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HEAD TO HEAD: Richard Cookson Should disadvantaged people be paid to take care of their health? Yes. BMJ 2008; 337: a589 [Full text]

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Share costs and benefits in diabetes care

Urban Rosenqvist   (9 July 2008)

Need to consider how 'health' is defined

Niyi Awofeso   (22 July 2008)

Share costs and benefits in diabetes care 9 July 2008
Urban Rosenqvist, Professor em Uppsala university, dpt of Public Health and Caring Science, 751 85 Uppsala, Sweden Send response to journal: Re: Share costs and benefits in diabetes care	The result of good diabetes care can be measured as a lowered rate of acute and long-term complications. The person with diabetes is in charge of the day to day management and can thus have a strong impact on the outcomes [1]. The better she performs the more can be saved by the health service system. We calculated that every pound spent for educating the patient would give a two pound return if it resulted in a lowering of HbA1c one percentage unit [2]. The sums involved are not so great (£ 1 300) and patients might want to get something more valuable back for their job. Many complain that they are not listened to. Maybe that could be bought for the sum and result in an even better outcome. Litteratur 1. Sarkadi, A., A. Veg, and U. Rosenqvist, The influence of participant's self-perceived role on metabolic outcomes in a diabetes group education program. Patient Education and Counseling, 2005. 58(2): p. 137-145. 2. Tennvall, G.R., U. Rosenqvist, and L.G. Nilsson, [It is worth concentrating on prevention of complications. An example from diabetic care]. Lakartidningen, 1997. 94(34): p. 2817-21. Competing interests: None declared
Need to consider how 'health' is defined 22 July 2008
Niyi Awofeso, Associate Professor School of Public Health, University of New South Wales, Sydney, Australia Send response to journal: Re: Need to consider how 'health' is defined	A missing thread in the very interesting dialogue between Jenny Popay and Richard Cookson on whether or not the poor should be paid to look after their own health is that both authors took the definition of health for granted. In fact, at the core of the conditional cash transfer controversy is the issue of how health is defined in a given setting. The word ‘health’ was derived from the old English word ‘hoelth’, which meant soundness of the body, or physical fitness.1 At its most basic level, physical fitness is highly influenced by nutritional intake. Malnutrition currently kills 3.5 million, mainly poor, people every year. About $US15 billion is required yearly for the next several years to make basic food accessible to the poor. Hence, in the 21 nations identified by the World Health Organization as having significant under-nutrition and malnutrition problems, means-tested conditional cash transfer to help financially disadvantaged people cope with rising food prices will, ideally, provide poor families with access to a nutritious food basket, and help keep children at school instead of engaging in child labour primarily to feed themselves and their siblings. The devil is in the detail. Due to chronic poverty in many parts of the world, will disadvantaged people actively seek to remain disadvantaged (e.g. by keeping their children persistently malnourished) in order to continue to qualify for such cash transfers? Will access to health enhancing foodstuffs translate to a more equitable distribution of food in household units? Is the autonomy provided by conditional cash transfers a good enough trade-off for the restriction of disadvantaged people to purchasing specific subsidized foods, or receiving food handouts? The difficulties inherent in a very basic, nutrition-based definition of health are magnified when health is defined as “a complete state of physical, mental and social well-being, and not merely the absence of disease or infirmity”2. Adequate attention to, and consensus on, the operational definition of “health” in use will help to inform decisions on how best to enhance it. References 1. 1) Dolfman M. The concept of health: an historic and analytic examination. Journal of School Health 1973;43: 491-7. 2. WHO. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June 1946, and entered into force on 7 April 1948. Competing interests: None declared