public health and entrepreneurship...2015/05/20 · public health’s mission “…assuring...

LECTURE MODULE Public Health and Entrepreneurship

Prof. dr. Siswanto Agus Wilopo, SU., M.Sc., Sc.D.

Department of Public Health

Universitas Gadjah Mada

Yogyakarta

Lecture Agenda: Day 1

1. Population Health

2. Why Using System Approach in Public Health

3. Health Care System

4. Managing Quality of in Health Service Organization

5. Principle of Health Management


1. Professionalism and Quality

2. Public Health Policy Development and Evaluation

3. Continuity Care

4. Professionalism and Managerial Skill for Doctor

POPULATION HEALTH Describing

Public Health’s 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 Primary focus on population Personal service ethic, conditioned by awareness of social responsibilities

Public service ethic, tempered by concerns for the individual

Emphasis on diagnosis and treatment, care

Emphasis on prevention, health promotion for the whole patient and for the whole community

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

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)

Lines of specialization organized, for example, by:

analytical method (epidemiology) setting and population (occupational health) substantive health problem (nutrition)

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

Biological sciences central, stimulated by major threats to health of populations; move between laboratory and field

Numeric sciences increasing in prominence, though still a relatively minor part of training

Numeric sciences an essential feature of analysis and training

Social sciences tend to be an elective part of medical education

Social sciences an integral part of public health education

Clinical sciences an essential part of professional training 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

7

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

Public Health System Partners

Government & Tribes

As the Core of the

Public Health System

State

Government/

Public Health

Local

Government/

Public Health

Federal

Government/

Public Health

Tribal Health

Organizations/

Public Health

Community

Service

Organizations

Environmental

& Health Advocacy

Groups

Community

Non-Profits

Philanthropies

Professional

Associations

Individuals

& Families

Media Labor

Unions

Private

Business/

Industry

Substance Abuse

Service

Providers

Social

Service

Providers

Churches Community

Coalitions Schools

Police

Court System

Health Care

System

Mental Health

Service

Providers

WHY USING SYSTEM APPROACH IN PUBLIC HEALTH


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 …

… that’s because it’s based on principles fundamental to the nature of reality.

It’s organic.

It’s about feedback loops with delays.

It’s a Reality Fact of Life “There is no utopia in social systems”

• No restaurant can be all things to all people.

• Can’t 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 we’ll become unattractive … “strategic unattractiveness”

To Learn, We Need

Motivation& Aspiration

LearningLearning

Language

To describe relationships

To describe fundamental distinction between flows & accumulations

Brain

Memory Store & retrieve experience: success & failure

To handle dynamic complexity: multiple non-linear feedbacks with long and variable delays

Systems

thinking

skills

Thinking Skills

Causal Loop Diagrams

Stock & Flow Mapping

Stock & Flow Simulation

Models

LearningHistories

Skills: dynamic, system-as-cause, forest, operational, closed-loop, quantitative, &

scientific. Practice: CLD, S&F, Learn'g Labs

The Archetypes

See relevance & utility ... unleashthese qualities

Reality concepts, ladder of inference, dialogue, Mod. II ToA, group facil. grnd rules, personal

mastery, winning strategy

Traditional Business Thinking Skills

• Static thinking

• System-as-effect thinking

• Tree thinking

• Factor thinking

• Linear thinking

• Measurement thinking

• Proving-truth thinking

Learning Requires Languages, Brains, & Skills http://www.exponentialimprovement.com/cms/learning.shtml

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 Public’s Health, 2002

HEALTH CARE 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)

Delivering services

(provision)

Source: Adapted from WHO (2001)

Conceptual Framework (cont.)

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

Financing: 2. Financing

Creating Resources:

3. Human resources management

4. Pharmaceuticals management

Delivering Services:

5. Service provision 6. Information systems

Criteria:

Equity Access Quality

Efficiency Sustainability

Health System Functions Health System Performance

Impact

Stewardship: 1. Stewardship/ governance

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 Infrastructure

Procurement

Logistics & supplies

Information

OUTPUTS

Services

(availability,

affordability,

quality)

UTILIZATION

Coverage

Behavioural

change

OUTCOME

Improved

health

Reduced

mortality

OTHER DETERMINANTS OF HEALTH

(ECONOMIC, SOCIAL, POLITICAL)

Expanding the contents of health system metrics to measure performance

Areas of focus

• Governance: defining sector strategies, clarifying roles, managing competing demands

• Financing: ensuring fair and 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

Universal concerns

• Equity: to protect and improve health, as equitably as is possible.

• Being responsive to users

• 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 defining sector strategies, clarifying

roles,

managing competing demands

Health

outcomes

Coverage reaching those who need it

FUNCTIONS

Service provision ensuring adequate drugs, equipment,

infrastructure

improving organization, management

and quality of services

Financing ensuring fair and sustainable financing,

with financial protection

Quality & safety services of adequate quality and

safe harmful practices are reduced

Efficiency ensure that resources are used

'wisely'

Interventions that are relevant

GOALS OF THE SYSTEM

Financial protection ensure people are able to avoid

impoverishing health expenditures.

Responsiveness by treating people with dignity, and

ensuring confidentiality, irrespective of

who they are Human resources having a sufficient and productive workforce

Information ensuring the generation and use of

Information and knowledge

Equitable distribution

Public Health Challenges

http://www.time.com/time/magazine/0,9263,7601030505,00.html

Public Health Challenges

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

Health Care Crisis

http://aolsvc.timeforkids.kol.aol.com/time/magazine/0,9263,7601980713,00.htmlhttp://www.time.com/time/magazine/0,9263,7601911125,00.html

Health Care Crisis

Aging Population

Re-emerging Diseases

Emerging Diseases

Obesity

Health Disparities

Access to Quality Health Care

Health Insurance Costs

Uninsured and Underinsured

Rebalancing Health Priorities

Safer

Healthier

People

Vulnerable

people

Affected people without complications

(undiagnosed asymptomatic)

Affected people with complications

General

protection

Targeted

protection

Primary

prevention

Secondary

protection

Tertiary

protection

Death from

Complications

Traditional Healthcare

Safer

Healthier

People

Vulnerable

People

Affected People without complications


Affected People with complications

Traditional Healthcare

Disease Care

Traditional Public Health

Safer

Healthier

People

Vulnerable

People




Public Health System

Healthcare Delivery System

Disease Care

Need to Rebalance Health Priorities

Public Health Network

Health Protection: Health Promotion, Prevention, and Preparedness

Safer

Healthier

People

Vulnerable

People




“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?”

Questions

Transforming the Public Health System

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)

Structure and Functions

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

Workforce

The “Strategic Influence” of Public Health Leaders

Policy

PH

Leaders

Community

Experience

Politics

Resources

Programs

National-level Goals and Priorities

Health Protection Goals

Healthy People 2010

State and Community-level Goals

MAPP

State and Local Health Departments

Goals and Priorities

Leadership is Essential to Success

Improved

Performance

Agency Standards

System Standards

Laws and Policies

Community Engagement

Portfolio Management

Improved

Health

Outcomes +

Leadership

Workforce

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

“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)

Final Thoughts

public health and entrepreneurship...2015/05/20 · public health’s mission “…assuring...

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