© 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).
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