International Lessons for Place-based Health

NLGN’s recent Place-based Health conference brought together many experts in local and national healthcare to discuss the need to move away from reactive health services, towards holistic, place-based systems – and the practical changes needed to make this happen. If advocates of this approach are to be successful, they will need to collaborate and take advice from people working across the healthcare field. However, perhaps the last place one would expect to get relevant advice on making healthcare local is from those working in the field of international health.

There is much more crossover than one might think. In particular, advocates of preventative, place-based systems at all levels face many obstacles in being able to convince decision-makers of the efficacy of a more prevention-focused approach, and in bringing about the systemic shift in culture and practice that is so clearly needed. It is a widely recognised fact within the UK healthcare community that health and social care services are no longer sustainable in their current form. Despite a widespread consensus that priorities must shift from treatment to prevention, there has been little progress in bringing about this transformation.

One of the most prominent obstacles to this move is the so-called ‘Evidence Paradox’. The reluctance of the NHS to invest in preventative, place-based systems without clear evidence of their money-saving potential means that attempts to implement such systems are limited and the evidence is not being generated. This problem is similar to that faced by advocates of prevention in the international health system, who struggle to make persuasive arguments concerning the cost-effectiveness of preventative healthcare when concrete data is hard to collect. There are many lessons to be learned for those involved in local and national healthcare from the experience of those working in international health.

The first lesson is that the notion of funding prevention versus treatment is a false dichotomy. It is almost commonsensical that any good healthcare system requires both prevention and treatment, yet so often those involved in the debate seem to assume that healthcare funding is a zero-sum game in which rebalancing of funding to prioritise ‘unproven’ preventative measures will result in further financial strain on those providing treatment services. This, however, is simply not the case. There are countless examples from across the globe that provide evidence that an emphasis on both prevention and treatment is the best approach.

To take just one example, the Embangweni Mission Hospital in Malawi dramatically decreased maternal death rates through several measures spanning both treatment and prevention. On the prevention side, community health nurses worked throughout the region to provide prenatal care to women and to identify those likely to have problems in labour, advising them to go to hospital early so they could be closely monitored for complications. On the treatment side, the hospital invested in improving conditions in its labour and delivery rooms, worked hard to recruit and train nurses, and barred family members who hospital workers knew from experience would try to give women in labour potentially harmful, traditional, labour-inducing herbal concoctions. These efforts created a system in which prevention and treatment benefitted one another. The efforts of community nurses meant that fewer pregnant women showed up at the hospital in crisis, while the more numerous and better-trained nurses in the hospital were able to save more lives.

The second is that advocates of place-based health are missing the importance of marketing and PR for prevention. The fact is, prevention just isn’t as ‘sexy’ from a PR perspective as treatment. This is just as true in global health as it is in local. In 2007, a 31-second video called ‘The Lazarus Effect’, which depicted a woman with AIDs recovering from near-death following a course of anti-retroviral treatment, was released. The video quickly reached more than 1 million views on YouTube and resonated through the media, dramatically raising awareness of both the disease and the treatment.

This example is illustrative of the power a good story has in determining the attention that is paid to an issue. In treatment stories, the viewer or reader can see the cause and effect of a disease, as well as the tangible results of treatment, and there is a human face to the problem. It’s an easy sell. This, however, is exactly where prevention efforts fall flat as a cause célèbre. They lack the same pizzazz and appeal, coming across as mundane and making it much harder to persuade journalists to cover them. From a healthcare perspective, a woman never contracting HIV/AIDs is infinitely preferable to a woman being successfully treated for it. But from a PR perspective, there is no competition.

Advocates of place-based and preventative health systems, then, need to take two lessons from international health. They need to promote the benefits of a complementary health system in which prevention is seen to make the lives of those working in treatment easier, not harder. They also need to find a way to frame stories of successful prevention efforts in such a way as to provide competition to the ready-made media hole-in-ones that treatment stories give. By doing this, it may just be easier to persuade decision-makers in healthcare to leap the evidence gap and take the risk of investing resources in place-based health systems.

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