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adverse clinical effects , including polypharmacy and pursuing contradictory therapeutic regimes ( 16 , 17 ). More importantly , multimorbidity affects the nature and extent of the impact of health on one ’ s life . Even if the severe capacity limitations associated with blindness , deafness , immobility or profound cognitive decline are , at the population level , being “ compressed ” into the last segment of life , the accumulated impact on people ’ s capacity of multimorbidity will nonetheless profoundly affect their lives as they age .
PREPARING THE HEALTH SYSTEM FOR THE EMERGING NEEDS OF PEOPLE LIVING WITH LIMITATIONS IN FUNCTIONING
Given these demographic and epidemiological trends and their impact on functioning and disability , society is clearly obliged to respond by preparing the health system for the emerging needs of the population . This is not only because it makes good economic sense to ensure that people maintain a high level of functioning despite chronic conditions and ageing , and continue to contribute productively to society , but also because it is in everyone ’ s self-interest to create a society in which they can participate as fully as possible for as long as possible . And for countries who have signed and ratified the United Nations ’ Convention on the Rights of Persons with Disabilities ( CRPD ) ( 18 ) an effective societal response is a matter of human rights for those citizens whose level of health is suboptimal and who experience , or who are at risk of experiencing , disability .
Although shifting the focus of the healthcare system onto age-specific NCDs is a sensible strategy , it threatens to overlook the more salient feature of the health impact of these trends , namely that people are living longer but with more disability . In other words , the more notable health impact of ageing and NCDs on people ’ s lives will be that they will experience more limitations in their capacity to do , and to become , what they wish . Although premature mortality is an obvious health concern , at some stage in life mortality can no longer be argued to be premature . Despite this , concerns about functioning , including pain , mobility and self-care and independence , are always legitimate , whatever the person ’ s age . The goal of healthcare , therefore , must include , as a central outcome of interest , that of optimizing functioning in the face of inevitable disability , across all domains of life ( 19 ).
The challenge then becomes how health systems might be re-designed to most effectively respond to the demographic and epidemiological trends that will dominate the 21 st century , given that the salient impact of these trends will be a dramatic increase in the non-fatal health outcomes associated with impairments of the mind and body and associated declines in capacity and performance across all areas of life . What are the health strategies available to healthcare systems to meet this challenge ?
REHABILITATION : ONE OF THE FIVE MAIN HEALTH STRATEGIES
Since the Declaration of Alma Ata in 1978 ( 20 ), promotion , prevention , cure and rehabilitation have been recognized as the health strategies to achieve and maintain population health . More recently , within the context of the initiative for universal health coverage , the WHO has recognized palliative care as an additional strategy ( 21 ). Prevention aims to reduce the occurrence ( incidence ) of diseases , injuries and other health conditions through targeting risk factors with the long-term aim of reducing prevalence . Health promotion aims to optimize people ’ s intrinsic biological health . The curative strategy aims to eliminate or control disease conditions , thereby eliminating or minimalizing their impact on people ’ s capacity . Palliative care optimizes quality of life by relieving symptoms , pain , and mental distress during the process of dying . Rehabilitation , finally , aims to optimize people ’ s functioning associated with diseases , injuries and other health conditions in the context of an individual ’ s position in life and resources and in interaction with the physical , human-built , attitudinal and social environment ( 22 ).
These health strategies can be used to paint a broad-brush portrait of the history of healthcare in the last 2 centuries ( 23 ). In the 19 th century , because of poor nourishment , lack of hygiene , and infectious diseases , the death of infants and children was commonplace worldwide , but , in addition , life expectancy was very low even in high-income countries . For most of that century the curative strategy had almost no impact on the health of society . What drove improvements in health was a dramatic increase in economic performance and social progress in the Western world . This allowed for better nutrition for all , not just the wealthy . Construction of clean water and sewage systems and improved housing conditions led to better hygiene . In retrospect , we recognize that these improvements were preventive , making it the dominant strategy in the 19 th century ( 24 ).
The curative strategy was the dominant strategy in the 20 th century . This strategy was instrumental www . medicaljournals . se / jrm