All health systems in the world are immersed in service integration projects aiming to meet the challenge posed by the increased chronic disease and geriatric frailty. Based on this circumstance, King's Fund has published a document, "Population health systems. Going beyond integrated care" wondering how difficult could the integration of public health services be, given that improving health determinants and risk prevention can most effectively affect the way in which many people grow older and healthier.
The King's Fund document selects 5 experiences from different countries, that beyond the integration of services, are reaching community action: a) Kaiser Permanente, USA, focused on promoting physical activity and healthy eating; b) Nuka System of Care, Alaska, focused on community work to reduce domestic violence; c) Gesund Kinzigtal, Germany, focused on community groups that promote sport and health; d) Manukau Counties, New Zealand, created programs that emphasize healthy improvements in social housing; and e) Jönköping County Council, Sweden, formed discussion groups to promote health (life cafés, learning cafés, etc.)
David Citrin, Director of "Possible", an NGO working in Nepal since 2001, explains that, initially people went to the health camps of the organization to collect medicines. Upon noticing the effort that people made in order to obtain the drugs, the NGO immediately understood what was going on: drug surpluses were the currency in the food black market. It was evident therefore that his NGO was far from understanding the real needs of the community of Achham, the district that the government had assigned them. This led them to reorient their action towards an active program of social de-medication led by Nepalese volunteers working in accordance with the priorities set by a board of community health. This program is based on the promotion of dignity and respect, and aims to improve the health of the general population, rather than focusing only on solving health issues. David Citrin says that now, with the $20 per person per year that they have, their model is transformative and sustainable.
With these 6 examples, 5 of the first world and one from the third world, the obligation of health systems to understand the real problems of the population if they are to do more than to merely react, becomes obvious. The epidemic of obesity among people insured by Kaiser Permanente, for instance, but also the specific problems of communities with high levels of domestic violence, as it happens in Alaska, or growing poverty, as it happens in our environment nowadays, all these cases demand that the health systems providers focus their actions in accordance with the observed social realities.
Given how much the integration of services costs, now King's Fund says we should go further. I share this position, but I can see that it’s very unlikely that doctors and nurses alone, regardless of the logical concern, may affect the determinants of population’s health (remember that it is estimated that 80% of them do not depend on the health system action). However, the active program of social de -medication of Achham has opened my eyes. Can you imagine, for a moment, that we’ll raise our gaze, just as "Possible" did in Nepal, and we’ll be able to prioritize budgets that affect the determinants of health in terms of the impact on population health?