SEE ALSO definition; health policy; inequalities agenda; needs assessment; power; social determinants of health; zero-sum
The terms ‘upstream’ and ‘downstream’ refer to the level of intervention to positively impact on the health of people. At the individual (downstream) level, people may be treated for a condition using targeted strategies such as drug therapy for hypertension. At the population (upstream) level, public health works to address the determinants of health which relate to the conditions under which people live such as improved income and better access to health services (McKinlay, 1979).
The two terms originate from the analogy of busily dragging drowning people from a flooded river (downstream) without going (upstream) to discover the reason as to why they were falling or being pushed into the river (McKinlay, 1979). Downstream interventions are sometimes considered to be futile and short term whereas the upstream causality thinking has yielded a complex contemporary discussion of attribution of effect that embraces the social determinants of health with a greatly diminished regard to education and personal skills that are seen as individually based (McQueen and De Salazar, 2011).
The terms ‘top-down’ and ‘bottom-up’ are also used in the context of public health and can be sometimes confused with the terms ‘upstream’ and ‘downstream’. Top-down describes concerns that come from those in top structures ‘down’ to the people and offers a more rigid approach that runs the risk of becoming overly controlling. In contrast, a bottom-up approach encourages people to be actively involved in identifying their own needs and then to communicate these to those (above) who have the decision-making authority. In practice, an appropriate balance of both top-down and bottom-up approaches are necessary to provide an open and empathetic style of working that engenders the public’s trust and galvanizes and empowers others to take positive actions.
Whilst downstream interventions are important in themselves, evaluation of the outcome can be difficult. For example, individual counselling to assist smoking cessation will be mediated by broader social structural factors such as poverty and unemployment. The problem is that upstream interventions to improve the circumstances in which people live may not be a sufficient condition to produce health improvements, but may be a necessary precondition for other downstream interventions to be effective. Evaluating single upstream or downstream initiative may therefore fail to capture effects that rely on multiple interventions (Kelly et al., 2005).
KEY TEXTS
•Eberly, D. (2008) The Rise of Global Civil Society: Building Communities and Nations from the Bottom Up (New York: Encounter Books)
•Laverack, G. and Labonte, R. (2000) ‘A Planning Framework for Accommodation of Community Empowerment Goals within Health Promotion Programming’, Health, Policy and Planning, 15 (3): pp. 255–262
•McKinlay, J. B. (1979) ‘A Case for Refocusing Upstream: The Political Economy of Illness’ in E. G. Jaco (ed.), Patients, Physicians and Illness (New York: The Free Press)