Features ,function and

approach's of public health

Objectives

 Philosophy of Public Health

 Scope of Public Health
 Features of Public Health
 Core Functions of Public Health
 Essential Services of Public
Health
 Approaches of public health
 Public health interventions
Public health…..

 Public health is defined as “the science

and art of preventing disease, prolonging
life and promoting of health” (Winslow,
1923)
 What do you think of Public Health?

 Most people think of public health workers as

physicians and nurses, but a wide variety of other
professionals work in public health, including:
 veterinarians, sanitary engineers,
 microbiologists,
 laboratory technicians,
 statisticians,
 economists,
 administrators,
 industrial safety and hygiene specialists,
 psychologists,
 sociologists, and
 educators.
Scope of public health

1. Compare the scope of public health in

developing and developed countries
considering the prevalence of health
problems
 Scope of Public Health

 Public health systems vary in different parts of the world,

depending upon the prevalent health problems.

 In the developing world, where sanitation problems and limited

medical resources persist,
• infectious diseases are the most significant threat to public
health.
• public health officials devote resources to establish
sanitation systems
• immunization programs to curb the spread of infectious
diseases,
• provide routine medical care to rural and isolated
populations.
 Scope of Public Health…

In industrialized nations:
 sanitary food and water supplies
 excellent medical resources have reduced rates of infectious
disease.
 Instead, accidents and diseases such as:
• lung cancer, heart attacks, strokes are among the leading
causes of death.
 In these areas, public health goals include:
• education programs to teach people how to prevent
accidents
• lessen their risk for disease,
• maintenance of the excellent disease prevention systems
already established.
Features of Public Health
1. Social justice; is the central pillar of
public health
2. Inherently political nature
3. Expanding agenda
4. Link with government
5. Grounded in science
6. It focuses on prevention
7. Uncommon culture
 Social Justice Philosophy

 Justice indicates that there is fairness in the

distribution of benefits and burdens;

 How each member of a society is allocated his or

her fair share of collective burdens and benefits

 Factors that impede the fair distribution of benefits

and burdens: social class, racism, disability, etc..

 Collective action is necessary to neutralize or

overcome those impediments .

 Public health works to overcome those

impediments.
Inherently Political Nature

 Public Health is both public and political

in nature.

 The social justice component of public

health stimulates political conflict

 Governmental public health agencies

seeking to serve the interest of both
government and public health are
frequently caught in the middle.
 Expanding Agenda

 Prior to 1900, the primary problems addressed by public health

were infectious diseases and related environmental risks.

 After 1900, the focus expanded to include problems and needs

of children and mothers

 Middle of the century: chronic disease prevention and medical

care fell into public health

 Later, substance abuse, violence, injuries

 Recently: Bioterrorism, other disaster preparedness are also

added to the public health agenda
 Link with Government

Public health is linked with government in

Two ways:
1. Issuing policies that govern the health of the population
2. Directly provide programs and services that are designed to
meet the health needs of the population
 Grounded in Science
 Often five basic science of public health are identified:
 Epidemiology,
 Biostatistics,
 Environmental Science,
 Management Sciences and
 Behavioral Sciences.
 Occupational Health,
 Nutrition, and
 Maternal and Child Health
 Epidemiology and biostatics are essential tools of public health.
 Focus on Prevention

 Prevention is the purpose of public health

and is aimed at preventing disease;
however we are also preventing
 deaths,
 hospital admissions,
 days lost from school and work
 consumption of human and fiscal
resources; etc.
 Uncommon Culture
 Public health is unique in that many different sciences, art and
methods can contribute towards the same outcome.

 Vast majority of public health workers are not formally trained

in public health.

 As a result public health professionals include professionals

from different disciplines, like anthropologist, sociologist,
psychologist, physicians, nurses , nutritionist, lawyers ,
mangers
Why invest in public health?
 Why invest in public health?

 An effective approach is to prevent than to cure.

 Public health contributes a great deal more to the

health of a population than medicine does.
 better nutrition and housing, sanitation and
occupational safety

 Norm that public health is publicly funded as

market does not have incentive to fund this

 Public health facilitates economic growth and

contributes poverty reduction
 Why invest in public health?…

 For example: In east Asia countries public health

efforts raised labor productivity and life
expectancies which lead to rapid economic
growth in these countries

 Major economic loss can happen as a result of poor

public health such as poor municipal sanitation

 Poor public health takes economic tolls in various

ways
 reduced attraction for investors, tourists,
 continued expenditure in combating diseases and
 Reduced labor productivity
Core Functions of Public Health

 Assessment
 Policy Development
 Assurance
 The Ten Essential Services of Public Health

1. Monitor health status to identify community

health problems
2. Diagnose and investigate health problems and
health hazards in the community
3. Evaluate effectiveness, accessibility, and quality
of personal and population-based health services
4. Research for new insights and innovative
solutions to health problems
5. Inform, educate, and empower people about
health issues
 The Ten Essential Services of Public Health…
6. Mobilize community partnerships to identify and
solve health problems
7. Develop policies and plans that support individual
and community health efforts
8.Assure a competent public health and personal health
care workforce
9. Enforce laws and regulations that protect health and
ensure safety
10.Link people to needed personal health services and
assure the provision of health care when otherwise
unavailable
Frame Work for Core Functions of Public Health
 Assessment

 Regularly and systematically collect, assemble, analyze, and

make available information on the health of the community,

 Including statistics on health status, community health needs,

and epidemiological and other studies of health problems.
 Purpose and Scope of Needs Assessment

 What are the goals of the assessment?

 What is intended to be gained from it?

 How extensive will the assessment be?

 What resources are available to conduct

it?
 Data Collection for Needs Assessment

 Primary data
 Those that collected specifically for use in this process

 Secondary data
 Those already collected for some other purpose
 Essential Services under Assessment

Essential services

1 Monitor health status to  Morbidity/ mortality reports

identify community health  Surveillance
problems  surveys

2 Diagnose and investigate  Community needs assessment

health problems and  Surveys
health hazards in the
community
 Policy Development

 Every public health agency exercises its

responsibility to serve the public interest in
the development of comprehensive public
health policies by:
 promoting use of the scientific
knowledge base in decision-making
about public health and

 leading in developing public health policy

 Essential Services under Policy
Essential services
3 Inform, educate, and  Mass medias, Brochures,
empower people about  Leaflets, booklets
health issues  Community gatherings…
4 Mobilize community  Community involvement thorough
partnerships to identify CBOs,
and solve health  Community conversation
problems  Clubs

5 Develop policies and  Develop different policies,

plans that support  Guidelines and plans
individual and E.g.: drug policy, HIV/AIDS policy,
community health ART guideline, TB/Leprosy
efforts guideline, etc…
 Assurance

 Assurance is equivalent to the doctors actual treatment of

the patient.

 Public health has the responsibility of assuring public

health intervention in the community are available and
accessible to every one.
Essential Services under Assurance
Essential services

 Trainings
6 Assure a competent public health
and personal health care workforce • Pre- service training (ensure quality and
quantity), In service training and Mentoring
 Assignment of health personnel
 Regular technical supervision

 Quarantine law,
7 Enforce laws and regulations that
protect health and ensure safety  Sanitation ,
 STDs
 Monitoring and evaluation
8 Evaluate effectiveness,
accessibility, and quality health
services
 Out reach services
9 Link people to needed personal
health services and assure the  Campaigns
provision of health care when  Expansion of health posts
otherwise unavailable  Extension health workers
Essential Services of Public Health…

10. Research for new insights and innovative

solutions to health problems
– Research serves all functions of public
health
Public health intervention
Small Group Work

 What are the differences between

prevention, control, elimination,
eradication, and extinction?
 Prevention, Control, Elimination and Eradication

 Public health interventions dealing with infectious diseases

are defined based on their long term target:
1. Prevention
2. Control
3. Elimination
4. Eradication
5. Extinction
 1. Disease Prevention

 The goals of public health/or medicine are

to promote health, to preserve health, to
restore health, and to minimize suffering
and distress.

 These goals are embodied in the word

"prevention"
 Prevention: Definition and Concept

 Actions aimed at eradicating, eliminating or

minimizing the impact of disease and disability,
or if none of these are feasible, retarding the
progress of the disease and disability.

 The concept of prevention is best defined in

the context of levels, traditionally called
primary, secondary and tertiary prevention. A
fourth level, called primordial prevention, was
later added.
 Leavell’s Levels of Prevention

Stage of disease Level of prevention Type of response

Pre-disease Primary Health promotion and

prevention Specific protection

Latent disease Secondary Pre-symptomatic

prevention Diagnosis and treatment

Symptomatic disease Tertiary •Disability limitation for

prevention early symptomatic disease
•Rehabilitation for late
Symptomatic disease
Levels of prevention

Primordial prevention

Primary prevention

Secondary prevention

Tertiary prevention
 Primordial prevention

 Primordial prevention consists of actions and measures that

inhibit the emergence of risk factors in the form of
environmental, economic, social, and behavioral conditions
and cultural patterns of living etc.

 It is the prevention of the emergence or development of risk

factors in countries or population groups in which they have
not yet appeared

 For example, many adult health problems (e.g., obesity,

hypertension) have their early origins in childhood, because
this is the time when lifestyles are formed (for example,
smoking, eating patterns, physical exercise).
 Primordial prevention…

 In primordial prevention, efforts are directed towards

discouraging children from adopting harmful lifestyles

 The main intervention in primordial prevention is through

individual and mass education
 Primary prevention
 Primary prevention can be defined as the action taken prior to
the onset of disease, which removes the possibility that the
disease will ever occur.

 It signifies intervention in the pre-pathogenesis phase of a

disease or health problem.

 Primary prevention may be accomplished by measures of

“health promotion” and “specific protection”
 Primary prevention…

Primary prevention
Achieved by

Health promotion Specific protection

Immunization and seroprophylaxis

Health education
chemoprophylaxis
Environmental modifications Use of specific nutrients or supplementations
Protection against occupational hazards
Nutritional interventions Safety of drugs and foods
Life style and behavioral changes Control of environmental hazards,
e.g. air pollution
 Approaches for Primary Prevention

 The WHO has recommended the following approaches for the

primary prevention of chronic diseases where the risk factors
are established:

a. Population (mass) strategy

b. High -risk strategy
 Secondary prevention
 It is defined as “ action which halts the progress of a disease at
its incipient stage and prevents complications.”

 The specific interventions are: early diagnosis (e.g. screening

tests, and case finding programs….) and adequate treatment.

 Secondary prevention attempts to arrest the disease process,

restore health by seeking out unrecognized disease and treating
it before irreversible pathological changes take place, and
reverse communicability of infectious diseases.

 It thus protects others in the community from acquiring the

infection and thus provide at once secondary prevention for the
infected ones and primary prevention for their potential
contacts.
 Tertiary prevention

 It is used when the disease process has advanced beyond its

early stages.

 It is defined as “all the measures available to reduce or limit

impairments and disabilities, and to promote the patients’
adjustment to irremediable conditions.”

 Intervention that should be accomplished in the stage of tertiary

prevention are disability limitation, and rehabilitation.
Disability limitation

Disease

Impairment

Disability

Handicap
 Impairment, Disability and Handicap

 Impairment is “any loss or abnormality of psychological,

physiological or anatomical structure or function.”

 Disability is “any restriction or lack of ability to perform an

activity in the manner or within the range considered normal
for the human being.”

 Handicap is termed as “a disadvantage for a given individual,

resulting from an impairment or disability, that limits or
prevents the fulfillment of a role in the community that is
normal (depending on age, sex, and social and cultural factors)
for that individual.”
 Rehabilitation

 Rehabilitation is “ the combined and coordinated use of medical,

social, educational, and vocational measures for training and
retraining the individual to the highest possible level of functional
ability.”
 2. Disease Control

Concept of control:
 The term disease control describes ongoing operations
aimed at reducing:
 the incidence of disease,
 the duration of disease and consequently the risk of
transmission,
 the effects of infection, including both the physical and
psychosocial complications, and
 the financial burden to the community.

 Reduction of disease incidence, prevalence, morbidity or

mortality to a locally acceptable level as result of
deliberated efforts;
 2. Disease Control…

 Control activities focus on primary prevention or secondary

prevention, but most programs combine both.

control

elimination

eradication
 Control can be seen from two perspectives
 Local
 Particular level of control may be an aim or policy of the
country (countries may have their own optimal level)
 Requires economic analysis

 Global
 One country's/region control may affect others
 Locally optimal may not be globally optimal
 Examples of Disease Control
 Tuberculosis: China
 TB prevalence reduced by 40%, and cure rate was 95%

 Onchocerciasis: West Africa,

 Transmission halted
 22 million children in 11 counties are now free from threat
of river blindness

 Trachoma: Morocco,
 the incidence has been cut by more than 99%

 Chagas disease: South America

 decreased incidence of Chagas disease by 94%
 Disease Control programs in Ethiopia

 Malaria
 Tuberculosis
 HIV
 STI
 Blindness
 3. Disease Elimination

 Between control and eradication, an intermediate goal has been

described, called "regional elimination"

 The term "elimination" is used to describe interruption of

transmission of disease, as for example, elimination of measles,
polio and diphtheria from large geographic regions or areas

 Regional elimination is now seen as an important precursor of

eradication
 Elimination

 Reduction to zero of the incidence of a specified disease in a

defined geographic area as a result of deliberate efforts;
continued intervention measures are required.

Examples:
 Leprosy in Ethiopia
 Polio in Latin America and Caribbean
 Measles in 7 Southern Africa countries,
 Current Elimination Programmes

 Neonatal tetanus,
 Leprosy,
 Onchocerciasis,
 Trachoma and
 Lymphatic filariasis
 4. Disease Eradication
 Eradication literally means to "tear out by roots".

 It is the process of “termination of all transmission of infection

by extermination of the infectious agent through surveillance and
containment”.

 Eradication is an absolute process, an "all or none" phenomenon,

restricted to termination of an infection from the whole world. It
implies that disease will no longer occur in a population.

 To-date, only one disease has been eradicated, that is smallpox.

 4. Disease Eradication…

 It is defined as permanent reduction to zero of the worldwide

incidence of infection caused by specific agent as a result of
deliberate efforts.

 Intervention measures are no longer needed.

 Two main factors that determine the success of a disease

eradiation programme:
 scientific feasibility and
 political, social and economic factors
 Scientific feasibility
 It includes:
 availability of effective and practical interventions
 availability of diagnostic / surveillance tools
 demonstrated successful elimination of the disease in a
particular area.
 no animal reservoir for the organism is known or suspected
 transmission from one individual to another can be
interrupted (available technology to interrupt disease
transmission, vaccination which gives life long immunity
or effective drug).
 the burden of disease is important to international public
health
 Political, social and economic factors
 the cost effectiveness of eradication versus elimination or
control programmes;
 the ability to coordinate with other health programmes and
 the potential effects of the eradication programme on the health
system.
 the degree of societal and political commitment
 the capacity for financial, managerial and technical support
 Eradication…

 In theory, if the right tools were available, it would be possible

to eradicate all infectious diseases.

 In reality, there are distinct biological features of the

organisms and technical factors of dealing with them that
make their potential eradicability more or less likely.

 Three indicators however, are considered of primary

importance in determining the likelihood of successful
eradication.
 Three Indicators determining the likelihood of successful
eradication:

1. Availability of effective interventional tools to interrupt

transmission of the agent, such as a vaccine.
2. Availability of diagnostic tools, with sufficient sensitivity
and specificity to detect infections that can lead to
transmission of the disease, and
3. Humans are required for the life-cycle of the agent, which
has no other vertebrate reservoir and cannot amplify in the
environment.

 Disease eradication programmes should not bypass or

compromise existing health systems and attempts should be
made to expand benefits to health services beyond the limited
impact of eradicating the target disease.
 Example of Eradication

 Small pox

 During the 1900s, global efforts were made to eradicate seven

diseases
1. Hookworm
2. Yellow fever
3. Malaria
4. Yaws
5. Small pox
6. Guinea worm
7. Polio
 Eradication - Benefits

 A well-defined scope with a clear objective and end

 No illness or death from that disease
 Successful eradication programmes produce sustainable
improvement in health and provide a high benefit-cost ratio.
 No control program needed /Resources can be redirected
 Monetary benefits
 Eradication programmes are attractive to potential funding
 Provide equity in coverage for all affected areas
 Eradication - Pitfalls

 Diversion of attention and resources from equally or more

important health problems /Diversion of resources
 Higher short-term costs,
 Increased risk of failure and the consequences of failure,
 An inescapable sense of urgency, and
 High vulnerability of eradication programmes to interruption by
war and other civil disturbances;
 Perception of programmes as "donor driven";
 Placement of excessive, counterproductive pressures and
demands upon health workers
 Requirement of special attention for countries with inadequate
resources and or weak health infrastructure
 5. Extinction

Extinction: The specific infectious agent no longer exists in nature

or in the laboratory.

Example:
• none.
Vertical versus Horizontal Health Program
Small Group Work

 Define vertical and horizontal programs

 What are the differences between

vertical and horizontal programs?

 What are the advantages and

disadvantages of vertical and horizontal
programs?
 Vertical versus Horizontal Programs…

 Vertical programmes (also known as stand-alone, categorical

or free-standing programmes or the vertical approach) refer to
instances where the solution of a given health problem is
addressed through the application of specific measures through
single-purpose machinery.

 In contrast, integrated programmes (also known as horizontal

programmes, integrated health services or horizontal
approaches):

• seek to tackle the overall health problems on a wide front

and on a long-term basis through the creation of a system of
permanent institutions commonly known as general health
services and
 Vertical versus Horizontal Programs

 All health program planners face the question of how they can
most effectively and efficiently provide health services.

 Health services (curative and preventive) can be provided using

two modes of delivery: horizontal and vertical.

 At the launch of the ‘Health for All by 2000’, the strategy to

attain the set goals was a comprehensive primary health care
based on a horizontal mode of delivery of basic services (WHO
1978).
 Vertical versus Horizontal Programs…

 A few years after implementation of PHC

 difficult to attain the set goals, e.g., failure to control
malaria,
 There was increase in in incidence and prevalence of TB,
 Emergence of drug resistance TB and
 emergence of HIV/AIDS,

 There was a need to consider change in the strategy, selectivity

and prioritization of interventions, particularly in resource
limited settings.
 Vertical versus Horizontal Programs…

• include a variety of managerial or operational changes to

health systems to bring together inputs, delivery, management
and organization of particular service functions , or

• are described as a process where disease control activities are

functionally merged or tightly coordinated with
multifunctional health care delivery.
 Vertical Programs
 Vertical delivery of health services implies a selective targeting
of specific interventions not fully integrated in health systems .

 Vertical programs can operate parallel to other programs and

may have their own management, staff, financing and
procurement arrangements. In some situation it might even
have its own facilities.

Examples of vertical programs in our country?

 Leprosy and Malaria control programs were managed as

classical vertical program – with administrative and operational
activities centrally located and with minimum/ absent
integration with the general health system.
 Advantages of Vertical Programs

 they show quick results

 easier to manage than horizontal programs
 effective in reaching the target group
 easier to monitor
 useful when the overall health system is extreme weak
 attractive to donors
 Disadvantages of Vertical Programs

 very demanding on resources of public service,

 diverting human and financial resources from already
resource-constrained health systems (e.g. “National
Immunization Days, NIDs”)
 sustainability of vertical programs in terms of outcomes
and resources is always questionable
 fading political commitment
 Horizontal Programs
 By horizontal delivery: services are delivered through public
financed health systems and are commonly referred as
comprehensive primary care.

Examples:
 Routine Immunization: In most countries, EPI services are
fully integrated into health systems.
 Family Health
 Blindness control program
 Advantages of Horizontal Programs

 when services are fully integrated into health systems,

programs can be sustained
 horizontal programs are attractive to policy makers because of
their long-term sustainability.
 important for services which require comprehensive coverage
 where there is a sound infrastructure and functional health
systems, horizontal programs work well
 horizontal programs are cost effective
 Disadvantages of Horizontal Programs

 horizontal programs work well in a context of sound

infrastructure and functional health systems and work poorly
otherwise

 not easily managed as vertical program

 an integrated ‘horizontal’ system may not be as effective as a

vertical program in monitoring compliance to treatment and
serious side effects.
 Factors to be considered in developing countries in
choosing mode of delivery of health services

 Seriousness of a problem
 Geographical demands of health services,
 Available resources (human and financial)
 Sustainability of programs and
 Analysis of costs and benefits
 Donors interest

 ‘‘The selection of mode of delivery may depend whether one is a

donor, policymaker, or service provider. Considerations for
donors differ from that of policy makers.

 Poorly paid service providers have different incentives in

selecting vertical or policy makers in selecting horizontal
programs”
Thank you!