Introduction
Over the past two centuries, public health has achieved tremendous successes, illustrated most strikingly by the remarkable reductions in deaths and disability from many infectious diseases. However, there is still much to be done, especially with regard to what has become the major component of the disease burden in the WHO European Region, non- communicable diseases (NCDs), many of which are due to lifestyle factors and amenable to public health action.
The 2010 Global Burden of Disease Study reported that ischaemic heart disease was the leading cause of death in all parts of Europe in 2010 (Lozano, Naghavi et al. 2012) and the leading cause of disability- adjusted life years in central Europe, eastern Europe and central Asia, coming second in western Europe to lower back pain (Murray, Vos et al. 2012). Public health measures, such as tobacco control, salt reduction, improved diets and physical activity, and reduction in hazardous alcohol intake, are among the key actions that could help to accelerate progress in the struggle to reduce NCDs, both in Europe and beyond (Beaglehole, Bonita et al. 2011). There is a growing body of evidence to suggest that many of these interventions are cost- effective and of major long- term benefit to societies (McDaid and Suhrcke 2012).
The need for a sustained public health response to these epidemiological patterns has been recognized by a growing number of national and international organizations. The UN High- Level Meeting on Non- Communicable Diseases, in September 2011, has called attention to the urgent need for the prevention and control of non- communicable diseases worldwide. The new European health policy framework, Health 2020, adopted by the member states of the WHO European Region in September 2012 in Malta, has also emphasized the need for public health action, including through intersectoral policies (WHO 2012b).
One of its main pillars is the European Action Plan for Strengthening Public Health Capacities and Services (WHO 2012a), also adopted in Malta, which in turn builds on the 2008 Tallinn Charter (WHO 2008).
Objectives of this book
This book seeks to underpin these efforts. It has two broad objectives: (1) to provide a description and analysis of existing public health structures, capacities, and services in Europe, and (2) to set out, as far as possible, which structures, capacities, and services would be needed to strengthen public health action.
While many public health textbooks have been published in recent decades, no book seems to have been devoted to a comprehensive description of public health practice in Europe. This book starts to fill this gap. It draws on published and grey literature, as well as several ongoing or recent European research projects. Key sources of information included European Union (EU) funded studies of public health capacity (Aluttis, Baer et al. 2013) and knowledge translation of public health information (Lavis and Catallo 2012), a study by the European Observatory on Health Systems and Policies on intersectoral governance (McQueen, Lin et al. 2012), and self- assessments of public health capacities and services, undertaken by several European countries with the support of the WHO Regional Office for Europe (Koppel, Leventhal et al. 2009;
WHO 2009b; Ministry of Health of the Republic of Uzbekistan 2011). Finally, the Health Systems in Transition (HiT) country profiles of the European Observatory on Health Systems and Policies provided information on public health structures, capacities and services. Yet, as the contributions to this volume highlight, major gaps remain.
The second objective of this book is to set out which structures, capacities, and services countries in Europe should have to ensure the effective delivery of public health functions. In some cases, such as for dealing with public health emergencies, ensuring occupational health and safety, and other areas of health protection, these are set out in international agreements, conventions or, in the case of EU member states and those in the process of accession, by European directives. In other cases, such as for financing public health or ensuring the existence of a sufficiently large and well- trained public health workforce, European countries have made political commitments to improve the delivery of public health functions, in documents such as the 2012 European Action Plan for Strengthening Public Health Capacities and Services, which has been approved by all 53 member states of the WHO European Region.
The geographical scope of the book is, where relevant and possible, the entire WHO European Region, and it aims to reflect the very different situations in different parts of the region. Furthermore, the contributions to this volume strived to achieve an appropriate balance when discussing the work of various international organizations (EU, WHO and others), national governments, and sub- national and civil society actors.
The prospective audience for this book includes all those with an interest in understanding and improving public health practice in Europe. This includes researchers, professionals, managers, government advisers, policy- makers, and the general public. Naturally, the description and analysis of public health structures, capacities, and services might be of most interest to researchers, professionals, and recipients of services, while the description of what these structures, capacities, and services should look like, and what the policy options
Facets of public health in Europe: an introduction 3 are, might be of most interest to those developing policies in the health and other sectors. We hope that the book will serve as a useful guide to both constituencies.
Conceptual framework
What is public health? Although the term is widely used, its meaning is not always clear. Crucially, understandings of public health vary among different countries in Europe and the term is difficult to translate into some other European languages (Kaiser and Mackenbach 2008; Tragakes, Brigis et al.
2008). Although there is no generally accepted definition, a concept paper of the WHO European Region concluded in 2011 that the definition of public health put forward in 1988 by Sir Donald Acheson, and based on an earlier definition by Winslow (1920), serves as a useful point of departure (Marks, Hunter et al. 2011). Acheson (1988) defined public health as “the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society”.
The next question, then, is what kinds of actions are needed to achieve these goals. What are the most important public health services and activities?
A number of “essential public health functions” have been suggested in different parts of the world (WHO 2009a), including in the United States (US Department of Health and Human Services 1995) and the United Kingdom (Faculty of Public Health Medicine 2001). An international Delphi study conducted in 1997 produced another set of essential public health functions (Bettcher, Sapirie et al. 1998), which were subsequently modified by the Pan American Health Organization and the WHO Regional Office for the Western Pacific (WHO 2002, 2003).
An adaptation of these “essential public health functions” has been developed by the WHO Regional Office for Europe in the form of 10 essential public health operations (EPHOs). In line with the two objectives of this book, EPHOs can guide assessments of public health capacities and services, as well as the actions required to strengthen them (WHO 2012a). They also have the benefit of identifying horizontal activities across the whole political and administrative spectrum of policy- making, rather than focusing on the activities of specific institutions (Koppel, Leventhal et al. 2009).
The latest iteration of EPHOs was adopted by WHO in 2012 as an Annex to the European Action Plan for Strengthening Public Health Capacities and Services (WHO 2012a):
1. Surveillance of population health and well- being
2. Monitoring and response to health hazards and emergencies
3. Health protection, including environmental, occupational, food safety, and others
4. Health promotion, including action to address social determinants and health inequity
5. Disease prevention, including early detection of illness 6. Ensuring governance for health and well- being
7. Ensuring a sufficient and competent public health workforce
8. Ensuring sustainable organizational structures and financing 9. Advocacy, communication and social mobilization for health 10. Advancing public health research to inform policy and practice
EPHOs can be divided into core and enabling operations (WHO 2003). EPHOs 1–5 can be thought of as core public health operations, while EPHOs 6–10 are overarching operations that enable the delivery of public health activities (Figure 1.1). In practice, however, no public health system is organized according to these functions, elements of which can be found within many different activities and structures. Consequently, while the future accumulation of evidence may make it possible to structure a book according to these functions, this is not yet feasible, although some of the functions do map on to the ones examined in this book.
Structure of the book
This book is divided into four parts. Part 1 (Chapters 1 and 2) clarifies concepts and definitions, Part 2 (Chapters 3–13) explores how key public health functions are being delivered across Europe, Part 3 (Chapters 14–18) analyses the resources needed to deliver them, and Part 4 (Chapter 19) brings together key conclusions on the actions required for strengthening public health in Europe.
Following this introduction, Chapter 2 explores the changing context of public health in Europe. It reviews changing patterns of disease, the opportunities brought about by advances in information technologies, professional skills and qualifications, the increasing recognition of the social determinants of health, and the changing role of the state.
Chapter 3, which describes the monitoring of population health in Europe, is the first of the chapters exploring key public health functions. It argues that understanding population health is a crucial precondition for formulating
Figure 1.1 Ten essential public health operations Source: WHO (2012a)
Facets of public health in Europe: an introduction 5 effective public health policy and action. The chapter reviews the very diverse health information systems in place in Europe for population- wide monitoring and surveillance. It describes available information sources on health and healthcare utilization and explores where and why routine data are not available or reliable. The chapter concludes by making the case for increased international cooperation and European harmonization of data collection systems.
Chapter 4 discusses the role of the WHO and the EU in responding to public health emergencies, including infectious disease outbreaks. Based on the conceptual framework of an event management cycle, the chapter reviews the origin and function of the 2005 International Health Regulations, and examines which core capacities for surveillance and response are required at the national level. The chapter then describes how the WHO and EU support each step of national event management and how they strengthen national capacity to deal with public health emergencies.
Chapters 5–7 are concerned with key aspects of health protection. Chapter 5 explores current programmes and structures for occupational health and safety in Europe. It starts by clarifying the sometimes confusing terminology of occupational health and safety and then discusses the major international instruments in place for advancing occupational health and safety in Europe.
The chapter then assesses the diverging situation in different parts of the WHO European Region, the main challenges countries are facing in improving occupational health and safety systems, and which strategic directions they could follow. The chapter argues that modern public health services should include a strong programme for health and safety at work, strive for universal coverage and integration into primary health care, and in particular target vulnerable workers and high- risk sectors.
Chapter 6 begins by giving a brief overview of major environmental health hazards and the burden of disease that can be attributed to them. It then describes the main elements of environmental health services and the disciplines involved in this area. Actors and disciplines involved in delivering environmental health services in Europe vary widely, as does the training of professionals working in environmental health. The chapter identifies actions at the international, national, and local level to strengthen environmental health in Europe.
Chapter 7 addresses food and nutrition. Much of the disease burden in Europe is related to unhealthy nutrition, such as a high intake of foods rich in salt, added sugars, and saturated and trans- fatty acids, and an obesity epidemic is unfolding in most European countries. This chapter describes relevant international initiatives on food and nutrition, national policy actions, and efforts to improve surveillance, monitoring, and evaluation. It argues that primary health care should play a part in addressing obesity and malnutrition.
Chapter 8 assesses how health care can be informed by public health. Ideally, health systems should be geared towards the ultimate objective of improving population health. To achieve this goal, it is necessary to assess healthcare needs, effective and cost- effective interventions, and equitable allocation of resources. The chapter also considers how health services can become settings for health promotion activities.
Chapter 9 provides a review of cancer screening programmes in Europe.
It begins by discussing criteria for implementing screening programmes. The chapter then explores the evidence for screening for cancer of the cervix, breast, and colon, including some of the current controversies. This is followed by a review of cancer screening practices across Europe. The chapter concludes that there were major improvements, but also much scope for further progress.
It argues in favour of systematic, population- based screening activities, but also recognizes that financial and professional capacity differ widely across the WHO European Region.
Chapter 10 provides an overview of the organizational structures in place in Europe for health promotion activities, the integration of health promotion in health service provision, and the training of health promotion professionals. The chapter shows that countries in Europe differ widely in how far they promote the health of their populations. The scope for improvement seems to be largest in many of the countries of central and eastern Europe and the former Soviet Union, but there is also much room for improvements in western Europe.
Chapter 11 explores some of the ways to tackle the social determinants of health. There is overwhelming evidence on the impact of social, environmental, and economic factors on mortality, morbidity, and health inequalities in Europe.
Yet, action is far from straightforward and often requires complex, multisectoral policies and programmes. This chapter sets out how the necessary practical steps are nevertheless achievable, giving examples from the local, national, and international level. It argues that actions to reduce inequities in health should be universal, but still target the most vulnerable groups of the population in particular. Examples include the enforcement of seatbelt legislation or traffic calming measures in densely populated neighbourhoods, which offer benefits for the majority, while tackling inequities especially.
Chapter 12 discusses intersectoral working for public health. It reviews experience of adopting intersectoral policies at the national and supranational level in Europe and explores structures for intersectoral governance, including ministerial linkages, cabinet sub- committees, public health ministers, parliamentary and intersectoral committees, joint budgets, and delegated finance. The chapter then sets out ways of putting intersectoral structures and strategies into action. It argues that there is substantial scope for “lesson- learning” across Europe.
Chapter 13 addresses the use of health impact assessments in Europe.
It explains the purpose of these assessments, their key stages and the different forms they can take, including the trend towards integrated impact assessments and the use of rapid, community- led, and equity- focused health impact assessments. The chapter then discusses whether impact assessments should be mandated or voluntary. It concludes by arguing for the importance of embedding health in the decision- making processes of organizations and building relationships across sectors.
Chapters 14–18 discuss some of the key resources needed for public health.
Chapter 14 explores the great diversity that exists in the organization and financing of public health in Europe. In terms of organization, countries differ in the balance between centralized and decentralized public health operations, and how they address the vertical and horizontal integration of public health
Facets of public health in Europe: an introduction 7 activities across different programmes, sectors, and levels of care. In terms of financing, the share of total health expenditure devoted to public health and the mechanisms in place for raising revenues for public health activities differ widely. However, there tends to be a mix of sources of finance, with growing interest by health ministries, although not finance ministries, in taxes earmarked for public health purposes. The chapter concludes that it will be essential to maintain existing structures and levels of funding in the current economic climate.
Chapter 15 addresses the public health workforce. The delivery of public health services requires a well- trained and qualified health workforce, including both public health specialists and other health professionals. However, attempts to quantify the public health workforce have remained elusive. This chapter reviews the current structures in place in Europe for the education of public health workers. It starts by exploring existing definitions and common characteristics of the public health workforce in Europe, and then describes the current status of this workforce. The chapter concludes by outlining existing systems of education and professional development for public health in Europe and the measures needed for their further development.
Chapter 16 discusses public health leadership. Previously associated with a single person, position or institution, leadership in public health is now dispersed among local governments and communities, as well as other stakeholders. This chapter discusses what public health leadership is, what its functions are, and the forms it can take. It then reviews public health leadership in Europe at the national and international level and explores how it can be strengthened and developed. The chapter argues that public health leadership will increasingly have to reach out out to others, influence those that work beyond its control, and build coalitions and alliances.
Chapter 17 addresses public health research in Europe. It reviews existing EU- level structures to support public health research and then discusses recent EU- funded research projects that aimed to map public health research in the EU. The chapter then turns to a discussion of national structures to support public health research in Europe, with case studies of Italy, Finland, Poland, and Estonia. It argues that there is a need for national strategies for public health research, improved coordination between ministries of science, health, and finance, improved coordination across different research and innovation programmes within the EU, and better engagement with public health researchers, users, and partners, including civil society organizations.
Chapter 18 explores knowledge translation as it relates to public health information. It aims to encourage a discussion of the ways in which health information (including on health systems) is packaged for and interactively shared among public health policy- makers and stakeholders in Europe. The chapter draws on findings of a recent EU- funded research project that assessed contemporary efforts to broker information for public health policy and to bridge the gap between information and action in European public health.
It argues that knowledge brokering can help to address the gap between knowledge and practice through an emphasis on innovative information packaging and interactive knowledge- sharing mechanisms.
Chapter 19 brings together the main conclusions from the contributions to this book. It argues that there is substantial scope for strengthening public health functions and resources in many countries of the WHO European Region. More
Chapter 19 brings together the main conclusions from the contributions to this book. It argues that there is substantial scope for strengthening public health functions and resources in many countries of the WHO European Region. More