Strategic Planning In Public Health: A Program Approach

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Strategic Planning In
Public Health A Program Approach

• TH Tulchinsky MD MPH
• Braun School of Public Health
• Hebrew University-Hadassah, Jerusalem
• October 2003

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Strategy

• 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)

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Strategy 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.

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How to Fight and Win

• Who is the enemy?
• What are the enemys 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

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Battle 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

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The U-boat was the only thing I really feared in
WWII.Winston Churchill
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The Crisis of Battle of the Atlantic, Aug 1/42
to May 21/43Winston Churchill, World War II,
Vol 5
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Jack Maples 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)

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MVA Mortality and Mileage, United States,
1925-1997
Deaths
Vehicle Miles Traveled
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Cardiovascular Disease Mortality Rates, United
States, 1900-1999
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Expanded Host-Agent-Environment Paradigm

• Host - genetic, nutritional, life style,
  personality, psychosocial and other factors
• Agent - microbiologic, toxic, stress, work,
  nutrient excess or deficiency
• Environment vector, physical-societal context
• Intervention - clinical, preventive, environment
  

Host
Host
Environment
Agent
Environment
Agent
Intervention
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Determinants of Population Health
Income Social Status
Social Support Networks
Education
Physical environments
Biology genetic endowment
Employment working conditions
Healthy child development
Personal health practices coping skills
Health Services
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A Comprehensive Health Services Continuum
Manitoba
Promotion
Palliation
Hospitals
Healthy Public Policy Prevention Promotion
Protection
Support Services To Seniors
Community Health Centres
Outpatient Ambulatory Care
Rural Community
Urban Community
Tertiary
Palliation
Community Oriented Services
Home Care
Extended Treatment Long Term Care
Rehabilitation
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Health 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

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Healthy 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

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Infant Mortality, United States, 1900-1999
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Maternal Mortality, United States, 1900-1999
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Communicable 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

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Social Diseases TB, STIs, HIV, Hepatitis,
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

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AIDS Incidence, Deaths and Prevalence, United
States 1981-2000
1993 Definition Implementation
AIDS
Deaths
Prevalence
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Safe 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

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Non-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

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Motor 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

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Summary

• 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

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Working Toward Goals