module one-main

8/7/2019 MODULE ONE-MAIN

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MODULE ONE: CONCEPTS, PRINCIPLES AND

APPREOACHES OF PUBLIC HEALTH

By

Dr. Mwitari

1. Concepts, Principles and Approaches of Public Health

Topical Outline:i. Understanding public health

ii. Principles of public health: equity, access (availability, affordability and

acceptability), participation, disease prevention, health promotioniii. Vulnerable and disadvantaged groups

iv. Quality of health care and quality assurance in health care servicesv. Health Reforms (HRs)

vi. Primary Health Care (PHC) approachvii. The Bamako Initiative (BI)

viii. Millennium Development Goals (MDGs)

Understanding Public Health

Public health is derived from the terms public and health. Public refers to that which is of or concerns all people, while health refers to the state of holistic well-being, i.e.

physically, mentally, socially, and spiritually. The concept of disease refers to the state of

physiological and / or psychological dysfunction. Public health therefore may be definedas the combination of scientific knowledge, skills, attitudes / beliefs, and practices that isdirected to the improvement and maintenance of the health of all people. This is

contrasted with preventive medicine which is the branch of medicine that is concerned

primarily with preventing physical, mental and emotional disease and injury, in contrastto treating the sick and injured. Examples of public health concerns include:

• Large populations – large gatherings as in sports or other festivals, institutionslike schools and prisons, etc

• Human habitat / environment - housing, eating places, recreational places, etc

• Environment – physical, biological, chemical, and social

• Mobility – transportation, migrations, etc

Along with these concerns, public health faces challenges that include lack of resources,

rapid population growth, lack of awareness and motivation (KAS&P), inadequateplanning, and inappropriate and ineffective approaches and low quality of service.

The quality of health care services is constrained by poor access to health care, i.e.availability, acceptability and affordability, client satisfaction, and provider

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ineffectiveness and inefficiencies. Due to economic and social constraints, there is also a

general lack of adequate supervision, monitoring and evaluation, and overall quality

assurance.

While the focus of public health is all the people, emphasis is given to those who are

more vulnerable and disadvantaged, particularly children and women, the elderly, therural and urban poor, as well as those in risky occupations and workplaces.

Principles of Public Health

Public health is guided by the principles of equity, access, participation (community

participation, intersectoral collaboration and coordination, and participatory leadership)in facilitating the improvement and maintenance of health. Further, public health

emphasizes the principles of disease prevention and health promotion.

Equity of health care emphasizes provision of quality health care to all people accordingto need, without favour or discrimination, and on fair distribution of resources for health

care. This calls for mobilization of resources from viable sources wherever it is availableand distributing it to where it is needed for utilization. Note that equity does not

necessarily mean equal distribution, as health need and problems will not be equal for all

people. Children and women, for example, will have more health needs and problems

than the rest of the people.

Access to health care services in terms of physical availability, cost affordability and

socio-cultural acceptability are important factors in public health. People living near health care facilities tend to utilize the facilities more than those living far away. Barriers

like hills and mountains, valleys and rivers may prevent others from accessing health care

services. If the services cost a lot of money and time, people may be not be motivated toutilize them. Lastly, services should be socially and culturally acceptable to the people

they are meant for; otherwise they will shy away from them.

Community participation emphasizes the people’s involvement in identification and

prioritization of their problems, and in making decisions on interventions and

implementing them based on appropriate knowledge and using locally available resources

and appropriate technologies. Involvement commits people to willingly take part inactivities aimed at improving and maintaining their health. The level of commitment is

such that the people are willing to commit their resources and time for this for the

meeting and solution of their health needs and problems respectively. Active participationof the community in planning, implementation and evaluation of a health or health related

activity ensures acceptance, effectiveness, efficiency and sustainability, as well as

people’s ownership of the of the outcome of the activity in the spirit of self reliance andself determination. Effective participation requires that appropriate leadership that

facilitates people’s participation in decision making, implementation and evaluation as

well as feedback. This also fosters the involvement of other sectors in health care

activities, in recognition of the fact that good health results from different activities

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involving different sectors and professionals including health, agriculture, education,

water, works and housing, among others. Such collaboration is important for making

work easier by distributing roles and responsibilities appropriately, avoiding duplication,and fostering collaboration between sectors, and bringing about synergy of effort.

Public Health Approaches

Public health action focuses on three approaches, i.e. attacking the causative agent,

preventing its transmission, and enhancing the host defenses. The hallmark of publichealth is in the treatment of the sick, disease prevention, and health promotion. In

addition to improving the health of those affected, appropriate and effective treatment

removes the risk of spread of disease. Prevention of disease and promotion of health

ensure maintenance of health by removing the factors that aid the occurrence of diseaseand improving the capacity of the population to combat disease, which the main purpose

of public health.

Disease Prevention Approaches

Approaches for disease prevention include environmental management, immunization,appropriate behaviour, adequate good nutrition and prudent health care as well as

genetics and eugenics.

Environmental management includes sanitation (sanitary revolution during the 19thcentury), good housing with less crowding (small family), food hygiene, and ecological

changes. This area is given prominence in the health care systems of many countries and

dedicated departments and professionals in environmental health and other aspects of public health.

Immunization aims to increase both individual immunity and herd immunity and reducesusceptibility to infection. A good example of the success of immunization is the

eradication of smallpox in 1980 and the reduction of the immunization preventable

childhood diseases like polio, pertusis, diphtheria and tetanus.

Individual and group behaviours are also targeted in disease prevention. Such behaviours

include personal hygiene practices, appropriate eating habits, small family size, etiquette,

avoidance of substance abuse, legislation such as traffic laws, and safety seatbelt use invehicles for prevention of injury in case of accidents. In many countries smoking in

public is banned as a measure of cancer prevention.

Adequate food supply (production, distribution and utilization) and appropriate use

ensures that the people don’t have adequate nutrition without malnutrition, i.e. under-

nutrition such as kwashiorkor (PEM) and marasmus or over-nutrition such as obesity andheart disease. Adequate nutrition ensures avoidance of nutritional diseases such as

coronary heart disease, diabetes, and dental caries among others.

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Genetic and eugenics also have the potential for disease prevention and health promotion,

but these have not been may not be accepted for use in humans for ethical and moral

reasons The genetic approach takes the form of genetic counseling.

Prudent health care calls for timely health seeking behaviour and compliance to health

advisories. To do this, people need adequate knowledge on relevant education regardingtheir health and what it takes to improve and maintain health. This enables people to

make informed decisions and take the necessary actions.

Health Promotion Approaches

The health promotion approach includes health education and health information,

preventive measures, pro-health public policies and development, and environmentalsafety and security. Health promotion enables people, i.e. individuals, families, groups

and communities, to optimize their health and well being. Health promotion leads to a

spiral of health gain, i.e. the improvement in health status, in an individual or population,

attributable to an earlier intervention – thus the health gain spiral. The health promotionapproach ensures well-being and good health and gives people the ability to participate in

life activities with balanced physical, emotional, social and spiritual health respectively.The components of the health promotion approach entails education on health and health

related issues, environmental changes, behaviour enhancement (healthy behaviour), and

disease prevention (access to and utilization of preventive health services). This calls for

investing in health promotion that involves:

• Developing and establishing effective policies and services respectively

• Improving standards of living• Improving the environment (hygiene and sanitation)

• Promoting and practicing healthy lifestyles (behaviour)

• School health programmes• Community sensitization and mobilization

Vulnerable and Disadvantaged Groups

Vulnerability refers to the proneness to harm or injury, exposure to attack (to disease and

ill-health). Disadvantage on the other hand refers to unfavourable situation or handicap.

Children, women, the Elderly, rural and urban poor, and occupational groups such as

commercial sex workers, and long distance truck drivers among others, are considered

vulnerable to various health risks.

These vulnerable groups bear the greater burden of disease compared to the rest of the

population. Understandable, children have not developed their own immune and copingmechanisms and are dependant on other persons for their health and general well being.

Women on the other hand have a greater burden in society, including both social and

biological situations that make them vulnerable to disease. Similarly, the elderly are

reduced to the situation of children by the ageing process. The body defenses are

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degenerating and not regenerating any more. Commercial sex-workers and long distance

truck drivers are particularly vulnerable to sexually transmitted diseases, including

HIV/AIDS.

Quality of Health Care and Quality Assurance in Health Care Services

Quality of health care may be viewed in terms of access (availability, affordability and

acceptability), client satisfaction, and effectiveness and efficiency of the health care

provider. This is in line with the purpose of a health care system, i.e. to improve andmaintain the health of the community. Thus, access, satisfaction and effectiveness and

efficiency form the criteria for determination of the quality of health care.

Quality assurance is the process of assessing and monitoring the care of patients andassuring a high level of quality care by monitoring and checking the provision of services

in order to improve and maintain an acceptable degree or standard of excellence, and by

peer review and accreditation programmes, i.e. the capability of health professions to

monitor their own activities and to take action in the interest of maintaining standards.

By implication, quality assurance may be done internally (self-regulation) or externally inrespect to the health care providers. In the first instance, health providers may themselves

set rules and standards of performance which they enforce through predetermined

processes. This is seen in institutions where technical and management standards are

formulated for various processes and procedures and brought to the attention of staff for compliance by staff of the institution. The formulation of the standards may or may not

involve the staff depending on the type of leadership and institutional governance

systems. The latter is where standards are set by external agencies such as government or profession registration bodies and circulated to practitioners for compliance by individual

practitioners or institutions. This may involve legal or regulatory statutes being enacted

and enforced.

The quality of health care may be assessed in several ways three of which are listed

below:

o Review of utilization of health care services to assess utilization of facilities and

services

o In-depth evaluation of medical care

o Profile analysis to identify practitioners or institutions that are performing outside

accepted or defined bounds or norms

Health Sector Reforms

Health Reform is a process of deliberate positive change in the health care systems aimed

at improving the quality of health services delivery and health outcomes. Health Sector Reforms (HSRs) emphasize improvement of quality and equity through effective

resource management for improved performance. The general areas of focus include

structural changes, resource rationalization, and legal reforms.

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Structural reforms take the form of decentralization and intersectoral coordination.

Decentralization refers to the reorganization of management to outside units and may bedone in one of several ways including deconcentration, devolution, delegation, and

privatization. Deconcentration refers to the transfer of administrative responsibility to

local health sector units / offices. This may be vertical or integrated. Devolution is theshifting of authority to sub-national levels of government – region, district, county, or

other local authorities, giving functional independence from the central / national level.

Delegation is the transfer of managerial responsibility for certain functions toorganizations outside the central government structure, i.e. to local units or regional

bodies. Privatization is the shifting government functions to voluntary organizations or to

for-profit or non-profit organizations / agencies. Privatization of health care would mean

the government ceding the provision of health care to private health care providers andremaining with policy and regulatory roles.

Intersectoral coordination is the process of involving different sectors in health care.

Indeed several sectors have a contribution to health. For example, agriculture is key infood production while industry and trade are key in food processing and distribution.

Similarly, education and information sectors are important in information sensitization of communities on health issues. Other sectors also play different roles in relation to health.

The involvement of all these sectors enhances the attainment and maintenance of good

health and general well being.

Reforms in resource rationalization include changes in resource mobilization and

management, financial reforms and human resource rationalization. The purpose of

changes in mobilization and management of resource is to increase accountability andtransparency, avoiding wastage through theft, fraud, and corruption, particularly of

financial resources. Human resource rationalization aims to create a more effective

workforce that is well motivated and committed to results.

Legal reforms take the form of policy formulation and improvement of the planning

process, performance standards and performance monitoring. Legal statutes for theregulation of health care and control of health care standards are the focus of legal

reforms. This included the formulation of relevant policies relating to the organization

and delivery of health care services, as well as conditions that promote well being of all

people. Performance standards and performance monitoring have are implementedthrough commitments in performance contracts and other tools for control of

performance including job-descriptions and duty rosters.

In recent years health reforms have been made a condition for financial support to

developing countries by developed countries. The rationale for this is poor management

and corruption in the management of donor finances. In Kenya, health reforms have beenemphasized since the 1990s, although actually there have been reforms since

independence in the 1960s. (See table on history of health reforms in Kenya in Section

2).

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Primary Health Care

After the 2nd World War, consciousness of the gap between the developed and developingcountries was not only seen as an economic gap, but also as a gap in many social spheres

including health. Vertical programmes were started in both developed and developing

countries for the control of selected diseases such as malaria, tuberculosis among others.Many of these programmes focused on the development of health facilities and training

health personnel in the curative aspects of disease control. In the mid-seventies debate

was initiated on the need for an approach that was more oriented towards participation of for the control of common diseases and solution of common health problems. The

landmark event on primary health care was the International Conference on Primary

Health Care that took place at Alma-Ata in the then Soviet Union from September 6 to

12, 1978. The WHO Assembly adopted the Alma Ata Declaration the following year.

The Alma Ata Declaration defined Primary Health Care (PHC) as “essential health care

based on practical, scientifically sound and socially acceptable methods and technology

made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at

every stage of their development in the spirit of self-reliance and self-determination. Itforms an integral part both of the country's health system, of which it is the central

function and main focus, and of the overall social and economic development of the

community. It is the first level of contact of individuals, the family and community with

the national health system bringing health care as close as possible to where people liveand work, and constitutes the first element of a continuing health care process.” This is a

moving and winding definition that spells out key elements and principles of health care.

The Alma Ata Declaration on Primary Health Care elaborated eight elements of priority

essential basic services for implementation of the PHC approach, and countries were free

to add to the list any other element deemed priority in their own situations. The eightbasics services are education concerning prevailing health problems and the methods of

preventing and controlling them; promotion of food supply and proper nutrition; an

adequate supply of safe water and basic sanitation; maternal and child health care,including family planning; immunization against the major infectious diseases;

prevention and control of locally endemic diseases; appropriate treatment of common

diseases and injuries; and provision of essential drugs. It also elaborated a number of

principles, including equity, universal access, community participation, intersectoralcollaboration, participatory leadership, appropriate technology, and overall community

development for self-reliance and self-determination.

Implementation of PHC has not been fully implemented and has not achieved the goal of

Health for All. Implementation has been done selectively for some of the elements

elaborated in the declaration due to inadequate capacity of countries to implement thewhole package of essential services. In Kenya, this has seen the development of selected

vertical programmes based on the elements, including immunization, Health Education,

Maternal and Child Health, Nutrition, Malaria, and Diarhoea among others.

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The Bamako Initiative

The Bamako Initiative (BI) on community financing and management of primary healthcare, was formulated at a WHO/AFRO meeting of Health Ministers in 1987 at Bamako,

Mali as a way of accelerating the implementation of primary health care. This was after

the realization that the implementation of PHC was slow and would not meet the goal of HFA-2000. The BI aimed to increase the role of communities in the provision of health

care through financing and management, as a way of accelerating access to primary

health care services.

In Kenya there are three components of the BI:

1. Cost sharing in health care

2. Community participation in the management of health care through DistrictHealth Management Boards and Health Facility Management Committees.

3. Community Pharmacies (Commonly referred to as BI)

The Millennium Development Goals

The Millennium Development Goals (MDGs) are eight goals to be achieved by 2015 thatrespond to the world's main development challenges. The MDGs are drawn from the

actions and targets contained in the Millennium Declaration that was adopted by 189

nations-and signed by 147 heads of state and governments during the UN Millennium

Summit in September 2000.

• Goal 1: Eradicate extreme poverty and hunger

• Goal 2: Achieve universal primary education

• Goal 3: Promote gender equality and empower women

•

Goal 4: Reduce child mortality• Goal 5: Improve maternal health

• Goal 6: Combat HIV/AIDS, malaria and other diseases

• Goal 7: Ensure environmental sustainability

• Goal 8: Develop a Global Partnership for Development

While the MDGs focus on the reduction of poverty, it is recognized that this can not be

achieved if the health of the people is not improved and maintained at levels to enable

them lead productive lives. Three out of the eight goals (goals 4, 5 & 6) are directlyhealth. For the dame reason, the rest are equally related to health.

The MDGs synthesize, in a single package, many important commitments made

separately at international conferences and summits of the 1990s. They recognizeexplicitly the interdependence between growth, poverty reduction and sustainable

development, and acknowledge that development rests on the foundations of democratic

governance, the rule of law, respect for human rights and peace and security. They are

based on time-bound and measurable targets accompanied by indicators for monitoringprogress; and they bring together, in the eighth Goal, the responsibilities of developing

countries with those of developed countries, founded on a global partnership endorsed at

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the International Conference on Financing for Development in Monterrey, Mexico in

March 2002, and again at the Johannesburg World Summit on Sustainable Development

in August 2002.

In 2005, the Secretary-General prepared the first comprehensive five-yearly report on

progress toward achieving the MDGs The report reviews the implementation of decisionstaken at the international conferences and special sessions on the least developed

countries, progress on HIV/AIDS and financing for development and sustainabledevelopment.

Kenya is signatory toe the Declaration of the MDGs, and reports regularly on the same.

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