At the very time of writing this editorial, a few days before Christmas, Berlin, the capital of Germany, the land of Angela Merkel – about the only remaining top politician in Europe with a humanist view (Wir schaffen das!) on the challenge of hosting refugees from the war-ridden Middle-East – was hit by a brutal and murderous attack in a public space “par excellence”: a Christmas market, right in the center of the city. The warnings on Christmas markets as potential “soft targets” had, unfortunately, been proven right.
The contrast with the spirit of Christmas could not be greater. Indeed, Christmas – notwithstanding the excessive and irritating commercialization which envelop its celebration in many parts of the world – is also a time which reminds people of the ethical imperative to care (more) for each other, something that seems very much needed in our current times. From this religious and philosophical inspiration, we take the liberty to extrapolate and reflect on an issue that is (or at least should be) central to public health policies and programmes: the place of caring in the interface between people and health systems.
We believe that (the concept and practice of) patient-centered care (PCC) – or if you prefer, person-centered care – tries to capture this caring dimension. Essentially, PCC focuses on the quality of the interaction between a patient and a health worker. PCC embraces a holistic approach towards the provision of healthcare to an individual – health care that does not just take into account biopsychosocial elements, but also a patient’s preferences, ideas, concerns and expectations. PCC aims for an alliance between the health worker and the patient which implies the sharing of power and responsibilities. Central in PCC are mutual respect and empathy.
Providing care that is oriented towards a patient or person may sound obvious, but it was only acknowledged on a global scale towards the turn of the century. For instance, in 2001 the Institute of Medicine in the USA explicitly highlighted patient-centeredness as a key dimension of quality of care. Despite this formal recognition, PCC continues to be a neglected aspect in the delivery of care irrespective of the setting, whether high or low income (although perhaps not to the same extent). Focusing on low-income countries, we explored this gap in a recent article on PCC in sub-Saharan Africa, in the International journal of Person Centered Medicine. We arrived at the conclusion that the concept and practice of PCC in public first line health facilities are still underdeveloped in that part of the world. The title of the paper summed it up neatly: “Patient-Centered Care and People-Centered Health Systems in Sub-Saharan Africa: Why So Little of Something So Badly Needed?”
From the perspective of health workers, we found – quite obviously perhaps – that health worker attitudes are influenced by a broad variety of factors related to the socio-cultural environment, the personality of the health worker but also his/her working conditions, the patient’s characteristics, the structure and organization of the health system, etc. In an attempt to structure this variety of factors which have an impact on the delivery of PCC, we proposed a simple, three-layered model to conceptualize the individual interaction between a patient seeking care and a health worker (a medical doctor, clinical officer, nurse-practitioner, …).
In the context of high-income countries, even if there’s still room for further improvement (see for instance the care for the elderly in our own country, with shamefully long waiting lists…), substantial progress has been made towards PCC, for example through the increased recognition in academic and health policy circles of the value of Primary Health Care implemented via the practice of Family Medicine delivered by small multidisciplinary teams. As formulated by the late Barbara Starfield, Primary Care relates to the social integration of health workers in the local community they serve, a biopsychosocial approach to people’s problems, a long term relationship between health workers and people, a sound balance between technicity and human relationships, and an offer of truly integrated care…
In many sub-Saharan African countries, on the other hand, this sort of care is still rare, unfortunately. The reasons for this are many, but the fact that health workers and patients, when they interact in the context of modern health systems ( be it within the frame of educational programmes or when seeking health care) only rarely encounter ‘living models’ of care delivery that match the above-mentioned features, is certainly an important factor.
Against this backdrop, we strongly advocate for more patient-centeredness in health care, and for more research on the impact of socio-cultural, structural and organizational conditions on the development and system-wide recognition of PCC in different contexts. Instruments to measure PCC (or the lack of it) need to be developed and validated in a set of culturally distinct environments. And, perhaps most importantly, possible solutions need to be tested using a participatory action-research framework.
Following in the footsteps of Mahler, Mercenier and Van Balen…
When engaging in end-of-the-year musings on PCC in SSA, it would be inappropriate, almost indecent, not to refer to the recent loss of Dr. Halfdan Mahler who served as the Director-General of the World Health Organisation between 1973-1988. Dr. Mahler will go down in history as the visionary co-founder of the Primary Health Care (PHC) movement that culminated in the Alma Ata declaration in 1978. Dr Mahler passed away on December 14th. We honor his tremendous legacy.
At the same time, as faculty of the Public Health Department of the Institute of Tropical Medicine in Antwerp, we also seize the opportunity to pay tribute to the important work done in the domain of PHC and PCC by the late Professors Pierre Mercenier and Harry Van Balen, founders of the Antwerp school of thought. Their emphasis in teaching, practice and research on the famous triad of global, continuous and integrated care (or in French: “des soins globaux, continus et intégrés”) as key characteristics of quality health care, familiar to the many hundreds of students that have attended their classes, has not lost an inch of its relevance.
On that note, we wish all of you some restful and peaceful days ahead, and time with your beloved ones. Our warmest season’s greetings!