strategic planning in public health: a program approach th tulchinsky md mph braun school of public...
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Strategic Planning Strategic Planning In Public Health: In Public Health: A Program ApproachA Program Approach
TH Tulchinsky MD MPHTH Tulchinsky MD MPHBraun School of Public HealthBraun School of Public Health
Hebrew University-Hadassah, JerusalemHebrew University-Hadassah, Jerusalem
October 2003October 2003
StrategyStrategy• A set of essential measures (preventive and
therapeutic) believed sufficient to control a health
problem (Last J. Dictionary of Epidemiology, 3rd
edition, 2000)
• A program or series of measures, stratagems and
activities planned and carried out for the purpose
of achieving specific objectives (Webtser
Dictionary)
Strategy and TacticsStrategy and Tactics• Strategy - A plan or method or series of maneuvers
or stratagems for obtaining a specific goal or result.
• The art and science of planning and directing large scale use of resources with long range planning and development to ensure success in achieving objectives e.g. prevent or successfully combat disease in a population, plan a military campaign
• Tactics – use and deployment of resources in actual field conditions e.g. military, police, firefighting, public health.
How to Fight and WinHow to Fight and Win• Who is the enemy?
• What are the enemy’s objectives?
• What are our objectives?
• What are their resources/capabilities?
• What are our resources/capabilities?
• How best can we achieve our objectives?
• What are the most suitable methods of combat?
• Intelligence and modification of strategy and tactics
Battle of the AtlanticBattle of the Atlantic• Phase I, June 1939-April, 1943
– Convoy system, British codes broken
– German wolf packs control of sea lanes increasing
– Allies build quantitative strength, new technology
– Air gap 800 miles
• Phase II May 1943-1945– Crisis April-May 1943 -the tide turns
– Allied quantitative and qualitative achievements
– Air gap closed; convoys plus hunter-killer groups
– Technological advances e.g. radar, squid, torpedoes
– German innovations too late
“The U-boat was the only thing I really
feared in WWII.”
Winston
Churchill
The Crisis of Battle of the Atlantic,
Aug 1/42 to May 21/43
Winston Churchill, World War II, Vol 5
B a ttle o f th e A tla n tic , 1 9 3 9 -4 5: S h ip su n k vs. S u b su n k
0
200
400
600
800
1000
1200
1 2 3 4 5 6 7
Shipsunk
Subsunk
Battle of the Atlantic: The Turning Point,March-June and Oct-Dec, 1943
Churchill, Second World War, Vol 5: Closing the Ring, pps10-13.
Month Tonnage sunk Subsunk air Subsunk sea Subsunk totalMarch 515 7 4 12April 242 8 6 15May 199 18 12 40June 22 9 6 17Oct-Dec 47 ships 53
Jack Maple’s Law, NYPD 1993-96Jack Maple’s Law, NYPD 1993-96
• Objective – reduce crime and murder rates
• Methods
– 1. Accurate and timely intelligence
– 2. Rapid deployment
– 3. Effective tactics
– 4. Relentless follow-up
– 5. Continuous assessment and data
• Murders fell from 1,946 (1993) to 1,000 (1996)
MVA Mortality and Mileage, MVA Mortality and Mileage, United States, 1925-1997United States, 1925-1997
Vehicle Miles Traveled
Deaths
Cardiovascular Disease Mortality Rates, Cardiovascular Disease Mortality Rates, United States, 1900-1999United States, 1900-1999
Expanded Host-Agent-Environment Expanded Host-Agent-Environment ParadigmParadigm
• HostHost - genetic, nutritional, life style, personality, psychosocial and other factors
• AgentAgent - microbiologic, toxic, stress, work, nutrient excess or deficiency
• EnvironmentEnvironment – vector, physical-societal context• InterventionIntervention - clinical, preventive, environment
HostHost
AgentAgent EnvironmentEnvironment
HostHost EnvironmentEnvironment
AgentAgent InterventionIntervention
Determinants of Population HealthDeterminants of Population Health
Health ServicesHealth Services
Income & Social Status
Social Support Networks Education
Employment &working
conditions
Physical environments
Biology &genetic
endowment
Personal healthpractices &
coping skills
Healthy child
development
A Comprehensive Health Services A Comprehensive Health Services Continuum: ManitobaContinuum: Manitoba
Healthy Public PolicyPreventionPromotionProtection
CommunityOrientedServices
SupportServices
ToSeniors
Home Care
CommunityHealth Centres
ExtendedTreatment &
Long Term Care
OutpatientAmbulatory
Care
RuralCommunity
UrbanCommunity Tertiary
Rehabilitation
Palliation
HospitalsPromotionPromotion PalliationPalliation
Health ResourcesHealth Resources• Political and public support
• Community and media expectations and support
• Manpower and training
• Money
• Facilities for in-patient care – acute and LTC
• Community care – clinics, outreach, home care
• Drugs
• Vaccines
• Education
Healthy InfantsHealthy Infants• Healthy women in age of fertility e.g. iron and
folate• Good prenatal care and risk assessment• Good care during delivery e.g. in hospital• Good neonatal care e.g. vitamin K• Good infant care e.g. immunization, • Growth and development monitoring• Breast feeding plus vitamins A, C, D, iron• Formulas to one year• Solid foods from 4 months • Warmth, care, stimulus
Infant Mortality, United States, 1900-1999Infant Mortality, United States, 1900-1999
Maternal Mortality, United States, Maternal Mortality, United States, 1900-19991900-1999
Communicable Disease ControlCommunicable Disease Control
• Sanitation and hygiene• Safe water and food• Sewage collection and treatment• Education - public, professional, patients• Epidemiologic reporting, surveillance• Training in PH, epidemiologic investigation • Up to date immunization program• Good programs for “Social Diseases” i.e TB, STDs,
HIV, Hep B, Ca Cx• Good primary and secondary care treatment • Good laboratory support
Social Diseases: TB, STIs, HIV, Social Diseases: TB, STIs, HIV, Hepatitis, Cancer of CervixHepatitis, Cancer of Cervix
• Common risk groups and factors • “Noxious synergy”• Prevention and treatment strategies e.g anti-
retroviral drugs, immunization• Ambulatory and community care• Screening and case contact follow-up• Community outreach• Education• Specialized tertiary care and terminal care• Long term strategies for sustainable success
AIDS Incidence, Deaths and Prevalence, AIDS Incidence, Deaths and Prevalence,
United States 1981-2000United States 1981-2000
DeathsAIDS
Prevalence
1993 DefinitionImplementation
Safe Community Water SuppliesSafe Community Water Supplies
• Safe water sources – contamination• Coagulation• Filtration• Disinfection and residual chlorine - mandatory• Routine testing – bacterial and chemical• Routine chemical testing• Sanitary engineering inspection• Safe distribution and drainage systems• Updated standards• Epidemiologic monitoring of diseases
Non-Communicable Disease ControlNon-Communicable Disease Control
• Primary prevention– Reduce CVD risk factors – BMI, exercise, smoking – Good nutrition e.g. much vegetables, little fat
• Secondary Prevention– Hypertension and diabetes control– Good treatment of AMI, stroke– Technology assessment and adoption
• Tertiary prevention– Good long term care in community – Hospital care in extremis
Motor Vehicle Trauma ControlMotor Vehicle Trauma Control
• Primary prevention – Transport policy e.g. trains vs. cars– Laws and policing e.g. speed, seatbelts, helmets– Roads e.g. shoulders, roundabouts, lights– Alcohol control e.g. supply, taxation, – Education
• Secondary prevention– Emergency care at site– Good emergency transportation– trauma care in hospital– Good hospital care and training
• Tertiary prevention– Good rehabilitation care
SummarySummary
• Define the problem• Adopt program approach• Develop an intervention program and budget• Inter-sectoral cooperation• Political support and resources• Management group• Technology - “the state of the art”• Define realistic alternative approaches• Implementation tactical program• Intelligence i.e. continuous monitoring • Reevaluation and revision • Communicate what you are doing