Network for Education

In International Health

Understanding The Public Health and

Private Medical Care System
Prof. dr. Siswanto Agus Wilopo, SU., M.Sc., Sc.D.
Bagian Ilmu Kesehatan Masyarakat
FK-UGM

sawilopo@yahoo.com

The concepts of medical care and public health

WHAT IS PUBLIC HEALTH?

Public Healths Mission

assuring conditions in which people
can be healthy
organized community efforts aimed
at the prevention of disease and the
promotion of health.
Institute of Medicine, The Future of Public Health, 1988

TABLE 1 Traditional Distinctions Between Medicine and Public Health

Medicine

Public Health

Primary focus on individual

Personal service ethic, conditioned by awareness of social
responsibilities
Emphasis on diagnosis and treatment, care

Primary focus on population

Public service ethic, tempered by concerns for the individual

Medical paradigm places predominant emphasis on

medical care

Public health paradigm employs a spectrum of interventions

aimed at the environment, human behavior and lifestyle,
and medical care

Well-established profession with sharp public image

Multiple professional identities with diffuse public image

Uniform system for certifying specialists beyond

professional medical degree
Lines of specialization organized, for example, by:

Variable certification of specialists beyond professional

public health degree
Lines of specialization organized, for example, by:

organ system (cardiology)

patient group (pediatrics)
etiology, pathophysiology (oncology, infectious
disease) (occupational health)

technical skill (radiology)

Biological sciences central, stimulated by needs of patients;
move between laboratory and bedside

Numeric sciences increasing in prominence, though still a

relatively minor part of training
Social sciences tend to be an elective part of medical
education
Clinical sciences an essential part of professional training

Numeric sciences an essential feature of analysis and

training
Social sciences an integral part of public health education

Emphasis on prevention, health promotion for the whole

patient and for the whole community

analytical method (epidemiology)

setting and population (occupational health)
substantive health problem (nutrition)

Biological sciences central, stimulated by major threats to

health of populations; move between laboratory and field

Clinical sciences peripheral to professional training

What public health does

Prevent epidemics and spread of disease
Protect against environmental hazards
Prevent injuries
Promote and encourage healthy behaviors
Respond to disasters and assist communities
in recovery
Assure the quality and accessibility of health
services

How public health does its work

The Essential Public Health Services

1. Monitor health status
2. Diagnose and investigate
health problems
3. Inform and educate
4. Mobilize communities to
address health problems
5. Develop policies and
plans

6. Enforce laws and regulations

7. Link people to needed
health services
8. Assure a competent health
services workforce
9. Evaluate health services
10. Conduct research for new
innovations

S
C
O
P
E
O
F
T
H
E
S
Y
S
T
E
M

Churches

Community
Coalitions

Community
Service
Organizations

Schools

Police

Government & Tribes

As the Core of the
Public Health System

Environmental
& Health Advocacy
Groups

State
Government/
Public Health

Local
Government/
Public Health

Federal
Government/
Public Health

Tribal Health
Organizations/
Public Health

Community
Non-Profits
Philanthropies
Professional
Associations
Individuals
& Families
Media

Labor
Unions

Private
Business/
Industry

Public Health System Partners

7

Court System
Health Care
System
Mental Health
Service
Providers

Social
Service
Providers

Substance Abuse
Service
Providers

SYSTEMS THINKING

What is Systems Thinking?

Seeking to understand
system behavior by
examining "the
whole"
instead of by
analyzing the parts.
An unusual approach
raises concerns:

Systems Thinking
The only way to fully understand why a complex
problem occurs and persists is to understand the part
in relation to the whole (O'Connor & McDermott,
The Art of Systems Thinking: Essential Skills for
Creativity and Problem-Solving)
Traditional scientific approach = isolating small parts
of the system
Systems thinking = taking many interactions into
account

Systems thinking is needed for problems that are:

Complex problems that involve helping many actors
see the "big picture" and not just their part of it
Recurring problems or those that have been made
worse by past attempts to fix them
Issues where an action affects (or is affected by) the
environment surrounding the issue, either the
natural environment or the competitive environment
Problems whose solutions are not obvious

http://www.thinking.net/Systems_Thinking/Intro_to_ST/intro_to_st.html

This is risky ...

Systems Thinking
is not
thats because its
based on principles
fundamental
to the
nature of reality.
Its organic.
Its about feedback
loops with delays.

Its a Reality Fact of Life

There is no utopia in social systems
No restaurant can be all things to all people.

Cant have all at once:

lowest price, best quality, best service
The same is true for regions of the country

A corollary: Given free migration, no place can long

remain more attractive than any other place
We must think in terms of how well become
unattractive strategic unattractiveness

To Learn, We Need
Language

Brain

Learning

To describe relationships

Causal Loop
Diagrams

To describe fundamental
distinction between
flows & accumulations

The Archetypes

To handle dynamic complexity:

multiple non-linear feedbacks
with long and variable delays

Stock & Flow

Mapping
Stock & Flow
Simulation
Models

Thinking
Skills

Systems Skills: dynamic, system-as-cause, forest,

thinking operational, closed-loop, quantitative, &
scientific. Practice: CLD, S&F, Learn'g Labs
skills

Memory

Store & retrieve experience:

success & failure

Learning
Histories

Reality concepts, ladder of

Motivation
& Aspiration

See relevance & inference, dialogue, Mod. II ToA,

utility ... unleash group facil. grnd rules, personal
these qualities
mastery, winning strategy

Learning Requires Languages, Brains, & Skills

http://www.exponentialimprovement.com/cms/learning.shtml

Traditional Business
Thinking Skills

Static thinking
System-as-effect thinking
Tree thinking
Factor thinking
Linear thinking
Measurement thinking
Proving-truth thinking

Systems Thinking Skills

Dynamic thinking
System-as-cause thinking
Forest thinking
Operational thinking
Closed-loop thinking
Quantitative thinking
Scientific thinking

*physical condition: simultanagnosia

There are some fundamental systems-thinking

perspectives and approaches that are shared across
fields:
1. Increased attention to how new knowledge is gained,
managed, exchanged, interpreted, integrated, and
disseminated;
2. Emphasis on a network-centric approach that encourages
relationship-building among and between individuals and
organizations across traditional disciplines and fields in
order to achieve relevant goals and objectives;
3. The development of models and projections, using a
variety of analytic approaches (e.g., differential equations,
agent-based modeling, system-dynamics modeling) in
order to improve strategic decision making; and
4. Systems organizing in order to foster improvements in
organizational structures and functions

Ecological Framework for Influences on What People Eat

An Intersectoral Approach to Public Health

IOM. The Future of the Publics Health, 2002

HEALTH SYSTEM

Conceptual Framework
Need an approach that helps to:
Diagnose health systems strengths and weaknesses
Prioritize key constraints and areas for interventions
Identify potential solutions

Existing tools (in early 2005) did not offer

quantitative comprehensive health systems
assessments
Some focused on profiles (PAHO, European
Observatory)
None allowed for integration across health systems
functions

Conceptual Framework (cont.)

Used WHO framework
Functions the system performs
Stewardship
(oversight)

Creating resources
(investment and
training)

Financing
(collecting, pooling,
and purchasing)

Source: Adapted from WHO (2001)

Delivering services
(provision)

Conceptual Framework (cont.)

Drilled down into each function to structure assessment approach
and added link to performance and impact

Health System Functions

Health System
Performance

Impact

Stewardship:
1. Stewardship/
governance

Creating Resources:
3. Human resources
management
4. Pharmaceuticals
management

Financing:
2. Financing

Delivering Services:
5. Service provision
6. Information systems

Criteria:
Equity
Access
Quality
Efficiency
Sustainability

Health
Impact

Challenges

Priority health service areas

Private sector
Public health
Decentralization
Indicator-based approach
Quantitative indicators vs. qualitative questions
Screening questions
Desk review vs. stakeholder interviews

Challenges (cont.)
Accessible to a generalist
Technical approach and operational process
needed to be well-documented
General overview chapter on health systems
Key concepts defined and detailed descriptions of
indicators and technical analysis
Chapters on operational process

Basic framework for

health system metrics
INPUTS &
PROCESSES

Governance &
leadership
Finances
Human resources

OUTPUTS

UTILIZATION

OUTCOME

Services

Coverage

Improved
health

(availability,
affordability,
quality)

Behavioural
change

Infrastructure
Procurement
Logistics & supplies

Information

OTHER DETERMINANTS OF HEALTH

(ECONOMIC, SOCIAL, POLITICAL)

Reduced
mortality

Expanding the contents of health system

metrics to measure performance
Areas of focus

Universal concerns

Governance: defining sector

Equity:

Financing: ensuring fair and

Being responsive to users

strategies, clarifying roles,

managing competing demands
sustainable financing

Human resources: having a

sufficient and productive
workforce

Information and
knowledge: ensuring the

generation and use of information

Service provision: ensuring

adequate drugs, equipment,
infrastructure

Coverage: use of service by

those in need

to protect and improve

health, as equitably as is possible.

Financial protection:

to
ensure people are able to avoid
impoverishing health expenditures

Health service quality and

safety: more equitable access and
use of services, ensure that effective
interventions are used; services of
adequate quality and safe

Efficiency: to ensure that

resources are used 'wisely' and not

wasted

WHO Health System Performance Framework

Adapting it for Health System Metrics
Stewardship
Responsiveness

defining sector strategies, clarifying

roles,
managing competing demands

by treating people with dignity, and

ensuring confidentiality, irrespective of
who they are

Human resources
having a sufficient and productive workforce

Coverage
reaching those who need it

Information
ensuring the generation and use of
Information and knowledge

Quality & safety

services of adequate quality and
safe harmful practices are reduced

Financing
ensuring fair and sustainable financing,
with financial protection

Service provision
ensuring adequate drugs, equipment,
infrastructure
improving organization, management
and quality of services

Health
outcomes

Efficiency
ensure that resources are used
'wisely'
Interventions that are relevant

Financial protection
ensure people are able to avoid
impoverishing health expenditures.

Equitable distribution
FUNCTIONS

GOALS OF THE SYSTEM

Public Health Challenges

Public Health Challenges

Emerging Diseases (SARS, Pandemic Flu)
Re-emerging Diseases (XDR-TB)
Food Safety
Bioterrorism
Natural Disasters
Obesity
Aging Population

Health Disparities

Health Care Crisis

Health Care Crisis

Aging Population
Re-emerging Diseases

Emerging Diseases
Obesity

Health Disparities
Access to Quality Health Care
Health Insurance Costs

Rebalancing Health Priorities

General
protection

Safer
Healthier
People

Targeted
protection

Vulnerable
people

Primary
prevention

Secondary Tertiary
protection protection

Affected people
without
complications
(undiagnosed
asymptomatic)

Affected people
with
complications

Death from
Complications

Traditional Healthcare

Safer
Healthier
People

Vulnerable
People

Affected People
without
complications
(undiagnosed
asymptomatic)

Affected People
with
complications

Traditional Healthcare

Disease Care

Traditional Public Health

Safer
Healthier
People

Public Health System

Vulnerable
People

Affected People
without
complications
(undiagnosed
asymptomatic)

Affected People
with
complications

Need to Rebalance Health Priorities

Safer
Healthier
People

Vulnerable
People

Public Health Network

Health Protection: Health Promotion,

Prevention, and Preparedness

Affected People
without
complications
(undiagnosed
asymptomatic)

Affected People
with
complications

Healthcare Delivery System

Disease Care

Questions
Given the significant public health and health care
challenges we face, are Public Health Leaders
adequately prepared to address these issues?

What are the requisite leadership competencies

needed to address these challenges?

Do we have a system of leadership development

that can meet this challenge?

Transforming the Public Health System

Transforming the Public Health System

Structure and Functions

Setting Agency Standards

Public Health Accreditation Board

Setting System Standards

National Public Health Performance Standards

Establishing Public Health Laws and Policies

Community Engagement
MAPP

Local State Federal interaction (SMOs)

Transforming the Public Health System

Workforce

Competencies for Public Health professionals

Epidemiologists
Environmental Health
Nursing

Credentialing and certification

National Board of Public Health Examiners
Existing programs in nursing, environmental health,
laboratorians

Transforming the Public Health System

The Strategic Influence of Public Health Leaders

Politics

Policy

Programs

PH
Leaders
Resources

Experience

Community

Transforming the Public Health System

Goals and Priorities

National-level Goals and Priorities
Health Protection Goals
Healthy People 2010

State and Community-level Goals

MAPP
State and Local Health Departments

Leadership is Essential to Success

Leadership

Agency Standards

System Standards

Laws and Policies

Community Engagement

Workforce

Portfolio Management

Improved
Performance

Improved
Health
Outcomes

Thoughts about Leadership Competencies

Foresight

Insight

Action
(Johansen, 2007)

Anticipate needs and sense emerging trends

Forecast what might happen

Provoke new thoughts and ideas

Move from problem-solving to tackling dilemmas

Early action

Better results

Issues Surrounding Leadership

Development
Continuum Dilemma

Leadership vs. Management competencies

Basic vs. Advanced
Regional vs. National

Crisis Leadership
Integrated or single program?

Discipline specific Leadership

How to build effective networks

Fragmentation
Develop a system for Leadership
Shared vision, shared funding, common purpose

Final Thoughts

Leaders are visionaries with a poorly developed sense

of fear and no concept of the odds against them
(Robert Jarvik)

Success is the child of audacity

(Disraeli)

THANKS