Community health-improvement collaboratives, which represent both health care consumers and health care providers in efforts to improve health care systems at the local level, are becoming a major force for improving health care systems throughout the world (1-3). However, many authors have argued that members of local collaboratives must unite around shared principles in order for their efforts to be successful (4-7). This article describes the development of a set of ethical principles, based on essential health needs, that can serve as a common foundation for collaboratives attempting to improve local health care systems.

Many nations have already organized their health care systems according to principles chosen to help them best meet the needs of consumers. For example, Canada based its health care system on the principles of comprehensiveness, universality, portability, accessibility, and public administration (8). Similarly, the proposed Clinton health plan (9) and Newt Gingrich's recommendations for transforming the U.S. health care system (10) both placed basic ethical principles and fundamental consumer health interests at the forefront.

In early 2000, as a small group of community leaders in Memphis, Tennessee, considered how to reorganize regional health systems to better meet the needs of their community, they sought to articulate principles that communities could use to improve the health of community members. These leaders served as the founding board for a newly incorporated nonprofit Memphis health-improvement collaborative that was to become the Healthy Memphis Common Table. The founding board's first step was to form a diverse, 12-member interdisciplinary team that included the 9 founding board members and 3 additional community representatives. The board consisted of four experts in pertinent areas (health care policy, preventive medicine, international health insurance finance, and ethics), three consumer representatives (a small business owner, a person with a chronic illness, and a faith community representative), a primary care physician, and a specialist physician. The three additional members added to the interdisciplinary team were an attorney with expertise in corporate health care, a political scientist, and a nurse. This team led a 5-year process to identify the principles that can best guide health care providers, payers, and consumers toward common goals related to the health of community members and to the quality of the health care that they receive (Table 1).

Team members began by brainstorming at a group retreat during which they produced a preliminary list of potential core principles. They then conducted independent literature reviews to identify ethical principles articulated by other health care systems and shared their findings with all team members. The group next identified a list of core ethical principles that other systems had in common and merged this with the preliminary list. Team leaders then refined this augmented list of principles with facilitator assistance. During near monthly meetings, the team continued to refine its list of principles through a consensus process until team members reached agreement on what the principles should be and how they should be worded.

The principles identified during this process were adopted as the founding principles of the Healthy Memphis Common Table, a healthy city collaborative for the Memphis metropolitan area (11-13). In November 2003, the Healthy Memphis Common Table organized a summit at which it presented the principles to community leaders. At the end of the summit, in a public ceremony attended by more than 300 health care leaders, the chief executive officers of all the major area hospitals, together with government, public health, physician, consumer, and faith community leaders, publicly signed a pledge to uphold the principles.

Following the initial publication of the principles, the Healthy Memphis Common Table board conducted a second group consensus process to consider additional public input and formulate an acronym for these principles that would be useful in disseminating them to the public. The acronym they came up with, HealthCARE (health plus choice, access, responsibility, and education in health care), depicts the health care principles shared by health care consumers, providers, and payers (Table 2). These principles provide a framework for bringing everyone together in a spirit of cooperation around a "common table" to improve the health and health care of the community.

The following principles are based on what people need from a health care system in order to flourish. The broad acceptance of such needs-based principles requires that community members share a basic conception of what minimum standards for human health and health care will be sufficient to enable them to pursue happiness without outstripping their community's ability to provide what are determined to be necessary services.

Since affirming the HealthCARE principles, the community partners of the Healthy Memphis Common Table have worked together to launch a community-wide obesity and diabetes initiative. This effort has been directed by a community partners council that includes representatives from health care consumers, small and corporate businesses, government entities, schools, hospitals, health care providers, insurance companies and health plans, quality improvement organizations, universities, trade groups, media, fitness centers, youth groups, faith-based organizations, not-for-profit agencies, and medical advocacy and support groups (19). Several competing major providers are working together for the first time on this initiative, and more than 15 multidisciplinary action teams are working through community partner organizations to build community awareness about the health risks of diabetes and obesity, as well as to augment community screening efforts, improve obesity and diabetes management, and demonstrate a business case for health promotion efforts (13). The Healthy Memphis Common Table is also expanding current efforts to improve chronic disease care in the Mid-South region of the United States by publicly reporting information on the quality of health care and by engaging consumers and providers in efforts to improve the quality of care. These efforts are now part of the Robert Wood Johnson Foundation's national Aligning Forces for Quality program to engage consumers, physicians, and payers in improving health care quality (20).

Health care principles, such as those of HealthCARE, provide a framework on which communities can base their expectations for justice in health care and develop health care systems that are accountable to community members and committed to the good of society. By rallying communities around common goals, healthy city collaboratives can help improve local health care systems, but to be most effective and overcome divisions that afflict the health of our communities, these collaboratives must foster broad participation and consensus among community members. Because of the local nature of many health issues, communities should adopt, affirm, and adhere to health care principles that hold all community members ― consumers, providers, health care administrators, insurers, businesses, government entities, and other institutions ― accountable for the health of people in their own neighborhoods.