International collaboration in primary care: A win–win situation

More than a hundred years ago Virchow argued that democracy and socio-economic reform would enable states to empower people to attain better health [1]. More than 20 years ago the fall of the Berlin Wall and associated political changes had catapulted reform to the top of the international agenda and by 2004 the Baltic States had joined the European Union. Throughout this upheaval and beyond, Scandinavian countries have been steadfast in support of their neighbours, not least in the field of primary health care, as the paper by Wilkens et al. shows [2]. The World Bank, the European Union, and Scandinavian governments supported programmes of reform to develop family doctors both in the Baltic states [3] and elsewhere in Central and Eastern Europe [4,5]. This was against the background of the updated WHO Alma Ata declaration [6,7] calling for international action to develop primary care and, in particular, to achieve “Health for All”. Reinforced by a will to move away from the past [8], by sustained evidence from Starfield [9], and by personal links such as those exemplified by Wilkens et al. [2], primary care has been established in these regions. Between-country comparisons in the NORBALT survey showed that social inequalities in the Baltics had diminished with regard to utilization in the primary care sector [10]. However, a review of the position of family medicine in CEE countries felt there was an important need for academic support and exchange of expertise in the ongoing development of primary care structures [4]. We can, and should, continue this process of international comparisons and collaboration to inform best practice and enhance understanding of issues that concern us all. Although recognized major causes of mortality and morbidity affecting Scandinavia and the Baltics are known to be similar, a different perspective can be reached by international comparison. Karanikolos compared changes in life expectancy in the Baltics with Finland [11]. Finland provides a good comparator to the EU overall average, and there has been a long history of collaboration with the Baltics in the FINBALT Health monitor from 1990 onwards [12]. Decomposing aggregated figures permits more subtle trends related to age, gender, and cause to be revealed when comparing data from all four countries. In fact, the gap in life expectancy between Finland and the Baltic States widened in the 1990s and is now narrowing, but slowly. Life expectancy is increasing, but not in the elderly in the Baltics, and Lithuania has lost its early advantage relative to Estonia and Latvia. Therefore, international comparison can provide useful pointers for future primary health care development.

Similarly alcohol consumption and its related problems remain an important health concern and international comparisons can be useful. It appears that while reports from primary care in western EU countries such as the UK and The Netherlands demonstrate a struggle with binge drinking [13], in the Baltics promising inroads have been made, e.g. in Estonia and Lithuania, by raising taxes and controlling advertising, although mortality related to alcohol is still significant [11]. Public involvement in health care development is recognised as being needed for clinical effectiveness and to develop an increasing awareness of costs [14,15], and Scandinavia can provide useful models of engagement. However, transferable learning, for example sustainable cultural change of the sort that could benefit a European country, can be seen in other health care systems at different stages of evolution [16]. International comparisons therefore support transferable learning in sometimes unexpected dimensions and can provide bilateral benefit.

Wilkens et al. present a rare review [2] spanning several years of international activity involving the Baltics. Such longitudinal reviews show the bilateral benefits of collaboration and the significance of establishing relationships over time. The vision and tenacity of participants is laudable and increasingly relevant as primary care develops to meet the challenges of the twenty-first century centred on health promotion, chronic disease, and personalized care. The use of IT should enable better data collection and collaborative working within and between countries, whereas the costs of appropriate development and support of e-health in primary care may well be best collaboratively shared [17].

The World Health Organization has distinguished community empowerment and de-centralization as processes crying out for research. Wilkens's paper shows that international development and research requires long-term vision and relationships – these do not flourish without long-term (usually government) support. In the twenty-first century the rapidity of information flow globally facilitates health care professionals’ awareness of shared current health issues. International comparisons using various frameworks [18,19] enable sharing of best practice, promote transferable learning, and generate new perspectives. This will ultimately enable a better local grip on the contemporary complexity of health and primary health care delivery.

In the twenty-first century economic climate it is a professional imperative not to “reinvent the wheel”, but to share experience for the common good. Additionally, the contemporary emphasis on global reform moderated by local sensitivity lends itself to international primary care research and development, and above all sustained collaboration.