The document discusses value-based community health and outlines some challenges and opportunities. It notes that the Galician Health Service is responsible for public health policies and universal healthcare coverage in Galicia. While primary care was reformed in the 1980s-1990s, there is no fully established community health project today. The document examines definitions of value-based healthcare and community health. It recommends developing a portfolio of projects to improve population health outcomes and harness social determinants of health. However, evidence for community health interventions is limited. The document concludes that primary care needs to develop its own triple aim-based community health model to promote effective programs, citizen involvement, and cost-effectiveness.

1. LOOKING FOR VALUE-BASED COMMUNITY HEALTH
Jordi Varela
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2. THE GALICIAN AND SPANISH FRAMEWORK
The Galician Health Service (SERGAS) is the public body responsible
for deploying public and community health policies and offering
health services to the citizens of Galicia, within the framework of a
National Health System of national scope, universal coverage and
financed through the general budgets.
The General Health Law of 1986 gave coverage to the reform of
primary care that was implemented from the decade of the 80s and
90s following the guidelines of the Alma-Ata declaration of 1978.
As a result of all this, the primary health care in Spain has been
planned with population criteria and with administrative circuits that
give it the gatekeeper function, a key issue in the management of the
entire health system, a function that is clearly insufficient today for
the desires of primary care that wants to be the backbone of the
system
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3. WHAT ARE WE TALKING ABOUT WHEN WE TALK ABOUT VALUE?
In 2006, Michael Porter and Elizabeth Teisberg published “Redefining
Health Care. Creating Value-Based Competition on Results”, where they
affirmed that payers and providers are very concerned in demonstrating
that they work a lot, and very little, or nothing, in assessing what their
work contributes to the health of people and communities.
Health systems should seek to obtain the maximum possible
value for the health of people for every dollar they spend.
The value is the perception that people have about clinical
effectiveness in relation to costs of the clinical actions.
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4. WHAT IS VALUE-BASED HEALTHCARE?
Value-based healthcare is a healthcare delivery model in which
providers, including hospitals and physicians, are paid based on patient
health outcomes. Under value-based care agreements, providers are
rewarded for helping patients improve their health, reduce the effects
and incidence of chronic disease, and live healthier lives in an evidence-
based way.
WHAT IS VALUE-BASED COMMUNITY HEALTH?
Although there is no fully established definition, if we want to introduce
the Porterian concept of value in community health, we must take into
account the three drivers that define the essence of value:
a) The effectiveness of the programs
b) The perception that citizens have of them
c) The costs attributable to these actions
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IHI RECOMMENDS A CHANGE PROCESS THAT INCLUDES:
1. Identification of target populations
2. Definition of system aims and measures
3. Development of a portfolio of project work that is
sufficiently strong to move system-level results
4. Rapid testing and scale up that is adapted to local needs
and conditions

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IHI BELIEVES THAT TO DO THIS WORK EFFECTIVELY, IT’S
IMPORTANT TO:
1. Harness a range of community determinants of health
2. Empower individuals and families
3. Substantially broaden the role and impact of primary
care and other community-based services
4. Assure a seamless journey through the whole system of
care throughout a person’s life

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THE DETERMINANTS OF HEALTH PARADOX
Michael Marmot states that if the determinants of health are mostly social, the solutions must also
be social. It must be admitted that the capacity that health services have to modify the influence of
the environment, housing, education, transport or work on population health is limited.
Not only that, but by
promoting activities and
interventions for which
neither organizations, nor
health professionals are
especially competent, could
distort health care priorities,
which has often contributed
to the medicalization of life,
according to Iona Heath.
The primary solution should
not be medication but a
genuine commitment to
fairness and justice in a
humane society.

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TRYING TO MANAGE THE DETERMINANTS OF HEALTH PARADOX

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TRYING TO MANAGE THE DETERMINANTS OF HEALTH PARADOX

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TRYING TO MANAGE THE DETERMINANTS OF HEALTH PARADOX

12. LACK OF A COMMUNITY HEALTH PROJECT
Community health is an intervention model that aims to improve the
health of a defined community that should operate from primary care
among others community services to adjust their actions to the social
reality of each territory.
The reality of community health in Galician primary care is tremendously
varied, with professionals who act exclusively in a reactive manner or
others that undertake community actions without enough scientific basis.
There are primary care teams that are very involved in the affairs of their
community and others that are not at all.
The conclusion is that, despite of having a primary care with
universal access and close proximity, there is neither a
homogeneous discourse nor a clear community health project.
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13. ASSESSING EVIDENCE IS NOT BEING EASY
“Solid evidence exists of the effectiveness of strategies for health promotion and for the
prevention of various chronic diseases, and the primary health care system is an ideal
setting to carry out these interventions. Nonetheless, a major gap remains between
knowledge and practice.”
“Successful implementation of health promotion and disease prevention interventions
requires that they be designed with an awareness of the barriers that exist in the
setting where they will be carried out, the skills of the professionals responsible for
the intervention, and the others characteristics such: health status, needs, values
and preferences of citizens.” 13
Few studies and poor evidence,
or even lack of it

14. WHAT DO COCHRANE REVIEWS SAY?
According to Cochrane reviews, primary health care models should promote the following
programs, because there is some evidence supporting them:
1. Information strategies on childhood vaccinations in low adherence groups.
2. Programs for the promotion of maternal and neonatal health primarily aimed for at-risk
groups.
3. Behavioural interventions to reduce the risk of sexual transmission of aids among men who
have sex with men.
4. Programs to reduce tobacco use among young people (weak evidence).
5. The prevention of diabetes 2 (studies are all in developing countries, and the evidence is low).
6. Community interventions aimed at increasing influenza vaccination among those over 59.
7. Fall prevention programs in older people living at home, with a particular emphasis on
physical exercise.
8. Activities aimed at people with multiple chronic conditions to prevent depression and improve
difficulties in its functionality.
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15. WHAT ABOUT THE TRIPLE AIM AS A MODEL FOR A VALUE-BASED
COMUNNITY HEALTH?
There is no universal model of community health in primary care, but I will cite
some that can help:
a) The Medical Research Council Framework (Campbell 2007,
Craig 2008) with five sequential phases
No triple aim
b) The community engagement: improving health and
wellbeing and reducing health inequalities (NICE 2016)
Double aim
c) The hierarchy of preventive interventions (Simon & Ann
Capewell 2017)
Weak triple aim
d) The asset-based approach (Rafa Cofiño 2016) could be useful to
revitalise health promotion or community health interventions.
Triple aim
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17. CONCLUSIONS
To promote the value of community health, the primary care system needs
to develop its own model, that would be a triple aim based, promoting
effective activities, involving citizens in the objectives of the programs and
performing cost-effectiveness studies.
In this new framework, the need for more training of primary care
professionals should be foreseen, in addition to the coordination of
strategies with the other services that also act in the community such as
social services, public health, or mental health.
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