Context: Although the evidence is overwhelming that healthcare is delivered more effectively if one involves the targeted communities in decisions concerning their health, top-down programs still rule the world. Objectives: In order to highlight the benefits of a community-oriented approach, we report the experiences from Ghent, Belgium on COPC styled healthcare initiatives and COPC modelled multidisciplinary education. Community-oriented Primary Care and Education: COPC is a five-step model combining primary health care, public health and community data and resources. The involvement of community (members) is a crucial element in any effort to effectively enhance health (care) in a given community. Small scale examples from two health centers are given. In order to train future healthcare workers to be able to function with the communities, they participate in a one-week interdisciplinary course based on the COPC cycle at the University of Ghent. The COPC program in relation to Its practical organisation, goals and limitations are presented and discussed. Conclusion: In order to reach health objectives set out by disease-specific or health promotion programs, a community-sensitive approach is needed, especially for the most deprived communities. The COPC model offers inspiration and can be a practical tool to work with communities. It is also feasible to create a short COPC exercise to prepare future healthcare workers for complex community work. This model is one of the ways to concretise some of the main objectives of TUFH.

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Context: Collaborative action is required to address persistent and systematic health inequities which exist for most diseases in most countries of the world. Objectives: The Academic NGO initiative (ACANGO) described in this paper was set up as a focused network giving priority to twinned partnerships between Academic research centres and community-based NGOs. ACANGO aims to capture the strengths of both in order to build consensus among stakeholders, engage the community, focus on leadership training, shared management and resource development and deployment. Methods: A conceptual model was developed through a series of community consultations. This model was tested with four academic-community challenge projects based in Kenya, Canada, Thailand and Rwanda and an online forum and coordinating hub based at the University of Ottawa. Findings: Between February 2005 and February 2007, each of the four challenge projects was able to show specific outputs, outcomes and impacts related to enhancing health equity through the relevant production and application of knowledge. Conclusions: The ACANGO initiative model and network has demonstrated success in enhancing the production and use of knowledge in program design and implementation for vulnerable populations.

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Introduction: The Sherbrooke-Estrie integrated cardiovascular health program (SEICHP) was developed in the Canadian province of Quebec. It was among the 12 field projects selected in 2001 around the world by the World Health Organization (WHO) to implement the TUFH (Towards Unity for Health) strategy as a way to improve health development responding to people's needs through integration of health services and partnership among key stakeholders. SEICHP tailored and applied the TUFH approach. It developed comprehensive and integrated services for people suffering or being at risk of cardiovascular problems in its region of influence. It emphasized complementarity, efficiency of resource use, interprofessional collaboration and partnership. In this, SEICHP complied with TUFH criteria. Information on how it adapted and applied these with relative success is reported. Lessons for health development: Even though difficulties in evaluation represent a limitation, major lessons learned linked to TUFH criteria include: the necessity to involve the public health and individual health people at all phases of program development and implementation, including the identification of information to be collected; an emphasis on integration brings health professionals to realize the importance of interdisciplinary work and academic institutions to modify their educational programs; restraining and supporting factors to partnership must be considered purposefully to optimize the partnership process; and optimal assessment of impact is difficult to attain. Conclusion: TUFH gave SEICHP a comprehensive conceptual framework for health development to work with. It had a highly significant impact on its development and provides direction for its future actions.

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Background: In Australia, population health and public health are core aspects of postgraduate general practice training. Aims: This paper describes an academic general practice training post in population health and public health for rural GP registrars in North Western New South Wales. Furthermore, this paper describes how this training post incorporates the principles of "Towards Unity for Health". Methods: In 2000, a collaborative reference group of local and national organisations advised on curriculum development. During training, GP registrars conduct a research project applying population health and public health principles in a rural community. Content and thematic analyses of research documents and GP registrar evaluations were used to provide examples of how this training post incorporates principles of "Towards Unity for Health". Results: The posts have been evaluated and were viewed favourably by registrars, local and national organisations. Six GP registrars have been recruited to undertake this training post since 2001. Their research projects include: smoking cessation, childhood obesity and hepatitis C. After completing this form of training, two registrars have become involved in medical education and three have remained to work in the region. The educational model developed in this project has similarities with "Toward Unity for Health" with partnerships developed between academic institutions and health managers. Discussion: This paper presents a feasible model to train GP registrars in population health and public health skills in a rural region. Further research is required to assess the applicability of this model to other regions of Australia and internationally.

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Context: The devolution of health services from the Department of Health to the Local Government Unit in the Philippines in 1992 led to the deterioration of the management of local health services. The UP College of Medicine (UPCM) has forged a partnership with a Local Government Unit of a rural municipality to implement a community based health program geared towards the development of local health systems. Objective: Program objectives were: (1) to provide learning opportunities for UPCM faculty, medical residents and students in community medicine; and (2) to assist communities develop their health systems. Interventions: In July, 2004, the UPCM jointly drafted a municipal health plan with its partner municipality. Before the actual planning session, the rural health midwives were assisted by the UPCM students in determining the health needs of their communities and in drafting community health plans. The plans were then presented by the midwives in a 2-day planning workshop, and became the basis of the municipal health plan. Main Outcomes: The outcome of the workshop was the first municipal health plan that this health office had drafted. Main outcomes from the implementation of the plan included the organization of the Local Health Board, improved health service provision by the municipal health office, active health committees in selected villages and better learning opportunities for medical residents and interns. Conclusion: Colleges of Medicine in the Philippines can and should play a role in the development of local health systems within the overall framework of Alma Ata Primary Health Care. National health planners should seriously consider this role of the health academe.

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Context: The Uganda Program for Human and Holistic Development (UPHOLD), a USAID-funded project which supports health services in 34 Ugandan districts, was conceived at a time when promising interventions could not be expanded due to fragmented systems. This paper focuses on how the program addressed fragmentation to improve service delivery in the health sector. Approach: UPHOLD achieved results by utilizing grants and technical support to strengthen capacity in a decentralized setting to foster institutional behavior change, promote strengthened partnerships among stakeholders in health, and produce increased transparency and accountability. In addition, the Lot Quality Assurance Sampling (LQAS) survey methodology was institutionalized to promote a culture of evidence-based decision-making at the district level. Results: Evidence-based decision-making and partnership-oriented implementation led to programmatic results and institutional behavior change in districts through synergetic relationships between local governments and Civil Society Organizations. The use of Insecticide Treated Nets increased from 11.2% in 2004 to 17.2% in 2005, clients utilizing HIV/AIDS counselling and testing services increased from 6,205 in 2004 to 85 947 in 2005 and using Lot Quality Assurance Sampling methodology has begun to positively influence district and national staff mind sets leading to more evidence-based planning and decision-making. Conclusion: The pillars of 'evidence-based decision-making' and 'partnerships', together with approaches which strengthen existing synergies, produced more results, faster. Programs designed to work with fragmented settings should consider using the same pillars and blocks to ultimately make a difference in the lives of program beneficiaries.

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Context: In 1999, Towards Unity For Health developed principles for patient-based health systems which included partnerships, raising the level of partnerships, integration of individual, population and public health, information management and measurement of outcomes. Objective: To address the health workforce crisis in an area of remote north western New South Wales (NSW) in Australia. Method: The NSW Rural Doctors Network applied the TUFH principles in overcoming much of the crisis and developing an ongoing local health system which has answered many of the local needs. Conclusion: The project provided experience for policy change and development at both State and National levels.

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Context: This paper describes a unique experience in community-based primary care in the Barceloneta, an economically deprived neighbourhood in Barcelona, Spain. The paper analyzes the reasons for the successes and failures of the project in light of TUFH principles. Methods: The Primary Care Team (PCT) that staffed and ran the Health Centre in the Barceloneta facilitated the active participation of entities and individuals from the neighbourhood in deciding questions of care provision and resource allocation. They also collaborated with other service providers in the neighbourhood including pharmacists, with whom the PCT developed a program for monitoring diabetic and hypertensive patients in the local pharmacies. Results: The health centre registered some of the best outcomes in Barcelona, including: time spent with each patient; capacity for the physicians to resolve patient visits without a referral; and patient satisfaction. Outcomes for patients followed by their local pharmacists were equivalent to those seen in the clinic, with lower costs. Despite these impressive results, conflicts among and between various stakeholders led to the project's termination. Conclusions: Innovations in any system can lead to conflicts of interest between stakeholders, derailing even demonstrably effective programs. A stable partnership with other stakeholders, particularly the community and health care administrators, in this case, is key. However, the community is not monolithic, and efforts must be made to ensure that other stakeholders do not widen intercommunity disputes. Effective dissemination of information on the impact of the project on the population is important to maintain relationships with the various stakeholders.

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Context : Breast cancer is the most common non-skin malignancy among U.S. women. Vulnerable populations such as low-income women, racial/ethnic minorities, and the uninsured have lower rates of screening mammography use and bear a disproportionate burden of disease. Objectives : The Breast Cancer Education Project (BCEP) was created to address the needs of medically underserved women in Cook County through high-quality breast cancer screening, education and support. The BCEP also provides a service-learning opportunity in which medical students can provide a valuable health service while obtaining important skills that enable them to work more effectively within medically underserved communities. Conclusion : The BCEP is an innovative collaboration between academic medical centers, safety-net health systems, community based organizations and public health organizations. It represents a model for addressing issues of disparate access to breast cancer screening within vulnerable communities that contribute to higher breast cancer mortality.

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