Stronger national public health institutes for global health
Authors: Thomas R Frieden, Jeffrey P Koplan
Journal: The Lancet (2010)

Although strengthening health-care systems is receiving increased attention, strengthening public health systems and institutions could save far more lives at lower cost. Public health institutes monitor, implement, and oversee programmes to prevent disease. Life-saving and cost-saving programmes include immunisations, control of communicable diseases including diarrhoeal disease, reduction of motor-vehicle crashes, and tobacco control. Over the past decade, many countries have considered, strengthened, or created national public health institutes (NPHIs), often following a major event such as the outbreak of severe acute respiratory syndrome.1Binder S Adigun L Dusenbury C Greenspan A Tanhuanpa P National Public Health Institutes: contributing to the public good.J Public Health Policy. 2008; 29: 3-21Crossref PubMed Scopus (26) Google Scholar, 2International Association for National Public Health InstitutionsFramework for the creation and development of National Public Health Institutes.http://www.ianphi.org/uploads/resources/Framework%20for%20NPHI.pdfDate: 2007Google Scholar The core function of an NPHI is monitoring and responding to health threats. Monitoring requires reference laboratories and surveillance. Response requires outbreak control and implementation of evidence-based public health actions. NPHIs can include disease-specific control programmes, support to state, provincial, or local public health entities, surveillance and control for non-communicable diseases and injuries, occupational and environmental health, and vital registration (table).3Frieden TR Henning KJ Public health requirements for rapid progress in global health.Glob Public Health. 2009; 4: 323-337Crossref PubMed Scopus (17) Google Scholar These functions can be done by more than one institution in a country, and some countries have collaborated to establish regional institutions. Effective public health responses often require a multidisciplinary team, including skills needed for communicable and non-communicable disease control programmes. For example, the response to biosecurity threats involves expertise in infectious diseases, chemical hazards, engineering, environmental remediation, and risk communication.TableCore and potential functions of a national public health instituteCharacteristicsConsiderationsCollection and dissemination of surveillance informationCore information includes reportable conditions, including reporting for compliance with international health regulationsCan include vital registration, community surveys, phone surveys; new technologies include mobile devices for data collection and internet-based information collectionReference laboratoryDefinitive confirmation of diseases and conditionsCan include infectious, environmental, biomarker, and other laboratory testsInfectious disease outbreak detection and controlRapid response to suspected outbreaks of diseaseRequires close coordination with state and local health departments, and ability to mobilise response within hours or lessDisease-specific infectious disease programmesImmunisation, tuberculosis control, malaria prevention and control, HIV/AIDS, prevention and control of sexually transmitted diseases, etcSome countries maintain disease-specific control programmes in different institutes for historical or other reasons; there are potential synergies among programmesSurveillance and control of non-communicable diseasesTobacco control, nutrition, reproductive and maternal and child health, cancer, cardiovascular diseaseInteractions with civil-society groups and other parts of national government (finance, revenue, planning, etc) are crucialSurveillance and control of injuriesIncludes both intentional (homicide, suicide, civil conflict, sexual violence) and unintentional (road traffic, falls, drug misuse, etc)Transportation policy, addressing both prevention and response, with epidemiological analysis to identify opportunities for prevention, are all essentialNational public health leadershipPriority setting, policy analysis and implementation, public health research agenda, technical guidelines, and recommendationsResponsibility often shared with other national and subnational entitiesSupport to state, provincial, or local public health entitiesCan include funding, guidance, technical support, or provision of some or all staff to subnational public health agenciesArrangements vary from countries in which state or provincial health staff are employed by NPHI to others where there are limited interactionsOccupational healthMonitoring and establishing science-based guidelines to promote workers' safety and healthRegulation might be done by other entities; mediating between worker and union and business and industrial interests can be challengingEnvironmental health and safetyWater and sanitation, food safety, air qualityCommunity concerns often drive activities, and highest risk exposures might not be those that receive most attentionRegulation of pharmaceuticals and biologicalsCan include standard setting, testing, approval, and safety monitoringSome institutes, currently or previously, produced drugs and vaccinesWorkforce training and developmentInternal to agency at all levels (programme, epidemiology, laboratory, specialty), other public health agencies, medical staff, and othersDistance learning increasingly important and effectiveEmergency preparedness and responseGenerally via organised incident-management system with specific sections addressing epidemiological, clinical, communications, logistical, and other elements of responseCoordination with other national, international, and subnational response units is keyPrevention of birth defectsFortification of foods with iodine and folic acid particularly important; surveillance and support to affected populationsScaling up effective interventions is key; better understanding burden and amenability to intervention in birth defects is needed to further reduce incidenceHealth communicationsCommunication with the general public, mass media, electronic media, specific risk/interested groups, policy makers, and health-care workersSpeed, clarity, and credibility are key; electronic media bring new risks and opportunitiesMonitoring and improvement of health-care qualityOngoing community surveys and surveys of health-care institutions, with focus on adherence to and results of prevention effortsCan be facilitated by electronic health records; community surveys are expensive but generally essential to complement surveillance of health-care system Open table in a new tab The evolution of one NPHI—the US Centers for Disease Control and Prevention (CDC)—illustrates key issues.4Langmuir AD The Epidemic Intelligence Service of the Center for Disease Control.Public Health Rep. 1980; 95: 470-477PubMed Google Scholar, 5Etheridge E Sentinel for health: a history of the Centers for Disease Control. University of California Press, Berkley and Los Angeles1992Google Scholar The CDC grew out of a 1940s domestic malaria-control programme and initially focused on infectious disease control through laboratory and epidemiological expertise. Over decades, it expanded to include surveillance, prevention, and control of non-communicable diseases, injuries, and birth defects as well as occupational and environmental health. The CDC has been increasingly involved in global health activities since the 1950s. Emergency preparedness and response, always a core function, received increased attention after the 9/11 World Trade Center and anthrax attacks. CDC's role in the US health-care system continues to evolve with the passage of health-reform legislation and increased focus on prevention through clinical care. To be effective, an NPHI must have credibility and be independent, technically expert, and apolitical, which requires independence from parent ministries of health on technical issues. But if an NPHI is seen as being too independent, it might not be able to address important health challenges. A related issue is whether the entity has regulatory authority—the US CDC has limited regulatory authority but provides guidance to other federal agencies and state and local public health agencies which have more. In other countries, the role of the NPHI can include regulation of pharmaceutical production or sale, and of medical care. Supporting state/provincial and local public health entities is critically important; providing funds and personnel (through training, staffing, or short-term and long-term staff deployed from the NPHI) is the most effective way to increase implementation of technical guidance. NPHIs can provide only reference laboratory services or can also provide oversight, technical support, and materials to subnational laboratories. There is potential for tension between service provision, training, and research. In the USA, this was addressed through the Epidemic Intelligence Service, in which trainees learn by doing.4Langmuir AD The Epidemic Intelligence Service of the Center for Disease Control.Public Health Rep. 1980; 95: 470-477PubMed Google Scholar, 6Thacker SB Dannenberg AL Hamilton DH Epidemic intelligence service of the Centers for Disease Control and Prevention: 50 years of training and service in applied epidemiology.Am J Epidemiol. 2001; 154: 985-992Crossref PubMed Scopus (86) Google Scholar The US CDC and international partners have helped start 37 similar programmes.7Centers for Disease Control and PreventionField epidemiology (and laboratory) training program (FE(L)TP).http://www.cdc.gov/globalhealth/fetpDate: 2010Google Scholar These programmes provide public health leadership and contribute to the development of the NPHI. Some NPHIs do basic research; in the USA, this function is more often done by the National Institutes of Health. NPHIs might also seek to improve individual and community health directly. Health-communication efforts often include websites, targeted to both medical staff and the public, and active media outreach to provide prompt and accurate health information. Policy changes, such as laws to promote immunisations or reduction of behavioural and environmental risks, can be effective, although critics might see such efforts as too directly political. Some NPHIs lead community mobilisation, such as immunisation and anti-tobacco campaigns. NPHIs can provide crucial expertise to protect the public's health. Increasing the number, scope, and effectiveness of NPHIs in developing countries will enable better prevention and control of infectious diseases and reduce the burden of non-communicable diseases and injuries. Success will depend on accurate collection, analysis, and dissemination of data to implement and monitor evidence-based programmes. NPHIs require more staff and resources, although on a much smaller scale than the need for additional clinical personnel. Stronger NPHIs enable countries to implement and monitor health programmes that save money and lives by basing decisions on country-specific data on health burden, efficacy of interventions, and implementation status of health programmes. To improve both health and health systems, developing countries need to greatly increase resources and authority of NPHIs. We thank Kevin De Cock, Richard Garfield, Patricia Simone, and Donald Shriber for helpful comments, and Kimberly Dills for assistance with manuscript preparation. TRF is the Director of the Centers for Disease Control and Prevention. JPK declares that he has no conflicts of interest. CDC's Thomas Frieden—protecting health and reducing costsWhen Michael Bloomberg was elected Mayor of New York in 2001, he started looking to appoint a new Health Commissioner. The dust from the Sept 11 attacks had barely settled, so when asked which public health issue would require the most Mayoral support, many of the job candidates answered, bioterrorism. Thomas Frieden said, tobacco. He got the job, and after almost 8 years serving as the New York City Health Commissioner, Frieden was, last year, appointed to the US top spot for public health. Barack Obama named him as the 16th Director of the US Centers for Disease Control and Prevention (CDC). Full-Text PDF