How Discourses Stifle the Primary Health Care Strategy's Intent to Reduce Health Inequalities

Abstract

New Zealand’s Primary Health Care Strategy (PHCS) has a stated commitment to defined populations who suffer disproportionately from ill health. This thesis examines whether some prevailing discourses actually decrease the focus on health inequalities. Words and ideas shared by a group can be considered a discourse when the underpinning values serve a social and political function for that group. To examine whether discourse was constraining health care I considered the nursing and medical media pertaining to both the PHCS and the primary health care nursing framework and sought their dominant discourses. I found that the nursing and medical media focused on predominantly professional and industrial issues. These were expressed very differently with the medical media reacting to the ramifications of the PHCS especially Primary Health Organisations (PHOs), while the nursing media had a visioning quality, imagining how nursing could function in primary health care (PHC). The result was that, in the media studied, the upheaval of the PHCS left professionals mainly wondering about their own professional interests, rather than considering what those who suffer from health inequalities needed. The discourse of the PHCS may also serve political rather then altruistic purposes. I found historical examples of where discourse had underpinned health policy and I suggest that current (Ministry of Health) MOH discourse values decentralised community health decision making. The decentralised community health model of small community PHOs situates the responsibility for health locally. This health responsibility may gloss over factors in community health which are affected by Government policy such as employment policy, and thus should be dealt with centrally by legislation. These factors have been found to be the most pertinent in health inequalities. So while models of community partnerships may seem to place communities as agents in their own health, this downplays the determinants of health which are beyond their control. Moreover the multiple PHOs through the country, while costly in the repetition of bureaucracy, also make analysis of the PHCS difficult, since there is in effect multiple Primary Health Care Strategies being played out in each area, as interventions of various qualities are implemented. Having shown that discourse can decrease the focus on health inequalities due to other professional and political drivers. I then looked at health initiative concepts which are effective, efficient and equitable given the current set up of PHOs and nursing innovations.