials aimed at addressing problems in after hours (AH) primary medical care (PMC). The study's objective was to determine if the four trials, where telephone triage was the sole innovation, led to a reduction in AH service utilisation and change in service mix towards AH GP clinics. Changes in utilisation and mix of AH GP clinic and home visits, ED and ambulance use were monitored in the trial areas, and in a national sample to adjust for the effects of secular trend. Pre- and post-trial telephone surveys of two separate random samples of approximately 350 AH PMC user households in each area were conducted.
Results
Some types of AH PMC use became more frequent in both of the standalone services using nurse-administered proprietary call centre software, which were aimed at better addressing population need (Statewide call centre; Regional call centre). Service use overall (95%CI: 1.03–1.83) and GP clinic use (95%CI: 1.07–2.00) increased in the metro area of the Statewide call centre and in GP clinic (95%CI: 1.04–2.14) and home visits (95%CI: 1.03–3.91) in the non-metro area of the Regional call centre. Service mix only changed in the non-metro area of the Regional call centre with increased contact in GP home visits (95%CI: 1.02–4.38). Levels of use remained unchanged in both embedded services using other than proprietary software, which were established to support the GP workforce (Deputising service; Local triage centre). Service mix only changed in the Deputising service with a change away from AH GP clinics in both contact (95%CI: 0.39–0.97) and frequency (95% CI: -2.12 – -0.7).
Conclusion
Bearing in mind limitations in estimating AH PMC utilisation levels and mix, it is concluded that the impacts of telephone triage were generally smaller in Australia than reported elsewhere. There were different impacts on levels of service utilisation and service mix in standalone call centres and embedded services. Impacts of telephone triage on service utilisation and mix are influenced by the type of telephone triage offered, the goals of the agency providing the service, as well as local factors. (345 words)
doi:10.1186/1743-8462-2-30
PMCID: PMC1334205  PMID: 16343354
3.  A health policy for hearing impairment in older Australians: what should it include? 
Background
As in all western countries, Australia's older population experiences high levels of hearing impairment coupled with relatively low levels of hearing device usage. Poor hearing diminishes the quality of life of affected individuals and their families. This paper discusses how to improve Australian hearing health policies in order to better combat this impairment amongst older Australians.
Method
We searched the databases Medline, Meditext and Web of Science to find articles that discussed strategies and innovations to assist the hearing health of older people, and related this material to observations made during the Blue Mountains Hearing Study in NSW between 1997 and 2003.
Results and Discussion
The literature search identified five areas for inclusion in a comprehensive hearing health policy in Australia. These are: early intervention; addressing of hearing aid expense; the use of assisted listening devices; hearing rehabilitation, and; screening and education. Further research in Australia is critical if we are to develop a strong approach to the increasing prevalence of age-related hearing loss.
Conclusion
Australia needs to act now to address hearing impairment as it is a major cause of disability in those aged 55 and over. Federal and State governments should collaborate to construct a comprehensive hearing health policy that tackles poor levels of hearing health through early intervention, addressing hearing aid expense, encouraging the use of assisted listening devices, rehabilitation, screening and education. A good start would be to declare age related hearing impairment as a National Health Priority Area.
doi:10.1186/1743-8462-2-31
PMCID: PMC1326208  PMID: 16343355
4.  Implementation failures in the use of two New Zealand laws to control the tobacco industry: 1989–2005 
Background
We reviewed the implementation of New Zealand laws in relation to the activities of the tobacco industry and their allies. Material for two brief case studies was obtained from correspondence with official agencies, official information requests, internet searches (tobacco industry documents and official government sites), and interviews with 12 key informants.
Results
The first case study identified four occasions over a period of 14 years where New Zealand Government agencies appeared to fail to enforce consumer protection law, although apparent breaches by the tobacco industry and their allies had occurred in relation to statements on the relative safety of secondhand smoke. The second case study examined responses to a legal requirement for the tobacco industry to provide information on tobacco additives. There was failure to enforce the law, and a failure of the political process for at least 13 years to clarify and strengthen the law. Relevant factors in both these cases of 'policy slippage' appear to have been financial and opportunity costs of taking legal action, political difficulties and the fragmented nature of government structures.
Conclusion
Considered together, these case studies suggest the need for governments to: (i) make better use of national consumer laws (with proper monitoring and enforcement) in relation to tobacco; and (ii) to strengthen international law and resources around tobacco-related consumer protection. A number of options for achieving these aims are available to governments.
doi:10.1186/1743-8462-2-32
PMCID: PMC1325239  PMID: 16354296
5.  Community pharmacy services to optimise the use of medications for mental illness: a systematic review 
The objective of this systematic review was to evaluate the impact of pharmacist delivered community-based services to optimise the use of medications for mental illness. Twenty-two controlled (randomised and non-randomised) studies of pharmacists' interventions in community and residential aged care settings identified in international scientific literature were included for review. Papers were assessed for study design, service recipient, country of origin, intervention type, number of participating pharmacists, methodological quality and outcome measurement. Three studies showed that pharmacists' medication counselling and treatment monitoring can improve adherence to antidepressant medications among those commencing treatment when calculated using an intention-to-treat analysis. Four trials demonstrated that pharmacist conducted medication reviews may reduce the number of potentially inappropriate medications prescribed to those at high risk of medication misadventure. The results of this review provide some evidence that pharmacists can contribute to optimising the use of medications for mental illness in the community setting. However, more well designed studies are needed to assess the impact of pharmacists as members of community mental health teams and as providers of comprehensive medicines information to people with schizophrenia and bipolar disorder
doi:10.1186/1743-8462-2-29
PMCID: PMC1345690  PMID: 16336646
6.  Recent developments in targeting access to high cost medicines in Australia 
Background
In Australia, the Pharmaceutical Benefits Scheme (PBS) has developed a set of arrangements to control access to high-cost medicines to ensure their use is cost-effective. These medicines include the tumour necrosis factor-alpha inhibitors (TNFIs) for the treatment of rheumatoid arthritis. The aim of this first phase of a qualitative study was to explore basic views on the restricted access to TNFIs in order to confirm where further investigation should take place in the next phase.
Methods
Semi-structured interviews were conducted in 2004 with a member of the four relevant stakeholder groups. Participants were asked their opinions about features of the establishment, process and effects of the system of restricted access to TNFIs. Views on the collaboration between stakeholder groups in the decision-making process were also collected.
Results
The principle of 'controlled access' to TNFIs was supported in general. There were concerns regarding some of the specific eligibility criteria. Wider and more transparent stakeholder consultation was judged desirable. Some flexibility around prescribing of TNFIs by physicians, and regular review of the arrangements were proposed. These themes will inform the next phase of the study.
Conclusion
This first phase highlighted a range of issues associated with the PBS arrangements restricting access to TNFIs. Timely review and report of issues and concerns associated with such policy developments that arose in practice are essential. There is a need for a more comprehensive exploration across a wide range of stakeholders with different perspectives that will in turn be helpful in guiding policy and practice around national arrangements to manage access to high-cost medicines.
doi:10.1186/1743-8462-2-28
PMCID: PMC1325248  PMID: 16305742
Access to medicines; tumour necrosis factor inhibitors; pharmaceutical benefits scheme; drug reimbursement
7.  Development of a health care policy characterisation model based on use of private health insurance 
Objective
The aim of this study was to develop a policy characterisation process based on measuring shifts in use of private health insurance (PHI) immediately following implementation of changes in federal health care policy.
Method
Population-based hospital morbidity data from 1980 to 2001 were used to produce trend lines in the annual proportions of public, privately insured and privately uninsured hospital separations in age-stratified subgroups. A policy characterisation model was developed using visual and statistical assessment of the trend lines associated with changes in federal health care policy.
Results
Of eight changes in federal health care policy, two (introduction of Medicare and Lifetime Health Cover) were directly associated with major changes in the trend lines; however, minor changes in trends were associated with several of the other federal policies. Three types of policy effects were characterised by our model: direction change, magnitude change and inhibition. Results from our model suggest that a policy of Lifetime Health Cover, with a sanction for late adoption of PHI, was immediately successful in changing the private: public mix. The desired effect of the 30% rebate was immediate only in the oldest age group (70+ years), however, introduction of the lifetime health cover and limitations in the model restricted the ability to determine whether or if the rebate had a delayed effect at younger ages.
Conclusion
An outcome-based policy characterisation model is useful in evaluating immediate effects of changes in health care policy.
doi:10.1186/1743-8462-2-27
PMCID: PMC1312311  PMID: 16274489
8.  General practice and the New Zealand health reforms – lessons for Australia? 
New Zealand's health sector has undergone three significant restructures within 10 years. The most recent has involved a Primary Health Care Strategy, launched in 2001. Primary Health Organisations (PHOs), administered by 21 District Health Boards, are the local structures for implementing the Primary Health Care Strategy. Ninety-three percent of the New Zealand population is now enrolled within 79 PHOs, which pose a challenge to the well-established Independent Practitioner Associations (IPAs).
Although there was initial widespread support for the philosophy underlying the Primary Health Care Strategy, there are concerns amongst general practitioners (GPs) and their professional organisations relating to its implementation. These centre around 6 main issues:
1. Loss of autonomy
2. Inadequate management funding and support
3. Inconsistency and variations in contracting processes
4. Lack of publicity and advice around enrolment issues
5. Workforce and workload issues
6. Financial risks
On the other hand, many GPs are feeling positive regarding the opportunities for PHOs, particularly for being involved in the provision of a wider range of community health services. Australia has much to learn from New Zealand's latest health sector and primary health care reforms.
The key lessons concern:
• the need for a national primary health care strategy
• active engagement of general practitioners and their professional organisations
• recognition of implementation costs
• the need for infrastructural support, including information technology and quality systems
• robust management and governance arrangements
• issues related to critical mass and population/distance trade offs in service delivery models
doi:10.1186/1743-8462-2-26
PMCID: PMC1291356  PMID: 16262908
9.  "There's no place like home" A pilot study of perspectives of international health and social care professionals working in the UK 
Background
Many countries are reporting health workforce shortages across a range of professions at a time of relatively high workforce mobility. Utilising the global market to supply shortage health skills is now a common recruitment strategy in many developed countries. At the same time a number of countries report a 'brain drain' resulting from professional people leaving home to work overseas. Many health and social care professionals make their way to the UK from other countries. This pilot study utilises a novel 'e-survey' approach to explore the motives, experiences and perspectives of non-UK health and social care professionals who were working or had worked in the UK. The study aims to understand the contributions of international health and social care workers to the UK and their 'home' countries. The purpose of the pilot study is also in part to test the appropriateness of this methodology for undertaking a wider study.
Results
A 24-item questionnaire with open-ended and multiple choice questions was circulated via email to 10 contacts who were from a country outside the UK, had trained outside the UK and had email access. These contacts were requested to forward the email to other contacts who met these criteria (and so on). The email was circulated over a one month pilot period to 34 contacts. Responses were from physiotherapists (n = 11), speech therapists (n = 4), social workers (n = 10), an occupational therapist (n = 1), podiatrists (n = 5), and others (n = 3). Participants were from Australia (n = 20), South Africa (n = 10), New Zealand (n = 3) and the Republic of Ireland (n = 1). Motives for relocating to the UK included travel, money and career opportunities. Participants identified a number of advantages and disadvantages of working in the UK compared to working in their home country health system. Respondents generally reported that by working in the UK, they had accumulated skills and knowledge that would allow them to contribute more to their profession and health system on their return home.
Conclusion
This pilot study highlights a range of issues and future research questions for international learning and comparison for the health and social care professions as a result of international workforce mobility. The study also highlights the usefulness of an e-survey technique for capturing information from a geographically diverse and mobile group of professionals.
doi:10.1186/1743-8462-2-25
PMCID: PMC1283969  PMID: 16253132
10.  The place of public inquiries in shaping New Zealand's national mental health policy 1858–1996 
Background
This paper discusses the role of public inquiries as an instrument of public policy-making in New Zealand, using mental health as a case study. The main part of the paper analyses the processes and outcomes of five general inquiries into the state of New Zealand's mental health services that were held between 1858 and 1996.
Results
The membership, form, style and processes used by public inquiries have all changed over time in line with constitutional and social trends. So has the extent of public participation. The records of five inquiries provide periodic snapshots of a system bedevilled by long-standing problems such as unacceptable standards, under-resourcing, and poor co-ordination. Demands for an investigation no less than the reports and recommendations of public inquiries have been the catalyst of some important policy changes, if not immediately, then by creating a climate of opinion that supported later change. Inquiries played a significant role in establishing lunatic asylums, in shaping the structure of mental health legislation, establishing and maintaining a national mental health bureaucracy within the machinery of government, and in paving the way for deinstitutionalisation. Ministers and their departmental advisers have mediated this contribution.
Conclusion
Public inquiries have helped shape New Zealand's mental health policy, both directly and indirectly, at different stages of evolution. In both its advisory and investigative forms, the public inquiry remains an important tool of public administration. The inquiry/cause and policy/effect relationship is not necessarily immediate but may facilitate changes in public opinion with corresponding policy outcomes long after any direct causal link could be determined. When considered from that long-term perspective, the five inquiries can be linked to several significant and long-term contributions to mental health policy in New Zealand.
doi:10.1186/1743-8462-2-24
PMCID: PMC1351184  PMID: 16216131
11.  Australian health policy on access to medical care for refugees and asylum seekers 
Since the tightening of Australian policy for protection visa applicants began in the 1990s, access to health care has been increasingly restricted to asylum seekers on a range of different visa types. This paper summarises those legislative changes and discusses their implications for health policy relating to refugees and asylum seekers in Australia. Of particular concern are asylum seekers on Bridging Visas with no work rights and no access to Medicare. The paper examines several key questions: What is the current state of play, in terms of health screening and medical care policies, for asylum seekers and refugees? Relatedly, how has current policy changed from that of the past? How does Australia compare with other countries in relation to health policy for asylum seekers and refugees? These questions are addressed with the aim of providing a clear description of the current situation concerning Australian health policy on access to medical care for asylum seekers and refugees. Issues concerning lack of access to appropriate health care and related services are raised, ethical and practical issues are explored, and current policy gaps are investigated.
doi:10.1186/1743-8462-2-23
PMCID: PMC1282570  PMID: 16212674
12.  A network approach for researching partnerships in health 
Background
The last decade has witnessed a significant move towards new modes of governing that are based on coordination and collaboration. In particular, local level partnerships have been widely introduced around the world. There are few comprehensive approaches for researching the effects of these partnerships. The aim of this paper is to outline a network approach that combines structure and agency based explanations to research partnerships in health. Network research based on two Primary Care Partnerships (PCPs) in Victoria is used to demonstrate the utility of this approach. The paper examines multiple types of ties between people (structure), and the use and value of relationships to partners (agency), using interviews with the people involved in two PCPs – one in metropolitan Melbourne and one in a rural area.
Results
Network maps of ties based on work, strategic information and policy advice, show that there are many strong connections in both PCPs. Not surprisingly, PCP staff are central and highly connected. Of more interest are the ties that are dependent on these dedicated partnership staff, as they reveal which actors become weakly linked or disconnected without them. Network measures indicate that work ties are the most dispersed and strategic information ties are the most concentrated around fewer people. Divisions of general practice are weakly linked, while local government officials and Department of Human Services (DHS) regional staff appear to play important bridging roles. Finally, the relationships between partners have changed and improved, and most of those interviewed value their new or improved links with partners.
Conclusion
Improving service coordination and health promotion planning requires engaging people and building strong relationships. Mapping ties is a useful means for assessing the strengths and weaknesses of partnerships, and network analysis indicates concentration and dispersion, the importance of particular individuals, and the points at which they will fragment. A narrative approach adds an assessment of whether the partnerships are being used and valued. The approach outlined here, which examines structure and agency as separate but related explanations, has much to offer in examining partnerships.
doi:10.1186/1743-8462-2-22
PMCID: PMC1276782  PMID: 16209718
13.  Comparison of the uptake of health assessment items for Aboriginal and Torres Strait Islander people and other Australians: Implications for policy 
Background
Health Assessment (HA) items were introduced in 1999 for Aboriginal and Torres Strait Islander people aged at least 55 years and all Australians aged over 75 years. In 2004 a new item was introduced for HAs among adult Aboriginal and Torres Strait Islander people aged 15–54 years. The new item has been applauded as a major policy innovation however this enthusiasm has been tempered with concern about potential barriers to its uptake. In this study we aim to determine whether there are disparities in uptake of HA items for Aboriginal and Torres Strait Islander people compared to other Australians.
Method
The analysis was based on Health Insurance Commission data. Indigenous status was ascertained based on the item number used. Logistic regression was used to compare uptake of HA items for older people among Aboriginal and Torres Strait Islander people compared to other Australians. Adjustments were made for dual eligibility. Uptake of the HA items for older people was compared to the uptake of the new item for Aboriginal and Torres Strait Islander people aged 15–44 years.
Results
Our analyses suggest a significant and persistent disparity in the uptake of items for older patients among Aboriginal and Torres Strait Islander people compared to other Australians. A similar disparity appears to exist in the uptake of the new adult Aboriginal and Torres Strait Islander HA item.
Conclusion
Further engagement of primary care providers and the community around the uptake of the new HA items may be required to ensure that the anticipated health benefits eventuate.
doi:10.1186/1743-8462-2-21
PMCID: PMC1239906  PMID: 16150154
14.  Restructuring Primary Health Care Markets in New Zealand: from Welfare Benefits to Insurance Markets 
Background
New Zealand's Primary Health Care Strategy (NZPHCS) was introduced in 2002. Its features are substantial increases in government funding delivered as capitation payments, and newly-created service-purchasing agencies. The objectives are to reduce health disparities and to improve health outcomes.
Analysis
The NZPHCS changes New Zealand's publicly-funded primary health care payments from targeted welfare benefits to universal, risk-rated insurance premium subsidies. Patient contributions change from fee-for-service top-ups to insurance premium top-ups, and are collected by service providers who, depending upon their contracts with purchasers, may also be either insurance agents or risk-bearing insurance companies. The change invokes the tensions associated with allocating risk-bearing amongst providers, patients and insurance companies that accompany all insurance-based funding instruments. These include increases in existing incentives for over-consumption and new incentives for insurers to limit their exposure to variations in patient health states by engaging in active patient pool selection.
The New Zealand scheme is complex, but closely resembles United States insurance-based, risk-rated managed care schemes. The key difference is that unlike classic managed care models, where provider remuneration is determined by the insurer, the historic right for general practitioners to autonomously set patient charges alters the fiscal incentives normally available to managed care organisations. Consequently, the insurance role is being devolved to individual service providers with very small patient pools, who must recoup the premium top-ups from insured individuals. Premium top-ups are being collected only from those individuals consuming care, in proportion to the number of times care is sought. Co-payments thus constitute perfectly risk-rated premium levies set by inefficiently small insurers, raising questions about the efficiency and equity of a 'universal' insurance system pooling total population demands and costs. The efficacy of using financial incentives to constrain costs and encourage innovation when providers retain the right to arbitrarily recoup costs directly from patients, is also questioned.
Results
Initial evidence suggests that total costs are higher than initially expected, and prices to some patients have risen substantially under the NZPHCS. Limited competition and NZPHCS governance requirements mean current institutional arrangements are unlikely to facilitate efficiency improvements. System design changes therefore appear indicated.
doi:10.1186/1743-8462-2-20
PMCID: PMC1224852  PMID: 16144544
15.  (Re)form with Substance? Restructuring and governance in the Australian health system 2004/05 
The Australian health system has been the subject of multiple reviews and reorganisations over the last twenty years or more. The year 2004–2005 was no different.
This paper reviews the reforms, (re)structures and governance arrangements in place at both the national and state/territory levels in the last year. At the national level some progress has been made in 2004/05 through the Australian Health Ministers' Council and there is now a national health reform agenda, albeit not a comprehensive one, endorsed by the Council of Australian Governments (COAG) in June 2005. Quality and safety was an increasing focus in 2004–2005 at both the national and jurisdictional levels, as was the need for workforce reform. Although renewed policy attention was given to the need to better integrate and coordinate health care, there is little evidence of any real progress this last year. More progress was made on a national approach to workforce reform.
At the jurisdictional level, the usual rounds of reviews and restructuring occurred in several jurisdictions and, in 2005, they are organisationally very different from each other. The structure and effectiveness of jurisdictional health authorities are now more important. All health authorities are being expected to drive an ambitious set of national and local reforms. At the same time, most have now blurred the boundary between policy and service delivery and are devoting significant resources to centrally 'crisis managing' their service systems. These same reasons led to decentralisation in previous restructuring cycles. While there were many changes in 2004–2005, and a new national report to COAG on health reform is expected at the end of 2005, based on current evidence there is little room for optimism about the prospects for real progress.
doi:10.1186/1743-8462-2-19
PMCID: PMC1208850  PMID: 16120207
16.  Strengthening Medicare: Will increasing the bulk-billing rate and supply of general practitioners increase access to Medicare-funded general practitioner services and does rurality matter? 
Background
Recent increases in the bulk-billing rate have been taken as an indication that the Federal government's Strengthening Medicare initiative, and particularly the bulk-billing incentives, are 'working'. Given the enduring geographic differences in the supply of general practitioners (GPs) it is timely to reconsider the impact that this increase in the provision of 'free care' will have on access to Medicare-funded GP services in rural and urban areas of Australia. Utilisation has been modelled as two different stochastic processes: the decision to consult and the frequency of consultation.
Results
In the decision to consult model the supply of FFS GPs is a more important predictor of utilisation than the bulk-billing rate. Paradoxically the modelling predicts that ceteris paribus increases in either GP supply or the bulk-billing rate appear to have perverse effects in some areas by decreasing utilisation. In the frequency of consultation model, GP density is not a predictor and increasing the bulk-billing rate will unambiguously increase the frequency of consultation across all areas. In both models, the positive impacts associated with changes in supply and cost are constrained outside the inner metropolitan area by reduced geographic accessibility to Medicare-funded GP services. The modelling also shows that people are more likely to consult a GP in areas of high socioeconomic disadvantage, although socioeconomic status is not a predictor of frequency of consultation.
Conclusion
Bulk-billing rates and the supply of FFS GPs are important features of the Australian health care system that are, potentially, amenable to policy manipulation. The implications of this research are that government policies designed to achieve similarity in these characteristics across geographic areas will not result in equity of access because they fail to address problems caused by geographic inaccessibility in rural and remote areas. Attempting to increase bulk-billing rates in some of these areas may, in fact, reduce access to FFS GP services.
doi:10.1186/1743-8462-2-18
PMCID: PMC1215471  PMID: 16111496
17.  An Australian childhood obesity summit: the role of data and evidence in 'public' policy making 
Background
Overweight and obesity in Australia has risen at an alarming rate over the last 20 years as in other industrialised countries around the world, yet the policy response, locally and globally, has been limited. Using a childhood obesity summit held in Australia in 2002 as a case study, this paper examines how evidence was used in setting the agenda, influencing the Summit debate and shaping the policy responses which emerged. The study used multiple methods of data collection including documentary analysis, key informant interviews, a focus group discussion and media analysis. The resulting data were content analysed to examine the types of evidence used in the Summit and how the state of the evidence base contributed to policy-making.
Results
Empirical research evidence concerning the magnitude of the problem was widely reported and largely uncontested in the media and in the Summit debates. In contrast, the evidence base for action was mostly opinion and ideas as empirical data was lacking. Opinions and ideas were generally found to be an acceptable basis for agreeing policy action coupled with thorough evaluation. However, the analysis revealed that the evidence was fiercely contested around food advertising to children and action agreed was therefore limited.
Conclusion
The Summit demonstrated that policy action will move forward in the absence of strong research evidence. Where powerful and competing groups contest possible policy options, however, the evidence base required for action needs to be substantial. As with tobacco control, obesity control efforts are likely to face ongoing challenges around the nature of the evidence and interventions proposed to tackle the problem. Overcoming the challenges in controlling obesity will be more likely if researchers and public health advocates enhance their understanding of the policy process, including the role different types of evidence can play in influencing public debate and policy decisions, the interests and tactics of the different stakeholders involved and the part that can be played by time-limited yet high profile events such as Summits.
doi:10.1186/1743-8462-2-17
PMCID: PMC1198217  PMID: 16029512
18.  Population health and wellbeing: Identifying priority areas for Victorian children 
Background
Population health information, collected using soundly-designed methodologies, is essential to inform policy, research, and intervention programs. This study aimed to derive policy-oriented recommendations for the content of a health and wellbeing population survey of children 0–12 years living in Victoria, Australia.
Results
Qualitative interviews were conducted with 54 academic and policy stakeholders, selected to encompass a wide breadth of expertise in areas of public health and inter-sectoral organisations relevant to child health outcomes, including universities, government and non-government agencies across Victoria. These stakeholders were asked to provide advice on strategic priorities for child health information (data) using a structured interview technique. Their comments were summarised and the major themes were extracted. The priority areas of health and wellbeing recommended for regular collection include obesity and its determinants, pregnancy and breastfeeding, oral health, injury, social and emotional health and wellbeing, family environment, community, health service utilisation, illness, and socioeconomic position. Population policy questions for each area were identified.
Conclusion
In contrast to previous population survey programs nationally and internationally, this study sought to extract contemporary policy-oriented domains for inclusion in a strategic program of child health data collection, using a stakeholder consultation process to identify key domains and policy information needs. The outcomes are a rich and relevant set of recommendations which will now be taken forward into a regular statewide child health survey program.
doi:10.1186/1743-8462-2-16
PMCID: PMC1180818  PMID: 16029511
19.  Engaging with holism in Australian Aboriginal health policy – a review 
Background
The ideal concept of Aboriginal holistic health is centrally placed in Australian Aboriginal health policies and strategies. Its effective uptake promises, as advocates suggest, reorienting the complex Australian health system to enable health improvements. However, continual reminders assail us that Aboriginal health is shocking, appalling, disastrous, disgraceful and damning. Could incapacity to engage effectively with the concept undermine health system improvements? The aim of this review of Australian literature was to identify the range of meanings attached to Aboriginal holistic health and engage with their implications for the health system.
Results
In terms of literature synthesis I found that policy makers cannot rely on this approach to provide coherent arguments for meaningful engagement with the concept because authors in general: are uncritical and un-reflexive in the use and interpretation of the concept; often provide no reference for their understandings; tend to alter the concept's definition and constituent elements without justification; ignore the wide range of mainstream literature about holism and health; and fail to acknowledge and examine the range of Aboriginal concepts of health. I used the ten themes from this literature to highlight implications for the health system, and found that a most profound contradiction exists in the acceptance of the English language concept 'holistic' as immutably Aboriginal. Additionally, a range of contradictions and mixed messages within the themes challenge the validity of the concept. Significantly, with the boundary of the concept constructed as diffuse and ethereal, the diverse and uncritical literature, and mixed thematic meanings, it is possible to justify any claim about the health system as holistic.
Conclusion
It seems not so much incapacity to engage, but incapacity to coherently articulate Aboriginal concepts of health, which prevents advisory bodies such as the National Indigenous Council to imbue whole-of-government approaches in accordance with Aboriginal values.
doi:10.1186/1743-8462-2-15
PMCID: PMC1187865  PMID: 16014165
20.  Interventions to facilitate health workforce restructure 
There are recognised shortages in most health professions in Australia. This is evidence that previous attempts at health workforce planning have failed. This paper argues that one reason for such failure is the lack of appropriate structures for health workforce planning. It also suggests that Australia needs to move beyond planning for particular professions and that health workforce planning needs to be based on identifying skill shortages as much as shortages in particular named professionals.
The paper proposes specific policy suggestions to facilitate workforce flexibility and health workforce planning in Australia.
doi:10.1186/1743-8462-2-14
PMCID: PMC1200557  PMID: 15987520
21.  Consumer access to health information on the internet: health policy implications 
Background
Providers of health care usually have much better information about health and health care interventions than do consumers. The internet is an important and rapidly evolving source of global health-related information and could provide a means of correcting for asymmetric information. However, little is known about who accesses this information and how it is used in New Zealand.
The aims of this research were to: determine the nature of the health information sought, how respondents use the information, how helpful they perceive the information to be, and the self-assessed value of such information.
Methods
The researchers conducted an anonymous five minute telephone and mall intercept survey of randomly selected Wellington residents who had searched for health-related information on the internet. Investigators entered the data into an Excel spreadsheet and transferred it to SPSS for data cleaning, data exploration and statistical analysis. Search time costs were based on the opportunity cost of income foregone and respondents were asked to provide a money value for the information found.
Results
Eighty-three percent of respondents accessed the internet from home, and 87% conducted the search for themselves. Forty-five percent of people were looking for general health and nutrition information, 42% for data about a specific illness and 40% for a medicine.
After finding the information, 58% discussed it with a family member/ friend/ workmate, 36% consulted a general practitioner, 33% changed their eating or drinking habits, and 13% did nothing. Respondents found the information very quick to find and useful. It took them on average 0.47 hours and cost $12 (opportunity cost of time) to find the information. The average value of the data found was $60 and the net benefit to the consumer was $48 ($60 – $12).
Conclusion
The results of this research could assist providers of health information via the internet to tailor their websites to better suit users' needs. Given the high perceived value of internet health information (greater than the average general practitioner fee) and the fact that some of the information found may be unreliable or even unsafe a valuable public health policy initiative would be to provide an improved New Zealand health information website containing information on how to evaluate data sourced from the world-wide-web and links to a range of useful and trustworthy health information sites.
doi:10.1186/1743-8462-2-13
PMCID: PMC1188053  PMID: 15985172
22.  Patient-initiated switching between private and public inpatient hospitalisation in Western Australia 1980 – 2001: An analysis using linked data 
Background
The aim of the study was to identify any distinct behavioural patterns in switching between public and privately insured payment classifications between successive episodes of inpatient care within Western Australia between 1980 and 2001 using a novel 'couplet' method of analysing longitudinal data.
Methods
The WA Data Linkage System was used to extract all hospital morbidity records from 1980 to 2001. For each individual, episodes of hospitalisation were paired into couplets, which were classified according to the sequential combination of public and privately insured episodes. Behavioural patterns were analysed using the mean intra-couplet interval and proportion of discordant couplets in each year.
Results
Discordant couplets were consistently associated with the longest intra-couplet intervals (ratio to the average annual mean interval being 1.35), while the shortest intra-couplet intervals were associated with public concordant couplets (0.5). Overall, privately insured patients were more likely to switch payment classification at their next admission compared with public patients (the average rate of loss across all age groups being 0.55% and 2.16% respectively). The rate of loss from the privately insured payment classification was inversely associated with time between episodes (2.49% for intervals of 0 to 13 years and 0.83% for intervals of 14 to 21 years). In all age groups, the average rate of loss from the privately insured payment classification was greater between 1981 and 1990 compared with that between 1991 and 2001 (3.45% and 3.10% per year respectively).
Conclusion
A small but statistically significant reduction in rate of switching away from PHI over the latter period of observation indicated that health care policies encouraging uptake of PHI implemented in the 1990s by the federal government had some of their intended impact on behaviour.
doi:10.1186/1743-8462-2-12
PMCID: PMC1173079  PMID: 15978139
Data linkage; Health Policy; Health Insurance; Australia.
23.  Reducing perinatal mortality among Indigenous babies in Queensland: should the first priority be better primary health care or better access to hospital care during confinement? 
Background
The perinatal mortality rate among Indigenous Australians is still double that of the rest of the community. The aim of our study was to estimate the extent to which increased risk of low birthweight and preterm birth among Indigenous babies in Queensland account for their continuing mortality excess. If a large proportion of excess deaths can be explained by the unfavourable birthweight and gestational age distribution of Indigenous babies, then that would suggest that priority should be given to implementing primary health care interventions to reduce the risk of low birthweight and preterm birth (eg, interventions to reduce maternal smoking or genitourinary infections). Conversely, if only a small proportion is explained by birthweight and gestational age, then other strategies might need to be considered such as improving access to high-quality hospital care around the time of confinement.
Methodology
Population-based, descriptive study of perinatal mortality rates among Indigenous and non-Indigenous babies, in Queensland, stratified by birthweight and gestational age.
Results
Indigenous babies are twice as likely to die as their non-Indigenous counterparts (rate ratio1998–2002: 2.01; 95%ci 1.77, 2.28). However, within separate strata of birth weight and gestational age, Indigenous and non-Indigenous rates are similar. The Mantel-Haenszel rate ratio adjusted for birth weight and gestational age was 1.13 (0.99, 1.28). This means that most of the excess mortality in Indigenous babies is largely due to their unfavourable birth weight and gestational-age distributions. If Indigenous babies had the same birth weight and gestational age distribution as their non-Indigenous counterparts, then the relative disparity would be reduced by 87% and 20 fewer Indigenous babies would die in Queensland each year.
Conclusion
Our results suggest that Indigenous mothers at high risk of poor outcome (for example those Indigenous mothers in preterm labour) have good access to high quality medical care around the time of confinement. The main reason Indigenous babies have a high risk of death is because they are born too early and too small. Thus, to reduce the relative excess of deaths among Indigenous babies, priority should be given to primary health care initiatives aimed at reducing the prevalence of low birth weight and preterm birth.
doi:10.1186/1743-8462-2-11
PMCID: PMC1168887  PMID: 15918912
24.  Re-interpreting the data on the cost and effectiveness of population screening for colorectal cancer in Australia 
Three studies report estimates of the cost and effectiveness of alternate strategies for screening the average-risk Australian population for colorectal cancer. The options considered are faecal occult blood testing, double contrast barium enema, sigmoidoscopy and colonoscopy. At present, there is no consensus over which screening method is optimal by the economic criterion. Also, the existing studies report a mixture of average and incremental cost-effectiveness ratios derived from data collected between 1994 and 2002. We suggest average cost-effectiveness ratios are not useful for decision-making and illustrate how they differ from the preferred incremental cost-effectiveness ratio. We then update the cost data reported in the three studies to 2002 prices and calculate incremental cost-effectiveness ratios where not previously available. Our re-analysis of one study contradicts the conclusions drawn by the authors, who had only calculated average cost-effectiveness ratios. In particular, we find their recommendation of population screening with colonoscopy would cause, annually, between 33 and 1,322 years of life to be lost and between $M17 and $M87 to be wasted. Based on updated cost data and the incremental analysis, our findings indicate that population screening using biennial faecal occult blood testing ($39,459 per life-year gained), annual faecal occult blood testing ($30,556 per life-year gained) and colonoscopy ($26,587 per life-year gained) are cost-effective. Hence, the decision over which method of screening is optimal remains ambiguous across the three studies. We recommend policy-makers choose the study they believe produces the most accurate estimates of cost and health effect, identify their willingness to pay for health benefits and consider other issues relevant to the decision.
doi:10.1186/1743-8462-2-10
PMCID: PMC1173078  PMID: 15904536
25.  Recent developments in the funding and organisation of the New Zealand health system 
During the 1990s, the New Zealand health sector went through a decade of turbulence with a series of major structural changes being introduced in a relatively short period of time. The new millennium brought further change, with the establishment of 21 district health boards and the restoration of a less commercially-oriented system. The sector now appears to be more stable. However many incremental changes are in train and there has been considerable turbulence below the surface as key players jostle for position. This paper reports on some of the recent changes that have occurred in the restructuring of the New Zealand health system. Three issues are discussed: the devolution of funds and decision-making to district health boards, developments in primary health care, and the position of the private health insurance industry.
doi:10.1186/1743-8462-2-9
PMCID: PMC1142303  PMID: 15877820

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