Characteristics of health organizations

To adequately understand the nature and complexity of health organizations, it is essential

to go back to some of the concepts of General Systems Theory. It was conceived by

Bertalanffy in the 1940s, with the aim of constituting a practical model to conceptualize

phenomena that the mechanistic reduction of classical science could not explain. General

systems theory provides a unifying theoretical framework for both the natural and social

sciences by providing broad concepts, such as organization, totality, globality, and dynamic

interaction, that take into account the circumstances of both.

System concept

Ludwig von Bertalanffy defined the system as: “a set of interdependent and interacting

elements; “a group of combined units that form an organized whole and whose output is

greater than the output that the units could have if they functioned independently.”

The characteristics of the systems will have to do with the parameter used to compare them.

Regarding their constitution, they can be physical/concrete systems, or abstract systems.

Examples of each of them are hardware and software. Systems can also be open or closed,

depending on their relationship with the environment.

There is no system outside of a specific medium; The system exists in a medium, which

conditions it. The environment is the set of all elements that, within specific limits, can

exert some influence on the functioning of the system. Living systems are open systems,

since they exchange energy and information with their environment. Examples of these
systems could be a cell, a plant, an insect, man, a social organization. So, we will consider

the healthcare organization an open system.

System properties

1. General systems theory states that a system is a totality and that its components and

attributes can only be understood as functions of the total system. A system is not a

random collection of components, but an interdependent organization, in which the

behavior and expression of each one influences and is influenced by all the others.

The concept of totality means, in other words: “the whole constitutes more than

the simple sum of its parts.”

2. Organic and social systems are always oriented towards an objective or goal, even if

it is only the tendency to fight to stay alive, and even if it has developed

dysfunctionally.

3. In systems there are two opposing and complementary forces: A) The homeostatic

force, thanks to which the system tends to remain in the previous state, that is, in

equilibrium. Homeostasis is the relatively constant internal state of a system that is

maintained through self-regulation or negative feedback (Cannon introduced the

concept in physiology in 1932, to explain the relative constancy of certain

physiological dimensions); and B) The morphogenetic force, contrary to the

previous one, which would be the cause of the changes in the system (this concept

was introduced by Maruyama to describe phenomena of change in the structures of

a system, thanks to positive feedback). These two forces would allow the system to

remain stable and adapt to new situations thanks to feedback mechanisms.

 4. In a system the results are not determined, neither by the initial conditions nor by

the nature of the process or the parameters of the system. The final behavior of open

systems is based on their independence from the initial conditions. This principle of

equifinality means that identical results can have different origins, because what is

decisive is the nature of the organization.

PURPOSE AND FUNCTIONS OF PUBLIC HEALTH IN COLOMBIA

In accordance with the provisions of Decree Law 4109 of 2011, in its capacity as
scientific-technical authority, the National Institute of Health will have as its
objective: (i) the development and management of scientific knowledge in health
and biomedicine to contribute to improving the conditions of people's health; (ii)
carry out basic and applied scientific research in health and biomedicine; (iii) the
promotion of scientific research, innovation and the formulation of studies in
accordance with the public health knowledge priorities of the Institute; (iv) health
surveillance and security in matters within its jurisdiction; the production of
biological inputs; and (v) act as a national reference laboratory and coordinator of
special networks, within the framework of the General Social Security System in
Health and the Science System. Technology and Innovation.

Features

1. Act as a national reference entity in public health and technical coordinator of

the networks of: epidemiological surveillance, laboratories, organ and tissue
donation and transplants, blood banks and transfusion services, within the
framework of the Science, Technology and Innovation System.
2. Operate and develop the public health surveillance and control system within
the framework of the General Health Social Security System.
3. Strengthen comprehensive management, in order to achieve a high level of
efficiency and competitiveness, guaranteeing quality and excellence in the
products and services provided by the INS.
4. Develop, produce or market directly or through strategic alliances, goods and
services of interest in public health with quality standards within the
framework of the General System of Social Security in Health and the
National System of Science, Technology and Innovation.
5. Promote, guide, coordinate and execute public health research within the
framework of the National System of Science, Technology and Innovation.
6. Analyze information about the health situation of the Colombian population
in order to make policy proposals for decision-making, within the framework
of the General System of Social Security in Health and the National System
of Science, Technology and Innovation.
7. Create and articulate a network of scientific-technical research centers in
public health, in which all entities that carry out research, validation and
technology transfer activities in public health sciences participate, in order to
contribute to the use rational use of all the scientific capacity that the country
has in this field.
8. Exercise the functions of the National Health Observatory in accordance with
articles 8 and 9" of Law 1438 of 2011.
9. Design and implement, within its competence, the operating model of the
Health Surveillance and Security System within the framework of the
General Social Health Security System.
10. Issue concepts on toxicological classification and evaluation of the toxicity
risk of pesticides that are going to be used in the country, a function that the
Institute will assume in the terms and deadlines indicated in the
reorganization decree of the Ministry of Health and Social Protection.
11. Participate in the planning, development and coordination of public health
information systems, in coordination with the Ministry of Health and Social
Protection, territorial entities and other entities of the health system.
12. Formulate, propose and control, within the framework of its powers, the
execution of programs for the prevention, promotion and protection of public
health.
13. Prepare diagnoses that determine possible public health risks that are
associated with disasters of any type or origin.
14. Coordinate and articulate, within the scope of its powers, actions to evaluate,
overcome and mitigate risks that affect public health, with national and
territorial entities.
15. Promote, guide and carry out skills training activities for human resources
that provide services in Public Health, in accordance with the policy of the
National Government.
16. Promote the participation of laboratories and institutions that carry out
analyzes of public health interest in external performance evaluation
programs to encourage improvement in the quality of the tests carried out by
said laboratories.
 17. Coordinate and advise the National Network of Public Health Laboratories,
Network of Blood Banks and Transfusion Services and National Network for
Organ and Tissue Donation and Transplantation, on matters within their
jurisdiction and serve as a national public health and reference laboratory.
18. Define strategies and promote and coordinate plans and programs for
technology transfer and technical assistance for the National Network of
Public Health Laboratories, Network of Blood Banks and Transfusion
Services and National Network for Organ and Tissue Donation and
Transplantation, in coordination with the Ministry of Health and Social
Protection.
19. Participate in the evaluation of public health technologies, within their
competence.
20. Research, develop, produce, market and provide essential goods and services
in public health, in accordance with the parameters established by the
Ministry of Health and Social Protection, directly or through alliances or
strategic associations.
21. Participate in coordination with the Ministry of Health and Social Protection
in the design and execution of programs and activities aimed at preventing,
reducing or addressing the effects on health caused by disasters, calamities or
emergencies, in coordination with the authorities of the National Prevention
System. and Disaster Assistance, SINPAD.
22. Participate with specialized agencies or other entities, within the framework
of the associative or cooperation forms provided for by the rules of the
science, technology and innovation regime.
23. The other functions assigned by law.

Theessential functions of public health: an emerging

theme in health sector reforms

Fernando Muñoz, 1 Daniel López-Acuña, 2 Paul Halverson 3 Carlyle Guerra de

Macedo, 4 Wade Hanna, 5 Monica Larrieu, 6 Soledad Ubilla, 7 and José Luis
Zeballos 8

SUMMARY In the Americas, health sector reforms face the challenge of

strengthening the governing role of health authorities and an
important part of this role consists of complying with the essential
functions of public health (EFPH) that are the responsibility of the
State. at its central, intermediate and local levels. To achieve this, it
is crucial to improve public health practice and the instruments to
 assess its current state and the areas in which it must be
strengthened. By virtue of the above, the Pan American Health
Organization (PAHO) has launched the "Public health in the
Americas" initiative, aimed at the definition and measurement of
FESP as a basis for improving public health practice and strengthen
the leadership of health authorities at all levels of the State. This
article summarizes conceptual and methodological aspects related to
the definition and measurement of FESP and analyzes the
implications of measuring their performance in improving public
health practices in the Americas.

In the Americas, health sector reform processes have focused mainly on structural, financial
and organizational changes in health systems and adjustments to the provision of care
services to people. Public health has been neglected as a social and institutional
responsibility, precisely when it requires the most attention and when government support
is most needed to modernize the infrastructure necessary for its exercise (1).

The reintegration of public health into the sector's transformation agenda requires a clear
definition of its role (2) and the operationalization of the concepts that underpin it, among
them the essential functions of public health (EFSP) ( 3). For the recovery of public health
and for its insertion in the transformation processes of the system, it is also important that
these operational categories, such as the FESP, can be characterized and measured, in order
to determine their degree of compliance, both on the part of the State and civil society (4).

The reforms of the sector face the challenge of strengthening the steering function of the
health authorities and an important part of that steering role consists of complying with the
FESP that are the responsibility of the State at its central, intermediate and local levels. To
achieve this, it is crucial to improve public health practice and the instruments to assess its
current state and the areas in which it must be strengthened (5).

By virtue of the above, the Pan American Health Organization (PAHO) has taken the initial
steps to launch a continental initiative called "Public health in the Americas", aimed at the
definition and measurement of the FESP as a basis for improving the practice of public
health and strengthen the leadership of health authorities at all levels of the State. This
initiative, which is being coordinated by the Division of Health Systems and Services,
involves all the technical units of the headquarters as well as the PAHO representations in
the countries, and has had the participation of the Director Emeritus of PAHO, Dr. Carlyle
Guerra de Macedo, as project advisor and has developed the instruments for measuring the
performance of the FESP in conjunction with the Centers for Disease Control and
Prevention ( Centers for Disease Control : CDC) of the United States of America ( USA)
and the Latin American Center for Research in Health Systems (CLAISS). The project has
contemplated various instances of interaction with experts from academia, scientific
societies, health services and international organizations, brought together in a network of
continuous feedback on its development, and is representing a valuable opportunity to
review the current state of practice. of public health in the Region of the Americas.

The scope of the "Public Health in the Americas" initiative can be summarized as follows:

• promote a common concept of public health and its essential functions in the Americas;

• create a framework for measuring FESP performance applicable to all American

countries;

• support the evaluation of public health practice in each country, based on the performance
measurement of the FESP;

• propose a continental action plan to strengthen infrastructure and improve public health
practice, based on the findings of the EPHF performance measurement;

• publish in the first half of 2001 The State of Public Health in the Americas , a book that
will bring together the different results of the project and offer an overview of the degree of
compliance with the EPHF in the Americas.

Below are some of the conceptual and methodological aspects that have been formulated as
part of the "Public Health in the Americas" initiative, with special emphasis on the
definition and measurement of the FESP that must be developed and that constitute the task
and the responsibility of the health authorities of the countries of the continent. Likewise,
the implications of measuring the performance of the FESP to improve public health
practice in our continent are analyzed (6).

THE CONCEPT OF FESP AND ITS RELATIONSHIP WITH STRENGTHENING

THE GUIDING FUNCTION OF HEALTH AUTHORITIES

The concept of public health on which the definition of the FESP is based is that of
collective action, both by the State and civil society, aimed at protecting and improving
people's health. It implies a notion that goes beyond population or community interventions
and includes the responsibility of ensuring access to health care and its quality. It is not
referred to public health as an academic discipline, but as a social practice of an
interdisciplinary nature. Public health is not synonymous with the responsibility of the State
in matters of health, since its work goes beyond the State's own tasks and does not cover
everything that the State can do in matters of health.

Definition

The FESP have been defined as the conditions that allow better performance of public
health practice.

One of the most important decisions of the "Public Health in the Americas" initiative is
related to the need to adapt the definition of the FESP indicators and standards to allow the
practice of public health to be strengthened through the reinforcement of the necessary
institutional capacities. This approach seems better than a methodological approach that
includes both functions and fields of public health activity. If the functions are well defined
to include all the capabilities required for good public health practice, good functioning will
be assured in each of the fields of action or work areas of public health ( table 1 ).

It is important to refer here to the frequent confusion between the role of the State in health,
normally exercised by the Ministry of Health or its equivalent as a health authority, and its
responsibility as guarantor of the proper development of the FESP. Although the State has a
non-delegable role in directly delivering or guaranteeing compliance with the FESP, these
only represent a fraction of the state's responsibilities in the field of health. It is a very
relevant fraction, without a doubt, whose proper compliance is essential not only to raise
the health levels and quality of life of the population, but is also part of the governing
responsibility that the State has in matters of health, also characterized for tasks of
conduction, regulation, modulation of financing, surveillance of insurance and
harmonization of provision. To emphasize this with an example, a public health agency that
does not have a comprehensive and reliable system for monitoring health events can hardly
aspire to be credible when it gives its opinion or acts regarding financial allocation to the
different components or sectors of the health system. health.

It is also relevant to refer here to the difficulty involved in establishing a clear separation
between the responsibilities of public health in the conduct of services aimed at the
prevention of diseases and the promotion of health in defined population groups, and those
that have to do with the organization of services aimed at individual curative care. The
emphases in this matter are undoubtedly different. It is an essential heritage of public health
to dedicate itself to the first of these functions. Regarding the second, its essential
responsibilities point more to concern for equitable access to services, the guarantee of their
quality and the incorporation of the public health perspective into national health policies.
This does not prevent health professionals from training to manage patient care services.
On the contrary, it is desirable that they do so, precisely to incorporate public health
concepts into the work of such organizations. This last activity uses, however, disciplines
that transcend what we call "public health."

The usual conception of public health as synonymous with health work contributes to a
dilution of responsibilities in different areas of this last activity and can lead to an
inefficient use of health resources. The measurement of EPHFs and the evaluation of their
performance by health authorities should help avoid this risk.

Background

In recent years, important efforts have been made to seek a better definition and
measurement of EPHFs. Among them, it is worth highlighting the Delphi study conducted
by the World Health Organization (WHO) and the National Public Health Performance and
Standards Program (NPHPSP) of the USA. These initiatives are briefly reviewed below.

The WHO Delphi study on FESP

In January 1997, the WHO Executive Board recommended promoting the conceptual
development of the EPHF as a way to have a tool to implement the renewal of the "health
for all by the year 2000" policy. For this purpose, it was decided to carry out an
international study using the Delphi technique, aimed at redefining the concept of FESP
and obtaining an international consensus on the central characteristics of these functions
(7). In this study, 145 public health experts of different nationalities were consulted in three
consecutive rounds. The result was nine FESPs, namely:

1. Prevention, surveillance and control of communicable and non-communicable diseases.

2. Monitoring of the health situation.

3. Health promotion.

4. Occupational health.

5. Protection of the environment.

6. Legislation and regulation in public health.

7. Public health management.

8. Specific public health services.

9. Health care for vulnerable groups and high-risk populations.

The authors strongly recommended further national and international studies. Some
controversial issues were also highlighted, such as the relationship between health care
services and FESP, an area where there was no consensus regarding the degree to which
individual patient health care can be considered a basic and essential function of health.
public.

The US National Public Health Performance and Standards Program (NPHPSP)

The 1998 public health report of the US National Institutes of Health (NIH), produced after
more than 60 years of different attempts to define and measure the functions of public
health and to evaluate the functioning of public health agencies, defined three groups of
functions (evaluation, policy development and assurance) for public health organizations,
and provided a rational framework for many of the efforts aimed at evaluating public health
services carried out in the last decade in that country (8).

In 1994, a task force on the major functions of public health, co-chaired by the Director of
the CDC and the Assistant Secretary for Chronic Disease Control and Health Promotion
and composed of representatives of public health service agencies and the nation's leading
public health organizations, noted the confusion caused by multiple versions of the "major
functions" and tasked a subgroup led by the Public Health Practice Program Office and the
Center CDC's National Center for Chronic Disease Prevention and Health Promotion ,
developing a consensus on "essential public health services" . This group developed a
9

consensus statement that aims to: 1) explain what public health is; 2) clarify the essential
role of public health throughout the health system, and 3) provide transparency to the
linkage of public health functioning with health outcomes (9).
In 1994, the Public Health Functions Steering Committee adopted the document "Public
Health in the United States of America" (10), in which the vision "healthy people in healthy
communities" and mission to promote physical and mental health and prevent disease,
injury and disability are supported by the following main objectives of public health:

• Prevention of epidemics and the spread of diseases.

• Protection against environmental damage.

• Prevention of damage to health.

• Promotion and encouragement of healthy behaviors.

• Response to disasters and assistance to affected communities.

• Guarantee of quality and accessibility to health services.

In the same document, 10 essential public health services were defined:

1. Health status monitoring to identify community health problems.

2. Diagnosis and investigation of health problems and risks in the community.

3. Information, education and empowerment of people on health issues.

4. Mobilization of community associations to identify and solve health problems.

5. Development of policies and plans that support individual and collective health.

6. Compliance with laws and regulations that protect health and provide safety.

7. Linking people with health care services and ensuring provision of health services where
they are not available.

8. Guarantee of competent human resources for public health and health care.

9. Evaluation of the effectiveness, accessibility and quality of individual and collective

health services.

10. Research on new approaches and innovative solutions to health problems.

As you can see, these services can be grouped into each of the main functions previously
defined. Services 1 and 2 are included in the evaluation function; services 3, 4 and 5 in
policy development, and services 6, 7, 8 and 9 in assurance. Service 10 (research) is
considered related to all main functions as a basis for the management of the public health
system (10).

Currently, the NPHPSP is leading a joint effort to develop standards for public health
practice. Measurement tools for evaluating public health practice, both at the local and state
levels, have been designed in conjunction with other public health organizations. These
instruments are detailed questionnaires with sections for each of the 10 essential services.
Each service is defined in detail, with indicators that represent local and state standards, and
with measurements and submeasures for each of the included indicators. After a three-year
design period, the instruments are being tested in the different state and local realities of the
USA.

Progress in the definition of the FESP for the Region of the Americas

In a first stage, the project was dedicated to the task of examining the advances previously
developed in the definition of EPHFs, to look for coincidences between the various
approaches (11). The result is presented in Figure 1 .

As can be seen at the intersection of these three approaches, there is an important degree of
coincidence between the advances made by the NPHPSP, the WHO study and the PAHO
proposal.

There are two functions in the WHO study and in the initial reflection of PAHO that
represent important fields of public health action. Using a functional approach rather than a
field approach, these two functions (environmental health and occupational health) could be
treated as areas of public health work where all EPHFs included in the intersection of these
three approaches must be applied to improve the functioning of public health in these fields
of action. The disaster preparedness function requires very specific actions that are not
necessarily part of the rest of the FESP and can be included as a separate function.

The WHO study defined a specific function for public health management that will be
important to incorporate for measurement in the Region of the Americas. Something
similar occurs with the development of human resources in the field of public health,
included in the NPHPSP.

THE FESP THAT HAVE BEEN IDENTIFIED IN ORDER TO MEASURE THEIR

PERFORMANCE IN THE COUNTRIES OF THE AMERICAS

Below are described each of the 11 FESP that have been identified as critical for the
practice of public health in the countries of the Americas and that are contained in the
instrument for measuring their performance that has been developed by PAHO in
collaboration with the CDC and CLAISS. The list that follows the title of each of them
corresponds to the components that comprise it and that form the basis for the definition of
standards, indicators, measurements and submeasurements currently under development.

Essential function No. 1: monitoring and analysis of the health situation of the
population

• Updated evaluation of the country's health situation and trends and its determinants, with
special emphasis on the identification of inequalities in risks, damages and access to
services.

• Identification of the health needs of the population, including the evaluation of health
risks and demand for health services.

• Management of vital statistics and the specific situation of groups of special interest or
higher risk.

• Generation of useful information for evaluating the performance of health services.

• Identification of extra-sectoral resources that contribute to health promotion and

improvement of quality of life.

• Development of technology, experience and methods for the management, interpretation

and communication of information to those responsible for public health (including extra-
sectoral actors, providers and citizens).

• Definition and development of instances for evaluating the quality of the data collected
and its correct analysis.

Essential function No. 2: public health surveillance, research and control of risks and
damages in public health
• Ability to carry out investigation and surveillance of epidemic outbreaks and patterns of
presentation of communicable and non-communicable diseases, accidents and exposure to
toxic substances or environmental agents harmful to health.

• Public health infrastructure designed to conduct population screening, case detection and
epidemiological investigation in general.

• Public health laboratories capable of conducting rapid screening and processing the high
volume of tests necessary for the identification and control of emerging health threats.

• Development of active epidemiological surveillance and infectious disease control

programs.

• Ability to connect with international networks that allow better confrontation of health
problems of interest.

• Preparation of national health authorities to activate a rapid response, aimed at controlling

health problems or specific risks.

Essential function No. 3: health promotion

• Health promotion actions in the community and development of programs to reduce risks
and damage to health that have active citizen participation.

• Strengthening intersectorality in order to make health promotion actions more effective,

especially those aimed at the field of formal education of youth and children.

• Empowerment of citizens to change their own lifestyles and be an active part of the
process aimed at changing the habits of the community and demanding that the responsible
authorities improve the conditions of the environment to facilitate the development of a
"culture of health." ".

• Implementation of actions aimed at ensuring that citizens know their health rights.

• Active collaboration of health services personnel in the development of educational

programs in schools, churches, workplaces and any other relevant social organization space
to provide health information.

Essential function No. 4: social participation and empowerment of citizens in health

• Facilitation of organized community participation in prevention, diagnosis, treatment and

rehabilitation programs.

• Strengthening the construction of intersectoral alliances with civil society that allow the
use of all human capital and material resources available to improve the health status of the
population and promote environments that favor healthy living.

• Support in technology and experience for the constitution of networks and alliances with
organized society for health promotion.
• Identification of community resources that collaborate in promotional actions and in
improving the quality of life, reinforcing their power and ability to influence decisions that
affect their health and their access to adequate public health services.

• Information and defense before government authorities regarding health priorities,

particularly in relation to those whose response depends on improvements in other aspects
of the standard of living.

Essential function No. 5: development of policies, plans and management capacity that
support public health efforts and contribute to national health stewardship

• Development of political decisions in public health through a participatory process at all

levels that is consistent with the political and economic context in which they are
developed.

• Strategic planning at the national level and support for planning at subnational levels.

• Definition and refinement of public health objectives, which must be measurable, as part
of continuous quality improvement strategies.

• Evaluation of the health care system to define a national policy that guarantees the
delivery of health services with a population focus.

• Development of codes, regulations and laws that guide public health practice.

• Definition of national public health objectives to support the stewardship role of the
Ministry of Health, or its equivalent, with regard to the definition of objectives and
priorities for the entire health system.

• Public health management, as a process of construction, implementation and evaluation of

organized initiatives designed to address population health problems.

• Development of decision-making skills based on scientific evidence and that incorporate

resource management, leadership skills and effective communication.

• Quality performance of the public health system, in terms of successful management

results, demonstrable to providers and users of services.

Essential function No. 6: regulation and supervision in public health

• Development and supervision of compliance with health codes and/or standards aimed at
controlling health risks derived from the quality of the environment; accreditation and
quality control of medical services; quality certification of new drugs and biological
substances for medical use, equipment, other technologies and any other activity that
involves compliance with laws and regulations aimed at protecting public health.

• Generation of new laws and regulations aimed at improving health, as well as promoting
healthy environments.
• Protection of consumers in their relationships with health services.

• Execution of all these regulatory activities in a timely, correct, consistent and complete
manner.

Essential function No. 7: evaluation and promotion of equitable access of the population to
necessary health services

• Promoting equity in access to health care, which includes evaluating and promoting
effective access of all citizens to necessary health services.

• Evaluation and promotion of access to necessary health services through public or private
providers, adopting a multisectoral approach that allows working with various
organizations and institutions to resolve inequities in the use of services.

• Development of actions aimed at overcoming barriers to access to public health

interventions.

• Facilitation of linking vulnerable groups to health services (not including the financing of
this care) and to health education, health promotion and disease prevention services.

• Close collaboration with government and non-government agencies to promote equitable

access to necessary health services.

Essential function No. 8: Human resource development and public health training

• Education, training and evaluation of public health personnel to identify the needs for
public health services and health care, efficiently address priority public health problems
and adequately evaluate public health actions.

• Definition of requirements for the licensure of health professionals in general and

adoption of programs for continuous improvement of the quality of public health services.

• Formation of active alliances with professional development programs that ensure the
acquisition of relevant public health experiences for all students, continuing education in
management and leadership development in the field of public health.

• Capacity development for interdisciplinary work in public health.

Essential function No. 9: quality assurance of individual and collective health services

• Promotion of the existence of permanent quality assurance systems and development of a

permanent monitoring system of the results of the evaluations made through these systems.

• Facilitation of the publication of standards on the basic characteristics that quality

assurance systems must have and supervision of compliance with this obligation by service
providers.

• Existence of a health technology evaluation system that collaborates in the decision-

making processes of the entire health system.
• Use of scientific methodology to evaluate health interventions of different degrees of
complexity.

• Use of this system to raise the quality of the direct provision of health services.

Essential function No. 10: research, development and implementation of innovative

solutions in public health

• Constant innovation, ranging from applied research efforts to drive changes in public
health practices to formal scientific research efforts.

• Development of research carried out by health authorities at different levels.

• Establishment of alliances with research centers and academic institutions to timely carry
out studies that support the decision-making of national health authorities at all levels and
in the broadest field of action.

Essential function No. 11: reducing the impact of emergencies and disasters on health

• Planning and execution of prevention, mitigation, preparation, response and early

rehabilitation actions related to public health.

• Multiple approach to the damage and etiology of each and every one of the possible
emergencies or disasters in the country's reality.

• Participation of the entire health system and the broadest intersectoral collaboration in
reducing the impact of emergencies and disasters on health.

MEASURING FESP PERFORMANCE

The idea of performance measurement is to globally identify the strengths and weaknesses
of public health practice, in addition to allowing an operational diagnosis of the areas that
require greater support to strengthen the public health infrastructure, understood in its
entirety. broader meaning, that is, including human capabilities and the facilities and
equipment that are necessary for its good performance.

To advance in achieving this objective, it is important that the decision to measure be

followed by the development of instruments that can be continually improved until
reaching the "reasonable optimum" that allows their routine use at the different levels at
which public health is exercised. in the region . The development of FESP measurement
10

instruments involves a long process of defining the function to be measured, the indicators
and standards of performance or compliance thereof, and the measurements and
submeasurements that act as verifiers.

Defining “reasonable optimal,” rather than “minimum acceptable,” standards of

performance
As in other performance measurement processes, a decision must be made between
defining acceptable standards and using optimal standards. The definition of acceptable
levels implies a difficult choice and is necessarily arbitrary, whether a level comparable to
the hypothetical average reality of the Region is chosen or what some expert or group of
experts deems as the minimum necessary for the development of a function. Obviously, the
decision to opt for optimal standards must be relativized according to the global reality of
the Region. Given the heterogeneity of this panorama, the standards will be optimal for the
best conditions that can be demanded, in the medium term, from all the countries of the
Region, which implies relying on "expert" judgment for this purpose. Despite this, opting
for these reasonable optima seems more appropriate and consistent with the objective of
strengthening the public health infrastructure as soon as possible.

Initial development of measurement instruments

The team in charge of the project has distributed to various groups of professionals and
public health experts a first draft of the instrument that includes the definition of the
functions to be measured. This process had its formal culmination in the meeting of the
network of institutions and experts convened by PAHO for this purpose. eleven

To minimize bias, the validation and subsequent application of the instrument will be done
with the help of the experience of a group of people in charge of decision-making, coming
from diverse aspects of public health practice and from different levels of the health system
in various areas. countries.

A list of FESP such as the one presented is obviously subject to errors and cannot pretend
to satisfy each and every one of the visions that the world of public health has on the
subject. Decisions such as the inclusion of citizen empowerment or the stimulation of
intersectorality in the functions of promotion or social participation imply some degree of
arbitrariness, making it impossible to avoid the repetition of areas specific to more than one
function, with different emphases. . Obviously, the reality of daily public health practice
does not allow an absolute separation of functions, not even in the work of the same person.

Measuring EPHF is not only an interesting methodological exercise, but should allow for
improving public health practices and establishing well-functioning standards and
benchmarks for continuous improvement. The process also aims towards greater
transparency of public health practices and services and to give greater clarity to the
generation of public health knowledge and practices based on scientific evidence. Finally,
measurement should create the basis for better and greater allocation of resources for public
health actions.

PILOT TESTS FOR THE VALIDATION OF THE INSTRUMENT AND PLAN FOR
ITS APPLICATION IN THE REGION

During the months of April and May 1999, a validation exercise of the FESP performance
measurement instrument was carried out in three countries: Bolivia, Colombia and Jamaica.
This was carried out with a group of key informants that includes officials from the
different levels of health authority (central, intermediate and local), academic experts and
representatives of public health professional societies.

The instrument is being adjusted based on the results obtained in the pilot tests and a
refined version will be available in early September 2000. Subsequently, its dissemination
in all member countries is contemplated, in order to define mechanisms for applying the
instrument between October 2000 and April 2001.

The fundamental objective is for each country to use it as an instrument for self-assessment
of the state of public health practice, as a diagnostic tool that is comparable between all
countries and as a vehicle to encourage the development of national health plans.
improvement of public health practice.

USING PERFORMANCE MEASUREMENT RESULTS TO GENERATE AN

ACTION PLAN TO IMPROVE PUBLIC HEALTH PRACTICE IN THE
AMERICAS

The definition and measurement of FESP is conceived as a contribution to the institutional

development of public health practice and to the improvement of dialogue between public
health and other disciplines involved in health care. On the other hand, a better definition of
what is essential should contribute to improving the quality of services and obtaining more
precise definitions of institutional responsibilities. In this sense, it seems logical to expect
that public health's willingness to be accountable to citizens for the results of its work
begins with what is most unique and exclusive to it, and not because of the responsibilities
it shares with other approaches or disciplines. that intervene in general decisions regarding
health policy or about the destiny of health systems. The legitimacy and convening capacity
of public health for the development of intersectoral actions should be strengthened by a
more precise measurement of the essence of its work.

Better measurement of EPHF should also allow better quantification of the resources
necessary to ensure an adequate public health infrastructure, information that is essential
for governments, decision-makers and international cooperation agencies.

Finally, the definition and measurement of the FESP are fundamental to contribute to the
strengthening of public health education in the Region, an activity that today is
experiencing a crisis largely related to the lack of definition of the aforementioned roles.

REFERENCES

1. Lopez-Acuña D. Monitoring and evaluating health sector reform in Latin America and
the Caribbean. London: Health Care International, The Economist Intelligence Unit (in
press).

2. Mullan F. Don Quixote, Machiavelli and Robin Hood: public health practice, past and
present. Am J Public Health 2000;90;702-706.
3. Pan American Health Organization/World Health Organization. Challenges of public
health education. Washington, DC: PAHO/WHO; 2000.

4. Musgrove P. Public and private roles in health. World Bank Discussion Paper No. 339.
Washington, DC: World Bank; nineteen ninety six.

5. Pan American Health Organization/World Health Organization. XL Board of Directors

Meeting. The Rectorate of the Ministries of Health in the sectoral reform processes.
Washington, DC: PAHO/WHO; 1997.

6. Pan American Health Organization/World Health Organization. II Pan American

Conference on Public Health Education, Mexico City, November 11-13, 1998. Report.
Washington, DC: PAHO/WHO; 1999. (Series 15. Human resources development).

7. Bettcher DW, Sapirie S, Goon EH. Essential public health functions: results of the
international Delphi study. World Health Stat Q 1998; 51:44-54.

8. Mays GP, Halverson PK, Miller CA. Assessing the performance of local public health
systems: a survey of a state health agency efforts. J Public Health Manag Pract 1998;4:63-
78.

9. Harrel J, Baker E. The essential services of public health. Leadersh Public Health
1994;3.

10. American Public Health Association, Association of Schools of Public Health,

Association of State and Territorial Health Officials, ECS, National Association of County
and City Health Officers, National Association of State Alcohol and Drug Abuse Directors,
National Association of State Mental Health Program Directors, Public Health Foundation,
United States Public Health Service, Agency for Healthcare Research and Quality, Centers
for Disease Control, Food and Drug Administration, Health Resources and Services
Administration, Indian Health Service, National Institutes of Health, Office of the Assistant
Secretary for Health, Substance Abuse and Mental Health Services Administration: Report
of the Public Health Functions Steering Committee, 1995.

11. Pan American Health Organization/World Health Organization. 126a. Executive

Committee Session: essential public health functions. Washington, DC, June 26 to 30,
2000. Washington, DC: PAHO/WHO; 2000. [CE126/17(eng)].

ABSTRACT In the Americas, health sector reforms are facing the challenge of
strengthening the steering and leadership role of health authorities.
The
An important part of that role consists of fulfilling the essential
essential
public health functions (EPHFs) that are incumbent on all levels of
functions of
government. For that, it's crucial to improve public health practice, as
public
well as the instruments used to assess the current state of public
health: an
health practice and the areas where it needs to be strengthened. For
 emerging that purpose, the Pan American Health Organization has started an
theme in initiative called "Public Health in the Americas," with the objective
health of defining and measuring EPHFs, as a way of improving public
sector health practice and strengthening the leadership provided by health
reforms authorities at all levels of government. This article summarizes
conceptual and methodological aspects of defining and measuring
EPHFs. The article also analyzes the implications that measuring
performance on these public health roles, responsibilities, and
activities would have for improving public health practice in the
Americas.

1
Latin American Center for Research in Health Systems (CLAISS). All correspondence
should be sent to Fernando Muñoz at the following postal address: CLAISS, José Miguel
de la Barra 412, Piso 3, Santiago, Chile. Email: claiss@ctcreuna.cl
2
Division of Health Systems and Services Development, Pan American Health
Organization/World Health Organization (PAHO/WHO), Washington, DC, United States
of America.
3
CDC, Atlanta, United States of America.
4
Director Emeritus, PAHO/WHO, Washington, DC, United States of America.
5
Centers for Disease Control and Prevention (CDC), Atlanta, United States of America.
6
PAHO/WHO, Washington, DC, United States of America.
7
CLAISS, Santiago, Chile.
8
Program for the Organization and Management of Health Systems and Services,
PAHO/WHO, Washington, DC, United States of America.
9
For the purposes of this publication, the term "essential public health service", coined by
the US project, is equivalent to that of "essential public health function".

Pan American Health Organization/World Health Organization. Public health in the

10

Americas. Instrument for measuring essential public health functions. HSP (mimeographed
document), Washington, DC, April 2000.

Expert Consultation Meeting. Essential public health functions and performance

11

measurement of public health practice. Washington, DC, September 9-10, 1999.

Pan American Health Organization Washington - Washington - United States
Email: contacto_rpsp@paho.org
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