# Principles of Public Health Practice/Public health practice and health systems

Public health is broader than the health systems of a country. Yet, they are integrally linked. In some countries like Brazil there is a unified system. In other countries, such as the United States, each state has its own functions with an overlay of Federal jurisdictions for some aspects of health and health care. How does the Australian system compare with those overseas. What does twenty year of conflict and war do to the ability of a country to care for its citizens? How important is the prerequisite of peace?

## Learning activity instructions

Each week we hold a lectorial and a tutorial. A lectorial is a short lecture followed by a group activity, and the tutorials are for discussion and practising group activities.
Lectorial
* View the playlist here.
* Consider recent events relating to the Federal Budget and think about what this might mean for Australians. Come to the lectorial prepared to discuss this.
* Attend the lectorial.
Tutorial
* Attend your tutorial session and be prepared to discuss the presentation.
* Keep track of the various take away messages from the presentations. What patterns are emerging about stigma?
* Start to prepare for the final assessment.

## Why is it important to understand the relationship between public health practice and the health systems of a country or region?

Weather systems are amazing. Their interaction can have synergistic effects far exceeding the individual system. After all, the systems involve energy. I have lived through some of the worst weather systems imaginable. They have often taken or destroyed lives. Yet, they were often spectacular.
Human systems can interact as well. They can either increase a good or eliminate the realistic possibility of growth and development. We know this from our recent past.
To flush out Saddam Hussein, we destroyed all of Iraq's infrastructure. What does that mean? We wiped out water treatment and purification plants. We destroyed sewage facilities. Power stations and substations were destroyed. So were road and rail infrastructures. In a sense, we bombed Iraq into the stone age. Then, we said that they could only have limited access to food and medical supplies. What happened? Did Saddam Hussein give himself up? No. But, thousands, perhaps hundreds of thousands of the young and the old died prematurely.
Imagine what would happen should the world should decide to stop shipping to and from Australia. How long do you think that the living standard of Australians would hold up? Probably not as long as Iraq where sharing of resources is more deeply ingrained. The larger human systems that public health practitioners work with are necessary for conducting life in the fashion that most of us have come to expect. Our longer average life-spans are largely mostly due to our better sanitation, improved agricultural standards, our more uniform access to better nutrition and increased sharing of public resources.
This all requires peace and stability. But, even with such goods, there can be problems without just access to resources for living.
For instance, hospitals can extend the life of people in acute circumstances and we are glad of this. If you have a hospital, you want it to be organised to help as many people as possible with conditions which cannot be dealt with in any other manner. However, most people throughout history have died prematurely as a result of sub-acute and chronic conditions such as malnutrition. Finding ways to care for people with sub-acute or chronic conditions before they become acute is one function of public health. However, because many people have no other source of healthcare, they will frequently present to the acute sector seeking assistance. This is tremendously ineffective AND inefficient.

## Background

Public health practitioners work towards the creation and functioning of important systems where health is actually generated. This is typically outside of the acute setting. They also work within the hospital system to ensure that it functions in the best way possible for those who are absolutely dependent on their services. Increasingly, our work requires us to ask what the mediating structures between the larger systems and the acute system might be (AIHW 2014a). We are returning to a more adequate public understanding of what is meant by primary health care after being too heavily influenced by the economic agenda of other organisations with global reach (AIHW 2014b). The local and state levels of government are important players in any process of determining resource allocation, as are many other stakeholders who are often overlooked (Macdonald 1999).
Therefore, it is important for practitioners to be well grounded in their understanding of both the ethical and economic domains and their interaction (Culyer 2001; Hurley 2001). Still, issues relating to equity and the (relative) autonomy of the person are important and must have a privileged place in our decision-making processes (NHMRC 1993/1999). Tensions between different levels of engagement and between various persons and their social networks influence how we conceptualise issues and opportunities (Cookson, et al, 2008). One area where differing values and concerns easy lead to conflict in priority setting has to do with decision-making around medicine. Public health practitioners have much to contribute to both thinking about the issues and implementing equitable solutions in this domain (Kaplan 2008).
While evidence of what might or might not work in terms of priority setting can be difficult to find or apply, we do have some long-term experiments to consider. The state of Oregon proposed one approach to this process of priority-setting (Perry & Hotze 2011). While things did not always work out as proposed, the reasons for this and the learning that can be gained by considering what worked and why provide other local, state, national and international health bodies with significant material for reflection (Saultz 2008). What is particularly clear is how various policies and stakeholder interests impinge on the ability of governments and collectives to provide for the public good of health for persons, families, groups, communities and the broader society.
It is a duty incumbent upon current and future public health practitioners and the communities that they serve to become better acquainted with the principles and practices that facilitate priority-setting in terms of resource allocation across the health care system and the larger systems that influence health. This is why it is important for ethics to be an integral aspect of economics. Without this integration, it is possible for decision-makers to think that economics is merely about dollars (Lee & Gellhoed 2011). In fact, economics should deal with a broader range of goods than monetary considerations. Education, employment and health are also resources as well. The aspirations of a people cannot be overlooked in this domain. Fundamentally, in human societies, people and their capacity for sociability are the most important resources for growth and development across a range of factors. Increasing the capacity of organisations, communities and the workforce to both understand and implement these insights is a crucial concern of public health education (NSWHealth 2001).
References and Resources
AIHW (2014a) Australia's Health System. In, Australia's Health 2014. Canberra: Australian Institute of Health and Welfare. Accessed at: http://www.aihw.gov.au/australias-health/2014/health-system/.
AIHW (2014b) Primary Health Care (8.3). In, Australia's Health 2014. Canberra: Australian Institute of Health and Welfare. Access at: http://www.aihw.gov.au/australias-health/2014/preventing-ill-health/#t3.
Cookson, R., McCabe, C. and Tsuchiya, A. (2008) Public Healthcare Resource Allocation and the Rule of Rescue. Journal of Medical Ethics. 34(7): 540-544. Accessed at: http://www.jstor.org/stable/27720132. [A copy of the discussion paper upon which the article is based can be obtained at this URL: http://eprints.whiterose.ac.uk/10915/1/HEDS_DP_07-04.pdf].
Culyer, A.J. (2001) Economics and ethics in health care. Journal of Medical Ethics 27:217-222. Accessed at: http://jme.bmj.com/content/27/4/234.full.
Hurley, J. (2001) Ethics, economics, and public financing of health care. Journal of Medical Ethics. 27:234-239. Accessed at: http://jme.bmj.com/content/27/4/234.full.
Kaplan, W. (2008) Background Paper 3 Approaches to Priority Setting: Priority Medicines for Europe and the World "A Public Health Approach to Innovation". Geneva: World Health Organization. Accessed at: http://www.who.int/medicines/areas/priority_medicines/BP3_Approaches.pdf.
Lee, M. and Gellhoed, E. (2011) Teaching Resource Allocation--And Why it Matters. Virtual Mentor (AMA Journal of Ethics) 13(4):224-227. Accessed at: http://journalofethics.ama-assn.org/2011/04/medu1-1104.html.
Macdonald, M. (1999) Resource Allocation in Integrated Delivery Systems and Healthcare Networks: A Proposed Framework to Guide Ethical Thinking. Healthcare Management Forum 12(4):24-29. Accessed at: http://hmf.sagepub.com/content/12/4/24.full.pdf.
NHMRC (1993/1999) Ethical considerations relating to health care resource allocation decisions. Canberra: National Health and Medical Resource Council.
NSWHealth (2001) A Framework for Building Capacity to Improve Health. Sydney: New South Wales Health Department. Accessed at: http://www.redaware.org.au/wp-content/uploads/2014/07/A-Framework-for-Building-Capacity-to-Improve-Health.pdf.
Perry, P.A. and Hotze, T. (2011) Oregon's Experiment with Prioritizing Public Health Care Services. Virtual Mentor (AMA Journal of Ethics) 13(4):241-247. Accessed at: http://journalofethics.ama-assn.org/2011/04/pfor1-1104.html.
Saultz, J.W. (2008) Defining Basic Health Benefits: Lessons Learned From the Oregon Health Plan. Family Medicine 40(6):433-7. Accessed at: http://www.stfm.org/fmhub/fm2008/June/John433.pdf.

## Learning Outcomes

Why is it important to understand the relationship between public health practice and the health systems of a country or region?
Upon completion of this topic, through your own investigations, group preparation, tutorial participation and lectorial explorations, you should be able to:
   * Explain how it is possible for public health to be both a part of and a context within which the health systems of a country or a region operate.
   * Describe the various ethical and economic concerns by which public health practitioners might evaluate a health system in terms of performance.
   * Interpret various health policies in terms of their capacity to prioritise the use of resources within a health system individually and collectively.
   * Anticipate how resource allocation targeting workforce and community capacity development might influence public health practice within a health system.