To life !
To Life !
If you are a Canadian who has followed the debate raging around our health system, you will have heard how disease prevention and the promotion of healthy living are fundamental to health care. Were citizens more aware of these concepts and made them integral to their daily lives, it would be a boon not just to them, but to the health system itself.
In an ideal world, such preventive health practices would also be integral to a network of primary health care clinics. These clinics would be far more than places where the patient goes for prescriptions that “magically” solve problems with pills. The patient would also find there supports that help him or her examine and modify personal living habits.
To be sure, here and there throughout the country you will find co-operative and community clinics that are imbued with this philosophy and strive to live it on a daily basis. But can you imagine disease prevention and health promotion as a fundamental strategy to which an integrated network of health establishments is devoted – clinics, hospitals, rehabilitation centres? Moreover, a network that affirms not just in words, but in its actions and operating practices the impact of social factors on the state of the population’s health – the “social determinants” of health?
To put it another way, imagine having the means not just to ensure access to health services, but also to mobilize networks of citizens to break down isolation, to counter social exclusion, to heighten awareness of healthy living, and to facilitate intergenerational dialogue. In short, imagine that the relationship between the individual and the health establishment is not that of a passive consumer receiving professional “care,” but one in which each person is acknowledged and respected as a unique individual with a role to play in their own health and in the functioning of the health system itself.
Sound utopian? Then look west ... way west, to the Land of the Rising Sun, to be exact – and you’re in for a surprise. Across the Japanese archipelago a network of consumer co-operatives that manages and owns numerous hospitals, clinics, and rehabili- tation centres has been growing for more than 50 years.
Over 120 co-operatives representing nearly three million members act as a forum where citizens discuss problems of health and daily life and endeavour to resolve them through actions taken in collaboration with the caregivers and health professionals of these establishments. Nurses, social workers, doctors, physiotherapists, and other health care professionals are active partners in what amounts to a community-led approach to health care. This role is reinforced through the work that Japan’s health co-op’s do in training doctors and other health profession- als. Within a context of disease prevention, each clinic’s reputa- tion rests on how healthy its members are, not how many prescriptions its staff write or procedures they perform.
Welcome to the network of the Health Co-operative Association of the Japanese Consumers Co-operatives Union (HCAJCCU)!
In the autumn of 2007 a long-cherished dream of Jean-Pierre Girard came true. He took a group of Canadians to Japan so they could immerse themselves in the co-operative approach to health taken by Japan’s health co-ops (see sidebar, p. 8,“The 2007 Japan Study Tour”). The 12 participants had read and heard much about the model, but seeing it work over a packed 7-day tour was a revelation. One of the most powerful insights concerned what the Japanese call Han: the fundamental unit of preventive health practice.
Han are cells of 10-20 citizens living in the same vicinity, on the same street, in the same neighbourhood. They agree voluntarily to meet at a local hall or recreation centre for a few hours an average of once a month and take part in an ongoing process of disease prevention. Closely aligned with Japan’s consumer co-ops in which Han play a central role in nutrition education and in the production and distribution of healthy food, Han undertake a wide variety of activities relating to health. Members learn how to conduct various health checks, including blood pressure, measuring weight and muscle mass, stool and urine analysis, and tests for diabetes. The results are then sent to a professional at the health co-operative where prompt action can be taken if the data indicate a significant anomaly.
Health professionals often play an important role in these meetings. In the autumn, for example, a nurse goes to the groups to suggest how they can protect themselves from colds. Another part of the meeting may involve physical activity as a way to promote exercise and socializing. To strengthen the bonds between members, there is also the tea ceremony ( Japanese tea, naturally) offering members a time to chat and relax.
In this way, Han address another determinant of health, one we in Canada too often ignore: the vital role of a solid social network. Han undermine the loneliness that is the fate of so many, especially older people, at a time when modernization and the growth of vast urban centers are threatening traditional social bonds in Japan. The impact of the Han on the social health of Japan’s communities is unquestionable.
That wasn’t the end of our discoveries. We also visited rehabilitation centres for the aged. We were astonished to learn that in some of these centres the average age is 85! Over 45% of the residents return home after a short stay. Once again we sensed the network’s deep sensitivity for the social bonds that operate outside the health establishment. Over and above the care it lavishes on individuals, this network mobilizes people and builds community so that social bonds develop where otherwise there is only isolation and loneliness.
Understanding health primarily as a personal responsibility, not a normative and bureaucratic one (as is too often the case in Canada), this great network of co-operatives is pro-active in many civic initiatives. For example, we learned how the co-ops partnered in a World Health Organisation program to redesign cities in light of the mobility requirements of aged people.(1)
As we know, our cities have been conceived and planned from the perspective of maximum efficiency. Everything has to run smoothly and rapidly. But are the 15 seconds that pedestrians are permitted to cross an intersection enough for a senior? Is the interval between public benches too great for seniors in need of a rest? What about the distribution of ramps so they can get around safely? And so on. What works for a middle-aged person can be a terrible burden on the elderly. It stands to reason that as the population ages, the city must be reconfigured to these new needs.
Co-op involvement in civic action has held immense benefits for the general public. At the time of the dreadful earthquake that shook Kobe in 1995, the co-operative health network was among the first to mobilize support and comfort for the casualties. Many members as well as health professionals pitched in voluntarily. In many respects, the co-op network was speedier and more efficient than the public system. Network doctors also moved swiftly to intervene on Sri Lanka’s behalf during the tsunami of 2003.
Social justice also acts as a catalyst for network action. In the course of a workshop held during our tour, network spokespersons clearly expressed their profound displeasure at the tendency of the Japanese Health Ministry to increase the user portion of health service fees (see sidebar, this page,“Japan’s Health System”). Applied across the board, this measure would naturally penalize most heavily those who are poorest.“Would it not deprive them of vital services, including disease prevention?” they asked.“Would not both the individual and the system ultimately lose if an illness went undetected and intervention was delayed?”
Time and again we heard how the local co-op hospital refused to discriminate between patients on the basis of ability to pay.
Fundraising activities by the co-op and especially the local Han supplement clinic revenues and ensure that all users have access to the same levels of care.
Disease prevention, health promotion, social justice, solidarity, and civic action – the values espoused by Japan’s co-operative network echo the values held by many Canadians. But now what? What does this all mean for the way we practice health care in Canada?
Let’s be clear. Nothing remotely like this exists in Canada. Despite their pioneering work across this country, co-operative and community clinics remain marginal to our health system, whereas the health co-op network is central to that of Japan. Wholly unlike the walk-in clinics that are proliferating in Canada, and erode even the relationship between patient and physician, the Japanese clinics help residents to organize in order to address their health needs and aspirations comprehen- sively. Neighbours and health professionals exercise control over primary health care in a way that rewards local innovation and accountability without disturbing the role of the State in health finance and regulation.
To build a network of similar purpose and value in Canada, boldness and innovation are key. It is essential that linkages and joint action be developed between community health centres and health co-operatives around a common agenda for reform. It is urgent that together we present to the public an alternative that goes beyond the simplistic rhetoric of public versus private care that has dominated the health debate in Canada. There is another way forward beyond the rigid institutionalization of publicly-managed health care on the one hand and the gross inequities of private, profit-driven health care on the other.
No question, building a third way forward means debate, weighing risks, and rethinking the linkage between our health system and the State (2). But Japan’s health co-operatives demonstrate that it is possible for us to think globally and act locally, all within a health system whose driving force is the citizen.
1)For more information, go to the website of the World Health Organisation, www.who.int/ageing/en.
2) For some time Yves Vaillancourt, Professor at the Université du Québec à Montréal, has been reflecting on the role of the social economy in the renewal of the Welfare State – a type of partnership between the public sector and collective enterprises.His most recent work,“Vers un État stratège partenaire de la société civile” (available in French only) presents the concept of a Strategic State that partners with civil society.