Essential Public Health Functions: Public Health System Performance

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Essential Public Health Functions Public Health
System Performance
10/14/2005
Kelly Saldana, MPH, MPIA
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Effective Health Systems are Important to Ensure
the Sustainability of Public Health Interventions
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Which Came First . . . ?
Public Health Programming for Sustainability
Public health interventions should take into
account system issues. Strengthening systems
through specific public health interventions will
lead to overall system strengthening OR The
effective performance of public health functions
throughout the health sector leads to improved
outcomes in public health interventions.
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Health System Strengthening through the lens of
the Essential Public Health Functions
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Evolution of Public Health Functions

• 1988 IOM publishes The Future of Public
  Health identifies core functions in public
  health assessment, policy development, and
  service assurances, and identifies the level of
  government--federal, state, and local--at which
  these functions would best be handled. (Report
  Updated in 2002)
• CDC Center for Public Health Practice established
  
• 1997 WHO Essential Public Health Functions
  Working Group Part of renewal of Health for
  All initiative International Delphi study
  identifies 25 public health functions
• 1998 US National Public Health Performance
  Standards Program developed 10 Essential Public
  Health Services and assessment instruments
• 2001 Public Health in the Americas Initiative
  develops 11 EPHFs and assessment tool which is
  applied throughout the Americas

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What are Essential Public Health Functions?

• Policy development
• Social Participation in health (EPHF4)
• Development of policies institutional capacity
  for planning management in public health
  (EPHF5)
• Evaluation and promotion of equitable access to
  necessary health services (EPHF6)
• Strengthening institutional capacity for
  regulation enforcement in public health
  (EPHF7)
• Quality assurance in personal and population
  based health services (EPHF9)
• Collection dissemination of evidence for health
  policies
• Monitoring, evaluation and analysis of health
  status (EPHF1)
• Research in public health (EPHF10)
• Prevention and control of diseases
• Public health surveillance, research and control
  of risks and threats to public health (EPHF2)
• Health Promotion (EPHF3)
• Reducing the impact of emergencies and disasters
  on health (EPHF11)
• Human resource development
• Human resources development and training in
  public health (EPHF8)
• Intersectoral action for better health

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Why public health functions?

• Failures/Declining Capacity in public health
• Shifts in demographic and epidemiological trends,
  
• Changes to the health environment or determinants
  of health
• Provide a foundation for any public health
  activity
• Mechanisms for ME are inherent in several public
  health functions
• They emphasize institution and capacity building
  for sustainability
• They describe a spectrum of competencies for
  health systems
• No particular organizational structure
• all key to the MDGs and the realization of
  other global initiatives

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A focus on Essential Public Health Functions is
used to advance work in Health Systems/Services
Country Examples

• Indonesia a focus on decentralization
• Hungary a focus on health promotion and NCDs
• Russia process of consensus building around
  core public health functions
• China to strengthen the public health response
  to SARS and other emerging threats
• Georgia enhancing the ability to act on public
  health information
• LAC- as part of health reform/system
  strengthening agenda
• India to understand governance issues

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Using the Essential Public Health Functions to
Prioritize National Level Action in Health Systems
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Essential Public Health Functions Measurement Tool
What is it?

• Systems view of public health service delivery
• Measures specific aspect of stewardship (steering
  role)
• Emphasis is on Functions, governance and
  organizational structures need to be examined
  separately
• Evaluates whether certain functions are performed
  
• not how well they are performed
• Self-evaluation of the public health system
• polls of experts
• Results reflect perceptions of officials
  regarding the effectiveness of different
  functions
• Negative results can be more informative than
  positive results

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Essential Public Health Functions Measurement Tool
What can it do?

• Used to identify the most pressing gaps in public
  health services
• Identifies optimal level of performance
  stimulates higher achievement by providing
  benchmarks which systems can strive to achieve.
  Each function represents the gold standard of
  performance
• Process for continuous quality improvement of
  public health practice
• Can identify problems in translating
  resources/activities into effective use or into
  health outcomes
• Brings different actors in the system to the same
  table increases communication
• Reorient resource allocation toward specific
  public health interventions

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Where has it been applied? What flexibilities
does it have?
Essential Public Health Functions Measurement Tool

• U.S. Used at state and local levels, responses
  on a scale of 1 to 4
• Latin America by group consensus regional and
  sub-regional aggregation of data
• India individual responses robust data for
  each indicator, can be disaggregated by level of
  the health system
• Fiji, Malaysia, Viet Nam as a case study guide
  for developing proposals to strengthen the EPHFs
  and protect their implementation

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What kind of information can I get from this tool?

• Summary Results (by function) . . .

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Aggregated by Region
Source Pan American Health Organization/World
Health Organization, Public Health in the
Americas Conceptual Renewal, Performance
Assessment and Bases for Action. 2002
Washington, DC. PAHO
15
Country Level Results
Source Das Gupta, M Rani, M. Indias Public
Health System How well does it function at the
national level? World bank Policy Research
Working Paper 3447. 2004. Washington, DC. World
Bank
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What kind of information can I get from this tool?

• Results by Indicator . . .

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• Indicator analysis allows for the identification
  of specific weaknesses within each function

Source Pan American Health Organization/World
Health Organization, Public Health in the
Americas Conceptual Renewal, Performance
Assessment and Bases for Action. 2002
Washington, DC. PAHO
18

• By indicator EPHFs can be broken up into
  component parts to analyze broader aspects of the
  health system

Source Pan American Health Organization/World
Health Organization, Public Health in the
Americas Conceptual Renewal, Performance
Assessment and Bases for Action. 2002
Washington, DC. PAHO
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• Indicator analysis allows for diagnosis of
  specific deficiencies in meeting public health
  objectives
• 9.2 Improving user satisfaction with health
  services
• 4.1 Empowering civil society for decision
  making in public health
• 7.3 Advocacy and action to improve access to
  necessary health services

Source Pan American Health Organization/World
Health Organization, Public Health in the
Americas Conceptual Renewal, Performance
Assessment and Bases for Action. 2002
Washington, DC. PAHO
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What kind of information can I get from this tool?

• Results by Specific Questions/Sub questions. . .

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• Additional information can also be obtained by
  analyzing responses within indicators

Source Das Gupta, M Rani, M. Indias Public
Health System How well does it function at the
national level? World bank Policy Research
Working Paper 3447. 2004. Washington, DC. World
Bank
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Indicator Analysis to Identify Discrete
Improvement Actions
Source Das Gupta, M Rani, M. Indias Public
Health System How well does it function at the
national level? World bank Policy Research
Working Paper 3447. 2004. Washington, DC. World
Bank
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What kind of information can I get from this tool?

• Regional Results . . .

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Analysis by Socio-Economic Features
Source Pan American Health Organization/World
Health Organization, Public Health in the
Americas Conceptual Renewal, Performance
Assessment and Bases for Action. 2002
Washington, DC. PAHO
25
Analysis by Health Outcomes
Source Pan American Health Organization/World
Health Organization, Public Health in the
Americas Conceptual Renewal, Performance
Assessment and Bases for Action. 2002
Washington, DC. PAHO
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Future Directions for Work on Public Health
Functions

• Costing of public health functions
• Use of the measurement tool for continuous
  quality improvement
• Development of best practices for strengthening
  the EPHFs
• Wider acceptance/promotion/application of the
  approach as a key part of health systems work

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Is it possible to make a significant difference
in health outcomes by focusing on health systems
interventions?

• Which comes first?

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Pearls?
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Sources for Additional Information

• Bettcher, D Sapirie, S Goon, E. Essential
  public health functions results of the
  international Delphi study. World Health
  Statistical Quarterly. Vol. 51 No. 1 1998.
  Geneva. World Health Organization
• Centers for Disease Control and Prevention
  National Public Health Performance Standards
  Program http//www.cdc.gov/od/ocphp/nphpsp/
• Claeson, M Elmendorf, E Miller, D Musgrove, P.
  Public Health and World Bank Operations. 2002.
  Washington DC. World Bank http//siteresources.wor
  ldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/
  Peer-Reviewed-Publications/PHOperations.pdf
• Das Gupta, M Rani, M. Indias Public Health
  System How well does it function at the national
  level? World bank Policy Research Working Paper
  3447. 2004. Washington, DC. World Bank
  http//econ.worldbank.org/files/40042_wps3447.pdf
  
• Pan American Health Organization/World Health
  Organization, Public Health in the Americas
  Conceptual Renewal, Performance Assessment and
  Bases for Action. 2002 Washington, DC. PAHO
  http//www.campusvirtualsp.org/eng/pub/PublicHealt
  hAmericas/index.html
• World Health Organization Regional Office of the
  Western Pacific, Essential Public Health
  Functions A three country study in the Western
  Pacific Region. 2003. http//www.wpro.who.int/NR/r
  donlyres/7472FD5D-BBD0-4640-8EB8-3EAC8A2276B9/0/Es
  sential_public_health_functions.pdf