Basics of Public Health

Contents
Introduction
Definition of health
Declaration of Alma Ata – ​Comprehensive​ Primary Healthcare
​ rimary Healthcare
Development Conference, Italy – ​Selective P
Definition of Public Health
Public Health vs. Clinical Medicine
Public, International, Global and Planetary Health
Levels of Prevention
Social Determinants of Health
Definition of Health Systems
Cross-national learning
Introduction

This document is meant to provide each PHLT participant with a ​basic set of notions on Public
Health, which will be built upon during the workshop. It is important that each participant read this
document thoroughly before the start of the workshop in order to take full advantage of the
sessions. We hope you will thus be able to further your knowledge on Public Health, and increase
the quality of your work!

The extras are meant to give you a little more, if you are interested in going a little more in depth in
the various topics.

Definition of health

There are ​different models that provide various definitions of health. The most well known and used
definition is however the one provided by the ​World Health Organisation (WHO)​, often judged as a
little too idealistic:

“​Health is a state of complete physical, mental and social well-being and

not merely the absence of disease or infirmity​”. (Preamble to the
Constitution of the WHO, 1946 - 48)

Around the same period, ​the Declaration of Human Rights was adopted, notably containing a
reference to health:

“​Everyone has the right to a standard of living adequate for the health
and well-being ​of himself and of his family​, including food, clothing,
housing and medical care and necessary social services, and the right to
security in the event of unemployment, sickness, disability, widowhood,
old age or other lack of livelihood in circumstances beyond his control​”.
(Declaration of Human Rights, 1948).

Extra:​ Definition of Mental Health

“​Mental health is defined as a state of well-being in which every individual realizes his or her own
potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able
to make a contribution to her or his community​”. (WHO)

Declaration of Alma Ata – ​Comprehensive​ Primary Healthcare

The declaration of Alma Ata (1978) was a result of society’s growing

orientation towards Primary Healthcare​, and regarded as the first
international declaration in favor of PHC as a key element to promote
and protect people’s health. In 1975 for example, the World Health
Assembly defined programs in Primary Healthcare as a ​priority​.
Different threads such as this one finally came together in occasion of
the ​International Conference on Primary Healthcare​, organized
between WHO, UNICEF and the USSR in 1978, which produced the
Declaration of Alma Ata​. Representatives from 134 countries were present. In competition with the
USSR, China was absent. The Declaration of Alma Ata holds 10 main points (see declaration).

“…expressing the need for urgent action by all governments, all health and development workers,
and the world community to protect and promote the health of all the people of the world…​”
(Introduction)

“​The Conference strongly reaffirms that health, which is a state of complete physical, mental and
social well-being, and not merely the absence of disease or infirmity, is a fundamental human right
and that the attainment of the highest possible level of health is a ​most important worldwide social
goal whose realization requires the action of many other ​social and economic sectors in addition to
the health sector.​” (1st point)

Emphasis was put on:

- Construction of medical posts in rural areas, as opposed to hospital construction

- Disapproval of over-specialized medical personnel in ‘developing’ countries
- The strong link between health and development
To read the declaration: ​click here

In point 10, the declaration affirms that health for all people would be possible by the year 2000. The
declaration does not state how funding will be obtained for the achievement of its goals.

Development Conference, Italy – ​Selective ​Primary Healthcare

The Alma Ata declaration was criticized for its “too broad objectives”, and for being “too idealistic”
and vague. A conference was organized in Bellagio, Italy, to analyse the state and inter-relations
between health and population programs (and particularly analyse strategies from a “cost-effective”
point of view). Basing the conference on a paper published prior (“​Selective Primary Health Care, an
Interim Strategy for Disease Control in Developing Countries”), the term ​“Selective Primary Health
Care” appeared. This term refers to choosing specific ​low-cost technical interventions to tackle
defined health problems (which are the causes of the most amounts of deaths) ​in poor countries​.
The interventions took a more finalized shape in the following period, known as ‘GOBI’:

Growth monitoring, Oral rehydration techniques, Breast feeding,

Immunization. The benefit of having these 4 specific interventions was
that they were considered to be easy to monitor and evaluate. Easier
evaluation means that requests for funding are also more effective. In
the next few years, ‘FFF’ was also added:

Food supplementation, Female literacy, Family planning​. This led to the final term of ‘​GOBI-FFF​’.

Compared to the Alma Ata declaration, a more specific solution to tackling world health problems
was therefore defined, with a seemingly clearer path to action and achievement of defined
objectives.

For more history and information:​ ​click here

Definition of Public Health
Surprisingly, different sources offer quite diverse definitions, which however contain some common
points, notably: decision making based on data and evidence (vital statistics, surveillance and
outbreak investigations, laboratory science), ​a focus on populations rather than individuals, a goal of
social justice and equity​, and an emphasis on ​prevention​ rather than curative care.

“​Public Health refers to all organized measures (whether public or private) to ​prevent disease,
promote health, and prolong life among the ​population ​as a whole​”. (Charles-Edward A. Winslow,
1920)

“​Science of protecting the safety and improving the health of ​communities through education, policy
making and research for ​disease and injury prevention​”. (University of Pittsburg)

“O​ne of the efforts to protect, promote and restore ​the people’s health​. It is the combination of
sciences, skills and beliefs that is directed to the maintenance and improvement of the health of all
the people through collective or social actions”.​ (Dictionary of Epidemiology, Last, 2001)

As a discipline, Public Health comprises a very interdisciplinary approach​, as health can be of

concern of many different disciplines.

The way health is pursued is through ​assessment ​of a certain issue, the definition of a ​target
population (which can significantly vary in size and type) and the development of a ​time-bound plan.
Indicators of health are representative of improvement made in a certain domain, being key
elements for quality evaluation and further work in the chosen field.

Examples of public health​: promotion of breastfeeding, promotion of handwashing, delivery of

vaccinations, distribution of condoms,...

Public Health vs. Clinical Medicine

As most people know, Public Health is the medicine of populations, whereas clinical medicine
strongly focuses on the individual. Of course these both have areas of intersection (e.g. in
prescribing exams, clinical medicine takes into account measures defined by public health to attempt
to limit excessive spending). There are however many other differences as well, which will be
explained in the following table:

Public Health (PH practitioner) Clinical Medicine (Doctor)

Population oriented
Work ethic oriented on public service
Disease prevention and health promotion
Predominant emphasis on interventions aimed
at environment, behavior and lifestyles
Based on life sciences, starting from health
threats to populations
Social and public policy disciplines are central
to the discipline of Public Health
(Harvard T.H. Chan School of Public Health)
Individual oriented
Work ethic oriented on personal service
Diagnosis, treatment and care
Predominant emphasis on care
Based on biological sciences, stimulated by
patient needs
Social sciences are optional and often not
particularly emphasized

Another short text describing the difference (very basic): ​click here
Public, International, Global and Planetary Health

Public Health:​ ​see definition above

Extra​: the Institute Of Medicine 1988 Future of Public Health Report defined the mission of Public
Health as: “​fulfilling society’s interest in assuring conditions in which people can be healthy​”

International Health: For a long time used to define health work abroad, with the focus on efforts
performed in ‘developing’ countries, often referring to topics such as tropical diseases, water
sanitation, malnutrition, maternal health,… and possibly also to broader themes such as chronic
diseases and health systems. Focus is put on countries other than one’s own

“​The application of the principles of public health to problems and challenges that affect low and
middle-income countries and to the complex array of global and local forces that influence them​”.

Global Health: Focus on issues that transcend national boundaries, therefore issues that touch
multiple countries, or the cause of which cannot be limited to within a given country such as climate
change, polio eradication, influenza and dengue. Global health can also refer to efforts such as the
fight against obesity, tobacco control and migration of health workers, among others. Global health
efforts can therefore be limited within borders, but also transcend them – differently from
International Health.

“​Global health uses the resources, knowledge, and experience of diverse societies to address health
challenges throughout the world​”.

Source: ​click here​ (key document!!)

Levels of Prevention

There is rarely Public Health without the concept of Prevention. The concept of prevention is
broader in Public Health than in the understanding of the general public. Prevention can happen
before or after diseases manifest and is divided into 4 levels:

Primary prevention: Measures that aim to avoid injury or disease before they occur. Examples:
immunization, brushing one’s teeth, hand washing, sun screen, bans on the use of hazardous
products,…

Secondary prevention​: Measures that aim to avoid further injury or worsening of a disease once it
has occurred. It also deals with latent diseases and attempts to prevent an asymptomatic disease
from progressing to a symptomatic one. Examples: screening tests (e.g. mammogram), after the
disease but before the symptoms have occurred, modified work so injured workers can return to
work safely while recovering

Tertiary prevention: Measures that aim to decrease the negative effects and further health
complications of a chronic illness or permanent impairment. In this case both the disease and the
symptoms have already occurred. Examples: support groups to share strategies for living well with a
certain condition, rehabilitation programs, chronic disease management programs (e.g. diabetes,…)

Quaternary prevention: Measures that aim to decrease the quantity of unnecessary or excessive
medical exams, therefore protecting the patient physically, financially and ethically.
Source 1: ​click here

Source 2 (+ image): ​click here

Social Determinants of Health

Social determinants of health are social characteristics that which influence their health. These
conditions concern the environment in which people are born, in which they grow, live work and age
as well as the systems that are present to deal with illness. As strong influencers of these conditions
we can name the distribution of money, power and resources. Social determinants of health
(commonly referred to as SDH), are the key to understanding health inequalities between different
geographical and political areas.

The WHO established a Commission on Social Determinants of Health, which worked between 2005
and 2008. In their final report, the Commission defines three general recommendations/principles
of action to address the issue of health inequalities:

- Improve daily living conditions – the circumstances in which people are born, grow, live,
work and age.
- Tackle the inequitable distribution of power, money and resources – the structural drivers of
those conditions of daily life – globally, nationally and locally.
- Measure and understand the problem and assess the impact of action – expand the
knowledge base, develop a workforce that is trained in the SDH, and raise public awareness
about the SDH.
Example of work conditions as a social determinant for mental health​:

Source 1: ​click here

Source 2: ​Full report of the Commission

Source 3: Oxford Handbook of Public Health Practice, 2013 Edition

Definition of Health Systems

As medical students, the concept of ‘input’ and ‘output’ is a very familiar idea. We find this concept
also for what concerns Health Systems. There are hundreds of different systems around the world,
which however stem from a few common principles.

How is the structure of a health system defined?​ (concept of “Frameworks Planning”)

It is possible to use a rational approach when defining a health system. This rational approach seeks
to answer the following points:

- What is the desired state?

- How are things now?
- Identify possible pathways (options)
- Choose the most cost-effective one
Health Systems are not as rigid and easy to control as e.g. car manufacturing (here we would apply a
‘hard’ approach). Because they are people-based, with complex and difficult-to-define, detailed
objectives, healthcare systems are considered to require more of a ‘soft’ system approach.

This ‘soft’ approach will include repetitive interventions (and evaluation), recognition of cultural
constraints as well as participation in planning by most or all parties affected by the system.

A few important concepts:

1. Input vs. Output

Health system input: patient’s needs, healthcare professionals, infrastructure, resources

Health system output: changes in patient’s health, quality of life

2. Two examples of Health Care Models

The key to most Health Care Models lies in the source of financing, and how the services are
delivered.

- Bismarck Model, Germany (1883) – introduction of national health in surance

Entitlement to healthcare based on contribution status. Revenues come from
wage deductions, employees and employers pay half each. Benefits covered
are defined. Insurance provided by occupational sickness fund (managed by a
coalition of workers’ representatives as well as business representatives).
Relationship with providers is through contracts or patient reimbursement.

- Beveridge Model, UK (1942) – report which layed the foundations for the
NHS
 Entitlement to healthcare based on citizenship/residence. Revenues come from general
taxation. Benefits covered are comprehensive. Insurance provided by the State. Relationship
with providers is integrated.

Key questions to understanding a Health System better:

- How much money is collected and who decides this?

- Who collects the money and from whom?
- Who and what is covered?
- At what price are services bought and how are services paid for?
- Where are the services delivered and by whom?
- How are the resources gathered?
- How are the resources distributed to purchasers?
Source: Oxford Handbook of Public Health Practice, 2013 Edition

Cross-national learning
Questions to ask when engaging in cross-national learning:

- What is the problem I face? Which other countries are facing a similar problem?
- What solutions have other countries tried? Have they worked? Why?
- What data would help me find out? Are they available?
- Are the data comparable, up-to-date, and accurate?
- What factors contributed to the success of the policy? Are these factors present here? What
adaptations or changes would be needed?
- What else was going on? How important were contextual factors?
Source: Oxford Handbook of Public Health Practice, 2013 Edition