Bart Criel is medical doctor by training. He worked for 7 years as a medical officer at district level in rural Congo (DRC). He is currently Associate Professor at the Public Health department of the ITM Antwerp. His field of work is mainly on organization of local health care delivery systems and programs of social protection in health.
I had the privilege and pleasure to comment upon the (excellent) Position paper for Chronic Care in Belgium that was recently published by the Belgian Health Care Knowledge Centre – an institution well-known in this country under its local acronym KCE. Officially, my role was to “validate” the report. This rather flattering description of my expected inputs does not match the considerable “return” I got from reading the report (that can be found on the KCE website). Yes, I learned quite a lot from studying this extremely well documented and referenced report.
The position paper presents a detailed outline of policy recommendations that gravitate around the following axes: the planning, provision and coordination of routine care in the primary care setting; the provision of acute episode response and specialized services; early identification; support of patient and informal caregiver empowerment, including self-management; health promotion and primary prevention activities. The paper refers to the need for multisectoral efforts and explicitly mentions the WHO commissioned report on Social Determinants in Health. It further emphasizes the need for manpower planning and training of health workers; for development of protocols and tools for communication; for development of information and communication technology applications; for quality improvement initiatives to empower patients and patient organisations; and for a number of organizational reforms within the Belgian health system. The relevance of the paper for the situation in LMICs is striking: the contexts differ of course (especially the level of resources available), but the organizational challenges are quite universal, as well as the responses in terms of health systems design (at ITM we forwarded the position paper to our MPH students – who come from all over the world).
When the editors of the IHP newsletter requested me to write an editorial on the paper, I saw a nice opportunity to share with you some of the thinking the report provoked in me and to reflect on the recent increased interest in chronic diseases (the new “flavour of the month”?), be they communicable or not. I will not dwell on the obvious relevance of addressing lifestyle issues in the control of chronic diseases, nor on the equally obvious need to address social determinants, but rather concentrate on the role of local health systems and health services.
A thought that frequently popped up in my mind when going through the KCE report was a feeling of… but we do know what the solutions are, don’t we, as well as an impression of… old wine in new bottles. This is not necessarily a negative thing– it may be, and indeed is, wise to sometimes repeat things and to position them once more at the centre of policy debates, if only to strengthen our convictions, to dissipate possible doubts or to provide firm support to pursue work in the same direction.
One of the advantages of getting a bit older is that there is an increased time-span for one to reflect upon. The Primary Health Care (PHC) strategy, as defined in Alma Ata in 1978, did not explicitly refer to chronic diseases – but it did clearly emphasize the need for prevention and control of locally endemic diseases and the need for appropriate treatment of common diseases (and, my addition, are chronic diseases not also common diseases?). In my view, PHC was, is and remains a relevant, or should I say – the relevant – approach to handle care of chronic diseases. The current increase in the prevalence of a range of chronic diseases is new, but the operational strategies to address them probably aren’t… The Lancet Comment by De Maeseneer et al. goes very much in the same direction.
One of the comments I wrote on the KCE report was the following: The quality of care for chronic patients in a health system can be seen as a tracer for the overall functioning (or ill-functioning) of the health system. Indeed, a system that takes good care of its chronic patients – a difficult enterprise as the report amply shows – is a good system. It is my conviction that the implementation of the recommendations formulated in the position paper will benefit the system as a whole, far beyond the care for chronic diseases.
The relevance of PHC as a strategy to address people’s health problems, be they acute or chronic, has been eloquently argued in the 2008 World Health Report ‘Primary Health Care, Now More Then Ever’ – mandatory reading for ITM’s Masters students! Especially the 3rd chapter of this landmark report – the chapter entitled ‘Primary Care: Putting People First’ – makes a strong case, with all the possible global evidence that one would want, for health care delivery systems to be based on the philosophy of PHC. And a correct interpretation of PHC implies that key roles in its field implementation not only lie in the development of accessible first line health services staffed by multipurpose health workers providing an integrated package of care and which coordinate their action with the other players in the local health delivery system, or in the active involvement of patients, families and communities, but also in the use of specialists and hospitals whenever appropriate. The notion of a continuum of care is extremely valid when addressing chronic diseases, and rests upon the development of local health systems where the activities at the different tiers of care, from patients up to specialists in a hospital environment, are coordinated in a complementary way.
Another thought that popped up in my mind was related to the possible future role and place of vertical programs in the endeavor to do something about chronic diseases. I am not in the vertical program “bashing” business. That is not only simplistic and counter-productive, it also fails to acknowledge that vertical programs are, or rather can be, powerful resources in addressing health problems and strengthening health systems. Vertical programs basically are organizations staffed by people who are experts in a given disease and who produce strategies, recommendations and guidelines for an evidence-based control of “their” disease. There is a clear need for such people. Not to use their expertise would be utterly silly. The set-up of a program results from a (preferably autonomous) policy decision, which is justified by the frequency, the severity and the social perception of the health problem – i.e. it corresponds to the need felt in a society for due attention to a specific health problem. However, the way how a program is operationalised in the field may vary: for some program activities it may be justified to have them carried out in a “vertical” way, i.e. by specialized people in services functioning in parallel to existing services; for other activities there may be a strong case for integrating them into existing “horizontal” services. In the case of chronic diseases, there is a wealth of arguments to favor the latter approach.
What is then my point? My point is that the current – worldwide – chronic diseases epidemic may very well justify the creation of specific national administrations and expert teams looking into the best ways of preventing and treating the disease. It does, however, not justify the possible creation of parallel systems to the existing health care delivery apparatus. Hence the sometimes ambivalent feelings I have when taking stock of the swelling stream of editorials and papers demanding specific attention for chronic diseases. It is of course important and justified to put chronic diseases high on the agenda and to discuss the organizational challenges that the care for chronic patients will imply (see the Lancet series on NCDs; see more specifically the plea by Atun et al. for more responsiveness of health systems to non-communicable diseases). The increased attention is of course OK, but what I would not like to see happening is that the control of chronic diseases does not go much beyond the creation, all over the world, of the Nth disease control program…. (the DRC counts today about 55 vertical programs; do we really want a 56th program on NCDs? Or does the priority lie elsewhere?). And what I fear most of all is that the set-up of these programs would ignore the fact that the managerial and operational solution for addressing chronic diseases is already crystal clear: i.e. more of PHC.
Let’s not get into the situation – a caricature, hopefully – where in a couple of years from now, specialized cadres from newly created chronic disease programs, with lots of (earmarked) resources, would offer health workers specific training in and provide specific support for the management of given chronic diseases (with each donor favoring its own “pet” NCD?), as if these were a sliceable part of a comprehensive and integrated package of care, that can be insulated from the wider service delivery system. As I wrote to KCE: a system that takes good care of its chronic patients is a good system. Taking good care of chronic diseases is about implementing PHC. Nothing more, but also nothing less. So let’s get to it. The time is now, more than ever.