# Principles of Public Health Practice/What are the core values underlying public health?

In this topic we are looking at some of the values that underpin public health practice such as: equity, social justice, participation, efficiency, effectiveness, acceptability, affordability and accessibility. We will also consider how different interest groups might contest these or the conclusions that people come to by seeking to apply these values.
Getting to grips with how these actually work out in practice will help you to better understand the key concepts associated with your first assessment. After viewing the materials of this topic and reviewing the materials of the earlier topic, you should be able to see what we mean by public health. It is about protecting and promoting health and preventing disease.
It is possible for people to use the key concepts of a) primary care and primary health care, b) health promotion, c) population health, and d) public health in different senses. However, there is a way to think about them as all contributing to a coherent understanding about how we can achieve better health outcomes for everyone. See if you can put the puzzle together.

## Learning activity instructions

Each week we hold a lectorial and a tutorial. The lectorial is a lecture involving audience participation. The tutorials are for discussing the and group activities relating to the topic, and for working on the assignments.
Lectorial
* Watch the videos in this playlist
* Read through this topic's page
* Attend the lectorial
Tutorial
* Download and review the workshop materials
* Attend the tutorial

## What are the core values underlying public health practice and how might they be contested by various interest groups (e.g., governmental, non-governmental, commercial and non-commercial)?

The cartoon to the right (above) makes an important point about Equity. Equity refers to having a stake, or an recognised interest, in what is going on around us. It means not just bearing the burdens of life; it also means having a fair share of the benefits as well. Often, the main rule of a rat-race life seems to be, "First in, best dressed"; the mighty get the lion's share of the goods. This is a rather short-sighted value. It focuses on strength or agility to the exclusion of dignity and participation. This might be all right for baboons; but, it doesn't do well for humans in the long run.
Humans do their best work, achieve their most distinctly human accomplishments, in cooperative groups. This is especially true when these groups consider the needs of the weaker members. Participation of all members of the group in each aspect of an endeavour is a more appropriate value than everyone for themselves. Unfortunately, we are more likely to talk about participation, rather than enact it. Therefore, we can loose perspectives that might better help us to deal with a situation. Even good people can get rattled about an issue and start solving a problem before they know what that problem is really.
Sometimes you have just got to pick up the kids and run during an earthquake, tsunami or volcanic eruption. But, most of the time, we need to enact the courage required to foster leadership. Such leadership takes the time to assess, plan, implement, evaluate with agenuine involvement of all affected parties. This approach may take longer; but, the results are likely to be stronger because of wider and better take up (effectiveness) and last longer because of a sense of ownership that supports sustainability (efficiency).
Besides, and more fundamentally, it supports an understanding of human rights expressed in the Universal Declaration of Human Rights. This declaration was hammered out after World War II. The deliberations and discussions were led by Eleanor Roosevelt who allowed input from all sides of the contest. Then, she moved the deliberations forward towards a common declaration. There are few people who can do this well. It is worth noting that Australia played a critical role in all of this.
Australia has continued to play an important role in much of the development of health promotion and a participatory approach to public health over the last seventy years or so. You can be a part of that continuing tradition in your own practice. But, there will be people, groups and communities which will benefit from ignoring a participatory approach. As a person and a public health practitioner, you will need to be alert to what is really going on around you.
As the Aboriginal or Indigenous people of most colonised areas have learned, consultation is often confused with participation in the rhetoric of the colonisers. Here is how that often works. Suppose I ask you what you think and you tell me. I can, then, claim that you have participated in the decision-making process. I can do this even though there may be no intention of putting into practice anything you should suggest is important. This sort of "engagement" is unlikely to result in the engendering of resources and processes that are acceptable, accessible and affordable to the people who should benefit from them.

## Background

Different people will have different lists of core values that underlie public health practice. The following are not exhaustive. However, they are deemed foundational by those who practice a more community oriented approach to public health. It is important to keep listening to others to hear what they have to say and see how they see. You do not have to agree; but, you do need to understand and take a sympathetic stance towards how people are seeking to live in the world.
Justice is often described as the balancing between burden and benefit. There should be a fair distribution of the two. Justice assumes that people can meet their responsibilities and be held accountable fairly uniformly across the community. This meets somewhat the criterion of "consistency and conditions of enforceability" discussed in the Nuffield Council on Bioethics (2007:149) document, Public Health: Ethical Issues. Yet, not everyone is as capable of being accountable as others. Children and the weak or those enduring infirmity are often in this class. The same can be true of those who are regularly discriminated against by their societies or who are not even considered members of the society as is often the case with refugees and asylum seekers. In these cases, we are looking to a deeper value, equity. Equity is the idea that everyone should have some stake in the things that make life meaningful. Guy and MacCandless (2012:S55) make the following observation:
    To be clear, "equity" and "equality" are terms that are often used interchangeably, and to a large extent, they have similar meanings. The difference is one of nuance: while equality can be converted into a mathematical measure in which equal parts are identical in size or number, equity is a more flexible measure allowing for equivalency while not demanding exact sameness. For example, a child entering school who does not speak English is at a substantive disadvantage compared to her native English-speaking classmates. Though the entire class may receive equal instructions in language, the non-Enlish-speaking student requires additional tutoring, if her training is to be equitable with that of her classmates.
Participation is a critical aspect of both social justice and equitable processes. People need to have some say in what is happening to them if they have a stake in their families, communities and societies. Participation is about having a voice to shape decisions, implementations and evaluations that influence our lives (Hayes 2012). But, participation can vary in its manner and its potential outcomes. In terms of governance of programs relating to various groups in a community, de Lancer Julnes and Johnson (2011:223) describe the following types of participation:
    Inform: provide the public with balanced and objective information to assist them in understanding the problems, alternatives, opportunities, and/or solutions;
    Consult: obtain public feedback on analysis, alternatives, and/or decisions;
    Involve: work directly with the public throughout the process to ensure that public concerns and aspirations are consistently understood and considered.
    Collaborate: partner with the public in each aspect of the decision including the development of alternatives and the identification of the preferred solutions; and
    Empower: place final decision making in the hands of citizens.
A classic trio of concerns relates to the question of whether a service or program is "accessible, acceptable and affordable" within a particular community or context. This is a summary of the Alma-Ata Declaration as found in the Health Promotion Glossary (WHO 1998:3-4). However, we should not overlook that equity, participation and the prerequisites of health are also considered. Similarly, and this is often overlooked, the Declaration also specifies that primary health care approaches should be both "practical" and "scientifically sound". Here is a dimension that can lead to conflict. If we are engaging the community equitably and community members are participating fully, to what degree should we be encouraging the use of local knowledge and methods that have yet to be tested? It may be practical to use these methods because they are acceptable; but, is it scientifically sound? There are no easy answers to this question. However, the consequences can be quite costly when moves are made in either direction.
Two last related values will be considered in this backgrounder: effectiveness and efficiency. In relation to the first word, we should also reflect on a similar term, efficacy. Efficacy, has to do with how well something works in the best of circumstances. There is an important assumption made that if something will not work in the best conditions, it will probably not work in the worst. For example, if you buy a box of cheap matches that are difficult to light in your house, they are likely to be even less easy to light out in the woods when you are trying to start a fire late on a rainy night. Efficacy requires that we know something will actually work. Effectiveness is about measuring how something works in a variety of contexts. After we have determined whether something is efficacious and effective, we need to know if it will be efficient. Will it get the job done with as few resources as possible and at a rate of expense that is sustainable? This is the question of efficiency which may be measured as: cost/efficacy, cost/effectiveness, cost/utility and cost/benefit (Lazaro y de Mercado 2004:608).
Who will decide what is most important?
References and Resources
    de Lancer Julnes, P. & Johnson, D. (2011) Strengthening efforts to engage the Hispanic community in citizen-driven governance: An assessment of efforts in Utah. Public Administration Review 71(2):221-231.
    Guy, M.E. (2012) Social Equity: Its legacy, its promise. Public Administration Review (Special Issue) 72(S1):5-13.
    Hayes, R. (2012) Having a voice: Participation and the problem with the National Male Health Policy. Health Issues. 109:4-8.
    Lazaro y de Mercado, P. (2004) Drug-eluting stents: Efficacy, effectiveness, efficiency, and evidence. Revista Española de Cardiología. 57(7):608-612.
    Marmot, M. Achieving health equity: from root causes to fair outcomes. The Lancet, 370(9593), 1153-1163. doi: http://dx.doi.org/10.1016/S0140-6736(07)61385-3
    Marmot, M., Friel, S., Bell, R., Houweling, T. A. J., & Taylor, S. Closing the gap in a generation: health equity through action on the social determinants of health. The Lancet, 372(9650), 1661-1669. doi: http://dx.doi.org/10.1016/S0140-6736(08)61690-6
    NCOB (2007) Public health: Ethical issues. London: Nuffield Council on Bioethics.
    Sen, A. (2002). Why health equity? Health Economics, 11(8), 659-666. doi: 10.1002/hec.762
    WHO (1998) Health Promotion Glossary. Geneva: World Health Organization.

## Learning Outcomes

Upon completion of this topic, through your own investigations, group preparation, tutorial participation and lectorial explorations, you should be able to:
   * Explain how an understanding of primary health care developed from the Alma Ata Declaration can inform participation in public health practice.
   * Discriminate between the concepts of efficacy and effectiveness and explain the importance of the distinction.
   * Outline the various understandings of efficiency and evaluate them to in terms of accessibility, affordability and acceptability in primary health care.
   * Justify a position on the concept of equity as it might relate to the engendering, access and use of resources in public health practice.