Health is the fundamental right of every citizen and it's very important that the government and international organisations provide basic healthcare whenever its needed.
The more we focus on prevention and promotive health the less the need for curative and rehabilitative services. Need greater thrust on the prevention and promotion. Also, we can not totally avoid curative and rehabilitative services but reduce the need for those.
I think there are 2 key components for achievement of balance:
1. Integration: these different services must talk to each other, must have common goals and share the same evidence-based clinical protocols.
2. Intelligent payment method: forget fee-for-service, implement other methods that recognize value for patient.
At this time, I do not believe we can isolate one element at a time...it diverts focus, energy, and resources. There is a fundamental lack of health literacy at the participant level. In the US especially at this time, it is critical to engage one community at a time, enlisting the participation of all stakeholders including participants, and the specific health drivers affecting that community. The tools, human capital, and technology exist to facilitate this transformation towards more preventive and chronic condition management through healthy lifestyle behavior change, however. It begins with education, consistently, and continually from all stakeholders all the time. There is no one pill or widget that will satisfy all the requirements. Identify the needs of your community and for population health management's sake, identify the elements that both practitioners and participants will recognize and participate within for successful impact and ultimately outcome. Respectfully, Ken
I don’t think we can readily determine the appropriate balance of promotive, preventative, curative and rehabilitative health services for a given community.
However, applying the precautionary principle, we should work on the assumption that a significant proportion of reactive service effort could be avoided if we had responded earlier to signs of change.
I like this quote from Jay H. Bernstein’s paper “The Data-Information-Knowledge-Wisdom Hierarchy and its Antithesis”:
"The failure to recognize change that requires response arises from the tendency to insulate oneself from information about changes, which could help one devise an appropriate adaptive response."
As I understand, expenditure on health promotion in industrialised countries is in the region of a few percent of health budgets at best. Zola’s river of health promotion springs to mind. We’re so consumed in treatment that we are insulated from the less dramatic signs of change in the community (at individual and group levels). This means change that is current or change that can be predicted through our understanding of determinants and change mechanisms.
Reactive services are essential and always will be – but shouldn’t we be planning for systems where reaction is not the norm?
Well written and said, David. I do believe we are on the same page. The model I describe is not reactive but do to it's managed foundation would allow for necessary reactive measures when required. Is it a failure to recognize change or a refusal to move forward?
As a Public Health worker dealing in Brasil, what I acna say is that although in THEORY you can have someone to tell you how much investments you need in each area, the main catch is HOW they are being applyied and to WHOM this investmet is reverting.
Do your workforce understand where your population is and where it must be in the future? Are the goals attainable? Are the goals REALLY important? Is infrastructure an issue? Is everybody motivated (including financially) to this change?
If you need more information get in touch!
Rogerio Luz Coelho, MD, MSc
Specialized in Family and Comunity Medicine in Brasil
Absolutely Rogerio! You must first assess the community with the local health entity there for at risk population identity and to determine what is currently being done. Companhia Athletica in Brasile is doing a good job delivering an integrated model of healthy lifestyle behavioral change elements from what was once just retail fitness. They have active physician teams, coordinate somewhat with hospitals in their various markets and have stratified into software the most problematic chronic conditions facing the populations in their markets. Because we want as professionals we want to successfully manage the population health initiatives we are implementing, we will need to also integrate elements that assist with consistent improvements short, mid, and long term and then educate, coach, and facilitate the teams necessary to deliver. In the two years that I worked with CIA above, their professionals demonstrated the skill sets and passion necessary to succeed. Thank you for the thought provoking discussion and I look forward to its continuation. Respectfully, Ken Germano
As the 'right equilibrium' between all these aspects is specific to every situation, it is through specific decision-making on specific problems, each time looking into opportunity costs and improvements at the margin that we can optimize the functioning of a health system. And afterwards looking of course at the impact of the decision. Optimizing is an iterative process.
Contrary maybe to earlier suggestions in this discussion, it is important to realize that preventive is not better or worse than curative care or promotion initiatives. It depends on the type of problem and what effect each initiative can produce. Preventive care or promotion does a lot of times increase the need for curative care, because the demand is stimulated. This is a good thing, and the very reason why integration is needed.
Brilliant, Paul. Well said! We are in complete agreement regarding the integration of all the required elements community by community for their individual attributes and uniqueness.
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