MPH 600 Introduction Public Health Planning and Goal Setting in Public Health

1. MPH 600 Introduction Public HealthPlanning and Goal Setting in Public Health William R. Nelson, M.D., M.P.H. Past Director Chesterfield County HD, VDH Kim Buttery, Past Commissioner VDH.

2. Core Functions of Public Health Assessment Policy Development Assurance From The Future of Public Health :Institute of Medicine 1988

3. GOALS & Objectives • Use of data to formulate and make decisions: to establish “Policy” • What is Policy •  How health policies are formulated •  Forces that shape development of policy

4. "Policy" A definite course of action adopted as expedient, or from considerations: e.g. "a business policy" Definition from the American Heritage Dictionary

5. Evolution of Health Policy • Common Wisdom- Learned from direct observation • Age of Discovery- Application of the scientific method • Prospective Age – Population based analysis

6. Policy Development "Policy development is the means by which problem identification, technical knowledge of possible solutions, and societal values join to set a course of action." Institute of Medicine Report. ‘The Future of Public Health’ – 1988 Review summary and Pages 44 and 45

7. Policy Development Problem Identification Technical Knowledge Societal Values

8. Problem Identification •  Anecdotes •  Media •  Public Health Data •  Epidemiology In the News Data tells a story Epidemiology points to the answers

9. Technical Knowledge of Solutions • Basic Science •  Clinical Studies •  Economics •  Law • Health Behavioral theory- Pyschology

10. Societal Values • Political Process • Legislative, Judicial & Executive expression • Social & Political Sciences • Interest Groups • Town Hall Meetings • Blogs, Web Pages

11. Setting a Course of Action •  Easier Said; • Having a vision • Setting goals • Picking objectives • Designing action steps  Than Done • Legal and regulatory framework • Funding • Organizational structure to accomplish • Work plan: staffing, equipment • Cooperation or interest of those affected • Patient/provider, customer/provider, community/leader relationships

12. Framework for Analysis • Establish the contract: desired result of the effort • Layout the Alternatives: options to consider • Predict the consequences: use of data and models • Value the outcome: numerous valuation strategies • Make a choice: legal, ethical, societal, moral, financial and practical parameters

13. Making the Choice • The Decision Maker; Role of “the Decider” • A person • A group of people • The Analyst • The Staff • Significant Influences

14. Private Sector • Easier when only the bottom line is considered: not always the only question • Increasingly complex • Conventional wisdom = always more efficient • Rise of public-private sector

15. Public sector; more difficult • All the following want a hand in the decision making: • Congress • Federal Courts • Executive Branch • State Legislature • Governor & Executive Branch • State Courts • Activists • Local Councils/Supervisors • City/County Execs • Here is the local health department! Activists and concerned individuals at every level

16. Comparison of Clinical Medicine and Public Health Practice

17. Chief Complaint – Problem Identification

19. Review of Symptoms- Community Health Status Indicators

20. E. Coli 0157:H7 in Virginia

21. Examine the patient • Death rates by cause (See Vital Statistics) • Hospital admissions • NHANES • BRFS • Reportable Diseases • Registries • Cancer • Birth Defects • Alzheimers

22. Differential diagnosis - Develop a hypothesis Rates of cancer in this neighborhood are NOT elevated Rates of cancer in this neighborhood are elevated, but this is a random effect. A specific type of cancer is appearing more often than it should. The increased rate of cancer is related to an exposure to a certain chemical in the drinking water. Congestive Heart Failure Pulmonary Embolism Chronic Obstructive Lung Disease

23. Clinical tests -- Case Control Studies Prospective studies Environmental testing Hemoglobin 12 gm/dL WBC 18,000/mm

24. Medication Surgery Diet Physical, emotional, or behavioral therapy Lifestyle changes Stop the exposure Screening programs Prevention programs Promote diet and lifestyle changes Engineering Changes in community structure Treat the Treat the disease problem

25. Treating a Societal ConditionRx = Policy Development Problem Identification Technical Knowledge Societal Values

26. Re-interview regarding symptoms Re-examine periodically Repeat lab tests when helpful Death rates by cause (See Vital Statistics) Hospital admissions NHANES BRFS Reportable Diseases Registries Parameters set up specifically for this Example: Healthy People 2010 Healthy People 2010 Home Page Monitor Patient -- Monitor Health Results Indicators

27. Evolution of Health Care • 800 AD – 1900’s hospitals = poor houses • 1800’s – bacteriology becomes a science • 1870-1910 Hygiene Movement: rise of science • 1945 Specialization following vast improvement of surgery and use of antibiotics associated with WW II. • 1980s Identification of limited and competing resources, movement to primary care, ambulatory care cost reduction • 21st century- continued explosive growth of costs creates a financial and political crisis

28. Great Health Policy Moments • 1600s Bill of mortality – London • 1918- Flexner Report; use of the science and standards vs. apprenticeship • 1935 Social Security Act • 1946 Hill Burton Act • 1965 Medicaid/Medicare • 1980s Medicare implements capitation: DRGs • 1990s Health Care Reform- managed care • 21st Century- struggle over health care system • Emergence of chemical and biologic weapons: • Public Health Security and Bioterrorism Preparedness and Response Act

29. An Example of a recent problem that lead to an urgent program goal using the previously described actions.

30. Anthrax as a Weapon: United States • An urgent program goal to “assess the danger to Virginians”

31. Quickly determined despite media hype that the dangers were to selected political figures and postal workers.