Making decisions on public health: a review of eight countries

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The public health workforce at the federal, state, and local levels must be prepared to respond to an array of needs, such as the assurance of health-related environmental safety, the interpretation of scientific data that can influence health outcomes, or the clarification of vast amounts of highly technical information after a community emergency.

In addition to meeting the scientific and technical requirements of public health practice, state and local public health officials are often expected to provide community leadership, manage community reactions, and communicate about risk, protection, and prevention. Current estimates indicate that approximately , individuals are working in salaried public health positions, with many more contributing to this mission through nongovernmental organizations or on a voluntary basis HRSA, Public health practitioners have training in a variety of disciplines, including the biological and health sciences, psychology, education, nutrition, ethics, sociology, epidemiology, biostatistics, business, computer science, political science, law, public affairs, and urban planning.

Recent studies have shown, however, that the current public health workforce is unevenly prepared to meet the challenges that accompany the practice of public health today. Moreover, the major changes in technology, biomedical knowledge, informatics, and community expectations will continue to challenge and redefine the practice of public health, requiring that current public health practitioners receive the additional, ongoing training and support they need to update their existing skills Pew Health Professions Commission, Given that early public health efforts in the United States were aimed at improving sanitation, controlling infectious diseases, assuring the safety of food and water supplies, and immunizing children, it is hardly surprising that public health workers at that time were predominantly graduates of schools of medicine, nursing, and the biological sciences.

Today, however,. For example, as part of the performance of essential services, members of the public health workforce must be prepared to engage the community in effective actions to promote mental, physical, environmental, and social health. Advances in biomedical and genomics research and technologies have the potential to change the way public health practitioners think about population-level disease risk and how disease prevention and health promotion activities might be practiced.

The need to strengthen the public health workforce was recognized by IOM in and has been the focus of a variety of efforts since then. Some of these activities will be discussed in the chapter on the role of academia in the public health system Chapter 8. A few key efforts focusing on the current workforce rather than training new workers are also covered here. In particular, the report The Public Health Workforce: An Agenda for the 21st Century USPHS, called for greater leadership on workforce issues from national, state, and local public health agencies; use of a standard taxonomy to better assess and monitor workforce composition; competency-based curriculum development; and greater use of new technologies for distance learning.

An almost universal priority for workforce development is ensuring that all public health practitioners have mastery over a basic set of competencies involving generalizable knowledge, skills, and abilities that allow them to effectively and efficiently function as part of their public health organizations or systems CDC-ATSDR, ; DHHS, ; CDC, d see Appendix E for an extended list of competencies for public health workers.

Beyond the Data – Tracking Environmental Health Data for Public Health Decision Making

Many experienced public health professionals require a variety of cross-cutting competencies to help them meet the routine and emergent. In addition, a recent survey of the local public health infrastructure found that several specific public health occupations are projected to be the most needed in the coming 5 years NACCHO, e.

The Council on Linkages between Academia and Public Health Practice 8 has developed a list of 68 core public health competencies in eight domains see Box 3—2 , with different levels of competency expectations for frontline public health workers, senior professional staff, program specialists, and leaders Council on Linkages between Academia and Public Health Practice, Use of this list as the basis for training and continuing education for the public health workforce. The Council on Linkages between Academia and Public Health Practice is composed of leaders from national organizations representing the public health practice and academic communities.

The council and its partners have focused attention on the need for a public health practice research agenda. Efforts are under way in the various public health training networks to establish models that will contribute to a systematic approach to competency-based training that is linked to the essential services framework and grounded in prior competency validation efforts CDC, e. The issue of workforce training and competency is central to the success of any public health system. Governmental public health agencies have a responsibility to identify the public health workforce needs within their jurisdictions and to implement policies and programs to fill those needs.

In addition, an assessment of current competency levels and needs is essential to develop and deliver the appropriate competency-based training, as well as to evaluate the impact of that training in practice settings.

Role of government in public health: Current scenario in India and future scope

Workforce training and education efforts may be conducted in partnership with academia and other relevant and appropriate community partners, and ideally, a percentage of public health employees should be targeted annually for continuing education DHHS, By mid, there were 14 Training Centers and 15 Preparedness Centers, which form the backbone of a national public health training network.

Both types of cen-. Given the importance of the workforce in carrying out the mission of public health, the committee finds that education and development of the current workforce must continue to be a fundamental priority within the broader efforts to improve the state and local public health infrastructure. Therefore, the committee recommends that all federal, state, and local governmental public health agencies develop strategies to ensure that public health workers who are involved in the provision of essential public health services demonstrate mastery of the core public health competencies appropriate to their jobs.

The Council on Linkages between Academia and Public Health Practice should also encourage the competency development of public health professionals working in public health system roles in for-profit and nongovernmental entities. To facilitate ongoing workforce development, the committee encourages public health agencies to engage in training partnerships with academia to ensure the availability of coordinated, continuous, and accessible systems of education.

These systems should be capable of addressing a variety of workforce training needs, ranging from education on the basic competencies to continuing education for individuals in the specialized professional disciplines of public health science.

Announcements

Furthermore, the committee recommends that Congress designate funds for CDC and HRSA to periodically assess the preparedness of the public health workforce, to document the training necessary to meet basic competency expectations, and to advise on the funding necessary to provide such training. Senior public health officials must have the preparation not only to manage a government agency but also to provide guidance to the workforce with regard to health goals or priorities, interact with stakeholders and constituency groups, provide policy direction to a governing board, and interact with other agencies at all levels of government whose actions and decisions affect the population whose health they are trying to assure Turnock, These tasks require a unique and demanding set of talents: professional expertise in the specific subject area; substantive expertise in the content and values of public health; and competencies in the core skills of leadership.

Those who have mastery of the skills to mobilize, coordinate, and direct broad collaborative actions within the complex public health system must lead in implementing the actions outlined in this report. They require the skills for vision, communication, and implementa-. Although many of these skills are innate for most professionals and other leaders, they need constant refinement and honing.

CDC has pioneered the development and funding of a national Public Health Leadership Institute, and in the intervening dozen years, more than leaders in public health have been exposed to leadership training and skill building described in more detail in the Academia chapter. Furthermore, a similar network of State and Regional Public Health Leadership Institutes has been funded and, over time, has developed the capacity to work collaboratively through a national network, which permits institutes to benchmark and share best practices and continue the process of learning needed to help with state-of-the art curriculum and educational training efforts.

Equally notable has been the development of the Management Academy for Public Health, a joint effort of the major public health philanthropies.

Advancing towards Universal Health based on primary health care

Although effort is still at an early stage, this academy has already generated graduates who work hand in glove with senior leadership in public health organizations. Furthermore, the Turning Point Initiative devotes efforts to increasing collaborative leadership across all sectors and at all levels Larson et al. Another key to leadership is continuity in office long enough to exert the leadership and to provide the institutional memory to defend public health agencies and the public health sector from the political winds of the moment.

Yet, the committee finds there has been great difficulty in recruiting, developing, and retaining the leaders so vital to the job. Health officials must work with legislators who operate on 2-year terms. Given that the average tenure of a state health officer is relatively short an average of 3. Additionally, because state health officers report to many governing bodies, they generally have less direct access to policy makers, and state health officials must prioritize the issues that they think deserve the most attention Meit, Political factors at the state level can also have a significant impact on the abilities of public health leadership to influence policy.

To address the specific issues of discontinuity occasioned by the rapid turnover, particularly of state health officials, the Robert Wood Johnson Foundation has funded a unique State Health Leadership Initiative administered by the National Governors Association to immerse newly appointed officials in a curriculum for political leadership and provide a network of resources and mentors. Governmental public health leadership is a critical component of the infrastructure that must be strengthened, supported, and held accountable by all of the partners of the public health system and the community at.

For this reason, the committee recommends that leadership training, support, and development be a high priority for governmental public health agencies and other organizations in the public health system and for schools of public health that supply the public health infrastructure with its professionals and leaders. Credentialing is a mechanism that is used to certify specific levels of professional preparation. There are many different forms of credentials, including academic degrees, professional certifications, and licenses.

For example, medical credentials include medical degrees to certify successful completion of course work, professional testing e. An individual credentialed as a Certified Health Education Specialist CHES has successfully completed a course of study and passed a competency-based test. Although some public health workers are credentialed as physicians, nurses, health educators, or environmental health practitioners, few are credentialed within those professions specifically for public health practice.

Most physicians working in public health lack board certification in preventive medicine or public health; most nurses working in public health lack credentials in community public health nursing; and most individuals working as health educators lack the CHES credential. Furthermore, no single credentialing or certification process has been established to test the various competencies required for the interdisciplinary field of public health; thus, the majority of the public health workforce 80 percent lacks credentials HRSA, CDC d has recommended the use of credentialing.

Such a process would complement efforts to establish national public health performance standards for state and local public health systems based on the essential public health services framework and the related objectives of Healthy People Objective 23—11 DHHS, Although this national effort focuses on experienced public health leaders, support is growing for the concept of credentialing at a basic level all public health workers and at an. Certification or credentialing would help establish that public health practitioners have a demonstrated level of accomplishment in and mastery of the principles of public health practice.

In terms of building the capacity of the public health workforce, the credentialing process could help document the knowledge, skills, and performance of experienced workers who may not have formal academic training and could encourage other workers to seek additional training to meeting credentialing requirements.


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An especially important component of this process is that it could play a key role in shaping the training and preparation of future public health practitioners and leaders. The key challenge is whether and how public health organizations can begin to integrate competency-based credentialing in their hiring, promotion, performance appraisal, and salary structures. Although the idea of credentialing has considerable support at the federal level, states and particularly localities have voiced concerns that workforce credentialing mandates may become too closely tied to federal funding mechanisms.

In these situations, the fiscal impact could be grave for public health departments that do not or cannot meet credentialing requirements community informants, personal communications to the committee, The committee finds that in the ongoing debate about public health workforce credentialing, what is most needed is a national dialogue that can address the full range of issues and concerns.

Therefore, the committee recommends that a formal national dialogue be initiated to address the issue of public health workforce credentialing. The Secretary of DHHS should appoint a national commission on public health workforce credentialing to lead this dialogue.


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The commission should be charged with determining if a credentialing system would further the goal of creating a competent workforce and, if applicable, the manner and time frame for implementation by governmental public health agencies at all levels. The dialogue should include representatives from federal, state, and local public health agencies, academia, and public health professional organizations who can represent and discuss the various perspectives on the workforce credentialing debate.

The role of communication in public health practice cannot be underestimated. Governmental public health agencies must. Informing and advising the public about health promotion and disease prevention are standard duties of both state and local public health agencies, and listening to community voices is also critical for programs to be effective. In emergency situations, public health professionals must have the ability to communicate clearly and effectively—being aggressive and credible enough to command attention—with both the public and other officials about the nature of the health hazards and the steps necessary to minimize health risks.

The response to the discovery of anthrax exposures in the fall of brought into sharp focus the importance of effective communication in the face of serious health risks. According to New York Times medical reporter Dr. Lawrence Altman, lapses and delays in communication with the public and with public health and health care professionals could have made the situation worse had the anthrax exposures been more widespread Altman, Altman suggested, however, that CDC could have issued information as a part of the parallel public health investigation that was already under way.

It should be noted that CDC used the Health Alert Network many times after September 11, , to alert public health officials and to disseminate information. The lack of information from DHHS was also frustrating to other federal, state, and local leaders and governmental public health officials, some of whom learned about new cases and contamination in their states though network and cable television newscasts Connolly, The lesson from these and other communication breakdowns is evident: clear and effective communication, both internal and external, is a critical service of the governmental public health infrastructure.

Because the responsibilities of public health agencies cover all aspects of health, public health officials are in a unique position to provide timely, accurate health-related information to the public on a wide variety of topics, ranging from depression and other mental health issues to obesity and physical activity, environmental health and safety, emergency preparedness, and policies that affect health or health outcomes.

However, few public health agencies have staff members who are trained to interact effectively with the public and to work effectively with the news media. Of these people, most are working in DHHS and other federal health agencies. Of the others, are working in state and territorial public health agencies and 12 are working in voluntary agencies HRSA, Given the tremendous potential of the mass media and evolving information technologies, such as the Internet, to influence the knowledge, normative beliefs, and behavior patterns of individuals and groups, governmental public health agencies must be prepared to use these communication tools.

The public health workforce must have sufficient expertise in communications to be able to engage diverse audiences with public health information and messages and to work with the media to ensure the accuracy of the health-related information they convey to the public. For example, public health officials can develop relationships with journalists and assist them in accurately representing health risks and interpreting the significance of new research findings so that reporting on public health issues is accurate and members of the public can make informed decisions about protecting their health.

For these reasons, the committee finds that communication skills and competencies are crucial to the effective performance of the 10 essential public health services and the practice of public health at the federal, state, and local levels. Therefore, the committee recommends that all partners within the public health system place special emphasis on communication as a critical core competency of public health practice. Governmental public health agencies at all levels should use existing and emerging tools including information technologies for effective management of public health information and for internal and external communication.

To be effective, such communication must be culturally appropriate and suitable to the literacy levels of the individuals in the communities they serve.

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