Community-centered Health Care
The United States' health-care system combines impressive innovation and product development with business practices that disadvantage many Americans. On the one hand, our system yields great achievements; new drugs and medical products tackle difficult illnesses, fix major problems such as heart defects, and improve function for the disabled. On the other hand, many people dislike — even hate — how difficult it is to navigate this system. Although it is a global leader, the American health-care system is more costly and less effective than it could be. What might alter this imbalance and enable "health care" to better promote health?
Epidemiologists identify five principal determinants of health and well-being: education, social networks, physical environment, economic security, and professional health care. Put differently, our overall health outcomes depend much more on our social and material contexts than our individual access to health-care professionals. Yet as currently constructed, our health-care system does not nurture mutually enhancing relationships. Nor does it address the neighborhood effects that shape health determinants. Relatively few health-care dollars go toward bolstering the place-based social bonds so crucial to our well-being.
We depend too much on large placeless systems offering services, and not enough on local place-based stewards extending care. The fee-for-service model creates a structural bias toward increasing treatment, with few incentives promoting health creation. This bias has fed the exponential expansion of diagnostic labels and prescription drugs. In 2024 the New York Times reported that a growing percentage of Americans were taking three or more different classes of psychiatric medications. Illegal "non-prescribed" drug use is also a concern, as people learn the habit of medicating their personal problems. Erica Komisar says of American kids: "We're using medication as a long-term fix. We're not getting to the origin of the stress." We can say the same about many vulnerable segments of the population.
Instead of relying on medication just to cope, we should encourage the co-creation of health in the places we call home. More and more studies highlight the link between our relationships — including neighborhood belonging — and health. While poverty explains part of the health-care paradox, people who lack supportive community are most affected. Health outcomes worsen when families turn to professionals rather than neighbors, when the mentally ill are transferred to large institutions rather than supported by relationships in neighborhoods, and when the elderly wither in hospitals rather than participate in communities of care. Costs rise for the health-care system and dissatisfaction spreads in the community.
Debates about health-care reform usually become disputes about insurance coverage, but the deeper questions we must ask concern the proper balance between local, in-person community and the large systems that make up the sector. The remarkable gains of the past century show the necessity of those large systems, but meanwhile we have neglected our communities.
This neglect affects every American, diminishing a sense of individual agency and belonging. Residents with serial crises seek coping mechanisms or quick fixes. Cormac Russell notes how this alienation amounts to "displacing [people] as agents in their own lives," leading to "patronizing institutional interventions." A citizen becomes a client. This diminution of the individual also wounds our locales, for communities rely on sturdy citizens and committed local stewards to flourish and to mentor the next generation. Improving this country's health-care system must start by treating individuals less as hapless patients and more as dignified community members.
CO-CREATING, NOT PROVIDING
The American fee-for-service model centers around the individual, providing few incentives for insurance companies, hospitals, and other providers to take a place-based approach. Finding examples of such place-centered care in the United States is challenging.
For the market to value population health, corporate incentives — if not profits, then financing or outcome-based payments — must be tied to how healthy people are in specific geographies. In the American context, this is only likely when either a single insurance company covers, or a single hospital treats, a significant proportion (say, half) of the people in an area — with expenses linked to resident health. For example, some rural areas have only one health-insurance company. In Hawaii, only one or two insurers serve most of the market. Where hospitals treat nearly everyone living in the surrounding area, they could receive fixed payments per resident.
Few American health-care companies, then, feel any "ownership" of specific places. Instead, they are siloed, focusing on one service specialization (e.g., cardiology), or a small percentage of the population, resulting in fragmentation and misaligned incentives. To find examples of what a different approach might look like, we must travel overseas.
Singapore, home to one of the world's best health-care systems, offers an alternative, place-based model. Facing an aging population, rising prevalence of chronic diseases, growing strains on its health-care system, and ascending costs, Singapore's Ministry of Health has steadily shifted the focus from health provision to health co-creation. This strategic shift was encapsulated by the 2017 announcement of its "Three Beyonds" strategy: beyond health care to health, beyond hospital to community, and beyond quality to value. As part of this initiative, Singapore's government restructured its six regional health systems into three large, public, integrated health-care organizations.
Yishun Health is part of the National Healthcare Group (NHG), one of these big three. Centered on its anchor hospital, Khoo Teck Puat Hospital (KTPH), which serves about 550,000 people, it has gone further than its peers in rethinking its approach. Building on NHG's 2019 River of Life strategy to build "capacity and capability," this network shows what a community-centered approach looks like in practice and how it differs from a "coping community."
Yishun Health's transformation sprang from a recognition that higher efficiency or more inpatient and ambulatory services would not address the rising demands on its system. Many patients, including lower-income residents, sought health care on a purely reactive basis, resulting in late and highly expensive care from inpatient services at the emergency unit. Stays were short, and the underlying social determinants of health went under-addressed. Older patients often needed continuing care within their neighborhoods that the organization could not adequately provide. Meanwhile, the community care that once played a large role in people's lives had diminished.
Yishun Health incrementally transformed itself through an asset-based community-development strategy. This approach galvanized residents to undertake communal health-creating activities on their own, strengthening social bonds and interfamily networks in the process. The effort began in 2011 with a series of conversations with residents. A report by Dr. Wong Sweet Fun, who led the strategy, details "a fundamental shift in the way we saw residents." The organization looked "beyond the walls of the hospital" to treat residents differently, not simply as potential patients but as community members who co-create their own care and only occasionally need hospital care. The goal was turning providers into facilitating supporters rather than central actors, and integrating care across health, social, environmental, and behavioral domains in the Yishun and Sembawang areas of northern Singapore.
This model identifies and enhances assets within rather than seeking problems for outside entities to address. It works in a defined geographical area — a neighborhood — and leverages groups of people bonded by common interests; local institutions; built infrastructure; relational networks; and residents' stories, culture, and heritage. Residents are the best assets, for they contribute their talents, skills, experience, and time. These people, not service providers, own their health — and that of their neighbors. This deepens belonging, cohesion, and a sense of agency. The more residents work together to foster health, the less need for intervening systems.
This is population-health strategy at its best. Dr. Wong writes: "Residents are active producers of health, not passive recipients of care...participat[ing] in each other's lives instead of being isolated at home." Community life not only "instill[s] a sense of personal achievement," it also reduces "life stressors" and bolsters "support circles and safety nets...raising the threshold for" calls to medical personnel. This decreases the effort, funding, and manpower required from the health-care system.
REVERSING ROLES
Based on Yishun Health's experience, it takes four stages for providers to switch roles and become supporters of co-creation. First, the organization moves its resident-engagement efforts from a distant location (such as the hospital) directly into neighborhoods, establishing "community nodes," or centers where residents can meet and check in with each other. Activities include cooking, eating, learning, exercising, and having fun, with time for socializing and much tea and coffee to boot. And there are many more groups and offerings: volunteer hairdressers, moms' groups, meal delivery, health coaching, community cooks, life skills, games for kids, dance groups, community gardening, repairing household items, reading groups, sewing, swimming, and singing. Share a Pot, which incorporates the Asian customs of communal eating and exercising and the health benefits of traditional bone soup, plays an especially important role in delaying frailty in the elderly.
Second, the organization promotes an abundance of diverse activities rather than a few flagship programs. This ensures all residents can find something they like. Participation levels become a good indicator of success. Moreover, as participation grows, residents start new initiatives. This further promotes resident participation while giving them a voice concerning decisions that affect their lives. Daily routines give stability, and help residents establish robust, overlapping social networks. The closeness — participants typically live within about 300 yards or a few blocks — lowers barriers to joining.
For example, residents turned a neglected corner into a community library and meeting point. First, a resident placed a shoe cabinet in the area for use as a bookshelf for children gathered for a regular reading activity. Then, three retirees living nearby decided to expand it into a library. As 67-year-old Chia Kam Poi said, "It was just a small shelf of books, but I thought we could do better." Applying skills learned at a neighborhood woodworking class, they turned discarded furniture into shelves and tables. The three then asked friends for donations, collecting more children's books plus more than a thousand magazines, comics, and books in multiple languages for neighbors of all ages to use. It works on an honor system. Since the space's establishment, other neighbors have given clothes, toys, and snacks for others to take as they need. A local high school donated an additional thousand books. An informal message board has been established as well as Facebook and Instagram pages. "It has gone beyond being just a library — people have taken ownership of this space," reflected Chia.
If anyone needs assistance to socialize or participate — due to shyness, limited mobility, or weak ties to their community — Yishun Health's staff connectors introduce them to community groups or accompany them to activities. The goal is to anchor people in community in a lasting manner, allowing neighborhoods to undergird health. As neighbors know each other better, they become one another's agents of introduction and accompaniment, lessening the need for Yishun Health's involvement.
This process leads to the third stage: Health-care providers begin to remove themselves as their connecting work gets accomplished. Meanwhile, more community nodes are established to increase the frequency and regularity of participation, boost social capital, and enhance mutual care. There are 39 such nodes as of this writing.
In the fourth and last stage, the community becomes self-sustaining, with residents initiating and leading in restored roles as citizens and residents. The need for outside help subsides: A Regional Team of nurses and connectors continues to meet residents at community spaces but in a supplementary capacity. When a need arises, the first place to go is the local Community Health Post rather than a distant facility.
The Yishun Health approach contrasts with social prescription, which is transactional and driven by systems. Instead of referring people to activities, Yishun Health encourages residents to produce them. Instead of merely leveraging community, it seeks to bolster it. And instead of looking for ideas anywhere, it looks to the neighborhood. The result is a more self-sustaining ecosystem.
This new health co-creation model remains in an early stage, serving only a portion of the target population and thus lacking comprehensive data. However, early indications show promise. One study of low-income residents living in public rental blocks showed significant reductions in emergency-room admissions (-25%), acute admissions (-35%), and average length of hospital stay (-39%). A second study revealed an even greater reduction in each category (-44%, -56%, -66% respectively) for those receiving additional support from the hospital-to-home program. Demand for health-care services is dropping. Success is visible on the streets. Good neighborliness gives everyone the chance to stay socially engaged and connected.
FREEDOM AS THERAPY
For another model abroad, we can look to Trieste, Italy. Trieste shows how a whole city can build an alternative, community-based model for addressing mental-health challenges. Recognized by the World Health Organization as an exemplar of community-based mental-health care, the Trieste model sharply contrasts with approaches elsewhere. While the Trieste model's focus is narrower, many of the principles used by Yishun Health apply. Community stands at center stage, with health-care systems assuming a supportive rather than dominant role, nurturing social ties before seeking medical solutions.
Franco Basaglia, who took over as director of the city's psychiatric hospital in 1971, pioneered the Trieste approach. He believed in treating people who have mental-health challenges with dignity and respect, not marginalizing them from regular social life. "Freedom is therapeutic," goes one of his mottoes. He understood that while some people with mental-health challenges need medication, therapy, and possibly even institutionalization, most need changes in their social contexts — stronger communities and more accommodative classrooms and workplaces.
The discovery of psychiatric drugs, the civil-rights movement, and rising costs, among other factors, drove a deinstitutionalization movement across the West in the 1960s and '70s. In countries such as the U.S. and U.K., a sharp drop in mental-health resources followed the closure of facilities. Trieste, by contrast, saw a sharp uptick in community care and services, meaning no decline in overall resources. When the city's asylum was shuttered in 1980, the province systematically redirected its funds into the community, blurring the line between the community and the health-care system.
There are four core features of the Trieste model. First, it centers on communities, with a network of community mental-health centers largely open 24/7. Horizontal relationship building occurs between staff and users (their term for "patients"), rather than the traditional hierarchy of staff over clients. Centers are casual: no white coats or nametags, no referrals needed, and no bureaucratic hurdles to overcome. A warm, club-like feeling permeates, welcoming users to drop in as needed to grab lunch, to meet with therapists or friends, or to acquire medication.
Second, this model emphasizes social recovery with the end goal of full participation in the community. This mission not only spurs users to work on their own recuperation, but it also brings great therapeutic value. Social connections and kinship ties play an important role.
Third, whole-person care supports residents in their daily needs and life plans. This includes housing, which is integrated into the program. Options range from independent living to family-style arrangements to special residences. The person's whole life and needs, not just a fixed conception of what's wrong, structures care. This approach does not downplay disorders but sees them as only one part of a larger picture.
Lastly, peers offer support, guidance, and wisdom gleaned from their own experiences. Peer involvement helps staff steer people away from hospitals or incarceration, both of which cause great psychological damage. Instead, they are guided toward more home-like short-term housing managed by peers. As Andy Young writes for Nursing Times in the U.K.: "Good mental health is rooted in social cohesion, not the individual."
The system and its individual practitioners practice accountability to the needy instead of leaving people to navigate health care's complexities alone. Heart Forward, a Trieste-inspired mental-health charity in Los Angeles, summarizes what the model promises: "We will catch you if you fall. You will be served by familiar faces who won't lose you." For example, if someone is hospitalized at a central facility, someone from that person's local center will visit and attempt to reintegrate him.
The result is a strong support structure helping with everything from early warning to employment. This structure features an acceptance of those living with mental challenges as full members of the community. This can mean organized public events — a poetry festival, say — that incorporate people fresh from the hospital, assuring them of their valued place in the neighborhood.
If someone suspects a need, help is close by. For example, a man worried about his mother — she was older than 80, suffering from bipolar disorder, and had been in a manic, sleep-deprived state for days — reached out to the community mental-health center in the Trieste suburb of Maddalena. A psychiatrist, along with a nurse who had cared for the woman for years, visited her home and sat with her for two hours, finally convincing her to take her medicine. They then worked together to establish a schedule of daily home visits that honored her desire to not go to a hospital.
As the preceding story shows, this approach forswears coercion and isolation — techniques commonly used elsewhere for patients in crisis. On the contrary, "relentless negotiation" takes places, sometimes across multiple visits. Only 18 patients were treated against their will out of the nearly 5,000 whom the Trieste Department of Mental Health served in 2018. Friends and family are welcome to visit facilities. The spaces are inviting and casual, "comfortable rather than clinical," reflecting the emphasis on hospitality and a family ethos.
UNDENIABLE RESULTS
The model is working. Trieste, once blighted by the highest suicide level in Italy, has seen that figure significantly decline. Only two people staff a special office handling cases of mentally ill persons committing violent crimes. Whereas Trieste and Gorizia once had 1,200 mental-hospital beds, today these provinces have only a handful of beds (46 for 360,000 people). Yet the area suffers no shortage, nor does it maintain waiting lists for treatment. Alessandra Oretti, acting director of a psychiatric service for the two provinces, says that "[t]he elimination of bureaucratic hurdles is part of the reason for the [lack of] waiting lists" because problems are often addressed before they escalate. The percentage of the Italian national budget that goes toward mental health ranks among the lowest in the developed world at just 3.5%.
The Trieste model contrasts with the U.S., where the focus for individuals with mental-health concerns is "crisis stabilization" without much intentional community support. As a result, American neighborhoods suffer from crisis upon crisis. System services are fragmented — there is a separate department for mental health, housing, jail, and so forth — without much coordination around the person, leading to isolation. Many mentally ill persons end up in jail or on the street, where they comprise a disproportionate share of both populations. In Los Angeles, for example, more than one-third of the county-jail inmates are mentally ill people without access to the services they need.
Meanwhile, mental-health advocates focus on scaling up services and increasing the rights of the mentally ill, or treat biomedicine as the answer. Not much emphasis is placed on community. As with many individuals in elderly care, people may appear physically stable but are fundamentally unwell and unfree, their independence and citizenship compromised.
Beyond the constraints that burden so many lives, the American health-care system exacts a severe longer-term financial toll that rarely receives consideration. Allen Frances, former chair of the department of psychiatry at Duke University School of Medicine, concludes:
Neglecting people with mental illnesses greatly increased costs for police, prisons, hospitals, emergency rooms, nursing homes, and services for the homeless. Indifference to the suffering of people with mental illnesses is not only inhumane, it has economic consequences.
If the well-being of our fellow citizens weren't reason enough, financial risks heighten the urgency of reform efforts.
PURPOSEFULLY UNPRESCRIBED
What can Yishun and Trieste teach us about co-creating health? And how can American health-care companies, government leaders, philanthropists, and others help those principles take root here? While the obstacles to change in the U.S. appear daunting, there are several lessons we can take away from successful shifts to a community-centered approach in Singapore and Trieste.
First, we need to change the incentives facing health-care organizations. As long as profits and financing depend on diagnoses, tests, and treatments, industry organizations will seek to increase them. Only altering incentives or developing new ones can change this. In the Singaporean case, the territorial nature of Yishun Health automatically gives it a vested stake in facilitating resident co-creation of health.
What would create a similar dynamic in the U.S.? Several possibilities exist. These include creating more place-based, integrated health systems, and incentivizing insurance companies or hospitals that cover a high enough share of a geographic population to play a stewarding role in the health of neighborhoods. Policymakers should establish "pay for results" programs that incentivize companies in or out of the health-care sector to boost neighborhood-wide health (e.g., Medicaid capitation contracts that pay hospitals a fixed, predetermined payment per patient). They should also seek novel ways to reward residents and health-care organizations that enhance their locales, perhaps in the form of neighborhood health-savings accounts that accumulate funds as health-care costs decline.
Second, the more health-care offerings are embedded within neighborhoods and involve residents, the more effective they will be. In both the Yishun Health and Trieste cases, the goal is to go "beyond the walls of the hospital" and act as members of the community, providing as light a touch as possible to those in need. Both Yishun and Trieste established health-care nodes — clinics or centers — within neighborhoods and prioritized informal relationships with residents.
Both health systems also blur the role of professional provider and citizen user, creating a more equal relationship in the process. They proactively encourage family and neighbors to step into each other's lives. The professionals live as neighbors, interacting without nametags and uniforms. This reduces barriers to interaction and deformalizes health spaces. They go beyond traditional health-care services, working with other sectors as needed and keeping an open-door policy. In both Singapore and Trieste, organizations invest staff and money in ways that empower residents, gather neighbors, share space, instigate community groups, and foster social connection at every turn.
Third, government, corporations, and philanthropies in the health-care sector should devote a larger portion of their spending to initiatives encouraging neighborhood-based co-creation of health. Yishun Health, which "owns" its geography's whole-population health in a way Trieste does not, shows what this might look like. So does the Greater Rochester Health Foundation's Neighborhood Health Status Improvement initiative, a New York state-based example that invests in community animators and builders to enhance social connectivity block by block in and around the city. Relatively modest investments in place-based social generation can yield large cost reductions.
Lastly, we can step back from labeling people with specific illnesses. Over-diagnosis converts citizens with much to offer society but who occasionally use health services into passive dependents on professional clinics. This situation risks transforming them, in Cormac Russell's words, into "a psycho-medical puzzle beyond the capacity of the unqualified individual or their community to understand or heal unless a professional's expertise is sought to bring it under medical control."
The subjectivity of many diagnoses amplifies this danger. Too often, we view diagnoses like Attention-Deficit/Hyperactivity Disorder (ADHD) as clearly defined and identifiable when in fact they aren't straightforward medical conditions. ADHD in particular is described in vague terms open to various interpretations and subject to powerful commercial pressures. Prescribers usually possess limited information about causes and about solutions beyond medication.
Trieste's approach limits the downsides of overdependence on professional support. As the multiplication of diagnoses has triggered an embrace of labels among today's youth, Trieste resists the false binary that classifies someone as "normal" or "abnormal." We all lie on a spectrum, normality is somewhat subjective, and neurodiversity inheres in the human condition.
Policymakers, philanthropists, and health-care companies should instead ask: How can neighborhoods best co-create health, and what policies will enable residents and local groups to accomplish this better? Where they cannot act alone, how can these place-based groups most benefit from outside support, and what is the best way to provide assistance? How can professionals proffer needed help in ways that do not undermine community efforts? "It's exciting and inspiring to see Yishun Health shifting from crisis management to capacity building," notes Ralph Broad, director of Inclusive Neighborhoods Ltd. "A strong health system is one that helps people to not need it, or to need less of it — purposefully unprescribed." The aspiration of America's health-care system should be similar: purposefully unprescribed citizens.
TOWARD A COMMUNITY FRAME
Who might jumpstart such change? The U.S. Department of Health and Human Services could design a set of pilots producing enough good data to encourage collective federal and state action. Alternatively, an enlightened governor or hospital-system leader could work to change incentives at the state or local level. Insurers could strategically choose to focus on the health of specific places, including adopting neighborhoods. An urban government could invest in neighborhood community building not only to foster health, but also to reduce crime and school drop-out rates. Place-based philanthropists could seed pilot programs and incentives that reshape the priorities of health-care companies in their regions.
While skeptics may argue that Americans are wary of communal solutions to social problems, our history suggests otherwise. From the early days of settlement through the 1960s, the country boasted a rich local associational life. This civic culture encouraged people to support each other and solve problems organically, with a limited role for government and big, outside service providers. While individualism thrived, so did mutual support. Today we see those two things in conflict, but historically, society's strength nurtured risk-taking and self-reliance. Restructuring health care so neighbors can co-create health together would recover this dynamic.
Health-care costs are rising and rising. Growing personnel shortages plague areas such as mental health and geriatric support. The American population is aging, while the young suffer worsening mental health. These challenges demand that we step outside our sickness frame, in which we view health primarily in terms of what is wrong, and learn from the Singapore and Trieste approaches. There, a community frame shows us how to see what each person can contribute to his and others' health.
Adopting a community frame would not only bolster the co-creation of health but reduce dependence on costly, professional systems, empowering citizens and revitalizing the neighborhoods where they live.
