UK health system can learn from innovations in world’s poor regions, conference hears

BMJ 2013; 346 doi: (Published 18 April 2013) Cite this as: BMJ 2013;346:f2500

Re: UK health system can learn from innovations in world’s poor regions, conference hears

We would like to thank Matthew Limb for his report on learning opportunities for the UK health system from innovations in world´s poor regions (1). Additionally, in our response we would like to point into the specific direction of learning opportunities in primary health care for wealthy countries. As Matthew Limb already mentioned by referring to Matthew Harris, the effective model of primary care had played a big role in the health improvement of the Brazilians which might be adapted for use in the UK (1). However, the primary care approach used in Brazil is the community-based primary health care approach (3) instead of the primary medical care approach widely used in wealthy countries if at all. Therefore, we raised the question: Are community-based and community-oriented primary health care relevant only for developing countries?

Five years after the proclamation of the rebirth of the Alma Ata declaration (2) the community-based (3) and community-oriented (4) primary health care approaches became the recommended strategies for developing countries to work towards the millennium development goals. Community-based and community-oriented primary health care (CBPHC or COPC) focus on community health needs and priorities as the starting point for resulting health interventions and policies such as to reduce maternal and child mortality. They complement the individual diagnosis of a person`s problem with a "community diagnosis" addressing the "upstream causes" of ill health like the social determinants of health (4) and are highly focused on active community participation, empowerment and equity. Both approaches are effective in improving the health of individuals and attribute to the social, structural, and economic development of the communities (3,4).

But what about wealthy countries like Austria, Belgium, Germany, or the USA?

The social and political goals of CBPHC and COPC described in the Alma Ata declaration were never fully embraced in these countries. An emphasis on secondary and tertiary care provided by hospitals and specialists became the main strategy and retained their disproportionate share of local health economies (5). In Austria and Germany the utilization of medical care, in particular at the specialist level, is very high and so are the expenditures on health; however, the healthy life expectancy in both countries is below the EU 27 countries average (6). In Belgium, there is a gap in the healthy life expectancy of men aged 25 between the lowest and the highest educational group of 17.8 years (7). This “policy” now endangers the healthy life expectancy of an aging society suffering from chronic diseases and multi-morbidity (8) and is challenged by increasing health inequalities aggravated by the financial crisis and austerity politics (9). It is evident since the 1960s that medically-focused health services alone, no matter how effective, cannot change the overall health condition of a population unless the social determinant of health are addressed (10).

The growing group of mainly socially disadvantaged people with chronic conditions would benefit most from a reorientation of health systems which support self-management, health promotion, and disease prevention at the household/community level; based on that continuity and coordination of care from the personal to the first and second level of care could be guaranteed. Complications, hospital admissions and costs could be avoided by strengthening lay care through CBPHC and COPC (9). Moreover, a paradigm-shift from "problem-oriented" to "goal-oriented" (11) care could protect people from harm which may ensue through unnecessary procedures (12). In times, when a powerful health industry with its supply-induced market tries to steadily increase the number of worried- but well people to sell their products, community-oriented approaches could help people to develop their health literacy in order to be able to make healthy choices in a world dominated by neoliberalism and to foster a better understanding of the determinants of health and health care systems themselves.

These reflections lead to the conclusion that CBPHC/COPC is needed in developed countries as well to improve medical care without losing the gains achieved: it is needed to address the social determinants of health, to integrate personal and community-oriented health services based on the health needs of individuals and communities (13). CBPHC/COPC could be a strategy to reach the goal of health equity throughout the population and to ensure the efficient and responsible use of scarce resources (9).

There are some CBPHC/COPC projects in Austria, Belgium, Germany, and the USA that show sustainable success. However, these initiatives stay mainly outside the regular health care system and are often challenged by a lack of resources, which constantly endangers their sustainability. Additionally, the lack of funding for continuous evaluation and of related scientific research makes these projects invisible for interested stakeholders and the scientific community. Moving towards active community participation would make a huge difference and could become – also in the developed world - a key-feature of health systems oriented towards relevance, equity, quality, person- and people-centeredness, cost-effectiveness, sustainability, and innovation.

(1) Limb M. UK health system can learn from innovations in world´s poor regions, conference hears. BMJ 2013;346 Epub 18 April 2013.
(2) Lawn JE, Rohde J, Rifkin S, Were M, Paul VK, Chopra M. Alma-Ata 30 years on: revolutionary, relevant, and time to revitalise. Lancet 2008;372(9642):917-27.
(3) Perry H, Freeman P, Gupta S, Rassekh BM. How Effective is Community-Based Primary Health Care in Improving the Health of Children? A Review of the Evidence: Community-Based Primary Health Care Working Group - American Public Health Association, 2009.
(4) Rhyne R, Bogue R, Kukulka G, Fulmer H. Community-Oriented Primary Care: Health Care for the 21st Century. Washington: American Association for Public Health, 1998.
(5) Gillam S. Is the declaration of Alma Ata still relevant to primary health care? BMJ 2008;336(7643):536-8.
(6) Hoffmann K, Stein KV, Maier M, Rieder A, Dorner TE. Access points to the different levels of health care and demographic predictors in a country without a gatekeeping system. Results of a cross-sectional study from Austria. Eur J Public Health 2013; Epub 5 February 2013.
(7) Bossuyt N, Gadeyne S, Deboosere P, Van Oyen H. Socio-economic inequalities in health expectancy in Belgium. Public Health 2004;118(1):3-10.
(8) De Maeseneer J, Boeckxstaens P. James Mackenzie Lecture 2011: multimorbidity, goal-oriented care, and equity. Br J Gen Pract 2012;62(600):e522-4.
(9) De Maeseneer J, Willems S, De Sutter A, Van de Geuchte I, Billings M. Primary health care as a strategy for archieving equitable care: a literature review commissioned by the Health Systems Knowledge Network. Ottawa: WHO Commission on the Social Determinants of Health, Health System Knowledge Network, 2007.
(10) Litsios S. The Christian Medical Commission and the development of the World Health Organization's primary health care approach. Am J Public Health 2004;94(11):1884-93.
(11) Mold JW, Blake GH, Becker LA. Goal-oriented medical care. Fam Med 1991;23(1):46-51.
(12) De Maeseneer J, Roberts RG, Demarzo M, Heath I, Sewankambo N, Kidd MR, et al. Tackling NCDs: a different approach is needed. Lancet 2012;379(9829):1860-1.
(13) van Weel C, De Maeseneer J, Roberts R. Integration of personal and community health care. Lancet 2008;372(9642):871-2.

Competing interests: No competing interests

03 June 2013
Kathryn Hoffmann
Researcher and lecturer at the Medical University of Vienna
Martin Sprenger (Medical University of Graz), Andy Maun (University of Gothenburg), Manfred Maier (Medical University of Vienna), Jan de Maeseneer (Ghent University)
Medical University of Vienna, Centre for Public Health, Department of General Practice
Kinderspitalgasse 15/I, 1090 Vienna, Austria