© Borgis - Postępy Nauk Medycznych 5/2016, s. 316-321
*Dorota Cianciara1, Sylwia Piętka1, Janusz Sytnik-Czetwertyński2, Jarosław Pinkas3
Essential public health operations in the WHO European Region
Podstawowe funkcje zdrowia publicznego w regionie europejskim Światowej Organizacji Zdrowia
1Department of Epidemiology and Health Promotion, School of Public Health, Centre of Postgraduate Medical Education, Warsaw
Head of Department: Dorota Cianciara, PhD, Associate Professor
2Department of Economics, Law and Management, School of Public Health, Centre of Postgraduate Medical Education, Warsaw
Head of Department: Iwona Wrześniewska-Wal, MD, PhD
3Department of Healthcare Organizations and Medical Jurisprudence, School of Public Health, Centre of Postgraduate Medical Education, Warsaw
Head of Department: Jarosław Pinkas, MD, PhD
Zdrowie publiczne (ZP) jest nauką i sztuką zapobiegania chorobom, przedłużania życia oraz promowania zdrowia poprzez zorganizowane działania społeczeństwa. Jego rola polega na świadczeniu populacyjnych usług zapobiegawczych i wspieraniu innych usług systemu zdrowia, a zwłaszcza indywidualnych usług leczniczych tzw. medycyny naprawczej. Obecnie w wyniku uwarunkowań epidemiologicznych, demograficznych, społecznych i ekonomicznych powszechnie oczekuje się zwiększenia wydajności usług ZP. W 2012 roku w regionie europejskim Światowej Organizacji Zdrowia przyjęto rezolucje o poprawie stanu zdrowia ludności regionu (tzw. polityka „Zdrowie 2020”) oraz o usprawnieniu usług ZP na rzecz realizacji „Zdrowia 2020” (tzw. plan zwiększenia potencjału ZP). Polska jako sygnatariusz tego porozumienia jest zobowiązana do podjęcia odpowiednich działań i sprawozdawczości. Podłożem planu zwiększenia potencjału ZP było wyznaczenie zakresu działania ZP (tzw. 10 podstawowych funkcji ZP) oraz zdiagnozowanie aktualnego stanu zaawansowania prac w krajach regionu. Największe problemy z realizacją funkcji ZP, a więc także największe potrzeby zmian, stwierdzono w krajach wschodniej i południowej części regionu. Zwiększenie potencjału ZP w Polsce wymaga m.in. współpracy z przedstawicielami medycyny naprawczej. Celowi temu powinien służyć jednolity dla wszystkich specjalności kurs specjalizacyjny z ZP.
Public health (PH) is the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society. Its role is to provide population-wide preventive services and to support other services of the health system, especially individual treatment services, as so-called curative medicine. Nowadays, as a result of epidemiological, demographic, social and economic circumstances, it is widely expected to increase the efficiency of PH services. In 2012 in the European region of the World Health Organization there were adopted resolutions on improving the health of the region’s population (i.e. policy framework “Health 2020”) and to improve PH services towards reaching the “Health 2020” (i.e. a plan of strengthening PH services across the European region). Poland as a signatory of this agreement is required to take appropriate action and reporting. The underlying proposal for strengthening PH capacities was to determine the PH scope (i.e. 10 essential PH operations, EPHOs) and to diagnose the current state of art in the region. The leading problems with the implementation of EPHOs, and therefore the greatest need for improvement, was found in the countries of eastern and southern parts of the region. Strengthening the PH capacities in Poland requires, among others, cooperation with representatives of curative medicine. This objective should be used consistently in unified PH course for all doctors applying for the specialization.
The representatives of the United Nations who created the World Health Organization (WHO) recognized that health is one of the fundamental human rights, a condition for security and peace and a common value (1, 2). Poland accepted this stand in 1948, through the ratification of the Constitution of the WHO (3). Later, the United Nations has repeatedly stressed the value of health in numerous resolutions, including the Millennium Development Goals, being an obligation of the international community to undertake development activities for 2015 (4).
The WHO and the European Union stated that investments in health are an investment in the development of individuals and humanity, social well-being and prosperity, not a cost. These bodies agree that a well-functioning health system enables maintaining and improving health and thereby contributes to social development and wealth (5, 6). It is therefore essential in the life of individuals and of every society, the functioning of states and global development. At the same time – in the current organizational structure and with the current level of funding – most of the national health systems cannot cope with the new health needs and social expectations (7, 8). One of the responses to the crisis in health systems is striving to increase the efficiency of public health (PH).
The aim of this article is to present the role of PH in the health system and actions taken in the European Region of the WHO in order to increase the capacity and efficiency of PH.
The following study understand PH as a science and an art of preventing disease, prolonging life and promoting health through organized activities of a society. The definition was formulated by Sir Donald Acheson and adopted by the WHO (9, 10). Health policy means action plans for health.
Observing the Polish public debate gives the impression that the most important role in maintaining the health of the population is played by healthcare, especially specialist and hospital one. Meanwhile, restorative medicine is just one of the links in a complex system that works for health.
According to the WHO – in a task aspect – a health system is “a team of public and private organizations, institutions and resources that work to improve, maintain or restore health”. The system provides services for individuals and entire populations, as well as conducts intersectoral actions. Through them, it seeks to modify the plans of other social sectors to influence the environmental, social and economic determinants of health (e.g. improvement of the sewage treatment system, influencing legislation related to tobacco and road safety, etc.) (5, 11).
According to the World Bank – in a structural aspect – a health system (fig. 1) includes: (a) resources and processes to provide preventive and curative services (medical care); (b) resources and processes associated with services, norms, standards (health services); (c) a fragment of the economy responding to the health needs through: the production and distribution of medicinal products and devices, activity of providers and insurers, education and vocational training, rehabilitation, etc. (health sector); (d) elements of the activities of other social sectors critical to health, such as e.g. food production, transport, housing, education, etc. (determinants of health) (12).
Fig. 1. A health system. Source: Bitrán et al. (12)
In Poland, different terms are customarily used, most often the “health care system” term. However, in legislation, the term “health care” has at least two different meanings (13). The “health care system” term is similarly vague. Model studies on the Polish system pay relatively little attention to population services, as well as inter-sectoral actions, or relations with the entities for which health is not a priority for action (14).
PUBLIC HEALTH IN A HEALTH SYSTEM
A well-functioning health system provides services to three groups of recipients: the entire population, individual patients and the chronically ill and disabled. Population prevention services are the domain of PH and individual diagnostic and therapeutic – restorative medicine (treatment). Care services, addressed to individuals, families or communities, are the domain of social assistance in its broader meaning (15).
PH uses a wide range of methods, including technological, economic, legislative, control and law enforcement, aimed at modifying the natural, anthropogenic and social environment. PH instruments include medical methods, such as: vaccinations, mass screening and control of infections associated with health care. It also includes “soft” methods, such as education, social marketing, advocacy and social engineering (e.g. community development).
Currently, European health systems exhibit asymmetry in the levels of development of these services and the dominance of restorative medicine. However, due to many conditions, other cells, i.e. PH and care, are becoming increasingly important. It results, among others, from the extending life span and population aging, the prevalence of chronic diseases and risk factors for these diseases, the rising cost of health care, the economic crisis on the financial market crisis with refugees, large direct and indirect costs of health inequalities, the health inequalities as well as rising social expectations towards various forms of health care. We are currently witnessing an unprecedented re-evaluation of system services.
A well-functioning health system should also ensure coordination of the services of prevention, treatment, rehabilitation and care, and thus create a coherent health care package. Providing a wide range of services, at the right time and place, being also time effective and cost-effective, is internationally known in the literature as integrated or coordinated care (16). In Poland, coordinated care determines the harmonization of primary health care (PHC) specialist outpatient care (SOC) and hospital services (17).
Today, in many countries, system integration of services, especially the population/preventive PH services and individual/curative ones, is insufficient (18). It should be noted, however, that the desire for integration is common and visible in the search for theoretical research and practical activities. A specific example may be a US plan to integrate those services in the context of natural disasters and mass threats (19) and a plan to protect the PH structures and resources and treatment as part of the critical infrastructure (20).
“HEALTH 2020” AN incentive FOR THE DEVELOPMENT OF PUBLIC HEALTH
“Health 2020” is a political document, unanimously approved by the Resolution of the European Regional Committee of the WHO in 2012 (21). The WHO European Region includes 53 countries in Europe and outside Europe – all developed after the breakup of the Soviet Union, as well as Israel and Turkey. This region is characterized by the presence of very large differences between countries in terms of economic development, culture, the health of residents and the occurrence of health inequalities (22).
“Health 2020” is a kind of a guide for Member States to create their own health policies with the participation of governments and societies, and also a joint declaration of achievement health goals defined throughout the region by 2020 (23-25). The document structure is shown in tables 1 and 2. One of the four priority areas of action is to expressly increase PH capacity. In addition, the other three areas are closely related to the activities of the PH. Over the years, they have collected convincing scientific evidence in fact that many interventions in the area of PH, including health promotion and disease prevention, can be effective in improving health, and the same time, result is savings or generate additional measurable benefits. Therefore, achievement of the main goal of “Health 2020” depends on the implementation of professional activity at the population level.
Tab. 1. Structure of the European policy “Health 2020”. Own development
|The main goals (vision)|
|Significant improvement of the health and well-being of populations, reducing health inequalities, strengthening PH, ensure people-centred health system that are universal one, fair, sustainable and of high quality|
|Strategic objectives |
|1. Improve the health of all and reduce health inequalities|
2. Improve leadership and participatory governance for health
|Priority areas for policy action|
|1. Investing in health throughout a life-course approach and the empowerment of people|
2. Tackling the major health challenges of noncommunicable and communicable diseases
3. Strengthening people-centred health systems, public health capacity and emergency preparedness, surveillance and response
4. Creating resilient communities, capable of adapting to changes in the environment, and supportive environments
|Broad target areas|
|1. Burden of disease and risk factors|
2. Healthy people, well-being and determinants
3. Processes, governance and health systems
|1. Reduce premature mortality|
2. Increase life expectancy
3. Reduce health inequalities
4. Enhance well-being
5. Ensure universal health coverage and the right to the highest attainable level of health
6. Set national goals and targets related to health
Tab. 2. A cross table of areas, objectives and priority areas of the European policy “Health 2020”. Source: the WHO (2013) (13)
|Objective areas||Targets||Strategic objectives||Priority areas|
|Burden of disease and risk factors||1||1||2|
|Healthy people, well-being and determinants||2||1||1 and 4|
|3||1||1 and 4|
|4||1||1 and 4|
|Processes, governance and health systems||5 and 6||2||3|
“Health 2020” was being developed for two years as a result of numerous consultations conducted also outside Europe. There were several important reports developed, including ones on the health situation, and the organization and functioning of PH and health systems in the region (26-30). The proposed actions are based on knowledge and evidence gathered as a result of the implementation of, among others, the Strategy for Health for All, the Healthy Cities Project, the Millennium Development Goals and the policy of “Health 21”. Currently, the WHO provides dozens of ancillary studies on various aspects of the implementation of this policy, including measures to improve PH.
Implementation of the objectives of “Health 2020” has been monitored by the WHO since 2014 with the use of quantitative (baseline data is from 2010) and qualitative indicators. This year’s European Report on Health, issued every three years, is a flagship publication of the WHO office in Copenhagen, presenting the first results of the implementation of the “Health 2020” (31).
To sum up – the current European health policy clearly emphasizes the importance of health and the quality of life in the system of values. Very strong emphasis was placed on the strengthening of PH, including drawing attention to: the social determinants of health, empowerment of communities and patients, the so-called resilient communities, health promotion, disease prevention, the so-called whole-of-government and whole-of-society approach and interactive health governance system.
Health is in fact a fundamental value, s source of creative activity, a basis for implementation of plans. Health protection is one of the key drivers of the development of science, the humanities, and the economy. A health policy gives the public the opportunity of creation (32, 33).
BASIC FUNCTIONS OF PUBLIC HEALTH
For the purposes of the implementation of the policy “Health 2020”, a list of Essential Public Health Operations (EPHOs) has been developed for the European region (10). There had existed a similar list, however, it became necessary to modify it for the current needs.
Currently, the functions include:
Surveillance of population health and well-being.
Monitoring health hazards and emergencies and responding to them.
Health protection, including environmental, occupational, food safety, etc.
Health promotion, including actions focused on social determinants of health and health inequalities.
Disease prevention, including early detection of illness.
Provide governance for health and well-being.
Provide adequate and competent PH workforce.
Provide a sustainable PH organizational structure and financing.
Advocacy, communication and social mobilization for health.
Developing research in the field of PH to conduct policy and practice.
Each of these functions is described in detail. Functions 1-5 are considered the core (core EPHOs). In this group, functions 1 and 2 are intelligence and 3 to 5 are the main PH services. Providing the leading services requires specialized competence, i.e. profiled knowledge, skills, and attitudes of employees. In the previous decade, many countries carefully defined the competencies of PH employees, including general and specific competencies, e.g. in the field of epidemiology and health promotion (34-38). While functions 6 to 10 include the so-called enabler EPHOs, the performance of which requires competence in the field of PH and other disciplines. Grouping function clusters is shown in figure 2.
Fig. 2. Clusters of the essential public health functions. Source: the WHO (2012) (42)
CURRENT capacity OF PUBLIC HEALTH
Development of a list of essential operations was linked to the results of the PH capacity (conditions) research in 27 EU countries and an analysis carried out in 41 countries of the European Region of WHO (39, 40). Both surveys were based on self-assessment of the progress of work (according to the questions asked and criteria), so the results obtained by this method are some approximation. Unfortunately, they are not satisfactory. It was found that greatest number of countries (approx. 50%) carries out activities related to the classically understood PH, i.e. surveillance, monitoring health situation and prevention. The lowest number of countries developed activities related to staff training. Assessment of the quality of the activities is even more worrying (fig. 3). Insufficient development of PH was found especially in the eastern and southern parts of the WHO European Region.
Fig. 3. Estimated range and quality of the basic functions of public health in the WHO European region. Source: the WHO (2012) (48)
White circles – the estimated percentage of countries that conduct any activities related to EPHOs (range), black circles – the estimated implementations of the full range of EPHOs (quality)
N/A – not available
Currently, the WHO proposes a regular monitoring of the national PH capacity and services with an advanced self-assessment tool (41). In Poland, such a review was conducted as a result of cooperation with the Ministry of Health. It showed numerous weaknesses within PH and time will tell how it will be used.
EUROPEAN PLAN TO INCREASE PUBLIC HEALTH capacity
Simultaneously with the adoption of the “Health 2020”, the WHO Regional Committee approved the “European Action Plan for Strengthening Public Health Capacities and Services” (42-44), since the implementation of this policy requires improvement of population services in health system. A clue to the development of the plan was the overview of the current PH capacity discussed above. This plan indicates what actions within each function (EPHOs) should be taken in 2012-2020 by Member States and by the Regional Office in Copenhagen and the WHO headquarters in Geneva.
In the following years, reports were published on the cost-effectiveness and profitability of PH intervention, which reinforces the importance of this plan (45). For example – profitable interventions (or “better” than cost-saving ones) in the short term (0-5 years) included, among others: road injury prevention, active transport, walking and cycling, safe green public spaces, protection against heat waves, healthy employment, insulation and ventilation of buildings, legislation to counteract violence, prevention of postnatal depression, family support psycho-social support for older people, reducing the availability of alcohol (46). Figure 4 includes a “meme” as an illustration.
Fig. 4. Cost-effective public health interventions. Source: the WHO (2013) (46)
Implementation of the “Health 2020” policy and PH development are dependent on, among others, the competencies of PH employees. To a large extent, they also depend on cooperation with other stakeholders of the health system and their willingness to support such plans. Education and communication are therefore really important. In 2010, Lancet published an extensive article on the education needs of different groups of health workers, including doctors, in the new millennium (47). It described three historical stages of education for different professions related to health protection. At the beginning of the twentieth century, informative learning was most common, based on knowledge, and the goal was to “produce” experts. In the mid-century, formative learning originated, based on the problem, which was used to build competencies around socializing and education of professionals.
Currently, there is an urgent need for transformative learning and teaching interdependence.
Transformative learning attributes included abandonment of: (a) memorizing facts in favor of the capability of searching for information, analysis and synthesis aimed at making a decision, (b) obtaining certificates for achieving key competences to work in a team, (c) an uncritical acceptance of the existing educational model for creative thinking, adapting other people’s experiences to local needs. The aim of the transformation is to produce the change agent, a person responsible for the creation of conditions conducive to the implementation of changes, supporting this change and assessing its effects.
Interdependence within education is abandonment of: (a) teaching in isolation (silo teaching) in favor of interdisciplinary and interprofessional teaching, (b) education in one institution in favor of networks, coalitions and consortiums, (c) institutional navel-gazing of educational entities in favor of participating in the global flow of the content of education, resources and innovation.
In such a context – that of transformative education and that attempting to show the interdependence of the problems – the uniform specialized course of public health should be assessed (48). The intention of those managing the health system was to create a platform for an agreement between representatives of restorative medicine and PH.
Constitution of the World Health Organization. International Health Conference. New York, 22 July 1946.
Konstytucja Światowej Organizacji Zdrowia. Porozumienie zawarte przez Rządy reprezentowane na Międzynarodowej Konferencji Zdrowia i Protokół dotyczący Międzynarodowego Urzędu Higieny Publicznej, podpisane w Nowym Jorku dnia 22 lipca 1946 r. Dz. U. 1948 nr 61 poz. 477.
Ustawa z dnia 29 stycznia 1948 r. o ratyfikacji konstytucji Światowej Organizacji Zdrowia, jak również porozumienia zawartego przez rządy reprezentowane na międzynarodowej konferencji zdrowia oraz protokołu dotyczącego Międzynarodowego Urzędu Higieny Publicznej, podpisanych w Nowym Jorku dnia 22 lipca 1946 r. Dz. U. 1948 nr 10 poz. 72.
UN General Assembly: United Nations Millennium Declaration. Resolution adopted by the General Assembly, 18 September 2000. A/RES/55/2.
WHO: The Tallinn Charter: Health systems for health and wealth. WHO Regional Office for Europe. Tallinn, Estonia 25-27 June 2008.
Suhrcke M, McKee M, Sauto Arce R et al.: The contribution of health to economy in the European Union. Health & Consumer Protection Directorate General, Luxemburg 2005.
WHO: The World Health Report 2008 – primary health care. Now More Than Ever. Geneva, WHO.
McKee M, Basu S, Stuckler D: Health systems, health and wealth: The argument for investment applies now more than ever. Social Science & Medicine 2012, 74(5): 684-687.
Acheson D: Public health in England: the report of the Committee of Inquiry into the Future Development of the Public Health Function. HMSO, London 1988.
WHO: Strengthening public health capacities and services in Europe: a framework for action. WHO Regional Office for Europe, Copenhagen 2011.
Piotrowicz M, Cianciara D, Wysocki MJ: Systemy zdrowotne dla zdrowia i dobrobytu – Karta z Tallina. Przegląd Epidemiologiczny 2009; 63(2): 321-324.
Bitrán R, Gómez P, Escobar L et al.: Review of World Bank‘s experience with country-level health system analysis. The World Bank, Washington 2010: 6-7.
Dercz M, Izdebski H: Prawne aspekty organizacji i funkcjonowania systemu zdrowia publicznego w Polsce. Analiza prawa ustrojowego, materialnego i formalnego; http://www.nierownosci.mz.gov.pl/__data/assets/pdf_file/0018/32625/Prawne-aspekty-organizacji-i-funkcjonowania-systemu-zdrowia-publicznego-w-Polsce.pdf (dostęp z dnia: 22.01.2016 r.).
Golinowska S (red.): Zarys systemu ochrony zdrowia. Polska 2012. NFZ, European Observatory on Health Systems and Policies, Warszawa 2012: 45.
Golinowska S (red.): Raport Finansowanie ochrony zdrowia w Polsce. Zielona Księga II. Wersja trzecia. Warszawa 2008: 10.
WHO: Integrated health services – what and why? Technical brief no. 1, May 2008.
Ministerstwo Zdrowia. Policy paper dla ochrony zdrowia na lata 2014-2020. Krajowe Ramy Strategiczne. MZ, Warszawa 2014: 126.
WHO: Modern health care delivery systems, care coordination and the role of hospitals. WHO Regional Office for Europe, Copenhagen 2012, 6-8.
U.S. Department of Health and Human Services. Healthcare Preparedness Capabilities: National Guidance for Healthcare System Preparedness. Office of the Assistant Secretary for Preparedness and Response 2012.
U.S. Department of Health and Human Services. Homeland Security. Healthcare and Public Health Sector-Specific Plan. An Annex to the National Infrastructure Protection Plan 2010.
WHO: Resolution EUR/RC62/R4. Health 2020 – The European policy framework for health and well-being. WHO Regional Office for Europe, 2012.
WHO: Review of social determinants and the health divide in the WHO European Region: final report. WHO Regional Office for Europe, UCL Institute of Health Equity, Copenhagen 2013.
WHO: Health 2020. A European policy framework and strategy for the 21st century. WHO Regional Office for Europe, Copenhagen 2013.
Opolski JT, Wysocki MJ: Zdrowie 2020 – nowe założenia polityki zdrowotnej. Cz. I. Przegląd Epidemiologiczny 2013; 67: 87-91.
Opolski JT, Wysocki MJ: Zdrowie 2020 – nowe założenia polityki zdrowotnej. Cz. II. Przegląd Epidemiologiczny 2013; 67: 735-739.
WHO: Information document. The evidence base of Health 2020. WHO Regional Office for Europe, 2012.
UCL Institute of Health Equity: Review of social determinants and the health divide in the WHO European Region. Final report. WHO Regional office for Europe, Copenhagen 2013.
WHO: Preliminary review of institutional models for delivering essential public health operations in Europe. WHO Regional Office for Europe, Copenhagen 2012.
WHO: Public health policy and legislation instruments and tools: an updated review and proposal for further research. WHO Regional Office for Europe, Copenhagen 2012.
Kickbusch I, Gleicher D: Governance for health in the 21st century. WHO Regional office for Europe, Copenhagen 2012.
WHO: The European health report 2015. Targets and beyond – Reaching new frontiers in evidence. WHO Regional Office for Europe, Copenhagen 2015.
Lipiec J: Kalokagatia. PWN, Warszawa 1988.
Woźniak Z: Globalizacja problemów zdrowotnych i starzenia się a rodzina. [W:] Tyszka Z (red.): Współczesne rodziny polskie. Ich stan i kierunek przemian. Wydawnictwo Naukowe Uniwersytetu Adama Mickiewicza, Poznań 2001.
The Council on Linkages Between Academia and Public Health Practice: Core Competencies for Public Health Professionals. June 2014.
Public Health Agency of Canada: Core Competencies for Public Health in Canada: Release 1.0. Ottawa, September 2007.
European Centre for Disease Control: Core competencies for EU public health epidemiologists in communicable disease surveillance and response. Technical document. Second revised edition. Stockholm, June 2009.
Australian Health Promotion Association: Core Competencies for Health Promotion Practitioners 2009.
Dempsey C, Battel-Kirk B, Barry MM: The CompHP Core Competencies Framework for Health Promotion Handbook February 2011.
European Union: Public Health Capacity in the EU – Final Report. EU 2013.
WHO: Review of public health capacities and services in the European Region. WHO Regional Office for Europe. Copenhagen 2012.
WHO: Self-assessment tool for the evaluation of essential public health operations in the WHO European Region. WHO Regional Office for Europe, Copenhagen 2015.
WHO: EUR/RC62/Inf.Doc./5 Strengthening public health services across the European Region – a summary of background documents for the European Action Plan. WHO Regional Office for Europe 2012.
WHO: Resolution EUR/RC62/R5 European Action Plan for Strengthening Public Health Capacities and Services. WHO Regional Office for Europe 2012.
WHO: European Action Plan for Strengthening Public Health Capacities and Services. WHO Regional Office for Europe Office for Europe 2012.
Merkur S, Sassi F, McDaid D: Promoting health, preventing disease: is there an economic case? Policy Summary 6. WHO Regional Office for Europe 2013.
WHO: The case for investing in public health. The strengthening public health services and capacity A key pillar of the European regional health policy framework Health 2020. WHO Regional Office for Europe, Copenhagen 2014.
Frenk J, Chen L, Bhutta ZA et al.: Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet 2010; 376(9756): 1923-1958.
Rozporządzenie Ministra Zdrowia z dnia 2 stycznia 2013 r. w sprawie specjalizacji lekarzy i lekarzy dentystów. Dz. U. 2013 poz. 26.