The future of public health: a local health department view.

This is an examination of factors responsible for the "disarray" in public health activities as described in the Institute of Medicine report on The Future of Public Health. It approaches the problem primarily from the viewpoint of the local health agency. Three contributing factors are discussed: disproportionate national expenditures for medical care as compared to public health funding; structural flaws in organization leading to functional difficulties; and medical profession opposition to an expanded role for local health departments. The problem of inadequately sized local governmental jurisdictions which are unable to supply sufficient resources for their health departments is discussed, and the complexities of remedial mergers across political boundaries are explored. Suggestions for improving the functions of local health departments include the provision of medical care services, not as a last resort as the Institute of Medicine report suggests, but as equal and perhaps superior competitors in the marketplace; increased state financial and technical support; and a proposed new federal program, The Health Objectives 2000 Act, S.2056, which will make specific provision to greatly strengthen health departments, facilitate the incorporation of missing skills and expertise in local health units, and enhance their capabilities to function as front-line agencies which are essential for achieving effective public health action.

A priority rating system for public health programs.

When resources are limited, decisions must be made regarding which public health activities to undertake. A priority rating system, which incorporates various data sources, can be used to quantify disease problems or risk factors, or both. The model described in this paper ranks public health issues according to size, urgency, severity of the problem, economic loss, impact on others, effectiveness, propriety, economics, acceptability, legality of solutions, and availability of resources. As examples of how one State can use the model, rankings have been applied to the following health issues: acquired immunodeficiency syndrome, coronary heart disease, injuries from motor vehicle accidents, and cigarette smoking as a risk factor. In this exercise, smoking is the issue with the highest overall priority rating. The model is sensitive to the precision of the data used to develop the rankings and works best for health issues that are not undergoing rapid change. Cost-benefit and cost-effectiveness analyses can be incorporated into the model or used independently in the priority-setting process. Ideally, the model is used in a group setting with six to eight decision makers who represent the primary agency as well as external organizations. Using this method, health agencies, program directors, or community groups can identify the most critical issues or problems requiring intervention programs.

The multidrug-resistant tuberculosis challenge to public health efforts to control tuberculosis.

After years of steady decline, there has been an unprecedented resurgence of tuberculosis (TB) in the United States and outbreaks of multidrug-resistant tuberculosis (MDR-TB). The authors assess the nature, epidemiology, and implications of MDR-TB; provide suggestions for preventing drug resistance among patients with drug-susceptible TB; and offer recommendations for managing patients with MDR-TB. They outline the National Action Plan to Combat MDR-TB. Close collaboration among medical practitioners and staff members of TB control programs is needed to ensure the most effective management of patients with TB and their contacts. This collaboration is one of the most important steps for successful control of MDR-TB.

Cooperation and collaboration between a public health unit and midsized private industry in health promotion programming: the Polymer Heart Health Program experience.

In 1990, Cobequid Health Unit was approached by Polymer International, a plastics manufacturer, and planning began for a worksite cardiovascular risk factor screening and follow-up program. In 1991, 302 Polymer employees (89.1%) participated in a screening. Follow-up included smoking cessation programs, fitness opportunities, dietary counselling, and physician referral for further investigation of blood pressure and cholesterol levels. Policy and environmental changes include heart healthy foods at the cafeteria, development of non-smoking policy, and coverage under the corporate group insurance plan for dietary counselling. This process demonstrates the potential for public health and private industry to collaborate in preventive efforts and the principles required for success.

[Organization of veterinary public health activities in Europe]. / Organisation des activités de santé publique vétérinaire en Europe.

Information provided by the national Veterinary Services on the organisation of veterinary public health activities is given for twenty European countries. For each country, details are presented of the respective role and responsibilities of each ministry and institution at the national and regional levels of administration.

[Organization of the public health services in Latin America and the Caribbean]. / Organización de los Servicios de salud pública veterinaria en América Latina y el Caribe.

The organisation of veterinary public health (VPH) services in countries of Latin America and the Caribbean has resulted from an historical process which has consolidated the structure of these services and the concept of VPH. This concept comprises five principal plans of action: promotion of animal health in order to increase the production of protein of animal origin; protection of foods for human consumption; vigilance, prevention, control and eradication of zoonoses; promotion of environmental protection, together with the development of biomedical models. These plans of action serve the purpose of improving human health and well-being, which is essential for the socioeconomic development of populations. Within this context, the authors describe the organisation of VPH services for health and agriculture, which have a part to play in intersectorial collaboration and in social participation. Finally, an account is given of progress in the control of rabies, brucellosis and tuberculosis, and the organisation of integrated programmes for food protection and also the control and eradication of foot and mouth disease. Technical cooperation with the Pan American Health Organisation (PAHO) assists these activities and intersectorial coordination, principally between health and agriculture.

Organisation of veterinary public health in the Western Mediterranean region.

This paper describes the administrative organisation of veterinary public health (VPH) activities in seven countries of the Western Mediterranean region. These structures vary greatly, as a function of the national administrations overall and, in particular, as a result of assigning VPH to either the Ministry of Agriculture or Public Health. Whereas the VPH unit is generally involved in specific veterinary food hygiene activities, the control of zoonotic diseases is most often assigned to the Veterinary Services. In most countries of the region, VPH is still approached as too narrow a discipline, and the importance of VPH activities is often not recognised by decision-makers at the highest governmental levels.

Organisation of veterinary public health activities in countries of the Eastern Mediterranean region.

This review covers the organisation of veterinary public health (VPH) activities in countries of the Eastern Mediterranean region, with reference to zoonoses and hazards to man from foods of animal origin. A study of the region shows that no separate VPH units exist within the national Veterinary Services. Although these Services are gradually being upgraded and strengthened, most of their resources are spent in controlling serious contagious animal diseases such as foot and mouth disease, rinderpest and Newcastle disease. Rabies, present in almost every country of the region, is a zoonosis which no Veterinary Service can ignore. Other serious zoonoses affecting the region include echinococcosis, brucellosis, leishmaniasis, anthrax, toxoplasmosis and tuberculosis. Salmonellosis is one of the most serious food-borne zoonoses, while hazards from the increased presence of additives, pesticides, antibiotics and hormones in foods of animal origin are other emerging VPH problems. Many obstacles hamper efficient reorganisation of VPH activities. These include the inherited colonial system of assigning VPH activities to other authorities (health inspectors) rather than to Veterinary Services; the confusion as to which authority should actually be responsible in a given field; the lack of epidemiological studies and knowledge of the real extent of VPH problems; lack of training; inadequately staffed and poorly equipped Veterinary Services; and lack of public awareness. Nonetheless, a few countries have made excellent progress in reorganising VPH activities and in eradicating serious zoonoses. International organisations like the OIE, FAO and WHO can help greatly in establishing efficient VPH programmes.

Planning, organisation and administration of veterinary public health activities.

Advice is given on how to set up a veterinary public health programme, drawing on recommendations of the World Health Organisation (WHO). Trichinellosis control is used as an example of planning procedures.

Organisation of veterinary public health in the south Asia region.

In the South Asia region vast human populations are exposed daily and with considerable intensity to close contact with vast animal populations and their excreta. There is no veterinary public health unit in the World Health Organisation (WHO) South-East Asia Regional Office (SEARO) in New Delhi (India), the Western Pacific Regional Office (WPRO) in Manila (Philippines) or the Eastern Mediterranean Regional Office (EMRO) in Alexandria (Egypt). However, these offices do support a number of activities on zoonoses and food-borne diseases in WHO member countries of the region. Maintenance of the health of farmers and of their families (often termed "rural health") has assumed increasing importance in most member countries of the region. In most of the countries, there is no actual veterinary public health unit functioning as a national body common to the ministries of health and agriculture. Among the commonest zoonotic diseases prevalent in member countries are rabies, brucellosis, Japanese encephalitis, echinococcosis, tuberculosis, visceral leishmaniasis, taeniasis, salmonellosis, campylobacteriosis and leptospirosis. A national plan is necessary for each country to give priority to controlling these diseases, based on health systems research or primary health care, with intersectoral and regional cooperation through the South Asian Association for Regional Cooperation (SAARC) under Technical Cooperation among Developing Countries (TCDC). There should be a strong unit for veterinary public health in all WHO regional offices to coordinate zoonotic disease surveillance, training and control programmes in countries of the region.

Organisation of veterinary public health in the western Pacific region.

Information on veterinary public health organisation and activities was obtained from government sources in countries located in the Western Pacific region. This region has a wide range of geographical features, population densities, farming practices, social structures and disease prevalences. In spite of this variation, there is common agreement on the importance of veterinary public health both for the provision of safe food and for the control of zoonotic diseases. Not all countries, however, are able to put all the resources they would wish into these activities; financial, social and personnel constraints are recognised.

Organization of veterinary public health in the United States of America and Canada.

Veterinarians in the United States of America and Canada are involved in a variety of activities which contribute to improving human health and well-being. Some of these activities can be considered as a part of veterinary public health (VPH), including: zoonoses control, food safety, environmental protection, comparative medicine, disaster medicine and animal welfare. Both countries have federal systems, and their VPH activities are dependent on close interaction between health and agricultural agencies at the national, state or provincial, and local levels. In addition to governmental agencies, other entities such as academic institutions and various professional associations are also important contributors to VPH activities in the two countries.

Organisation of veterinary public health in Africa.

Veterinary public health (VPH) is not integrated into the mainstream of public health services in Africa. There are no formal mechanisms within government public health services through which veterinary skills and resources can be effectively harnessed to bear upon community health. There is no conscious, overt or substantial effort by public authorities to incorporate VPH services in the overall approach to public health. VPH activities cover mainly the control of the major animal diseases transmissible to man (zoonoses), meat inspection and, to a limited degree, the quality control of milk, fish and their products. These services are carried out by the Veterinary Services of the Ministry of Agriculture in each country. Concerning education, only 7 of the 28 schools of veterinary medicine in Africa have separate departments where VPH subjects such as epidemiology, food hygiene, zoonoses, biostatistics, community health, public administration, preventive medicine and other related fields are taught by public health-trained and oriented staff. Elsewhere the teaching of VPH subjects is delegated to staff whose foremost interests are in pathology, microbiology and clinical medicine. Postgraduate training in VPH is fast developing in the veterinary schools of Nigeria, Kenya and Uganda. Political instability, war, famine and poverty which deplete human and material resources, lack of intersectorial cooperation in matters of public health and lack of vigour on the part of the veterinary profession as a whole to assert its broader role in the community also contribute to the poor organisation of VPH in Africa. International collaboration in VPH is spearheaded by the Food and Agriculture Organisation (FAO) and the World Health Organisation (WHO). These agencies, along with the Office International des Epizooties (OIE) and other international organisations or groups, are active in promoting the development of VPH programmes by setting guidelines on the organisation and management of VPH, coordinating control programmes for the major zoonoses and providing financial and technical expertise.

Veterinary public health in Israel.

The epizootiological and ecological conditions in Israel, as well as socio-economic and agricultural structures, have created a unique and hazardous veterinary public health (VPH) situation. The paper describes various VPH problems concerning zoonotic diseases, products of animal origin and rural ecology, and the attempts to solve them by the State Veterinary Services and Animal Health.

Organisation of veterinary public health in Australasia and the Pacific Islands.

The authors present the structure and functions of the Veterinary Public Health Services in Australasia and the Pacific Islands. Services in the region range from the extensive and highly developed organisations of Australia and New Zealand to those meeting the needs of the subsistence agriculture economies of some of the smaller island groups. Geographic isolation and strict quarantine measures have kept the region free from serious infectious animal diseases, and veterinary public health efforts are concentrated on preventing and combating epizootic diseases.

Improving public health care: lessons on governance from five cities.

Policy-oriented investigations into public health care delivery have been limited, especially during the Reagan era of competition and profit-based health care, when the inner city was essentially forgotten. In this study, policymakers toured five urban public health care systems in different parts of the country to promote consideration of a new governance for Chicago and Cook County's complicated and uncoordinated care for the medically indigent. A comparison of patterns of governance revealed strengths and weaknesses of each model. Local leadership and the political will to evolve a system of care, with clear connections between the public and private sectors, account for each city's relative success in addressing mounting needs of inner-city populations.

[A new approach to public health. Strategies for its implementation]. / El nuevo enfoque de la salud pública. Estrategias para su implementación.

Public Health System accepts "New Public Health" only in a theoretical way, since in the practice essential modifications to get "Health For All-2000" aims are not implemented. It is necessary to look "bridge-heads" that permit to introduce changes gradually to reorganize Health Services. In the present article, different alternatives are analyzed, all of them giving priority to the programmes that consider Health as a natural resource. These programmes can be "Governmental Programmes" so Health policies coming from the Health Department can be assumed by the others Public Administration Departments.

[Hospital financing systems: an analysis of trends and a study of the consistency of reform proposals for introduction into public health systems]. / Els sistemes de finançament dels hospitals: anàlisi de tendències i estudi de consistència de les propostes de reforma per a la seva implantació en els sistemes sanitaris públics.

The author comments in this paper on the recent literature on reforms in hospital reimbursement systems. Instead of taking a theoretical approach to this topic, the article adopts a "middle of the road" view, by looking at the consistency of applying some of these reforms (mainly on contract management and DRGs) in Public Health Systems. After recognising some of the existing problems in the management of public hospitals in Spain, the author advocates for a common sense strategy to health reforms in terms of the following: (i) at the time of implementing changes in the hospital sector keep targets defined as simple as possible, (ii) go to reforms through a step-by-step procedure, and (iii) whenever things look complex, use basic "house-keeping" economics, instead of just importing additional economic literature from abroad.

The role of official tax-supported agencies in home care. A personal perspective.

This article examines the role of the tax-supported, official public health agency and compares it with the private, nonprofit agency as both participate in making home health care available.

The managerial process as a key to successful breastfeeding for promoting infant health in Thailand.

A strengthening of the managerial process within the health care delivery system can facilitate and encourage successful breastfeeding. This process includes problem-based planning, multidisciplinary team approach, leadership development and generation training. The process has proved to be very successful in promoting breastfeeding and improved infant health. It can be applicable to other urban settings throughout Thailand and perhaps to other developing countries.