In the fourth article of this five-part series, Dr Millie Nakatsuka discusses how reform must be integrated into the broader context of the public health landscape
2024 marks the 46th anniversary of the Alma-Ata Declaration, which identified primary healthcare as the key method of achieving ‘Health for All’. OECD analysis, however, continues to show that substantial chronic underinvestment in preventive healthcare and chronic disease management persists, reflecting a global failure to adopt coherent coordinated health policies, and to rationally plan cost-effective healthcare aligned with population health priorities. Instead, governments regularly misallocate and waste resources on ad hoc politically motivated projects, all too often catering to the lobbying power of vested interest groups.
The scope of this article has been expanded as any reform needs to be integrated into the broader context of the public health landscape to maximise the efficiency and effectiveness of medical service provision and improve health outcomes, particularly within emergency departments.
Over the past half-century, piecemeal, uncoordinated strategies have failed to address the emerging challenges of modern healthcare, particularly the growing crisis of emergency department overcrowding, instead preferring micro-level strategies primarily targeted at optimising patient flow within emergency departments. This first emerged in the 1980s, when America pioneered dedicated ‘fast track’ or ‘minor care’ areas within the emergency department for the triage of non-urgent and low-acuity patients.
A similar tactic was taken in the United Kingdom’s 4-hour National Emergency Access Target (2004). These measures created the illusion of temporary relief by focusing on short-term quantifiable results, rather than addressing the root causes of the longstanding supply- demand imbalances. In the light of escalating demand and overburdened healthcare systems, especially after the pandemic, urgent systemic reform is critical if high-quality and free universal healthcare is to be realised as more than a mere dream.
Rapid changes in universal healthcare and public attitudes
The utopian idea that no-cost universal healthcare is a fundamental human right has become widely accepted after the original 1948 Universal Declaration of Human Rights. Concept creep has broadened the scope of ‘essential healthcare’ by emphasising the importance of equity over cost-effective population health priorities. This has jarringly occurred in the same healthcare systems undertaking simultaneous and substantial post- GFC austerity measures to curtail essential public services, exacerbating structural problems in the face of the increasing health demands of our ageing populations and the recent pandemic.
Over the past two decades, population healthcare expectations have escalated dramatically, with increasing numbers of patients seeking prompt emergency medical attention for acute minor complaints. In Australia, young people are particularly reluctant to pay out-of-pocket expenses. Substantial financial incentives have failed to
stem an alarming decline in private health insurance enrolment, particularly in the under-30s demographic. This resistance to mere financial incentives reflects a growing disconnect between health systems and public perceptions, which have been becoming increasingly dissatisfied and frustrated with the failure to provide public services equivalent to the private system.
Recent Australian developments
In 2012, America launched the ‘Choosing Wisely’ initiative as ‘more is not always better’ when it comes to healthcare, a campaign that spread to more than 30 countries. In Australia, it primarily targeted healthcare providers rather than consumers, with consequent limited penetration into public awareness. Subsequently, to alleviate the overcrowding of emergency departments, Australia adopted various educational slogans, calling for ambulances and emergency departments to be used only for emergencies. However, the impact was limited, perhaps as the emergency department is the first point of call for many patients who are unable to navigate or access, due to various factors, the alternative services in the complex evolving healthcare system. The messages may also have been viewed as merely another austerity message, justifying the reduction of services.
The campaign was later supplemented to raise public awareness of alternative options for the emergency department, particularly the new urgent care or priority primary care centres and virtual emergency departments. At the same time, existing alternative services have been expanded and promoted, including after-hours primary care services, and 24-hour health advice helplines. Over the last two years, further emphasis was placed on increasing public health literacy, with the 2023 rollout of health promotion targeting disadvantaged and vulnerable socio-demographic groups to help access the acuity of medical complaints, and understand the difference between routine, urgent, and emergency care.
Pathways for systemic change
Public health interventions to improve health literacy are critical to achieve both a population-wide paradigm shift, and reorientate our healthcare systems towards primary healthcare, the “best and only choice to achieve universal health coverage”. (1)
- Focus on healthcare navigation
- Educate the public about the scope of emergency medicine, which is solely focused on the care of emergency medical crises. Also, it provides guidance on self- assessment of the severity and urgency of acute medical issues, promotes awareness of the triage services that can help differentiate emergency from urgent or routine care, and explains alternative services to the hospital emergency department.
- Strengthen public health responses
- Mass media campaigns to raise awareness of the harms arising from unnecessary investigations, treatments, and procedures. Our messages about reducing unnecessary neuroimaging for acute vertigo in emergency departments integrate into this campaign.
- Reinforce population health priorities
- Promote realistic expectations to ensure the sustainability and equity of universal health coverage.
- Rally support for health reform
- Mobilise public and political support for necessary systemic healthcare reforms by engaging community leaders and influencers.
Upcoming article on innovative technologies
In the final part of this series, we explore emerging innovative technologies in telemedicine, artificial intelligence, and smartphone technology.
References
- Investing in the radical reorientation of Health Systems towards primary health care: The best and only choice to achieve Universal Health Coverage [Internet]. World Health Organization; [cited 2024 Aug 16]. Available from:
