Most countries are struggling to meet the growing demand for health care. At the heart of this struggle is an inability to define health as more than just ‘the absence of disease’.

This definition comes from the bio-medical model, a way of thinking that underpins most health systems. Although this model has served us well, in a world increasingly blessed with longer lives and greater understanding of the human body, the presence of disease is becoming a norm – something to be managed as part of living. Through the bio-medical model, the demand for health care, already unsustainable, will only grow.

Our approach to health has to change. Most people in health are aware of this. Through our research, we have learned that many are also aware that current approaches fail to understand how people and communities understand their own health or respond to their day-to-day realities.

These thoughts drive our organization and have led to this report. Our mission is to describe the field of practice that bridges how health systems and communities can approach ‘health’.

We describe the field through a set of principles. The principles are primarily based on the work of the members of the Creating Health Collaborative, an international group of innovators exploring – and creating – health from the perspective of communities.

Since Our Last Report

The principles in this report refine and expand upon those presented in our last report, Eleven Principles for Creating Health, which was published in April 2016. We used the term ‘creating health’ to convey the idea of a broader understanding of health, one that goes beyond the bio-medical model.

Since then, however, we’ve seen the term used as a synonym for the prevention of sickness. In our work, ‘creating health’ and ‘preventing sickness’ are fundamentally different. The former is defined by how communities describe ‘health’. The latter is defined solely by biomedical measures. We have decided, therefore, to stop using the term ‘creating health’ for the principles.

Since our last report, we have learned that, although many health systems are engaged in understanding how they can affect the social risk factors that correlate to sickness, risk factors alone explain only about half of morbidity and mortality. The missing link seems to be whether people have a sense of control over their lives. This requires them to have agency – the ability to make purposeful choices.

This core importance of agency extends to collective agency. A sense of being able to come together to create change is conceivably as core to the health of a community as a sense of control is to an individual’s health.

The 12 Principles

The 12 principles that follow, then, describe a process that fosters community agency. It is an inclusive, participatory and responsive process to collectively agree priorities and derive, implement and evaluate solutions. The principles are:

1. Include in a community’s collective effort those who live there, those who work there, and those who deliver or support services provided there
2. Spend time understanding differences in context, goals and power
3. Appreciate the arc of local history as part of the story of a place
4. Elicit, value and respond to what matters to community residents
5. Facilitate and support the sharing of power, including building the capacity to use it and acknowledging existing imbalances
6. Operate at four levels at the same time: individual, community, institutional and policy
7. Accept that this is long-term, iterative work
8. Embrace uncertainty, tension and missteps as sources of success
9. Measure what matters, including the process and experience of the work
10. Build a vehicle buffered from the constraints of existing systems and able to respond to what happens, as it happens
11. Build a team capable of working in a collaborative, iterative way, including being able to navigate the tensions inherent in this work
12. Pursue sustainability creatively; it’s as much about narrative, process and relationships as it is about resources

Although presented as a list, the principles are a web of inter-related ideas, each needing to be considered in constant context of the others.

Looking Ahead

Although this report is based on the work of the many innovators within the Creating Health Collaborative, it is agnostic to their framing and models. This is intentional. There is a huge amount of activity in the space between health systems and communities. Each innovator faces pressure to sell his or her framing and promote his or her model. Rather than back one or the other, we seek to hold open the space so that many flowers may bloom.

The principles, and the way of working that they describe, are not new – but they are new to many working in health. Our hope is that by gleaning, listing and explaining these principles we’re able to help those in health looking to better include and respond to communities. Implicit to this work is the need to foster community agency.

While it’s difficult and long-term work, we have seen it to be achievable – and worth the effort.