Back to Position Papers

Integrating medicine and public health Introduction Medicine and Public Health are considered two different disciplines, the former being focused on individual patient care and consultation, the latter, on population oriented issues. In addition, medicine primarily addresses the diagnosis and treatment of diseases; public health primarily addresses promotion and prevention. Historically, the differences were not only based on the professional perspective and skills, but also on the institutional and social environment in which they were applied. Medicine is mainly concerned with the physical health of the patient; public health addresses the health of populations and its behavioral, social and economical determinants. (1). Health professionals in different parts of the world prefer to express the divide as "individual care and public health", This is not a semantic difference, as the distinction reflects different points of view of the health professions (as "medicine" may be considered the work of the physicians only) and also the particular characteristics of the health worker functions and of the country health care system. Today, the organization of health services is fragmented, as demonstrated by the division between individual health care and community health services; biomedical and psychosocial models ; curative and preventive care; services provided by generalists and specialists; public and private sectors. In this respect the emphasis on biological mechanisms diverts attention from the behavioral, social, economic, cultural and environmental conditions and there is also growing imbalance in the availability and use of resources in both individual health care and community health services. As another result of the fragmentation of services, there is growing disparity in terms of the delivery of health services among different groups in the population, among the indigenous communities, people in the slums, among the poorest sector of the society and children with special needs (child labor, child traffic, child soldiers). As the divide between medicine and public health is expressed mainly at the primary care level, it is habitual for medicine and primary medical care to be taken as synonymous. It is important to emphasize the differences between primary medical care and primary health care, the latter being a more comprehensive approach to health and health care. In the U.S., specialty care is often regarded as the epitome of medicine, and some regard primary care as more closely related to public health, specially since primary care providers may offer prevention and community-based services. The on-going debate, of an ideological and organizational nature, may help to narrow the gap between medicine/individual health care and public health, particularly where professionals and organizations agree to recommend a community orientation of primary care. Furthermore, as the separation may also be due to the traditional defined framework of each discipline, Heller (2) claims that there is a need to re-define public health, because of the absence in the classical definitions, of precise understanding of the public, as in contrast to the individual health components. He proposes a new definition of Public Health as the "use of theory, experience and evidence derived through the population sciences to improve health of the population, in a way that best meets the implicit and explicit needs of the community (the public)". This definition gives emphasis to the "public" in a way that might be clearer to people who are not public health practitioners. Although there are questions on "What's new about the "New Public Health" (3), the components of "Health Promotion such as Health Education, Prevention and Protection", may have a role towards Integration and in that way should be considered. The defined framework of the Public Health discipline, has been dealt with by the WHO International Study (4) regarding the formulation of Essential Public Health Functions (EPHF), and by the US Department of Health and Health Services (5) which developed the 10 EPHF. Both include functions that are covered by individual health care. Individual health care could be considered as part of public health functions when they are able to produce population-wide benefits (4). The meaning of integration To avoid misunderstandings and misconceptions it is necessary to pay attention to different meanings given to integrated care and therefore to Integration. Integration is a multidimensional concept that reminds us that the word comes from Latin integer, that is "to complete"; integrated means "organic parts of a whole", or "reunited parts of a whole" (6) and according to the Webster Dictionary it is "the act or instance of combining into an integral whole". Questions arise on whether this integration refers to health care with social care or whether it is the integration of different levels of care, or whether it is an activity, a process, or a structure. Batterham et al (7) point out that Integration could be conceptualized as a process (of the two related concepts of patient care and public health integration) with an integration structure. Above all, it is necessary to assess that "Integration is "real" (and) not merely a convenient shorthand term to describe a class of programs" (Cronbach 1989, cited in ref.7) The search for appropriate approaches for integration We suggest an examination of three dimensions in order to deal with the possible alternatives of integration: a) The need to have and implement approaches to integrate primary care and public health Lasker (8) states that in spite of the fact that the separation between these two fields related to medical practice had remained "as it was in the late 1970s, there are today reasons to re-evaluate their relationship". Not only to recognize that the two sectors are under economic and performance pressure, but also to realize that neither of them can accomplish their mission alone. In the present situation the medicine perspective gives "great weight to biologism and medicalization" (9), there is lack of consideration of the socio-economic and political causes of the ill-health process (10), and there is a lack of coordination when the two disciplines are dealing with the same population. All these realities have negative effects on health and on health care services, and lead to deterioration in "productivity of health services and a loss of quality, rise in costs and inequities" (11). Another expression of the need of narrowing the gap comes from the experience in the relation between health and humans rights as mentioned at the PH Textbook 2002, "…as the human rights approach has made increasingly clear, this stark differentiation between medicine and public health is not longer fully relevant either to human rights or to health". (12) b) The effectiveness of the proposed approaches There is evidence that by integrating primary care with public health in diverse socio-economic situations and health services systems, there is a positive impact on the health of people. (13-18) As an illustration of an integrative approach Community Oriented Primary Care (COPC), which integrates primary care and community medicine, takes responsibility for a defined population, by an assessment of its health needs, setting priorities and planning and implementing programs to address the identified needs (19-20). In that respect COPC is considered as public health at local level. Also the Primary Health Care (PHC) approach incorporates curative and rehabilitative actions (clinical care) and promotive and preventive actions (public health). Approaches like those of Medicine Public Health Initiative (21), Planned Approach to Community Health (PATCH) (22), Healthy Communities (23), and Community–Campus Partnership for Health (CCPH) (24) could be important facilitators and protagonists in the different versions of integration, given their targets and their national scope in the USA. In Sri Lanka the integration of Family Planning and related services of Maternal Health in the PHC services (25) based in several strategies that were implemented within and outside the health sector, determined an important decrease in maternal mortality. The integration of Leprosy Services in the PHC system of Sri Lanka required improvement in logistics, promoting changes of attitudes, training of health workers and support by an intensive advertising campaign to inform the population; this integration determined a more efficient process of diagnosis, treatment and management of the disease. (26). In Costa Rica, the development of the National Health Care System with reforms of the health care infrastructure and strengthening of the PHC services included approaches of integrated care for the population. (27) The reforms counted with a political will to support the approach (28) and resulted in the improvement of health conditions in the country. till there is a need for further research on effectiveness, as commented on studies that show that integrated structures (29) are associated more with integration of management but less with "integrated practice-related services". c) The feasibility to integrate both fields This dimension should be analyzed by an assessment of two complementary aspects: whether there are models that are explicitly oriented to the integration and second, experience with interventions that have already been implemented. With respect to the first aspect, Lasker (8) describes four "movements" to relate individual patient care to a broader socio-physical environmental: Social Medicine, COPC, Preventive Medicine and initiatives to increase population perspective in medical education. While the latter implies a necessary long term investment, there is an extensive literature on the other three "movements" that have already been implemented and provide information on the feasibility of their interventions. In the developing countries primary health care also constitutes a movement with an extended experience and application. The feasibility probe needs to take into account resources (financial, personnel, facilities), conformity with health policy (local, regional, national), attitudes of health team members (interest, motivation, cooperation), and cultural milieu (citizen/society relationship, democratic spirit (28) . Epidemiology as a key element in the integration It is also important to relate to the central function of epidemiology in the analysis of separation or integration of the two fields of practice. Although before the 1900s, clinical medicine and public health interventions were related, the changes (evolution) in both disciplines after that period, determined that epidemiology "moved" to Public Health, and the teaching in Epidemiology became part of the Schools of PH. This exit from the Medical Schools was one of the main causes of the gap between medicine and public health. In the second part of the XXth Century, when the emphasis on epidemiology shifted from the macro to the micro-environment, with the study of personal characteristics and habits, it returned to a renewed relationship with the clinical professions. Moreover the development of Clinical Epidemiology and Molecular Epidemiology tended to bring issues of public health closer to Clinical Medicine (30). An illustration of the role of epidemiology in the integration of medicine and public health is in the complementary use of epidemiological and clinical skills in primary care. General Practitioners and Family Physicians are frontline gatherers of information about the health needs of their patients, their families and their community. Epidemiological methods and expertise, help to the clinical professionals to achieve a broader identification of the health needs at population level and in that way to an appropriate assessment of the effectiveness of alternative interventions to implement in their communities. Because often the physicians apply their findings only to the individual patient, this gap could be narrowed by integration of clinical medicine and public health. Ibrahim points out the increasing awareness by integrated medical delivery systems and managed care organizations, of the value of population-based health principles in medical and public health practice. The principles relevant to an integrative approach are: a community perspective, a clinical epidemiology perspective, evidence-based practice, an emphasis on outcomes and an emphasis on prevention. (31) The implementation of these principles requires the organization of a Management Information System, for which professionals involved in the integration, need to acquire the necessary skills, or to receive an easy access to an appropriate expertise support. The isolated use of epidemiological methods by integrated medical systems to assess quality of care provided to patients does not mean an integration of medicine and public health. Why does the separation in the health services still prevail Although the medical and health literature offer designs, comments and advocacy for the different models of integration, there is not a wide adoption of these models. The reasons for this limited application might be related to the lack of relevance of the diverse approaches, a) to local policy, b) to local conditions and resources, c) to professional attitudes and d) to community perceptions. The identification and analysis of these constraints should help in reducing them, and in the channeling of delivery of care towards a more rational organization. a) Constraints due to health policy reasons The lack of agreement with health policy, with the decision-making process, with specific decisions taken by health authorities, may create difficulties in the re-orientation: Desiscions taken from the top-down instead from the bottom up Introduction of accountability without appropriate consultation and prior preparation for the change can constitute a new threat for organizations and for individual professionals Priority setting as a requirement at the institution level for the changes in service patterns which may result in postponement with a subsequent disturbance of other activities Separated funding streams, for public health and medical services Separated entrenched bureaucracies for public health and medical services There may also be tensions between the policy of Primary Care and Public Health, as seen in the new forms of organizations in the personal health services in the USA. These services are claiming an orientation toward primary care assuming responsibility for the care of populations, and in this way they are "creating strains in the linkage between the two sectors". It is pointed out that managed care also "poses a threat to…public health"(32) by focusing on enrolled populations and in prevention activities. In the reform process undertaken by a new health policy at the National Health Services (NHS) at the national level in the UK, Ashton (33) considered four caveats as the obstacles in the integration of the whole of "public health to be subsumed under primary health care (PHC)": A narrow view of Health Promotion by PHC Staff in PHC would not be motivated to PH work Some tasks could not be done at PHC (e.g.: health strategy) The need to reconcile the conflict between individual and collective health, may require separation of the roles of advocate, mediator and enabler In an assessment of the policy of the NHS, an editorial in the BMJ (34) notes - "PC and PH being too apart", while an editorial in the Journal of Epidemiology and Community Health (35) points out that PC and PH need to converge but warns that "…this goal will be achieved with difficulty". One of the health policies that affect the integration in the Asian Region is the decentralization of health services. The communities and towns that have adequate and extra resources tend to be innovative in meeting the needs of the population while in communities and towns that are poor in resources, the interventions are limited and usually they have scarce health supplies. The impact of educational innovations integrating the teaching of clinical medicine and public health are blunted when there is not a comparable health policy of service innovation. b) Constraints due to lack of resources and/or to economic/ financial reasons Although there have been changes in West African countries in the academic curriculum with the inclusion of community medicine and public health in medical studies, in the practice is very difficult to apply integration due to the lack of human resources (e.g.: one physician for 20-80.000 inhabitants). Studies on the changes in the NHS in the UK are revealing the contractual, organizational and financial difficulties manifested by the professionals with regard to the reforms related to integration. (36) A new approach, is a re-orientation that demands extra funding in an already constrained budget, and although in the long run the change becomes more manageable initially presents a difficult challenge. The marked difference between type and amount of resources available in each field, creates animosity among practitioners of both branches while the required resources for the integration may not be a simple addition of what is available. Time required for re-orientation of health services in already overloaded practices (the demand!) is a formidable hindrance in the planning and implementation process. c) Constraints due to professional attitudes and training Health professionals of the two fields of practice have pursued different career pathways, with primary care practitioners having had little training in skills of population health, and public health doctors and nurses being far away from the day to day overloaded patient consultations, practices in which new responsibilities are added, such as health promotion and prevention. The reluctance to change that might be present in professionals of both fields, may also have a role in the barriers to adopt an integration approach. The difficulty in converting to a pro-active attitude in a health practice after having been trained and practiced in a re-active mode and, the difficulty in setting priorities at the Health Team level on the order of urgency in addressing health needs, might slow down the adoption of the integrative approach. When public health professionals undertake a Health Needs Assessment (HNA) as an end, and not as a means towards meeting those needs by an appropriate intervention, it constitutes an obstacle to the integration. An important factor in professional attitudes relates to remuneration, where fee-for-services constitutes an obstacle to integration. Incentives could be a very useful element in changing attitudes. The integration needs to take into account the perception of professionals who see this process as a continuum, in which the extremes are distinct as disciplines, from individual care to responsibility for public health, but, " …the rest of the continuum is inextricable". (37) In addition, training programs both in public health and in medicine need to be re-tooled, if graduates are to be prepared to practice in an integrated system d) The community's perceptions and priorities The community perception about the professional role in personal care, to prescribe and to answer to the individual's demand ("medical role") prevailing over public health counseling ("promotion role"), may influence their perspectives towards integration. The very close relationship between the individual and his personal medical doctor creates links and opinions that are quite different from the connection with anonymous professionals in the "distant" public health services. Most individuals perceive their own health needs in terms of treatment of symptoms or disease. This is the service provided by clinical medicine, and the personal physician who provides this service is the health care professional recognized by most persons. While the separate public health department or public health programs provide an important service, it is often not recognized or appreciated by the community. The public may therefore not recognize the value of integration of public health and medicine. What are the conditions to create integration? Although Integration may have diverse expression according to specific local health care systems of different countries, there are five conditions that should be considered as indispensable to create Integration: [modified from Boelen C (ref. 6)] a) Common set of values (quality, equity, relevance and cost-effectiveness) b) Common population concern c) Shared health information system d) Organizational approach to integrate interventions e) Partnership with stakeholders Role of the "stakeholders" Proposals for integration require the active involvement of disciplines, institutions and sectors, not only that of the medical sector alone! It is been suggested that this involvement for integration should be a partnership among five stakeholders: Policy Makers Health Managers Health Professionals Academic Institutions Communities Each one of the stakeholders would need to have a defined role in the development of the Integration. a) Role of policy makers Whether integration could be implemented at local, regional or national level, health policy is necessary to enforce a sustainable re-orientation of health services. The relation between health policy and politicians should be directed to answer the increasing demand for rational organization of delivery of health care. The allocation of resources is very much dependent on explicit health policy; in that case the policy could be a catalyst force to be considered and followed by the other stakeholders. To promote Integration may relate not only to the health systems reforms but also with the need to reach consensus to develop "strategies and plans to promote greater integration of health care delivery", as expressed (38) in the current discussion on health care in Canada. b) Role of health managers Managers are responsible for organizing, financing and management of health services (health organizations, insurance plans). Since the main concern for health managers at an institutional level might be the coverage of their care and the cost-effectiveness of the services they provide, the proposal of an integrated service should be based on rational and accountable systems. c) Role of health professionals Because health professionals are made up of a number of disciplines with specific skills and responsibilities, their roles should be formally established to become essential partners in the integration. While clinical professionals have been trained with a focus on curative medicine and on tertiary care, an integrated system would require them to perform activities related to the disciplines and activities of public health. In this respect the motivation of the professionals becomes an important element in the acquisition of relevant skills. Changes have been observed in the attitudes of the organizations of professionals as shown by the WONCA (39) Durban Declaration, on the need for family physicians to extend their field of action from the individual and the family, also to the community. In addition, the publication of the WONCA Guidebook on "Improving Health Systems: the Contribution of Family Medicine", analyzes the different roles of Family Medicine in the implementation of Primary Health Care, which features elements needed in the integration of Primary care and Public Health (40). It is worth mentioning that there are two different streams among family physicians, those who give emphasis to the clinical and communication skills as the central issue of their contribution to primary care, and those who emphasize that family medicine should extend its field of action towards Community Medicine (41). Family physicians could fulfill leadership roles in working towards integration between medicine and public health. The involvement of other health professionals in the integration of medicine and public health are of paramount importance. Nurses who have close relationships with patients and with other people in the community, have an important role in narrowing the gap between individual and community care (42). The involvement of Health Visitors, District Nurses, School Nurses and Practical Nurses in a health-needs assessment process in a primary care setting in Manchester (43), is another example of integration, as an interface between primary care and community development through a public health approach, d) Role of academic institutions Academic institutions, because of their wide spectrum of functions in education, research and services delivery, have the potential to understand and address complex issues related to the process of integration of health services. Academic leaders should also review their prejudice against changes on the traditional teaching programs. The educational strategy for integration might be the one that assures a cultural change and in that sense pre-graduate education is of crucial relevance. The development of the Network of Community-Oriented Educational Institutions for Health Sciences (today The Network: TUFH) including Schools of Medicine all over the world, provides an essential bridge towards the integration of health services. Students, from the very beginning of their studies should be made aware of people's health needs in their communities, and learn about the processes for dealing with those needs. The teaching of Community Medicine can be considered as a means for addressing the fragmentation of services, and therefore should be part of the training of health sciences professionals (medical, nursing, public health) (44-45). The social accountability of academic institutions requires a commitment that must be reflected not only on a "different" location of training (more "community-based") but also providing students with learning experiences to recognize the population's health needs. This practice will determine better understanding of the ill-health process at community level, might create a sense of "belonging" to the community (44) and create appropriate attitudes towards Integration among graduates. e) Role of communities In an integrated approach, the community is not a consumer but a partner, with rights and responsibilities. In that sense, the other four stakeholders need to be accountable to the community by consulting the community members for suggestions, priorities and special needs. On the other hand, the community must acquire a suitable organization to serve in facilitating its partnership in the whole process, in protecting its rights, and ensuring an active involvement in all relevant collaborative activities with the health services. However, institutions and professionals stakeholders hold considerable power in the society while communities, especially in the impoverished areas, hold little. This imbalance of power is in itself an important source of ill health and disparities in health in different societies, and therefore the integration of medicine and public health must consider a greater participatory role of the community in health and health related interventions. The Child Centered Community Development (CCCD) (in the Asian Region) has been endorsed as the program approach in Plan International. Children health clubs have been important groups in the community to facilitate and promote public health activities and even the practice of medicine through child to child scheme, with school authorities and parents support. The social accountability of the four stakeholders is not only in regard to provision of services, but also regarding the socio-economic determinants of health. Community members should be included as participants in health activities, while exploring their participation in decision making. In this respect, the integrative approach should include an active intersectorial coordination. The five stakeholders commitment Proposals for integration among the five stakeholders should consider the opportunities and the constraining factors in the forging of the partnership, not only for an increase of communication, but also for an appropriate commitment of each one of them, from ad-hoc arrangements to long term commitments. In the search of feasible integrated approaches, there is an essential need by the integrated organization to have an appropriate budget to purchase, for example, the health services related to its population needs. It is also important to consider that the integration at local/regional level or by providers at national level is "almost impossible" without the political support of the medical services and public health authorities. Role of The Network: TUFH Considering the reality described above, the main questions should be: Who is actively taking care of the people's health needs? Are there approaches that promote the health of the public more effectively than the option of technical coordination of primary care and public health? How should the integration deal with inequalities in health and health determinants take into account human rights? There is a rich global experience in the community-orientation of medical studies, led by The Network: TUFH (as its previous name indicates: Network of Community Oriented Educational Institutions for Health Sciences). The twelve field projects underway worldwide by TUFH, at the local and regional level, are new patterns of services for integration, with a sustainable partnership among the stakeholders of the health sector. The amalgamation of both organizations creates a new reality in the development of the necessary partnerships for an integration of medicine and public health. By the creation of the Taskforce on Medicine and Public Health, The Network: TUFH takes the responsibility to share with other similar "movements", its contribution in leading the integration on a global basis. No specific approach could be suggested, since the aim of the Taskforce is to promote the principles of integration with their universal value, while the implementation will depend on the local reality. To promote and incorporate the values of quality, equity, relevance and cost-effectiveness (11) it is necessary to consolidate a base derived from scientific knowledge, practical experience and firm convictions and to consider the relationship with the social, economic and political sectors of society. For the fulfillment of this role, an essential requirement is coordination with all the people who at individual and institutional level, are already committed to the improvement of the population's health. Corresponding author on behalf of the writing group: Jaime Gofin Email: jaime@md2.huji.ac.il References 1) Gruskin S, Tarantola D, Health and human rights. In: Oxford Textbook of Public Health, 4th Ed. Detels R, McEwen J, Beaghehole R and Tanaka H (eds) Oxford University Press, New York, 2002 2) Heller RF, Heller TD, Pattison S. Putting the public back into public health. Part I. A re-definition of public health. Public Health 2003; 117 (1):62-65. 3) Awofeso N, What's New About the "New Public Health". AJPH 2004; 94:705-709. 4) Bettcher DW, Sapirie S and Goon E. Essential public health functions:results of the international Delphi study. World Health Statistics 1998; 51:44-54. 5) Public Health Functions Steering Committee. Public Health in America. Washington DC:US. Department of Health and Human Services, 1995. Available at http://www.health.gov/phfunctions/public.htm 6) Kodner DL, Spreeuwenberg C. Integrated care: meaning, logic, applications, and implications – a discussion paper. Int J Integrated Care November 2002. Available at www.ijic.org/publish/articles/000089. 7) Battterham T, Southern D, Appleby N, ElsworthG, Fabris S, Dunt D, Young D. Construction of a GP integration model, Soc Sci Med. 2002; 54:1225-1241. 8) Lasker RD, Medicine and Public Health – The power of collaboration, Part I: The Collaborative Imperative, New York: New York Academy of Medicine, 1997. 9) Pan American Health Organization, On the Theory and Practice of Public Health: One Debate, Several Perspectives, Washington, D.C., Pan American Health Organization 1993. 10) Werner D and Sanders D, Questioning the Solution: The Politics of Primary Care and Child Survival, Health Rights, Workgroup for People's Health and Rights, Palo Alto, California, 1997. 11) Boelen C. Towards Unity for Health: Challenges and Opportunities for Partnership in Health Development, by Boelen C, A working paper, World Health Organization, Geneva, 2000. 12) Gruskin S, Tarantola D, Health and human rights. In: Oxford Textbook of Public Health, 4th Ed. Detels R, McEwen J, Beaghehole R and Tanaka H (eds) Oxford University Press, New York, 2002 13) Hart T et al, Twenty-five years of audited screening in a socially deprived community, BMJ. 1993; 302:1509-1513. 14) Abramson JH, Community-oriented primary care – strategy, approaches, and practice : a review. Public Health Rev. 1988; 16:35-98. 15) Harvey P. The impact of coordinated care: Eyre Region South Australia 1997-1999. Aust J Rural Health. 2001; 9(2):69-73. 16) Longlett SK, Kruse JE, Wesley RM. Community-oriented primary care: critical assessment and implications for residents education. J Am Board Fam Pract. 200; 14:141-147. 17) American Journal of Public Health vol. 92 (11) November 2002; eight articles on Community Oriented Primary Care (COPC). 18) Illife S, Lenihan P. Integrating primary care and public health: learning from the community-oriented primary care model. Int J Health Services. 2003; 33(1):85-98. 19) Kark SL, The Practice of Community - Oriented Primary Care. New York, NY: Appleton-Century-Crofts; 1981. 20) Epstein L, Gofin J, Gofin R, Neumark Y. The Jerusalem Experience: Three Decades of Service, Research, and Training in Community-Oriented Primary Care, Am J Public Health. 2002; 92:1717-1721. 21) Cashman SB, Anderson RJ, Weisbuch JB, Schwarz, and Fulmer HS. Carrying Out the Medicine/Public Health Initiative: The Roles of Preventive Medicine and Community-responsive Care. Acad Med. 1999; 74:473-483. 22) PATCH: Planned Approach to Community Health. Available at: http://www.cdc.gov/nccdphp/patch. Accesed January 27, 2004. 23) Cashman SB, Stenger J. Healthy Communities: A Natural ally for Community-Oriented Primary Care. Am J Public Health. September 2003; 93:1379. 24) Community-Campus Partnership for Health (CCPH) Available at: http://www.futurehealth.ucsf.edu/ccph.html Accesed February 3, 2004 25) Fernando D, Jayatilleka A, Karunaratna V. Pregnancy – reducingh maternal deaths and disability in Sri Lanka: national strategies, Br Med Bull. 2003; 67:85-98. 26) Kasturiaratchi ND, Settinayake S, Grewal P. Processes and challenges: how the Sri Lankan health system managed the integration of leprosy services. Lepr Rev. 2002; 73(2):177-185. 27) Bertodano I, The Costa Rican health system: low cost, high value. Bull World Health Organization. 2003; 81(8):626-627. 28) Barrett B. Integrated local health systems in Central America. Soc Sci Med. 1996; 43(1):71-82. 29) Reilly S, Challis D, Burns A, Hughes J. Does integration really make a difference?: a comparison of old age psychiatry services in England and Northern Ireland, Int J Geriatr Psychiatry. 2003; 18:887-893. 30) Adami HO, Trichopoulos D. Epidemiology, medicine and public health. Int J Epidemiol. 1999; 28:S1005-S1088. 31) Ibrahim MA, Savitz LA, Carey TS, Wagner EH. Population-based health principles in medical and public health practice. J Pub Health Manag & Pract. 2001; 7(3):75-81. 32) Starfield B. Public Health and Primary Care: A framework for proposed linkages; Amer J Public Health. 1996; 86 (10):1365-1369. 33) Ashton J. Public Health and Primary Care: Towards a Common Agenda. Public Health.1990;104:387-398. 34) Hannay DR. Primary Care and Public Health – Too far apart. BMJ.1993; 307:516- 517. 35) Bhopal R. Public health medicine and primary health care: convergent, divergent, or parallelpaths? J Epidemiol and Community Health. 1995; 49:113-116. 36) Cornell SJ. Public health and primary care collaboration – a case study. J Pub Health Medicine. 1999; 21 (2):199-204. 37) Parsons L et al. Primary care and public health – differing roles create tensions (letter), BMJ. 1993; 307:1144. 38) Bergman H, Beland F. Commentary on: The Future of Health Care in Canada. Int J Integrated Care March 2002; Available at www.ijic.org/publish/articles/000086/ 39) WONCA Durban Declaration. Available at: www.rudasa.org.za/download/durbadec.pdf. Accessed February 8th, 2004 40) Boelen C, Haq C, Hunt V, Rivo M, Shahady E. Improving Health Systems: The Contribution of Family Medicine – A Guidebook. World Organization of Family Doctors (WONCA). Bestprint Printing Company, Singapore, 2002. 41) Foz G, Gofin J, Montaner Gomis I. Atencion Primaria Orientada a la Communidad. Cap. 20, in: Atencion Primaria – Conceptos, organizacion y practica clinica, Martin Zurro A, Cano Perez JF eds. 5th Ed, Barcelona, Elsevier, 2003. 42) Kark SL, The Practice of Community - Oriented Primary Care. New York, NY: Appleton-Century-Crofts; 1981. 43) Horne M, Costello J. A public health approach to health needs assessment at the interface of primary care and community development: findings from an action research study. Primary Health Care Research and Development. 2003; 4:340-352. 44) Gofin J. Planning the Teaching of Community Health(COPC) in an MPH Program. Public Health Reviews. 2002; 30:293-301. 45) Waterstone T and Sanders D. Primary Health Care teaching: some lessons from Zimbabwe. Medical Education.1987; 21:4-9. Appendix I The role of NGO's in integration in the Asian Region NGO's has been recognized by the States in the Region as partners in health and development and in that way in the practice of medicine and public health together. Cambodia and Bangladesh: The government and the NGO's have been working together through a public-private partnership to improve quality of health services. Thailand: A network of NGO's, Government and the Academia was created to address both the medical and public health issues of HIV/AIDS India: A district-wide approach was implemented to address the issue of malaria in Orissa in partnership with NGO's, District Health Authorities and community-based organizations. Indonesia and Philippines: NGO's have been working with government institutions in the integration of medicine and public health as part of the Early Childhood Care and Development Program. The Plan International an NGO has been working in the Asian region through a program approach called Child Centered Community Development (CCCD). Children are at the center of what Plan is doing and it promotes the process of consultation with the children and the children's voice are heard in the whole program development cycle of situational analysis, planning, implementation monitoring and evaluation. In this sense CCCD acts as an advocate of children rights. Children health clubs have been important groups in the community that facilitate and promote public health activities and the practice of medicine through child to child scheme. The school authorities as well as parents have been very supportive of this approach. For example, in Bangladesh has been a powerful force to promote 100% latrine construction and campaigning for immunizations. In Pakistan and Nepal, children have promoted good health habits through street plays, dram and theater. Primary Care in the Region provides essential health packages, mainly to children and women. While primary care services are being managed by government health institutions, the role of Plan is through capacity building of health workers and volunteers, and also organizing village health committees. Appendix II Towards Unity for Health principles in family medicine and primary care in Catalonia (Spain). The project “Towards Unity for Health” aims to “foster unity in providing health services based on the people needs, through a sustainable integration of medicine and public health or, in other words, of individual health and community health-related activities”. This must be realized by getting the various actors operating in the health services delivery system to enter into creative relationships. In Spain the specialty of medicine working in primary health care has been called “Family and Community Medicine (FCM)” (1978). From its beginning (1983), the Catalan Society of Family and Community Medicine (CSFCM) has tried to develop the “community aspects” of the specialty, by promoting the training and the practice of Community Medicine by family physicians and primary care teams. Between 1986 and now, more than 20 courses of Community Oriented Primary Care (COPC) and related aspects have trained about 500 physicians and other health professionals in primary care. A working group of COPC was created in 1987, that has lead these training activities and also in developing the community care aspects of the Spanish residency program in family medicine. Recently, the working group has started a project aimed at developing the practice of Community Medicine by teaching health centers were FCM residents train to practice COPC (“pilot experiences”), in order to link training and practice for the community role of the family physician and the primary care team. In 2003, the Catalan Institute of Health Studies, an organization belonging to the Catalan Government, created a Working Group for Training in Community Medicine, with the aim of developing community skills for family physicians and other primary care professionals, in partnership with the Catalan Society of FCM and the residency training program of this specialty. The Working Group of the Institute of Health Studies organized a conference on the Integration of Community Medicine in Primary Care in November 2003. As a result of this Conference, some initiatives are beginning in the collaboration between primary care and public health... The stakeholders identified by TUFH as actors of the integration model are participating in the project of our Catalan Working Group, in the following way: Policy makers: we have the support of the office of public health of the Department of Health of Catalonia, that is considering the possibility of using motivated health teams for pilot experiences of innovative intervention programs that will try to integrate public health activities into their clinical activities. Health managers: the Catalan Institute of Health (the public provider of primary care) and other primary care providers support the pilot experiences that are integrating community medicine into primary care, as well as the training that comes from this experience. Of course, the next step will be to obtain their financial support for these activities. Health professionals: family physicians are involved as a members of health teams and as a teachers of family medicine, and a strong model of participation of professionals is being implemented in the centers of the pilot projects. An important professional group to incorporate is that of social workers. The working group of COPC of the CSFMC is also involved, and now we are beginning to involve the Catalan Society of Public Health. Academic institutions: in addition of the Institute of Health Studies, the residency training program of FCM is also a partner for this project. One of the catalan universities, the Autonomous University of Barcelona is also involved. In this environment, we are trying to involve the health centers participating in the pre-graduate education of physicians in the teaching of community medicine. Until now, nothing has been done about community medicine training in the schools of medicine in Spain. Communities: the participation of the local community is a requisite activity for the involvement of a primary care team in the pilot projects. Other major degrees of involvement of the community in the global project must be considered. In our country, an important institution to involve as a representative of people's needs are the local governments. In response to your final questions, I think that in my region, health professionals are the most active agents taking care of the people's health needs, not the institutions. This fact reinforces the need to involve and integrate all the actors in health of the community. It also responds your second question: coordination of primary care and public health is the best strategy and there is a great need to reorient the content and methods of the work of health care services. In reference to your last question, addressing inequalities and determinants of health as a human right is not possible without the strategy of the integration of stakeholders and the reorientation of health services. Appendix III An illustration of partnership in projects to reduce child trafficking in West Africa Terres Des Homes (TDH) Foundation is an NGO with the aim to improve the life conditions of most vulnerable children, working in 30 countries around the world. TDH have developed five projects in Benin and Togo in West Africa, using the Community Oriented Primary Care (COPC) approach, to reduce child trafficking in those countries. The developmental process included: a situational analysis of the psychosocial factors in infancy, a vulnerability study, the identification of priorities, an assessment of existing projects to know the feasibility of the new project, planning and implementation. The areas of intervention include health care, psychosocial, educational and cognitive aspects. The main strategies take into account: Primary Prevention: Campaigns in the whole country to increase awareness in communities at high risk of child trafficking and the creation of local committees to fight against this problem. Secondary Prevention: Reduction of risk factors and the reinforcing of protective factors; advocacy at the political level to create and apply a new law against child trafficking. Tertiary Prevention: Rehabilitation of the victims reducing risk factors to avoid the recidivate. The Projects are: Project Oasis (in Benin and Togo) implemented by a multidisciplinary team of MD-MPH, physician, nurse, social workers, psychiatry, legal assistants, and educators. The target populations are 10 communities. Since 2001, 1300 children have been reintegrated to their families. The advocacy component is implemented by national ministries and international organizations. Project on the Production of Educational Materials as part of the primary prevention includes a film, posters, a book for children and a guide for teachers. This project has been supported by UNICEF,EU, Care Benin, Plan Benin and other International organizations. A Comprehensive Approach Against Child Trafficking in Benin, of secondary prevention at the local level, to reduce the main risk factors: lack of knowledge about children's rights, lack of alternative schools and kindergartens, lack of birth certificates, illiteracy of parents, poverty, others. Local authorities and parents are the partners, together with other local NGO's. Education Project based on awareness campaigns by support to local schools to reduce migration of children who are victims of trafficking and to support shelters that are protecting trafficked children. This project is developed by a Consortium of Catholic Relief Services, TDH and World Education. With a comprehensive and multidimensional approach through intersectorial and multidisciplinary interventions these projects have the support of as many as 14 partners, to deal with trafficking in children older than 5 years old as the most important public health (bio-psycho-social) problem in West Africa. Appendix IV Medicine and public health- educational strategies for bridging the gap in the Unites States To accomplish the goals of Network: TUFH, strategies are needed for addressing each of the barriers to integration. The educational barrier is especially important since it is both a reflection of the problem as well as a source of the problem. It reflects and perpetuates the long standing structural separation of the health professionals. If educational barriers are not addressed it is difficult to imagine successful integration at other levels. The following outlines potential strategies for using education to bridge the gaps between public health and clinical care. Efforts in each of these areas are underway in the United States though the U.S. has a long way to go. Network: TUFH could examine and build upon these and other efforts. 1. Coordination of content- Currently public health content is inadequately integrated into clinical education. In addition clinical and laboratory concepts related to infectious disease are no longer emphasized in most public health education. To address the first component, the Association of Academic Health Centers and the Association of Teachers of Preventive Medicine have developed a Taskforce made up of physicians, physicians assistants, nurses, pharmacists, and dentists and have agreed upon a Clinical Prevention and Population Health Curriculum Framework to guide the integration of these field into clinical health professional training. 2. Common community experiences- The need to share common experiences in the community has often been recognized by students and has led to the experiential service-learning movement. Community-Campus Partnerships for Health has now taken the lead in the U.S. in creating formal structures and options for service learning in health. 3. Cross training and research- Physicians have often received public health training and been awarded the MPH degree. The curricula have usually been distinct without any intellectual or structural integration. Efforts to formally coordinate MD-MPH training has been recommended as part of the CDCs initiative in Medical Education. The Association of American Medical Colleges in currently conducting a survey of MD-MPH programs. NIH is actively seeking research proposals that cross disciplinary boundaries. 4. Inter-professional education- Training to deliver services as a team has rarely been part of health professional education. The Institute of Medicine has recently focused on the importance of inter-professional education. The Hartford Foundation is currently funding efforts to stimulate experiments in inter-professional education. These and other educational approaches would benefits from a global discussion. Network: TUFH may be able to play a pivotal role in stimulating and disseminating this process. Appendix V "Health Commons"- an illustration of collaboration among stakeholders in New Mexico The term, “Health Commons” refers to the collaboration between different stakeholders in the community to address intractable health problems that cannot be adequately addressed by any one health discipline, not even by the health system on its own. They usually require the participation of different sectors of society, for the social determinants our most vexing problems are broad and include social, economic, cultural and linguistic factors not easily amenable to traditional healthcare interventions. The “Health Commons” approach usually entails co-locating and integrating a myriad of medical, behavioral, public health and social services in a single, accessible, community or neighborhood location (“one stop shopping”). In New Mexico, intractable problems which the commons attempt to address include a growing disparity in health status between different ethnic and socio-economic groups, poor access to affordable healthcare by the medically uninsured and a shrinking healthcare workforce in rural areas whose populations are growing. Santa Rosa is in the frontier county of Guadalupe with a population of about 5,000, located in the high desert plains of eastern New Mexico. Because it straddles an interstate highway with no other medical facility within 200 miles on either side, when its small, 12-bed hospital threatened to close because it lost its only doctor and faced a financial crisis, it became a local and state health access crisis. The state governor asked the state’s only medical school to intervene. The faculty and residents in the Department of Family and Community Medicine put together an emergency intervention in which upper level residents would provide stop-gap hospital coverage with faculty supervision until a new doctor could be hired. The local hospital board received board training from the university. One of the residents was recruited by the community to be a new, permanent doctor. Concerned about fragmented services, the community prevailed on the local doctor and the public health office to all move into the community hospital to share resources, reduce overhead and collaborate in their practice. To keep the hospital open and pay off the debt, however, the county residents had to vote to approve an increased property tax. A successful campaign was waged by the business community to sway voters to support their hospital. The method used was to pay all hospital employees in rare, $2 bills in the monthly pay period before the election. Suddenly, the entire community saw $2 bills paying for goods throughout the community - candy stores, barbershops, grocery stores. The point was clear - keeping the hospital open meant numerous jobs and economic development for Santa Rosa. Since that time, the community’s competence in recruiting, retaining and supporting its health workforce has grown and become a model. The hospital, now financially stable, employs three physicians and a nurse practitioner, and is now the second largest employer in the county. In the Southeast Heights of Albuquerque, a high crime area with many immigrants and few social services, the city government and university built a clinic to serve the neighborhood’s unique needs. Over the past decade, clinic’s services expanded to meet priority needs expressed by the community. It now offers a host of co-located programs including primary care, oral health, mental health, social services and public health. The community’s voice is expressed through a grass roots organization and the community’s voice has led to programs of unique importance to that population - Hispanic and Vietnamese interpreter services, locally employed “doulas” (lay birth attendants) and an immigrant women’s health group which started a home cleaning service to improve their economic status. Community health workers have been trained and employed to link the community with the clinic. Working with the school system, two school-based health clinics in the local middle and secondary school have been established to provide early intervention in youth health problems and to serve as a vehicle for increasing school graduation rates because data shows that unemployment and dropping out of school are two of the greatest risks to health. Thus, a successful approach to major, complex health problems as diverse as rural health workforce recruitment or provision of culturally competent services to immigrant populations requires cooperation between public health and medicine and the participation of different sectors of society beyond the health sector - truly a “Health Commons.” In each case, students and residents are learning to participate in broad community coalitions through practicing in a “Health Commons” service model.