Forty-eighth Regional Committee for Europe: Copenhagen, 14-18 September 1998: developing public health in the European Region

W O RLD H EA LTH ORGANIZATION R egional O ffic e for E urope COPENHAGEN REGIONAL COMMITTEE FOR EUROPE Forty-eighth session, Copenhagen, 1 4 - 1 8 September 1998 Provisional agenda item 3(d) EUR/RC48/13 + EUR/RC48/Conf.Doc./9 18 May 1998 05108 ORIGINAL: ENGLISH Developing Public Health in the European Region Public health will be the key to delivering the new agenda o f Health for All (HFA) in the twenty-first century within Member States. Yet there is still a long way to go in the European Region before public health practice and training can be considered strong enough to meet this challenge. Public health deals with the structures, processes and competences required to monitor, protect and promote the health o f defined populations. Whereas public health used to rely heavily on legislation and concentrated on programmes for disease control, the new HFA-based public health is more strategic. It draws on the contribution o f many sectors, disciplines and actors; it operates in policy-making spheres as well as at technical levels; it encourages community participation; and it places strong emphasis on the social, economic and environmental determinants of health. Within Europe there is now a fast-growing HFA-inspired movement towards promoting health in different settings, with the involvement o f a host o f new actors, agencies and sectors. However, this movement needs a more solid foundation in terms o f public health infrastructure, function and practice. Such strengthening o f public health will depend on public health practitioners possessing improved capabilities and enjoying higher status and standing; on systems at national and local levels that facilitate coordination and intersectoral work; on availability o f the resources and tools for effective advocacy and technical work; and on giving people from a variety of professional backgrounds and other actors incentives and encouragement to become involved in such work. Better education needs to be delivered through schools and university departments o f public health, with a sharper focus on HFA. Public health ideas and education also need to be spread among the wider constituency o f people interested in health outside the health professions. Member States may take advantage o f the new HFA strategy to review and strengthen their public health capacities and practice at national and local levels, and this document outlines a series o f proposals in that regard. CONTENTS Page Introduction................................................................................................................................................................. 1 What is modern public health?................................................................................................................................. 1 The current state of public health in Europe........................................................................................................... 3 Public health actors and ways o f working.............................................................................................................. 4 Implications of strengthening population-based public health ........................................................................... 5 Education for public health practice........................................................................................................................ 5 WHO’s role in developing public health in the European R egion.....................................................................6 Partners, management and resources....................................................................................................................... 7 Conclusions................................................................................................................................................................. 7 EUR/RC48/13 page 1 1. Achieving Health for All (HFA) in the twenty-first century in the countries o f the European Region depends crucially on changing the social, economic and environmental factors that lead to poor health, as well as on changing people’s lifestyles and assuring high quality care of those with disease and disability. The enhancement of public health capacities and skills is vital if the HFA strategy is to be further developed and successfully implemented. 2 . In essence, public health practice is concerned with describing the health experience of populations (and the underlying factors or determinants) as an essential prerequisite to drawing up and carrying out policies aimed at improving health. Health improvement is therefore the ultimate goal both of the HFA policy and o f the public health infrastructure that is needed to support it. Public health practice is always a dynamic combination o f knowledge about health and the causes of ill health, and action towards health improvement. That action cannot be taken by public health practitioners alone but entails a commitment by the multiple influences and actors within modern plural societies, including national and local governments, private and public enterprise, civil society with its many networks and influences, and ultimately populations themselves. 3. These various sources o f influence and action must be informed about public health matters, and their commitment to and cooperation in action must be secured. Modern public health practice is therefore intellectually complex: it includes not merely scientific and technical practice but also the knowledge and skills to build effective coalitions and partnerships for health and collectively to manage actions for health improvement. This capacity to achieve positive change for health can be described as public health management. 4. When compared with this functional description o f what is required it is clear that public health practice in the European Region needs substantial development. While one important justification must be the very serious public health situation in many countries in the east of the Region, the requirement for more effective public health infrastructure and practice is seen in all the countries o f the Region. Yet in the face o f these challenges, public health services are receiving less support in some countries, and there is still not enough public health training and dissemination o f public health experience and practice. 5. Countries throughout Europe therefore need to take determined action, supported by WHO, to improve their public health structures, capacities and instruments, drawing on each other’s experience, working in partnership with existing and new public health institutions, and providing new and flexible educational opportunities for the many individuals involved in public health action. W h a t is m o d e r n p u b l i c h e a l t h ? 6 . Public health may be considered as the structures and processes by which the health ofpopulations is understood, safeguarded and promoted through the organized efforts o f society. 7. Public health management describes the structures and processes by which the changes necessary fo r health improvement throughout society are defined and effectively implemented. 8 . These two definitions capture the twin pillars o f knowledge and action which are the basis o f all effective action to improve health. The fundamental perspective, and the essence o f modern public health, is that o f identifying and responding to the needs o f the whole o f a defined population. This focus on whole populations can be extended further, to regard public health as one of the key intellectual and practical contributions to attaining Health for All through sustainable development within countries. Health itself is one of the fundamental prerequisites for such development, as well as one o f its most significant products. I n t r o d u c t i o n EUR/RC48/13 page 2 9. Set in that context, the extensive scope of public health becomes clear. It is concerned with all of the forces in society that influence health for good and for ill, and with the interaction between health and other factors for sustainable development. This perspective means that the multi-dimensional nature of health must be acknowledged and accommodated in public health action. It also identifies the capacities and skills required to take that action. These extend beyond the technical sphere, to embrace new skills of cooperation and coordination between the multiple actors who exert an influence on health. 10. Public health management focuses on the management skills needed to promote change and health improvement. The people engaged in public health management must act as powerful advocates for health, taking a comprehensive integrated approach. They must focus their attention, in programmes for health, on the whole spectrum of health promotion, disease prevention, treatment and rehabilitation, with progress defined in terms o f objectives and targets and evaluated using agreed indicators. Public health management must be transparent, consultative and able to obtain the commitment o f complex networks of partners at international, national and local levels. 11. In this way countrywide movements for health may be created by mobilizing all sectors and involving national and local government, public and private enterprise, civil society, the professions, and communities, families and individuals. Networks defined in terms o f settings for action (e.g. regions, cities, schools, hospitals) can play an important role here. 12. The scientific and technical content of public health can be considered in this context. The classical skills include the epidemiological and quantitative data-handling skills needed to analyse population health, and the political, administrative, social science and economic capacities necessary to develop and implement policies for change and health improvement within complex environments with multiple actors. 13. These capacities need to be influential both within the wider society and within the health system itself. In the latter case, public health considerations must affect decisions concerning priorities and investment within programmes o f care. The balance between health promotion, disease prevention, therapy and care must increasingly be struck in a considered rather than an ad-hoc fashion, and it must be based on available scientific evidence about the effectiveness and relative cost-benefit o f available interventions against the ultimate criterion o f health improvement. 14. In addition, public health must exert a constructive influence on health professionals to promote evidence-based clinical practice, the identification of indicators o f good quality outcomes, and systems for the systematic collection and review of outcome-based information which will lead to benchmarking, positive changes in practice and quality improvements. 15. The effectiveness o f public health practice will depend on its location and authority within the political, administrative and social system in each country. Strengthening public health therefore requires both the development o f structures for public health practice within and outside the health sector, and the building of capacity for professional practice itself. The key issues for the development of public health are: - its philosophy and orientation - integrating the values o f Health for All; autonomy - the ability to speak on behalf of the population’s health needs; - authority - influencing decisions that relate to strategic orientations and resource allocation in health development and care; - accountability - for the scientific validity and relevance o f its contribution; - resource base - drawing on the underlying economic forces o f health and society; professional standing and status - respectability, taking part in decision-making, sense o f purpose, career incentives, working standards and income (all o f which are essential preconditions o f good public health practice). EUR/RC48/13 page 3 16. Public health tasks can therefore be summarized as consisting of: • Advocacy, leadership and coordination: Public health is delivered from both within and outside the health sector, through collaboration with government, academic, commercial and voluntary bodies. Public health principles serve as inspiration for these partners and offer a framework for coordinated action. The sine qua non of good public health practice is that its practitioners are in a position and able freely and independently to advocate the health needs of a defined population and coordinate the processes that promote healthy public policies and accountability for health. • Technical work: Five technical areas o f practice, reflecting the skills taught in schools of public health, can be identified. They apply both to public health practice seen in broad terms (for example, as a district director o f public health) and to work within specific sectors (for example, heart disease or child health): ( 1 ) analysis o f population health status and setting o f objectives and targets; (2) maximization of the use o f local resources (financial, human, social, capital); (3) policies for improving population health; (4) action to support evidence-based clinical practice, health promotion and intersectoral collaboration; and (5) collection and use o f outcome date to review performance. • Implementation and management: The practice of public health requires authority, resources, institutional connections, the ability to mobilize political and community support, and the drive to achieve change in plural, multisectoral environments. T h e c u r r e n t s t a t e o f p u b l i c h e a l t h in E u r o p e 17. The terms “public health” and “public health management” are, however, not universally understood as they are used in this paper. The definition and practice of public health currently varies in Member States according to their different national structures. In some countries, “public health” is still thought of only as a system of legislation and programmes for disease control. Many use the term “public health” to refer variously to traditional “sanitary” or “hygiene” services for environmental health; services for communicable disease surveillance and control; health promotion services for specific client groups, such as mothers and children; and health services provided by the State for certain socially disadvantaged groups. While all these services remain important and contribute to health improvement, they lack the vital perspective o f meeting the needs o f the whole population. 18. Some examples can be given to illustrate these different perspectives on public health services within the European Region: • In some countries, such as the central Asian republics, the administration o f health services has been decentralized while funding from central taxation has been retained. Environmental and communicable disease control activities continue to be delivered through the Sanitary/Epidemiological Surveillance Service. The regional (oblast) health administration is the natural point for the development o f public health functions. • In other countries undergoing health reforms, for example countries of central and eastern Europe, health care is now funded largely through social insurance. Communicable disease control, environmental health and occupational health services are organized largely through regional centres. Ministries of health are devolving functions to district administrations, where public health practice can be best developed. There is an expanding Healthy Cities network. • Some western European countries have national health services which are centrally funded and locally administered. Often health services themselves are separate from those responsible for environmental health and hygiene, which are municipal functions. Public health physicians, working in local health administrations, may produce an annual report on the state o f health o f the local population and advise on health policies and resource decisions. EUR/RC48/13 page 4 19. Across Europe there are many important initiatives and changing practices in relation to public health. All take the perspective o f the whole population. The fast moving HFA-inspired movement for promoting health in settings such as healthy cities and schools has largely taken place outside the traditional public health services and has involved a host of new actors, agencies and sectors. These rapidly expanding networks have developed into powerful forces and platforms for modern public health thinking and practice. Health promotion, ecological development and community activism have significantly broadened the disciplinary, institutional and operational base of public health in many areas. However, the conceptual differences between medical and non-medical disciplines, between the advocates o f health promotion, disease prevention and health education, and between the health services and other sectors, are still far from resolved. There is a great need for a wider understanding o f the determinants of health and a heightened awareness o f the benefits o f the new public health, both o f which can be fostered through professional education and political and technical debate. 20. Responsibilities and roles are also changing. There is now increasing recognition of the importance of action at the local level. Decentralization gives local governments a greater role in health and environmental matters. Action at the local level is rapidly becoming an essential component o f any national or subnational health strategy: certainly, partnerships for health across sectors, and community participation and empowerment, are easier to achieve at this level. Local health reporting, for politicians, professionals and the public, is a vital prerequisite for such local action. 21. What is needed now is to give greater coherence to these initiatives and changes across Europe, and to adopt a more systematic approach to developing the structures and skills that are needed if public health and public health management are to achieve real influence. Public health considerations and practitioners must be included in the structures and processes which prepare and take decisions at all levels. P u b l i c h e a l t h a c t o r s a n d w a y s o f w o r k i n g 22. Because all specific public health problems are rooted in a political, social, economic and human context, public health practice must be effective within and across all the institutions and networks in society as a whole, as well as at the level of communities, families and individuals. The most significant challenges for societies are to affect the social determinants of health, to improve human behaviour in the use o f resources, consumption and social relationships, and to promote health and ensure sustainable development in countries through integrated approaches to policy and management. 23. The influences working for health improvement and HFA within society will be diffuse and all- embracing, but they will also need definition and focus. It is this combination o f breadth and depth in the influence and practice o f public health in societies that makes the tasks of public health infrastructures and practitioners so fascinating, but also so complex. A great number o f people working in society are therefore involved in public health in a variety o f guises, some but not all o f which are formally identifiable with public health as a scientific and intellectual discipline. Four levels of public health practitioners and practice may be defined: • On a broad scale, public health is supported by many people in their daily work - for example in schools, the media, town planning, architecture, sports associations and welfare services - as well as by professionals such as pharmacists, social workers, nurses and doctors. • The many scientific and technical skills needed for public health practice are provided by epidemiologists, information scientists, social scientists, health economists, operational researchers, lawyers, political and administrative scientists, experts on infectious disease control, environment and health specialists, etc. • Some detailed understanding o f population perspectives and public health issues is needed by health service managers, so that they can be aware o f the relationship o f their service (hospital, health centre) to the surrounding population and think in terms not only o f the quantity o f services delivered and money spent but also o f the needs of the whole population and the health gain to be achieved by those services. EUR/RC48/I3 page 5 • Leadership in public health, at both national and local levels, must come from public health professionals with full postgraduate training in public health and experienced in population-based public health management in a variety of political and administrative situations. Some examples will illustrate the range of their tasks: - analysing o f the health status of the local population; - working with environmental health specialists to control pollution and increase sustainability; - working with health promotion specialists to promote healthy behaviour; - working with health service organizations to promote primary care, preventive medicine and cost-effective clinical practice; - working with central and local administrations to support economic development and to reduce the health effects of poverty and social exclusion that lead to inequalities in health. I m p l i c a t i o n s o f s t r e n g t h e n i n g p o p u l a t i o n - b a s e d p u b l i c h e a l t h 24. Few countries in Europe currently have in place an adequate policy and organizational framework for effective public health practice at all the levels defined above. The structural and functional representation o f public health and its effective involvement in decision-making need substantial development in most countries. It is not appropriate here to be specific about the exact administrative structures required, but the voice o f public health and public health management should be present and heard whenever political and administrative decisions affecting health or health systems are taken. Research and educational capacity needs to be further developed through schools and university departments o f public health and geared to meeting the needs and demands entailed by the HFA policy concepts inherent in modern public health practice. 25. There is therefore an urgent need for countries to review the current state of their public health infrastructure and practice, and to plan improvements which will reflect the values, goals and objectives of the HFA policy. Piecemeal improvements in technical services and efforts to upgrade training without parallel changes in the organization o f public health practice should be avoided. At national level, governments may review the legislative and policy frameworks for public health. Such reviews may be backed up by developing support structures for information management and training. Resource and organizational development planning will be essential. At local and community levels, strong population- based public health practice will also be essential, based on effective public health reporting. It will be vitally important to engage local government in this process. 26. At national level chief medical officers and directors-general of health can lead intersectoral work by a number o f ministries to achieve HFA. Public health professionals at regional, city and community levels should play similar roles. Local authorities can create the mechanisms for health development planning that draw on the contribution o f different sectors, with the strong participation o f citizens and community groups. Public health practitioners are well placed to play an advocacy role here, on behalf of minorities and disadvantaged groups, for example. E d u c a t i o n f o r p u b l i c h e a l t h p r a c t i c e 27. As has already been emphasized, the challenge o f educating people for public health extends broadly, reaching many whose working lives have a powerful influence on health within society and who need to understand the issues and influences involved in health development. In addition, public health practitioners themselves need skills to inform and influence the varied and sometimes contradictory networks o f authority and decision-making within today’s complex societies, as well as the systems thinking and management skills required to be effective within a particular form o f political and administrative machinery. EUR/RC48/13 page 6 28. At the moment, there is simply too little educational capacity available in Europe to meet these needs. Those working outside formal health structures, either outside or within the health system, are too little exposed to population-based public health thinking. There are too few people with the scientific and technical skills required for public health practice, and public health professionals themselves are often poorly equipped to achieve change within modern plural societies, where many, if not most, health influences lie outside their formal bureaucratic or administrative sphere of responsibility. 29. For these reasons, the development of additional educational capacity in Europe in terms o f both educational institutions and curricula is vitally important. There have been some positive developments recently, with additional schools o f public health and new curricula being created. Some progress has also been made towards achieving better coordination, for example through the Association o f Schools o f Public Health in the European Region (ASPHER). The importance o f the link between education and public health research is increasingly recognized. 30. However, there is still a gap between academic curricula and the needs of practitioners at all the levels of practice defined above. In part, this is because many teachers are not themselves directly engaged in public health practice, or have a limited understanding o f the complex educational requirements o f modern public health. In addition, public health education in some Member States has tended to emphasize management skills for doctors, rather than the broader population perspectives required for public health. In other countries, there is an almost total lack of public health education. 3 1. The training function of schools o f public health and academic departments of public health in the European Region therefore needs to be considerably strengthened, and public health-related education needs to be made much more widely available to all o f the many interest groups and professionals involved. Teachers, economists, architects, town and transport planners, health system civil servants and managers, and all other health professionals are just some o f those who need to be able to learn about the perspectives and processes of public health, to be given the motivation and skills to undertake health impact assessments o f their work, and to search for more health-promotive solutions in meeting the challenges raised in their daily working lives. In addition, many more need to be trained so that they acquire the formal scientific and technical skills, as well as the public health management skills, required for high-level professional public health practice. 32. These requirements call for many more multidisciplinary opportunities for training in public health, and for flexible courses and curricula that allow for the part-time and distance learning which fits in well with the demands of work and family. For example, both clinicians and health system managers need to be offered, flexibly and imaginatively at various stages in their professional careers, more and better training in the quantitative population-based perspectives and skills o f public health. 33. New schools of public health will be required as a high priority, if HFA is to be achieved across Europe. A further great step forward would be the systematic development o f an HFA-inspired framework public health curriculum for Europe, including all the required main educational perspectives while allowing for local flexibility concerning the precise educational content and educational practice. W HO’S R O L E IN D E V E L O P IN G P U B L IC H E A L T H IN T H E E U R O P E A N R E G IO N 34. The adoption, by the Regional Committee at this session, of the health policy for Europe for the twenty-first century will be an excellent incentive for Member States to review their own situations. The Regional Office for Europe (EURO) should support this by intensified work in the years ahead. This work may include: • developing strategies for promoting a commitment to strengthening public health organization and practice in Member States and an awareness and understanding o f the benefits, approaches and methods o f modern public health; EUR/RC48/13 page 7 • undertaking a descriptive study (with case studies of good practice) o f current public health structures and practices in a representative sample of Member States; • sharpening existing tools and guidance for the development o f public health systems and capacities, with special emphasis on advocacy, authority, independence, coordination, institutional links and the management o f change; • promoting the development of schools o f public health throughout the Region and of HFA-based training and continuing education curricula; • establishing closer cooperation with professional associations and international bodies in the field of public health; • using Healthy Cities and similar networks to improve public health practice at local level and enhance collaboration in public health training; • preparing for an international conference on public health practice, to be attended by representatives of all Member States; this conference would seek to foster an understanding of and political commitment to public health and to promote good practices across the Region, providing a platform for dialogue between politicians, practitioners, teachers and the professions allied to public health. 35. The development of public health practice across Europe will benefit from leadership from EURO, not only because of the natural affinity o f local public health practice with the international objectives of WHO, but also because the existing varied public health structures in Member States need a unified vision and direction. P a r t n e r s , m a n a g e m e n t a n d r e s o u r c e s 36. Countries’ partners in strengthening public health will include ASPHER for continuing education; the European Public Health Association (EUPHA) for maintaining professional standards; and the European Union, whose 1992 Maastricht Treaty offers important opportunities for public health through intersectoral policy development, health promotion and programmes against specific diseases (including cancer, HIV/AIDS and rare diseases). 37. The new global HFA strategy also provides an opportunity to work with foundations and other funding agencies to strengthen public health across the new European map. In the 1920s the Rockefeller Foundation financed a number o f public health developments in Europe, including in particular several national schools of public health. HFA strategies in Member States will only be effectively implemented if there is now a similar drive and determination to develop public health structures and skills, and if sufficient educational measures are taken to increase the numbers of public health personnel, and heighten their skills and commitment, at all levels. C o n c l u s i o n s 38. Public health provides the means whereby HFA policies and plans can be drawn up and carried out, and public health practitioners contribute to this by assessing the population’s needs, mobilizing support and driving change. 39. Public health practice across the Region is currently rather weak, however, and many national health systems give too little attention to public health. There is a need to strengthen the leadership, position, authority, capacity and organization o f public health. Public health systems and practices should be geared towards addressing the determinants of health, they should advocate and promote healthy public policies and healthy and sustainable development, they should provide processes for independent advocacy o f populations’ health and accountability, they should facilitate community involvement, and they should have adequate authority and power to take part in decisions about the allocation of resources. EUR/RC48/13 page 8 40. Member States should review their current public health performance and organization, with a view to developing the capacity to implement the renewed HFA strategy. Particular emphasis should be placed on intersectoral and local public health action, on involving a wide range of actors and disciplines, and on public health training. 41. The Regional Office for Europe is committed to helping Member States strengthen and broaden their public health efforts.