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Abstract Background Historically in Australia, all levels of government created collective wealth by owning and operating infrastructure, and managing natural assets, key public goods and essential services while being answerable to the public. This strong state tradition was challenged in the 1980s when privatisation became a widespread government approach globally. Privatisation involves displacing the public sector through modes of financing, ownership, management and product or service delivery. The Australian literature shows that negative effects from privatisation are not spread equitably, and the health and equity impacts appear to be under-researched. This narrative overview aims to address a gap in the literature by answering research questions on what evidence exists for positive and negative outcomes of privatisation; how well societal impacts are evaluated, and the implications for health and equity. Methods Database and grey literature were searched by keywords, with inclusion criteria of items limited to Australia, published between 1990 and 2022, relating to any industry or government sector, including an evaluative aspect, or identifying positive or negative aspects from privatisation, contracting out, or outsourcing. Thematic analysis was aided by NVivo qualitative data software and guided by an a-priori coding frame. Results No items explicitly reflected on the relationship between privatisation and health. Main themes identified were the public cost of privatisation, loss of government control and expertise, lack of accountability and transparency, constraints to accessing social determinants of health, and benefits accruing to the private sector. Discussion Our results supported the view that privatisation is more than asset-stripping the public sector. It is a comprehensive strategy for restructuring public services in the interests of capital, with privatisation therefore both a political and commercial determinant of health. There is growing discussion on the need for re-nationalisation of certain public assets, including by the Victorian government. Conclusion Privatisation of public services is likely to have had an adverse impact on population health and contributed to the increase in inequities. This review suggests that there is little evidence for the benefits of privatisation, with a need for greater attention to political and commercial determinants of health in policy formation and in research.

Abstract Background Meso-level, regional primary health care organisations such as Australia’s Primary Health Networks (PHNs) are well placed to address health inequities through comprehensive primary health care approaches. This study aimed to examine the equity actions of PHNs and identify factors that hinder or enable the equity-orientation of PHNs’ activities. Methods Analysis of all 31 PHNs’ public planning documents. Case studies with a sample of five PHNs, drawing on 29 original interviews with key stakeholders, secondary analysis of 38 prior interviews, and analysis of 30 internal planning guidance documents. This study employed an existing framework to examine equity actions. Results PHNs displayed clear intentions and goals for health equity and collected considerable evidence of health inequities. However, their planned activities were largely restricted to individualistic clinical and behavioural approaches, with little to facilitate access to other health and social services, or act on the broader social determinants of health. PHNs’ equity-oriented planning was enabled by organisational values for equity, evidence of local health inequities, and engagement with local stakeholders. Equity-oriented planning was hindered by federal government constraints and lack of equity-oriented prompts in the planning process. Conclusions PHNs’ equity actions were limited. To optimise regional planning for health equity, primary health care organisations need autonomy and scope to act on the ‘upstream’ factors that contribute to local health issues. They also need sufficient time and resources for robust, systematic planning processes that incorporate mechanisms such as procedure guides and tools/templates, to capitalise on their local evidence to address health inequities. Organisations should engage meaningfully with local communities and service providers, to ensure approaches are equity sensitive and appropriately targeted.

Abstract Background Evidence-informed primary health care (PHC) planning in decentralised, meso-level regional organisations has received little research attention. In this paper we examine the factors that influence planning within this environment, and present a conceptual framework. Methods We employed mixed methods: case studies of five Australian Primary Health Networks (PHNs), involving 29 primary interviews and secondary analysis of 38 prior interviews; and analysis of planning documents from all 31 PHNs. The analysis was informed by a WHO framework of evidence-informed policy-making, and institutional theory. Results Influential actors included federal and state/territory governments, Local Health Networks, Aboriginal Community Controlled Health Organisations, local councils, public hospitals, community health services, and providers of allied health, mental health and aged care services. The federal government was most influential, constraining PHNs’ planning scope, time and funding. Other external factors included: the health service landscape; local socio-demographic and geographic characteristics; (neoliberal) ideology; interests and politics; national policy settings and reforms; and system reorganisation. Internal factors included: organisational structure; culture, values and ideology; various capacity factors; planning processes; transition history; and experience. The additional regional layer of context adds to the complexity of planning. Conclusions Like national health policy-making, meso-level PHC planning occurs in a complex environment, but with additional regional factors and influences. We have developed a conceptual framework of the meso-level PHC planning environment, which can be employed by similar regional organisations to elucidate influential factors, and develop strategies and tools to promote transparent, evidence-informed PHC planning for better health outcomes.

Background Debate continues in public health on the roles of universal or targeted policies in providing equity of access to health- related goods or services, and thereby contributing to health equity. Research examining policy implementation can provide fresh insights on these issues.Methods We synthesised findings across case studies of policy implementation in four policy areas of primary healthcare (PHC), telecommunications, Indigenous health and land use policy, which incorporated a variety of universal and targeted policy structures. We analysed findings according to three criteria of equity in access – availability, affordability and acceptability – and definitions of universal, proportionate-universal, targeted and residual policies, and devolved governance structures.Results Our analysis showed that existing universal, proportionate-universal and targeted policies in an Australian context displayed strengths and weaknesses in addressing availability, affordability and acceptability dimensions of equity in access.Conclusion While residualist policies are unfavourable to equity of access, other forms of targeting as well as universal and proportionate-universal structure have the potential to be combined in context-specific ways favourable to equity of access to health-related goods and services. To optimise benefits, policies should address equity of access in the three dimensions of availability, affordability and acceptability. Devolved governance structures have the potential to augment equity benefits of either universal or targeted policies.

BackgroundDespite growing evidence on the social determinants of health and health equity, political action has not been commensurate. Little is known about how political will operates to enact pro-equity policies or not. This paper examines how political will for pro-health equity policies is created through analysis of public policy in multiple sectors. MethodsEight case studies were undertaken of Australian policies where action was either taken or proposed on health equity or where the policy seemed contrary to such action. Telephone or face-to-face interviews were conducted with 192 state and non-state participants. Analysis of the cases was done through thematic analysis and triangulated with document analysis. ResultsOur case studies covered: trade agreements, primary healthcare (PHC), work conditions, digital access, urban planning, social welfare and Indigenous health. The extent of political will for pro-equity policies depended on the strength of path dependency, electoral concerns, political philosophy, the strength of economic and biomedical framings, whether elite interests were threatened and the success or otherwise of civil society lobbying. ConclusionPublic health policy actors may create political will through: determining how path dependency that exacerbates health inequities can be broken, working with sympathetic political forces committed to fairness; framing policy options in a way that makes them more likely to be adopted, outlining factors to consider in challenging the interests of elites, and considering the extent to which civil society will work in favour of equitable policies. A shift in norms is required to stress equity and the right to health.

BackgroundUniversal health coverage (UHC) is central to current international debate on health policy. The primary healthcare (PHC) system is crucial to achieving UHC, in order to address the rising incidence of non-communicable diseases (NCDs) more effectively and equitably. In this paper, we examine the Australian case as a mature system of UHC and identify lessons for UHC policy to support equity of access to PHC and reduce NCDs. MethodsOur qualitative research used policy mapping and monitoring and 30 key informant interviews, and applied policy theory, to investigate the implementation of Australian PHC policy between 2008 and 2018. ResultsAlthough the Australian PHC system does support equity of access to primary medical care, other ideational, actor-centred and structural features of policy detract from the capacities of the system to prevent and manage NCDs effectively, deliver equity of access according to need, and support equity in health outcomes. These features include a dominant focus on episodic primary medical care, which is a poor model of care for NCDs, and an inequitable distribution of these services. Also, a mixed system of public and private insurance coverage in PHC contributes to inequities in access and health outcomes, driving additional NCD demand into the health system. ConclusionCountries aiming to achieve UHC to support health equity and reduce NCDs can learn from strengths and weaknesses in the Australian system. We recommend a range of ideational, actor-centred and structural features of UHC systems in PHC that will support effective action on NCDs, equity of access to care according to need, and equity in health outcomes across geographically and ethnically diverse populations.

BackgroundThere is an increasing emphasis on the importance of comprehensive primary healthcare (CPHC) in improving population health and health equity. There is, therefore, a need for a practical means to determine how comprehensive regional primary healthcare organisations (RPHCOs) are in their approach. This paper proposes a framework to provide such a means. The framework is then applied to assess the comprehensiveness of Australian RPHCOs. MethodsDrawing on a narrative review of the broader literature on CPHC versus selective primary healthcare (SPHC) and examples of international models of RPHCOs, we developed a framework consisting of the key criteria and a continuum from comprehensive to selective interventions. We applied this framework to Australian RPHCOs using data from the review of their planning documents, and survey and interviews with executive staff, managers, and board members. We used a spidergram as a means to visualise how comprehensive they are against each of these criteria, to provide a practical way of presenting the assessment and an easy way to compare progress over time. ResultsKey criteria for comprehensiveness included (1) focus on population health; (2) focus on equity of access and outcomes; (3) community participation and control; (4) integration within the broader health system; (5) inter-sectoral collaboration; and (6) local responsiveness. An examination of Australian RPHCOs using the framework suggests their approach is far from comprehensive and has become more selective over time. ConclusionThe framework and spidergram offer a practical means of gauging and presenting the comprehensiveness of RPHCOs, and to identify gaps in comprehensiveness, and changes over time.

Background Despite the value of community health systems, they have not flourished in high income countries and there are no system-wide examples in high income countries where community health is regarded as the mainstream model. Those that do exist in Australia, Canada, the United States and the United Kingdom provide examples of comprehensive primary healthcare (PHC) but are marginal to bio-medical primary medical care. The aim of this paper is to examine the factors that account for the absence of strong community health systems in high income countries, using Australia as an example.Methods Data are drawn from two Australian PHC studies led by the authors. One examined seven case studies of community health services over a five-year period which saw considerable health system change. The second examined regional PHC organisations. We conducted new analysis using the ‘three I’s’ framework (interests, institutions, ideas) to examine why community health systems have not flourished in high-income countries.Results The elements of the community health services that provide insights on how they could become the basis of an effective community health system are: a focus on equity and accessibility, effective community participation/control; multidisciplinary teamwork; and strategies from care to health promotion. Key barriers identified were: when general practitioners (GPs) were seen to lead rather than be part of a team; funding models that encourage curative services rather than disease prevention and health promotion; and professional and medical dominance so that community voices are drowned out.Conclusion Our study of the community health system in Australia indicates that instituting such a system in high income countries will require systematic ideological, political and institutional change to shift the overarching government policy environment, and health sector policies and practices towards a social model of health which allows community control, and multidisciplinary service provision.

The 2007 Northern Territory Emergency Response (NTER) targeted Aboriginal communities in the Northern Territory in Australia. The NTER imposed draconian measures unfavourable to health, contributing to health inequities. There is little research investigating why the NTER was framed so negatively, and how this framing passed into legislation so unassailably. We used institutional theory to understand what factors contributed to the NTER agenda framing, what institutional factors enabled its dominance over pro-equity frames, and what lessons can be learned for future efforts to improve public policies for health equity. We interviewed 21 key policy actors, including actors with a role in the NTER, government opposition, Aboriginal civil society, non-Indigenous stakeholders, and actors from the Little Children Are Sacred report and Northern Territory government, and the Coalition of Aboriginal Organisations that provided alternative pro-equity policy framings that were not taken up. We found Federal government framing was driven by a deficit discourse of Aboriginal and Torres Strait Islander peoples in the media, and the Federal government's interest in winning the upcoming election, trialling welfare reform, and gaining more control over Northern Territory Indigenous Affairs. The framing passed almost unchanged into legislation because of the government's closed processes that excluded Aboriginal perspectives, the media's failure to report dissenting Aboriginal voices, and the power the Federal government was able to wield over the Northern Territory. The most critical action needed for more pro-equity Indigenous Affairs policy is resourced structures to provide more structural power for Aboriginal and Torres Strait Islander people to influence policy.

Abstract Background Many nations have established primary health care (PHC) organizations that conduct PHC planning for defined geographical areas. The Australian Government established Primary Health Networks (PHNs) in 2015 to develop and commission PHC strategies to address local needs. There has been little written about the capacity of such organizations for evidence-informed planning, and no tools have been developed to assess this capacity, despite their potential to contribute to a comprehensive effective and efficient PHC sector. Methods We adapted the ORACLe tool, originally designed to examine evidence-informed policy-making capacity, to examine organizational capacity for evidence-informed planning in meso-level PHC organizations, using PHNs as an example. Semi-structured interviews were conducted with 14 participants from five PHNs, using the ORACLe tool, and scores assigned to responses, in seven domains of capacity. Results There was considerable variation between PHNs and capacity domains. Generally, higher capacity was demonstrated in regard to mechanisms which could inform planning through research, and support relationships with researchers. PHNs showed lower capacity for evaluating initiatives, tools and support for staff, and staff training. Discussion and conclusions We critique the importance of weightings and scope of some capacity domains in the ORACLe tool. Despite this, with some minor modifications, we conclude the ORACLe tool can identify capacity strengths and limitations in meso-level PHC organizations. Well-targeted capacity development enables PHC organizations’ strategies to be better informed by evidence, for optimal impact on PHC and population health outcomes.

Abstract Background While in general a country’s life expectancy increases with national income, some countries “punch above their weight”, while some “punch below their weight” – achieving higher or lower life expectancy than would be predicted by their per capita income. Discovering which conditions or policies contribute to this outcome is critical to improving population health globally. Methods We conducted a mixed-method study which included: analysis of life expectancy relative to income for all countries; an expert opinion study; and scoping reviews of literature and data to examine factors that may impact on life expectancy relative to income in three countries: Ethiopia, Brazil, and the United States. Punching above or below weight status was calculated using life expectancy at birth and gross domestic product per capita for 2014–2018. The scoping reviews covered the political context and history, social determinants of health, civil society, and political participation in each country. Results Possible drivers identified for Ethiopia’s extra 3 years life expectancy included community-based health strategies, improving access to safe water, female education and gender empowerment, and the rise of civil society organisations. Brazil punched above its weight by 2 years. Possible drivers identified included socio-political and economic improvements, reduced inequality, female education, health care coverage, civil society, and political participation. The United States’ neoliberal economics and limited social security, market-based healthcare, limited public health regulation, weak social safety net, significant increases in income inequality and lower levels of political participation may have contributed to the country punching 2.9 years below weight. Conclusions The review highlighted potential structural determinants driving differential performance in population health outcomes cross-nationally. These included greater equity, a more inclusive welfare system, high political participation, strong civil society and access to employment, housing, safe water, a clean environment, and education. We recommend research comparing more countries, and also to examine the processes driving within-country inequities.

Abstract Background The People’s Health Movement (PHM) was formed in 2000 and drew inspiration from the Alma Ata Declaration on Primary Health Care’s ‘Health for All’ (1978). Since then PHM has been an active part of a global counter-hegemonic social movement. This study aimed to gain insights on social movement building, drawing on the successes and failures reported by activists over their experiences of working in the Health for All social movement to improve health, justice and equity. Methods Qualitative research methods were employed in this study to capture complex and historical narratives of individual activists, through semi-structured interviews and subsequent thematic analysis of transcripts. The research design and analysis were informed by social movement theory and literature on health activism as a pathway for social change. In this study we examine the semi-structured interviews of 15 health activists who are part of the PHM, with the aim of deriving lessons for strengthening movements for Health for All. Results This study locates the activists’ narratives within a socio-political analysis of the global trends of late modern individualism and capitalist neoliberalism. This highlights the challenges faced by civil society groups mobilising collective action and building social movements for Health for All. The study found that within the constraints of the neoliberal socio-political and economic conditions which have caused the rise in social and health inequities, this group of long-term health activists have been nurturing alternative approaches to structuring society and building collective agency to improve health. Conclusion The practical long-term experiences of the PHM activists examined in this study contribute to a better understanding of the processes and motivations that lead to and sustain health activism, and the dilemmas, strategies, impacts and achievements of such activism.

Abstract Objective: This paper examines whether Australian regional primary health care organisations – in this case, Medicare Locals (MLs) and Primary Health Networks (PHNs) – have engaged with migrant and refugee health, and what factors encourage work in this area. Methods: The study used mixed methods with surveys of ML (N=210) and PHN staff (N=66), interviews with ML (N=50) and PHN (N=55) staff, national consultations with migrant and refugee organisations (N=8 groups with 62 participants), and analysis of ML and PHN documents. Results: Needs assessment documents identified migrant and refugee health issues in 46% of MLs and 74% of PHNs. However, 48% of MLs and 55% of PHNs did not report any activities on migrant health, and 78% and 62% did not report any activities for refugees, respectively. Key factors identified by participants as associated with whether ML and PHN focus on migrant and refugee health were the determination of local priority areas, policy context and funding, collaboration with migrant and refugee organisations and communities, and mechanisms for engagement. Conclusions: Despite the importance of primary health care for migrants and refugees, there was relatively little attention paid to these population groups in MLs and PHNs, with a small number of notable exceptions. Implications for public health: The paper concludes with a range of recommendations for improving regional primary health care organisation engagement with migrant and refugee health.

Abstract Objective: This paper provides a case study of the responses to alcohol of an Aboriginal Community Controlled Health Service (The Service), and investigates the implementation of comprehensive primary health care and how it challenges the logic of colonial approaches. Methods: Data were drawn from a larger comprehensive primary health care study. Data on actions on alcohol were collected from: a) six‐monthly service reports of activities; b) 29 interviews with staff and board members; c) six interviews with advocacy partners; and d) community assessment workshops with 13 service users. Results: The Service engaged in rehabilitative, curative, preventive and promotive work targeting alcohol, including advocacy and collaborative action on social determinants of health. It challenged other government approaches by increasing Aboriginal people’s control, providing culturally safe services, addressing racism, and advocating to government and industry. Conclusions: This case study provides an example of implementation of the full continuum of comprehensive primary health care activities. It shows how community control can challenge colonialism and ongoing power imbalances to promote evidence‐based policy and practice that support self‐determination as a positive determinant for health. Implications for public health: Aboriginal Community Controlled Health Services are a good model for comprehensive primary health care approaches to alcohol control.

Abstract Background Collaborative care is a means of improving outcomes particularly for people with complex needs. The Partners in Recovery (PIR) program, established in Australia in 2012, provides care coordination to facilitate access to health and social support services for people with severe and persistent mental illness. Of the 48 PIR programs across Australia, 35 were led by Medicare Locals, the previous Australian regional primary health care organisation and nine involved Medicare Locals as partner organisations. Aims To identify features which enabled and hindered collaboration in PIR programs involving Medicare Locals and determine what can be learnt about delivering care to this population. Methods Data were collected from 50 interviews with senior staff at Medicare Locals and from eight focus groups with 51 mental health stakeholders in different Australian jurisdictions. Results Successful PIR programs were based upon effective collaboration. Collaboration was facilitated by dedicated funding, a shared understanding of PIR aims, joint planning, effective network management, mutual respect and effective communication. Collaboration was also enhanced by the local knowledge and population health planning functions of Medicare Locals. Jurisdictional boundaries and funding discontinuity were the primary barriers to collaboration.

Objective and importance of study: Considerable evidence suggests that adverse social determinants of health (SDH), such as poor education, unemployment, food and housing insecurity, interpersonal violence, inadequate social support and poverty, are key determinants of health and wellbeing. This prospective cohort study piloted a screening tool to collect individual SDH data in a South Australian hospital inpatient population. We explored participants’ attitudes to SDH screening in brief follow-up interviews. Methods: This mixed-methods study used an SDH screening tool to collect individual-level SDH data from inpatients living in a highly disadvantaged socio-economic area. Participants had a primary diagnosis of chronic obstructive pulmonary disease (COPD), heart failure (HF) or diabetes mellitus. Follow-up interviews were completed post discharge via telephone. Descriptive statistics were employed to examine the prevalence and type of adverse SDH reported by the sample. Thematic analysis was applied to explore participants’ attitudes to the screening. Results: The sample population (N = 37) reported a substantial burden of a range of adverse SDH (mean 4.7 adverse SDH experienced per participant, standard deviation 2.8). Participants involved in follow-up interviews (n = 8) believed screening might enhance communication between healthcare providers and patients and assist in identifying underlying social problems. Conclusion: A screening tool for SDH was successfully used to collect individual-level data in a hospital setting. An array of adverse SDH was common in the sample population. Participants believed screening for SDH may potentially benefit doctors and patients. A larger study is required to more robustly characterise the adverse SDH affecting individuals in this population and to explore how the healthcare system might effectively intervene.

Objective While there is urgent need for policymaking that prioritises health equity, successful strategies for advancing such an agenda across multiple policy sectors are not well known. This study aims to address this gap by identifying successful strategies to advance a health equity agenda across multiple policy domains.Design We conducted in-depth qualitative case studies in three important social determinants of health equity in Australia: employment and social policy (Paid Parental Leave); macroeconomics and trade policy (the Trans Pacific Partnership agreement); and welfare reform (the Northern Territory Emergency Response). The analysis triangulated multiple data sources included 71 semistructured interviews, document analysis and drew on political science theories related to interests, ideas and institutions.Results Within and across case studies we observed three key strategies used by policy actors to advance a health equity agenda, with differing levels of success. The first was the use of multiple policy frames to appeal to a wide range of actors beyond health. The second was the formation of broad coalitions beyond the health sector, in particular networking with non-traditional policy allies. The third was the use of strategic forum shopping by policy actors to move the debate into more popular policy forums that were not health focused.Conclusions This analysis provides nuanced strategies for agenda-setting for health equity and points to the need for multiple persuasive issue frames, coalitions with unusual bedfellows, and shopping around for supportive institutions outside the traditional health domain. Use of these nuanced strategies could generate greater ideational, actor and institutional support for prioritising health equity and thus could lead to improved health outcomes.

Abstract Background Despite calls for the application of complex systems science in empirical studies of health promotion, there are very few examples. The aim of this paper was to use a complex systems approach to examine the key factors that influenced health promotion (HP) policy and practice in a multisectoral health system in Australia. Methods Within a qualitative case study, a schema was developed that incorporated HP goals, actions and strategies with WHO building blocks (leadership and governance, financing, workforce, services and information). The case was a multisectoral health system bounded in terms of geographical and governance structures and a history of support for HP. A detailed analysis of 20 state government strategic documents and interviews with 53 stakeholders from multiple sectors were completed. Based upon key findings and dominants themes, causal pathways and feedback loops were established. Finally, a causal loop diagram was created to visualise the complex array of feedback loops in the multisectoral health system that influenced HP policy and practice. Results The complexity of the multisectoral health system was clearly illustrated by the numerous feedback mechanisms that influenced HP policy and practice. The majority of feedback mechanisms in the causal loop diagram were vicious cycles that inhibited HP policy and practice, which need to be disrupted or changed for HP to thrive. There were some virtuous cycles that facilitated HP, which could be amplified to strengthen HP policy and practice. Leadership and governance at federal–state–local government levels figured prominently and this building block was interdependently linked to all others. Conclusion Creating a causal loop diagram enabled visualisation of the emergent properties of the case health system. It also highlighted specific leverage points at which HP policy and practice can be improved. This paper demonstrates the critical importance of leveraging leadership and governance for HP and adds urgency to the need for increased and strong advocacy efforts targeting all levels of government in multisectoral health systems.

Background Community Health Workers (CHWs) are proven to be highly effective in low- and middle-income countries with many examples of successful large-scale programs. There is growing interest in deploying CHW programs in high-income countries to address inequity in healthcare access and outcomes amongst population groups facing disadvantage. This study is the first that examines the scope and potential value of CHW programs in Australia and the challenges involved in integrating CHWs into the health system. The potential for CHWs to improve health equity is explored. Methods Academic and grey literature was searched to examine existing CHW roles in the Australian primary healthcare system. Semi-structured telephone interviews were conducted with a purposive sample of 11 people including policymakers, program managers and practitioners, to develop an understanding of policy and practice. Results Literature on CHWs in Australia is sparse, yet combined with interview data indicates CHWs conduct a broad range of roles, including education, advocacy and basic clinical services, and work with a variety of communities experiencing disadvantage. Many, and to some extent inconsistent, terms are used for CHWs, reflecting the various strategies employed by CHWs, the characteristics of the communities they serve, and the health issues they address. The role of aboriginal health workers (AHWs) is comparatively well recognised, understood and documented in Australia with evidence on their contribution to overcoming cultural barriers and improving access to health services. Ethnic health workers assist with language barriers and increase the cultural appropriateness of services. CHWs are widely seen to be well accepted and valuable, facilitating access to health services as a trusted ‘bridge’ to communities. They work best where ‘health’ is conceived to include action on social determinants and service models are less hierarchical. Short term funding models and the lack of professional qualifications and recognition are challenges CHWs encounter. Conclusion CHWs serve a range of functions in various contexts in Australian primary healthcare (PHC) with a common, valued purpose of facilitating access to services and information for marginalised communities. CHWs offer a promising opportunity to enhance equity of access to PHC for communities facing disadvantage, especially in the face of rising chronic disease.

Abstract Background Life expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected – they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available. New research network In order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens. Conclusion Further research using this framework has considerable potential to advance effective policies to advance health and equity.

Background Epidemiological evidence on the social determinants of health inequity is well-advanced, but considerably less attention has been given to evaluating the impact of public policies addressing those social determinants. Methodological challenges to produce evidence on policy outcomes present a significant barrier to mobilising policy actions for health equities. This review aims to examine methodological approaches to policy evaluation of health equity outcomes and identify promising approaches for future research. Methods We conducted a systematic narrative review of literature critically evaluating policy impact on health equity, synthesizing information on the methodological approaches used. We searched and screened records from five electronic databases, using pre-defined protocols resulting in a total of 50 studies included for review. We coded the studies according to (1) type of policy analysed; (2) research design; (3) analytical techniques; (4) health outcomes; and (5) equity dimensions evaluated. Results We found a growing number of a wide range of policies being evaluated for health equity outcomes using a variety of research designs. The majority of studies employed an observational research design, most of which were cross-sectional, however, other approaches included experimental designs, simulation modelling, and meta-analysis. Regression techniques dominated the analytical approaches, although a number of novel techniques were used which may offer advantages over traditional regression analysis for the study of distributional impacts of policy. Few studies made intra-national or cross-national comparisons or collected primary data. Despite longstanding challenges of attribution in policy outcome evaluation, the majority of the studies attributed change in physical or mental health outcomes to the policy being evaluated. Conclusion Our review provides an overview of methodological approaches to health equity policy outcome evaluation, demonstrating what is most commonplace and opportunities from novel approaches. We found the number of studies evaluating the impacts of public policies on health equity are on the rise, but this area of policy evaluation still requires more attention given growing inequities

Abstract Background Worldwide, there are competing norms driving health system changes and reorganisation. One such norm is that of health systems’ responsibilities for population health as distinct from a focus on clinical services. In this paper we report on a case study of population health planning in Australian primary health care (PHC) organisations (Medicare Locals, 2011–2015). Drawing on institutional theory, we describe how institutional forces, ideas and actors shaped such planning. Methods We reviewed the planning documents of the 61 Medicare Locals and rated population health activities in each Medicare Local. We also conducted an online survey and 50 interviews with Medicare Local senior staff, and an interview and focus group with Federal Department of Health staff. Results Despite policy emphasis on population health, Medicare Locals reported higher levels of effort and capacity in providing clinical services. Health promotion and social determinants of health activities were undertaken on an ad hoc basis. Regulatory conditions imposed by the federal government including funding priorities and time schedules, were the predominant forces constraining population health planning. In some Medicare Locals, this was in conflict with the normative values and what Medicare Locals felt ought to be done. The alignment between the governmental and the cultural-cognitive forces of a narrow biomedical approach privileged clinical practice and ascribed less legitimacy to action on social determinants of health. Our study also shed light on the range of PHC actors and how their agency influenced Medicare Locals’ performance in population health. The presence of senior staff or community boards with a strong commitment to population health were important in directing action towards population health and equity. Conclusions There are numerous institutional, normative and cultural factors influencing population health planning. The experience of Australian Medicare Locals highlights the difficulties of planning in such a way that the impact of the social determinants on health and health equity are taken into account. The policy environment favours a focus on clinical services to the detriment of health promotion informed by a social determinants focus.

Objective and importance of study: The importance of social determinants for individual health recovery outcomes is well recognised in public health. However, no succinct social health screening (SHS) tool exists that has been developed with information from clinicians and patients. This proof-of-concept study asked health consumer advocates, patients and clinicians about their attitudes towards social determinants of health (SDH) and the usefulness of an SHS tool for collecting these data for use in clinical settings. We then developed a streamlined SHS tool to bring this knowledge to clinicians, and conducted a proof-of-concept trial to check its acceptability with patients and clinicians. Methods: This qualitative study had two stages. Stage 1 involved focus groups with health consumer advocates and interviews with clinicians about the draft SHS tool. Stage 2 involved refining the SHS tool and piloting it with 50 new patients in anxiety disorder and sleep disorder clinics, which often treat patients living in disadvantaged socio-economic conditions. The tool was evaluated by patients and clinicians. The data were analysed using framework analysis. Results: All interviewees were positive about the benefits of addressing SDH in clinical practice to help reduce health inequities. We developed and refined an SHS tool that could be completed by patients (‘self-complete’). Conclusion: The response to introducing an SHS tool in clinical settings was positive. Further piloting across diverse clinical settings is required to determine efficacy. This tool promotes public health equity outcomes by improving clinician understanding of individual social circumstances, and has the potential to provide useful epidemiological data on SDH.

Abstract Objective: To examine case studies of good practice in intersectoral action for health as one part of evaluating comprehensive primary health care in six sites in South Australia and the Northern Territory. Methods: Interviews with primary health care workers, collaborating agency staff and service users (Total N=33); augmented by relevant documents from the services and collaborating partners. Results: The value of intersectoral action for health and the importance of partner relationships to primary health care services were both strongly endorsed. Factors facilitating intersectoral action included sufficient human and financial resources, diverse backgrounds and skills and the personal rewards that sustain commitment. Key constraining factors were financial and time limitations, and a political and policy context which has become less supportive of intersectoral action; including changes to primary health care. Conclusions: While intersectoral action is an effective way for primary health care services to address social determinants of health, commitment to social justice and to adopting a social view of health are constrained by a broader health service now largely reinforcing a biomedical model. Implications: Effective organisational practices and policies are needed to address social determinants of health in primary health care and to provide a supportive context for workers engaging in intersectoral action.

Abstract Objective: There is little literature on health‐service‐level strategies for culturally respectful care to Aboriginal and Torres Strait Islander Australians. We conducted two case studies, which involved one Aboriginal community controlled health care service and one state government‐managed primary health care service, to examine cultural respect strategies, client experiences and barriers to cultural respect. Methods: Data were drawn from 22 interviews with staff from both services and four community assessment workshops, with a total of 21 clients. Results: Staff and clients at both services reported positive appraisals of the achievement of cultural respects. Strategies included: being grounded in a social view of health, including advocacy and addressing social determinants; employing Aboriginal staff; creating a welcoming service; supporting access through transport, outreach, and walk‐in centres; and integrating cultural protocol. Barriers included: communication difficulties; racism and discrimination; and externally developed programs. Conclusions: Service‐level strategies were necessary to achieving cultural respect. These strategies have the potential to improve Aboriginal and Torres Strait Islander health and wellbeing. Implications: Primary health care's social determinants of health mandate, the community controlled model, and the development of the Aboriginal and Torres Strait Islander health workforce need to be supported to ensure a culturally respectful health system.