HSC 6636: Public Health 1 Dr. Lawrence West, Health Management and Informatics Department,...

HSC 6636: Public Health

1Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest

Topics

• What is Public Health?• Public Health Functions• Government Authority for Public Health• Challenges and Opportunities

“Public health affects the lives of Americans profoundly, but more often than not it is invisible to them.”

Text, p. 58



The Public Health Problem

• Can we postulate that efforts to achieve public health are not as effective as they could be?– Or that the level of public health is not as high as it

could be?• If so, we want to look for all of the factors raised

in the chapter that impede achieving the best possible level of public health

• Also identify those efforts that are helpful– Why were they implemented?– Why are they helpful?– Who pays and who benefits?



History of Public Health

• What are the implications of Table 4.1 for the efficient maintenance of public health in the United States?

• Just as we did with health care financing, outline the history of public health in the U.S. and how this history resulted in the structure of public health activities we have today.



What is Public Health?

• Three Assumptions (p. 91)– Healthy population is in the public interest– Health is strongly determined by community and

societal-level forces– Working at a collective or community level, these

forces can be marshaled to improve a population’s health



What is Public Health (cont.)

• Public Interest in Public Health– The text gives limited justifications for how public

health is in the public interest– Expand all of the mechanisms through which

individual and collective welfare is improved when your neighbors are healthy…

– …or when efforts to improve public health are undertaken

• Is Health a “right” as defined by the WHO? (p. 92)




• Determinants of Health– “Yet health care services account for an estimated

95% of federal health expenditures, even though effective public health interventions would do much more to improve health” (p. 93)

– “It then follows that the nation’s heavy investment in the personal health care system is a limited future strategy for promoting health” (pp. 93-4, quoting Institute of Medicine, 2003)

• Once again, why is it that we see this situation?

Individual behaviors (50%)

Genetic makeup (20%)

Medical practice

(10%)

Environment

(20%)

Source: HAS 3111 Slides




• Determinants of Health (cont.)– Consider the section “Challenges for Public Health

Policy” on p. 94. What argument is this section making…?

• Importance • Prevalence• Modifiability • Effectiveness of

Changes– … and how come the authors concluded with this

statement, “Yet with notable exceptions, the public health field has been slow to adopt evidence-based practice or the analysis of effectiveness and cost-effectiveness.” (p. 94)

See next slide




• Intervention Considerations for a health risk from p. 94– Importance: How big an impact does the risk

have?– Prevalence: How common is the risk?– Modifiability: How easy is it to change the risk?– Effectiveness: How easy is it to change the

outcomes of the risk (impacts on quality of life)?• Let’s add

– Acceptability: The willingness of individuals or groups to accept specific interventions




• Three Categories of Intervention– Primary Prevention: Avoid the onset of a condition– Secondary Prevention: Identifying and treating

people with risk factors or preclinical disease– Tertiary Prevention: Treating an established

disease to restore functioning, minimize negative impact, or prevent complications

• Prevention Targets– Universal– Targeted




• We have developed a framework for evaluating public health activities

– Risk intervention considerations

• Importance • Prevalence

• Modifiability • Effectiveness of Changes

• Acceptability

– Categories of intervention

• Primary • Secondary

• Tertiary

– Intervention target

• Universal • Targeted



Public Health Functions

• Distinctive* Approach to Problem Solving– Assessment– Policy Development– Assurance (monitoring)

* This approach isn’t distinctive at all. Many disciplines with a formalized decision making process have these steps in disciplines as diverse as military decision making and the systems development lifecycle taught in informationsystems courses



Public Health Functions (cont.)

• Assessment– Which element(s) of our framework does

assessment affect?– What tools are available for performing

assessment?• Revisit Chapter 2• How have these tools changed over time?• What weaknesses remain?




• Policy Development– What is “policy development”?– Name a public health policy not mentioned

in the text• Identify policy originator• Whether formal or informal

– Give examples of agencies or types of individuals that engage in policy development




• Assurance– Assurance is the ability to ensure that policies are

implemented and followed• Communication • Monitoring and detection• Enforcement

& correction– West’s Comment: Any organization’s (including

government’s) effectiveness is in large part tied to its ability to enforce its will across the decision space over which it claims authority. The quality of the decisions are also important.




• Assurance (cont.)– What are the bases for most forms of assurance in

government activities (including health care)?




• Problem Solving Example (pp. 101-2)

– Note the 6-step process listed here (in contrast to the 3-step process on p. 99)

– Also note the interweaving of the three steps within the six-step process

– And the multiple agencies involved• Consider the 6th step, “Revisit and Refine” as

being cyclically related back to the first step, “Define the problem”– If the evaluation reveals continuing issues these

become the kickoff of a new solution round




• Overlap in Functionality– Note the multiple mentions of layers of

responsibility for many issues– Each participant has distinct motivations,

decisions, costs, and expected payoffs– Identify when these conflict and align– What impediments are there to cooperation?



Governmental Authority for Health

• In 1974 the United States implemented a national 55 MPH maximum speed limit to conserve fuel in the wake of the 1973 oil crisis

• Where is the constitutional authority for this law?• How was it actually implemented and enforced?• What are the implications for health care policy



Governmental Authority for Health (cont.)

• Federal Agencies– No fewer than 13 major agencies under DHHS– Also VA, USDA, EPA, NHTSA, OSHA, HUD

• State Agencies– No uniform organization among the states

• Division of responsibility between state & local• State laws “fragmented and badly out of date”

(p. 109)

• What states actually provide– Professional licensing



Challenges and Opportunities

• New Name for National Association of County and City Health Officials

• Improving competencies– Performance standards– Performance evaluation– What are the costs and payoffs!!?

• Standardizing services• Accrediting services



Challenges and Opportunities (cont.)

• What do the lessons of Hurricane Katrina have for public health services in the U.S?

• What other threats are looming?– Are public health organizations prepared for

these?– What about individuals?




• Consider a repeat on the scale of the 1918 influenza pandemic– 40-50 million deaths in 18 months worldwide– 550,000 deaths in the U.S. (out of 92 million)

• What would be the impact on and what preparations should these agencies conduct?– A private hospital ‒ Law enforcement– Medical office ‒ School board– Grocery chain ‒ County health

department




• Bioterrorism and mass casualty terrorist threat– Some funding resources

• Efforts to modernize public health statutes• Resistance to public health efforts on the

grounds of individual liberty or political or religious beliefs– Develop a chain of causality that might lead to

someone believing that adding fluoride to the municipal water supply was a Communist plot




• Public Relations– Is it justifiable for public health officials to lobby for

increased funding?– What weaknesses do public health organizations

have with respect to funding?– What impediments are there to building trust with

the public?



Governmental Authority for Health (cont.)

• State & Federal Relations– Dominated by funding– Categorical funding removes flexibility– Tradeoffs

• Local knowledge and resources• National resources • Economies of scale and scope at the national

level– Federal government authorized to act in multi-

state situations

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HSC 6636: Public Health 1 Dr. Lawrence West, Health Management and Informatics Department,...

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