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On-line version ISSN 1680-5348Print version ISSN 1020-4989
Rev Panam Salud Publica vol.12 n.1 Washington Jul. 2002
Temas de actualidad / Current topics
Innovative care for chronic health conditions1
Key words: chronic disease, health policy, health expenditures, World Health Organization.
Managing chronic health conditions over a period of years or decades is one of the greatest challenges facing health care systems around the world. Some 60% of the global disease burden now comes from such noncommunicable disease as diabetes, cardiovascular disease, and cancer; from HIV/AIDS; from such mental disorders as depression and schizophrenia; and from amputations, blindness, joint disorders, and other ongoing physical impairments.
Globally, the prevalence of chronic conditions is growing. This rise is due in part to public health successes, with persons living longer and increasingly facing one or more chronic conditions. Also contributing to the increase are urbanization, the adoption of unhealthy lifestyles, and the worldwide marketing of tobacco, alcohol, and other health risks.
By the year 2020, 80% of the disease burden in the developing countries of the world is expected to come from chronic conditions. Compounding the problem is the fact that adherence to therapies for chronic conditions can be as low as 20%. This results in poor health outcomes at a very high cost to society, governments, and families. Nevertheless, health systems around the world do not have a plan for managing chronic conditions, and the systems simply treat symptoms when they occur.
In response to this situation the World Health Organization (WHO) has launched several new initiatives, including one dealing with innovative care for chronic conditions. One element of that chronic care project is a new WHO publication entitled Innovative Care for Chronic Conditions: Building Blocks for Action. The new report is intended to alert decisionmakers around the world to these worrying trends in global health, and to offer solutions for managing this rising burden in chronic conditions. The information could be useful for countries regardless of the resources they have available to deal with these problems. Further, reorienting health care systems will require not just financial resources but also leadership and informed guidance from decisionmakers.
Progress in biomedical and behavioral management has substantially increased the ability to effectively prevent and control a number of chronic conditions. There is growing evidence that patients can do better when they receive effective treatments, self-management support, and regular follow-up. To produce positive results, however, depends not just on individual health care workers but also on organized systems of care.
In developing countries, persons with chronic conditions present mainly at the primary health care level and must be treated there. However, most primary health care is oriented toward acute problems and the urgent needs of patients. Both high-income and low-income countries spend billions of dollars each year on unnecessary hospital admissions and expensive technologies. As long as the acute care model dominates health care systems, health care expenditures will continue to rise but without a corresponding increase in the health status of populations.
The financial impact of chronic health conditions extends beyond just the direct costs of medical treatment. Patients and families also pay in terms of reduced workdays and lost employment. Governments and employers suffer from the loss of workers due to death and disability. Poor households can find themselves in a vicious cycle of poverty and poor health. Where a parent has a chronic condition that makes it impossible to work, family resources are reduced and the health of the children in the household can be endangered. Women with poor nutritional status bear children who will experience chronic conditions in adulthood such as diabetes, hypertension, and heart disease. These adults with chronic conditions may find it hard to secure employment, thus perpetuating the cycle.
ESSENTIAL ELEMENTS FOR TAKING ACTION
Decisionmakers can take actions that will reduce the impact that chronic conditions have on their citizens, their health care systems, and their economies, in areas that include financing, resource allocation, and health care planning. Decisionmakers should focus their efforts on eight key areas, according to the new WHO report.
Shifting the focus of the health care system from acute to chronic care
Health care is organized around an acute, episodic model of care that fails to meet the needs of many patients with chronic conditions. Such health problems as diabetes, asthma, heart disease, and depression require extended and regular health-care contact. Treating many chronic conditions involves medication and often requires patients to make lifestyle adjustments in order to handle their persistent health problems.
A new paradigm could help manage diverse patient demands in the face of limited resources, and educating key decisionmakers and the general public could help bring about that change. Officials can begin to assemble information on the problem of chronic conditions in their country. The mass media can be used as a forum for educating individuals and building new attitudes. Credible experts can encourage the spread of new ideas such as through local demonstration projects showing innovative care models and strategies.
Managing the political context of health care
For a successful shift in the model of care, there must be information sharing and consensus building among such stakeholders as political decisionmakers, health care leaders, and patients, their families, and other community members as well as the groups that represent each of them. Each group will have its own values, interests, and scope of influence. Each of these groups will need to be educated on the growing burden of chronic conditions and the existence of effective strategies for managing them. To help in this process, systematic reviews can be assembled on the costs and effects of managing chronic conditions, and local research can be used to demonstrate the cost-effectiveness of innovative care models and strategies.
Building integrated health care systems
Health care systems must guard against the fragmentation of services. Care for chronic conditions needs integration to ensure shared information across health care settings and providers. That integration is also needed across time of care, from the initial patient contact onward. Integration also involves coordinating financing across different arms of health care (e.g., inpatient, outpatient, and pharmacy services), including prevention efforts, and incorporating community resources that can extend the reach of formal health care services. The result of integrated services is improved health, less waste and inefficiency, and a more positive experience for patients.
Such integration will require that policies, plans, and financing structures all reflect consistent messages about chronic conditions. If possible, information systems should be upgraded so they increase coordination and information sharing across public and private health care settings and providers as well as across time.
Aligning government policies and strategies in order to promote good health results
The policies of all the diverse authorities within government need to be analyzed and to be brought into line in order to maximize positive health outcomes. Health care should be aligned with labor practices (e.g., assuring safe working conditions), agricultural regulations (e.g., overseeing pesticide use), and education (e.g., teaching health promotion in school).
There must also be linkages with sectors outside the government. Among these can be private health workers, including traditional healers. Appropriate regulation and legislation can curb the marketing of such public health risks as tobacco and alcohol.
Using health care personnel more effectively
Doctors and other health care personnel of all professional levels can play a role in better managing chronic health conditions. These personnel need new models of care applying a team-care approach, and they also need to be knowledgeable of the strong base of scientific evidence that can guide the proper management of chronic conditions. Health care personnel also need improved skills in communications, behavior change techniques, patient education, and counseling. Where there are multipurpose health care workers, their decision-making can be reinforced by better linkages with specialists.
Continuing education on managing chronic conditions can be made mandatory for a wide range of health care workers. In addition, medical schools and other training programs can be encouraged to include instruction on chronic conditions.
Centering care around the patient and family
Managing chronic conditions requires lifestyle and daily behavior change. Given that, health care for chronic conditions must be centered around the patient and family. Current clinical practices often relegate the patient to the role of a passive recipient of care. Shifting the care approach could leverage what patients themselves can do to promote their health.
Patients and their families need to have information about managing chronic conditions¾including self-management. Health care interactions can include instruction for patients and their families, to build their knowledge and skills, and the same can be done through workshops for patients.
Supporting patients in their communities
Health care for chronic conditions must extend beyond the clinic walls and into the patients' living and working environments. Patients and their families need support from other institutions in the community, including community groups and nongovernmental organizations. Community groups should be supported in playing a role in policy-making and the planning of services. Employers need to be informed about managing chronic conditions, and there should be support for prevention and self-management efforts in the workplace.
Most chronic conditions are preventable, as are many of the complications of chronic conditions. Among the appropriate prevention strategies are early detection, increasing physical activity, reducing tobacco use, and limiting prolonged, unhealthy nutrition.
Prevention should be a component of every contact between patients and health care providers. Health care workers must have information and skills to help patients minimize risks associated with chronic conditions. Regulation and legislation that curb the marketing of tobacco and alcohol can promote prevention. Population-based prevention can be supported, such as by monitoring risk factors and identifying persons at risk of developing chronic conditions. Suitable incentives can be put into place to reward providers who emphasize prevention.
WHO has launched two other new projects related to its initiative on innovative care for chronic conditions. One has to do with adherence to long-term therapies, and the other focuses on primary health care for chronic conditions. During the first phase of the three projects, best practices and affordable health care models for chronic conditions have been identified, analyzed, and synthesized. That process has involved a number of international experts, organizations, and institutions. Among the next steps for the projects will be country demonstration projects that implement proven strategies and health care models.
The full report on innovative care for chronic conditions can be ordered from the WHO by contacting: WHO Marketing and Dissemination, 1211 Geneva 27, Switzerland; telephone: 41 22 791 24 73; fax: 41 22 791 48 57; e-mail: firstname.lastname@example.org. The report can also be ordered via the Internet at: www.who.int/ncd/chronic_care/index.htm. The price of the report is Swiss francs 14 in developing countries and Sw. fr. 20 (US$ 18.00) elsewhere.
Innovaciones en la atención de las afecciones crónicas
Tratar las afecciones crónicas durante años o décadas es uno de los mayores retos a los que se enfrentan los sistemas de salud de todo el mundo. Cerca del 60% de la carga de morbilidad mundial actual se debe a enfermedades no transmisibles como la diabetes, las enfermedades cardiovasculares y el cáncer; a la infección por VIH/sida; a trastornos mentales como la depresión y la esquizofrenia, y a las amputaciones, la ceguera, las artropatías y otras discapacidades físicas. Se espera que hacia el año 2020 el 80% de la carga de morbilidad de los países en desarrollo se deba a afecciones crónicas. No obstante, los sistemas de salud de todo el mundo no tienen todavía un plan para hacer frente a estas afecciones y se limitan simplemente a tratar los síntomas cuando aparecen.
Para enfrentar esta situación, la Organización Mundial de la Salud (OMS) ha lanzado varias nuevas iniciativas, entre ellas una que trata de las innovaciones en la atención a las afecciones crónicas. Uno de los elementos de este proyecto sobre la atención crónica es una nueva publicación de la OMS titulada Innovaciones en la atención a las afecciones crónicas: elementos para la acción. Según ese informe, las autoridades deberían emprender acciones para reducir el impacto de las enfermedades crónicas en sus ciudadanos, sus sistemas de salud y sus economías. Los esfuerzos deberían centrarse en ocho áreas clave: 1) cambiar el centro de atención de los sistemas de salud de la asistencia aguda a la asistencia crónica; 2) gestionar el contexto político de la atención sanitaria; 3) crear sistemas de salud integrados; 4) alinear las estrategias y las políticas gubernamentales para promover buenos resultados sanitarios; 5) usar más eficazmente el personal sanitario; 6) centrar la atención en el paciente y su familia; 7) apoyar a los pacientes en sus comunidades, y 8) poner mayor énfasis en la prevención.
1 Based on: World Health Organization. Innovative care for chronic conditions: building blocks for action: global report. Geneva: WHO; 2002. (WHO Document No. WHO/NMC/CCH/02.01).