“What can I do now or in the future, acting alone or within an organization, to help achieve Health for All though Primary Health Care?”
As I am not currently directly involved with health and social services, but have significant experience and knowledge, I am in a strong position to help communicate these ideas and hopefully thus help to contribute to processes of change. A few years ago I wrote the following personal mission statement.
“I wish to develop the Renaissance concept of Opera, where people work together closely to resolve the issues they face, from a participatory, equal, just, sustainable and whole system perspective.”
I love the following statement by Karl Popper.
“I think that there is only one way to science – or to philosophy, for that matter: to meet a problem, to see its beauty and fall in love with it; to get married to it and to live with it happily, till death do ye part – unless you should meet another and even more fascinating problem or unless, indeed, you should obtain a solution. But even if you do obtain a solution, you may then discover, to your delight, the existence of a whole family of enchanting, though perhaps difficult, problem children, for whose welfare you may work, with a purpose, to the end of your days.”
I wish to develop the very valuable ideas of this course for a British context. This will require:
- Further research about how health for all is being implemented elsewhere on this planet, summarizing this knowledge succinctly, and creating an accessible and authoritative knowledge base. A training manual, best practice summary and reference material are critical to this, possibly with helping to rewrite the wiki entry, which is currently very poor. Historically, many of these ideas are part of British thinking. William Morris, News from Nowhere, Upton Sinclair Co-ops and Colin Ward the Child in the City come to mind.
- Bringing together like-minded people in Britain to discuss this and work up implementation proposals. Contacts with universities and think tanks in Britain like Demos or New Economics Foundation would be very valuable.
- Working up and beginning implementation of some practical examples. Britain does have many of the parts, good adult education, extra care schemes, possibly the required legal structures, sure start centres, but these are not joined up and not comprehensive and citizen centred. The disability world is developing centres for independent living, which are also a useful model.
There are real specific challenges and obstacles to meet and overcome.
The idea of health for all is not yet part of the current political agenda in England, which is about improving efficiencies of the current systems, has very strong political beliefs about the free market and cutting red tape and is not yet in a position to think in the system redesign ways that are required to implement health for all because it is crisis focused, attempting to save money. There is lip service to the ideals for example of prevention, and some law, for example the concepts of “nothing about us without us” and medical and social models in the disability world, but these are add ons to existing ways.
We are focused on crises in hospitals, quality standards of care homes and care assistants, “the deficit” and quality of food. Wales and Scotland are probably further ahead, but I am unaware of anyone proposing radical changes. We are assuming we must continue with our existing silos and structures of GP’s, hospitals, care homes, nursing homes, domicillary care assistants,…, all with differing funding stream, regulations and bureaucracies. Torbay is using some of the health for all ideas.
The first issue is to get these ideas on the agenda, and it is not clear that policy makers have the space to listen, or in fact want to listen, because they believe they know what they are doing. The philosophy is to destroy regulations and allow “freedom” which in reality will help the existing power holders, especially the very large drug and health companies, who are thinking in terms of individual patients they can sell health services to, not in terms of comprehensive understanding of everyone’s needs and excellent joined up responses.
The existing structures of hospitals, GPs, domiciliary and residential care are all being looked at separately with disjointed incrementalist improvements being proposed in these sectors. “Polyclinics” are being developed in some areas, but these are really micro hospitals, not centres for implementing health for all.
Participation is not really on the agenda. All GP’s, hospitals etc have complaints systems, there are various organisations to propose things, my GP does have a patient’s group, it is actually a health centre, but it is all adaptations of existing structures and processes, not building communities together and developing what might be possible. There were in the 1970’s community work initiatives, and there is a lot of research available, but it is being forgotten. Questions are not asked about the health of communities.
There is no reason why the health for all ideas should not be delivered via local co-operatives where all neighbours are full members and are regularly involved, that employ the local doctors and health and social service staff, that have full education and training responsibilities.
Futuresearch is an example of how a community meets to discuss their history, where they are now and their issues, and where they wish to be.
There are real issues about patient confidentiality that need thinking through. Alma-Ata is proposing a world where key people can be trusted with what they know about each other.
To conclude, the ideas are around but have basically been overwhelmed in the day to day. The strategic thinking has not returned to first principles, as stated at Alma-Ata.
Someone asked how to get somewhere, the response was I would not start from here!
The Brazilian model should be studied closely to work out how it may be transferred to Britain. In principle, most of the parts required to create a reinvigorated district nurse system on a community base already exist. There are care managers and competent support and care workers. They are not working on clearly defined geographical bases, so for example care assistants are spending long times travelling to clients when they could be working very close to where they live within a defined community. They are thus not able to build up the census, statistical and local knowledge that is critical to make these initiatives work.
The synergies that could happen by properly thinking through all the needs of a community, what resources they already have and asking what their priorities are similar to those posited in ideas like the singularity. There are already many people with the required education, skills and experience. They have not been trained to think and work in health for all ways, the systems they are working within actually prevent them doing so.
Terrifyingly, we are probably employing many staff in British health services who are highly experienced in health for all ways from their home countries, and are actually destroying their expertise.
A database and discussion group of people working in British health and social services who have worked in health for all structures in their home countries is critically important.
There are already places that could easily be excellent centres for their communities, like sheltered schemes with impressive ranges of services that could be delivered to people living nearby.
Although Health for All has been developed in primarily rural areas, I see no reason why these principles, of people knowing their neighbourhood in detail, able to build up detailed census information of areas, properly managed, paid and trained, should not be used in cities.
Technology like smart phones and video conferencing make these ideas easily embedded.
Organisations like BRAC have already worked out the main issues. We have in London a significant Bangladeshi population who probably are highly experienced in health for all ways.
“BRAC is a development organisation dedicated to alleviate poverty by empowering the poor, and helping them to bring about positive changes in their lives by creating opportunities for the poor.
Our journey began in 1972 in the newly sovereign Bangladesh, and over the course of our evolution, we have been playing a role of recognising and tackling the many different realities of poverty. We believe that there is no single cause of poverty; hence we attempt tackling poverty on multiple fronts.
Focus on women – BRAC places special emphasis on the social and financial empowerment of women. The vast majority of its microloans go to women, while a gender justice programme addresses discrimination and exploitation.
Grassroots Empowerment – BRAC’s legal rights, community empowerment and advocacy programmes organise the poor at the grassroots level, with ‘barefoot lawyers’ delivering legal services to the doorsteps of the poor.
Health and Education – BRAC provides healthcare and education to millions. Our 97,000 community health workers offer doorstep deliveries of vital medicines and health services to their neighbours. BRAC also runs the world’s largest private, secular education system, with 38,000 schools worldwide.
Empowering farmers – Operating in eight countries, BRAC’s agriculture programmes work with governments to ensure food security by producing, distributing and marketing quality seeds at fair prices, conducting research to develop better varieties, offering credit support to poor farmers and using environmentally sustainable practices.
Inclusive Financial Services – BRAC attempts alleviating poverty by providing CEP and TUP services, disbursing over a billion dollars in microloans annually, augmenting microfinance with additional services like livelihood and financial literacy training. Farmers get access to seasonal loans, high quality seeds and technical assistance. Millions now have the freedom to take control of their lives.
Self-Sustaining Solutions – BRAC’s enterprises and investments generate a financial surplus that is reinvested in various development programmes subjected to poverty alleviation.
Thinking local, acting global – Besides Bangladesh, BRAC spreads antipoverty solutions to 10 other developing countries, which are Uganda, Tanzania, Sierra Leone, South Sudan, Liberia, Haiti, Afghanistan, Pakistan, Sri Lanka and the Philippines.
Unprecedented scale and reach – Today, BRAC reaches an estimated 126 million people with over 100,000 employees worldwide.