12.9 Structures and strategies for public health intervention
Oxford Textbook of Public Health
Structures and strategies for public health intervention
Don Nutbeam and Marilyn Wise
Policies and interventions to address the determinants of health in populations
Determining priority and direction: setting health goals and objectives
The United States: Healthy People
Stimulating action to address goals and objectives
Developing public policy for health: the challenge to improve intersectoral action
Investing for health as a model for intersectoral action
Developing infrastructure and delivery systems for public health interventions
Key elements of infrastructure for public health
The earlier chapters of this book confirm that the scientific base for public health is substantially developed. However, to be effective, the science of public health must be ‘applied’. The twenty-first century brings with it the need to improve the effectiveness of public health action further—to apply existing knowledge and strategies of public health intervention to all sectors in order to achieve improved health and well being for all.
To do this there needs to be health policy that links a nation’s investment in its health sector with improved population health outcomes. Such policy should also provide a mandate for the use of the full range of public health strategies (as well as health care services) to achieve these outcomes. There must be an infrastructure for public health that provides public health leadership, and contributes directly to the policies, institutional development, and programmes that are necessary to deliver improvements in the health of populations, and to reduce the inequities in health, which have been identified and explored in other chapters.
This chapter describes key elements of health policy and strategy that have been found to be effective in guiding national public health action, and the components of an infrastructure that is necessary to enable countries and communities to design, deliver, and evaluate public health interventions.
Figure 1 provides an overview of the essential elements of the chapter. Based on analysis of experiences in several countries, Fig. 1 traces the steps which link identification of the determinants of health, through definition of priorities and development of policy, to the infrastructure and delivery system required by health sectors (and governments) to guide and implement effective public health action (National Health and Medical Research Council 1997a; International Union for Health Promotion and Education 1999).
Fig. 1 Overview of an infrastructure for public health intervention.
Figure 1 illustrates the importance of establishing an infrastructure and delivery system for public health as the foundation that enables governments to apply public health science both to the analysis and investigation of public health problems, and to the design, delivery, and evaluation of public health interventions. The infrastructure includes the capacity to link evidence of the effectiveness of these public health actions to a process of regular review and redefinition of problems and priorities for public health and for related policy.
Following the structure in Fig. 1, the chapter explores the need for an initial analysis of the full range of determinants of public health problems—economic and social, alongside behavioural and environmental. This analysis can then be used to guide the selection of priority population health outcomes—expressed as goals and objectives. It goes on to explain the ways in which such measureable outcomes have been used as a benchmark against which investment in health (public and private) can be assessed. It also outlines ways in which goals and objectives have been helpful in guiding action with other sectors to develop public policy and to develop and implement tools such as health impact assessment.
The chapter concludes with an overview of the capacity needed by the health sector (and government) to direct and guide action to improve the health of populations. Examination of the history of public health in industrialized countries indicates the need for constant vigilance on the part of public health professionals and activists. This is to ensure that governments’ investment in health continues to include a focus on action to protect and promote the health and well being of populations, and that governments maintain and develop their capacity to act effectively to achieve health for all.
Policies and interventions to address the determinants of health in populations
Earlier chapters describe a range of personal, social, and environmental factors that are related to increased risk of disease, and of adverse outcomes from disease. Analysis of the determinants of the health of populations is essential to clarify the relative importance of each, and to identify those that are modifiable through public health intervention. These determinants include individual characteristics and behaviours, such as smoking and diet, which have been the focus for the majority of public health interventions in developed countries to reduce the burden of non-communicable disease in the population.
Epidemiological analysis also reveals major differences in disease experience between different groups in the population with different social, economic, and environmental circumstances. Although some of these differences can be explained by differences in individuals’ health-related behaviours (such as tobacco use and food choices), more of the difference is explained by the different social, economic, and environmental circumstances in which people live and work (Evans et al. 1994; Marmot and Wilkinson 1999).
In the case of coronary heart disease, Marmot’s work in the United Kingdom has indicated that a high proportion of the variance in premature deaths between different social groups cannot be adequately explained by known behavioural and other personal risk factors (Marmot and Wilkinson 1999). Some other factors are at work, and these appear to be related to differences in the social status and economic conditions of different populations.
Effective policies and interventions to modify these social, economic, and environmental conditions, have the potential to produce even greater gains in health status than those attributed to changes in lifestyles and improved health care in many developed countries in the past two decades.
In many ways this is not a new discovery. Creating supportive environments for health has been a major goal of public health policy and action for the past 150 years. Environmental interventions to provide clean water and waste disposal, safe food, and safe living and working conditions led to major improvements in public health in industrialized countries. The implementation of effective mass immunization programmes has been effective in reducing morbidity and mortality among children in many developing countries throughout the twentieth century.
However, during the twentieth century the very success of public health policy, research, and practice meant that it became ‘invisible’ in many countries. In industrialized countries, the policies, strategies, and structures that had been so effective in reducing mortality and morbidity across their populations were in decline by the middle of the twentieth century. The great proportion of health sector investment was (and remains) largely in biomedical intervention. Public health interventions have tended to become marginalized, and rather narrowly focused on the identification of biological and behavioural risk factors for non-communicable diseases—followed by interventions that aimed to change individuals’ lifestyles.
By the late 1970s it was becoming increasingly obvious that national investment in health in most countries was, in reality, investment in services to diagnose and treat ill health. Progress towards improving the health of populations was limited, particularly in light of the fast-increasing expenditures on health care services. Limited public health interventions to address behavioural risks were having some impact on the lifestyles of those who were wealthier and better educated—those best placed to make change. In doing so, these interventions may also have had an unintended effect of exaggerating existing differences in health status between social groups.
In 1977, partly as a reaction to these developments in health systems, Health for All was developed as a concept, and adopted as the main social target of governments and the World Health Organization (WHO 1980). This resolution represented a commitment to explore new avenues to solve health problems and gave prominent attention to the need to reduce growing health inequalities between and within countries. Health for All has provided one focal point for a renaissance in public health, focused on addressing inequalities in health in many countries.
Finding ways of taking action that would effectively address these determinants of health represents a major challenge for governments and public health systems in all countries. This is especially the case in understanding how best to address the inequities in health between and within countries. For many, a significant turning point in the conversion of this renewed interest and understanding into public health action has come through the Ottawa Charter for Health Promotion (WHO 1986). The Charter advocated a ‘new’ approach to public health, where public health intervention has come to be understood as action which is directed towards improving people’s control over all modifiable determinants of health. Thus public health interventions are not only directed at personal behaviours, but also the public policy, and living and working conditions which both influence behaviour indirectly, and have an independent influence on health.
This more sophisticated approach to public health action is based on accumulated evidence concerning the inadequacy of overly simplistic interventions of the past (National Health and Medical Research Council 1997b; International Union for Health Promotion and Education 1999). For example, efforts to communicate to people the benefits of not smoking, in the absence of a wider set of measures to reinforce and sustain this healthy lifestyle choice, are doomed to failure. A more comprehensive approach is required which explicitly acknowledges social and environmental influences on lifestyle choices, and addresses such influences alongside efforts to communicate with people. Thus, more comprehensive approaches to tobacco control are now adopted worldwide. Alongside efforts to communicate the risks to health of tobacco use, these also include strategies to reduce demand through restrictions on promotion and increases in price, to reduce supply by restrictions on access (especially to minors), and to reflect social unacceptability through environmental bans (US Department of Health and Human Services 1994b). This more comprehensive approach is not only addressing the individual behaviour, but also some of the underlying social and environmental determinants of that behaviour.
Developing the policies, strategies, and infrastructure needed to address these determinants of health has proved to be a challenge for governments and health systems worldwide. Although the links between social, economic, and environmental factors and different patterns of health and disease in populations are relatively easy to identify, the pathways through which to influence these are less well understood (Kawachi et al. 1999). In addition, social and economic conditions, and physical environments, are created by sectors other than health. The health sector’s role in these is largely indirect. A total government approach is needed to develop sophisticated solutions to the complexities of this broader range of health determinants.
Encouragingly, there is evidence that the health policies and strategies of some nations (e.g. the United Kingdom and the United States (Department of Health 1999; US Department of Health and Human Services 1999a,b) have been evolving in response to the growing understanding of the social, economic, and physical environmental determinants of health. There is also evidence of growing concern about inequalities in health on the part of governments and/or their health sectors. This can be seen in national and regional strategies for health in several countries, and most obviously in those countries that have adopted health goals and objectives to guide government policies to improve health (Nutbeam and Wise 1996). In Europe in particular, the WHO has promoted health targets as a mechanism for defining differences in health status between populations, and to target reductions in these differences—the central tenet of Health for All (WHO 1985, 1999).
Determining priority and direction: setting health goals and objectives
The identification of health objectives and targets is one of the more visible strategies that have been adopted by several regions, countries, and states since the late 1970s to direct the activities of their health sectors. Such a strategy provides a public statement of the direction and intent for health-related investment and activity by indicating the desired impact on the determinants of health, and intended outcomes in terms of disease incidence and prevalence, and population health and well being.
The United States was the first country to attempt this in a comprehensive format in 1980 (US Department of Health and Human Services 1980). In 1985, the WHO Regional Office for Europe published a set of targets for Health for All that were adopted by all member states (WHO 1985). These documents served as models for subsequent programmes in different countries and regions worldwide.
The use of goals and objectives to provide direction for public health intervention has evolved considerably in the past 20 years. The experience in several countries is well documented, and the examples from the United States, United Kingdom, and Australia presented here illustrate the evolution of different approaches that have been taken. Differences in approach can be seen to setting priorities, to the technical task of defining health targets, and the influence of political processes on the widely differing strategies adopted to achieve the targets.
The United States: Healthy People
During the period 1979 to 1980 the United States published Healthy People: the Surgeon-General’s Report on Health Promotion and Disease prevention (US Department of Health and Human Services P1979) and Promoting Health/Preventing Disease: Objectives for the Nation (US Department of Health and Human Services 1980). Using a ‘management-by-objectives’ planning model, measurable national health goals and objectives were established for the first time. The United States adopted a ‘life-stage’ approach to analysing the health status of Americans, and 15 priority issues were identified. Measurable objectives were then set for each, using a standardized classification system.
Reviews of progress conducted in the following decades (US Office of Disease Prevention and Health Promotion 1986; US Department of Health and Human Services 1994a) indicated significant improvements in the health of the population in all major areas, but most notably in relation to infants and children. These reviews also highlighted new and outstanding challenges such as HIV/AIDS, and the relatively poor health of minorities. These new issues, in turn became important priorities for action in the future.
A revised set of objectives for the decade 1991 to 2000 was published in 1990 following a 3-year programme of consultation (US Department of Health and Human Services 1990). The 300 targets were organized into 22 priority areas with particular emphasis on achieving greater equity in health status. This report placed greater emphasis than the earlier document on strategies to achieve more substantial action in pursuit of the targets over the next decade. In particular, an implementation programme was based on the creation of a Healthy People Consortium of more than 350 organizations. In addition to the 54 state and territorial health departments, Consortium organizations represented older adults, racial and ethnic coalitions, educators, businesses, health care providers, and academic institutions. These organizations contributed to the development of the objectives in different ways and were encouraged to use the objectives to guide their own decision-making and action.
The most recently published objectives, Healthy People 2010, highlight the progress that has been achieved in relation to several key objectives (for all Healthy People 2010 references visit the website http//www.health.gov/healthypeople/). This includes further progress in reducing infant mortality and increasing childhood immunization rates, as well as reductions in heart disease and stroke, and a levelling off in rates of smoking, alcohol, and illicit drug use. Outstanding challenges are also highlighted, including high rates of violence and abusive behaviour, high rates of obesity, and low levels of leisure time physical activity.
Healthy People 2010 also reflects further sophistication in understanding the determinants of health as well as the need for social action to address the determinants. It states:
…the underlying premise of Healthy People 2010 is that the health of the individual is almost inseparable from the health of the larger community and that the health of every community in every State and Territory determines the overall health status of the Nation. That is why the vision for Healthy People 2010 is ‘Healthy People in Healthy Communities’ (www.health.gov/healthypeople/Volume1/intro/, p.2)
This is reflected in the systematic approach to improving health summarized in Fig. 2, composed of four key elements: goals, objectives, determinants, and health status. Healthy People 2010 has two overarching goals:
Fig. 2 Healthy people in healthy communities: a systematic approach to health improvement. (Source: US Department of Health and Human Services 1999a.)
to increase the quality and years of healthy life
to eliminate health disparities.
Progress in achieving these goals will be monitored through 467 objectives in 28 focus areas. The majority of these objectives focus on reduction or elimination of illness, disability, or premature death among individuals or communities. Significantly, other objectives focus on broader issues such as improving access to high-quality health care, strengthening public health services, and improving the availability and dissemination of health-related information. The important influences of income and education on health is explicitly recognized in Healthy People 2010 as key issues in achieving the goal of eliminating health disparities.
Healthy People 2010 is significantly different from the previous American health objectives in the extent to which it analyses the ‘critical influences that determine the health of individuals and communities’ (www.health.gov/healthypeople/Volume1/deter/,p.1). The document describes how individual biology and behaviours influence health through their interaction with each other and with individuals’ social and physical environments. In addition policies and interventions can improve health by targeting factors related to individuals and their environments, including access to quality health care.
The outcomes expected of these processes are ultimately reflected in changes to health status, which are assessed by a range of measures including mortality and morbidity, life expectancy, and quality of life.
The implementation of policies and programmes to achieve the objectives remains substantially the responsibility of the states and the Consortium partners. This strategy contrasts with that adopted in other countries where governments have adopted a more direct role in action to address targets. Such differences in strategy undoubtedly reflect differences in social organization and in health systems between the United States and countries in Europe.
The process of developing the most recent health objectives was highly participatory and consultative in nature. This engagement has been essential to ensuring the continued commitment of the states and the Consortium partners to commit resources to actions directed towards achieving the objectives. Many of the Consortium partners have made use of the objectives to guide their priority setting and public health programmes. A new section in Healthy People 2010 provides a ‘toolkit’ of:
guidance, technical tools and resources to help States, Territories and tribes to develop and promote successful, state-specific Healthy People 2010 plans. (http://www.health.gov/healthypeople/state/toolkit/)
The toolkit provides ideas and guidance on how to obtain resources, engage community partners, set health priorities, and manage interventions intended to address local priorities. In addition, the objectives have been specified by the United States Congress as the measure for assessing the progress of the Indian Health Care Improvement Act, the Maternal and Child Health Block Grant, and the Preventive Health and Health Services Block Grant (http://www.health.gov/hpcomments/2010fctsht.htm).
The evolution of health objectives in the United States illustrates well a progressively more sophisticated understanding of the determinants of health. The most recent objectives in Healthy People 2010 reflect a much more comprehensive appraisal of the action required to address the major public health challenges in the United States, including the social and economic determinants of health alongside the behavioural and biological. It also goes further than ever before in advocating and mandating (where feasible) action to address the objectives.
Although the United States process is technically outstanding, a perceived weakness is the rather loose connection between the development of health objectives and the policies and resources that are required to address them. In contrast, approaches to health goal and objective setting in the United Kingdom and Australia have been more overtly linked to policy and public health programmes.
Amidst the significant reforms of the National Health Service (NHS) in England and Wales during the 1980s, the government focused progressively on the need to redirect health policy and health services to the achievement of health. The Health of the Nation was published in 1992 (Department of Health 1992b). Five key areas were identified, goals and targets were set for each, and strategies for achieving the targets were included.
Unlike the American objectives, the targets in the Health of the Nation were overtly linked to the development of policy and programmes in tended to address the targets. A Ministerial Cabinet Committee was set up ‘to oversee implementation, monitoring and development of the English strategy and to be responsible for ensuring proper co-ordination of United Kingdom-wide issues affecting health’ (Department of Health 1992b). The role of the NHS was specified, making it clear that ‘improving health should be the prime concern of every NHS authority and health professional and manager in the NHS’ (Department of Health 1992b). A report outlining First Steps for the NHS was also published in 1992 (Department of Health 1992a).
The co-ordinated implementation programme included wide dissemination of the strategy throughout the community, oversight of its progress within government, action both within and outside the NHS, and action to ensure that monitoring, research, review, and reporting occur as required. Key Area Handbooks (Department of Health 1993) suggested actions that might be taken by the NHS, local authorities, employers, and schools.
A change in government in 1997 gave new impetus to these initiatives, culminating in publication of a strategy for public health, Saving Lives: Our Healthier Nation, in 1999 (Department of Health 1999). This strategy sets targets for improvements in health in four priority areas: coronary heart disease, cancer, injury, and mental health/suicide. It also seeks to address social inequalities in health by addressing the social, economic and environmental determinants of health. The report states that:
While the roots of health inequality run deep, we refuse to accept such inequality as inevitable. Moreover, we fully accept the responsibility of Government to address such deep-seated problems. That is why we are committed to a wide-ranging programme of action, right across Government, to tackle them. (Department of Health 1999)
To emphasize this commitment, the report is signed by ministers from all relevant portfolios of government, rather than just the Minister for Health. The report specifies a range of programmes and policies to support action to achieve the targets. These include newly funded health system initiatives to improve individual access to health information and advice, stimulating local community action for health through health improvement programmes, and the creation of health action zones in geographical areas of greatest social need. These activities are combined with a strong emphasis on achieving high standards of practice, improved workforce training, and improved disease surveillance. In sectors other than the health sector, a commitment is made to health impact assessment of policies, although the tools for this remain somewhat underdeveloped (Scott-Samuel 1996; Department of Health 1999).
The British strategy overtly links targets for improving health to health system strategies, and to intersectoral action. It also reflects an understanding of the need to invest in the development of the infrastructure required to deliver effective programmatic responses. In these elements, the British approach represents a model of how to link target setting to policies and resources, which address both the underlying determinants of health, alongside behavioural and health system factors. The process of implementation and the effectiveness of these links will need to be carefully examined in the coming years.
The report Health for All Australians published in 1988 (Health Targets and Implementation Committee 1988) was Australia’s ‘first national attempt to compile goals and targets for improving health and reducing inequalities in health status among population groups’. Unlike other countries at the time, the Australian report contained a series of costed recommendations on strategies to address national health priorities.
Five priority areas were selected, including nutrition, cancer, and the health of older people. The Australian health ministers endorsed these and the National Better Health Programme was established with funding for 4 years to initiate strategies to achieve the targets in each of these areas. Although progress was made in building infrastructure for and improving resources for health promotion activity, the programme did not make the anticipated progress in achieving the targets. The reasons for this varied across the different elements of the programme. Progress was clearly limited by the nature of relations between the state and federal governments, which often delayed action, and by a failure to engage adequately the different sectors that needed to be involved in effective action to address these priorities (Commonwealth Department of Health, Housing and Community Services 1992).
In 1991 the Commonwealth Health Department commissioned a review of these targets. The review was intended to consider what progress had been made in relation to the 1988 targets and to examine options for extending the range of targets to reflect a ‘social view of health’. This review process extended over 2 years, and included substantial technical consultations with academics and health professionals, and political discussions on the policy implications with individual state health ministers and their departments. The process led to proposals for major revisions in the report Goals and Targets for Australia’s Health in the Year 2000 and Beyond published in 1993 (Nutbeam et al. 1993). This report included not only revisions to many of the originally proposed health targets concerning premature mortality and morbidity and behavioural risks, but also proposed two new categories of health targets concerned with personal health literacy and healthy environments.
Figure 3 is derived from the report and provides an illustration of the framework for the targets and the relationship between the different types of targets that were proposed. It shows how each of three key determinants of health—health literacy, health behaviours, and healthy environments—is inextricably linked to the other two. The report made a strong case for co-ordinated public health action to address all of the determinants, particularly by adding to existing efforts to promote health literacy and healthy lifestyles with matching attention to the creation of healthy environments.
Fig. 3 Relationship between the four groups of health targets. Examples of targets are shown in oval boxes. (Source: Nutbeam et al. 1993.)
The section of the report on healthy environments reflected the greater attention and recognition being given to social, economic, and environmental determinants of health status. This part of the report was structured partly to reflect the way in which government was organized (e.g. housing, employment, environment), and partly to build upon existing working relations between the health sector and other sectors (e.g. health-promoting schools). Such an approach was seen as important both in defining the respective roles of the different sectors, in establishing a workable model for monitoring progress, and determining accountability for the achievement of targets (Nutbeam et al. 1993). At the time, this analysis and overt recognition of the links between socio-economic conditions and health was unique.
The subsequent history of this report and its proposals is somewhat mixed, although the initial responses were very positive (Pickering et al. 1994). The report served as a catalyst for the inclusion of a commitment to develop national health goals and targets as a part of the Medicare Agreement between the federal government, States, and Territories. Thus for the first time Australia had a statement concerning desired population health outcomes within the legislative agreement (Medicare Agreement) which governs the release of resources for the publicly funded health system. The Agreement committed the Commonwealth and States to a process leading to finalization of national health goals and targets in a limited number of priority areas within 1 year.
The product of this effort, Better Health Outcomes for Australians (Commonwealth Department of Human Services and Health 1994), was disappointing in many respects, particularly where it failed to encompass adequately the social, economic, and environmental determinants of health that were a prominent feature of the recommendations from the review which preceded it. No concrete plans were set down to link the targets to a strategy for their achievement. Rather, individual states and territories were left to interpret and act upon the priorities as seemed relevant to local circumstances. Changes in government at federal and state levels since the development of the report further blunted overt action to address these national priorities, but has resulted in greater attention being given to the development of an infrastructure for improving health through a national public health partnership (National Public Health Partnership 1998). This is referred to in greater detail below.
Stimulating action to address goals and objectives
As indicated above, health targets have been promoted by the WHO as a mechanism for defining differences in health status between populations, and to target reductions in these differences. In the three examples above, progressive improvements in routinely collected information and greater investment in research have provided both better data with which to define these differences and improved understanding of some of the determinants of health.
The strategic direction that can be defined by health goals and targets is ultimately dependent upon the quality of the data on which targets are set. This has restricted the priorities and directions that may be indicated by the development of objectives and targets. In Australia, for example, the first health targets in 1988 were restricted to those health indicators for which adequate national data existed—effectively ruling out specific targets to reduce key determinants of differences in health status among population groups. Similar restrictions have limited the targets and objectives adopted in the United States and United Kingdom. While more accurate data enable more precise goals and targets to be set, the limitations of existing national data can inhibit the setting of goals and targets, particularly those addressing social, economic, and environmental determinants.
There is now a better understanding of the need to achieve a balance between meeting the rigorous technical requirements of target setting, and the strategic purpose of providing policy direction. For example, in the United States the 2010 objectives have been expanded to include new areas where indicators do not currently exist in an agreed form, with the intention of stimulating action to develop appropriate indicators in areas such as ‘health literacy’ (US Department of Health and Human Services 1999a). This serves as a stimulus for action to address poor health literacy in the population even though widely accepted indicators and adequate surveillance are not yet in place.
Setting targets does not guarantee that any effective action to address them will follow. Indeed, the available evidence to link target setting to improved health is slim (Nutbeam and Wise 1996). Conceptually, health goals and targets are the proposed outcomes of a nation’s entire investment in the health of its population. Therfore much of their potential benefit lies in the extent to which they are used to guide and measure the results of investments in health. To date this has rarely been the case.
Only the United States has had experience of using health targets to guide public policy over an extended period. In this case the process of development and review of the health objectives has offered some valuable technical and strategic lessons. Here, at the very least, the objectives have offered a benchmark against which changes in population health status could be observed over time, and act as a catalyst for response (US Department of Health and Human Services 1986, 1994a).
Direct government action to achieve targets and objectives can most easily be observed in the United Kingdom and Australia, where the development of targets has been directly managed by governments, and explicit commitments have been made to develop interventions to address the targets. Unfortunately, this link of health targets and objectives to political processes has not always been a stable base on which to build sustainable public health interventions. The examples from Australia confirm the political nature of public health intervention and the attendant risks.
A specific national programme was established to address the health goals and targets identified in 1988. Rather than being viewed as the responsibility of the whole of government, or even the health care system, the achievement of significant change in major non-communicable diseases and related behaviours was assigned to a modestly funded and poorly co-ordinated programme of activities (Commonwealth Department of Health, Housing and Community Services 1992).
Despite the comprehensive review that took place in the early 1990s—including extensive consultation across the country with politicians, public servants, public health practitioners, and communities—the political process that finally decided on priorities reverted to a narrow set of disease-specific goals and targets, ignoring the opportunity to take the riskier but ultimately necessary approach of identifying environmental and social mobilization goals and targets. By selecting the goals that were least threatening to established administrative and funding arrangements, the potentially more effective, but harder to achieve, health system reform and intersectoral action are ignored or given relatively limited emphasis.
This experience in Australia also indicates how a change in government, or even a change in minister, can lead to a reinterpretation of the nature and purposes of the targets, and substantial dislocation of any action to achieve the targets. Other examples of this experience can be observed in Canada, New Zealand, and The Netherlands (Beaglehole and Davis 1992; Nutbeam and Wise 1996).
Despite these chastening experiences, it is clear from the American experience that focusing on health outcomes and the determinants of health can act as a catalyst for public health interventions. However, comprehensive progress in relation to health objectives and targets will not be made until there are system-wide responses that are backed by resource incentives.
The American experience also suggests that national health objectives can survive changes in government provided that they are developed by a quasi-independent agency, are based on good technical support, and are supported by strong coalitions for action outside of government. Overall, in those countries that have adopted health objectives or targets, the objectives appear to have played an important role in focusing attention on the need for the following:
a broad base for health policy across the different sectors of government
changes in resource allocation to develop capacity for public health intervention
the development of methods and structures which enable action to promote health and prevent disease.
In those countries that have adopted them, health objectives represent a public acknowledgement of the responsibility of governments to address the determinants of health. Health goals and objectives are not a substitute for health-oriented public policies and a viable public health infrastructure, but they can provide a powerful mechanism for public accountability and a substantial platform for the growth and development of public health programmes.
Developing public policy for health: the challenge to improve intersectoral action
Examination of the determinants of health provided in this and other chapters in this textbook has clearly demonstrated the important contribution that can be made by sectors other than the health sector to the achievement of improvements in health. These include the housing, education, transportation, and employment departments of government, as well as the activities of the departments of treasury and finance in relation to economic activity and income. In developing health targets, each of the countries referred to above has, to some extent, made the nature of this challenge explicit, and have provided a platform for concerted intersectoral action. In some cases this is through coalitions of government, non-government, and community organizations (such as in the United States), while in others it has led to the establishment of interdepartmental activity within government (as in the United Kingdom).
Experience in these examples has highlighted the dangers inherent in the health sector seeming to impose its priorities on other sectors. In general, the best strategy appears to be to focus on existing practical opportunities for collaboration by exploring the potential for integrating health goals to reduce risk and promote health into the work programmes of other sectors. This approach to building on existing common ground between sectors, combined with transparency in purpose, appears to offer a basis for developing the effective partnerships for health that are required to advance health and achieve greater equity in health by addressing its underlying determinants.
Experience in Australia, for example, has indicated that there are formidable obstacles, technical and political, to achieving a unified, national response to the complex problems of addressing the environmental, social, and economic determinants of health (Nutbeam and Harris 1994). Where progress has been achieved it has been through bilateral partnerships between the health services and other sectors. In the latter case such action is most achievable where there are clearly defined goals and targets of obvious mutual benefit, and where the roles and responsibilities of each sector and are clearly defined (Harris et al. 1996).
Investing for health as a model for intersectoral action
The patchy responses to the development of national health plans, goals, and objectives highlighted above are related to the frailty of the infrastructure for public health intervention in many countries. Encouragingly, the last two decades have seen a rejuvenation of interest and investment in public health in many countries. Although much of that investment has been ad hoc—in targeted programmes and services rather than in a well-defined public health system or infrastructure—it has represented a restatement by governments of the need to take an active role in protecting, promoting, and restoring the health of their populations. Even during this period of history in which neoliberal assumptions about the primacy of needs of the economy dominate governments’ reform agendas (Mossialos and Permanand 2000), there has been acceptance that government is ultimately responsible for the health of the public (US Department of Health and Human Services 1999a).
The experiences of the last three decades have also confirmed that well-designed public health interventions, combined with significant community support and high levels of political commitment, can succeed in improving the health of populations (National Health and Medical Research Council 1997b). Analysis of these successes reveal that it is no longer possible or useful to develop interventions that attempt to persuade people to change their lifestyles and health behaviours in the absence of action to change the environments and institutions that shape people’s choices. This is especially the case if improved health is to be experienced by all sections of society, not just those with greater wealth and education. Such an analysis also implies the need to link public health with economic and social policy (Mossialos and Permanand 2000), and for public health practitioners to become more fully engaged in the processes of public policy development and implementation.
Once again, this is hardly new. Any analysis of the determinants of health has shown that throughout history, the greatest improvements in people’s health have mainly arisen from social and economic improvements that also promote health. The WHO have taken this argument much further by making the case that a healthier population can make a more productive contribution to overall development, requires less social support in the form of health care and welfare benefits, and is more able to support its community and avoid actions that, over the long term, damage its environment (WHO 2000). This logic dictates that investment aimed at securing positive health and well being also brings social and economic benefits for the whole community, and vice versa.
It is clearly established that priority social and economic policy areas—such as education, income maintenance, workplace regulation, housing, transport, agriculture, and communications—as well as private initiatives, have a profound influence on health. Governments have a great potential to improve or worsen people’s health through their policy decisions in these areas. This increasingly applies to the private sector too. Great harm can be done to health by misguided public policies or private initiatives. For these reasons, actions to improve and protect the health of the public have to be grounded in a policy structure which:
is sensitive to the impact on health of policy decisions across all government sectors
maximizes opportunities for matching economic and social development goals with health development goals and objectives.
This logic is the basis for the WHO’s Investment for Health strategy which offers a model for achieving a ‘whole of government’ approach to improving public health. Ziglio et al. (2000) describe this strategy as:
a practical approach based on the rationale that resources are best applied in a way that not only addresses the main causes of ill-health in a credible, effective and ethical manner, but also furthers the achievement of goals for social and economic development
They state that:
The ideas behind these principles are not new. We intuitively know them to be right. But very few (if any) countries or regions in the world systematically apply these principles to decisions about improving the health of their people.
Some of the key elements of the Investment for Health concept are described by Ziglio et al. as follows.
A focus on health—the objective is to achieve effective action to tackle the root causes of ill health and create opportunities for better health. Health improvement will not always be the primary policy goal, but there is a commitment to assess the population health impact (both positive and negative) of public policy decisions, development strategies and investment decisions, particularly those with social and economic implications. Economic development can be used as a means of improving both the social infrastructure and people’s health. Tools for health impact assessment are essential to support this element of the strategy.
Genuine intersectoral working—in view of the importance for health of decisions and actions by sectors such as agriculture, education, finance, housing, social services, and employment, a sensible and effective strategy to improve health requires the active inclusion of all sectors to achieve the synergism required to improve population health. The adoption of mechanisms within government to enable intersectoral action for health is vital to support this strategy.
Equity focus—the WHO global strategy of achieving Health for All is fundamentally directed towards achieving greater equity in health between and within populations and between countries. Equity implies that all people will have equal opportunity to develop and maintain their health through a fair distribution of the resources and opportunities that support health. A mix of programmes to address fundamental differences in opportunity and access to resources, as well as targeted programmes for disadvantaged individuals and communities is required to support this element of the strategy.
Sustainability—in this context, this term has a dual significance, signalling firstly, the aim to create an Investment for Health process that is durable and resilient; and secondly, that investments are made and resources are managed in ways which do not compromise the health and well being of future generations. Mechanisms to embed the strategies within government, and to build and strengthen an infrastructure for public health are required to ensure the sustainablility of the strategies and their effects.
Achieving such a substantial commitment to health is by no means an easy political task. The European Office of the WHO has carried out national Investment for Health appraisals in several countries including Slovenia, Hungary, Romania, and Malta (Ziglio et al. 2000). This has involved external appraisal, and reporting back to the Health Ministry and/or Parliament on:
the strategy needed to improve the health status of the population
the potential for investment for health in the country
the infrastructure needed to build, support, and sustain Investment for Health.
Each part of the appraisal identifies the opportunities to promote health more effectively through key economic and social development policies. This strategy represents a sophisticated attempt to put into public health practice the logical consequences of contemporary analyses of what determines health in populations. Although the approach has not been widely adopted, or implemented over a prolonged period, it illustrates the important challenge facing public health advocates and practitioners. This challenge is to engage government and the private sector in a dialogue about the health impact of policies and practices, and to consider the scope for a synergystic relationship between health, economic, and social development strategies. Like health goals and targets, the Investment for Health strategy is not a substitute for investment in a public health infrastructure in countries. Rather, it is a mechanism that facilitates the dialogue needed to link investment for health with economic and social development, and support action across sectors to improve the health of the public. Underpinning such a strategy will be more formally organized systems and structures for public health interventions in different countries.
Developing infrastructure and delivery systems for public health interventions
To be effective, the science of public health must be ‘applied’. The science, strategies, and tools used in public health are too often used only to describe and analyse public health problems, and to develop policy. To enjoy the fruits of this analysis, and of health-oriented public policy, it is essential that attention is also given to the development of the organizational capacity of the health sector, in particular, for effective public health intervention. These interventions include the health education and health promotion strategies described in previous chapters, as well as other forms of public health intervention required to assist people and communities to improve their control over the determinants of health.
Creating a sustainable infrastructure for public health has proved to be a complex undertaking for governments. The need for an effective public health service tends to be invisible both to governments and to the public except in times of crisis, and often oriented towards the control of infectious disease. There is relatively limited public demand for a strong public health service (compared with demand for health care services) in all but exceptional circumstances (Grossman and Scala 1993). However, the evolution of health policy to include recognition of the social determinants of health, and to commit governments to tackle non-communicable disease, has stimulated action by a number of countries to review and strengthen their infrastructure for public health.
Although there remain significant unanswered questions about the most effective systems or structures through which to ‘deliver’ public health interventions, there are emerging models for defining priorities for action, for working across government to address determinants of health, and for establishing elements of an effective public health infrastructure. Such an infrastructure should have the capacity to effectively implement the policies and deliver the programmes indicated through the preceding sections of this chapter.
The range of activities and sectors in which practitioners need to act, and the broad range of disciplines that can be said to make up the field of public health have made it difficult to define the ‘core business’ of public health. Several recent initiatives have sought to identify these ‘core functions of public health’. For example, the Healthy People 2010 document includes a major new section on public health infrastructure (US Department of Health and Human Services 1999a). A ‘Public Health Functions Project’ has been established to address these issues. Among the priorities for the project is the intention to describe the essential services of public health, define public health workforce, training, and education, and improve public health data (US Department of Health and Human Services 1999b). Similarly, the National Public Health Partnership in Australia has defined core public health functions (National Public Health Partnership 2000).
Within these lists of core functions, essential services, and public health practices there is still a considerable lack of conceptual consistency. A mix of intended outcomes, interventions (or strategies), and principles for ‘good practice’ is represented in all the lists. To help untangle these conceptual inconsistencies the distinction is made in Fig. 1 between the essential infrastructure required to lead the development of policy and interventions to achieve priority health goals and targets, and the delivery system required to develop and execute public health interventions.
Key elements of infrastructure for public health
The components of public health infrastructure are similar to those needed by most organizations to conduct their core business—resources, a skilled workforce, and information from research, supported by a system through which to ‘deliver’ the service or product. In other words, infrastructure refers to the material and human resources that that are required to direct and support action to promote, protect, and maintain the health of the population.
Figure 1 highlights three essential components of an infrastructure for public health as follows.
Secure and sustainable funding
Aside from the Investing for Health strategy discussed above, secure, recurrent financial resources are required to support a public health infrastructure within the health sector. Without such investment in a dedicated infrastructure, experience has shown that the public health system can quickly lose capacity (National Health and Medical Research Council 1997a; US Department of Health and Human Services 1999b).
Public health will not work if left to market forces. Most countries have recognized the need to invest in a public health infrastructure as a ‘public good’. In many cases these investments have provided capacity to analyse public health status, guide health decision-making, and respond to public health threats, especially infectious disease outbreaks. However, secure funding for the design, delivery, and evaluation of public health interventions directed to addressing non-communicable disease, and to tackling the social determinants of health has proved more elusive.
This ‘programme funding’ has proved to be much more difficult to sustain in many countries, particularly when interventions run counter to existing government policy or ideology, and especially when this contradicts economic policy (such as in relation to the sale of alcohol or tobacco, or nutritional programmes which conflict with agricultural practice). Providing a strong rationale for investing in public health interventions continues to be a major part of the role of public health professionals—requiring the use of both science (to demonstrate effectiveness) and political argument (to demonstrate professional and community concern).
The limited information available about the proportion of national recurrent health sector expenditure that is accounted for by public health infrastructure and programmes in different countries suggest that it is very small, relative to expenditure on acute and chronic health care services. Across several countries for example, it appears to be no more than 2 to 3 per cent of total health expenditure (Deeble 1999). While this does not include all the funding invested in public health it provide some indication of the minimal level of public investment through the health sector that might be expected to support public health infrastructure and intervention programmes.
In many countries it has proved necessary to find alternative sources of funding for public health interventions. The establishment of health promotion foundations has been one method used in some states in Australia, and now in some other countries. The funding for these organizations is generated by specific taxation levied by government on the sale of tobacco products. The legislation setting up the organizations originally required them to ‘buy out’ tobacco company sponsorship of sports, arts, and cultural events. After an initial phase during which funding was substantially applied for this purpose, most foundations have diversified their programmes and in some cases have been able to make a significant contribution to funding public health research and to actions to address social and environmental determinants of health.
The non-government and community sectors also play significant roles in funding research and interventions on issues such as cardiovascular disease prevention, tobacco control, or childhood injury prevention. Organizations such as heart foundations and cancer councils perform important roles in many countries, not only in raising money for research, but in direct community intervention to promote health and prevent disease. There are limitations imposed by their focus on single issues and by the level of funding that they are able to raise directly from their constituencies (in addition to government support). But their high levels of credibility among health professionals and community members mean that they can also be attractive as partners in developing and implementing public health interventions.
The private sector has also begun to take an increasing interest in contributing to public health and social development. In many cases the benefits of partnership are obvious and mutual. For example, in Australia the insurance industry has contributed significant levels of funding to specific programmes to reduce motor vehicle crashes, and the food industry has committed to a programme to improve consumers’ recognition of low-fat foods.
It is important to recognize that private sector contributions, in particular, are linked to the needs of business for community support and to assist marketing of specific goods and products. These needs do not necessarily clash with public health goals, but the mutual benefit in partnerships with the private sector is not always as apparent as it could be. The WHO Jakarta Declaration provides some useful general guidance on this issue concerning the need for transparency in relationships and clearly defined mutual benefit (WHO 1998). In negotiating partnership agreements with the private sector it is important to ensure that there is no potential conflict between the outcomes required by the company and the intended public health outcomes.
Workforce and leadership within and outside the health sector
The delivery of essential public health services requires a skilled competent workforce, often working in partnership with other organizations and the community (Public Health Leadership Society 1998). In addition to a specifically trained public health workforce, professionals from many different sectors can be considered as part of the broad public health workforce. There is equal need to support education and professional development for both groups.
Most specialist public health training is provided at the postgraduate level through universities—usually through schools or departments of public health. In some countries medical qualifications have been a prerequisite for entry into public health training; in others a wide range of undergraduate qualifications is accepted. Many disciplines contribute to the body of knowledge that underpins the field, but there is growing agreement about the core competencies required of all members of the specialist public health workforce (Commonwealth Department of Health and Aged Care 2000; Ottoson et al. 2000; US Council on Linkages 2000). Within the field there are also several specialties that have developed advanced training programmes—epidemiology and biostatistics, health economics, and health promotion are three of the more common specialty groupings. Specific competencies are also being developed in these disciplines within public health (Howat et al. 2000; McCracken and Rance 2000).
In some countries, governments have recognized the need to invest in training programmes to ensure that there are adequate numbers of trained public health professionals. In Australia, for example, the Public Health Education and Research Program (PHERP) was established by the Federal Department of Health and Aged Care in 1986 to fund universities to develop Master of Public Health programmes. Later, the PHERP was expanded to include funding to develop the quality and quantity of teaching and research in several specific areas of special need—environmental health, health promotion, mental health, health economics, and public health nutrition. This type of investment in the workforce has led to a rapid expansion in the quality and effectiveness of the public health workforce in Australia Commonwealth Department of Health and Aged Care 1999).
Professional associations also make a significant contribution to workforce development. These include public health associations (linked through the World Federation of Public Health Associations), epidemiological associations (linked through the International Epidemiological Association), and health promotion and health education associations (linked through the International Union of Health Promotion and Education). The conferences and journals produced by these organizations are an essential component of workforce development infrastructure. Such associations are also important in the development of and advocacy for healthy public policy in many countries.
The opportunities that are offered by the Internet for collaboration among institutions have resulted in new possibilities to establish national and international programmes and standards of quality in public health workforce training. The Internet also offers students the opportunity to access a wider range of public health training, some of it across national borders (Davies et al. 2000).
Public health intervention requires special skills that are different to those required to analyse health problems in a population. Influencing health behaviour in populations, and influencing the structural and environmental determinants of health, requires public health specialists to have substantial knowledge and skills in the behavioural, social, and political sciences. This will require educational institutions to extend the range of current training in many cases.
This emphasis on intervention also highlights the need for a different style of leadership from senior public health practitioners. Earlier sections in this chapter have indicated some of the difficulties inherent in collaboration across sectors. Leadership for public health intervention requires practitioners to work more closely with other sectors, to advocate effectively for the development and adoption of healthy public policy, and to create, with communities, a shared vision for the public’s health. There are few programmes that explicitly address the need for advanced training for public health leadership. One example is the Public Health Leadership Institute developed at the UCLA School of Public Health (Public Health Leadership Society 1998).
The training of other health professionals is gradually being adapted to provide them with basic knowledge of public health. Professionals in both the health sector (doctors, nurses, and allied health professionals) and other sectors (e.g. education, agriculture, or architecture) are increasingly being involved in developing policies and programmes that contribute to improvements in the health of the population. This is a major challenge and significant area for development in public health education in the next decade.
The education systems responsible for providing workforce development largely lie outside the ambit of the health sector. It is necessary that there are strong links between academic institutions and agencies responsible for public health. Examples of efforts to achieve this can be seen in the United States by the formation of the Council on Linkages between Academia and Public Health Practice, and in Australia by the National Public Health Partnership and the Public Health Education and Research Programme.
Supportive research, funding, and training
Public health research and development is central to continuous improvement in the relevance, quality, and impact of public health intervention. Research funding for public health can come from many sources. However, competition for health research funding is fierce, and public health research often competes poorly for funding which is dominated by biomedical and health services research. Within public health research, there is also a strong bias towards descriptive/investigative epidemiological research at the cost of adequate investment in intervention research. It is important to ensure that research addresses priority health/structural issues, population groups, and settings, and that it also addresses the need for methodological development specific to public health intervention.
One model used in Australia to enhance the quantity and quality of public health research was the establishment of a specific Public Health Research and Development Committee by the nation’s principal health and medical research funding agency—the National Health and Medical Research Council. A designated level of funding was allocated to public health research—most of it investigator driven. Other funding agencies also experimented with such designated funding to encourage public health research.
Although these models have now been abandoned, there has been growing recognition of the need for research funding bodies to ensure a balance between biomedical and public health research funding. In Australia, the National Health and Medical Research Council has explicitly incorporated a funding stream that is intended to enhance and support a greater level of ‘strategic’ research that will, in turn, enhance public policy in relation to health (National Health and Medical Research Council 2000). There has also been some enhancement of capacity within research funding agencies to ensure that they include public health research among their funded projects and to provide high quality peer review for public health research. The focus on public health research also led to enhanced training opportunities for public health researchers.
Within the discipline of public health there has been tension between the twin intellectual approaches to public health practice, with many public health researchers focusing on the development of knowledge rather than on the actions required to solve public health problems (Hunter and Berman 1997). The most obvious manifestation of this can be seen in the overwhelming investments made in monitoring and surveillance, and in research focused on improving knowledge about public health problems and their causes, rather than on improving knowledge of effective action to resolve the problems. Policies of research funding agencies need to give greater weight to ‘intervention’ and evaluation research, and ensuring that the peer review process includes reviewers with appropriate knowledge and skills in such research.
Because effective public health interventions include a complex set of actions to bring about widespread social change there is a need for the development of research and evaluation methods that better ‘fit’ the demands of evaluating action to resolve these more complex problems (Nutbeam 1998; Chapman 1993). Several efforts are being made to identify frameworks and criteria to ensure that the quality of evidence to guide public health interventions meets the highest possible standards of scientific rigour within the context of the complex actions that are needed to bring about positive changes in the health status of the whole population (McQueen 2000).
An effective system for public health research is dependent upon national/organizational research policy that highlights the need for specific public health research—as distinct from biomedical research. It then depends upon there being funds available specifically for public health research, and upon a strong system of peer review by qualified public health researchers. Furthermore, the strength of the research system depends upon the availability of high-quality research training for young researchers, and upon a career development path for public health researchers.
The infrastructure for public health is not, on its own, sufficient to ensure that effective public health interventions are developed, delivered, and evaluated. The infrastructure must then work to develop organizational capacity within and beyond the health sector to create a delivery system for public health intervention referred to in Fig. 1. The components of the delivery system are as follows.
A system for population-wide health monitoring and surveillance
Understanding the complex and changing health status of the population is a cornerstone of public health. A national comprehensive system for population-wide health monitoring and surveillance is an essential component of public health infrastructure. (The Centers for Disease Control and Prevention is a widely recognized example of an organization providing such information.) Such a system should facilitate on-going systematic collection, analysis, and interpretation of national or state population data relevant to the national public health effort. Such data need to be collected at national or state levels repeatedly over time. This ‘health intelligence’ is needed to identify problems, to set priorities for action, and to monitor progress (National Health and Medical Research Council 1997a).
In many countries health information is largely restricted to data on mortality, morbidity, and health system use. This information is vitally important for epidemiological investigation, and to provide broad guidance on public health priorities and policy, but has limitations in its usefulness for planning and monitoring public health interventions (Nutbeam 1996). A much wider range of information, such as that outlined below, is needed for this purpose.
National health information (National Health and Medical Research Council 1997a) is either national in coverage or has relevance nationally and relates to:
measures of health status in the population (including mortality and morbidity data)
measures of the determinants of the population’s health, including those in the external environment (physical, biological, social, cultural, and economic) and those internal to individuals (such as knowledge, behaviour, disease risk factors)
health interventions or health services, including interventions provided directly to individuals and those provided to communities, covering information on the nature of interventions, management, resourcing, accessibility, use, and effectiveness
the relationships among these elements.
Any type of health information system should enable analysis of the needs and progress of specific population subgroups with particular emphasis on disadvantaged groups. It must be capable of identifying inequalities in health status and their determinants.
The system for monitoring and surveillance should also be responsible for reporting on the ‘state of the health of the population’—on progress towards achieving health goals and targets, and on emerging issues or gaps. There are some useful examples of such reports being used effectively to highlight progress and the need for specific investment in action to address the needs of social and economically marginalized populations (McGinnis et al. 1992; US Department of Health and Human Services 1994a; Department of Health 1999).
Examples of efforts to improve the relevance and range of health status indicators are beginning to emerge. To measure the influence of social, economic, and environmental factors on the health of populations an expanded range of information is needed in national systems of monitoring and surveillance. Examples of initiatives that are being explored include the Genuine Progress Indicator (Hamilton 1998), the Index of Social Health (Miringoff 1996), the Index of Leading Cultural Indicators (Bennett 1994), and some proposed sustainable development indicators (Interagency Working Group on Sustainable Development Indicators 1997). Although there is need for further research on the core concepts that contribute to social capital, there are some examples of large-scale efforts to measure group membership and levels of social trust across populations (Kawachi et al. 1997).
These approaches to health indicator development extend the fundamentally important datasets currently used for health surveillance in most countries, and offer a mechanism to align improvement (or regression) in health status with other indicators of social and economic development.
Identification of national, regional, and local priorities, regular review, and redefinition
The identification of priorities for investment in public health interventions remains one of the most contentious issues in contemporary public health. The use of different criteria for establishing priorities leads to very different priorities for action (Nutbeam 1996). Nationally determined priorities do not always resonate with local needs and perceptions of what actions are important to improve health.
Among the different approaches to priority development are those determined by epidemiological, economic, and community perspectives. Although not mutually exclusive, each of these perspectives places ‘value’ on different outcomes and processes.
To date, epidemiological analysis has dominated priority setting at national levels. The national health goals and targets identified by many nations and regions discussed above have given priority to leading causes of preventable deaths and morbidity. Analysis of the incidence, prevalence, costs to the health care system and to society associated with the disease/injury, and an assessment of the feasibility of acting to prevent or reduce the incidence or prevalence of the condition are criteria that have been used to identify these priorities. Actions that are linked through epidemiological analysis to a reduction in disease are valued in such an analysis.
Increasingly, economic principles of efficiency are being proposed as a means of identifying priorities for public health intervention (National Health and Medical Research Council 1997a). The term efficiency is used here to mean obtaining optimal gain from investment. However, to use the concept of ‘efficiency’ as a criterion for identifying public health priorities it is important to distinguish between two components of ‘efficiency’. The first component concerns ensuring that the services to address a particular issue or problem (e.g. cardiovascular disease) are organized and resourced, which means placing investment across the range of interventions (preventive, curative, palliative, or all three) for a particular condition to maximize individual and community health gain. This is called ‘technical efficiency’. It means giving the greatest proportion of investment to the ‘part’ of the service that produces the greatest health gains—sometimes this will be prevention, sometimes it will be treatment. The evidence is also continually changing, and needs to be applied to readjust the balance of investment. However, even if investment within a programme area (e.g. cardiovascular disease) is efficient, it is possible that investment across the range of health issues and population groups is not well balanced.
The second component of efficiency is ‘allocative efficiency’. The analysis of the balance of investment based on assessment of allocative efficiency helps to identify priority issues or problems across the whole range of potential programme or service areas. At its most basic it is a tool for ensuring that a significant issue (such as mental illness) receives adequate resources compared with other, equally prevalent, severe issues. More sophisticated analyses will link investment in programme areas to predetermined population health outcomes, making decisions about the relative level of investment across different service/programme areas.
The third approach to priority setting reflects the growing evidence that the most effective and sustainable public health interventions have been characterized by high levels of community, organizational, and political support. This is particularly true at local level, which is also where national priorities are often seen to be remote from local concerns. Criteria for establishing priorities at local levels include extent of community concern about an issue, the capacity of the community to act to address the issue, and the capacity of local institutions, organizations, and people to contribute to action (Hancock and Minkler 1998). The process of participation in decision-making and perceived responsiveness to local priorities are valued through such an analysis.
These three perspectives on setting priorities are not mutually exclusive, and are best combined to achieve a sound basis for effective action which is nationally relevant, locally sensitive, and financially sound.
Furthermore, the development of priorities for public health intervention should not be considered a one-off event. The ‘health intelligence’ system established for defining priorities should also be capable of use in the review and redefinition of priorities. This is to ensure that there is capacity to redirect resources (as well as to increase the pool of resources) to address new priorities.
National, regional, and local programme delivery within and outside the health sector
As indicated above, epidemiological analysis of priorities for intervention has generally led public health intervention towards reducing risk factors and behaviours in individuals. This in turn has led frequently to highly differentiated vertical programmes within the health sector to tackle specific risks, such as tobacco use, or diseases such as coronary heart disease. Such programmes tend to have their own goals, resources, workforces, and research programmes (National Health and Medical Research Council 1997a). As a consequence, there has been limited scope for integrated programmes to address the social, economic, and physical environmental determinants of health. In contrast with disease/risk factor specific programmes, such integrated programmes are likely to focus more on policy and institutional change, in addition to the public information, education, and mobilization programmes.
In Europe and in Australia there are recent examples of processes being implemented that, amongst other things, are intended to encourage the redefinition of priorities to include greater emphasis on the underlying factors and environments that are ‘shared’ across different causes of disease and injury. In Australia, for example, instead of the public health funding from the Commonwealth to the states (providers) being distributed according to individual priority issues or population groups, a significant proportion of the ‘vertical programme’ funds is now pooled. States (providers) negotiate agreement with the Commonwealth (funder) on a specific range of public health outcomes that will be achieved within a specified period. In the United Kingdom the Our Healthier Nation strategy referred to above reflects an effort to shift the focus of public health programmes away from vertical programmes to address the underlying determinants of health (Department of Health 1999). Although vertical programmes remain the dominant organizational structure for public health intervention in both countries, these new initiatives are interesting attempts to link funding with the more contemporary analysis of determinants of health.
The comprehensive programmes that are needed to bring about the large-scale changes in the health of populations require public health infrastructure and action at national, regional, and local levels of jurisdiction. Experience has demonstrated the need for clear role delineation and mechanisms for co-ordinating activity, particularly where the focus of the activity is change in legislation (Bidmeade and Reynolds 1998), policy, or programmes in sectors other than health (National Public Health Partnership 1998). The exact nature of infrastructure needed at each level of jurisdiction has not been defined. However, there are examples of using the ‘core functions’ of public health as standards against which to assess local/regional and ‘programme-specific’ public health capacity (Turnock and Handler 1997).
In most countries the greater part of the systems for programme delivery are devolved to state, regional, or local levels. A significant factor in improving the infrastructure for programme delivery in some countries, including the United Kingdom and Australia, has been the establishment of subregional administrative structures within the health sector that are responsible for protecting, promoting, and maintaining the health of defined geographical populations. Within these structures, there have been initiatives to draw together the parts of the health care system that have the greatest ‘affinity’ with public health—divisions of population or public health. This has been an effective means of ensuring an ongoing public health service at local and regional levels. However, it has been less effective in refocusing public health action to address inequalities in health and the determinants of health, and it has not been an effective mechanism through which to increase the proportion of health sector spending on public health action.
In addition to its specialist public health services, the health sector has many other opportunities to make significant contributions to improving the health of the population—through its hospitals, general practitioners, nursing homes, and early childhood services, for example. The sector also has a more direct role in public health—as a major employer, as a consumer of non-renewable resources, and as a physical and social setting that can influence the health of patients, staff, visitors, and the community (Nutbeam et al. 1993). Mobilizing this significant untapped resource remains a major challenge for specialist public health practitioners.
As noted above, non-government, community, and professional organizations also play significant roles in the design and delivery of public health interventions. Many of these are linked to specific health issues, such as sudden infant death syndrome, HIV/AIDS, or schizophrenia. Others focus on the needs of specific population groups—older people, immigrants, or indigenous people. Such organizations have specific knowledge, experience, and access to individuals and communities that is often difficult for government agencies to obtain.
Local government also has a key role in public health. The Healthy Cities movement is largely based on this level of government. Municipal public health planning has been found to be an effective mechanism to bring together local government, communities, and key government agencies (including health) to define steps that each can take separately and together to improve the health of the population. In the United Kingdom a derivation of the Healthy Cities concept in the form of Health Action Zones represents a deliberate attempt to bring together the different agencies for public health at a local level. It is through this type of organizational structure that other sectors can be more successfully engaged in public health action. The health sector’s role in such relationships varies, depending on the context and the issue being addressed (Harris et al. 1996). However, a nation’s public health infrastructure must include people with the knowledge, skills, and resources (including power) to work effectively with other sectors. This is particularly important as the emphasis of public health action shifts from programmes developed and delivered by and within the health sector, to influencing public policy and organizations and programmes delivered by other sectors.
Systems for quality control, evaluation, and promotion of best practice
Public health interventions need to be evaluated. The frameworks for assessing the quality of evidence to guide public health interventions referred to above are a component of an effective public health infrastructure. However, such frameworks focus mainly on the quality of research design and methods, and less on the quality of the intervention (relevance, practicality of implementation, etc.) (Speller et al. 1997). There is a growing body of evidence that defines the characteristics of effective public health interventions (National Health and Medical Research Council 1997b; Malcolm and Dowsett 1998; Green and Kreuter 1999; International Union for Health Promotion and Education 1999). It is a base from which to develop standards of quality for the design and implementation of public health interventions in relation to specific issues or population groups. The Health Development Agency in the United Kingdom, the United States Task Force on Community Preventive Services (Task Force on Community Preventive Services 1999) in the United States, and the National Public Health Partnership in Australia are all working to develop further standards for application to national and regional intervention programmes. Use of such standards and guidelines in the development and implementation of public health interventions will be vitally important in improving the quality and impact of public health intervention in the future.
This chapter describes key elements of health policy and strategy that have been found to be effective in guiding national public health action, and the components of an infrastructure and delivery system required to design, deliver, and evaluate public health interventions. Public health intervention requires a complex mix of science, art (of practice), and politics. The emergence of non-communicable disease in most developed countries has required a radical reappraisal of what determines health, and what public health responses are most appropriate and effective. Four key challenges emerge from this chapter.
Addressing all determinants of health: it is increasingly apparent that, in many cases, public health practitioners need to expand the range of research methods used to identify public health problems and their causes. As well as using the traditional public health tools of epidemiology and demography, it is necessary to use the social, behavioural, and environmental sciences to obtain a more complete picture. More complex analysis of patterns of disease in populations, and of the determinants of disease will lead to better informed and potentially more effective interventions as a response. In addition, knowledge of current infrastructure and existing strengths in communities is a powerful platform from which to build effective public health interventions (Labonte 1999). Identifying this capacity within communities also requires the use of a wider range of research and consultation methods (McKnight and Kretzmann 1998). It also emphasizes the key role of communities in defining and prioritizing problems, and in developing solutions and is particularly important when working with communities that are disadvantaged or socially excluded.
Gaining visibility for public health: it is also clear from the analyses in this chapter that public health action often involves political processes. Public health practitioners need to use health data better to influence these political processes. Reporting on ever more sophisticated analyses of public health problems and their determinants will not, on its own, result in any action. However, this data is of great use in raising public and political awareness of health problems, and in highlighting the obligation of governments to develop policy that enables action to improve the health of the population. This includes engaging politicians in dialogue to identify priorities for efficient health sector investment, and when appropriate, advocating for action to support investment in public health interventions in the face of pressure for increased investment in health care services.
Influencing policy and plans for improving public health: the range of determinants of health means that public health practitioners will increasingly be required to provide technical advice on the impact on health of policies and practices in sectors other than the health sector. Health impact analysis is a relatively new and underdeveloped tool to assist this process. Such technical advice will inevitably lead to conflict in some cases that will require the public health practitioner to act as an advocate for health in the face of competing pressures. More positively, as evidence grows of the effectiveness of public health interventions it will be necessary for public health practitioners to operate across different sectors of government at national, regional, and local levels. Public health practitioners need skills in identifying the policy relevance of the evidence and in identifying the most effective ways to ensure the use of evidence in the development and implementation of public policy.
Working with people and organizations to improve health: public health practitioners need to be able to engage people and organizations in practical action to address the determinants of health. Such action will often occur at a local level. The capacity to develop and deliver interventions within local communities and through different settings (such as schools and worksites) is an essential public health skill. Practical guidance on the type of skills and strategies required of public health practitioners to achieve change for public health at this level is provided in Chapter 7.3..
The development of effective organizational structures through which to bring together the components of an effective public health infrastructure within the health sector (in particular) to provide the capacity to ‘orchestrate’ public health action is a major challenge for the twenty-first century. However, it is important to reflect on the fact that having the technical capacity to develop and deliver effective interventions is not sufficient, on its own. Without political commitment, action to promote health is, at best, difficult—at worst, impossible. The national infrastructure for promoting health must include people and strategies aimed at building and maintaining political support both for public health in general as a key area of government activity, as well as for the specific actions that must be taken if we are to succeed in improving the health of the population.
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