Personal Health Services Health Article

PERSONAL HEALTH SERVICES

"Personal health services" are the services that an individual receives from others to address health problems or for health promotion and disease prevention. It is helpful to consider the meanings and implications of each of these words. "Personal" is used to connote attention to improving or maintaining an individual's health state, though that state may directly impinge upon others, either in the family or community—there are emotional attachments to sick persons; an individual illness may diminish family resources and capacities; and illnesses have direct implications for communities, such as in the transmission of communicable diseases or in alternative uses for scarce clinical-care resources. Thus, a personal illness can have a profound impact on others, and on the health and well-being of the general public.

"Health" is not an easy term to define (see the discussion elsewhere in this volume), but in the context of health services, there are important conceptual issues. One, as noted above, is the role of health promotion and disease prevention in personal health services. Since many important dimensions of prevention are related to social behaviors or environmental modifications, they are often outside the usual health care system. Another is defining the boundary of health care in terms of appropriate themes. At least in the past, various community health centers and other medical care organizations provided assistance with housing, clothing, and personal legal matters, as well as referral to religious resources. This is not an issue of worthiness, but rather the implication here is that the content of medical services varies and must be explicitly addressed and defined.

The term "services" also requires discussion. While they often connote formal professional services, the patterns and content of care that impinge on a sick individual come from a variety of sources, many of which are neither professional nor part of any organized healing system. The same might be said of the administrative connotation of the term "services," implying not only a single health practitioner, but also care received from a variety of informal sources as well as from well-developed organizations and agencies. In fact, the history and sociology of health services suggest that most sick persons receive health care from diverse sources. Based on anthropological and other studies, there is evidence that all cultures have appointed healers to deal with infirmity. In some societies, these healers may be thought of as using folk, religious, or magical methods; and the sources and content of their lore may not always be clear. In these instances, healing takes place largely in the community, and generally outside of clinics or institutional settings. Interestingly, studying the lore and practices of traditional healing systems, usually in developing countries, has become an important activity in searching for new medicinal or other preventive or therapeutic entities that might have applications in Western societies.

In other societies, healers are much more well organized, and they have generally undergone varying degrees of professionalization and administrative organization. In this case, the healing is often performed in varying types of complex clinics and institutions, usually with a great degree of subspecialization. Nonetheless, no healing system totally dominates a given culture or society, and there are always challenges from alternative healing systems. It has been shown in many countries that many individuals seek and receive health care from highly diverse types of healing systems simultaneously.

LEVELS AND DIMENSIONS OF PERSONAL HEALTH CARE

There is no widely used taxonomy for the elements of personal health services, but there are conventional terms to describe the elements of formal health services hierarchies. One example, referring to the complexity or practitioners' discipline or training, is to consider the level of care as either general, specialty, or subspecialty in nature. Another general approach to care levels is the continuum of primary, secondary, and tertiary care. "Primary care" generally refers to personal care that is broad in scope and does not usually address complex, uncommon illnesses. Primary care is generally intended to be the first contact point when a patient suspects illness, and it provides a comprehensive view of the patient, with full clinical and restorative care for a wide range of common conditions, a full regimen of health promotion and disease prevention activities, and continuity and integration of care when severe or complex illness occurs. Primary care may occur in a variety of locations, but there is a clear community emphasis.

"Secondary care" generally represents the acute general hospital and related institutional and specialty settings in the community where such care is provided; it is intermediate in complexity and intensity. It is more likely to be delivered by specialist practitioners, to be more costly than primary care, and to have few of the attributes of primary care noted above. Primary care practitioners may participate in the delivery of secondary care in certain systems.

"Tertiary care" is the most complex, expensive, and technologically intensive level of care. It is generally available in fewer locations, is extremely resource intensive, and is mostly conducted by subspecialists. Examples include the most sophisticated trauma care, burn treatment units, bone marrow and organ transplant units, and complex types of surgical procedures. Also generally included in tertiary care are rehabilitative and restorative care, which are also a major component of tertiary prevention.

Another axis for understanding personal health care is the notion of "basic health care" versus other "nonbasic" health services. Basic care is not the same as primary care, because almost all definitions of basic care in industrialized nations include access to hospital and rehabilitative care, as well as certain tertiary services. Basic health care is a complex construct that is often the subject of considerable controversy. This controversy stems from diverse moral, social, and economic values about a set of care activities to which all persons in a given society would, or should, have access, if any should be provided at all. The complexity in defining basic health care is illustrative of the nature of personal health care in general.

To begin, a basic set of services might be defined in terms of affordability to individuals and societies. Thus, for fiscal, cultural, and historical reasons, the content of a basic set of services would differ in diverse societies and countries. The content of basic health care would be very different in rural China than in the suburbs of major American cities. Even within a particular country, obtaining political and economic consensus on whether, and how much of, a society's common resources should be provided for a set of basic services is often difficult. Some of this is related to varying views on taxation and the appropriateness of helping programs; other issues relate to moral or value judgments on specific elements of the basic "benefit package." For example, there is great contentiousness about the provision of therapeutic abortion, and about applying stem cells for organogenesis.

Variant views of the content of basic health care and the service package may also occur because of judgmental differences about which services are basic and which are discretionary. Some of this stems from professional and patient competition for a relatively fixed amount of resources, and, within a particular medical system, this is often at the heart of conflicts over basic-care content. For example, cosmetic surgery is often considered to be discretionary, but not all citizens of a given society would agree. Also, there is typically conflict over whether resources should used to provide very expensive services, such as bone marrow transplant, to a few persons, or whether the resources should be used to provide comprehensive primary care to many people. No matter how expensive or rare certain medical procedures may be, it is often politically and morally difficult to explicitly deny a critically ill individual such a service, especially in a more affluent society. Yet the reality is that there are economic and societal limits on the amount of care that can be provided, and a system for rationing and allocating personal health care is always present, even if it is sometimes inconsistent, implicit, and informal.

Sometimes there are diverse opinions concerning the delivery of preventive and health-promotion services as part of a set of basic health services. Prevention is a very important part of clinical care, but preventive services can be expensive, and will thus inevitably compete with illness services for fixed resources.