Let’s fix the health deficit through a more equitable distribution Dr Ayman Shenouda Highlighting inequity 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. Persistent disparities 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.[1] 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. Causal factors 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.[2] 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. [3] 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.[4] This is the formula for a healthy Australia. [ends] [1] 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 [2] 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 [3] 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 [4] 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/
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Dr Ayman Shenouda Announcing the Collingrove Agreement following the rural and regional health forum in Canberra on Friday 9 February 2018 from L–R: ACRRM’s Dr Michael Beckoff, National Rural Health Commissioner Professor Paul Worley, Minister for Rural Health Bridget McKenzie, RACGP Rural Chair A/Prof Ayman Shenouda. A milestone agreement Those who have been part of this journey will understand the significance of the Collingrove Agreement. Although I think on this topic, even the most casual observer will be across the division that has chocked us for so long. It’s been a long and often dusty road but we’re now steered in the right direction and towards developing a national rural generalist pathway together. Finding that common ground was relatively easy in one sense. You see, the one thing I’ve noticed having travelled extensively over the past four years as Chair of the RACGP rural faculty is that patience, passion and persistence is a common trait of rural GPs or any GP for that matter. From Longreach to Carnavon or Katherine to Goolwa and everywhere in-between and regardless of which camp they belonged – ACRRM or RACGP - there lies a great determination and commitment for their patient and rural community. An unbreakable connection which binds us all in addressing rural health disadvantage and securing a healthier future for all. Navigating slightly rougher terrain But in finding that common ground between the two GP colleges - while the destination remained the same - the road itself was indeed rocky. So rocky in fact it required an all-terrain vehicle for all involved and sometimes perhaps a tank may have been a slightly better choice! Still, despite years of division, I think it was that same spirit that made the Collingrove Agreement possible. An easy headline it may have seemed to those filtering the news last Friday, but the “RACGP and ACRRM collaborating on national generalist pathway” was truly momentous. And certainly, for those around the table at Collingrove Homestead in the Barossa Valley, South Australia, collaboration soon became the only solution. Sharing a picture for history’s sake of those present on those momentous couple of days 11-12 January 2018. Securing the milestone agreement from L-R: Dr Melanie Considine, RACGP Rural Deputy Chair, RACGP Rural Chair A/Prof Ayman Shenouda, ACRRM Censor in Chief A/Prof David Campbell, our National Rural Health Commissioner Professor Paul Worley, ACRRM President A/Prof Ruth Steward and Dr Rose Ellis from the Rural Doctors Network.
A common goal While the agreement itself is only four paragraphs long - the common ground here was significant. We had 7 million reasons to get this right. It is about equity of access in meeting the health care needs of rural and remote Australians through a responsive needs-based solution. Together we were determined to secure a strong, sustainable and skilled national medical workforce to meet the needs of these communities. More than a definition This is, of course, more than a about a definition but it was always a sticking point. On one hand there were those focussed on the name or a tendency to favour a definition over others. On the other, we knew that developing skills around the ongoing care considerations are the areas that best serve the community. And there’s the commonality – supporting doctors to acquire the skills to meet the needs of their communities. A dedicated and clear pathway for rural GPs to acquire those skills and utilise them in a way that is valued and recognised are important workforce factors. This was the cohesion that brought the clarity to the definition. So here is it - “A Rural Generalist (RG) is a medical practitioner who is trained to meet the specific current and future health care needs of Australian rural and remote communities, in a sustainable and cost-effective way, by providing both comprehensive general practice and emergency care, and required components of other medical specialist care in hospital and community settings as part of a rural healthcare team.” Pathway design Beyond the definition, it is the careful design of the pathway itself that will make the most difference. It needs to be a lot of things but at its core it is about ensuring the right skill mix against demand with supportive elements offering flexibility and choice. Key features which include a clear pathway for young doctors with flexibility that allows entry and exit at different stages. Ensuring adequate funding for the pathway itself alongside essential factors in establishing a critical mass of trainees but with enough flexibility for it to work within the varying jurisdictions. It should also allow lateral entry for practising GPs and other rural doctors who want to acquire new skills to address the shifting need in these communities. Ever changing needs like mental health and palliative care and in dealing with the extra problems which depend on the health needs and context of the community. The full range of competencies enabling them to deliver patient care closer to home in the primary and secondary care contexts. Or quite simply, training young doctors with the right skill set that makes them feel safe and supported to do their job which is addressing rural and remote community needs. There’s usually some bleeding before healing Despite years of focus, the disparity of health service delivery in rural and remote Australia remains a key policy failure. Much has been left to our overseas trained doctors who have been the backbone in delivering this care over this time. The lack of a solid training or workforce solution meant that the rural health system depended on individual efforts with very mixed results. Sometimes I feel the split between the colleges had to happen for us to be able to reach this agreement. The Collingrove Agreement is the culmination of 20 years of hard work by both Colleges in building capacity to deliver a needs-based solution for rural health. We’ve seen more collaboration over the past year than in the preceding 20 - through Bi-College Accreditation to this historic Collingrove Agreement. So, let’s keep it up! A Rural Generalist Pathway Taskforce is being formed in the coming months to work through the pathway design. There may still be a long road beyond Collingrove Homestead but I think this time it will be the recently resurfaced type! Ayman Shenouda Health Advocacy in 2018 Dr Ayman Shenouda Where are we now? I’m not the first to say that the 24-hour media cycle has taken a toll on our democracy. Some even say it killed journalism. I think the true damage lies in a loss of thoroughness and depth of thought. More specifically, the effects of the demise of principled advocacy and what it now takes to shape and change policy. Twitter now seems to set the policy agenda. But we’ve been in this chaotic and unpredictable world for some time now and we’re never going back to the pre-digital era of journalism. In mobilising support, is there the time and patience left to build a policy dialogue? Without it, we are just left with a policy vacuum and random tweets that lead us nowhere. Inclusive policy Considered policy development takes time. Good public policy relies on effective community involvement and consultation. Good implementation is also important. The process of implementation seems to be skipped entirely from the process these days, which makes the type of incremental change required in healthcare almost impossible. There seems neither the time nor the inclination for the inclusive process required for good policymaking. Even when good policy process does occur, it can all fall over in an instant as was the case recently for constitution recognition which went down without the noise it deserved. The doctor as advocate would be familiar with similar policy disappointment. It’s been a long road to reform and there has been plenty of blocks along the way. It’s clear that it is harder to get attention in such a cluttered space. Healthcare advocacy What does it take to shape and change policy in our own policy space? We advocate at different levels from individual patient advocacy through to more public advocacy or policy leadership roles on the national and sometimes international level. In a world ruled by Twitter, there’s not a lot of time for considered well design policy solutions. The type you need to communicate the evidence base or get the required policy reasoning across. But we still need to build that policy dialogue. This is why it is so important for us – as a community of healthcare professionals – to get it right. By getting it right I mean following good policy process. But how can we avoid the pitfalls of advocacy? Media can certainly help to set the agenda but I think a focus on inclusion is the best place to start. Right place, right time Magic happens when the right people are at the right place at the right time. When things are politically aligned and people at the table are smart and genuine in their intent - the moment when they recognise what leadership is all about - then Magic follows. When there is no personal or financial gain, leaders start to have a sense of what can be gained through collective advocacy for the benefit of their community. When the vision is clear and simple to understand by all involved implementation becomes a lot easier. Integrity always shines through Some people believe that politics is about being smart enough to make a lie look convincing. Sometimes this falls somewhere between a lie and a falsehood or the new “alternative facts” and post-truth era we now find ourselves in. Some politicians think they know better. They might even get away with some temporary gain but believe me, the power of truth has a longer and more effective success. People can smell dishonesty no matter how enticing a master deceiver may be. It is integrity that always shines through the brightest here. Making collective impact work When there is a genuine and clear goal that addresses the common agenda, people get together to make what look like impossible change feel like a walk in the park. This requires a collaborative approach to creating change to facilitate mutual support and collective impact. When you win the hearts and souls of people, what seemed impossible becomes not only possible but a lot easier to achieve. When everyone in the room feels safe and heard by others, suddenly they will be able to see and value others contributions. In my opinion, you should leave your personal views and judgment of others outside the room. After all, we need to be clear about one thing - it is not about you, it is about others and the trust they’ve placed in you to present their opinion. Some may not agree with me but at the end of the day, everyone is entitled to have their own views. Let’s hope health advocacy in 2018 is a place of inclusive reform. That we work together towards collective impact and a common agenda that will see sector-wide improvements. National Rural Health Commissioner: Putting the rural health agenda back on track Dr Ayman Shenouda A rural champion A visit this week to Wagga from our National Rural Health Commissioner Professor Paul Worley provided a great chance to work through some of our highest rural health priorities. This new champion for rural patients is exactly what we needed. He fits the job description well – independent, impartial and “a fearless champion” for rural health. He also has alongside him a strong rural health sector full of ideas for building a strong Australian rural health system. Getting the agenda back on track Rural patients are finally getting the focus they deserve and this is our chance to get the rural health agenda back on track. I think we finally have the policy settings in place for this to occur. But it all has to be orchestrated in a way that sees very specific locational needs acknowledged and addressed. This is where the new rural commissioner role comes in. We all have a key role here. There’s still a great deal of work which now needs to occur to ensure every instrument in this vital ensemble can be fully utilised. It is those featured instruments – whether string, woodwind, brass or percussion – each with its own unique qualities that really need to shine. These are the ones that fill in a critical gap and vital if we are going to provide a performance worthy of rural Australians. National Rural Generalist Pathway The first task is the National Rural Generalist Pathway. If we are to get this policy right we will need a broad policy lens with a commitment to needs-based planning encompassing all disciplines. We know that a sustainable health workforce solution for rural Australia needs to factor in flexibility in policy design. By this, I mean allowing for an optimal skill mix which is capable of meeting the very specific service needs of that community. Local needs analysis It is clear that we need reforms that can address maldistribution to meet growing service demand. But to do this we need to look at what is really happening in these communities. Skills planning through a rural generalist pathway solution must, therefore, encompass a much broader skill mapping exercise. This needs to be steered toward more integrated care and with a focus on the full multidisciplinary skill mix required to keep those services going. We need to find ways to capture current skill depth so that this can be prioritised better in policy. Reinforcing the importance of primary care and coordination of care so that the policies can follow. But really plotting that essential skill mix required to support rural models of care. Future supply and demand (against need) It is about having that critical mass of health professionals to achieve a sustainable service environment. This not only lifts constraints enabling more equitable access to services but creates a way to mobilise and build on peer support. In turn, reducing burn-out by formalising mechanisms for peer support-support networks. It provides safer working hours and leaves room for internal backfill for relief, as well as professional development or space to take on a supervising role. There’s been plenty of workforce planning occurring – PHNs, LHNs, and RHWAs – but we lack that common formula. No-one can see at a national level where the true hotspots are. We need to establish what constitutes a minimum workforce requirement or mix for a particular population size and then apply that across the country. Matching and forecasting the needs is complex but we have evidence-based approaches to estimating health workforce demand. HWA did years of work around it. I think we must clarify this area of workforce policy as a first key step. Once we have this formula then we’ll see a situation where training investment meets demand. There is just not enough aligning in terms of training pathways with workforce planning. This is vital as you can’t have a situation where you have three GP anaesthetists and no GP-obstetrician. This level of planning would also help in terms of succession planning and reassure those committing to these pathways that there is or will be a position for them. It provides a planned career pathway for them. Broad skill depth Broad skill depth is vital to addressing patient need in rural communities. We need to find a way to embed in workforce policy those skills most relied on in meeting this need. I think the discussion is also broader than the training pathway itself. We have to have an equal focus on the requirements of the existing workforce in meeting shifting community need. Training solutions need to enable private community-based practice. We really need to ensure we encompass a range of approaches factoring both procedural and non-procedural skills if we are going to align closely to need. If we support the full skillset required then we are closer to reflecting within the training the full scope of skills practised in rural general practice to meet community needs. This is how we can ensure we produce the next generation of doctors with the skills needed to provide both primary and secondary care. Training Hubs Past policies have had an impact on both recruitment and retention. It all comes back to securing that critical mass (of students). Early exposure which can establish that community connection early which can continue through to intern, prevocational and vocational training years. We’ve always said that we need to invest in more localised training solutions to provide for that community connection and rebuild a teaching culture. The hubs are well positioned to facilitate that vital community connection and link the various stages of training in a rural setting across the full training continuum. The training hubs provide that essential framework now but it is about facilitating those vital partnerships. This is how we can structure training against local healthcare need and service construct and build in those supportive factors so early exposure can be a positive experience. Nurture rural intention We need to nurture rural intention through targeted incentives and sufficient rural exposure strategies. A strong commitment to rural should come with benefits. Capture those wanting to pursue rural through a nurtured pathway and supports which include an investment in mentoring. Truly support RMOs skills and career path aspirations and reinvesting in these years by getting back the PGPPP in its true form. Newly developed policy offering primary care rotations through the new rural community-based interns is certainly acknowledged but it is a minimised model which really needs to be expanded. Vertical continuity over time Focusing more effort on areas that provide both a training benefit and meet a community health need is a way to secure an enduring rural benefit. Realising that a focus on the full multidisciplinary team is key to providing more integrated and improved patient-care strategies. Building this capacity through vertical integration of teaching and learning which promotes shared responsibilities. It’s that continuity that is needed most – vertical continuity over time to allow for varied exposure which results in the more resilient doctor. Flexibility is needed to ensure training reflects the local service context with an equal focus on community-based training. It helps develop that understanding of optimal care pathways providing continuity of care and a collaborative integrated care approach. Team and teaching culture Developing a strong team culture early has to also be a key focus. Those working in rural Australia know that it takes a dedicated team and an enduring local commitment to tackling the many challenges in delivering regional, rural and remote healthcare. We need to ensure more exposure to multidisciplinary team environments as well as enabling hospital and community partnerships through supportive policy. This is where the pathway solution has to extend beyond a focus solely on medicine. Improved support for supervisors has never had the policy focus it deserves. We need to increase the teaching capacity of rural communities while minimising the impact of burnout. Practice viability is a major consideration here. All these factors need to be considered in terms of ensuring a rural GP can take on a training or teaching role. Succession planning and providing that easy entry, gracious exit is key and would lift the load for many already overcommitted. A more sustainable future In designing rural policies which can provide a more sustainable future, the focus clearly has to come back to addressing health disparities between rural and urban Australians. A resilient multi-skilled generalist workforce capable of meeting current patient need now and into the future is all part of meeting that key requirement. We really need to capitalise on the policy settings we already have in place. The strong planning role of the PHNs and LHNs in identifying local level need. The facilitation role of the new training hubs in ensuring a more positive rural training experience. Existing strong College pathways and well-developed rural skills training program with inter-professional partnerships to build from. We now have that vital role in the National Rural Health Commissioner to ensure a more coordinated national policy and planning effort can occur. We’re well on our way in putting the rural health agenda back on track ensuring lasting change for rural Australians. [ends] Source: RACGP 2014. New approaches to integrated rural training for medical practitioners. Final Report. Available at: https://www.racgp.org.au/download/Documents/Rural/nrffinalreport.pdf Sustainable healthcare: A shift to a proactive, preventive approach with increased engagement2/11/2017 30 October 2017 Dr Ayman Shenouda Investing in health A greater investment in health requires a strong focus on patient-centred care prioritising both prevention and primary care. In progressing these shifts we’re currently locked within the constraints of our reactive healthcare system. Despite significant levels of funding, we’re just feeding a sick system here. This is less about payment reform or performance-based models but more one of prioritising and getting that focus right. In making that shift towards a healthier population and sustainable healthcare system it comes down to priorities, not just savings. Removing waste including through the removal of obsolete, redundant or unsafe treatments from the MBS item numbers is important. But so is ensuring we transition from our episodic, acute care or reactive model towards a more proactive one. Preventive care solutions To shift health outcomes then we need to address those causal factors. It’s not just medical care alone that influences health with social factors known powerful determinants of health.[1] Those causal factors affecting health status must be also be tackled. Socioeconomic factors – income, wealth and education – all impact. Those “upstream” factors which include social disadvantage, risk exposure and social inequities that play a fundamental causal role in poor health outcomes and must be addressed.[2] These are issues which play out over long periods and much longer than electoral cycles. But stopping the onset of illness is the only way to contain our rising disease burden.[3] Therefore, it is those emerging preventive care solutions, which fall as either proactive or predictive care, where we now need to focus.[4] A prescription for health This prescription for health is very different to the one we currently have and involves a Proactive, Preventive Approach with Increased Engagement. The shift is something we’ve been trying to do in primary care for some time but barriers from without our framework are limiting a full transition. The policy response involves a mix of proactive and predictive care solutions. For proactive care solutions, this involves improving treatment outcomes through stratifying at-risk individuals based on known algorithms ensuring preventive action is taken well before the onset of symptoms. [5] We know that certain behavioural risk factors - tobacco use, alcohol consumption, physical inactivity and unhealthy eating - are most amenable to change. We can do more to modify these behaviours as part of proactive care through stratifying individuals based on key risk factors for chronic disease.[6] While predictive care is about leveraging emerging technologies and using big data to not only stratify risk but predict risk and intervene even further upstream.[7] More predictive care, through improved analytics, genetic risk testing and technological developments build an even clearer picture. These early insights will help us anticipate issues pinpointing those behaviours to avoid and actions to take much earlier than before and before risk factors arise. [8] Risk and protective factors In transforming our health system, it is a focus on those risk and protective factors over time that really holds the answers. The Life Course Health Development (LCHD) framework offers a new approach to health measurement, health system design, and long-term investment in health development.[9] It takes into account those risk and protective factors and early-life experiences in determining long-term health and disease outcomes. [10] More understanding of how these health trajectories develop over a lifetime helps us influence change for optimal health development through more effective preventive strategies and interventions. [11]
2. Then an equal focus on protective factors –These are those protective or health-promoting factors which are of course broader than health but have a positive influence on our lives and are health affirming. From the best start through breastfeeding, positive educational influences or being more physically active throughout through to access to quality healthcare and strong social capital are just some examples. 3. Finally, increased engagement in striving for our own good health –Population health management really offers the collaborative approach required to empower patients and patient centred care. Informed and involved patients who are active participants in setting their own goals for wellness are central.[15] Those social factors and the government’s part in that to ensure we all have the best start and life possible is really key. Strategies for intervention It is these focus areas which hold promising strategies for intervention. Still, we see very few health dollars being prioritised for prevention. To fully support a stronger focus on prevention we need to pursue new data on risk and protective factors, investigating how and when they develop across the life course.[16] Through these key learnings, new proactive and predictive care solutions will need to be developed and prioritised in our healthcare system. This is not a new concept; many general practices already do this – identify and stratify patients according to risk – but it our current payment system really restricts us here in limiting to diagnoses. It is really just the difference between disease focus care and actually enabling more patient centred care. More incentives around prevention and in reducing risk are required to make this work particularly in general practice for an optimal business model. More broadly, this requires a whole of government shift, not just from within the health budget but towards a Health in All Policies (HiAP) approach. This will help redress inequities and give everyone a fair chance for health. The policy remit extends well beyond health and also beyond any discussions occurring right now around fee-for-service and performance-based models. If the government is really serious about shifting health outcomes then we need to think less about a system which drives episodic care and more about those broader factors that influence health outcomes. [1] 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/ [2] Bharmal N, Pitkin Derose K, Felician M, and Weden, M. Working Paper: Understanding the Upstream Social Determinants of Health. RAND Health. Prepared for the RAND Social Determinants of Health Interest Group. WR-1096-RCMay 2015. Available at: https://www.rand.org/content/dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf [3] MacIntosh E, Rajakulendran N, Khayat Z, Wise A. Transforming health: Shifting from reactive to proactive and predictive care. MaRS. 29 Mar 16. Part of the Transforming Health Market Insights Series. Available at: https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [4] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [5] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [6] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [7] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [8] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [9] Halfon N, Hochstein M. Life Course Health Development: An Integrated Framework for Developing Health, Policy, and Research. The MilbankQuarterly.2002;80(3):433-479. doi:10.1111/1468-0009.00019. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690118/ [10] Ibid. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690118/ [11] Ibid. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690118/ [12] Halfon N, Larson K, Russ S. Theories And Consequences. Why Social Determinants? Healthcare Quarterly, 14(Sp) October 2010: 8-20.doi:10.12927/hcq.2010.21979. Available at: http://www.longwoods.com/content/21979 [13] Tasmanian Government. Determinants of Health. Department of Health and Human Services. Available at: http://www.dhhs.tas.gov.au/wihpw/principles/determinants_of_health [14] Op. cit. Halfon et al. Available at: . http://www.longwoods.com/content/21979 [15] Ernst & Young. Population Health Management. EY Health Industry Post. News and analysis of current issues affecting health care providersandpayers.2014.Availableat: http://www.ey.com/Publication/vwLUAssets/Health_Industry_Post_population_health_management/$FILE/Health_Industry_post.pdf [16] Public Health Agency of Canada. Strategic Plan 2016-19. Improving Health Outcomes. A Paradigm Shift. Publication date: December 2015. Cat.: HP35-39/2015E-PDF ISBN: 978-0-660-03990-9 Pub.: 150173. Available at: http://www.phac-aspc.gc.ca/cd-mc/assets/pdf/ccdp-strategic-plan-2016-2019-plan-strategique-cpmc-eng.pdf |
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