Public Health Care Management (HCM 312)

JOINT PROFESSIONALS TRAINING AND SUPPORT INTERNATIONAL
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PUBLIC HEALTH CARE

MANAGEMENT II
(HCM 312)
A HISTORY OF PUBLIC HEALTH
The history of public health is derived from many historical ideas, trial and error,
the development of basic sciences, technology, and epidemiology. In the modern
era, James Lind’s clinical trial of various dietary treatments of British sailors with
scurvy in 1756 and Edward Jenner’s 1796 discovery that cowpox vaccination
prevents smallpox have modern-day applications as the science and practices of
nutrition and immunization are crucial influences on health among the populations
of developing and developed countries.
History provides a perspective to develop an understanding of health problems of

communities and how to cope with them. We visualize through the eyes of the past
how societies conceptualized and dealt with disease. All societies must face the
realities of disease and death, and develop concepts and methods to manage
them. These strategies evolved from scientific knowledge and trial and error, but
are associated with cultural and societal conditions, beliefs and practices that are
important in determining health status and curative and preventive interventions
to improve health.
The history of public health is a story of the search for effective means of securing
health and preventing disease in the population. Epidemic and endemic infectious
disease stimulated thought and innovation in disease prevention on a pragmatic
basis, often before the causation was established scientifically. The prevention of
disease in populations revolves around defining diseases, measuring their
occurrence, and seeking effective interventions.
Public health evolved through trial and error and with expanding scientific medical
knowledge, at times controversial, often stimulated by war and natural disasters.
The need for organized health protection grew as part of the development of
community life, and in particular, urbanization and social reforms. Religious and
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societal beliefs influenced approaches to explaining and attempting to control

communicable disease by sanitation, town planning, and provision of medical care.
Religions and social systems have also viewed scientific investigation and the
spread of knowledge as threatening, resulting in inhibition of developments in
public health, with modern examples of opposition to birth control, immunization,
and food fortification.
Scientific controversies, such as the contagionist and anticontagionist disputations

during the nineteenth century and opposition to social reform movements, were
ferocious and resulted in long delays in adoption of the available scientific
knowledge. Such debates continued into the twentieth and still continue into the
twenty-first century with a melding of methodologies proven to be interactive
incorporating the social sciences, health promotion, and translational sciences
bringing the best available evidence of science and practice together for greater
effectiveness in policy development for individual and population health practices.
Modern society in high, medium and low income countries still faces the ancient
scourges of communicable diseases, but also the modern pandemics of
cardiovascular disease, cancers, mental illness, and trauma. The emergence of
acquired immunodeficiency syndrome (AIDS), severe acute respiratory syndrome
(SARS), avian influenza, and drug-resistant microorganisms forces us to seek new
ways of preventing their potentially serious consequences to society. Threats to
health in a world facing severe climate and ecological change pose harsh and
potentially devastating consequences for society.
The evolution of public health is a continuing process; pathogens change, as do the

environment and the host. In order to face the challenges ahead, it is important to
have an understanding of the past. Although there is much in this age that is new,
many of the current debates and arguments in public health are echoes of the past.
Experience from the past is a vital tool in the formulation of health policy. An
understanding of the evolution and context of those challenges and innovative
ideas can help us to navigate the public health world of today and the future.
Definitions of key terms related to public health systems research
• Population Health refers to the physical, mental, and social well-being of

defined groups of individuals and the differences (disparities) in health
between population groups.
• Public Health reflects society’s desire and effort to improve the health and
well-being of the total population, by relying on the role of the government,
the private sector, and the public, and by focusing on the determinants of
population health.
• Social Determinants of Health represent non-medical factors that affect
both the average and distribution of health within populations including
distal determinants (political, legal, institutional, and cultural) and proximal
determinants (socioeconomic status, physical environment, living and
working conditions, family and social network, lifestyle or behavior, and
demographics).
• Public Policy encompasses the intentional actions or inactions by
government to address a problem affecting the public.
THE IMPACT OF PUBLIC HEALTH ON POPULATION HEALTH

At the turn of the new millennium, the Centers for Disease Control and Prevention
(CDC) summarized ten major achievements of public health in the US since 19001.
These include:
• Vaccination, which has resulted in the control or eradication of smallpox,
poliomyelitis, measles, rubella, tetanus, diphtheria, Haemophilus influenzae
type b, and other infectious diseases;
• Motor-vehicle safety (through safer vehicles and highways, use of safety
belts, child safety seats, and motorcycle helmets, and decreased drinking
and driving), which has resulted in significant reductions in motor vehicle
related deaths;
• Safer workplace (particularly in mining, manufacturing, construction, and
transportation), which has resulted in significant reductions in fatal
occupational injuries;
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• Control of infectious diseases (from clean water and improved sanitation,

and antimicrobial therapy), which has resulted in the reduction of typhoid,
cholera, tuberculosis, and sexually transmitted diseases;
• Decline in deaths from coronary heart disease and stroke (through risk factor
modification such as smoking cessation, blood pressure control, and early
detection);
• Safer and healthier foods (from decreases in microbial contamination and
increases in nutritional content), which has eliminated nutritional deficiency
diseases such as rickets, goiter, and pellagra;
• Healthier mothers and babies (through better hygiene and nutrition), which
has resulted in significant infant and maternal mortality reductions;
• Access to family planning and contraceptives, which has resulted in smaller
family size, fewer infant, child, and maternal deaths, and fewer HIV and
STDs;
• Fluoridation of drinking water, which has reduced tooth decay and tooth
loss; and
• Recognition of tobacco use as a health hazard, which has reduced smoking
related deaths.
From these achievements, it is clear that the major contribution of public health
has been to prolong life. In the 20th century, public health efforts resulted in the
reduction and prevention of mortality due to infectious diseases, infant and
maternal mortality, accidents and injuries. Later, public health’s focus shifted to
the reduction of mortality due to selected chronic diseases. The dramatic decline
in
What are the social determinants of health?
The social determinants of health (SDH) are the social and economic factors that
influence people's health. These are apparent in the living and working conditions
that people experience every day. The SDH influence health in many positive and
negative ways. Extreme differences in income and wealth, for example, have
negative health consequences for those who are living in poverty and these effects
are magnified when these people are congregated in poor regions. In contrast,
those who are well-off and living in well-off regions have better overall health.
The following is a list of fourteen social determinants of health:
Income and Income Distribution

Education
Unemployment and Job Security
Employment and Working Conditions
Early Childhood Development
Food Insecurity
Housing
Social Exclusion
Social Safety Network
Health Services
Aboriginal Status
Gender
Race
Disability
Examples of Social Determinants of Health
There are many conditions classified as SDOH, and these factors are often grouped
into five broad categories: Economic stability, education, social and community
context, health and healthcare, and neighborhood and built environment. The
following are specific examples of conditions from each category:
Economic Stability:
Socioeconomic conditions, such as income level
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Job opportunities and access to job training

Food Insecurity
Housing Instability Education:
Access to education and the quality of available education
Early childhood experiences and development
Literacy levels
Social and Community Context:
Social norms and attitudes
Discrimination
Incarceration Health and Healthcare:
Access to health care services
Health literacy levels
Neighborhood and Built Environment:
Living conditions such as housing status
Access to clean water and healthy foods Exposure to crime, violence, and
social disorder Access to public transportation.
Organization of the public health system and Professionalism and Ethics in
the Public Health
Additional article information
SYNOPSIS
As the public's health-care needs increase in complexity, renewed attention is
being given to the ethical dimensions of public health decision-making and the
development of public health ethics as a bounded area of teaching and research.
This article provides an overview of approaches to public health ethics and
decision-making, and suggests ways to incorporate the professionalism
competencies into the teaching of public health practice. The teaching of ethics
language, concepts, and tools for decision analysis helps to prepare students for
the inevitable ethical choices they will have to make in their professional practice.
The teaching of ethics and professionalism and the experiences of professionals
enrich each other and foster the critical link between education and practice.
Challenges in the delivery of health care, prevention of disease, promotion of

health, and development of health policy continue to increase in complexity and
scope. New technologies, emerging and reemerging infectious diseases,
globalization, and a growing gap between rich and poor prompt professionals to
ask, “What is the right thing to do?” in making decisions that will affect the public's
health. Professionalism and ethical values have always provided an implicit
grounding for public health practice. But only recently have there been attempts
to identify, define, and conceptualize public health ethics as a bounded area of
interest within the fields of both public health and bioethics.
Several reasons have been suggested to explain this new interest. Emerging
infectious diseases, a growing emphasis on population health, and attention to the
relationship between socioeconomic status and health have raised new moral
questions in the process of securing the public's health.1 Furthermore, as 9/11 and
recent natural disasters brought the essential role of public health to the nation's
attention, the ethical dilemmas in public health were again explicitly recognized as
different from those of clinical medicine, a major focus of bioethics.2,3
The Association of Schools of Public Health (ASPH) has identified professionalism—

an ability to demonstrate ethical choices, values, and practices in decision-making
and to commit to the practice of personal and professional values—as one of the
cross-cutting or interdisciplinary competencies necessary for graduate education
in public health.4 According to ASPH, such interdisciplinary competencies are
considered cross-cutting because they are integrated throughout all of the core
public health disciplines (i.e., biostatistics, environmental health sciences,
epidemiology, health policy and management, and social and behavioral sciences).
The development of competencies for professionalism in public health coincides

with the emergence of public health ethics, with its population-based focus, as a
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specialty area distinct from bioethics, with its individual-based focus. The teaching
of ethics from a public health perspective provides the language, content, and
context for recognizing value-laden choices and practices in public health. A
language and context for ethics and professionalism encourage the discussion of
ethically supportable options and behaviors among stakeholders, practitioners, and
public health decision makers. Because the best methods for teaching the
knowledge, skills, and behaviors included under the professionalism competencies
can be elusive, a variety of methods and philosophical viewpoints will emerge as
schools and programs move forward to ensure that curricula include mechanisms
for meeting the professionalism competencies as defined by ASPH.
An existing body of clinical ethics concepts and a growing literature on public health
ethics have provided a number of ways to think about ethics and professionalism.
While we recognize the utility of distinguishing between public health ethics and
clinical ethics approaches, we also agree with those who suggest that the traditional
separation between medicine and public health is no longer a useful distinction.5,6
Increasingly, complex conditions such as childhood obesity and multidrug-resistant
infections suggest that the conceptual divide between the public's health and
clinical care is fading. Ethical decisions made in the acute-care setting (e.g.,
decisions to resuscitate extremely low-birth-weight infants) can have a significant
impact on public health, just as public health interventions will affect clinical care
(e.g., routine testing of newborns for phenylketonuria, or PKU as it is commonly
known). However, defining public health ethics as a field different from clinical
ethics emphasizes the issues specific to population-based health and identifies a
moral grounding for public health practice. In this article, when not referring
specifically to either public health or clinical medicine, we use the term “health
care” to encompass the totality of formalized health activities relating to the
public's health (i.e., health-care delivery, health promotion, disease prevention, and
health policy).
This article presents an overview of issues and approaches that can be

incorporated into the teaching of the professionalism competencies. We proceed
by (1) presenting an overview of three different approaches to moral thinking that
inform the content of public health ethics, (2) reviewing frameworks for analyzing
public health conflicts from recent literature, and (3) applying a process for ethical
decision-making to the public health arena. The article also discusses the
challenges to teaching professionalism and ethics competencies, and provides
examples of the integration of ethics into the public health curricula.
APPROACHES TO PUBLIC HEALTH ETHICS
Public health ethics, as related to health care, can be viewed as deriving its content
primarily from three approaches to moral thinking. These approaches are found in
the moral values inherent in public health practice, the concepts and language of
bioethics, and the values implicit in a health and human rights perspective. These
approaches have contributed to and continue to shape the development of public
health ethics.
Approach 1: values inherent in public health practice
The first approach is derived from the ethical values inherent in the professional
practice of public health—values that are explicitly stated in a public health code
of ethics. This code was developed, appropriately so, by leaders and practitioners
in public health through the work of the Public Health Leadership Society. The
public health code of ethics, the “Principles of the Ethical Practice of Public Health,”
provides a statement of public health values, obligations, and ethical guidelines for
the field itself, for public health policies and programs, and for public health
institutions.
Approach 2: concepts and language of bioethics
A second approach to moral thinking that informs public health ethics arises from
bioethics and the application of its language, concepts, and theories to public
health.3 The professionalism competencies for graduate education in public
health, developed by ASPH, reflect some of these concepts and language. For
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example, virtues—the morally valuable character traits of an individual8—are

found in three of the competencies.
Approach 3: health and human rights perspective
A third approach to moral thinking for public health ethics is found in a health and
human rights perspective. The modern human rights movement and the
relationship between health and human rights have been traced to the United
Nations' 1948 Universal Declaration of Human Rights, which affirms that all
humans have basic, universal rights such as freedom and dignity.
While each of these three approaches has its advocates and critics, public health
ethics has been enriched and will continue to develop through the contributions of
each perspective. In addition to understanding the different approaches to moral
thinking that inform public health ethics, a basic familiarity with ways of
conceptualizing ethical issues and the use of a process for ethical decision-making
can provide tools for enhancing ethics discussions in the classroom.
FRAMEWORKS FOR CONCEPTUALIZING ETHICAL ISSUES IN PUBLIC HEALTH

PRACTICE
In teaching public health ethics, providing both the theoretical bases and practical
tools for ethical analysis and decision-making is critical. Answers to the question of
how to approach the teaching of both theory and practice are suggested by a
number of ways to conceptually frame ethical issues in public health, as well as
ways to analyze them. Frameworks for consideration of ethical issues and
decisionmaking in public health have been suggested using philosophical, political
science, problem-based, and social justice approaches. In addition, ethics
guidelines, values statements, professional consensus papers, and policy reports
have been formulated to frame general and specific issues, and provide ethical
guidance concordant with professional values.
Philosophical framework
Ethics is a branch of philosophy; therefore, philosophical paradigms have been
used most often in different approaches to moral reasoning. Roberts and Reich14
observed that three philosophical paradigms—utilitarianism, liberalism, and
communitarianism—underlie and inform most discussions of ethical questions in
public health. They noted that these paradigms provide useful tools for public
health decision-making. Morally problematic issues can be analyzed and ethically
justified by considering the consequences or outcomes of a public health measure
(utilitarianism), by appealing to rights of individuals or groups (liberalism), or by
considering the characteristics of what constitutes a good society
(communitarianism).
Political science framework

A political science perspective focuses attention on the perceptions of morality,
immorality, and degree of personal responsibility that underlie and shape opposing
political viewpoints. Political conflicts often surround public health decisions, such
as those concerned with drug policies, needle-exchange programs, or
familyplanning initiatives. Understanding political differences as rooted in different
moral viewpoints may lead stakeholders to move away from divisive and often
discriminatory policies and instead search for solutions based on shared
perceptions of moral good for all.
Problem-based framework
Another framework for conceptualizing ethical issues in public health might be
thought of as a problem-based approach. Weed and McKeown17 identified three
problematic situations in public health in which ethical values, duties, and
obligations compete or conflict. These three situations occur when public health
professionals must decide what level of scientific evidence justifies intervention
with a public health measure; when practitioners must weigh the role and limits of
advocacy in public health; and when they must consider individual concerns
against the good of the public. Weed and McKeown have selected these three
larger, indeterminate situations for their discussion, but acknowledge that other
situations create moral tensions in public health practice as well.
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Social justice framework

The ethical value of justice can also be considered a framework for identifying,
analyzing, and dealing with ethical issues in public health. While philosophers have
delineated different theories of justice, public health professionals have tended to
focus on social justice. Social justice applied to public health is concerned with
social determinants of health, disparities in socioeconomic conditions leading to
poor health, and fairness in the distribution of the social burdens and benefits
linked to the improvement of health.18 Social justice issues can be analyzed at the
local, national, and global levels. In regard to the U.S. health-care system, however,
Aday and colleagues argued that conventional perspectives of justice are
inadequate for addressing disparities in health care. They compared and
contrasted several views of justice and posited a framework for evaluating equity
in health care. An equity paradigm, as described by Aday and colleagues, focuses
on health disparities and the means of dealing with them. Health services
researchers can assess equity in health care by studying health disparities and the
reasons for their occurrence and persistence.
Professional guidance for ethical issues
Guidance for framing and examining specific ethical issues can be found in
numerous public health statements of values, such as codes of ethics, mission
statements, guidelines, and policy statements developed by professional groups.
These documents offer guidelines for professional behaviors and/or dealing with
difficult ethical situations encountered in practice. For example, CDC has
developed guidelines for the fair distribution of drugs and limitations on personal
freedoms that might be required during an influenza pandemic. For controversial
topics, such as the rationing of scarce resources during a public health emergency,
the publication of guidelines or value statements can stimulate public discussion of
the problem prior to an actual emergency. In general, guidelines are not meant to
be rigidly interpreted and can be reformulated as circumstances change. In
addition to being useful for addressing recurrent ethical dilemmas in practice,
guidelines and other value statements are useful tools for teaching students critical
analysis of real or hypothetical cases.
PROCESSES FOR ETHICAL ANALYSIS AND DECISION-MAKING IN PUBLIC HEALTH
Schools of public health are academic institutions with an implied mission to train
professionals for public health practice. Theory informs practice, but ultimately,
public health practitioners must be prepared to make difficult decisions in the field.
Students must be able to apply theory to practical problem-solving in the real world
of public health practice. The use of a methodological approach to ethical
decisionmaking will vary according to the complexity of the issues, but will help to
ensure that an issue is thoroughly examined and that differing moral views are
considered in a conflict situation. Such an approach, commonly used in teaching
ethics to health professionals, including public health professionals, follows a
process similar to that of the scientific method (Figure 3).
Recognition of an ethical concern or problem is the first step of the decision-making

process, followed by gathering data in an attempt to understand diverse aspects
of the problem. The data gathered will involve concrete information, such as
identification of stakeholders and cost analyses, but may also include less tangible
information, such as the differing values of individuals and groups, and
considerations of power relationships among stakeholders.
The next decision step is the identification of conflicting value orientations, which
can be accomplished through the application of different moral frameworks. For
example, a particular public health program requiring children to wear bicycle
helmets could be opposed by parents who are concerned with their right to make
their own choices for their children (a liberal framework). Or the program could be
advocated by health insurers focused on the cost of health care for preventable
injuries (a utilitarian perspective), or by community leaders advocating a
community value of living in a safety-conscious community (a communitarian
view).
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A next step would be to consider the conditions for the ethical support of a public
health decision. For example, in deciding whether to implement a public health
measure that could conflict with individual freedoms, which ethical considerations
should be given the most weight and why? Kass has suggested a framework using
six criteria to evaluate the ethics of public health policies and programs in such a
situation:
The goal of the public health measure must actually have the potential to improve
the public's health.
The public health measure must be effective in achieving its goals.
The burdens of the public health measure must be recognized.
Burdens should be minimized or alternate measures considered.
The public health measure should be fairly implemented.
The burdens and benefits should be balanced.
Similar criteria have been framed by Childress and colleagues regarding the
effectiveness of the public health measure, its proportionality between burdens
and benefits, the necessity of a particular measure in terms of alternate strategies,
the least infringement on individuals' freedoms or privacy, and the additional
obligation to justify the public health measure to the public with openness and
transparency.
Not all ethical dilemmas in public health involve direct conflicts between individual
liberties and public health priorities. For example, public health practitioners have
noted ethical concerns in collaborations with private industry and divided loyalties
inherent to working within a political system—though these concerns may
ultimately involve conflict between individual and social interests. But in the
analysis of any ethical concern, a systematic decision-making process should
consider public health values, stakeholder values, and ethical justifications for
action.
The final steps in the ethical decision-making process are to implement the public
health measure and to evaluate the decision-making process. While public health
measures themselves are often subjected to evaluation, those individuals involved
in the ethical decision-making process should also evaluate their decision-making
approach. Were all voices given a chance to be heard? Did the voices reflect the
diversity of those who would be affected by the decision-making? Were trust issues
with the community (if any) addressed explicitly and openly? Was it a respectful
process? How might the process be improved in the future? Keeping records of
ethical deliberations and their outcomes will encourage transparency in the
process, provide a means of comparing and contrasting future dilemmas, and
enable the collection of cases for educational purposes.
CHALLENGES TO TEACHING ETHICS AND PROFESSIONALISM IN THE PUBLIC

HEALTH CURRICULUM
In developing competencies for ethics and professionalism, ASPH uses ethics as a

grounding for the interdisciplinary competency of professionalism.4 The use of
ethics as a foundation for professionalism parallels that of other health professions
in defining professional values—for example, in 1995 the American Board of
Internal Medicine (ABIM) focused on professionalism in defining desired behaviors
and outcomes, and in integrating the teaching of those behaviors into the Internal
Medicine curriculum. The ABIM's concept of professionalism includes elements
such as altruism, accountability, a sense of duty, and a striving for excellence,29
issues that can be viewed as subsumed under a broader notion of ethics.
Whether personal morality can be taught within an academic discipline is a

longstanding controversy in the field of ethics, but students can be taught
professional obligations to themselves, their profession, their colleagues, and their
clients. All health professionals also have an obligation to understand and act in
accordance with the values of their profession, which are often explicitly stated in
professional codes of ethics. In addition, because of the complexities of health care
today, all professionals should be familiar with the major ethical issues and
controversies in their area of health expertise. In schools of public health,
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“professionalism,” with competency in ethical decision-making, can be taught

through referencing and reflecting on the public health code of ethics, faculty
modeling, case-based discussions within public health courses, and formal courses
in ethics.
The dominance of clinical ethics and a dearth of faculty cross-trained in both public
health and ethics have been noted as barriers to incorporating ethics instruction
into the public health curriculum. But more basic challenges exist with regard to
attitudes about the teaching of ethics and professionalism. While some faculty may
believe they are inadequately prepared to teach ethics, others may doubt the need
for explicit ethics instruction, believing that inherent individual moral values,
experience, and modeling of mentors are sufficient. However, personal views of
morality alone are insufficient to resolve ethical conflicts because differing moral
viewpoints are often the basis for a conflict. In addition, some individuals may
conflate their personal morality with ethics and consider the study of ethics as
necessary only for those individuals lacking in moral qualities.
A lack of familiarity with basic definitions and terms will impede discussion of
ethical issues in public health. A brief overview of ethics language and suggestions
for facilitators can be found in the introduction to Ethics and Public Health: Model
Curriculum.9 An important distinction for public health is the difference between
ethics and law. Because the law cannot say in every instance whether something is
right or wrong, ethical reasoning and decision-making will have to be used to
resolve a dilemma if the law does not address an issue. It is often said that the best
laws are ethical ones; however, legal and ethical perspectives may differ in regard
to the same issue.
TEACHING THE PROFESSIONALISM COMPETENCIES: THE UNIVERSITY OF TEXAS

EXAMPLE
The University of Texas School of Public Health (UTSPH) in Houston, Texas, in its
responsibility to train public health professionals, is meeting the professionalism
competencies in a number of ways. UTSPH has a faculty member with abioethics
background whose teaching and research interests are devoted solely to ethics,
and who is a resource for other faculty in incorporating the teaching of ethics into
specific courses. In addition, a number of faculty from different public health core
disciplines, who have interests, knowledge, and experience in ethics, make up a
cadre of those who formally incorporate ethics and professionalism into courses
and serve as resources to other faculty members. In conjunction with the teaching
of ethics and professionalism in individual, discipline-based courses, two ethics
courses—research ethics and health care ethics—are offered as electives to
students.
UTSPH offers a separate research ethics course to address the social, cultural, and
ethical aspects of the research process, as well as the many ethical issues and
controversies that have occurred and continue to occur as part of the research
endeavor. While Institutional Review Boards may engage in ethical
decisionmaking, their primary concern is compliance with federal laws rather than
research ethics per se. Training students in the responsible conduct of research
may help them learn professional behaviors. However, a case-based research
ethics course can also assist students in understanding how to balance research
design and implementation with the protection of human subjects, and to deal
with the everyday ethical decisions that are made in the conduct of research. As
part of the course, several faculty researchers from core public health disciplines
discuss ethical situations encountered in their own research, thereby contributing
with practical examples and as role models.
A health care ethics course is taught with the philosophy that public health
encompasses all aspects of health-care delivery, disease prevention, health
promotion, and policy. Several public health faculty members contribute their
expertise as lecturers or discussion facilitators. The course is interdisciplinary, with
students from UTSPH and the other four professional schools on the University of
Texas Health Science Center Houston campus. Ethical issues, whether framed as
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clinical or public health, are examined for their public health implications. Thus,
students are encouraged to examine ethical issues with an integrative view—i.e.,
while public health decisions may affect individuals, the ethical decisions of
individuals may have broader public health consequences as well.
Public health professionals confront ethical dilemmas routinely in public health

practice. This complex and rapidly changing field demands that educators give
renewed attention and emphasis to ethical decision-making. Students, faculty, and
practitioners will benefit from curricula in schools of public health that present the
theory, language, and analytical tools to explore contemporary ethical dilemmas,
both hypothetical and real. As the discourse in public health ethics advances, the
critical link between education and application in the field will be manifest in
professional publications and case studies, and in professionals better prepared to
resolve ethical dilemmas in their professional practice.
PUBLIC HEALTH LAW AND PUBLIC HEALTH POLICY
Public health law and public health policy are fundamental tools that assist states
in the task of protecting people from threats to health, preventing disease, and
striving for healthy populations.
The Public Health Law and Policies Team (LAW) assists governments on legal issues,
with a focus on modifiable risk factors for noncommunicable disease, such as
tobacco use, harmful use of alcohol, unhealthy diet, and inadequate physical
activity. The team offers a unique legal perspective, with expertise across law and
health, including NCD prevention, trade and investment law, commercial law and
litigation, drawing on experiences from jurisdictions around the globe and in
development of international norms.
LAW assists governments to develop new laws and regulations, such as by advising
on the experience of other jurisdictions and how to minimize litigation risk, by
reviewing and commenting on draft legislation and regulations, and assisting in
legislative drafting.
The team assists governments to defend implementation of WHO guidance in the

event of legal challenge, particularly where a government’s right to regulate to
protect public health is questioned. Examples include providing background
technical briefings on factual or legal issues, providing formal letters for
presentation before courts and, in some instances, amicus briefs.
LAW provides training and capacity building tailored to lawyers and policy focal
points relating to specific health interventions or bodies of law.
The team also supports development of new international norms and standards
within WHO and through engagement with other intergovernmental
organizations.
TYPES OF PUBLIC HEALTH LAW AND POLICY
Three Types of Public Health Law and Other Public Policy

Infrastructural: So called “enabling” public health statutes, which typically
specify the mission, function, structure, and authorities of state or local
public health agencies (also known as health departments).
Interventional: Federal, state, or local law or policy designed to modify a
health risk factor.
Intersectoral: Federal, state, or local law or policy implemented by a
nonhealth agency for a primary purpose other than health, but which has
intended or unintended health effects.
Public Policy. This term refers to the broad arena of positions, principles, and
priorities that inform high-level decision making in all branches of government, but
is often used to refer collectively to laws, regulations and rules, executive agency
strategic plans, executive agency guidance documents, executive orders, judicial
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decisions and precedents. Many public policies are not laws, but may have help
change norms and behaviors in health.
Each branch of government executive, legislative, and judicial makes contributions

to public policy.
Laws: Statutes and Ordinances. These are usually originated by the legislative
branch of government (e.g., Congress, state senate or assembly, city council).
Under the federal and most state constitutions, laws are not finalized until signed
by the chief executive officer (e.g., president, governor, mayor). Laws require
conformance to certain standards, norms, or procedures.
Regulations. These are rules, procedures, and administrative codes often

promulgated by the executive branch of government, such as federal or state
agencies, to achieve specific objectives or discharge specific duties. These are
applicable only within the jurisdiction or toward the purpose for which they are
made. Laws authorize administrative agencies to promulgate regulations.
Constitutional history and judicial precedents. These refer to the judiciary’s
interpretation of the Constitution, laws, and regulations, including case law from
prior judicial opinions.
What are the public health laws in Nigeria?
What are the public health laws in Nigeria?

Nigeria has several laws and regulations related to public health, including:
● The Quarantine Act of 1926 - regulates the control and prevention of

infectious diseases
● The National Health Act of 2014 - provides the legal framework for the
organization, financing, and delivery of health services in Nigeria
● The Environmental Health Officers Registration Council of Nigeria Act -
regulates the practice of environmental health in Nigeria
● The Tobacco Control Act of 2015 - regulates the production, sale, and use of
tobacco products in Nigeria
● The Food and Drugs Act of 2015 - regulates the manufacture, importation,
exportation, distribution, advertisement, and sale of food, drugs, cosmetics,
medical devices, and other related products.
These laws serve as the cornerstone for public health policies and programs in
Nigeria.
PUBLIC HEALTH FINANCE AND PUBLIC HEALTH WORKFORCE
Health financing is a core function of health systems that can enable progress
towards universal health coverage by improving effective service coverage and
financial protection. Today, millions of people do not access services due to the
cost. Many others receive poor quality of services even when they pay out-
ofpocket. Carefully designed and implemented health financing policies can help
to address these issues. For example, contracting and payment arrangements can
incentivize care coordination and improved quality of care; sufficient and timely
disbursement of funds to providers can help to ensure adequate staffing and
medicines to treat patients.
WHO’s approach to health financing focuses on core functions:
revenue raising (sources of funds, including government budgets, compulsory

or voluntary prepaid insurance schemes, direct out-of-pocket payments by
users, and external aid) pooling of funds (the accumulation of prepaid funds
on behalf of some or all of the population) purchasing of services (the payment
or allocation of resources to health service providers)
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In addition, all countries have policies on which services the population is entitled
to, even if not explicitly stated by government; by extension those services not
covered, are usually paid for by patients (sometimes called co-payments).
Who is the public health workforce?

The epidemiological shift in the burden of disease away from communicable
diseases to noncommunicable diseases (NCDs) and chronic conditions has pushed
public health systems to move beyond the control of individual disease-causing
agents to encompass intersectoral actions addressing the new root causes of
population ill-health. Furthermore, large health inequities still exist within and
between countries. This means that public health systems need to broaden their
remit to include a strong focus on the prevention and control of noncommunicable
diseases and on reducing health inequities. However, despite this shift in
population health needs, public health systems in Europe are struggling to adapt.
An assessment of public health capacity in the EU in 2013 found that countries
were generally stronger in traditional fields of public health, such as communicable
disease control and vaccination, and weaker in addressing the social determinants
of health and health inequalities (Aluttis et al., 2014).
To achieve intersectorality and deliver on health-in-all policies it will be necessary

to use the untapped potential of the wider public health workforce.
Modern public health practice embraces the study and control of a wide range of
health determinants; this endeavour requires many diverse skills, including
medical skills but also many others (Birt & Foldspang, 2009). Erwin & Brownson
(2017), for example, have stated that “the public health practitioner of the future
should be equipped with capabilities, such as systems thinking and methods,
communication skills, an entrepreneurial orientation, transformational ethics, and
policy analysis and response”. Moreover, there is a need for public health to
embrace wider disciplines such as political science, international law, climatology
and ecology (Middleton, 2016).
The diversity of the public health workforce also means that it is hard to advocate
for and organize this workforce as a single workforce across Europe. Given the
wideranging contexts within which the public health workforce must function and
the expressed need for the redesign of structures and public health processes
(Frenk et al., 2010) there can be critical gaps in workforce development. Achieving
goals to strengthen the public health workforce may require a re-conceptualization
of professional training and support mechanisms as well as setting priorities in
relation to competences development (Czabanowska et al., 2014; Czabanowska,
2016).
Key challenges
The contemporary and future challenges for public health put high demands on
professional education, recruitment and retention of staff, and require investment
in continuing education. A large number of public health graduates do not work in
public health roles, and in some countries two thirds of the public health workforce
do not have formal public health training (Pacchaud et al., 2013). Therefore, in
training the public health workforce to meet the health needs of the population, it
is also important to meet the needs of students and equip them with the skills they
may need in the workplace, as well as meeting the needs of potential employers
and working with them to ensure suitable career opportunities are available
(Lafranconi et al., 2016). The gap between public health training and public health
practice goes beyond the core public health workforce, resulting in blurred career
paths and a professional identity crisis in the field.
Public health workforce capacity varies greatly across the WHO European Region
and in many respects this variation reflects the wider organizational context of
public health; just as the boundaries of what constitutes public health are
contested, so too are the boundaries of the public health workforce. The
methodological challenges in estimating the size and scope of the public health
workforce are complicated by the different understandings and terminologies
across Europe with regard to the role and meaning of “public health”. This makes it
hard to conceptualize the public health workforce and to establish a European
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consensus (Aluttis et al., 2014). Such differences in terminology are evident in the
different names that exist across Europe for what is recognized by the EU as the
medical specialty of public health, called “hygiene and epidemiology” in the Czech
Republic, “hygiene and preventive medicine” in Italy, “public health and
epidemiology” in Poland and “social medicine” in Sweden (Westerling, 2009).
While the boundaries within which the public health workforce are found are not
clearly defined at the international level, the same is often true at the national
level. Consequently, for many countries only crude estimates on the size of the
public health workforce are available, as it cannot be clearly identified or
distinguished from the health care workforce and people working in other sectors.
A formally recognized core of public health professionals is still required to

safeguard the scientific and evidence-based approach to public health
interventions (Sim et al., 2007), but their role could be expanded to facilitate work
across silos with a wide range of professionals to coordinate complex responses to
public health issues and address the social determinants of health (Ribeiro et al.,
2016). In some countries, public health specialists play important roles in initiating
and leading work across sectors, such as in England and Sweden. In England the
role of Directors of Public Health in local authorities includes leading and
championing health improvement across the local authority. It seems that in many
other countries in Europe there is no clearly defined mandate for public health
specialists to lead on public health, either within the health system or across
sectors.
Developing the public health workforce

Lichtveld and Cioffi (2003) propose a framework for action which includes six
strategic elements for public health workforce development: monitoring
workforce composition, identifying competencies and developing a related
curriculum, designing an integrated lifelong learning delivery system, providing
individual and organizational incentives to ensure competency development,
conducting evaluation and research, and assuring financial support.
A key challenge in developing the public health workforce across Europe is to
professionalize its core personnel. This means developing systems for the
certification and registration of core public health workers to ensure a regulatory
framework is in place, as well as the development of competencies, training
pathways and ongoing professional development. Currently, only a few countries
in Europe have a specific certification or registration of public health professionals
(see Assuring the quality of public health services). In Poland, for example, there
are no clear roles for public health graduates, no career paths, and no systems for
accreditation or certification relevant to public health (Topór-Mądry et al., 2018).
Limited options for career progression are also a problem in Germany (Plümer,
2018). This lack of clearly defined training and continuing professional
development for the public health workforce is an issue across Europe and means
that many people working in public health are still following the traditional public
health paradigm based on infectious diseases control and environmental
monitoring, rather than the new public health which encompasses broader health
determinants.
It is instructive that of the nine countries covered in the accompanying volume

(Rechel et al., 2018), only three (England, the Republic of Moldova and the
Netherlands) have a public health workforce policy or plan. This illustrates that
proper workforce planning for public health is lacking in most countries. Initially, it
should be essential for countries to allocate responsibility for public health
workforce planning and development. An example of how this could be done is
England, where Public Health England has been charged with developing the public
health workforce, including its own staff, Directors of Public Health in local
authorities, and the wider public health workforce.
Developing the public health workforce also requires meeting the needs of the
wider public health workforce. Improving population health in Europe requires
intersectoral action and the combined efforts of people from many disciplinary
backgrounds and professions (Sim et al., 2007). A key challenge is to “find ways for
the diverse members of the wider workforce both to recognize that they have a
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public health role and to ensure they gain the competencies that will enable them
to fulfil the requirements specific to their role” (Sim et al., 2007). Policies are
needed to ensure that the wider public health workforce has a defined and
legitimate public health role in their job specification, allowing it explicitly to
improve the health of populations in their work. For example, most often, positions
of leadership in public health are held by clinicians who have followed clearly
structured career pathways. In contrast, the workforce they lead often includes
people who have come to public health through a myriad of pathways, sometimes
armed with specialist knowledge in some aspects of public health, but without
either access to the training needed or the legal right to assume positions of
leadership (Sim et al., 2007).
The core and wider public health workforce have complementary roles in
improving population health. The core public health workforce can act as a catalyst
to support evidence-based interventions that can be undertaken locally by
competent public health practitioners and the wider workforce (Sim et al., 2007).
Clearly employers of public health workers can also play a key role in developing
their workforce. This includes the provision of appropriate working conditions and
salaries, and fostering career development and continuing professional
development. National public health agencies are important here, but also local
and regional authorities.
Professional associations can play an important role in advocating for the needs of
the public health workforce at the national and European level (Allutis et al., 2013).
In 2013 Luxembourg, Cyprus, and Slovakia were the only EU Member States
without national associations on public health (Allutis et al., 2013).
International agencies such as the European Union (EU) and the World Health
Organization (WHO) have developed functional definitions of what needs to be
done under the umbrella of public health but have left it open as to who should
provide these functions. This is in large part due to the diversity across Europe in
how countries seek to meet the spectrum of public health needs. However, for
some subspecialties of public health, European-wide training programmes have
been established. These include programmes coordinated by the European Centre
for Disease Prevention and Control (ECDC), such as the European Programme for
Intervention Epidemiology Training (EPIET) and the Public Health Microbiology
Programme.
In most countries key aspects of public health are still provided by clinicians, i.e.
physicians who have specialized in public health and received postgraduate
training in the field. The United Kingdom seems to be the only country in Europe
where clinical training is not a prerequisite for specializing in public health.
The United Kingdom, Denmark and Norway were among the first countries to base
education in public health on a broad curriculum (rather than a narrow medical
one), covering essential public health areas and core competencies and following
a multidisciplinary approach. Elsewhere, education and training for public health
continue to evolve, with schools of public health in the United Kingdom and the
United States sometimes serving as role models (Aluttis et al., 2014). In
Switzerland, a recent study found that 69% of the public health workforce did not
have a specific public health degree and that training in public health sciences was
the most-reported competency needed by workers (Paccaud et al., 2013). Such
training could support the multidisciplinary role needed and help to build a more
cohesive public health identity and increase the visibility of public health as a
profession.
In most European countries, there seems to be a contradiction between the

extensive provision of public health education on the one hand and the lack of
career paths and employment opportunities for public health professionals on the
other. In much of Europe, career opportunities and incentives for further
professional development in public health are limited.
Several countries, including France, Germany, the Republic of Moldova and

Portugal, report that public health is not an attractive specialty for medical
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students (Chambaud & Hernández-Quevedo, 2018; Plümer, 2018; Ciobanu et al.,

2018; Gomes & Barros, 2016).
This is likely to be due to many factors, one being low salaries. In the Republic of
Moldova salaries of public health professionals are so low that many of these
professionals hold contracts equivalent to 125% of full-time positions, so that they
can make ends meet (Ciobanu et al., 2018). In Germany, changes to the Civil Service
Tariff in 2006 led to a discrepancy between the pay for public health specialists and
those in other clinical specialties, with much lower pay for public health, leading to
subsequent recruitment problems (Plümer, 2018). In England, the move of public
health services from the National Health Service (NHS) to local government in 2013
resulted in lower salaries for some newly appointed public health specialists.
Previously, recruitment and retention for positions was high, but in 2017 an
estimated 17% of Director of Public Health posts were vacant (Middleton &
Williams, 2018). In Italy, public health positions are particularly vulnerable to
budget cuts, as they are often in regional or local government authorities (Poscia
et al., 2018).
Without the ability to attract a sufficient number of young people to the profession,
the public health workforce is rapidly ageing as in the case of Portugal where 89.5%
of public health doctors were over 50 years of age in 2011 and therefore all
expected to retire by 2027 (Gomes & Barros, 2016). In the Republic of Moldova,
problems with recruitment have been aggravated by the outmigration of public
health workers, leading overall to the rapid ageing of the public health workforce
(Ciobanu et al., 2018). This illustrates the role that international migration can play
in the supply of public health workers in Europe. Within the EU, the recognition of
public health medicine as a medical specialty in 2008 strengthened its position and
raised its profile relative to other specialties (Westerling, 2009), but the associated
mutual recognition of qualifications also increased the likelihood of migration of
public health specialists across the EU.
European policy responses
Although public health as a medical specialty is now recognized by the EU, the
broader public health profession, being multidisciplinary and often dependent on
national contexts, is not clearly defined across the EU, hindering the recognition of
qualifications, professional mobility and the integration of public health
professionals into the single market (Czabanowska et al., 2015). A survey carried
out by the Association of the Schools of Public Health in the European Region
(ASPHER) identified the need for developing clear-cut professional qualification
models which would allow for the certification and licensing of the profession
across the EU (Bjegovic-Mikanovic et al., 2013).
The EU has set out a system for the recognition of professional qualifications in
Directive 2005/36/EC, amended by Directive 2013/55/EU (European Parliament,
2005, 2013). Depending on the national legislation and the profession in question,
the document provides three different legal approaches to the recognition of a
professional qualification. Automatic recognition is the first possible procedure,
but it is restricted to a limited number of regulated professions. In this case, the
host country should automatically recognize the qualification. A second approach
is the mutual recognition of qualifications to practice a so-called general system
profession. This procedure works on a case-by-case basis. In general, it establishes
that an individual should undergo compensatory measures only when the
education or the minimum required years of practice diverge drastically from the
receiving country’s regulation. The third approach is for individuals who establish
themselves in another member state by working or providing a service on a
temporary or occasional basis. The legislation might allow them to work without
prior recognition from the receiving country. However, Article 7 of the Directive
2005/36/EC restricts this model, stating that if there is a considerable difference
between the individual’s qualification or the training required by the member
state, in particular in a profession having implications for public health or safety, a
prior check or compensation measures may be needed.
There are several controversial aspects to Directive 2005/36/EC. Most importantly,

it excludes some professionals from mutual recognition by distinguishing regulated
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and unregulated professionals. Moreover, insecurity around the recognition of

qualifications for non-regulated professionals, especially in the health sector, can
be expected to lead to lower numbers of applications (Dussault et al., 2009).
The need for more concerted action involving many actors and sectors to support
the public health workforce has been widely recognized by professional
associations for public health. In 2017 the EU Health Policy Platform adopted the
Joint Statement on Public Health Workforce Development and Professionalisation,
signed by ASPHER and many leading public health associations (ASPHER, 2017). The
Joint Statement calls for consensus-building and collaborative cross-sectoral
engagement of all relevant health professionals in public health matters,
professionals in other relevant services and a competent and sufficient public
health workforce to drive the necessary changes forward. It points to the need for
developing the public health workforce by establishing communication and
coordination systems, clear roles and competences, education and training,
attractive career paths, continuing professional development, needs assessment,
and planning and forecasting. The Joint Statement also identifies the need for
strong associations of public health professionals, the development of the public
health role and competences of other professionals, the development of the public
health discipline and profession, and the nurturing of strong leaders to lead the
development, implementation and evaluation of public health strategies,
programmes and services.
WHO
Many frameworks for assessing the capacity of public health and the training of the
public health workforce have been developed, particularly in the United States and
the Americas. However, the dissolution of the Soviet Union and the resulting
disarray of public health services in the postcommunist countries led the WHO
Regional Office for Europe to develop its own essential public health operations
(EPHOs) to assist in establishing a minimum portfolio of public health services
(Martín-Moreno et al., 2016). The EPHOs can be used to assess and plan stronger
public health services and capacities; they centre around three main areas of
service delivery: health protection, disease prevention, and health promotion,
supported by enabling functions.
The EPHO assessment process can help to build capacity and allows professionals
to update their knowledge of contemporary public health functions, providing a
basis for the development of public health training curricula (Martín-Moreno et al.,
2016).
More recently, the WHO Regional Office for Europe has launched a collaborative
initiative called the Coalition of Partners (WHO, 2017). This initiative aims to take
collective action to strengthen essential public health services and capacities
across the WHO European Region. Three joint actions have been initiated with
regard to the public health workforce:
● A Core Competencies Framework for the Public Health Workforce in the

WHO European Region: This framework is anticipated to facilitate the
standardization of the skills required of public health professionals.
● A Handbook for Managing Public Health Professional Credentialing and
Accreditation Systems in the WHO European Region: The handbook is hoped
to serve as a reference tool for national education and health authorities, as
well as for professional bodies, concerned with establishing and
strengthening national credentialing and accreditation systems.
● A Roadmap towards Professionalization of the Public Health Workforce in
the WHO European Region: The roadmap aims to support countries in taking
action to further professionalize the public health workforce, describing a
variety of measures that countries can take, and identifying considerations
related to the implementation of these measures.
ASPHER
The Association of Schools of Public Health in the European Region (ASPHER) has
been a major advocate for the needs of the public health workforce in Europe. Its
work includes the development of a European list of public health core
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competencies to meet contemporary challenges in population health and in health

systems.
ASPHER’s European list of public health core competencies.
However, as noted above, job profiles need to reflect this training. This means that,
beyond harmonizing the training and education of the core public health workforce
across Europe, it is necessary to ensure that public health graduates can find a job
on the basis of their qualifications and have the skills to fulfil their public health
role.
The list of public health core competencies (Box 5.4), in conjunction with the
EPHOs, can help to professionalize the public health workforce (Foldspang, 2015).
To ensure sustainability it is necessary for public health to be an attractive
profession for young graduates so that the best candidates want to specialize in
public health. Recruiting and retaining public health workers requires the
consolidation of a clear professional identity, underpinned by clear professional
profiles and job descriptions (WHO Europe, 2017). In some countries this will
necessitate the development or acknowledgement of public health as a profession.
Despite the enormous diversity and fragmentation of the institutional landscape

for public health in Europe, there is a remarkable consistency across schools of
public health as to the type and level of skills and knowledge required for
professional public health training. This might be in part due to the active
harmonization efforts of bodies such as ASPHER and the WHO Regional Office for
Europe (Bjegovic-Mikanovic et al., 2013). However, although consistency has so far
been largely achieved in EU/EEA Member States, many of the post-Soviet countries
still focus on hygiene and do not teach the full scope of public health.
The next steps include greater networking and collaboration between schools of
public health to support countries in developing certification of the public health
workforce and other aspects of professionalization (Otok & Foldspang, 2016; Otok
et al., 2017). A Master’s degree in Public Health (MPH) still constitutes a basic part
of professional training and specialization in public health. In some countries there
are also undergraduate training courses for public health and graduates from these
courses would benefit from professionalization to fully exploit the opportunities
for intersectoral work outside the health sector. There is also a need for
harmonizing the training of the wider public health workforce. Public health will
need to be expanded to other professions to build awareness of how they can
impact on public health in both positive and negative ways. Working across
disciplines is often easier in countries with smaller populations as people know
each other, but there can also be capacity issues and there are countries, such as
Slovenia, without a national school of public health. Building capacity therefore
also needs to happen across countries. Initiatives at the European level can inform
the development of tools at the national level. One example of this is the Public
Health Training Academy.
Moving forward, achieving health-in-all policies and intersectoral working will

require a systemic approach, and a clear differentiation between the core and the
wider public health workforce. Currently, the public health workforce in Europe is
not always well defined or regulated. Many countries do not even have a public
health workforce plan, despite facing challenges in recruiting and retaining public
health workers. As a first step, it will be essential that the public health workforce
possesses core competencies, but there is also a need to build leadership capacity.
Key messages on the public health workforce.

It is clear that future initiatives must take a holistic approach to the development
of the public health workforce, recognizing its heterogeneous and interdisciplinary
nature. However, unless a core workforce of public health professionals is
authorized, the potential of the wide public health workforce realized, and
comprehensive and effective public health structures are in place, public health will
continue to be weak and underfunded. Professionalization raises the profile of
public health, making the public health workforce more visible to policy-makers
and the population at large.
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Human Resource Management and Leadership for Public Health Purpose of

human resource management
The purpose of human resources management in public health is to select and
develop an engaged workforce capable of meeting organizational and community
goals.
A cycle of human resource management activities
● workforce planning
● job analysis
● recruitment and selection
● socialization and motivation
● on-boarding
● training and development
● coaching and performance appraisal
● promotion, transfer, or termination strategies to address public health
human resources challenge - "Aging" public health workforce
● strengthen the skills and competence of the existing workforce to fill the
experience void left as workers retire
● effectively prepare and recruit students and professionals from other
disciplines to enter and remain the practice of public health
● examine the working environment of public health agencies
● coordinate recruitment and retention effort to reduce duplication ana
maximize efficiency and effectiveness
Job analysis
● a purposeful, systematic process for collecting information on the
important workrelated aspects of a job
● job analysis must collect data about job content, job requirements, and job
context
Job description
a written description of the basic tasks, duties, and responsibilities required of an
employee holding a particular job.
factors affecting the recruitment of public health workers
● salary and benefits
● the supply of workers with the needed skills
● the strength of the private sector
● the responsiveness of the personnel system to changes in the marketplace
● the reputation of the organization
● the morale of the current workforce - the skill of those charged with
recruiting. adverse effect
● selection process for a particular job or group of jobs that result in the
selection of members of any racial, ethnic, or sex group at a lower rate than
members of other groups primacy vs. recency
● Primacy: people form a lasting first impression based upon the first contact
or the first few minutes of an encounter
● Recency: people may form lasting impressions from their last encounter or
final few minutes with an organization.
10 common errors made when interviewing candidates
● Failing to establish rapport with the applicant

● Asking direct instead of open-ended questions
● Asking questions that are too general
● Asking multiple questions within the same questions
● Failing to ask reflective questions
● Asking leading questions.
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Not allowing enough time for the applicant to respond to questions

● Asking questions that identify or single out a candidate's protected group
status
● Spending too much time talking
● Failing to demonstrate active listening.
factors for enhancing 'organizational commitment'
● belief in the goals and values of the organization

● willingness to exert considerable effort on behalf of the organization - desire
to continue work with the organization. managerial motivation model
● According to the Porter and Lawler model, employee effort is determined by

two factors:
(1) the value placed on certain outcomes by the individual, and
(2) the extent to which the person believes that his or her effort will lead to
attainment of these rewards.
● Other theories of successful managerial motivation also emphasize the role
of individual 'expectancy' with respect to the assigned job. If people are
assigned to tasks for which they lack capability, their expectancy for
accomplishment and resulting performance will be low.
Guidelines for positive reinforcement

● Don't reward every worker in the same way; differentiate rewards based on
performance.
● Do something. Non-action by managers also influences employee behavior,
but there may be negative consequences to non-action on performance.
● Tell the individual worker what he or she can do to receive positive
reinforcement.
● Tell the worker what he or she is doing wrong.
● Do not correct the worker in front of others.
● Make the consequences equal to the behavior; reward good workers and
counsel employees with unsatisfactory performance.
For the employee's success, organization should recognize the
followings - Performance improves most when clear goals are mutually
established.
● Coaching is at the core of every interaction every day.

● Coaching comes from supervisors, peers, and direct reports.
● The key element of organizational learning is individual learning, and
individual learning comes from many sources, one of which is coaching.
Professional development
- Development leads to greater job satisfaction by the employees, improved
morale, reduced turnover, and enhanced performance.
- The organization benefits from a staff with a breadth of skills, knowledge, and
attitudes. Creativity and ownership in the success of the organization come from
enhancement of the quality of the workforce.
phase of performance management
(1) Performance planning, where objectives, standards, competencies, and a
development plan are mutually determined.
(2) Performance execution, which involves the actual work being accomplished.
(3) Performance assessment, which includes both parties independently assessing
how the plan was achieved.
(4) Collection of data from other parties, such as subordinates, peers, or customers.
(5) Performance review, where the results are discussed.
(6) The renewal of the agreement or contract for the following performance period.
for the performance appraisal, four parts should be included
- employee's self-assessment of his or her performance ("How do you think things

are going?")
- supervisor's feedback ("let me provide you with feedback on how you are doing
relative to the goals")
employee's feedback on working with the supervisor ("What can I do to make you
more
successful in your position?")
- development of a plan ("So, this is your development plan for next year") common
errors in performance management
- Contrast effect: The employee is compared with another employee or employees.

- First impression error: An initial observation rules the supervisor's thinking even
though it is no longer applicable.
- Halo or horns effect: One aspect of the employee's performance is generalized to
the entire performance.
- Like me effect: The supervisors may rate employees who are similar to him or her
higher than others.
- Skews to the center, negative, and positive: The supervisor has a tendency to rate
employees in the middle, or at the high or low end of the scale.
- Attribution bias:The supervisor has a tendency to attribute failing to factors that
are under the control of the employee and successes to outside causes.
- Recent effect: The supervisor remembers the most recent event instead of the full
performance period.
- Stereotyping: The supervisor ignores the individual and generalizes across groups
or work units.
Hard skill vs. Soft skill
Hard skill: cutting edge technical skill critical to a discipline

Soft skill: skills that are not discipline specific, but rather are strategic in nature,
crossdisciplinary, or inter-professional context
Trait theory in leadership

- leadership depends on the personal qualities (mental, physical, or cultural
attributes) or traits of the leader
- However, research has failed to reveal individual traits that predict leadership
effectiveness or success or even to separate leaders from followers. Possession of
a specific trait does not guarantee leadership success. behavior leadership
-nearly anyone could learn the behaviors of leadership
- behavioral leadership has two dimensions: task/production oriented vs. people
oriented
- leadership is about the transaction between works and leaders Transformational
Leadership
leadership that, enabled by a leader's vision and inspiration, exerts significant

influence
Principled Leadership
- Leadership that aligns behaviors and values; principled leadership is about how
we influence others and what it is that were trying to change about them
- this leadership model is based on ethics and principles that embrace higher and
less self-centered values
Leadership vs. Management

- leadership is about the future and discontinuous or disruptive change that must
take place to ensure the organization's survival in the chaos
- management's focus is on the present, assuring that operations which support the
vision and mission are run efficiently and effectively.
Adaptive Leadership
- leadership is a relational, social process through which the leader first facilitates
stakeholders, communities and those responsible for issues—and carefully
defining their thoughts and feelings about an issue.
-
Competency categories that are necessary for public health leaderhsip
- core transformational
- political
- transorganizational
- tram-building crisis leadership competency Emotional Intelligence
- the ability to reason about emotions and to use emotions to enhance reasoning
- emotional intelligence is comprised of the personal-emotional-social components
of general intelligence.
- leaders set the EI culture of their organizations. This culture directly impacts staff
morale, turnover, relationships with colleagues and ultimately patient
relationships as well.
- 'Personal competence' is the foundation of emotional Intelligence, and is
comprised of self-awareness and self-management.
'Social competence' is the other half of EI, and grows out of a solid foundation in
personal competence.
Cultural Competence
- the ability to interact effectively with people of different cultures
- An understanding of how a patient's cultural background shapes his beliefs,
values, d expectations for therapy.
Essential elements of cultural competence

- valuing diversity
- having the capacity for cultural self-assessment
- being conscious of the dynamics inherent when culture interact
- having institutionalized culture knowledge
- having developed adaptations to service delivery reflecting an understanding of
cultural diversity.
-
Organizational Culture
- the set of values, ideas, attitudes, and norms of behavior that is learned and
shared among the members of an organization
- organizational culture impacts employee engagement, which in turn impacts
worker commitment and productivity.
PUBLIC HEALTH SURVEILLANCE AND STRATEGIC PLANNING IN PUBLIC HEALTH

Public health surveillance is the cornerstone of public health practice and can be
defined as the “… systematic, ongoing collection, management, analysis, and
interpretation of data followed by the dissemination of these data to public health
programs to stimulate public health action.”1 Stakeholders in the United States at
all levels of government (i.e., federal and state, territorial, local, and tribal [STLT]),
in academia and industry, and the general public rely on high-quality, timely
surveillance data to detect and monitor diseases, injuries, and conditions; assess
the impact of interventions; and assist in the management of large-scale disease
incidents. Surveillance data are crucially important to inform policy changes, guide
new program interventions, sharpen public communications, and help agencies
assess research investments.
The public health surveillance enterprise in the U.S. is a long-term partnership that
operates through thousands of agencies at the federal and STLT levels. The U.S.
Centers for Disease Control and Prevention (CDC) generally does not collect public
health surveillance information directly, but relies on state and local health
departments and other systems to do so. CDC, however, plays an important
collaborative role in aggregating, analyzing, and disseminating surveillance data;
creating tools for surveillance; providing technical assistance to states and
territories; researching surveillance policy; and funding surveillance activities. In
the past few years, observers inside and outside CDC have identified some of the
most important influences shaping surveillance in the 21st century (e.g., security
concerns, technological advances, and health-care reform) and how these
influences may affect the surveillance enterprise. Observers have touched on the
need for ongoing evaluation of surveillance systems; standardization, with the goal
of developing sustainable and integrated systems; and system and workforce
adaptability to current demands. These observers have recognized many
challenges that could impede progress, such as funding, workforce, information
technology standards, patient confidentiality, and concerns about data access,
quality, and sharing.1–3 For example, one fundamental challenge is the tension,
both at the federal and STLT levels, between the needs of the whole surveillance
enterprise and specific disease control programs, which require specialized
surveillance data and are organized and funded along disease-specific lines.
CDC's overarching goal for federally supported surveillance activities is to get the
right information into the right hands at the right time. In a fresh attempt to better
achieve this goal, and in response to the observations and recommendations of
experts,1–3 the agency launched the CDC Surveillance Strategy in February 2014.4
We describe the essential parts of the Strategy, which is not meant to be a national
surveillance strategy; rather, it focuses on what CDC must do to impel progress and
augment trust with the agency's surveillance partners in the field. It builds on
previous work inside and outside CDC to arrive at a vision of public health
surveillance for the 21st century.1–3 The Strategy outlines three goals and 10
specific aims to improve surveillance capabilities, outcomes, and public health. By
embracing the current challenges as opportunities, fixing what needs to be fixed,
and working closely with its STLT partners, CDC can help revitalize U.S. public health
surveillance.
THE CDC SURVEILLANCE STRATEGY

the Strategy addresses fundamental problems found through external review,
stakeholder consultations, and internal assessments. Specific aims are contained
within each of the three goals. Goal 1 focuses on establishing new structures, Goal
2 on processes, and Goal 3 on improvements in public health surveillance
outcomes that can be accomplished relatively quickly. CDC aims to rapidly improve
its activities in the short term, while laying the groundwork for ongoing evaluation
and modification of surveillance systems in the long term. The Strategy will guide
CDC efforts to make U.S. surveillance systems more adaptable to rapidly changing
technology, more versatile in addressing evolving health threats, more adept at
accessing and leveraging health-care data, and more capable of meeting demands
for timely, population-specific, and geographically specific information. The
Strategy also facilitates work to consolidate surveillance systems, eliminate
unnecessary redundancies, reduce reporting burden, and improve data availability,
quality, and timeliness for all stakeholders.
Public health surveillance is the cornerstone of public health practice and can be
defined as the “… systematic, ongoing collection, management, analysis, and
interpretation of data followed by the dissemination of these data to public health
programs to stimulate public health action.”1 Stakeholders in the United States at
all levels of government (i.e., federal and state, territorial, local, and tribal [STLT]),
in academia and industry, and the general public rely on high-quality, timely
surveillance data to detect and monitor diseases, injuries, and conditions; assess
the impact of interventions; and assist in the management of large-scale disease
incidents. Surveillance data are crucially important to inform policy changes, guide
new program interventions, sharpen public communications, and help agencies
assess research investments.
The public health surveillance enterprise in the U.S. is a long-term partnership that
operates through thousands of agencies at the federal and STLT levels. The U.S.
Centers for Disease Control and Prevention (CDC) generally does not collect public
health surveillance information directly, but relies on state and local health
departments and other systems to do so. CDC, however, plays an important
collaborative role in aggregating, analyzing, and disseminating surveillance data;
creating tools for surveillance; providing technical assistance to states and
territories; researching surveillance policy; and funding surveillance activities. In
the past few years, observers inside and outside CDC have identified some of the
most important influences shaping surveillance in the 21st century (e.g., security
concerns, technological advances, and health-care reform) and how these
influences may affect the surveillance enterprise. Observers have touched on the
need for ongoing evaluation of surveillance systems; standardization, with the goal
of developing sustainable and integrated systems; and system and workforce
adaptability to current demands. These observers have recognized many
challenges that could impede progress, such as funding, workforce, information
technology standards, patient confidentiality, and concerns about data access,
quality, and sharing.1–3 For example, one fundamental challenge is the tension,
both at the federal and STLT levels, between the needs of the whole surveillance
enterprise and specific disease control programs, which require specialized
surveillance data and are organized and funded along disease-specific lines.
CDC's overarching goal for federally supported surveillance activities is to get the
right information into the right hands at the right time. In a fresh attempt to better
achieve this goal, and in response to the observations and recommendations of
experts,1–3 the agency launched the CDC Surveillance Strategy in February 2014.4
We describe the essential parts of the Strategy, which is not meant to be a national
surveillance strategy; rather, it focuses on what CDC must do to impel progress and
augment trust with the agency's surveillance partners in the field. It builds on
previous work inside and outside CDC to arrive at a vision of public health
surveillance for the 21st century.1–3 The Strategy outlines three goals and 10
specific aims to improve surveillance capabilities, outcomes, and public health. By
embracing the current challenges as opportunities, fixing what needs to be fixed,
and working closely with its STLT partners, CDC can help revitalize U.S. public health
surveillance.
THE CDC SURVEILLANCE STRATEGY

As shown in Figure 1, the Strategy addresses fundamental problems found through
external review, stakeholder consultations, and internal assessments. Specific aims
are contained within each of the three goals. Goal 1 focuses on establishing new
structures, Goal 2 on processes, and Goal 3 on improvements in public health
surveillance outcomes that can be accomplished relatively quickly. CDC aims to
rapidly improve its activities in the short term, while laying the groundwork for
ongoing evaluation and modification of surveillance systems in the long term. The
Strategy will guide CDC efforts to make U.S. surveillance systems more adaptable
to rapidly changing technology, more versatile in addressing evolving health
threats, more adept at accessing and leveraging health-care data, and more
capable of meeting demands for timely, population-specific, and geographically
specific information. The Strategy also facilitates work to consolidate surveillance
systems, eliminate unnecessary redundancies, reduce reporting burden, and
improve data availability, quality, and timeliness for all stakeholders.
Specific aims of goal 1: establishing new structures
The Surveillance Leadership Board, comprising senior CDC leaders, was established
in July 2014 to review, guide, and oversee the evolution of CDC surveillance
systems in accordance with the overall Strategy and established
recommendations.1–3 The Board, which is chaired by CDC's Deputy Director for
Public Health Scientific Services, is expected to boost accountability to policy
makers and public health partners. Rotating members are appointed from CDC
operating divisions responsible for disease, injury, and condition surveillance.
Initially, the Board is focusing on optimizing CDC investments in surveillance
systems infrastructure by
(1) assuring coordination among partners,
(2) making transparent recommendations,
(3) harmonizing CDC's efforts to work with health information technology (HIT)
standards development organizations,
(4) streamlining requests for public health reporting functionality in commercial
electronic health record (EHR) systems,
(5) monitoring new system implementation progress, (6) facilitating the use of best
surveillance practices, and
(7) evaluating overall Strategy implementation progress.
CDC developed a federal and STLT workforce training and support plan in October
2014 that integrates Strategy goals with CDC workforce investments. This plan
supports improved training of surveillance practitioners on new data sources, new
technologies used by clinical health-care providers, and new commercial,
governmental, and opensource surveillance system products. It addresses the
short-term training needs of public health practitioners, but also looks forward to
longer-term training and support of the surveillance workforce.
CDC created the CDC Health Information Innovation Consortium (CHIIC) in May
2014 to foster and promote creative solutions to surveillance challenges across
CDC programs and in STLT agencies.5 This consortium aims to improve the
availability, quality, and timeliness of surveillance data by accelerating the use of
new tools and approaches. The CHIIC acts as a collaborative forum for sharing
successes, learning from failures, and ensuring that informatics innovations are
connected to current national HIT standards and policy framework. Specific aims
of goal 2: processes
The incorporation of new HIT tools and approaches by CDC and STLT partners can
be improved through more effective policy and vendor engagement and through
support of innovative projects. CDC has established two senior-level positions in
the Office of Public Health Scientific Services to improve HIT policy engagement:
the Chief Public
Health Informatics Officer and the Senior Policy Advisor for Public Health Scientific
Services. These leaders work with the Surveillance Leadership Board and CDC's
various centers and offices, as well as other federal and STLT agencies, to
contribute to surveillance-related HIT policy efforts. CDC is increasing its
engagement with the Office of the National Coordinator for HIT (ONC) and other
federal information technology regulators, specifically through increased
interaction with the Department of Health and
Human Services HIT Policy Committee and developers of the Federal Health
Information Technology Strategic Plan, 2011–2015.6 CDC actively participated in
crafting the most recent version of the Strategic Plan. CDC is also collaborating on
projects with ONC to further STLT health agencies' capacity to implement HIT
strategies.
CDC developed a forum in June 2014 to systematically engage HIT and EHR vendors
regarding informatics technologies and tools that can advance surveillance systems
and practice.7 Vendor engagement provides opportunities for CDC programs and
STLT agencies to better communicate their needs to HIT and EHR vendors. In June
2014, CDC also began providing seed funding and technical support for small
innovation project awards to advance innovations in data collection, transport,
storage, analysis, visualization, and availability.
Specific aims of goal 3: improvements in public health surveillance outcomes To

demonstrate early success, CDC is pursuing four crosscutting initiatives intended
to improve existing, widely applicable platforms or tools that can benefit STLT
agencies and CDC programs. For example, CDC is creating robust, integrated
platforms that can be adapted for new surveillance needs. Figure 2 summarizes
these initiatives, their performance metrics, and how they address the specific aims
of the Strategy.
The National Notifiable Diseases Surveillance System (NNDSS) was established to

monitor the occurrence and spread of diseases and conditions voluntarily reported
by STLT agencies to CDC.8 NNDSS provides the infrastructure, standards, and
incentives for rapid electronic reporting of surveillance data for notifiable
conditions. NNDSS is used by numerous stakeholders to provide accurate and
timely information for surveillance and response. An important component of
NNDSS is the National Electronic Disease Surveillance System,9 which is used to
facilitate data collection and reporting. In response to stakeholders' needs and
evolving technologies, the NNDSS Modernization Initiative seeks to enhance
surveillance capabilities by standardizing the exchange, processing, and
provisioning of surveillance data.
The BioSense program provides data for public health officials to monitor and
respond to possible disease and hazardous conditions. It is an electronic
surveillance system with standardized tools and procedures for rapidly collecting,
sharing, and evaluating emergency department and other health-care-related
data. A recent internal review highlighted the potential of BioSense, particularly
regarding the increasing use of EHR, strengthening health-care partnerships,
extending surveillance practices and methods, and reducing costs. The BioSense
Enhancement Initiative builds on past successes, fixes problems, and improves the
ability of public health agencies to analyze, compare, and act on program data.
Electronic laboratory reporting (ELR) to public health agencies can improve

surveillance for reportable diseases and conditions by improving report timeliness
and completion. At the end of July 2013, approximately 62% of 20 million laboratory
reports were received electronically, compared with 54% in 2012.13 This third
initiative focuses on accelerating the adoption of ELR through collaboration among
clinical laboratories, laboratory information management system vendors, and
public health agencies.
Finally, modernizing and transforming the National Vital Statistics System (NVSS)
into a system capable of supporting near-real-time public health surveillance has
been a longstanding need. This fourth initiative focuses on the substantial mortality
surveillancerelated efforts needed to fully realize NVSS's potential as a surveillance
tool.
PUBLIC HEALTH SURVEILLANCE IMPLICATIONS
During the next 3–5 years, the CDC Surveillance Strategy will increasingly guide
program and agency-wide surveillance activities. Through it, the agency aims to use
its resources more efficiently and valuably for all stakeholders. By reducing the
number of standalone systems and increasing the use of robust, integrated
platforms, CDC seeks to increase functionality and decrease unnecessary
redundancies and reporting burdens on STLT agencies. By leveraging emerging
technologies in a more coordinated fashion with public health partners, CDC strives
to realize the vision of a digital infrastructure that provides data and information
to those who need it, when they need it, and in a form that enables them to act
upon it.
PERFORMANCE MANAGEMENT IN PUBLIC HEALTH AND ENGAGING IN

COMMUNITIES AND BUILDING CONSTITUENCIES IN PUBLIC HEALTH
Population-based health improvements that require behavioral and social change
at the community level are dependent on effective constituency participation. To
achieve needed constituency involvement, a public health leader must understand
what motivates and moves constituents to action on public health issues. This
article provides a framework and guidance on building effective constituent
involvement to achieve community health improvement. Within this framework,
aspects of managing the organizational practice of constituency building and
community engagement are discussed and linked with current public health
planning and mobilization models that support community-based health
interventions.
A Community Health Improvement Process

Many factors influence health and well-being in a community, and many entities
and individuals in the community have a role to play in responding to community
health needs. The committee sees a requirement for a framework within which a
community can take a comprehensive approach to maintaining and improving
health: assessing its health needs, determining its resources and assets for
promoting health, developing and implementing a strategy for action, and
establishing where responsibility should lie for specific results. This chapter
describes a community health improvement process that provides such a
framework. Critical to this process are performance monitoring activities to ensure
that appropriate steps are being taken by responsible parties and that those
actions arhaving the intended impact on health in the community. The chapter also
includes a discussion of the capacities needed to support performance monitoring
and health improvement activities.
In developing a health improvement program, every community will have to

consider its own particular circumstances, including factors such as health
concerns, resources and capacities, social and political perspectives, and
competing needs. The committee cannot prescribe what actions a community
should take to address its health concerns or who should be responsible for what,
but it does believe that communities need to address these issues and that a
systematic approach to health improvement that makes use of performance
monitoring tools will help them achieve their goals.
PROPOSING A PROCESS FOR COMMUNITY HEALTH IMPROVEMENT
The committee proposes a community health improvement process (CHIP) 1 as a

basis for accountable community collaboration in monitoring overall health
matters and in addressing specific health issues. This process can support the
development of shared community goals for health improvement and the
implementation of a planned and integrated approach for achieving those goals.
A CHIP would operate through two primary interacting cycles, both of which rely
on analysis, action, and measurement. The elements of a CHIP are illustrated in
Figure 4-1. Briefly, an overarching problem identification and prioritization cycle
focuses on bringing community stakeholders together in a coalition, monitoring
community-level health indicators, and identifying specific health issues as
community priorities. A community addresses its priority health issues in the
second kind of CHIP cycle—an analysis and implementation cycle. The basic
components of this cycle are analyzing a health issue, assessing resources,
determining how to respond and who should respond, and selecting and using
stakeholder-level performance measures together with community-level
indicators to assess whether desired outcomes are being achieved. More than one
analysis and implementation cycle may be operating at once if a community is
responding to multiple health issues. The components of both cycles are discussed
in greater detail below.
The actions undertaken for a CHIP should reflect a broad view of health and its
determinants. The committee believes that the field model (Evans and Stoddart,
1994), discussed in Chapter 2, provides a good conceptual basis from which to trace
the multifactorial influences on health in a community. A CHIP must also
The CHIP acronym adopted for this report is not unique to the community health
improvement process. In a health context, others use it to refer to community
health information programs/partnerships/profiles. See, for example, the
discussion of MassCHIP—the Massachusetts Community
The committee anticipates that communities will adopt their own designations for
their local community health improvement process.
SOCIAL MARKETING AND CONSUMERS-BASED APPROACHES IN PUBLIC HEALTH
Social marketing is used to address a broad range of health issues, including

improving nutrition, decreasing injuries, responding to infectious disease
outbreaks, and reducing risk factors that contribute to chronic diseases. It can be
used in both developing and highly developed countries and settings.
Social marketing as a public health intervention involves applying marketing
principles and practices to address challenges to population health for the purpose
of:
● Influencing health-related behaviors
● Promoting the adoption of new health-related products or services
● Making changes to social, environmental, economic, and policy factors
influencing people’s health (Andreasen 1995; Cheng et al. 2009; Daniel et al.
2009; Evans 2006).
Social marketing can be used in both developing and highly developed countries
and settings to address a broad range of public health topics, including but not
limited to:
● Improving nutrition
● Decreasing injuries
● Responding to infectious disease outbreaks
Reducing risk factors that contribute to chronic diseases

Many public health interventions use social marketing for outreach or engagement
with people in their communities. Other interventions may include activities
conducted in health-care settings, often to increase access to or improvement to
standard of living of the people in the community.
Social marketing, the use of marketing to design and implement pro-grams to
promote socially beneficial behavior change, has grown in popularity andusage
within the public health community. Despite this growth, many public
healthprofessionals have an incomplete understanding of the field. To advance
current knowl-edge, we provide a practical definition and discuss the conceptual
underpinnings ofsocial marketing. We then describe several case studies to
illustrate social marketing’sapplication in public health and discuss challenges that
inhibit the effective and efficientuse of social marketing in public health. Finally,
we reflect on future developments inthe field. Our aim is practical: to enhance
public health professionals’ knowledge ofthe key elements of social marketing and
how social marketing may be used to planpublic health interventions.
HEALTH EDUCATION, AND HEALTH PROMOTION, EVIDENCE-BASED PUBLIC
HEALTH
This review examines evidence-based practice (EBP) in health education and

promotion with a focus on how academically trained health educators develop EBP
skills and how health education and promotion practitioners access the literature
to inform their activities. Competencies and credentialing in health education
related to evidence-based practice are outlined and sources for evidence-based
practice literature in health education and promotion are described. An
exploratory questionnaire to consider teaching and resources in evidence-based
practice was distributed to faculty and librarians from the top 10 ranked health
education doctoral programs. Findings highlighted the integral value of EBP
instruction to the curriculum. Growth opportunities in evidence-based health
education and health promotion for instructors, practitioners, and librarians
include promotion and expansion of online evidence-based public health resources
to close the evidence-practice gap.
Health Education
Health education is one strategy for implementing health promotion and disease
prevention programs. Health education provides learning experiences on health
topics. Health education strategies are tailored for their target population. Health
education presents information to target populations on particular health topics,
including the health benefits/threats they face, and provides tools to build capacity
and support behavior change in an appropriate setting.
Examples of health education activities include:
Lectures
Courses
Seminars
Webinars
Workshops
Classes Characteristics of health education strategies include:
Participation of the target population.

Completion of a community needs assessment to identify community capacity,
resources, priorities, and needs.
Planned learning activities that increase participants' knowledge and skills.
Implementation of programs with integrated, well-planned curricula and materials
that take place in a setting convenient for participants.
Presentation of information with audio visual and computer-based supports such

as slides and projectors, videos, books, CDs, posters, pictures, websites, or
software programs.
Ensuring proficiency of program staff, through training, to maintain fidelity
to the program model. Examples of Health Education Interventions SLV
N.E.E.D. (Naloxone Education Empowerment Distribution
Program), implemented by the San Luis Valley Area Health Education
Center (SLVAHEC) provided educational sessions to providers and
community stakeholders on addressing opioid abuse.
Community health workers (CHWs) may deliver health education to the target
population. Examples of how CHWs support health education interventions are
available in the Community
Health Workers Toolkit.

Health education is also used in care coordination to address barriers to care. A
health educator is one type of care coordinator who deliver education to
individuals, families, and communities. Additional information is available in the
Rural Care Coordination Toolkit.
Considerations for Implementation

Health education activities should enhance the overall goal of the health promotion
and disease prevention program. Materials developed for health education
programs must be culturally appropriate and tailored to the target populations to
ensure cultural competence. In rural communities, this means addressing cultural
and linguistic differences, and addressing potential barriers to health promotion
and disease prevention in rural areas.
Health Promotion
Health promotion became a more independent stream within traditional public
health in the second half of the twentieth century. The key concept of health
promotion, as highlighted by the WHO (1984), has five principles:
1. actively involves the population in everyday-life settings;

2. directed towards action on the causes (determinants) of illhealth;
3. uses five strategic approaches that aim to influences and effect change at
the individual, community and organizational / policy levels, including
education, information, community development and legislation;
4. public participation and empowerment; and
5. key roles played by health workers, particularly in primary health. This
resulted in The Ottawa Charter for Health Promotion (Health & Welfare
Canada., 1986) which recognized that: "The fundamental conditions and
resources for health are peace, shelter, education, food, income, a stable
ecosystem, sustainable resources, social justice, and equity." Health
promotion is considered to be distinct from the New Public Health "by
emphasizing the wider social influences upon collective and individual
health".
In order to illustrate how these five principles outlined by the WHO are
interrelated, here are the provided model of health promotion in the mid-1980s
which comprises three overlapping areas:
1. health education;
2. prevention of ill health; and
3. health protection
MANAGEMENT AND PRACTICE AND SOCIAL ENTREPRENEURSHIP AND PUBLIC

HEALTH
Health care is one of the largest sector in terms of revenue and employment. It
comprises hospitals, medical devices, tele-medicine, medical tourism, health
insurance and medical equipment. Health care is provided by public and private
institutions. As the role of government is very much limited, private sector
enterprises play a major role in health care. Entrepreneurship is closely associated
with Business, technology and products. Social entrepreneurs are those who
combine business practices with social service with the combined motives of
service and profit. Social entrepreneurs play a great role in health care
development and improvement, as government and market failed to meet basic
health needs. Social entrepreneurship is the key to unlock the potential in health
care sector to ensure huge benefits to disadvantaged sections and underprivileged.
This paper is an attempt to analyse the opportunities for social entrepreneurship
in health care development and examine existing social entrepreneur models in
health care delivery at global level and national level. It also throws light on some
of the social entrepreneurs work in health care development.
Right to health is a fundamental right. Physical and mental well-being are
synonymous with economic development. Six of the eight broad targets for the
Millennium Development Goals and most of the Sustainable Development Goals
are directly related to health. Millennium Development Goals (2015) stated that
―millions of poor people still live in poverty and hunger without access to basic
services‖ such as health care, clean water, and sanitation. The new Sustainable
Development Goals adopted by the United Nations for 2016-2030 aim to eradicate
poverty; improve health and wellbeing; and provide access to clean water,
sanitation, and affordable and clean energy.
Health care is one of the largest sector in terms of revenue and employment. It
comprises hospitals, medical devices, telemedicine, medical tourism, health
insurance and medical equipment. Health care is provided by public and private
institutions. As the role of government is very much limited, private sector
enterprises play a major role in health care.
To ensure ―Health for All‖ government authorities confront various challenges

due to the large size of the country and diversity of its population in
socialeconomic, regional and cultural terms. Health care in India is provided by
Public authorities in parallel with private sector. Urban and rural households use
private medical sector more than public sector.
NEED FOR SOCIAL ENTREPRENEURSHIP IN HEALTH SECTOR:

Entrepreneurship is commonly associated with businesses, technology and
products. A Business entrepreneur measures performance in profit and return but
a social entrepreneur measures the positive returns to society. The main aim of
social entrepreneur is to broaden social, cultural and environmental goals (Singh,
2012) The defining characteristic of social entrepreneurs is their application of
business and entrepreneurial approaches to solving social problems among
disadvantaged populations.
Social entrepreneurs are change makers, who harness the power of markets and
create social impact with combined motives of service and profit. They create
enduring sustainable impact with for profit social ventures across sectors like
financial inclusion, livelihoods, education, affordable housing, renewable energy,
waste management, water and sanitation, and health care.
Social entrepreneurs play a crucial role in health care development as government

efforts alone are usually insufficient to ensure equitable health care for all. To
improve health care, social entrepreneurs are working along with government and
Nongovernment Organization (NGO). But unlike NGOs, social entrepreneurs do not
rely on charity for financing their project, rather they strive to become selfsufficient
by developing viable business models and taking financial risks. Social
entrepreneurs have emerged where governments and markets have failed to meet
basic health needs. Social entrepreneurs address multiple aspects of health
delivery—from individual health care needs to population health, from health care
professional capacity building to environmental health threats.
Several Healthcare organizations that engage in social entrepreneurship develop

health technologies for developing countries, improve child and maternal health,
restore broken health systems, and fight infectious diseases like tuberculosis,
malaria, and HIV/AIDS worldwide using cost-effective tools are working for the
advantage of poor and underprivileged communities.
Florence Nightingale is a typical example of social entrepreneur who completely
changed hospital practices and brought professionalism to nursing through her
uncommon determination and meticulous attention to detail. It is an example to
social entrepreneurship in health sector and urged a need to address and mitigate
the problems of HIV/AIDs, aging disability, reproductive and mental health.
(Drayton, 2006).
SOCIAL ENTERPRISE IN HEALTH AROUND THE GLOBE:
Social entrepreneurship utilizes effective business practices combined with social

and cultural awareness to change the lives of those in need. There are millions of
people in rural and poor communities suffering from lack of access to proper health
care. Social ventures go a long way to providing necessary interventions to increase
health awareness. The following examples of non-profit health organizations are
making a positive social impact all over the world.
PATH: It is an international non-profit health organization, with more than 70

offices around the world. It is known for developing and adapting latest
technologies, such as improved vaccination devices and new tools to prevent
cancer, to address health needs of developing countries. In addition to this it works
in partnership with governments and businesses to solve the health issues like
AIDs, tuberculosis, malaria and provide basic vaccination and access to health
technologies to the poor communities and work towards greater health equity for
women. Its vision is ―a world where innovation ensures that health is within reach
for everyone‖ and mission is ―to improve the health of people around the world
by advancing technologies, strengthening systems and encouraging healthy
behavior.
Unite for sight: It is a non-profit organization founded by Jenifer Staple –Clark in

2000 conducts programs in India, Honduras and Ghana performed over 99000
surgeries to those have vision impairment. It also conducts training programmes to
educate local communities to eradicate preventable blindness. It works through
experienced social entrepreneurs in partnership with local eye clinics, community
leaders, government bodies and hospitals to provide quality care to those live in
villages and live in poverty.
CHALLENGES FOR SOCIAL ENTREPRENEURS IN HEALTH SECTOR:
Problems of social entrepreneurs can be similar to the problems faced by their

counterparts in business sector. Some of them are as under.
Lack of financial Sources: Lack of financial source is the major challenge faced by
social entrepreneurs. Generally, they have run their business by investing their own
funds or from borrowings at high interest rates.
Rural vs. Urban Divide: A staggering 70% of the population still lives in rural areas
with limited access to hospitals and clinics and relies on alternative medicines and
government programs in rural health clinics. In contrast, the urban
centres have numerous private hospitals and clinics that provide quality health
care.
Demand for Basic Primary Health care and Infrastructure: Basic infrastructure,
especially in rural areas is still lacking, with respect to sanitation and water
management.
Lack of support from government: Lack of government support is a major hindrance

to the development of social entrepreneurs. Government is not providing any kind
of support for promoting social cause ventures. Policies and regulations of
government are rigid and complex, with no tax incentives or subsidies.
DISASTER PREPAREDNESS AND PUBLIC HEALTH RESPONSE AND PUBLIC HEALTH

AND HEALTH CARE QUALITY
Disaster preparedness is an area of study in public health that instructs the public
on how to prepare for disasters, both manmade and natural. The emphasis is on
developing proactive approaches to public health and disasters as opposed to a
general reactive approach. Disaster preparedness can work on a local, state,
national or even global scale, with different organizations working together to
ensure public safety and well-being.
What is deemed as an emergency or disaster?

A situation becomes an emergency or disaster when the magnitude of health
consequences has the potential to overwhelm a community in a situation not
routinely encountered.
● Bioterrorism
● Chemical emergencies
● Radiation emergencies
● Mass casualties
● Disasters and severe weather
● Outbreaks and incidents
What constitutes preparedness?

A recent article (CITE) suggests preparedness requires a community to have a
planned and coordinated rapid-response capability. This includes:
● Health risk assessment. Identify the hazards and vulnerabilities (e.g.,
community health assessment, populations at risk, highhazard industries,
physical structures of importance) that will form the basis of planning.
● Legal climate. Identify and address issues concerning legal authority and
liability barriers to effectively monitor, prevent or respond to a public health
emergency.
● Roles and responsibilities. Clearly define, assign and test responsibilities in
all sectors, at all levels of government and with all individuals, and ensure
each group’s integration.
● Incident command system. Develop, test and improve decision making and
response capability using an integrated incident command system (ICS) at all
response levels.
● Public engagement. Educate, engage and mobilize the public so people can
be full and active participants in public health emergency preparedness.
● Epidemiology functions. Maintain and improve the systems to monitor,
detect and investigate potential hazards, particularly those that are
environmental, radiological, toxic or infectious.
● Laboratory functions. Maintain and improve the systems to test for potential
hazards, particularly those that are environmental, radiological, toxic or
infectious.
● Countermeasures and mitigation strategies. Develop, test and improve
community mitigation strategies (e.g., isolation and quarantine, social
distancing) and countermeasure distribution strategies when appropriate.
● Mass healthcare. Develop, test and improve the capability to provide mass
healthcare services.
● Public information and communication. Develop, practice and improve the
capability to rapidly provide accurate and credible information to the public
in culturally appropriate ways.
Robust supply chain. Identify critical resources for public health emergency
response and practice and improve the ability to deliver these resources
throughout the supply chain. Expert and fully staffed workforce:
Operations-ready workers and volunteers. Develop and maintain a public health

and healthcare workforce with the skills and capabilities to perform optimally in a
public health emergency.
Leadership. Train, recruit and develop public health leaders to mobilize resources,
the public.
Accountability and quality improvement:

Testing operational capabilities. Practice, review, report on and improve public
health emergency preparedness by regularly using real public health events,
supplemented with drills and exercises when appropriate. Perfor mance
management. Implement a performance management and accountability system.
Financial tracking:
Develop, test and improve charge capture, accounting and other financial systems
to track resources and ensure adequate and timely reimbursement.
engage the community, develop interagency relationships and communicate with

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JOINT PROFESSIONALS TRAINING AND SUPPORT INTERNATIONAL

2, Tokunbo Alli Street, Ikeja Lagos

2, Tokunbo Alli Street, Ikeja Lagos

Tel: 01- 3427217, 08132733378

E-mail: inquiries@jptsonline.org , chrisafety@jptsng.org

PUBLIC HEALTH CARE

History provides a perspective to develop an understanding of health problems of

societal beliefs influenced approaches to explaining and attempting to control

Scientific controversies, such as the contagionist and anticontagionist disputations

The evolution of public health is a continuing process; pathogens change, as do the

• Population Health refers to the physical, mental, and social well-being of

THE IMPACT OF PUBLIC HEALTH ON POPULATION HEALTH

• Control of infectious diseases (from clean water and improved sanitation,

What are the social determinants of health?

The following is a list of fourteen social determinants of health:

Income and Income Distribution

Examples of Social Determinants of Health

Job opportunities and access to job training

social disorder Access to public transportation.

Organization of the public health system and Professionalism and Ethics in

the Public Health

Additional article information

Challenges in the delivery of health care, prevention of disease, promotion of

The Association of Schools of Public Health (ASPH) has identified professionalism—

The development of competencies for professionalism in public health coincides

This article presents an overview of issues and approaches that can be

APPROACHES TO PUBLIC HEALTH ETHICS

Approach 1: values inherent in public health practice

Approach 2: concepts and language of bioethics

example, virtues—the morally valuable character traits of an individual8—are

FRAMEWORKS FOR CONCEPTUALIZING ETHICAL ISSUES IN PUBLIC HEALTH

Political science framework

Social justice framework

Professional guidance for ethical issues

Recognition of an ethical concern or problem is the first step of the decision-making

CHALLENGES TO TEACHING ETHICS AND PROFESSIONALISM IN THE PUBLIC

In developing competencies for ethics and professionalism, ASPH uses ethics as a

Whether personal morality can be taught within an academic discipline is a

“professionalism,” with competency in ethical decision-making, can be taught

TEACHING THE PROFESSIONALISM COMPETENCIES: THE UNIVERSITY OF TEXAS

Public health professionals confront ethical dilemmas routinely in public health

PUBLIC HEALTH LAW AND PUBLIC HEALTH POLICY

The team assists governments to defend implementation of WHO guidance in the

TYPES OF PUBLIC HEALTH LAW AND POLICY

Three Types of Public Health Law and Other Public Policy

Each branch of government executive, legislative, and judicial makes contributions

Regulations. These are rules, procedures, and administrative codes often

What are the public health laws in Nigeria?

What are the public health laws in Nigeria?

● The Quarantine Act of 1926 - regulates the control and prevention of

PUBLIC HEALTH FINANCE AND PUBLIC HEALTH WORKFORCE

WHO’s approach to health financing focuses on core functions:

revenue raising (sources of funds, including government budgets, compulsory

Who is the public health workforce?

To achieve intersectorality and deliver on health-in-all policies it will be necessary

A formally recognized core of public health professionals is still required to

Developing the public health workforce

It is instructive that of the nine countries covered in the accompanying volume

In most European countries, there seems to be a contradiction between the