WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Fifty-third session Kyoto, Japan 16–20 September 2002 Provisional agenda item 15
WPR/RC53/10 16 July 2002 ORIGINAL: ENGLISH
ESSENTIAL PUBLIC HEALTH FUNCTIONS: THE ROLE OF MINISTRIES OF HEALTH Public health is a core element of governments’ attempts to improve and promote the health and welfare of their citizens. For many centuries, public health focused on hygiene, sanitation and communicable disease control, but recently it has expanded to include areas of emerging social concern. The public health infrastructure is also expected to respond to such issues as new technologies, the effects of globalization, migration and the potential use of bioterrorism. Unfortunately, there is evidence that current public health systems and services are not able to cope well with these modern challenges. Although the core areas of public health are generally understood, in many cases it has proved difficult for countries to define these further in a more detailed and systematic way. It is therefore difficult to ensure that public health activities are comprehensive and coordinated. The use of essential public health functions (EPHFs) may assist Member States to define more clearly and systematically the core areas of public health work for which governments are ultimately responsible. Governments need to ensure these essential functions are provided, but would not necessarily have to implement and finance them themselves. Implementation may be achieved through other government agencies,
community and nongovernmental organizations, and the private sector, among others. The Regional Committee may like to examine whether the EPHF concept will help Member States ensure a comprehensive approach to public health. The Committee may also like to review the nine essential public health functions that have been identified and to comment on their relevance to the Region. Further work may then be carried out by WHO in cooperation with Member States to refine the nine EPHFs and to undertake further analysis to determine the most appropriate role for the ministry of health in ensuring that these functions are carried out effectively.
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1.
INTRODUCTION
Public health systems and services today are generally not able to meet the broad range of public health demands that are expected of them. Unfortunately, the common broad descriptions and definitions of public health are very broad and do not help the systematic identification of the key components that need to be in place to ensure a comprehensive system for public health. Identifying "essential public health functions" (EPHFs) may assist in this regard. Nine EPHFs have been derived for this Region and tested in three countries. Member States are invited to consider the use of the nine EPHFs (Annex 1) to strengthen their health systems and to clarify the role and responsibility of the ministry of health.
2.
THE EVOLUTION OF PUBLIC HEALTH
2.1
The historical focus of public health Human endeavours in public health started at least 4000–5000 years ago, when Myceneans
built drainage systems, toilets and water-flushing systems.
Most subsequent civilizations have
introduced sanitation, hygiene and quarantine measures. In the last 1000 years, this has been driven in particular by the need to control widespread and serious epidemics of diseases such as cholera, leprosy, smallpox, typhus, typhoid, syphilis and the plague. In recent centuries, these public health measures have been more explicitly defined and implemented, following increased understanding and identification of the causes of diseases and the measures needed to control them. During the 18th and 19th centuries, public health expanded to include such areas as the welfare of children and workers; care of the aged, infirm and mentally ill; and the health problems associated with rapid urbanization. Nevertheless, the major focus of public health has for many centuries been centred on sanitation, hygiene and communicable disease control. Ministries of health in many countries appear to have been initially established to enable the State to apply a more systematic and effective approach in these areas.
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2.2
Challenges for and weaknesses in public health today Although some degree of control has been achieved over communicable diseases, this cannot
be taken for granted in future. Public health capacity to respond both to known communicable diseases and to emerging communicable diseases must remain. In many areas there is also a need to strengthen basic water and sanitation services. However, in addition to these traditional functions, the burden of noncommunicable diseases (NCD) has increased dramatically in almost all countries. In most cases, traditional methods used to control communicable diseases are not directly applicable to NCD, for these diseases are much more related to lifestyles and the interaction between people and their environments, and cannot be controlled through the use of vaccines, antibiotics and quarantine measures. At a practical level, however, vertical disease-specific programmes often predominate,
with little coordinated development of the overall public health system. Even where there are strong vertical public health programmes in specific areas, there are still concerns that the health situation is slipping backwards at times (demonstrated, for example, by decreasing immunization coverage rates). Projected demographic changes, including a substantial increase in expected numbers of older persons, will compound the pressures on the public health infrastructure in the future. Globally, even in countries with well-developed and resourced health services, concerns have recently been expressed about the inability of public health services and systems to cope with current public health problems. This is not surprising. The public health infrastructure of today has evolved from many centuries of concentration on traditional aspects of public health, including water, sanitation, hygiene and communicable disease control. Newer aspects, such as child health,
environmental health and noncommunicable diseases have become identified as part of public health during the last two or three centuries, and particularly in the most recent decades, but these have largely been added through various vertical programmes in an ad hoc manner. Recent public health work has also begun to identify determinants of health and ill-health more clearly, and it is apparent that these determinants are wide-ranging in nature and include such factors as income, housing and education. Furthermore, the public health infrastructure is now expected to respond to such issues as new technologies, the effects of globalization, migration, the potential use of bioterrorism, and increasing consumer awareness and demands for quality and choice of services. Many countries are actively undertaking or planning health reforms, the main thrusts of which are often decentralization, encouraging competition and developing the private sector. However, these reforms usually focus on the delivery of personal health services (primarily diagnostic and clinical treatment services, and particularly hospital-based services which often consume a large proportion of government health budgets). Few of these reforms include consideration of the effects of changes on the public health infrastructure. Market-driven reforms have provided opportunities to
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improve personal health services, but detrimental effects on public health services have been seen. It is also not uncommon for user charges to be introduced for all types of services, including public health services, and this can result in a decline in the use of services, particularly by the poor. Thus it is clear that a system that continues to focus only on the more traditional components of public health will be far from adequate to meet current expectations for public health services. These expectations will undoubtedly continue to expand in the future, particularly as more is learned about the socioeconomic and other determinants of health. There is, therefore, a need to provide a more systematic and comprehensive approach to defining all critical components of public health. Such an approach will help to ensure that the public health infrastructure covers all appropriate public health activities adequately and that it can function well in an increasingly complex and changing environment. This is a very significant challenge. 2.3 Current and future concepts of public health Key elements of modern public health theory and practice include: an emphasis on collective responsibility for health and the primary role of the state in protecting and promoting the public’s health; a focus on whole populations; an emphasis on prevention, especially the population strategy for primary prevention; a concern for the underlying socioeconomic determinants of health and disease, as well as the more immediate risk factors; a multidisciplinary approach that incorporates quantitative and qualitative methods; and partnership with the populations served. 1 These key elements of public health theory and practice are often reflected in the core areas of public health work. There is general agreement that these core areas of work include disease control, injury prevention, health protection, healthy public policy (e.g. housing, workplace, food), promoting health and equitable health gains, and combating threats to public health. In addition, there is a broad understanding of the types of public health outcomes being sought: improving health status and quality of life; decreasing health inequalities; increasing safeguards for the public’s health; and a decreasing acute and chronic disease burden.
1
Beaglehole, R., Bonita, R. op cit, Ref. 2, p.145 and box 7.1.
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These broad descriptions of key elements, core areas of work and public health outcomes are all consistent with modern definitions of public health.2 There is no doubt that public health today is viewed as a multidisciplinary science, and is conceptually very broad, concerned with the total ecological relationship between people and their environment. However, broad public health
definitions and concepts do not necessarily help countries to identify and evaluate the public health activities they currently undertake systematically, to identify gaps, and to plan and implement sustainable system changes. This is a key issue if countries are to be able to strengthen their public health systems and services.
3.
ESSENTIAL PUBLIC HEALTH FUNCTIONS
3.1
What are essential public health functions? The concept of essential public health functions enables States to identify the critical (or
“essential”) public health activities (or “functions”) that need to be in place in each health system. These essential public health functions (EPHFs) cut across different vertical programme areas, and so form a generic and systematic basis for enabling a comprehensive evaluation of both the strengths and the gaps and weaknesses at different operational levels within the current system. An analysis undertaken using this framework can serve as the basis for identifying options for strengthening essential public health functions in the future. EPHFs may be defined as “…a set of fundamental activities that address the determinants of health, protect a population’s health, and treat diseases [of public health significance]. These public health functions represent public goods, and in this respect governments would need to ensure the provision of these essential functions, but would not necessarily have to implement and finance them. They prevent and manage the major contributors to the burden of disease by using effective technical, legislative, administrative, and behaviour-modifying interventions or deterrents, and thereby provide an approach for 2
For example, public health may be considered to be “the art of applying science in the context of politics so as to reduce inequalities in health while ensuring the best health for the greatest number” (WHO. The World Health Report 1998: Life in the 21st century, a vision for all. Geneva, WHO, 1998). In this context, ‘politics’ refers in a neutral sense to the processes used by societies to make decisions when different values may be in conflict. The methods used to determine public health policies are those of politics. Public health is primarily concerned with the collective action taken by society to promote and protect the health of entire populations. This may be compared with clinical medicine, which deals primarily with problems of individuals and, therefore, may be referred to as personal health services.
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intersectoral action for health…This approach stresses the importance of numerous different public health partners. Moreover, the need for flexible, competent state institutions to oversee these cost-effective initiatives suggests that the institutional capacity of states must be reinforced.”3 Through collaborative work undertaken with Fiji, Malaysia and Viet Nam, the Regional Office has derived nine EPHFs that it also considers to be relevant and practical for other Member States in the Region to consider. The nine EPHFs are: 1: Health situation monitoring and analysis 2: Epidemiological surveillance/disease prevention and control 3: Development of policies and planning in public health 4: Strategic management of health systems and services for population health gain 5: Regulation and enforcement to protect public health 6: Human resources development and planning in public health 7: Health promotion, social participation and empowerment 8: Ensuring the quality of personal4 and population-based health services 9: Research, development and implementation of innovative public health solutions. These EPHFs, each of which can be defined further through a broad outcome statement and a series of tasks, are described in Annex 1. The collaborative work involving Fiji, Malaysia and Viet Nam was a case study which is also briefly further described in Annex 2. The work in the Region has also drawn on work undertaken by WHO Regional Office for the Americas/Pan American Health Organization through its “Public health in the Americas” initiative. 3.2 EPHFs: what is included and what is not? EPHFs focus on activities relevant to public health. Therefore a great many activities,
particularly those carried out by the health sector itself, are included. They include traditional public heath activities such as health situation monitoring and analysis (assessing health status, analysing trends in morbidity and mortality, and identifying current and potential threats to health), epidemiological surveillance, disease prevention and control, and regulation and enforcement activities to protect health. They also include such aspects as developing policy and legislation to
guide the practice of public health; developing and tracking measurable indicators of health; human resource development and planning in public health; health promotion, social participation and 3 4
Yach, D. Redefining the scope of public health beyond the year 2000. Current Issues in Public Health. 1996, 2:247-52. Country-specific interpretation permitted for italicized part of function.
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empowerment of communities; quality assurance for both public health and personal health services; and public health research. The EPHFs are broad, and act as a framework for all areas of government, not just those areas of public health which may officially lie within the jurisdiction of the ministry of health. They can encompass activities that are undertaken in many areas of government as well as the private sector. It is important to note that the EPHFs cover not only traditional public health activities and areas of work, but also such issues as access to health care and the regulation and overall monitoring of the safety of clinical services and health professionals, equity in the use of health services, the quality of those clinical services, and preparing for clinical and public health services' response to disasters. However, as the focus of EPHFs is on public health, it is not intended that these nine functions should include all aspects of all services delivered by the health sector. Specifically, the two key areas which are not included within the EPHF framework are: • Diagnostic and clinical services (including direct management, service planning and human resource development) that are not related to treating diseases of public health significance. Thus, the EPHFs do include clinical services needed for the treatment of tuberculosis, and also for the delivery of immunization for children. The inclusion of other activities can vary from country to country (for example, many would probably choose to include maternal and child health, as well as a number of other primary health care activities within EPHFs). EPHFs tend to exclude, for example, the delivery of surgical interventions in hospitals (but the safety and quality framework in which those services are delivered is included). • Overall policy and mechanisms for public financing. Methods by which funds are raised by governments for public sector activities are usually the responsibility of ministries of finance. However, the analysis of effects of the different methods of
raising those public funds (for example, from an equity and access to services perspective) is an important part of the EPHF framework. So too is advocacy by relevant agencies within the health sector for appropriate levels and mechanisms of financing. In addition, the EPHFs include the issue of advising on priorities of publicly-funded health services and the allocation of public funds. The only area in which funding is included is in relation to identifying adequate sources of funding for
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research relating to public health (this was included because it was recognized that most health systems provide very little public funding for public health research). 3.3 Can evaluating current vertical services achieve the same result? One approach to defining public health would be to evaluate the public health services that are currently delivered. Evaluating current services is important for improving the quality of those services. However, the problem with evaluating current services is that this does not involve an examination of the more fundamental question of what services should be provided. This is examined using the EPHF framework. In addition, as EPHFs do not have a boundary according to the current ways in which services are provided, this enables a fresh look at different ways in which these functions and tasks can be grouped most appropriately into services so they are carried out effectively and efficiently.
4.
WHO SHOULD BE RESPONSIBLE FOR EPHFS?
4.1
Who should take overall responsibility for EPHFs? The EPHFs represent public goods, and in this respect, governments as a whole need to ensure
they are provided, although actual provision of these activities can be undertaken through a mixture of public, private and nongovernmental organizations and community groups, depending on what is most relevant for the country. The EPHFs are broad, and act as a framework for all relevant parts of government which have jurisdiction for overseeing or implementing different public health activities or aspects, not just the ministry of health. It is possible to consider many of these key functions comprehensively only in communities where the rule of law exists, there is no substantial civil or political unrest and the community is not at war. 4.2 Who should be responsible for financing EPHFs? Although governments need to ensure that all EPHFs are provided, they do not always have to implement and finance them directly. Having said this, it is very important to recognize the nature of the EPHFs, for they are public goods, and individuals may be reluctant to pay directly for public health services because not all benefits accrue to them personally. Therefore, although private and nongovernmental organizations may assist in delivering these essential functions, governments may have to consider financing the greater part of the EPHFs, or at least to ensure that they are adequately
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financed from funds collected from society (for example, from funds already collected through a social health insurance or other relevant scheme). In some cases, the EPHFs are central to governments' stewardship and governance roles with respect to health, and it would be inappropriate for others to finance or provide core elements of these functions. In practical terms, it is possible to use different ways of funding and providing key public health activities, depending on their nature. For example, where there is a statutory requirement for a license to be issued before particular types of businesses (such as food vendors) can operate because of potential health risks, it would be quite possible for the local government or another agency with appropriate independence and expertise to be responsible for inspecting and issuing such licences. An appropriate fee could be charged to the operator of the business to recover the costs of undertaking this statutory function. However, reporting and investigations of human illness suspected of being caused by that business will probably be undertaken through a different system, involving reporting by health professionals to the relevant health authorities who would generally investigate, and where necessary control, outbreaks of disease. 4.3 What should the role of the ministry of health be with respect to EPHFs? Government has overall responsibility for ensuring EPHFs are delivered through some means, which could be public or private. Although these functions are broader than the health sector, the ministry of health plays a central role. As the government’s key adviser on health matters, it is critically important that the ministry of health should take the lead in evaluating the current provision of all EPHFs. The ministry of health must also form good relationships and links with other
ministries and agencies, academic institutions, and community-based and private organizations so that it can obtain up-to-date information and be in a position to provide government with comprehensive information and analysis on all health risks important to the country. In situations where other agencies and ministries are responsible for particular public health areas or activities, the ministry of health should ensure that a public health activity is being effectively undertaken and, where necessary, work actively with other ministries and agencies to identify gaps and weaknesses, propose solutions that will strengthen the public health system and ensure that all EPHFs are provided in an appropriate manner. The role of the ministry of health is particularly important within the health sector, for many of the EPHFs are undertaken there. In addition, health sector reforms often do not seem to include consideration of EPHFs, or the effect of reforms on the carrying out of EPHFs. It is therefore
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important that ministries of health ensure that careful and particular attention is paid to public health systems and services during periods of health reform. As many health protection enforcement activities involve the exercise of statutory powers to control health hazards and outbreaks of communicable diseases, the ministry of health is the most appropriate agency to ensure appropriate use of this power. Of course, it would also be possible for local governments to be responsible for carrying out such actions; the role of the ministry of health in this situation would be to ensure that the local authority is exercising its authority appropriately, and to coordinate and disseminate information between different local authorities in a timely manner, to ensure local governments are receiving specialised support to enable them to contain important health risks, and to take national action in response to serious health hazards that could potentially affect a large proportion of the population. 4.4 What factors can be used to identify a suitable role for other organizations? For many of the implementation aspects of EPHFs, there may be a role for other agencies or for the private sector. However, the following factors have to be considered. Is there any conflict of interest or ownership? Does the agency have sufficient technical capacity and experience, and is it a sustainable organization? Does the agency need to cooperate and share information with the ministry and others, or can problems be foreseen in this regard? Are there cost, efficiency and effectiveness gains in another agency undertaking this work? Is it appropriate for the agency to exercise any form of statutory powers and is there sufficient accountability? Who owns the information that the agency may generate, and, if another agency is chosen at a later date to continue this work, will the original agency provide all the necessary information on the services it has been delivering, or will it consider it to be its intellectual property or proprietary information? What else will happen as a consequence of the agency doing this work (for example, will it develop a database using proprietary systems that the ministry would have to purchase in order to access critical health information)? Thus, for some EPHFs it would be entirely appropriate for other agencies to carry out some of the work. However for others the function is too critical or central to the role of the ministry for it to be carried out by anyone else. Careful consideration and analysis is required before a key aspect of an EPHF is contracted to another agency for implementation.
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5.
CONCLUSION
It is clear that public health today is very broad.
It is also clear that the public health
infrastructure (systems and services) in many countries around the world is not able to cope with the breadth of demands for services that this entails. It can be difficult to define public health
systematically beyond very broad definitions or descriptions of the broad aspects usually considered to be part of public health. WHO considers that it is important for all Member States to evaluate and strengthen their public health infrastructure systematically and to define the role of the ministry of health more clearly and comprehensively. The concept of essential public health functions provides one way of doing this. Member States are therefore invited to consider the use of the nine EPHFs (Annex 1) to strengthen their health systems and to clarify the role and responsibilities of the ministry of health. If requested, WHO could undertake further work in this area, in collaboration with Member States. This could include confirming the suitability of, or modifying, the nine EPHFs to ensure their appropriateness for use in a broader range of countries in this Region. In addition, WHO could undertake further analysis that would assist Member States to identify a suitable role for the ministry of health with regard to essential public health functions (although it may be difficult to develop definitive criteria or other decision-making tools that would suit all health systems).
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ANNEX 1
THE NINE EPHFS
The following nine essential public health functions were developed after considering studies and work conducted by WHO;1 the US Department of Health and Human Services;2 the Centers for Disease Control and Prevention (CDC), United States of America; Centro Latino Americano de Investigacion en Sistemas de Salud; the Pan American Health Organization (PAHO)3 and the National Public Health Partnership Group in Australia.4 The US Department of Health and Human Services and CDC frameworks were similar, and were supported by a series of measurement instruments in various stages of development.5 These were therefore considered to be the most appropriate to draw on when developing EPHFs suitable for countries in the Region. The nine EPHFs, the associated outcome statements, and tasks are as follows. FUNCTION 1: Health situation monitoring and analysis Outcomes The outcomes of this function are the measurement, monitoring and analysis of changes in health status, including quality of life and health inequalities, and the acute and chronic disease burden. The function results in confidence that safeguards exist for the protection of the public’s health and provides early warning of problems.
1
Bettcher, D.W., Sapirie, S., Goon, E.H.T. Essential public health functions: results of the international Delphi study. World health statistics quarterly. 1998; 51: 44 - 55. 2 US Department of Health and Human Services. The public health workforce: an agenda for the 21st century. Washington, US Department of Health and Human Services Public Health Service, 1997. 3 Centers for Disease Control and Prevention, Centre Latino Americano de Investigacion en Sistemas de Salud, Pan American Health Organization/World Health Organization. Public health in the Americas: national level instrument for measuring essential public health functions. Washington, Pan American Health Organization, 2000, pilot test version. 4 National Public Health Partnership Group. National Delphi study on public health functions in Australia. Victoria, National Public Health Partnership Group, 2000. 5 Centers for Disease Control and Prevention. State public health system performance assessment instrument. Version STATE_7.5 ed, Atlanta. Public Health Practice Program Office, Centers for Disease Control and Prevention, 1999. Centers for Disease Control and Prevention. The draft local public health performance assessment tool. Atlanta, Public Health Practice Program Office, Centers for Disease Control and Prevention, 1999.
WPR/RC53/10 page 14 Annex 1 Tasks 1.1 Assess health status of the country, accurately and continuously, for larger administrative units within the country, and for specific groups that at higher risk than the general population. 1.2 Analyse trends in socio-demographic variables, mortality, morbidity, risks and hazards (personal and environmental), barriers to access to personal preventive services and personal treatment services of public health significance6 and coverage of population-based public health services. 1.3 1.4 1.5 1.6 Identify current and potential threats to health. Periodically assess health services needs (and/or targeted assessments). Identify resources and assets (in communities and in other sectors) to support public health. Profile health status by producing and distributing a health status profile (including 1.1-1.5 above). 1.7 Manage information by developing technology and expertise, and methods for management, analysis, quality control, and communication of information to all those with responsibilities for improving public health. 1.8 Integrate information systems by collaborating within the public health system, with other parts of the health sector, and with other sectors, including the private sector. FUNCTION 2: Epidemiological surveillance/disease prevention and control Outcomes The outcomes of this function contribute to improving health status and the quality of life, reducing health inequalities, safeguarding the public’s health and reducing the burden of disease.
6
Country-specific interpretation permitted for italicized part of function.
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Annex 1
Tasks 2.1 Conduct surveillance of outbreaks and patterns of communicable and noncommunicable diseases, injuries, and exposure to environmental agents harmful to health. 2.2 2.3 Investigate disease outbreaks and injury patterns, and the associated risks and hazards. Undertake case finding, diagnosis and treatment of diseases of public health significance, such as tuberculosis. 2.4 Access information and support services for better management of health problems of interest. 2.5 2.6 Respond rapidly to control outbreaks and emerging specific health problems or risks. Implement mechanisms to improve surveillance systems and disease prevention and control.
FUNCTION 3: Development of policies and planning in public health Outcomes The outcomes of this function are the development of policies and planning for the improvement of health status and quality of life, reducing health inequalities, safeguarding the public’s health, and reducing the burden of disease. Tasks 3.1 3.2 3.3 Develop policy and legislation to guide the practice of public health. Develop and evaluate plans to promote and protect public health. Review and update regulatory frameworks, policy, and their implementation, regularly and systematically in the light of health status and assessments of health needs. 3.4 Advocate for population-based perspectives in health services policy and the development of health sector regulation. 3.5 Develop and track measurable indicators of health.
WPR/RC53/10 page 16 Annex 1 3.6 Evaluate jointly with relevant health care systems so as to plan and to define policies regarding personal preventive and treatment services. FUNCTION 4: Strategic management of health systems and services for population health gain Outcomes The outcomes of this function contribute to implementation of strategies to improve health status and the quality of life, reduce health inequalities, safeguard the public’s health, and reduce the burden of disease. Tasks 4.1 4.2 Promote and evaluate effective access by all citizens to the health services they need. Resolve and reduce inequities in the use of health services by multisectoral collaboration that facilitates working with other agencies and institutions. 4.3 Overcome barriers to access to health services by individuals and communities by populationbased public health actions. 4.4 4.5 Facilitate the linkage of vulnerable groups to health services Develop competence in evidence-based decision-making that incorporates resource management, leadership capacity, and effective communication. 4.6 4.7 Advise on priorities of publicly-funded health services. Use evidence on safety, effectiveness and cost effectiveness to assess the utility of health technology and interventions. 4.8 Manage public health to build, implement, and evaluate organized initiatives to address public health problems. 4.9 Prepare for disaster and emergency response by the health system.
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Annex 1
FUNCTION 5: Regulation and enforcement to protect public health Outcomes The outcomes of this function contribute to the development and compliance with regulation that improves health status and the quality of life, reduces health inequalities, safeguards and protects the public’s health, and reduces the burden of disease. Tasks 5.1 5.2 5.3 5.4 Promulgate and implement laws and regulations in public health. Review, develop and update regulations in public health and develop capacity to regulate. Ensure enforcement of regulations and develop capacity for enforcement. Assess and promote compliance
FUNCTION 6: Human resources development and planning in public health Outcomes The outcome of this function is a workforce that can contribute to improving health status and the quality of life, reducing health inequalities, safeguarding the public’s health, and reducing the burden of disease. Tasks 6.1 Assess, perform and maintain an inventory of the human resource base including the professional attributes and distribution. 6.2 6.3 6.4 Project workforce requirements in terms of quantity and quality. Ensure an adequate human resource base for public health activities. Ensure workers are adequately educated and trained with demonstrable certification and recertification.
WPR/RC53/10 page 18 Annex 1 6.5 Coordinate between educational institutions and the workforce, with employers and employees, in the design and delivery of training programmes. 6.6 6.7 Promote continuing professional education. Monitor and evaluate education and training programmes.
FUNCTION 7: Health promotion, social participation and empowerment Outcomes The outcomes of this function make communities healthier by advocating health and empowering citizens through access to relevant, high-quality and effective information. Tasks 7.1 Contribute to improving the capacity and capability of communities and decreasing their vulnerability to risks and damages to health. 7.2 Create supportive environments to make healthy choices easy choices, by building coalitions, promoting relevant laws and policies, working intersectorally to make health promotion programmes more effective, and advocating with government authorities in relation to health priorities. 7.3 Empower citizens to change lifestyles and play an active role in changing community norms about particular behaviours to achieve permanent, large-scale behaviour change. 7.4 7.5 7.6 Facilitate and convene partnerships among groups and organizations to promote health. Communicate through social marketing and targeted media communications. Provide accessible health information resources at community levels.
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Annex 1 FUNCTION 8: Ensuring the quality of personal7 and population-based health services Outcomes The outcomes of this function ensure the quality of personal7 and population-based health services to improve health status and the quality of life, reduce health inequalities, safeguard the public’s health, and reduce the burden of disease. Tasks 8.1 Define appropriate standards for the quality of both personal and population-based health services. 8.2 8.3 8.4 Develop models of quality evaluation. Identify valid and reliable measurement instruments to monitor quality. Monitor and ensure safety and ongoing improvements in quality.
FUNCTION 9: Research, development and implementation of innovative public health solutions Outcomes The outcomes of this function contribute to innovative ways to improve health status and the quality of life, reduce health inequalities, safeguard the public’s health, and reduce the burden of disease. Tasks 9.1 9.2 9.3 Develop a public health research agenda. Identify adequate sources of research funding. Encourage cooperation and joint approaches between public health agencies and organizations to address funding and the conduct of research for the research agenda. 9.4 Ensure appropriate ethical safeguards for public health research.
7
Country-specific interpretation permitted for italicized part of function.
WPR/RC53/10 page 20 Annex 1 9.5 9.6 9.7 Develop processes for dissemination of research findings. Encourage participation of public health workers in research at all levels. Develop innovative programmes to address the identified problem.
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ANNEX 2
A THREE COUNTRY CASE-STUDY OF EPHFS IN THE WESTERN PACIFIC REGION
For some time, WHO has been concerned that a number of countries have been finding it difficult to identify public health functions that are missing from their systems, to organize their systems to respond to missing components, and to react to the major system changes that are occurring now or are projected in the next few years. These projected changes are related to such complex issues as decentralization, increased competition and privatization of primary health care and other public providers, and the desire to achieve greater integration between vertical public health programmes. There are major changes taking place in health systems in the Region and the case study was designed to generate practical examples and proposals that Member States can use to organize and strengthen essential public health functions. Another objective was to identify the probable impacts of key system changes on the organization of public health functions. Three Member States, Fiji, Malaysia and Viet Nam, agreed to participate in the research. The first stage of the case study involved analysis of the international literature and available frameworks by an international researcher, followed by a meeting of researchers, ministry staff, and WHO staff involved in the case study. During this meeting nine EPHFs were derived, each of which was further specified with an outcome, tasks, and the practices required to implement each task. In addition, the research framework included a number of preconditions, critical links, relationships and other factors that were considered necessary for the effective performance of each EPHF, in a context of appropriate governance and stewardship. The aim was to provide a methodology that would enable researchers from the three countries to undertake systematic and comprehensive assessments of the strengths, weaknesses and gaps in their systems, and by using this assessment to identify proposals which would help strengthen the public health infrastructure and make it more sustainable. A wider aim for the project overall was to provide a tested framework that other countries could consider and, through the case studies, to provide examples and ideas for different ways of systematically assessing the comprehensiveness and scope of the public health functions currently in place, as well as some alternative ways of strengthening these functions. Throughout the research, emphasis was placed on the operational level, for it was felt that the operational aspects of public health were often the most often under-resourced and weakest.
WPR/RC53/10 page 22 Annex 2 The nine EPHFs, tasks and practices were tested in the three quite different health system settings and found to be appropriate. It is therefore suggested that these nine EPHFs would be an appropriate starting point for any heath system in the Western Pacific Region. The nine EPHFs used in the study are those detailed in Annex 1. The report of this study is to be published as: The structure and sustainable delivery of essential public health functions in the Western Pacific Region: research report, and will be available from the Regional Office on request.