David Peiris

Director, Global Primary Health Care Program and Co-Director of Health System Science, The George Institute for Global Health
Professor Faculty of Medicine, UNSW Sydney

What inspired you to work in health research, and what's your background?

I came to research fairly late in my career. I'd been a practicing GP for about maybe 12 years and I was always very much more clinically focused. But in my clinical work, my passion was always around delivering good primary health care to underserved populations.

I worked in a remote Aboriginal community for a number of years and did my junior medical years in the Northern Territory. So I’d been working in Indigenous health as a clinician for quite a long time already when I came back to Sydney. Then I did a Master's of International Public Health at Sydney University, and doing that started to open up my horizons towards public health research.

I then had a year in New Zealand working as the clinical director for a Maori primary health organization. That was a non-clinical role, but it was where I started to look at designing and implementing programs to improve quality of care for Indigenous populations- in this instance Maori and Pacific populations in Auckland.

I moved back to Australia when a job at the George came up to do work on a new Indigenous health services research program. The program was then led by Alan Cass (now at Menzies School of Health Research), Alex Brown (now at SAHMRI) and Anushka Patel. The role seemed right up my alley because it was starting to bring that very practical, clinical focus, and the new work I was doing around quality improvement, into a research lens. That was 12 years ago and for the first few years I focused exclusively on that program of work, and did a PhD on it.

What keeps you motivated?

I think throughout all of my career, the focus hasn't really changed. It's still primary health care and strengthening systems for populations that miss out on access to good care. In the post-PhD era for me at the Institute, this focus was really important as the Institute was also growing regionally in India and China. I was able to take the learnings from the work I'd done in Indigenous health services and see its application in other settings.

This year it's the 40th anniversary of a landmark declaration on primary healthcare which was made in Alma-Ata in 1978 [Declaration of Alma-Ata]. The Declaration really sets up a charter for how to use primary healthcare as, essentially, a kind of restorative justice mechanism for community control of health services and framing access to quality health care as a right. Way back when I was a medical student, I saw the Declaration as being an absolutely inspirational document. It's interesting that it's being revisited this year, and a new declaration is about to be announced at Astana, Kazakhstan at the end of October.

I think all of the things in there were inspiring for me as a med student. They were inspiring for me when I worked in Indigenous health. And, they still remain very inspiring now as a more established researcher.

What's your role now?

My role now is as Director of the Primary Health Care Program and Co-Director of Health System Science, which may be difficult to understand. Health systems really encompasses a whole range of things in terms of how healthcare is organized, financed, the workforce that underpins it, and how systems are structured in terms of things like information systems. Then, even more broadly, not just in healthcare, but also how you might influence governments and industry to play an active role in the health of whole populations. So, it's a very broad area.

I come from the more grassroots primary care angle on health systems. At the Institute we've got activities on all ends of the spectrum, from more micro-level clinical interventions to try and improve care, right through to big policy changes. For example, the work in food policy and in injury prevention, which is trying to improve public health through government regulation.

A key part of my role is to harness our strengths across the Institute; provide support to all four regional offices; build networks through multi-lateral, government, industry and academic partnerships; and look at how we can use our expertise and experience to contribute to furthering our mission through stronger health systems.

What's an example of one of the micro activities?

We do a lot of work using point of care decision support systems. One of the things that came out of my PhD work was that it's very hard for clinical people to consistently apply guideline recommendations into practice, and to make those recommendations practical when there is a patient in front of you. This work has grown through our SMARThealth program and our staff lead projects in many countries, particularly in the Asia – Pacific region. These are simple, low cost tools that can essentially bring guidelines into the consultation, alert a provider to where best practice recommendations might be, and then using communication tools to be able to bring that into discussions with patients.

We've done a lot of trials to assess its effectiveness and learnt greatly how local contexts drive adoption of these types of strategies. For us, the next stage with that body of work is to test if it can be scaled to reach a larger group outside of just research project settings. That's where the health systems part becomes more important. Asking questions such as ‘how do you pay for these things?’ ‘How do you build a workforce that can sustain it?’ And, in information system management, ‘how can it actually be embedded into existing systems?’
Whereabouts are you thinking implementation of guideline tools into the existing systems?

We've got programs actively in Australia, China, Indonesia, India and the UK as well as other regions. We're at this interesting point where we're looking at how we can improve the process. We clearly can't do all this ourselves. It's about partnerships-
So it’s important to have both private and public partnerships. Particularly, partnerships where people have access to large networks.
In Australia, for example, we're exploring partnerships with industry providers of digital health products. In Indonesia, we're working with one of the district governments to embed the tools into the current information systems that are used there. In China, we're collaborating with China CDC on a project to strengthen their existing health information systems. So, not using our tools, but actually just incorporating our knowledge expertise into those existing systems.
In a number of areas we're now at this interesting point where we can see even bigger possibilities that could become quite a big scale national projects.

Is there a particular area that you're most excited about? A particular thing that you're working on, or a challenge that you can see?

To be honest, I find doing the mundane things, like supporting a clinic to function more efficiently, the most exciting stuff. Because, I just see the opportunity being so huge. And, this is always hard to communicate because my work isn't about a fantastic new pill, and, it isn't about a great piece of technology that's going to suddenly transform the world. It's about those slow plod things that might shift a service to a better quality and standard. This may, in itself, only be a little nudge, but if it can be done on a big scale, it actually has a huge reach and implication in terms of improving health.

I get excited about solutions to questions like, ‘how can you make a clinic workflow better?’ ‘How can workers become less busy but at the same time improve the quality of care they provide?’ And, ‘how can you make sure no one in the community gets left behind when delivering a better service?’ Or, ‘where can you find a bit of waste that could be removed out of the system to free up resources that are really scarce?’
Tackling these sorts of challenges is a very granular process, but also exciting in terms of the implications.