Partners in Practice

You are in the following situation: you are a health manager responsible for a population with limited resources and with overwhelming health problems that cluster in the poorest groups. It is easy to imagine your solution to be one that concentrates efforts on tackling these problems head-on.

Thus a country that has a high burden of HIV/AIDS, tuberculosis, malaria or maternal mortality would rightly invest its own resources, and foreign aid, into specific (“vertical’) programmes aimed at reducing these problems.

Such vertical programmes intuitively offer many benefits. They focus limited resources on priority health concerns. They make optimal use of limited human resource capacity by focusing staff on work of high impact. They can focus attention on a limited set of priorities with minimal distraction. The results of the intervention can be attributed to the investment and this would encourage more national and international support.

Perils of a vertical approach

Such a narrow approach to dealing with individual health problems in isolation can have a number of undesirable side-effects.

• Many of the countries in the developing world have a double burden of disease, communicable and noncommunicable, and vertical approaches have tended to favour the first in place of the second.
• Many of the priority health concerns have common delivery needs; greater efficiency could be achieved if more unified and coordinated approaches are used.
• A concentrated vertical attack on a disease would lead to predominantly medical or technological solutions while the causes of these diseases and the disparities in their distribution often have wider social causes.

The example of tuberculosis

It is valid to ask: how can a global health concern expand its focus to address broader health needs and inequities without losing its focus or compromising its desired outcomes? The StopTB programme of WHO has recently conducted an exercise to examine the issue and this summary draws on that unpublished work.

A vertical national tuberculosis programme will (in a simplified model) be concerned with case finding and treatment; it will focus on finding all people with the infection and treating them. In the case of infectious diseases, effective treatment is also a mean of prevention as it removes infectious cases from the population. This approach works and effectively reduces the incidence and mortality from TB, yet the achievements often fall short of the levels expected by global goals for control of the disease.

Yet much more can potentially be achieved from a wider societal approach to tuberculosis. For instance:

• In countries where major declines have been seen in the past, they have resulted from improvements in nutrition, housing, and overcrowding, from social rather than technological solutions.
• In countries with a high burden of tuberculosis, around 7% of cases are associated with HIV infection, yet this is not the only associated risk factor. Active smoking is associated with 23% of cases of TB in high-burden countries; indoor air pollution is associated with 26% of cases.( Lönnroth, Raviglione 2008)

So, what would change for a National TB programme manager if she were to take on board observations such as these? What could she do to increase the effectiveness of her programme?

1. The recognition the TB is associated with new risk factors (e.g. alcohol use, smoking, indoor air pollution, diabetes) alongside the traditionally recognised risks (malnutrition, poverty, HIV) at the very least provides avenues for defining new risk groups among whom more effective case finding efforts could be done;
2. The co-morbidities of TB offer a justification for a coordinated primary care approach where the investment in services provides treatment for the infection but also extends to the other conditions that co-exist with TB;
3. Finally a recognition of the historical evidence of what has worked in making major gains in TB control, as well as a consideration of the current inequities in the distribution of the disease, would lead her to at least consider joining in the advocacy for universal access to prevention and care, for more equity in health, and for programmes that address the social determinants as a whole.

A health promotion response

The current climate is very conducive to thinking of integrated preventive approaches that focus on wellness and community assets for health. In 2008, two landmark publications have been issued: the Report of the Commission on the Social Determinants of Health and the World Health Report on the renewal of Primary Health Care. Much has been said at this meeting on both these reports and this presentation will add the perspective of health promotion to the picture.

Health promotion is defined as the process of enabling people to increase control over, and to improve, their health. Since its early days, the leadership of the community and its own capacity to generate and control its own health has been central to health promotion. One of the founding documents of health promotion (“A discussion document on the concept and principles of health promotion”), inspired by Alma Ata, and now nearing its twenty-fifth anniversary, emphasises this concept. To quote selectively from it: “Health involves the population as a whole in the context of their daily life […] Health promotion is directed towards action on the determinants […] of health. [It] aims particularly at effective and concrete public participation [and] strengthening social networks and social support.”

The current public health challenges bring out the importance of these concepts and principles and make them as topical as ever. A vertical, technological solution to priority health concerns will have limited scope in the face of broad social causes and inter-connected diseases. Priority health programmes would usefully examine the potential impact of more community led approaches inspired by primary health care and the social determinants of health. Specific questions that health promotion seeks to answer in this context include:

1. How to harmonize national and global development goals in such a way as to promote unified approaches to health that address the “causes of the causes” of disease?
2. How to promote effective action across government sectors such that co-benefits are identified and other sectors recognize the incentive to assess their impact on health to maximize the benefits?
3. How to improve the capacity of communities to control their own health, in local settings such as schools, workplaces, and municipalities?
4. How to address individual agency in health without over-simplifying the causation of disease down to solely "lifestyles" factors?
5. How to improve the performance of the health sector itself in increasing the preventive content of its own work, delivering it to the vulnerable and disadvantaged populations, ensuring effective, universal access, as well as acting in leadership to promote health across the policies of the whole of government?

*Dr Gauden GALEA is Coordinator “Health Promotion” at the World Health Organization (WHO) Geneva. Contact: galeag@who.int
This article contains the views of the writer alone, and does not necessarily represent the decisions or the stated policy of the World Health Organization.

Ressources

• Lönnroth K, Raviglione M. Global Epidemiology of Tuberculosis: Prospects for Control. Semin Respir Crit Care Med 2008; 29: 481-491
• Wolrd Health Organization (2008) “Closing the gap in a generation: Health equity through action on the social determinants of health” http://www.who.int/social_determinants/final_report/en/
• World Health Organization (2008) “Primary Health Care – Now More Than Ever” http://www.who.int/whr/2008/en/index.html
• A discussion document on the concept and principles of health promotion, 1984. Reproduced in Health Promotion International. 1986; 1: 73-76 http://heapro.oxfordjournals.org/cgi/content/citation/1/1/73