Public Health - 2006

1. What is Public Health?

Public health is the organised response by society to minimise illness, injury and disability, and to protect and promote health.

Public health is predicated on the measurement and analysis of the burden of disease. In a resource scarce environment, this analysis informs the decisions that are made regarding which health activities/services are cost-effective for the population's health.

Public health is essential for the rational planning, development and delivery of improved health outcomes and health services. It recognises that health and health care occur in an economic and socio-cultural system both nationally and internationally, and therefore seeks to influence all sectors to maximise the health and wellbeing of society.

Public health recognises that some health aspects are determined primarily by societal factors rather than individual choices, and so collective responses from government and communities are required. Governments have the responsibility to provide opportunities and services for health in a way that facilitates full engagement by all members of the population. Public health should involve partnerships particularly interventions that are community driven. However, many of public health's greatest achievements have been through legislative change.

Public health activities seek to achieve:

• equity in health outcomes;
• distribution of resources in a planned manner based on need (determined by evidence or expert opinion), not wants; and
• maximisation of the total population's health, rather than individual health.

Equity can be considered as being equal access to services for equal need, equal utilisation of services for equal need, and equal quality of care or services for all. Central to an equity approach is the recognition that not everyone has the same level of health or capacity to deal with their health problems, and it may therefore be important to deal with people differently in order to work towards equal outcomes.

The setting, monitoring and reporting against achievement of standards is a strategic tool for public health policy makers and organisations. The aim of setting public health standards is to improve the quality of public health practice and the performance of health systems. Standards can be set to measure both process (for example, the degree of involvement of consumers in the development of health plans or the percentage of those eligible having a pap smear) and outcomes (for example, life expectancy or percentage of babies born with a low birth weight). They can also be a method of informing consumers what they should expect from a service or organisation.

Health and health care are viewed as a human right and a means to improving the quality of human lives. Public health has a role in challenging forces that work against health whether they be, for example, individual, commercial or global. There is an acknowledgement that international conventions and agreements impact on health within and across national borders. Public health also has a function in promoting health-sustaining production, consumption and employment and collaborating with the business sector to encourage socially and environmentally responsible and healthy products and services.

2. The Breadth of Public Health Activities

Public health activities should be equitable, effective, evidence-based, fair and inclusive. The starting point for public health activity is undertaking surveillance and data collection at both the population and community level. This facilitates calculating the burden of disease and understanding the impact of health interventions, action and inactions on that burden.

The burden of disease can be understood using a variety of measures. At present, although it has its weaknesses, of key importance is the Disability Adjusted Life Year (DALY). For a disease or condition, the DALY is the sum of the years of life lost due to premature mortality and the years of life lost due to disability with the condition. In other words, it includes the equivalent years of 'healthy' life lost because of having the disease or condition.

Another important factor to consider when prioritising investment in health interventions is the risk of an event occurring and the resultant burden of disease if it were to occur. For example, while the risk of an influenza pandemic is relatively small, if it were to occur, the burden of disease would be enormous. For this reason, significant resources are committed to addressing it.

Public health activities are broad-ranging in their conception and practice, but they can be categorised and considered under the following headings.

2.1 Health Protection

Public health activities seek to provide populations with clean air, water and food. Public health aims to identify and manage the spread of infectious diseases, radiation, chemicals and poisons, and environmental health hazards.

2.2 Health and Social Care Quality

Public health embraces equity in service planning, access, clinical effectiveness, quality, efficiency, and appropriate resource use. It prioritises research, audit, and evaluation.

2.3 Health Improvement

Public health acts to improve health and reduce inequalities. This includes interventions to increase access to employment, safe housing, and education, as well as initiatives to strengthen families and community.

3. The Medical Profession and Public Health

Medical practitioners are key providers of public health services in Australia. Much of this is undertaken in the form of health protection activities such as immunisation that are primarily delivered by general practitioners.

The Australasian Faculty of Public Health Medicine aims to achieve a high standard of population health through the practice of public health medicine, training and continuing professional development for members, the promotion of public debate on matters of public health importance, and the encouragement of public health research.

3.1 Public Health Workforce

An appropriately mixed and skilled public health workforce is essential for surveillance, data collection, and the effective delivery of public health interventions. Public health requires a team based approach. While such teams should always be led by an appropriately trained medical practitioner, they will variously need to include epidemiologists, university researchers, environmental health officers, nurses, allied health professionals, and others.

4. A Ministry of Public Health

Australia already has significant investment in the elements of public health. For example, efforts to improve the public health workforce come through the Public Health Education and Research Program, which includes reduced fees for tertiary post-graduate studies. Already the Australian Institute of Health and Welfare (AIHW) undertakes much of the necessary data collection and monitoring of the population's health. The AIHW aims to promote better health and wellbeing for Australians through better health and welfare statistics and information and is a key component of the public health system. Also important are the university researchers who undertake public health data collection and analysis. Australia has some of the world's leading researchers in this area.

However, creation of a Ministry of Public Health, administratively led by a public health physician, would send a clear signal to governments, industries and communities that health, as opposed to disease, was at the centre of the 'health' system. There would be a shift towards greater emphasis on the prevention of disease and maintenance of health. Service delivery aimed at curing disease, rather than being the focus of the health system, would be relegated to being just one element of it.

With the epidemiological data of risk factors and disease burden as the starting point, a Minister of Public Health would have a comprehensive view of the nation's health. This would facilitate determining the best, most cost-effective 'buys' in health for the whole population, as well as population sub-groups. A Minister of Public Health would need to have the vision and leadership to act on this information as it may be that with scarce resources the 'best buy' was in preventive activities such as straightening a road, rather than the politically popular building of a new hospital. With the leadership provided by a Ministry of Public Health at the Commonwealth level, this would provide an impetus for replicating this structure and approach in the States and Territories.

In this Ministry, health services would be reorientated to seek to achieve equity in health outcomes, distribute resources in a planned manner based on needs, and maximise the total population's health rather than focus on individual health and access to curative services. In a disease-preventing, health-promoting environment, all future government policies would be reviewed by those with public health expertise to determine whether a full examination of the health and equity impacts of the policy/legislation is required.

5. The AMA Position

5.1 The Australian Medical Association believes the Australian health system should be fair, equitable and inclusive of the people it exists to serve, and be effective and evidence based. Within this system it is the role of public health activities to seek to achieve equity in health outcomes, distribution of resources in a planned manner based on need, and maximising the total population's health rather than individual health. The AMA supports initiatives aimed at developing, implementing and sustaining such a health system.

5.2 The Australian Medical Association calls on the Commonwealth Government to establish an overarching Minister of Public Health to structurally shift the focus of the Australian 'health' system from disease to health, and to prioritise reducing health inequalities.

5.3 The Australian Medical Association regards public health as having a role in moderating forces that can compromise the health of the population whether they be individual, commercial or global. It also has a function in promoting health-sustaining production, consumption and employment, and collaborating with the business sector to encourage socially and environmentally responsible and healthy products and services.

5.4 The Australian Medical Association believes that all undergraduate medical courses should develop students' understanding of public health as defined in this Position Statement and how to embrace its principles throughout their professional career across all specialties.

5.5 The Australian Medical Association believes that all doctors, regardless of the speciality in which they work, should have an understanding of the basic tenets of public health and to apply them to their work and their interactions with patients. The AMA encourages all doctors to be passionate and informed advocates for public health.

5.6 The Australian Medical Association believes that all interventions aimed at improving the health of the public should have an independent evaluation component built into their funding.

5.7 Workforce

5.7.1 The Australian Medical Association believes that surveillance, data collection and delivery of public health activities requires an appropriately mixed and skilled public health workforce. Where workforce members come together in teams, it is important that these public health teams are led by an appropriately trained medical practitioner.

5.8 Health Protection

5.8.1 The Australian Medical Association believes that the health of the population as a whole is an important measure of the success of the government in the area of health, rather than only using measures of health service provision.

5.9 The Australian Medical Association believes that a healthy environment is essential to human health. Clean air, water and food are the most obvious essentials, but threats to the environment from, for example, fossil fuel burning, are also intricately linked with human health. Built environments need to be developed with human health and the health of the environment as the prime drivers.

5.10 Health and Social Care Quality

5.10.1 The Australian Medical Association recognises that the cost of health care is ever-increasing. The AMA believes that the allocation of health care resources must reflect community values. The process of resource allocation to different health interventions should engage the community and be distanced from political interference.

5.10.2 The Australian Medical Association believes that service funding and development should as much as possible be based on evidence and cost effectiveness data. If a service is evidence based, cost effective, and available to the population, the government must plan to ensure it is accessible to all, irrespective of where they live.

5.11 Health Improvement

5.11.1 The Australian Medical Association calls for a health system (preventive and curative) that has the resources, capacity, infrastructure and workforce to place an emphasis on the prevention of disease, rather than treatment. Preventive care services need to be systematic and engaging of individuals and communities.

5.11.2 The Australian Medical Association believes that government funding priorities should be determined so that populations at risk are allocated funding at a level that recognises their relative disadvantage. The Australian Medical Association is supportive of policies that seek to decrease health inequalities within our community.

5.11.3 The Australian Medical Association believes that the healthy choices need to be the easy choices, and that there is a strong role for legislation in the achievement of public health outcomes.

5.11.4 The Australian Medical Association calls on governments and health services/boards to actively engage communities in understanding the health of their community and contributing to its improvement.

5.11.5 The Australian Medical Association believes the cross collaboration between sectors such as housing, education and employment is crucial to inequality reduction initiatives and improving the health of those with least power in our society. This particularly includes those who are marginalised or excluded from society, such as those with a mental illness.

5.11.6 The Australian Medical Association is supportive of anti-discrimination legislation as this will enhance legal, societal, financial and healthcare equity within the community.

5.11.7 The Australian Medical Association believes that public health interventions should take place within the contexts of culture and family. These contexts are important factors in designing and implementing public health initiatives.