Modern Public Health Systems: Core Functions & Evolution

1. King Saud UniversityCollege of Business AdministrationDepartment of Health Administration Masters` Program PA 507 –Introduction to Public Health First Semester 1437/ 1438 Mohammed S. Alnaif, Ph D.alnaif@ksu.edu.sa Dr. Mohammed Alnaif

2. MODERN PUBLIC HEALT H SYSTEMS Learning Objectives List and define the three core functions of public health. Define the meaning of populationin the context of public health. Describe how the social - ecological model is important when considering public health efforts of prevention. Name the three levels of prevention in public health and explain how they differ. Dr. Mohammed Alnaif

3. MODERN PUBLIC HEALT H SYSTEMS Outbreaks of cholera, dysentery, and typhoid fever were not uncommon in the world at the beginning of the nineteenth century. The challenging social and economic conditions of the time, including overcrowding, lack of a clean public water supply, lack of waste disposal systems, and a general lack of public hygiene played a large part in the high incidence of these diseases. Dr. Mohammed Alnaif

4. MODERN PUBLIC HEALT H SYSTEMS Over time, however, the development of public health systems, including a public water and sanitation system; the establishment of government public health departments; and the development and distribution of vaccines, led to a dramatic decrease in the incidence of these preventable diseases. Today, these infectious diseases no longer pose significant public health problems in most countries. As this historical account illustrates, public health systems are vital to the prevention of many health issues that directly affect our health and well – being. Dr. Mohammed Alnaif

5. MODERN PUBLIC HEALT H SYSTEMS The underlying goal of public health is the prevention of disease, and throughout this chapter we will emphasize how the structure and function of public health systems are designed with this goal in mind. The threecore functions of public health, assessment, policydevelopment, and assurance, form the foundation of all public health activity in all countries. Dr. Mohammed Alnaif

6. MODERN PUBLIC HEALT H SYSTEMS Public Health’s Three Core Functions There are similarities between the field of publichealth and the field of medicine. In the same way that physicians in the medical field attempt to diagnose and treat diseases in individuals, public health officials make efforts to identify and diagnose health problems in the population, define policies that will treat the problem, and then follow up on the health of the population to make sure the treatment is working effectively. Dr. Mohammed Alnaif

7. MODERN PUBLIC HEALT H SYSTEMS Public Health’s Three Core Functions The three core functions of public health are assessment, policy development, and assurance. These functions were laid out and defined by the Institute of Medicine over twenty years ago in order to clarify public health’s role in society. Assessment Through the process of assessment, the public health community works to identify and understand social and other issues, such as the environment, that affect our health. Dr. Mohammed Alnaif

8. MODERN PUBLIC HEALT H SYSTEMS Public Health’s Three Core Functions Assessmententails gathering information about a health problem in order to create a clear picture of the situation that needs to be addressed, its potential causes, and which groups of people are most affected. Once a public health issue has been fully assessed, the public health community can use the information to decide whether it is a top priority that should be addressed. If so, officials need to generate a plan to solve the problem, and the process continues into the second core function: policy development. Dr. Mohammed Alnaif

9. MODERN PUBLIC HEALT H SYSTEMS Public Health’s Three Core Functions Policy Development After a public health issue has been assessed, officials can make decisions about the best way to address the issue and begin the process of problem solving. Policy development is the process of formulating the best strategy to approach a public health problem and implementing the new program or law. During policy development, the importance of the issue being addressed in comparison to other urgent public health issues, the availability of resources, and the feasibility of solving the problem all must be considered. Dr. Mohammed Alnaif

10. MODERN PUBLIC HEALT H SYSTEMS Public Health’s Three Core Functions Policy Development If the problem is deemed a priority with a realistic solution, then a specific plan can be created and resources can be mobilized to carry it out. Policy development is an inherently government – driven process because new laws and public money are often required to carry out the plan or policy. After new programs and policies are created and implemented, it is essential to make sure that they are executed effectively. This leads us to the third core function of public health: assurance. Dr. Mohammed Alnaif

11. MODERN PUBLIC HEALT H SYSTEMS Public Health’s Three Core Functions Assurance Through the first two core functions, assessment and policy development, a public health issue is first clearly described and a program is designed and implemented to address it. The final step is to assure that public money and resources are being used responsibly to carry out the plan and that the success of public health programs are monitored so they can be changed or discontinued as deemed appropriate. This step is called assurance, and it is an ongoing function that loops back into the process of assessment and policy development. Dr. Mohammed Alnaif

12. MODERN PUBLIC HEALT H SYSTEMS Public Health’s Three Core Functions Assurance For example, during the assessment of a public health issue, public health officials may discover that an existing program is doing little to solve the issue or, even worse, may be exacerbating the problem. In this case, assessment and assurance overlap and in turn inform the development of new policies to replace current programs. Figure 2.1 illustrates the cycle of assessment, policy development, and assurance. Dr. Mohammed Alnaif

13. FIGURE 2.1 Public Health Core Functions and Ten Essential Services • Monitor health • Diagnose and investigate Assessment • Inform, educate, empower • Mobilize community partnerships • Develop policies Policy Development Research • Enforce laws • Evaluate • Link to or provide care • Assure a competent workforce Assurance Dr. Mohammed Alnaif

14. MODERN PUBLIC HEALT H SYSTEMS The Three Core Functions in Action A Real - Life Example: Obesity in the United States First Core Function: Assessment Through data gathered in national surveys in the late 1990s, public health researchers learned that the prevalence of obesity and overweight had increased dramatically over the past few decades among both children and adults. Second Core Function: Policy Development to address the public health and economic challenges posed by the increased prevalence of overweight and obesity in the United States, Congress established the Nutrition, Physical Activity and Obesity Program (NPAO) in 1999. Dr. Mohammed Alnaif

15. MODERN PUBLIC HEALT H SYSTEMS The Three Core Functions in Action Second Core Function: Policy Development The program is administered through the Centers for Disease Control and Prevention (CDC), and funding is distributed to participating states. The goal of NPAO is to help states address the problems of poor nutrition and physical inactivity and reduce the burden of obesity and associated chronic diseases by employing evidence – based programs for increasing physical activity, increasing consumption of fruits and vegetables, decreasing TV viewing, and increasing breastfeeding. Dr. Mohammed Alnaif

16. MODERN PUBLIC HEALT H SYSTEMS The Three Core Functions in Action Third Core Function: Assurance As part of the program, participating states are required to submit semiannual progress reports summarizing their progress with respect to infrastructure, collaborations, implementation, and evaluation. The CDC uses these reports to manage and improve the program. Through a process of ongoing assessment, policy development, and assurance, NPAO continues to improve and expand its activities. Dr. Mohammed Alnaif

17. MODERN PUBLIC HEALT H SYSTEMS The Three Core Functions in Action Third Core Function: Assurance Today, the program works with twenty three states to address obesity and other chronic diseases. NPAO seeks to influence the full spectrum of factors that determine these health outcomes, from individual behavior to public policy. This broad approach is called the social – ecological model, a concept we will explore in further detail later in this chapter. Dr. Mohammed Alnaif

18. MODERN PUBLIC HEALT H SYSTEMS Understanding Population The term populationhas various meanings depending on the context. For example, one might refer to the number of individuals in the country of Saudi Arabia by saying that its population is about 28,000,000 people or collectively refer to the Saudi population by saying that the population of the Saudi Arabia is very diverse. However, in the context of public health, a population is defined as a group of people who share characteristics such as age, race, gender, geography, income level, and country of origin and who are commonly affected by a public health issue. Dr. Mohammed Alnaif

19. MODERN PUBLIC HEALT H SYSTEMS Understanding Population For an issue to become a public health priority, it must affect a defined group of people, or a population. As an example, a program might identify a specific age group with high rates of obesity living in Riyadh as its target population. In public health, the population is often discussed in the context of a population focus or population health. This usage implies an underlying focus on the group rather than the individual. Dr. Mohammed Alnaif

20. MODERN PUBLIC HEALT H SYSTEMS Understanding Population Public health is uniquely concerned with the group dynamic, and this concern encompasses both small communities and entire countries. The population focus of public health is considered the hallmark of the field. According to the Institute of Medicine, “A public health professional is a person educated in public health or a related discipline who is employed to improve health through a population focus.” In fact, the key, unifying factor in all public health work is a focus on population – level health. Dr. Mohammed Alnaif

21. MODERN PUBLIC HEALT H SYSTEMS Understanding Population Promoting population – level health is complicated by the huge number of factors that influence health, well – being, and disease. These factors include complex biological causes and often encompass subtle social dynamics. A broad perspective that can account for this interrelated web of health risks and determinants is required to understand population health, and the need for such an approach gave rise to the social – ecological model of health. This model provides a framework for understanding population health and for carrying out public health’s three core functions effectively. Dr. Mohammed Alnaif

22. MODERN PUBLIC HEALT H SYSTEMS The Social – Ecological Model as a Framework for Prevention Understanding, influencing, and changing population - level health is a complex and difficult task. For public health professionals, the goal is to identify the important health issues facing populations, understand their underlying causes, design interventions to solve existing problems, and prevent the health issues from arising in the future. To succeed, we need a framework that accounts for multiple, interrelated health determinants and aids our efforts to promote health at the population level. Dr. Mohammed Alnaif

23. MODERN PUBLIC HEALT H SYSTEMS The Social - Ecological Model as a Framework for Prevention According to the Institute of Medicine, the social - ecological model “assumes that health and wellbeing are affected by interaction among multiple determinants of health … and … emphasizes the linkages and relationships among … factors.” As mentioned in the previous section, it is important to look beyond biological risk factors to fully understand health. In fact, at least 50 percent of mortality can be attributed to factors other than biology or medical care. Dr. Mohammed Alnaif

24. MODERN PUBLIC HEALT H SYSTEMS The Social - Ecological Model as a Framework for Prevention What are these other factors? The social - ecological model considers four levels of influence when describing health, identifying public health issues, and designing interventions. These four levels are the individual level, the relationship level, the community level, and the societal level. These four spheres of influence overlap and interact, as depicted in Figure 2.2. Dr. Mohammed Alnaif

25. FIGURE 2.2 Levels of Influence Society Community Interpersonal Individual Dr. Mohammed Alnaif

26. MODERN PUBLIC HEALT H SYSTEMS Four Levels of Influence Individual Level Our health is largely determined by personal factors such as our genetic predisposition, behavior, attitude toward health, motivation, beliefs, and family history. Prevention strategies at the individual level might include mentoring and education to positively change personal influences on health and illness. Dr. Mohammed Alnaif

27. MODERN PUBLIC HEALT H SYSTEMS Four Levels of Influence Relationship Level (Interpersonal) Our health is also greatly influenced by relationships with peers, partners, and family members. Prevention strategies at the relationship level often include education and peer or family programs to promote relationships that support a positive health outcome. For example, a program designed at the relationship level might focus on diet and lifestyle education for both those with diabetes and their families, recognizing that close family members can provide moral and practical support in making the important diet and exercise changes that are critical for the appropriate management of diabetes and the prevention of serious complications. Dr. Mohammed Alnaif

28. MODERN PUBLIC HEALT H SYSTEMS Four Levels of Influence Community Level Our health is influenced by our experience in our social environment, such as our neighborhood, school, and place of work. Prevention strategies at the community level often seek to change policy and the system as a whole through means such as awareness campaigns or local programs. For example, a program to promote physical activity might aim to make neighborhoods more pedestrian friendly by establishing well - lighted and convenient walking paths and by educating the public about the importance of building exercise into the daily routine. Dr. Mohammed Alnaif

29. MODERN PUBLIC HEALT H SYSTEMS Four Levels of Influence Societal Level Finally, our health is shaped by macro - level factors in society as a whole, such as religious and cultural beliefs, economic policies, gender or racial inequalities, and social norms. Prevention strategies at the societal level may employ many approaches in combination, such as creating new policies, awareness campaigns, and programs, and they are often carried out by multiple tiers of government and private or nonprofit entities. Dr. Mohammed Alnaif

30. MODERN PUBLIC HEALT H SYSTEMS Four Levels of Influence The social - ecological model can be used to inform theory, design research studies, create community programs, develop policy, and evaluate existing interventions. Several versions of the model exist, some of which include an additional level of influence called the institutionalor organizationallevel. This level of influence fits between the relationship and community levels and allows research and interventions to focus more directly on the dynamic within organizations such as schools, mosques, or the workplace. Dr. Mohammed Alnaif

31. MODERN PUBLIC HEALT H SYSTEMS Applying the Social - Ecological Model Research A major challenge facing public health researchers is obtaining the data required to define the nature and magnitude of a public health problem. Historically, only simple data such as mortality and morbidity (rates of death and disease) have been collected and used in epidemiological studies. These data are limited in their ability to completely describe health among populations. More recently however, broader recognition of the social - ecological model and the myriad of factors that can contribute to a health problem have supported a shift to more detailed data collection. Dr. Mohammed Alnaif

32. MODERN PUBLIC HEALT H SYSTEMS Applying the Social - Ecological Model Research When smoking was added to the list of reportable diseases and conditions in 1996, it was the first time that a health behavior became part of surveillance. This represented a landmark for public health research. Over time, even more data have become available through the increased reporting and surveillance of demographic and lifestyle risk factors, such as physical activity. This has in turn served to better inform health policy and intervention design. Dr. Mohammed Alnaif

33. MODERN PUBLIC HEALT H SYSTEMS Applying the Social - Ecological Model Research The merits of the social - ecological model, including its comprehensiveness and ability to account for the complexity of health, create a challenge for research. Public health researchers must make every effort to think in broader terms and address a greater number of research questions in their work. Furthermore, research must often employ interdisciplinary teams of investigators, including social scientists, epidemiologists, biostatisticians, clinicians, and economists in order to bring an appropriate level of expertise to all components of the model. Dr. Mohammed Alnaif

34. MODERN PUBLIC HEALT H SYSTEMS Applying the Social - Ecological Model Programs and Interventions The complexity of the social - ecological model can make it difficult to apply its principles when designing programs and interventions to address public health issues. Over time, however, the model is being used to design public health programs with increasing success. Two examples of the social – ecological model in practice are discussed below. The first is a large - scale program that addresses violence throughout the United States, and the second is a nonprofit organization that assesses the health needs of an immigrant community. Dr. Mohammed Alnaif

35. MODERN PUBLIC HEALT H SYSTEMS A Real - Life Example at the National Level: The CDC and Violence Prevention The Centers for Disease Control and Prevention (CDC) is a government agency dedicated to protecting health and promoting quality of life through the prevention and control of disease, injury, and disability. In the late 1970s, the CDC identified violence as a priority area for public health, and throughout the 1980s it established goals and programs for the prevention of violence. By the early 1990s, the CDC established a Division of Violence Prevention (DVP), which monitors violence and related injuries, conducts research on factors affecting violence, creates and evaluates violence prevention programs, and helps state and local governments implement programs. Dr. Mohammed Alnaif

36. MODERN PUBLIC HEALT H SYSTEMS A Real - Life Example at the National Level: The CDC and Violence Prevention To fully understand violence as a public health issue and to inform these prevention efforts, the CDC relies on the social - ecological model of health. Because violent behavior is extremely complex in its root causes, the CDC has examined the interplay between individual, relationship, community, and societal – level influences on susceptibility to and protection from violent behavior. As a result of this effort, the prevention strategies employed include a continuum of activities, such as community education and awareness efforts, identification of risk and protective factors, and surveillance of violent behavior, to further inform educational prevention programs. These activities address all levels of the social – ecological model in order to create a sustainable approach to violence prevention. Dr. Mohammed Alnaif

37. MODERN PUBLIC HEALT H SYSTEMS A Real - Life Example at the Local Level: Puentes de Salud and Immigrant Health Puentes de Salud (Bridges to Health) is a nonprofit organization that works as an innovative model for health promotion in the South Philadelphia Latino community. This population has grown dramatically in the past decade, and social support systems targeting this community, including health care, education, and public assistance, has lagged behind. The community has a high prevalence of preventable chronic disease, largely attributable to lifestyle factors. Recognizing multiple and interacting determinants of health, the Puentes de Salud model uses a social - ecological approach to address public health issues facing this community. Dr. Mohammed Alnaif

38. MODERN PUBLIC HEALT H SYSTEMS A Real - Life Example at the Local Level: Puentes de Salud and Immigrant Health The model includes providing primary health care, basic dental care and screenings, and referrals to low - cost or free specialist care in the community, as well as health education programs, community outreach, and training of future health care professionals. Through collaborations with private and public organizations, including academic institutions, Puentes offers classes and workshops in immigration legal issues, nutrition, and English as a second language. The Puentes model targets many different angles of the social and health problems of this Latino community and exemplifies the social – ecological model at work at the grassroots level. Dr. Mohammed Alnaif

39. MODERN PUBLIC HEALT H SYSTEMS Three Levels of Prevention The underlying goal of all public health efforts is prevention. Preventing disease before it begins reduces unnecessary suffering and makes the best use of health care resources. Prevention works on multiple levels and in some cases may even apply to certain subsets of the population who already have disease. There are three levels at which prevention efforts can be focused, known as the primary, secondary, and tertiary levels. Dr. Mohammed Alnaif

40. MODERN PUBLIC HEALT H SYSTEMS Three Levels of Prevention At the primary prevention level, we seek to prevent disease before it begins. Activities at this level include health promotion and education, as well as provision of primary health care services. At the secondary prevention level, our goal is to detect disease while it is still in its early stages and reduce its progression and effects. This level includes screenings and case finding, followed up by early intervention and control of risk factors. At the tertiary prevention level, advanced disease is already present, so we seek to reduce complications and mortality. At this level, efforts are focused on disease management and continuing care. Dr. Mohammed Alnaif

41. MODERN PUBLIC HEALT H SYSTEMS Three Levels of Prevention The primary level of prevention is the most effective for many public health issues, and ideally, the majority of resources should be focused at this level. However, people who are already ill can still benefit from prevention efforts at the secondary and tertiary level, as outlined in Table 2.1 Below are two examples of how activities or interventions can target each level of prevention for a public health problem. Dr. Mohammed Alnaif

42. Table 2.1 the Three Levels of Prevention Dr. Mohammed Alnaif

43. MODERN PUBLIC HEALT H SYSTEMS Three Levels of Prevention Motor vehicle safety is another example of a public health issue for which we can intervene at multiple prevention levels. Primary prevention of motor vehicle crashes includes improving road safety, for example by adding medians or barriers to prevent motorists from crossing into oncoming traffic or running off the road. In addition, installing traffic signs and lights are examples of primary prevention interventions because their purpose is to prevent crashes from occurring. Dr. Mohammed Alnaif

44. MODERN PUBLIC HEALT H SYSTEMS Three Levels of Prevention Secondary prevention includes efforts to reduce injury or severity when a crash occurs. To accomplish this, we can install and require the use of seat belts in cars as well as car seats or booster seats for children. We also can establish and enforce speed limits to minimize damage done in a crash. Finally, tertiary prevention in motor vehicle safety involves minimizing disability or injury caused by a crash. This may be accomplished by ensuring that an adequate and responsive Emergency Medical Services (EMS) system exists and that there is access to trauma centers for rapid medical care of crash survivors. Dr. Mohammed Alnaif

45. MODERN PUBLIC HEALT H SYSTEMS Three Levels of Prevention For virtually any public health problem, there are strategies to prevent an outcome from occurring (primary prevention), to limit the negative impact of an event (secondary prevention), and to reduce long - term disability or morbidity associated with the event (tertiary prevention). It is important to recognize and identify action steps at all levels of prevention. Dr. Mohammed Alnaif

46. MODERN PUBLIC HEALT H SYSTEMS Three Levels of Prevention Historically, the prevention message and focus of public health has alienated some individuals who felt they were viewed as public health failures because some aspect of their life or experience had not been prevented. For example, many primary prevention efforts exist to prevent birth defects and developmental disabilities. When designing public health messages about prevention, it is critical to be sensitive to the fact that members of the audience may have the health attribute or condition the message seeks to eliminate. Dr. Mohammed Alnaif

47. MODERN PUBLIC HEALT H SYSTEMS The Public Health System Public health is tied to government by the very nature of its core functions. As described in previous sections, public health is responsible for assessing public health issues, developing policy, and assuring that policies and programs are carried out. Only governments (at all levels) has the authority to create new laws, regulate programs and industries, and use taxpayer money to fund public health initiatives. Because of this important tie to government, an understanding of the governmental public health infrastructure is essential to your understanding of public health. Dr. Mohammed Alnaif

48. MODERN PUBLIC HEALT H SYSTEMS The Public Health System Globally Every country establishes its health care delivery and public health systems in accordance with its history, culture, economics, politics, and resources. Often, health systems are built up over time in response to stimuli such as economic changes, outbreaks of infectious disease, or a threat of bioterrorism. Not all systems will or should look alike. In this section, we consider public health systems around the world. We will then turn our attention to the unique challenges facing developing countries as they work to establish new public health systems. Dr. Mohammed Alnaif

49. MODERN PUBLIC HEALT H SYSTEMS The Public Health System The largest public health agency in the Saudi Arabia is the Ministry of Health. This umbrella agency includes a wide range of sub agencies, whose activities include research, health service provision and financing, industry regulation, health promotion, policy analysis and development, surveillance, and intervention design. Deputy Minister for Public Health The MOH’s Agency for Public Health takes as its target achieving a future vision focused on “Better Public Health”, making use of all possible means Dr. Mohammed Alnaif

50. MODERN PUBLIC HEALT H SYSTEMS Deputy Minister for Public Health Vision: “We aim to make the Saudi public health the best in the world”. Message: ”We seek to promote and protect the health of citizens and residents, and establish basis for a healthy society through working scientifically and professionally, making use of qualified specialists in various fields of public health, and through committing to the highest standards of scientific research, continuing medical education, and training; that is to be added to encouraging community participation in improving public health through awareness and support”. http://www.moh.gov.sa/en/Ministry/Structure/Agents/PublicHealth/Pages/vision.aspx Dr. Mohammed Alnaif