Integrating personal and population approaches to health care: A Perspective from Africa Steve Reid Primary Health Care Directorate University of Cape Town

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Borders North South Urban Rural RichPoor IndividualCommunity Adequate resources Few resources Clinical care Population health

The “Inverse Care” Law “The availability of good medical care tends to vary inversely with the need for it in the population served." – Dr Julian Tudor Hart : 1971

PRACTICE POPULATION POPULATION AT RISK HEALTH FOR ALL HEALTH FOR ALL PATIENT - PRACTITIONER

THE PRACTICE POPULATION The patients we know People who present themselves for care Those who can afford to come Those who are not too old or to young to present themselves when they are ill Those who do not live too far away Those who know or believe that they need help THE POPULATION AT RISK People who are not yet ill but are likely to become so Sick people who do not present themselves for care Those who do not know or believe that they need help Those who are scared Those who cannot afford the transport costs to get care Those without medical insurance Children and the elderly Those who live in remote rural areas

TERTIARY HOSPITAL HEALTH FOR ALL POPULATION AT RISK HEALTH FOR ALL

HIGH SPEED CONTINUOUS INTERNET HEALTH FOR ALL DIAL -UP PC INTER- MITTENT PEN AND PAPER!

Drs Sidney and Emily Kark

Community Oriented Primary Care “A continuous process by which primary health care is provided to a defined community on the basis of its assessed health needs, by the planned integration of primary care practice and public health”. Abramson, 1988

PRACTICE POPULATION HEALTH FOR ALL Case-finding Early detection Follow -up Home visits Screening “Outreach” Mobile clinics HEALTH FOR ALL

Gruen RL, Pearson SD, Brennan TA. Physician-Citizens – public roles and professional obligations. JAMA 2004; 291:94-98

Brazil – Family Health Programme Programa de Saúde da Família (PSF) Total population 180m, rural population 40m Family Health Teams provided by municipalities 1 family doctor 1 nurse 1 nurse assistant 4 to 12 CHWs Community orientation Treatment and prevention and health promotion

PRACTICE POPULATION HEALTH FOR ALL POPULATION AT RISK HEALTH FOR ALL

Types of Boundaries in healthcare Geographic / Socioeconomic – North - South – Urban - Rural Organizational / Structural – Individual - Community – Clinical practice - Population Health Philosophical / Process – Flexibility in application – Innovation and creativity

Types of Engagement HIV+ patients on ARVs – whole population Hospital staff – wellness Diabetics on treatment & community screening Faith-based organization – Sunday clinics School teachers – healthy lifestyles Premature mothers support group Clothes bank at hospital Apple project – handouts in waiting room

Creativity – Roger van Oech ExplorerArtistJudgeWarrior

“Umuntu ngumuntu ngabantu” A person is a person by virtue of other people

“Intersubjectivity” “I am defined in and through my meeting with you. And you are defined by your reflection in my eyes. By looking at me, you see yourself more clearly, and vice-versa.”

Eudora Welty "My continuing passion is to part a curtain, that invisible veil of indifference that falls between us and that blinds us to each other's presence, each other's wonder, each other's human plight."

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