Essential public health functions -their place in the Health-for-All Policy for the 21st century The 101 st Session of the Executive Board continued discussion on the "Health-for-All Policy for the 21st Century" and proposed for adoption the text which had emerged from extensive consultations at various levels. The resulting declaration certainly reflects the wish of the Executive Board to convey the message that WHO really intends to face new challenges that emerge as a consequence of worldwide changes in the demographic, technological and epidemiological situation. The renewed HFA policy declaration asserts that the health and well-being of people is the ultimate aim of social and economic development. Ethical concepts of equity, solidarity and social justice underpin the new policy. An important step forward is the recognition of essential public health functions as part and parcel of universal access to health care. The spectrum of health care is very wide. It ranges from (a) pure public goods, for example, immunization and other preventive care, health promotion, food handling, sanitation, communicable diseases control, school health, and many other public health functions; (b) diseases due to lifestyles and unhealthy behaviour or special risks, such as smoking, alcohol or drug abuse, pollution of all kinds, injuries and accidents; (c) socio-medical care of the elderly and chronically ill; to (d) diseases of the type "statistical certainties", such as those related to age, gender or poverty; and (e) all other diseases that occur throughout the lifespan of each individual and may be termed "chance occurrences". This wide spectrum of health care services indicates clearly that public health functions play an important part in the provision of health care and that health professionals in determining their current and future obligations have to consider striking a balance between individual and community health care and between curative and preventive, promotive and restorative care. In spite of the well-formulated, and globally accepted definition of PHC, many countries, regardless of the structure and organization of their health systems are currently faced with similar challenges in the area of health policy. They face increasing pressures on public resources to address problems of illness and to support the provision of essential public health. These pressures come primarily from the combination of new costly technologies, and new disease patterns reflected in longer life and increasing chronic disease, emergence of new diseases or infections, resurgence of diseases that were once considered well under control, exacerbated in some countries by high rates of population growth. The main causes of the coming crisis in world health include: overpopulation with the attendant pressure on the food and water supply, the loss of biodiversity, and increasing disparities between rich and poor. An example of the danger of overpopulation is the rapid growth of the world's large cities which already face enormous public health challenges, including increasing AIDS populations, high substance abuse, high homicide rates and limited access to health care for vulnerable populations. The challenges in the area of health policy that most countries face at present are considered as justified and expected. The response is to reform the existing health care system, and to identify new ways of financing health care in order to improve cost-effectiveness, efficiency and responsiveness to patients. However, a great deal of concern is currently being expressed about the lack of appropriate emphasis on essential elements of public health in proposals for health care reforms. In most settings, improvements in allocative efficiency would be reflected in shifts of resources from treatment to prevention. A more difficult shift would be from more intensive late care to less intensive early care - a general shift away from speciality care as a routine procedure. Till now, however, health care policy debates and decisions have all too often concentrated on health service organization and financing and only limited consideration has been given to possible health effects. All those engaged in public health are vested with immense power over the lives of their fellow citizens. Public health will only be served in the long term if this power is exercised with appropriate responsibility. The ultimate safeguard is in the constant evaluation of the effects of interventions both at the community and the individual level. Regrettably, the tools for such evaluation are part of the curriculum of public health schools, not of medical schools. This means that essential public health services must be the primary responsibility of official public health agencies. Public health is still far from being the main focus of public policy makers. The latter need to rethink their methods and strategies if they are to make significant impact on public political agenda. They need to rethink means for reaffirmation of public (not just individual) responsibility for health, associated with evidence-based action to protect and promote population health. Public means not necessarily government, certainly not the health ministry alone, but a collective multipartner responsibility. Public may just mean "an organized effort of society". Evidence-based certainly means epidemiology, the core of public health science, and other quantitative and qualitative research methods and frames; it is just a multi- and interdisciplinary endeavour. Action, too, means, a collective multipartner effort, specifically designed to implement objectives which have been developed on the basis of the evidence presented, and the application of political judgement by policy makers. In summary, the unequivocal statement of the HFA 21st Century Policy is that everyone should enjoy the full right to health and that the ethical concepts of equity, solidarity and social justice mean that essential public health functions form the basis of the new WHO's strategy, that health is mainly a public good and in consequence should be provided and dispensed by governments. If, in the current economic and political climate, not all health care can be considered as public goods, than at least essential public health functions deserve such a recognition.
Professor Jerzy Leowski Director, School of Public Health and Social Medicine, Medical Centre for Postgraduate Education, Warsaw, Poland Member of the WHO Executive Board
Wid hlth statist. quart., 51 (1998)
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