摘要：Community-oriented primary care (COPC) developed and was tested over nearly 3 decades in the Hadassah Community Health Center in Jerusalem, Israel. Integration of public health responsibility with individual-based clinical management of patients formed the cornerstone of the COPC approach. A family medicine practice and a mother and child preventive service provided the frameworks for this development. The health needs of the community were assessed, priorities determined, and intervention programs developed and implemented on the basis of detailed analysis of the factors responsible for defined health states. Ongoing health surveillance facilitated evaluation, and the effectiveness of interventions in different population groups was illustrated. The center’s international COPC involvement has had effects on primary health care policy worldwide. FOR MORE THAN 25 YEARS beginning in 1970, the feasibility of applying the principles of community-oriented primary care (COPC) was demonstrated in different forms of primary health care practice at the Hadassah Community Health Center in the Kiryat HaYovel neighborhood of western Jerusalem. 1, 2 COPC was based on principles of social medicine developed by Sidney and Emily Kark in rural South Africa in the mid-20th century 3– 5 and brought by them to Israel in 1958. This pioneer development of COPC occurred against the backdrop of 3 major features of primary health care in Israel at that time. First, the health service providers, with whom nearly the entire population was insured, responded only to demand for care. Second, primary health care involved very limited health promotion and disease prevention primary health care services, especially for adults. Third, an extensive network of mother and child health centers focusing on preventive services existed throughout the country, and this network was organizationally and functionally separate from the curative care system. The COPC approach that grew out of primary health care in Israel and the concepts developed in rural South Africa were conceptualized as “a continuous process by which PHC [primary health care] is provided to a defined population on the basis of its defined health needs by the planned integration of public health with primary care practice.” 6 This approach involved a recognition that, in line with the World Health Organization definition of health as far more than absence of disease, health services should be responsive to health needs in the widest sense and should be flexible in their response to changes in these needs. In addition, health services’ responsibility is to the health of all members of the defined community and the subgroups entitled to health care, irrespective of whether or not they seek it. The basing of health care planning and delivery on assessed health needs was achieved by the introduction of epidemiology as a central feature of the Hadassah Community Health Center’s practice. These epidemiological skills were necessary to answer what Sidney Kark labeled the “five cardinal questions” that formed the strategic basis for the development of COPC 1 : What is the community’s state of health? What are the factors responsible for this health state? What is being done about it? What more can be done, and what is the expected outcome? What measures are needed to continue health surveillance of the community and to evaluate the effects of existing programs?
