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exercise to examine the issue and this summary draws on that unpublished work.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
