Editorial Issue 1 2013
Evidence for the future

Primary health services need to know and adapt to their environment if they are to remain effective and responsive to their communities. Australian primary health has a rich tradition of research into the needs of specific populations and evaluation of innovative programmes to meet those changing needs. As an example of this research and practice tradition, several papers in this issue of the Journal illustrate how primary health services adapt to people of different cultures: Mercer et al. examine the way that health workers must understand the importance of Māori ownership and control of health initiatives; Ward et al. look at the use of health services by young Aboriginal people in New South Wales; Wollersheim et al. report on an innovative mobile phone-based approach to provide peer support for isolated southern Sudanese refugee women.

However, understanding and meeting the needs of the community is only part of the challenge for primary health services – they also need to respond to serious funding challenges. We often talk about evidence-based health care, usually referring to evidence on which programmes and therapies are based. We talk less frequently about the need for primary health services to provide evidence that what they do is effective, efficient and appropriate. Without explicit evidence of effectiveness framed in terms that appeal to governments and treasurers in particular, community programmes are vulnerable to funding cuts as the competition for scarce health dollars heats up in all jurisdictions. Queensland last year reduced funding to health promotion and population health programmes, and the McCann report into non-hospital-based services in South Australia has recommended substantial cuts to health promotion, women’s and youth health programmes. The rationale used to support the recommendations was lack of relevance to hospital avoidance, chronic disease management and population health, or lack of evidence of effectiveness (SA Health website http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/about+us/publications+and+resources/reports/review+of+non-hospital+based+services, verified 31 January 2013). Ironically, the national health reform emphasis on primary health care in the form of Medicare Locals may be contributing to the risk to community health services funded by the states, which use the rationale that Medicare Locals will provide these services.

The long time frame and multiple factors that contribute to outcomes of health promotion programmes make it difficult to demonstrate convincing evidence of their effectiveness, and make them a much softer target for cutting than clinical programmes that have higher perceived effectiveness in a shorter time. Scarce human resources in primary health also mean scarce resources and skills for process and impact evaluation. However, primary health services must somehow build support from key players in each jurisdiction. Primary health services must be seen to fill a critical gap in the sector, and must be embedded in the health system at all levels. In one of the papers in this issue of the Journal, Maclean et al. identified some factors that contribute to the sustainability of alcohol and other drug interventions in community health settings, but which apply just as well on a larger scale: embedding changes in the operations of agency, filling a critical gap in sector, building support from key individuals and agencies, and planning realistically for future ownership. At a recent Forum about the McCann review in SA, volunteers called Community Foodies from a small health promotion programme showed how their personal stories of impact on themselves and their communities could have a powerful effect and convince a large audience that they were filling a critical gap in the sector. People in primary and community health can and must apply their creativity and innovation to building ongoing support for the survival of the sector.

Elizabeth Kalucy OAM
Editor in Chief