The potential for multi-disciplinary primary health care services to take action on the social determinants of health: actions and constraints

In 2008 the Commission on the Social Determinants of Health (CSDH) recommended the need for health systems to be based on primary health care (PHC) and to be able to take action on the social determinants of health (SDH). These recommendations were reinforced by the World Health Organization’s Rio Political Declaration on Social Determinants of Health [1] and a United Nations Declaration on the Prevention and Control of Non-communicable Diseases [2]. Each saw comprehensive PHC as having a role in reducing health inequities through action on SDH. These recommendations built on earlier WHO statements on PHC and the Ottawa Charter for Health Promotion [3] and the subsequent series of global health promotion conferences (see [4]) each of which have stressed the need for a reoriented health sector and healthy public policy through intersectoral action. This paper examines the extent to which six case study PHC services in Australia took action on the SDH and the constraints they faced in doing so. The paper starts with an exploration of debates about the roles, function and ideological underpinnings of PHC in the past thirty years particularly in relation to tackling SDH.

The concept of PHC evolved during the 1970s, influenced by and influencing the basic needs approach to social development [5]. Informed by both the disappointments experienced in implementing the basic health services approach [6] and by the significant progress in improving health in China in the 1960s and 1970s, as well as by the achievements of many small, mostly NGO-inspired, community-based healthcare initiatives [7] including the Aboriginal community-controlled movement in Australia [8], the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) elaborated the strategy of PHC as the means to achieve ‘Health for All’ by the year 2000. The WHO Alma Ata Declaration [9] saw PHC as a focus for community action to tackle the underlying determinants of health thus situating PHC within a broader social movement designed to reduce inequities and improve living conditions for whole populations [6, 10–12].

This social view of health was not new in the 1970s and has roots going back to the nineteenth century. In Europe both Engels [13] and Virchow [14] recognised that disease affected the poor more than the rich and that social conditions were vital in this relationship. A similar recognition was evident in Latin America where the social medicine movement, also with its roots in the nineteenth century, placed emphasis on the social basis of health [15]. The Marxist argument that health inequities have their origins in social class difference and the reproduction of these classes through capitalism has been applied to contemporary society [16]. This body of thinking argues that understanding the SDH requires an analysis of how class-driven poverty, and the alienation and relative powerlessness that goes with it, sets the scene for constellations of vulnerabilities and behaviours which contribute to multiple diseases. The role of the health sector in addressing these conditions of vulnerability, and the behaviours and diseases to which they give rise, requires a comprehensive approach which goes beyond service provision to address social and economic inequities.

Despite the strong case for a comprehensive PHC approach it was challenged very soon after the Alma Ata Declaration was published. Walsh and Warren [17] argued that “until primary health care can be made available to all, services targeted to the few most important diseases may be the most effective means of improving the health of the greatest number of people” (p. 973). This technical argument ignores the sociological arguments for comprehensive PHC. The debate between selective and comprehensive PHC reflects deeply rooted perspectives on how health is created and why it is distributed unevenly in societies. The logic of a selective PHC is rooted in disease and behavioural epidemiological understandings which do not attempt to account for the social and political basis of health and which align more closely with a biomedical than social approach to health. Biomedicine sees diseases as residing in the bodies of individuals and so actions to address them are directed at curing the individual or persuading them to reduce their risk factors for disease [18], emphasizing curative and rehabilitative therapies. The biomedical paradigm has established a pervasive and powerful position [19, 20] and it continues to dominate in health systems around the world. This position of privilege is reinforced by the individualism that is at the heart of neo-liberalism [10]; and, indeed, the rise of biomedicine in the early 20^th century has been argued as due partly to its ideological alignment with industrial capitalism [16]. The hegemony of these ideas was argued powerfully by Tesh [21] when she showed that the “hidden arguments” in many public health debates are actually ones of ideology in which the dominant ideology of individualism remains hidden and is presented as taken-for-granted knowledge.

Applying Tesh’s [21] insight to the debates about PHC suggest that the seemingly “apolitical” perspective of selective PHC and its focus on treating a few diseases with largely medical therapies also serves to maintain the status quo in terms of resource and power distribution. Health politics lie in controlling the costs of publicly funded health care, managing the conflicts between health professionals for control of health care and developing efficient management models [22]. In this context the potentially redistributive role of PHC in dealing with underlying causes is inevitably controversial and contested, uncomfortably positioning PHC services as one of the key meeting points between biomedicine and sociological understandings. Comprehensive PHC may be opposed because it is perceived to be (and may actually be in practice) threatening to the social, economic and political status quo given that its aim is to reduce health inequities by challenging the inequitable structures which underpin them [16, 23]. This position raises many questions for the ways in which PHC services are able to respond to SDH and what factors support or impede responses. The mixed progress in improving health under the western bio-medical model has led to continued debate about styles of PHC. Thus increasing burdens of chronic disease (which are complex to manage) in countries at all levels of development [24, 25] and the increased inequities in wealth and health over the last two decades [26–28] indicate that comprehensive PHC is needed as much today as it was in 1978.

Despite this support for comprehensive PHC, commentators have argued that PHC (including in Australia) has become more selective as an individual and disease based approach has overtaken the original 1978 vision [29–31] and that behavioural paradigms dominate despite acknowledgement of the importance of SDH [32]. In Australia successive Federal governments have chosen to give resources and policy attention to developing primary medical care rather than strengthening comprehensive PHC. There has also been a progressive withdrawal from the community managed services introduced in the 1970s by the reformist Whitlam Labor government to PHC services that are directly managed by the state health departments, with the exception of the Aboriginal community controlled sector. The adoption of selective rather than comprehensive PHC models is also underpinned by the lack of any serious research or policy attention to what comprehensive models of PHC could or should look like in practice. In the 2008 Now More Than Ever WHO report on PHC, there is no attempt to articulate or describe possible practices of comprehensive PHC. Nor does the report suggest how such practices could evolve from more selective PHC models. This presents PHC practitioners and managers with dilemmas [10, 33] reminiscent of Hoggett, Mayo and Miller’s [34] analysis of development social work in the UK where they noted the uncomfortable position of workers between the neo-liberal policies of the state and local communities. Comprehensive PHC implies challenge to the status quo of unhealthy structures, which means that PHC workers implementing this strategy at a local level will come against the power structures that maintain and reproduce the status quo. Practicing PHC in a way that does challenge power structures has rarely been considered in the literature. PHC research has focussed on “slices” of work conducted in PHC centres rather than the responses of workers to these contradictions [35, 36]. The only insights in the literature come from books considering these tensions in PHC. Broom [37] explores the contradictions between feminist ideology and the operation of state funded women’s health centres and demonstrates the very significant dilemmas that were posed for services trying to reconcile the contradictions in their practices. Legge et al’s [38] analysis of 185 published accounts of PHC practice stressed the importance of community involvement, collaborative local networking, vertical networking, integrating a concern for the local (“micro”) level and longer term, macro issues and the importance of change consciousness. Baum, Fry and Lennie [39] described the Australian community health movement and Baum [40] details the experience of PHC in South Australia. Both highlighted very similar elements for best practice to those identified by Legge et al. [38]. A strong community health sector working on principles of comprehensive PHC operates in some provinces in Canada (see http://www.cachc.ca/) and Lefkowitz [41] describes the community health movement in the United States highlighting its roots in the civil rights and social justice movements. This small evidence base does suggest that practicing comprehensive PHC requires PHC workers to be reflexive about the role of a PHC service when it practices in a manner that extends beyond delivering services to individuals and seeks to empower people and communities to change the conditions that give rise to poor health in the first place. Giddens [42, 43] stresses that a fundamental feature of modernity is the reflexivity of social life and that there has been an acceleration in the processes of social reflexivity. These processes extend to professional practices such as those associated with comprehensive PHC, which requires engagement with individuals and the structures that shape their chances for health. Thus it is important to determine PHC workers’ awareness of how social conditions constrain and promote health and how they perceive these conditions affecting their practice and how their practice is itself constrained by structures.

Despite recognition of the potential role of PHC services in responding to SDH [1, 24, 58] there has been no delineation of the role or the dilemmas PHC services have to confront in order to be effective actors. Our study has documented some of these dilemmas and also demonstrates the potential of PHC to play a constructive role. Our study has documented that PHC workers in our six case study services were able to respond to the SDH by developing a practice which means that their service provision to individuals is done in a way that recognises and takes into account the limitations placed on people’s agency by the economic and social conditions in which they live. The PHC services also provide services at a community level which both acknowledges the importance of community connectedness to health and also responds to threats to the community’s health. Advocacy for individuals is a powerful way of assisting individuals to gain access to vital economic and social resources which assist them to cope with illness or maintain their health. Policy advocacy is also important in regard to threats to the overall health of communities. Thus we have found that PHC do play a very constructive role in addressing the SDH and also found evidence that they could do more given a strong policy and management mandate. We found that the tensions between selective and comprehensive approaches to PHC are playing out in the six services in our study. The services they offer and strategies they engage in span biomedical, behaviours and social approaches much as described by Labonte [59]. Most of our respondents showed an appreciation of how social determinants affected health and often, in the face of this information, felt somewhat impotent about their potential to respond to these determinants. The communities served by the services were disadvantaged and had heavy burdens of disease that reflected poverty, high unemployment and lack of education. This burden of disease led to very heavy demands for services to treat illness and in this context taking action on SDH can seem like a luxury. Even those respondents who expressed a strong determination to base their work on a social model of health struggled to articulate how they could do this beyond the fact that their practice reflected an appreciation of the structural constraints their clients faced and some advocacy work. This feeling was reinforced by the fact that so many SDH are complex and deeply rooted in structural class and race inequities and the current political economy of Australia.

When our respondents spoke of the limitations to the work they could do on the SDH it was in terms of a complex world where they were struggling to understand the interactions between different determinants, were conscious of the ways in which unfair economic arrangements made their work difficult because of the disadvantage experienced by their clients, and doing this against a backdrop of organisational change. Our interviews indicated that most PHC workers are reflexive in their response to the dilemmas they face in their work in ways similar to the reflexivity Giddens [42] suggests is required of people in the face of the contradictions of late modernity. It also appears that the more the workers approach their work with an appreciation of the deep-rooted, entrenched nature of SDH the more they used reflexive responses. This was most evident in Congress, the Aboriginal community controlled service which understood their work as playing out against the backdrop of Aboriginal dispossession and the consequent low socio-economic status of Aboriginal people and the institutional racism characteristic of broader Australian society. The complexity of the structures within which social determinants play out mean that without this reflexivity it is easier to revert to individualised medical or behavioural strategies in the absence of a more systematic analysis of the structural causes of health inequities. Hoggett, Mayo and Miller [34] examine the dilemmas of development work in the UK in terms of the need for the workers to traverse “dilemmatic space”. The space occupied by PHC is indeed dilemmatic and our study suggests it is becoming more so as health departments reduce PHC to a selective model which focuses almost entirely on services to individuals and does not pay attention to the SDH and their impact across communities. The services are committed to social justice and most staff appreciate the need for changes to people’s living conditions in order to improve health. Yet their hands are tied in most respects and they see their ability to assist clients to make real changes as limited. They understand the importance of a social view of health but work in a broader health system that reinforces a largely bio-medical view. And even for many who see the broader social view, the discourse on SDH itemizes a number of conditions (mimicking behavioural epidemiology and its lists of specific risk factors) rather than presenting a more unified political analysis of how these conditions may be linked, potentially adding to workers’ sense of not being able to make much of a difference. For those working in Aboriginal health services the dilemmatic space is further complicated by a post-colonial world with its legacies of extreme dispossession, racial discrimination and burdensome bureaucratic requirements [60]. A further issue for PHC services is that their managers are relatively powerless in bureaucratic hierarchies compared to their acute service colleagues, which means that their advocacy for a SDH approach is not made from a position of power and influence. This reinforces the importance of supportive policy and a mandate from fund holders to take action on SDH.

It is evident from our study that a comprehensive approach to PHC requires staff with a range of skills. Those focusing on the provision of services to individuals are necessarily more bio-medical and individually focused. Group work is an important aspect of practice and practitioners need skills in planning and running groups. The broader community-wide roles require community educators, community developers and organisers who are best able to respond to SDH. In these roles skills in community organising, policy development and advocacy and campaigning would be vital. It was these later roles that appear to be under question in the state-managed services. Workers fulfilling these roles all reported feeling that their work was not valued and as they left were being replaced by clinical staff.

A minority of workers (primarily those in community development roles) noted that forms of practice that seek to address social determinants soon come to be seen as ‘political’ because they involve challenging entrenched power. These workers reported feeling less able to speak out about health issues when they challenged vested interests and so highlighted the dilemmas of being employed as a public servant in a role which, if done well, requires workers to be vocal advocates. Congress’s commitment to self-determination has to be negotiated with a state that struggles to come to terms with a long history of colonial dispossession and white hegemony. The subsequent lack of education, housing and employment that characterises Aboriginal people in Alice Springs cannot be addressed by a PHC service alone, even though it is able to contribute to reducing historical disempowerment through its community management and advocacy work. In the same way the state-managed PHC services operate in communities where people have experienced intergenerational unemployment, lack of education and live in poverty, reflecting international and national economic trends. These complexities, rooted in societal structures make PHC actors committed to a social view of health almost frozen in the headlights of these overwhelming forces whose causes are far removed from the reach and influence of the PHC services.

One way of dealing with the dilemmatic space in which the PHC workers find themselves is to build alliances and develop PHC as a social movement. This seemed to be happening most at Congress, a key player in the Aboriginal community controlled health movement which has been a political force since the 1970s [8, 32, 61]. SHine SA was part of a broader movement for sexual health. By contrast the state-managed services’ staff made frequent reference to the limits on their agency to take political stances as public servants. However, in the 1990s and early 2000s government managed services did appear to engage in advocacy to a far greater extent [39, 62]. In this period the services, while still funded and managed by the state government health department, had independent boards of management which gave the PHC services the ability to advocate against government policy and reflect community concerns [63]. In the earlier period (1980s-1990s) there was also an active community health movement in Australia which provided a focal point for national and state lobbying for comprehensive PHC based on a social model of health [46]. The National body – the Australian Community Health Association - was defunded in 1996, and with its demise the social movement that had supported the community health sector ebbed away over the following years.

It is worth noting that since these interviews, there has been considerable change in the South Australian PHC landscape, including the Review of Non-Hospital Based Services [64] which has resulted in the state government endorsing comprehensive cuts to health promotion in state managed PHC services. Indications are these reforms will further reduce state managed PHC services’ scope for action on the social determinants of health.

The study is based on case studies which has allowed for detail consideration of six PHC services and contributes to understanding about the nature of practice in relation to action on the SDH. It is also able to show the impact of organisational environments on the operation of the PHC services. Its limitation is that the number of case study sites was relatively small and so the basis for generalisation is limited. The study did not include fee-for-service general practice which, in Australia, solely provides primary medical care and does not have a broader role in relation to SDH.

Our study suggests that there are tangible ways in which PHC services are able to take the impact of the SDH into account in terms of the style of service delivery and the openness of their service to the communities they serve. The data from our study indicate that in all study sites aside from the Aboriginal controlled health service the organisational climate was perceived as becoming less amenable to action on the SDH than it had been in the recent past. This study is important in providing a nuanced account of the ways in which PHC services are able to respond to SDH, the constraints they face in doing so and the importance of supportive policies and practice. Responses to the SDH require political and social engagement that is not easy within government funded and managed services and the complexity of developing a practice that does offer a response to SDH requires further policy and practice development. In the absence of a supportive political and policy environment, building alliances with communities and social movements may be one strategy services can adopt, but the broadly unsupportive environment makes it very hard for services to act on the Commission on the Social Determinants of Health’s recommendations. Further research on the value of community control of PHC services is warranted by this study’s findings. In addition, research linking effective work on SDH by PHC services which assesses the types of policy, resource and managerial environments that made them possible would also be helpful to future policy development.