Beyond the Health Care System

Key messages & Research issues

• Chronic Diseases provide many opportunities for interaction to prevent deterioration: health promotion, primary prevention, treatment and rehabilitation are part of a continuum of management of a health condition.
• Determinants of Chronic Diseases and opportunities to influence those relate to the level of individuals and their direct environment, to social and community networks and to policy levels. Inequities play a major role, but the differentials are poorly understood. There is a big global disparity in action plans and strategies to address the determinants of Chronic Diseases.
• How to mainstream health in other policies? How to ensure interact with decision makers at different levels and with the general public, so that sound policies are made and followed by action?

Determinants of CDs

The generally slow progression and long duration of CDs provides many opportunities for interaction to prevent a deterioration of condition. From that perspective, a distinction between health promotion, primary prevention, treatment and rehabilitation is less relevant; they are part of a continuum of management of health conditions.

The development of CDs is influenced by determinants at different levels: by the general socio-economic, cultural and environment context (eg globalization, urbanization, ageing); by common modifiable risk factors (unhealthy diet, physical inactivity and tobacco use); by unmodifiable risk factors (age, heredity) and by intermediate risk factors (eg raised blood pressure, raised blood glucose, abnormal blood lipids, obesity) (World Health Organisation 2005). This classification suggests spheres of influence related to the individual and his direct environment, to social and community networks and to the policy level. Inequities play a major role, but the differentials between and within countries are poorly understood.

Human behaviour is central in the increased incidence in many CDs, in particular those that are diet related. Recently it was again shown that one third to half of the diabetic cases could be reversed or prevented with increased physical activity and a healthier diet (Knowler et al. 2009;Misra 2009). Health providers and promoters often focus on the individual as the primary cause of an unhealthy diet or a sedentary life style. However, evidence from intervention studies underlines the limited effect of interventions targeting the individual. Increasingly, the living environment is being accepted as the major determinant adversely affecting diet and lifestyle. Very often, the options for an optimal lifestyle are simply not available. Limited access to healthy foods (be it physical or economic), safety and cultural issues hampering physical activity, poor city planning are just a few examples.

Lessons from experiences in different contexts

Research, national action and political commitment in Cuba

In Cuba, the political commitment for better health is high, at national and local political levels. The government puts considerable resources into the national health system of public providers. CDs have been recognized as a problem since the eighties and regular nationwide surveys to the common risk factors have been performed. There is an intersectoral research programme and a national health program for the management of risk factors and the health determinants up to 2015. It promotes an integrated approach, focusing on health services reorganization to include promotion and prevention (strengthening the role of family doctor and first line health services, a modified function of the policlinics) and on inter-sectoral action and social participation, managed by the government. In terms of care, non-communicable disease management takes place at all levels of health services. The major antihypertensiva and streptokinase are produced locally, and acute care is present in most municipalities. One concrete outcome is a continuous downward trend in coronary heart disease since 1982.

National nutrition policies – Europe, USA and elsewhere

A well-documented example of the influence of an adequate policy response is the Karelia project in Finland, where the curve of mortality rates of coronary hearth disease showed a markedly increased decline from the introduction of a focused health policy (Puska 2002).

A global analysis of existing nutrition policies highlights the disparity in action plans and in particular the absence of strategies on chronic diet related diseases at the national policy level. Some countries in Europe have an exemplary comprehensive policy plan involving all sectors and developed in a very participatory way. Examples of good components of a nutrition policy are the systematic follow-up of certain indicators among target groups in specific environments (Danish indicator program for nutrition surveillance), a program against obesity, in family/community, in schools, in business/ in the health system (Spain), actions to improve availability and access to health food in neighborhoods and schools (USA) and an integrated food/nutrition policy for health and environment: healthy and sustainable (Sweden) (Lachat et al. 2005). These initiatives share a well developed multidisciplinary approach and environmental focus. Among LMIC, there are consistent policy documents in Niger, Swaziland, Mongolia, Cabo Verde, Congo.

How to optimise the environment?

This needs first of all recognition of the fact that the environment is important in shaping the behavior of individuals. Next, there is need for join action, policy making and regulation. The WHO database of national policy documents on nutrition may provide guidance for LMIC, especially for the process how to develop a national response. The consultation phase is very important, which can be organized in different ways, according to the institutional settings and levels of decentralization. Denmark, UK and France have an extensive English version of their policy, available online. Regulation is necessary with regard to advertising, the media and the food industry, in the present context of globalization and interdependence also at international level. Health professionals, especially those working in public health, could cross these bridges, by providing evidence; by creating awareness about the interrelation of problems and the responsibilities and potential roles that actors have, by advising in policy-making and, finally, by not to forget the individual patients. The relationship between risk factors, the development of CD and health outcomes is complex. The patient himself has a big influence in the course of many CD. This makes it difficult to determine the expected results of disease management. It will be a balance between autonomy, life expectancy, quality of life, in which the opinions of health professionals, the patient / his family and of health planners might differ.

Inter-sectoral approach

Ideally, health is mainstreamed in other policies, meaning that other sectors take into account the effects on health in their activities, for instance city-planning or school-programmes. This can be done in different ways, to different extents, from ‘health informed policies’ to systematic health impact assessments. In Cuba, health is a quality indicator in the development of all policies. On the other side, other sectors and actors should be involved in the development of health programmes. Examples are the involvement of parents, teachers and the children in the development of a program for obesity in children.

There are barriers at both sides in this dialogue. Professionals from other sectors might not feel competent to deal with health-related issues. Health professionals from their side are generally not well equipped to promote the inter-sectoral approach, don’t consider the wider implications of their health-related advice and are not inclined to take into account other views or shared decision-making. The advice to ‘eat fish twice a week’ is not coherent with sustainable fishery, for instance. A good example is making explicit the link between sustainability and health (Wilkinson et al. 2009). Other possibilities to stimulate a fruitful dialogue between health-related and other professionals are to involve actors, who might ‘break the ice’ and widen the scope of view. This means also to include subgroups in the population, traditional health providers, social networks, etc. Patients themselves can play an effective role in primary prevention of CD through increased awareness. This is being done in Cambodia by diabetic school teachers, who have been trained as peer educators and who in turn promote healthy lifestyle among school teachers, in order to improve the health communication with the school children.

To involve different community actors in a common dialogue is well suited for determinants that can be easily discussed in the public sphere, but more difficult to do with chronic social health-related problems which carry a taboo, like alcoholism, domestic violence, etc. Although media attention to critical incidents contribute to raising these issues on the agenda, it is very difficult to achieve community action. There can be even a tension between a high profile public debate and a practical approach to solve concrete problems, which often benefit more from a certain degree of discreteness.

Dialogue between research and policy

It is a challenge to have scientifically sound and complete evidence prevailing over commercial lobbying and selective scientific evidence, identified as a ‘toxic combination of policies, programs and politics’ (World Health Organisation 2008). Scientific institutions need to be able to function independently from the political power structures, yet at the same time be able to interact with them.

Besides direct interaction with decision makers, there are other ways to influence policy making. An example is the use of media, especially internet. The wide reach makes this a very powerful medium to influence opinions and behaviour of people and actions of organisations, such as private companies. Blacklists and greenlists, for example for the food industry, are both useful, enabling the public to make healthy choices.

Contributions by Mariano Bonet, Carl Lachat, Pol De Vos, Karen Pesse, Josefien van Olmen, Guy Kegels