Let’s fix the health deficit through a more equitable distribution
Dr Ayman Shenouda
The alarming population growth in our major cities is not surprising and highlights a lack of a national population planning approach for sustainable development.
This issue has been in the news recently and these conversations for me always highlight inequity and missed opportunities. There is usually fallout in distributional terms for rural Australia which continue to be left behind. This is despite the fact that rural areas don’t even get a mention in the discussion.
The lack of rural focus is the underlying problem here with no attention to the broader spatial dimensions which result in increasing inequities. This is a much bigger issue than the inconvenience of the long city commute to work. It’s about the fair distribution of impacts to bring about more equitable outcomes.
In prioritising health, we know a community’s economic health is closely tied to health outcomes. There are persistent inequities in Australia and particularly in our remote Aboriginal communities.
Returning from the Solomon Island’s recently and talking to a colleague about the plight of the people in the Pacific, I was reminded that some remote communities in Australia are worse than Third World.
To get to the bottom of the causes of health disparities you need to look to the social determinants of health. Invest in policies which protect those factors which stretch a range of personal, social, economic and environmental factors and you will get results.
Rural health disparities
The converse is, of course, true and this is why we have such marked health disparities in rural areas.
There is an estimated health deficit of $2.1 billion in rural and remote Australia.
The impact in health terms is that rural Australians are living shorter lives and they have poorer health outcomes and higher rates of disease. The more remote you go, the worse it is.
It is the compounding effect that impacts here - where we see high levels of socio-economic vulnerability combined with lack of access to services.
In addressing these issues, health workforce distribution is of course key to enabling access but so is getting to the bottom of what’s driving the disadvantage.
We need to focus on the value of working across sectors to address those causal factors.
It is those causal or upstream factors – social disadvantage, risk exposure and social inequities – that present the real opportunities for improving health and reducing health disparities.
These powerful determinants of health inequality are why we need to put the spatial dimension back into population planning. More collaborative planning is needed to address the unique needs of these communities.
Rural health investments
Part of the planning discussion needs to focus on the role that rural health investments have creating healthy and sustainable communities. There is a failure to recognise the comprehensive impact of health care funding as a driver for local economic development. 
I know from my own experience that just bringing a health service to an area will help to sustain it. When I established my practice at The Rock the medical facility was being run out of a rented room in the CWA building.
We worked hard to not only establish our practice but build the required broader health service around us. Through our sustained efforts the pharmacy soon followed, then a pathology service and now finally an aged care facility.
The economics of poor health
We know all too well the economic effects of poor health.
An investment in rural health boosts these local economies. A fairer health budget spend would realise strong returns and a healthier future for 30 percent of our population.
But, it is not just a rural issue as there are pockets of disadvantage elsewhere including in our cities and on the fringes and of course in regional centres as well.
Whether in urban or rural areas, pockets of entrenched disadvantage will remain unless we start to align health and causal factors in national planning.
Fixing the health deficit
We need to fix the health deficit through a more equitable distribution.
In planning for a healthier Australia, a much broader focus is required which targets and acts on those upstream determinants.
It’s not just medical care alone that influences health with social factors known powerful determinants of health. This is the formula for a healthy Australia.
 NRHA Fact Sheet. The extent of the rural health deficit. National Rural Health Alliance. 2016. http://ruralhealth.org.au/sites/default/files/publications/fact-sheet-27-election2016-13-may-2016.pdf
 Bharmal N, Pitkin Derose K, Felician M, Weden MM. Working Paper. Understanding the Upstream Social Determinants of Health. RAND Health. May 2015. https://www.rand.org/content/dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf
 Russell L. The economics of delivering primary health care in rural and underserved areas—what works? Menzies Centre for Health Policy. University of Sydney. 14th National Rural Health Conference. http://www.ruralhealth.org.au/14nrhc/sites/default/files/Russell%2C%20Kesley%2C%20KN.pdf
 Braveman P, Gottlieb L. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports. 2014;129(Suppl 2):19-31. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/
Nowhere to go: tackling homelessness for older women
Dr Ayman Shenouda
A measure of our society
It was Ghandi who said ‘a nation's greatness is measured by how it treats its weakest members’. I’m not sure where that places us as a society particularly with the rise of homelessness in Australia. I strongly believe that governments are there for those who need them the most. Better still, if we had their focussed investment on preventive strategies it is certain that our country would be much better off.
On the issue of homelessness, we’ve seen very slow progress. This is despite a strong focus by state and territory governments. But this issue cut across departments and really requires a national focus in my view particularly to direct funds to improve healthcare management in primary care.
Housing and employment are two significant social determinants of health. We know homelessness can significantly impact on health outcomes. While social and economic factors lead to increased risk exposures. The patient-centred medical home can help meet the healthcare needs of the homeless population but this is reliant on a targeted program of funding.
Rising rates of homeless older women
One in three older women are living in income poverty in Australia.[i] Older single women are particularly at risk of becoming homeless with significant numbers experiencing rental stress. This is a public health crisis and requires careful policy planning overtime which is difficult to do in our short-term electoral cycles. Health status must remain a priority across government and not just health to provide for integrated services and supports.
Social workers have warned that Australia is facing a generational “tsunami” of this older demographic in coming years. This policy catastrophe is really not all that surprising when you consider the soft policy responses to those known drivers of poverty.
Women have less super due to disparity in earnings with years of lost income due to time out for family. There are cost impacts which include high-priced housing or losing a job as well as broader factors such as the rising divorce rate or death of a spouse. There is also less capacity to earn with the casualisation of the workforce which is also marred by ageist stereotypes.
Combating ageism in our society is something this country really needs to work on.
How is it even plausible that in the modern workplace you are considered old at 45 or 50? This seems to be the case yet Australia’s future prosperity is reliant on older workers. Perhaps this factor alone will make our policymakers more focussed on solutions in future.
Older women are locked out of the jobs market. Losing a job is said to be one of the most common triggers that can plunge older women into poverty.[ii] Ageism has very real mental and physical health consequences. There is less discussion on the impact that ageism has on health and we need to be louder here. These are two clear areas which require more policy development.
My older female patients often describe feeling invisible and that’s always heartbreaking to hear. But it seems this invisibility may have also crept into the policy space. Like so many things, we know policy inaction will be more costly over time.
The UK in prioritising a Minister for Loneliness is perhaps a step in the right direction. Addressing issues of isolation will help build stronger, healthier older Australians and we really need that national policy setting.
We’ve been treating the symptoms and not the know causes for too long.
Securing long-term tenancy options for this vulnerable cohort has to be prioritised. The fact is that we have had enough warnings in order to evacuate safely from the impending tsunami. We need to address wealth inequality, and particularly gender and income disparity in later life. Addressing ageism and particularly employment-based age discrimination too.
It is about helping women before they reach crisis point. More integration across the health and homelessness support systems would help to identify earlier those at risk. Also, understanding those pathways to homelessness among older adults and ensuring prevention and service interventions are adapted to meet different needs is another key piece to this policy puzzle. [iii]
[i] O’Keefe, D. One in three older women living in income poverty in Australia: study. Australian Ageing Agenda. March 9, 2016. Available at: https://www.australianageingagenda.com.au/2016/03/09/one-in-three-older-women-living-in-income-poverty-in-australia-study/
[iii] Brown RT, Goodman L, Guzman D, Tieu L, Ponath C, Kushel MB (2016) Pathways to Homelessness among Older Homeless Adults: Results from the HOPE HOME Study. PLoS ONE 11(5): e0155065. https://doi.org/10.1371/journal.pone.0155065
Building healthcare capacity in the Solomon Islands
Dr Ayman Shenouda
A recent visit to the Solomon Islands provided some new insights into what it really means to be resilient. It is one of the least developed countries in the Pacific Region, the population languishes in poverty yet they make the most out of limited resources.
The community here face significant health challenges and on multiple fronts. They lack even the basic health infrastructure, and universal access seems an almost impossible health policy goal. Despite this, I found the healthcare teams here work with courage and resolve.
Health system challenges
Persisting social disparities mean they face significant health challenges through what is termed the “triple burden” of disease. The community deals with communicable diseases alongside rising rates of non-communicable diseases combined with the threat of climate change which we know already hits hard too regularly.
The Solomon Islands suffer from significant resource deficits and the underdevelopment of infrastructure is driving inequalities. There is no CT scanner in the country – that places new meaning on what it is to be deficient in resources here. This is a country of over 620,000 people spread across more than 900 islands and it is without essential imaging diagnostic tools.
Coverage of services is very weak. This is partly because past development efforts have lacked the required multi-level coordination to support any sort of integrated health system. Almost half of all health expenditure comes from donors which is mostly put to disease management with little left for service system development. [i]
The Good Samaritan
My visit to the Solomon Islands was unexpected and prompted by a local MP who approach me following some donations I made to the hospital in Tetere. They were relatively small contributions in the form of blood pressure and haemoglobin machines. From this visit, I learnt that while small they were vital and are the sorts of supports that help to develop capacity and reliability.
The Good Samaritan hospital is on the coast in Tetere in Guadalcanal province which is about 40km from Honiara. The caseload here is overwhelming. The hospital is basic with about 30 beds, that provides mainly chronic disease management, emergency medicine and obstetrics. There is one doctor per 60,000 population, two midwives and two nurses. But with that they perform miracles here - this team provides obstetric care averaging 170 delivers a month.
This is a population facing serious health problems yet you would be amazed by how well they cope with very little. The four most common conditions leading to critical illness are malaria, diseases of the respiratory system including pneumonia and influenza, diabetes mellitus and tuberculosis.[ii] Screening programs are grossly underdeveloped which increases critical care demand.
Most facilities are short staffed and without basic equipment. From Tetere it is one hour to Honiara for Xray or just to do bloods.
Despite the many challenges, the team use their clinical skills to the highest levels to provide the best care for their patients. It is the practical supports that they need the most and I think as a community of GPs we are well placed to do more.
Improving critical care
It is clear that the underdevelopment of healthcare infrastructure compounds inequalities.
In Pacific Island countries, including the Solomon Islands, there is a high need for basic critical care resources. Equipment such as oximeters and oxygen concentrators are needed as well as greater access to medications and blood products and laboratory services. [iii]
A cross-sectional survey study examining critical care resources in the Solomon Islands found that inadequate resources from primary prevention and healthcare contribute to the high degree of critical illness. This study suggested that the solution lies in simple therapies and context-appropriate resources to mitigate the high burden of morbidity and mortality.[iv]
Therefore, the emphasis should be on the development and acquisition of simple and inexpensive tools rather than complicated equipment. This helps to prevent critical care from diverting resources away from other important parts of the health system. [v]
This makes perfect sense in these resource-poor contexts and certainly, the healthcare team in Tetere provide a stunning example of making it work with almost nothing at all.
Empowerment is key to improving health service development in the Solomon Islands. The focus needs to be on strengthening the health system and improving access to services but bringing health care to these areas is no easy task.
It needs a partnership which filters right down to the community level. The Ministry of Health and Medical Services (MHMS) is really working hard towards enabling these partnerships to ensure a more planned approach to funding health services.
Australia is the largest provider of Official Development Assistance (ODA) to the Solomon Islands, providing almost two-thirds of overseas aid in 2016-17. We are the lead donor in the Solomon Islands health sector, with Australia’s main bilateral assistance provided through the Health Sector Support Program (HSSP) (equates to AUD 66m over four years to 2020). [vi]
Since 2008, the MHMS, with their development partners including Australia, has led a sector-wide approach (SWAp) to the delivery of health services in the Solomon Islands. The overall program goal for HSSP3 is to improve the access and quality of universal health care in the Solomon Islands. The current funding supports the Solomon Islands National Health Strategic Plan 2016-2020 and provides direct budget support, performance-linked funding and technical assistance.[vii]
What more can be done?
It is clear that Australia is doing its fair share for the Solomon Islands. There is now alignment in terms of ensuring best outcomes from this funding. This will certainly help build health services for this nation. But there is always more to do and GPs, in particular, can make a significant difference.
We need strategies to work through how best we can support our disadvantaged pacific neighbours from a community of GPs. Education partnerships being key and the RACGP already contributes in this way particularly in Papua New Guinea.
From my recent visit to the Solomon Islands, I have seen how the community there through their own resilience can achieve so much. Those working in Aboriginal Health would be familiar with what it takes to support patients in low-resource, laboratory-free settings. It would be great to share some of these learnings and provide more support for the Solomon Island communities.
[i] World Health Organisation. Article. Health closer to home: transforming care in the Solomon Islands. March 2017. Available at: http://www.who.int/features/2017/health-solomon-islands/en/
[ii]Westcott M, Martiniuk AL, Fowler RA, Adhikari NK, Dalipanda T. Critical care resources in the Solomon Islands: a cross-sectional survey. BMCInternationalHealthandHumanRights.Mar1,2012.doi:10.1186/1472-698X-12-1.Availableat: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307438/
[vi] Commonwealth of Australia. Independent Performance Assessment. Solomon Islands – Health Sector Support Program. Specialist Health Service. May 29, 2017; revised 24 July 2017.
Dr Ayman Shenouda