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Preference: Administration and Health Services

2

Is oral health the unspoken determinant?

BY AMA PRESIDENT DR TONY BARTONE

According to the Australian Institute of Health and Welfare’s (AIHW) report Australia’s Health 2012, most people will experience oral health issues at some point in their life. In fact, oral diseases are recurrently among the most frequently reported health problems by Australians.

Considered a disease of affluence up until the late 20th century, poor oral health outcomes have now become an indicator of disadvantage, highlighting a lack of access to preventative services. Insufficient access to, high cost of, or long waiting periods for dental services; and low oral care education, have all been associated with patients not seeking dental care when it is needed. Of course, non-fluoridised water supplies also has a role in explaining the prevalence.

However, more recently, it is the modifiable risk factors like poor nutrition, smoking, substance use, stress, and poor oral hygiene that are considered to have the greatest impacts on periodontal diseases. 

Dental conditions frequently rank in the top 10 potentially preventable acute condition hospital admissions for Aboriginal and Torres Strait Islander people and were the third leading cause of all preventable hospitalisations in 2013-14, with 63,000 admissions.

Like most other health conditions, Aboriginal and Torres Strait Islander people have poorer oral health outcomes. While Indigenous people currently have most of the same oral health risk factors as non-Indigenous people, they are less likely to have the same access to preventative measures, leading to marked disparities in oral health between Indigenous people and other Australians.

While the majority of oral health concerns are often considered inconsequential, such as avoiding certain foods, or cosmetic with people embarrassed about their physical appearance, there is a significant body of evidence which suggests that oral health may be the undiscussed determinant of health.

More than two decades ago, population-based studies identified possible links between oral health status and chronic diseases such as cardiovascular disease (CVD), diabetes, respiratory diseases, stroke, and kidney diseases, as well as pre-term low birthweight. And the relationship appears to lie with inflammation.

It is clear more research is needed to determine the exact links (if any), between periodontal disease and chronic disease condition, however, the growing body of evidence links poor oral health to major chronic illnesses.

The Government has made numerous financial commitments to improving access to dental services, however, oral health data will continue to demonstrate that without equitable access to dental services, Australians, and particularly Aboriginal and Torres Strait Islander people, will continue to suffer poorer oral health outcomes, and potentially poorer health outcomes, as a result. 

The AMA supports improved Doctor/Dentist collaborations if such partnerships could lead to increased early identification of both chronic disease and oral health conditions, particularly for Aboriginal and Torres Strait Islander peoples, for whom oral health services are less frequently accessed.

Dental Health Week is 6-12 August 2018.

Europe’s digital highway changing the future of health care

The European Commission continues to strategically progress digital changes to modernise its healthcare system, with significant funding announced in their June EU Budget. 

The budget announcement proposes to create the first ever Digital Europe program and invest €9.2 billion to align the next long-term EU budget 2021-2027 with tackling increasing digital challenges.

Andrus Ansip, the European Commissioner’s Vice-President for the Digital Single Market, said the announcement would ensure the EU budget was fit for the future.

“Digital transformation is taken into account across all proposals, from transport, energy and agriculture to health care and culture. We are proposing more investment in artificial intelligence, supercomputing, cybersecurity, skills and eGovernment – all identified by EU leaders as the key areas for the future competitiveness of the EU,” Mr Ansip said.

The European Commission’s legislative framework is based on new technologies enabling cross-border access of data to create more personalised, accurate and patient-oriented health care in a safe environment.

The framework is designed to overcome three challenges; ageing population and chronic diseases putting pressure on health budgets; unequal healthcare quality; and shortage of health professionals.

Currently EU citizens have the right to access health care in any EU country and to be reimbursed for care abroad by their home country.

The Commission’s digital health goal is to reduce administrative costs, avoid human errors, optimise the use of medical data and increase quality of services by systematically aligning healthcare IT systems and implement systems that support open standards-based data exchange.

The Commission recently established a set of measures to increase the availability of data in the EU, building on previous initiatives to boost the free flow of non-personal data in the Digital Single Market.

Thirteen European countries signed a declaration in April for delivering cross-border access to their genomic information. This is a game changer for European health research and clinical practice: sharing more genomic data will improve understanding and prevention of disease, allowing for more personalised treatments (and targeted drug prescription), in particular for rare diseases, cancer and brain related diseases. The target of the EU is to make one million genomes accessible in the EU by 2022.

The European Commissioner for the Digital Economy and Society, Ms Mariya Gabriel, said the agreement was founded in the understanding modern health relies on digital innovation and cross-border interoperability.

“Secure access to genomic and other health data among Member States is essential for better health and care delivery to European citizens and to ensure that the EU will remain at the forefront of health research.”

MEREDITH HORNE

New NHMRC code of conduct has researchers worried

 

A revised research code of conduct released by the NHMRC and Universities Australia this month has been criticised by several leading academics, who say it may be open to abuse.

Under the new code, any serious breach of research ethics, such as plagiarism, falsification or fabrication, must be investigated by the institution itself, rather than by an independent body. Academics have flagged several concerns with this arrangement. Cell biologist Professor David Vaux, who is deputy director of science integrity and ethics at Melbourne’s Walter and Eliza Institute of Medical Research, notes that including any external members on investigatory panels is optional in the new code of conduct.

“Self-regulation just doesn’t work. This represents a step backwards, and will inevitably lead to conflicts of interest,” he told the website Retraction Watch.

Academics are worried that without an independent investigating body, researchers are less likely to get a fair, impartial hearing, and that public confidence in Australian research might also take a hit.

It also means that institutions, even small ones, will have the extra burden of establishing their own research integrity offices. A much more economic solution, and the route most other developed countries have taken, is to pool resources into an independent body, says Professor Vaux.

Countries such as the United States, Canada and the United Kingdom have set up independent bodies to deal with serious research misconduct. Even China, hardly an exemplar of transparency, has recently said it will no longer rely on research institutions to investigate their own researchers and will set up a process within the Ministry of Science and Technology.

“We are going in the opposite direction to China,” notes Professor Vaux.

Another problem academics have flagged with the code is its preference for the term “breach”, categorised from minor to serious, rather than the more conventional “misconduct”.

While research “misconduct” is reasonably robustly defined as instances of plagiarism, falsification and fabrication, “breech” casts a wider net and potentially opens the door to investigating any so-called breach, US bioethicist Nicholas Steneck has warned in an interview with Nature Index.

The code defines research misconduct as serious breaches carried out with “intent, recklessness or negligence”, a definition that some say puts too much emphasis on the subjective state of mind of the researcher and not enough on the objective  trustworthiness of the research itself.

The Australian research community has faced a number of high-profile cases of research misconduct over the past few years. These include the case of Dr Caroline Barwood and Dr Bruce Murdoch of the University of Queensland, who in 2015 were among the very few medical researchers ever to face criminal charges in a case of research misconduct. Both were found guilty of fraud for falsifying research into Parkinson’s disease, and both received suspended sentences.

The new code of conduct came into force on 14 June, and failure to comply with it could result in suspension of NHMRC funding.

GPs and specialists: a dialogue of the deaf?

 

Ask almost any specialist about their dealings with GPs, and they’re likely to admit that coordination with primary care could be better. And ask any GP about their dealings with specialists, and you may well be on the receiving end of a gripe or two. Melbourne oncologist and Guardian columnist Dr Ranjana Srivastava has recently written that “shared decision-making that involves a specialist and a GP is rare”. She says that for all the talk of teamwork, there’s a lack of communication that has real downsides for the patient. Increasing numbers of patients with chronic comorbidities end up with fragmented care, Dr Srivastava says, with GPs being kept out of the loop due to delayed discharge summaries, and specialists finding it hard to track down busy GPs.

Who’s to blame? According to two large studies, it’s the specialists – if you’re a GP, that is. And of course it’s the GPs, if you’re a specialist. The first study, from the Netherlands, surveyed around 500 doctors – around half of whom were GPs and the rest specialists – about their mutual communications. The vast majority of GPs (85%) thought they were easily accessible by phone. The specialists did not agree: only 32% thought you could easily get a GP on the phone. The specialists were also sniffy about GP referral letters: just 29% of them thought referral letters were generally adequate. Nearly 90% of specialists thought they correctly addressed the issues in the referral letter. Unsurprisingly, the GPs disagreed: only half of them thought specialists adequately addressed the questions.

And did the specialists report back to the GPs in a timely manner? Yes, said 62% of specialists. No, said 78% of GPs. But when they did finally get that specialist report, the GPs overwhelmingly (92%) considered that they followed the specialist’s recommendations. Not so, said the specialists, fewer than half of whom thought the GPs did what was asked of them.

A US study finds similar disagreement between GPs and specialists. This was a considerably larger study involving nearly 50,000 doctors, who were asked about referral and consultations between primary care and specialist physicians. Around 70% of GPs reported that they always or most of the time sent notification of a patient’s history and reason for a referral to a specialist. But there may have been some fibbers among that cohort, as only 35% of specialists said they always or most of the time received such notification. But the imbalance worked both ways: while over 80% of specialists said they always or most of the time sent consultation results to the referring GP, only 62% of GPs agreed that this was the case. Doctors who did not receive timely communications were more likely to report that their ability to provide high-quality care was threatened.

The authors say their study shows the need for “systematic structures, tools and processes for information creation, transfer, receipt, and recognition by the sending and receiving physicians”.

Miscommunication between doctors is widely recognised as one of the main drivers of medical error. The Australian Medical Association has recently published guidelines to improve communications between GPs and other treating doctors. The AMA says specialist outpatient services need to have transparent systems that inform patients and referring doctors of expected wait times for services, and track the priority of referrals.

According to the new guidelines, discharge planning should include telephone, video or face-to-face case conferencing prior to discharge that includes GPs or referring doctors, and a documented plan of care.

“We are delivering very good outcomes for patients in the Australian health system, but we can and should do better. We are confident that the AMA guide will contribute to improved communication and, in turn, better overall care,” AMA President Dr Tony Bartone says.

AHPRA links complaints on its register, even unfounded ones

 

Have you had a complaint against you that was dismissed in a tribunal as without merit? Your entry in AHPRA’s publicly accessible online registry of practitioners will still list this complaint and link to the relevant court or tribunal ruling, the regulator has decided.

The Australian Health Practitioner Regulation Authority has announced that it has already begun to publicly link disciplinary and court decisions to the registration details of doctors, regardless of whether the doctor has been found guilty of anything.

Around 50 rulings made since February have already been added to the register, implementing a recommendation made by an independent review authored by Professor Ron Paterson on the practice of chaperoning to protect patients from doctors subject to allegations of sexual misconduct. In that review, Professor Paterson recommended that “the public register of health practitioners include web links to published disciplinary decisions and court rulings”.

Also quoted in that review is the Chair of the Medical Board of Australia Dr Joanna Flynn, who says that “the public has a right to know if there are conditions on a doctor’s registration or if there have been serious disciplinary or criminal offences proven against a doctor. It’s long overdue.”

The register will now include links to all court and tribunal rulings concerning a doctor, except for those which involve the doctor’s health.

But many are concerned that posting all rulings in the register, even when no rulings are made against the doctor, is going a step too far.

Medical defence organisation Avant says the move is “unfair and punitive, particularly for practitioners with no adverse findings against them”. Although the Medical Board of Australia has said that “no adverse finding” will be noted on the register, Avant says it is “concerned that this will be misinterpreted and misunderstood”, and that the allegations will be given more weight than the findings.

Earlier this year, Avant’s Chief Medical Officer Dr Penny Browne spoke on the issue at the AMA’s National Conference.

“A finding made many years before, that has no relation to the doctor’s current practice or conditions, will remain linked to the AHPRA register in perpetuity,” she told delegates.

“Imagine that you or I have been through the stress of a tribunal hearing and finally the findings state ‘allegations not proven’. It’s all over. You then try to move on with your life and later discover that the link to the decision is placed against your name on the AHPRA register with a subscript stating ‘allegations not proven’.”

She said that while transparency was important, the medical complaints process was already stressful for doctors.

AHPRA’s most recent annual report notes that of the 2718 matters involving medical practitioners settled over the year, the vast majority (71.2%) resulted in no further regulatory action.

Mr Hunt, are we there yet?  Continuing the public hospital funding journey

BY DR RODERICK MCRAE, CHAIR, AMA FEDERAL COUNCIL OF PUBLIC HOSPITAL DOCTORS 

By the time of this column’s publication, we may have had some further information from the Federal Minister for Health Greg Hunt, at the AMA’s National Conference, although the Budget is pretty fresh. We know public hospitals are fundamental to Australia’s overall health system, dealing with greater than six million admitted patient care episodes and around 92 per cent of emergency admissions in any one year. Nonetheless, we experience chronic under-funding partially because of near stagnant growth in financial support. This has been going on for just too long; we all feel the pressure day in, day out.  We know under-funding is building to crunch point.

AMA’s 2018 Public Hospital Report Card shows bed numbers per 1000 population are static; performance, basically, is plateauing at best; waiting lists, you know the sorry truth about that and our patients are suffering!  My December 2017 Australian Medicine column criticised the Council of Australian Government’s (COAG) savage imposed financial penalties where avoidable re-admissions or hospital-acquired complications are deemed to have occurred. The AMA’s 2016 Safe Hours Audit shows that in public hospitals, 53 per cent of doctors are at “significant risk” of fatigue with dangerous fatigue levels being reported across a raft of specialty groups.

So, the effect of underfunding is cumulatively adding up to seriously affecting our, and the system’s, ability to perform optimally for our patients, and our own health and wellbeing is at stake. That’s why the 2018 Budget decisions matter; it’s about what the future holds for public hospital medicine. Without vital new investment, required infrastructure, and human resource capacity, an appropriate standard of result cannot happen.

Reflecting on AMA’s pre-budget submission, what we have said is that the Budget must fully fund, for the medium to long term, internal capacity building and expansion of their integrated care responsibility.  Not to penalise an already underfunded sector via that sneaky COAG device that will redirect otherwise committed funds.  The AMA also says States and Territories must be fully compensated for any loss in private patient revenue and any funding decisions must not dilute support for patients electing private treatment. Mr Hunt has said he intends to look at these private patient issues so we don’t yet know where Government is headed.

Despite the known pressure on public hospitals the new 2020-25 Hospital Funding Agreement ratchets up this financial pressure on hospitals even further. Within existing levels of Federal funding, the Agreement will require public hospitals to implement new measures to cut waste, increase productivity and extend their responsibilities to engage in the care of chronically ill-patients post discharge to reduce overall admissions.

I agree integrated care is essential – but this work requires new Federal funding to pay for the hospital and primary sector resources required to deliver it. The public hospital funding in the 2018 Federal Budget was nothing more than the amount forecast over the forward estimates to maintain funding at current levels. 

There are many laudable new funding initiatives out of this Budget, to name some: a rural doctor workforce/training package, increased support for aged care in the home, and mental health/suicide prevention services, new research investment and (perhaps laughable!) the “unfreezing” of Medicare indexation. However, the Budget lacks consideration of how any savings from the Government’s yet to be finished MBS reviews will be re-invested into public health, and we still wait on needed big structural reform. There must also be funds to urgently begin development of a national medical workforce strategy.  On that, your Council of Public Hospital Doctors is working through the AMA to encourage all jurisdictions to cooperate more closely in their planning and coordinating of our future medical workforce to meet Australia’s future healthcare needs.

There’s an election coming; maybe this year; and Labor has promised an additional $2.8 billion ‘better hospitals’ fund to target reducing elective surgery waiting times and increasing emergency department bed numbers. Your CPHD will be looking to score both major parties as they release more health policy and keep a watching on eye on any moves to change public hospital private practice arrangements. We must push for the government to match Labor’s pledge and make Government fund for growth, not just, as it has been, keeping pace with activity. It’s matching funding with growth and having a workforce plan that really matters!

AMA ramps up its aged care advocacy

BY DR ANDREW MULCAHY, CHAIR, AMA’S MEDICAL PRACTICE COMMITTEE

It only takes a skim of the media headlines to know that the aged care system is failing older people. Many reported cases of poor quality care are a result of delayed medical care and neglect, and AMA members are deeply concerned for their older patients. There have been multiple inquiries and reviews into the system in the past couple of years. Government are well aware of the issues and, while there was a $5 billion funding increase in the aged care 2018-19 budget, more urgently needs to be done.

The AMA is responding to its members’ concerns by ramping up its aged care advocacy. In November 2017, the Medical Practice Committee (MPC) conducted a survey on AMA member experiences and perceptions of aged care to inform future AMA policy. In April 2018, a new Position Statement, Resourcing aged care was released. This Position Statement focuses on workforce and funding measures required for a good quality aged care system, and draws from the learnings of the aged care survey.

Aged care calls for adequate resourcing to ensure doctors are supported to deliver medical care to their older patients. One such measure includes appropriate remuneration to cover the opportunity cost of leaving a surgery to visit patients in Residential Aged Care Facilities (RACFs). The AMA also advocated for this policy change at the MBS Reviews’ General Practice and Primary Care Clinical Committee (GPPCCC). Dr Richard Kidd (Chair, Council of General Practice) and AMA Federal Secretariat called for increased MBS rebates for GP RACF attendances, telehealth consultation items for GPs, and for the Practice Incentive Program (PIP) Aged Care Access Incentive (ACAI) to remain.

MPC, with input from the Council of General Practice, has lodged six aged care submissions this year alone. These include:

  • Aged Care Workforce Strategy Taskforce – The Aged Care Workforce Strategy;
  • Australian Aged Care Quality Agency – Draft Standards Guidance (for the new Aged Care Quality Standards);
  • House of Representatives Committee on Health, Aged Care and Sport – Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia;
  • Medical Services Advisory Committee – New mobile imaging services for residential aged care facilities;
  • Aged Care Financing Authority – Respite Care; and
  • Department of Health – Specialist Dementia Care Units.

In addition to the House of Representatives Committee on Health, Aged Care and Sport for the Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia submission, Dr Tony Bartone and Dr Kidd gave evidence at a public hearing in May. Dr Bartone and Dr Kidd highlighted that AMA members have major concerns that the current aged care system is failing older people, and called for more appropriately trained aged care staff, especially registered nurses, in RACFs. Dr Bartone and Dr Kidd also highlighted that doctors need to be recognised and supported as a crucial part of the aged care workforce to improve medical access, care and outcomes for residents.

In addition to the Aged Care Workforce Strategy Taskforce submission, Dr Bartone recently attended both Aged Care Workforce Taskforce Summits. The summits are aimed at engaging stakeholders in developing a strategy for ensuring aged care workforce growth to meet older people’s needs. Dr Bartone highlighted that the current aged care workforce does not have the capacity, capability and connectedness to adequately meet the needs of older people.

MPC aged care advocacy efforts were also reflected in several Budget announcements, including:

  • the establishment of an Aged Care Quality and Safety Commission ($nil);
  • investment in rural aged care ($40million);
  • improvements to My Aged Care website access ($61.7million) and faster Aged Care Assessment Team (ACAT) assessments ($14.8million);
  • improved access to specialist palliative care services in RACFs ($32.8million);
  • a new mental health service for older people living in RACFs ($82.5million); and
  • 14,000 additional home care packages (plus 6000 additional packages as announced in the Mid-Year Economic and Fiscal Outlook) ($1.6billion).

However, more needs to be done to ensure older people receive quality care. 20,000 additional home care packages makes a small dent in the 104,602 people currently on the waiting list. The Productivity Commission stated in 2011 that the aged care workforce must quadruple by 2050 to meet demand, but there was no mention of a workforce strategy in the budget. MPC is waiting with bated breath for the Aged Care Workforce Strategy to complete its work (by the end of June 2018).

MPC will continue advocating for a better quality aged care system. 2018 will see the introduction of four additional aged care Position Statements, covering topics such as the health of older people, palliative care, clinical care, and innovation in aged care. So watch this space.

AMA aged care Position Statements and submissions can be accessed through: advocacy/aged-care.

 

Federal Council communiqué

BY DR BEVERLEY ROWBOTHAM, CHAIR, AMA FEDERAL COUNCIL

The May meeting of Federal Council is condensed to one day immediately before the start of National Conference. While shorter in length, the breadth of matters brought to the Council remains significant. The meeting was the last for outgoing President, Dr Michael Gannon, and several other members – Drs Susan Neuhaus, Gary Geelhoed, Robyn Langham, Lorraine Baker, Stuart Day, Andrew Mulcahy, and John Zorbas. As a result of the election of incoming President, Dr Tony Bartone, and Vice President, Dr Chris Zappala, Drs Brad Frankum and Gino Pecoraro also completed their terms. All have been substantial contributors to the work of Federal Council, in some cases over many years.

Dr Gannon provided an overview of his last weeks in office with highlights including a tour of remote Indigenous communities with the Hon Warren Snowdon, the Federal Budget with its wins for workforce, and attendance at the Council meeting of the World Medical Association in Riga.

The Secretary General’s report highlighted several wins in the Federal Budget which were the result of AMA advocacy. Most important among these was the introduction of a comprehensive medical workforce package. This included the establishment of the Murray Darling Medical School Network with a number of participating medical schools offering end-to-end rural medical school programs; an expansion of prevocational GP places for doctors in training; additional GP training places earmarked for rural generalists; and an emphasis on supporting doctors undertaking training in rural areas.

A major win in the Budget was the overhaul of bonded medical places which will apply to all new participants from January 2020. Existing BMP and MRBS participants have the choice to opt in. The changes offer more certainty and flexibility in how return of service obligations can be satisfied. Federal Council heard that the Secretariat is receiving calls from members expressing their delight in the life-changing outcomes from these announcements.

The AMA’s sustained advocacy for workforce reform included a medical workforce and training summit held in March 2018. An important theme from the summit was the need for a whole of government approach to planning the future delivery of health care and for all governments to collaborate more effectively on workforce planning, training and coordination.

Federal Council noted AMA activity on issues impacting on practice including medical indemnity reforms, private health insurance reforms, the ongoing MBS review, and reports on the significant engagement with aged care policy reform.

The AMA’s public health advocacy remains a consistently strong area of activity. Federal Council received an advanced draft of the Position Statement on social determinants of health, and received updates from the working groups on child abuse and neglect, and health literacy.

The Ethics and Medico-Legal Committee continues its revision of the AMA’s Position Statement on Medical Practitioners’ Relationships with Industry. It has commenced a review of the Position Statement on Conscientious Objection.

Federal Council agreed with a recommendation from the AMA’s Taskforce on Indigenous Health that the AMA sign on to the joint statement by non-Indigenous Australians in support of the Uluru Statement from the Heart.

Federal Council adopted the AMA Anti-Racism Statement which addresses racism in the medical workforce, and expresses support for good medical practice that reflects the cultural needs and contexts of patients.

The Council of Doctors in Training is working on the development of standardised questions to support State and Territory AMAs to run hospital health checks which measure and report on how well health services are meeting State-based industrial agreements and/or accreditation standards for doctors in training.

The Council of Private Specialist Practice has been considering a proposed website to support transparency of doctors’ fees. The Council noted the complexities of such a site and expressed its view that the site must be government-controlled. The Council also noted its concerns that such a website would be unmanageable if its aim is to capture every fee charged by a privately-billing doctor. Council acknowledged that there is a strong desire in government, and from consumers, to improve fees transparency and support patient awareness.

The Council of General Practice reported on the success of AMA advocacy in the Government deferring the introduction of the Practice Incentives Program Quality Improvement Incentive, which would have left many practices financially worse off. Five incentives scheduled to cease on 1 May 2018 will now continue until 30 April 2019.

The MBS Review, through its general practice and primary clinical care committee, is examining funding for GP visits to residential aged care facilities, including funding for telehealth consultation items. AMA advocacy has resulted in the referral to the MBS Review of consideration of funding for wound care items in general practice.

The Council of Public Hospital Doctors reported on its consideration of the impact of technology on workplaces, and the future of work and workers. Further analysis will be undertaken to look at potential industrial implications including task substitution, medico-legal issues, obsolescence, and outsourcing.

The Council of Rural Doctors outlined additional work that the AMA should undertake in considering rural doctor health. including longer working hours, lack of access to resources and professional support, professional and geographical isolation, and limited team support. The Council noted the work underway by the AMA subsidiary, Doctors’ Health Services Pty Limited, in sponsoring a trial of telemedicine consultations for rural doctors.

At the Annual General Meeting of members held on the day following the meeting of Federal Council, members voted unanimously to create a new position on Federal Council for a representative of Australia’s Indigenous doctors, nominated by the Australian Indigenous Doctors’ Association, and who is a member of the AMA.

 

[Articles] Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016

GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals.