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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