ECONOMIC AND SOCIAL COMMISSION FOR ASIA AND THE PACIFIC
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- ECONOMIC AND SOCIAL COMMISSION FOR ASIA AND THE PACIFIC
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UNITED NATIONS
ECONOMIC
AND
SOCIAL COUNCIL
GENERAL
E/ESCAP/SHD/3
10 September 2004
ORIGINAL: ENGLISH
ECONOMIC AND SOCIAL COMMISSION FOR ASIA AND THE PACIFIC
Subcommittee on Health and Development
First session
1-3 December 2004
Bangkok
SELECTED ISSUES CONCERNING THE PROMOTION OF HEALTH
AND DEVELOPMENT IN THE ESCAP REGION:
CAPACITY-BUILDING FOR PUBLIC HEALTH
(Item 5 (c) of the provisional agenda)
Note by the secretariat
SUMMARY
Public health is an evolving and dynamic field of action and knowledge that aims to restore, protect and
promote people’s mental, physical and social well-being. It emphasizes prevention rather than cure through
collective actions to address the underlying causes of disease and foster conditions in which communities or
population groups can lead healthy lives.
Public health practitioners include a wide range of professionals. Among them are policy analysts,
epidemiologists, demographers, social and behavioural scientists, health promoters, social workers and
community health workers. The development of their ability to meaningfully involve communities in public
health, work in multidisciplinary teams and communicate with government and community leaders is as
important as training them in technical skills. Public health practitioners need to have a solid understanding of
the social, economic and environmental determinants of health to be able to play a useful role in their health
impacts.
Communities and civil society organizations are key allies for public health. Building their capacity for
public health requires more attention than has been given in recent years. There is scope to build on their
initiatives to expand the resource base for public health.
This document provides an analysis of the capacity-building requirements for priority public health
problems and elaborates on some key aspects of capacity-building in public health. It supplements the other
three secretariat documents on the determinants of health, investing in health and the draft framework for
strategic action on promoting health and sustainable development.
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CONTENTS
Page
Introduction,
I.
IL
III.
1
PUBLIC HEALTH AS AN INTERSECTORAL INSTRUMENT FOR EQUITY
AND SOCIAL JUSTICE.................................................................. .....L.......
2
HUMAN RESOURCES DEVELOPMENT
2
A.
Analysing the resource gaps...................................
2
B.
Enhancing the scope of the public health curriculum
3
!
GREATER COMMUNITY INVOLVEMENT IN PUBLIC HEALTH
Conclusion
4
6
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Introduction
1.
At its historic sixtieth session, held in Shanghai, China, the Commission adopted resolution
60/2 of 28 April 2004 containing a regional call for action to enhance capacity-building in public
In doing so, it recalled the internationally agreed development goals in the Millennium
health.
Declaration, especially those that were health-related, and General Assembly resolution 58/3 of 27
October 2003 on enhancing capacity-building in global public health.
2.
The Asian and Pacific region, with 62 per cent of the global population, has shown consistent
economic progress and dynamism over the past few decades, which in turn has contributed to
improving the living conditions and health of its people. It also has a wealth of rich cultural, spiritual,
health and healing traditions.
3.
However, global macroeconomic policies and trends are affecting the region, resulting in loss
of livelihood, increased distress and migration, environmental pollution and destruction, and an
increase in conflict. These deeper social, economic and environmental determinants have a major
impact on the health of people, fuelling the transmission of disease. The cost of health care is rising,
while public expenditure on health is declining.
Health gains achieved over five decades are
beginning to be reversed in some population groups and countries. Inequities in health status and
access to health care are growing.
4.
The capacity of public health systems to deal with these problems is not keeping pace with
the escalation and evolving nature of public health challenges. The emergence of Hl V/AIDS, severe
acute respiratory syndrome and avian influenza serves as a wake-up call to the region and a challenge
to its health systems. Older, long-standing problems such as tuberculosis, malaria, diarrhoea and
undemutrition also take a heavy toll in suffering and death, without attracting as much media and
political attention. There is an urgent need to revitalize public health and its practice, and strengthen
health systems, building on the infrastructure, experience and expertise developed over the past
decades.
5.
Capacity-building for public health to respond more effectively to emerging health problems
in their development context would benefit from strengthening the knowledge and skills of public
health personnel and expanding the pool of human resources for public health. Such expansion could
be through mobilizing actors, such as communities and civil society organizations (CSOs), for public
health. The initiative for public health capacity-building must enable the greater involvement of
communities, especially the poor and vulnerable groups, in decisions that affect their health.
/...
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I.
6.
PUBLIC HEALTH AS AN INTERSECTORAL INSTRUMENT
FOR EQUITY AND SOCIAL JUSTICE
Public health is an evolving and dynamic field of action and knowledge. The practice of
public health care and improved economic and living conditions have resulted in major health gains
for populations in several countries since the early nineteenth century. This occurred through social
policies introduced even before the development of vaccines and antibiotics and included measures to
improve sanitation, hygiene, water supply, housing, nutrition and social security.
7.
The primary health-care (PHC) approach as a strategy to attain the international social goal of
“Health for All by 2000” was articulated at the landmark Alma-Ata Conference in 1978. It drew on
community-level experiences and challenges from different continents, including Asia and the Pacific.
8.
The Alma-Ata PHC strategy was rooted in the principles of equity and social justice in health
and health care. It expanded the scope for public health through highlighting the importance of
increasing social control and democratic political processes governing health and related services. It
attempted to give communities a greater voice in health systems through decentralization and
institutional mechanisms for participation in health decision-making.
9.
In moving beyond curative health care, PHC stressed intersectoral collaboration to address the
deeper determinants of health. To reach the social goal of health for all, PHC emphasized selfreliance at the individual, community and national levels and recommended the use of appropriate
technology to serve the needs of people. It promoted social means to reach these goals. However,
some countries have persisted with PHC and maintained their health gains, while others have not fully
implemented the PHC principles and thus not reaped the benefits. The challenge is to more deeply
address the social, economic and environmental or developmental determinants of health.
10.
Public health capacity-building within and outside of the health sector, combined with
increased investment in health and sustainable development, would facilitate the achievement of the
Millennium Development Goals.
II.
HUMAN RESOURCES DEVELOPMENT
A.
11.
Analysing the resource gaps
Developing a pool of well-trained, competent, highly motivated professionals and workers in
public health is a priority for all countries in the region. Within the public health system in many
countries of the region, there may be a need for analysis of the human resource gaps. The gaps may
occur due to factors such as a physical lack and/or a maldistribution of human resources. The human
resources, even if available, may require skill upgrading or retraining. Analysis of the gaps would
facilitate planning and forecasting of the number of trained public health personnel required at
different levels of the health system.
/...
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12.
Capacity-building in public health needs to transcend mere technical knowledge to include
the development of a service orientation which enables public health personnel to be more responsive
and accountable to those whom they are employed to serve, particularly the poor and groups who tend
to be excluded from health services.
13.
Public health service delivery has become more complex with a multitude of interventions
that require simultaneous implementation. They range from antenatal care and immunization to
focused disease control programmes, such as malaria and tuberculosis programmes. Most of these
interventions are implemented by the same public health workers at the ground level. With the trend
towards decentralization, there is growing pressure on grass-roots public health workers to manage a
far more complex range of tasks than they have been trained to undertake, including managerial,
financial and reporting functions.
14.
In much of the region, the scope of public health training remains narrowly confined to the
health sector. Many factors such as the supply of clean drinking water, the provision of adequate
sanitation and other measures to control environmental pollution directly impact health. Yet the
training of personnel responsible for environmental measures tends to exclude an understanding of the
health impact of their work.
Thus, training to ensure a public health orientation needs to be
introduced into the capacity-building of workers in diverse sectors.
15.
The development of sound and comprehensive policies that have a positive public health
impact requires that policy makers in all development sectors understand and act on the wider concept
of public health. Public health administration is a specialized function to be discharged by trained
public health professionals, rather than generalists, who may simply be assigned as a matter of
routine.
B.
16.
Enhancing the scope of the public health curriculum
There is considerable scope to enhance the public health curriculum of health professionals to
expand their capacity to understand and address the impact of the development determinants of health.
Many countries of the region do not have institutions that offer such courses. Furthermore, the public
health programmes are staffed by personnel who have a clinical orientation, but not a public health
one. There is much value in investing in institutions that develop in public health personnel the skills
that enable them to discharge their public health functions in the specific contexts of their work
environments.
17.
For decision-making in public health, reliable data and information tend to be unavailable.
Even if data and information were to be available, to use these effectively would require analytical
skills which may not be readily available in some parts of the region. To meet this gap, specific skills
for designing, assessing and financing interventions would be required. Health policy analysts and
health managers are two professional groups whose contributions could be vital to public health.
/...
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Health impact assessment (HIA) is an evolving approach that could be used to consider the
18.
potential, or actual, health impact of a proposed policy, programme or project. HIA is helpful for
understanding and dealing with risks to health before they become unmanageable. It is encouraging
that many countries of the region now undertake some form of HIA or have ongoing programmes to
assess the health impact of policies and proposals. There is scope to enhance the HIA capacity not
only of health ministries, but also of other ministries whose decisions and actions impact on health.
Public health practice is often perceived to be an expert-driven, prescriptive approach. At its
19.
interface with people in the Asia-Pacific region, who have their own culture and knowledge base,
public health practice has to take into account the cultural values and belief systems of the societies of
the region, as well as utilize the region’s rich knowledge base and traditional health and healing
practices.
20.
Over the past decades, much experience has been gained through community health and
development initiatives in the voluntary sector in the use of participatory and experiential learning
methods.
These methods include self-awareness and reflection, teamwork, social skills and an
understanding of culture and community dynamics, spiritual and ethical dimensions of health and
public health ethics. They have been used in the education of professionals to increase personal
motivation, enhance ability to support communities and facilitate networking among public health
workers.
21.
Personnel in charge of health facilities at all levels play an important role as health team
leaders. Exercises in leadership training, communication, teamwork, gender sensitization, social
analysis, understanding community dynamics and community organization, and public health ethics
are important to supplement the traditional components of public health training.
22.
In several countries there has been a mutually enriching interaction between modern public
health systems and indigenous systems of health and healing. Indigenous systems and practices that
are beneficial to health need to be appropriately reflected in the training of public health workers and
professionals.
III.
23.
GREATER COMMUNITY INVOLVEMENT IN PUBLIC HEALTH
The participation of communities and CSOs brings new institutional, technical, political and
financial resources to public health. For this to occur, capacity needs to be created for evolving
policies and programmes which are informed by evidence and experience derived from good practice.
24.
CSOs could contribute to public health through interactions within national health systems.
The interactions could be through the provision of hospital services and emergency relief and health
interventions to poor and remote communities.
There is significant evidence of civil society
contributions in enhancing the public accountability of policy processes and highlighting areas of
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public health interventions that demand social action, public advocacy or innovative and community
based responses to health issues. At the international level, CSOs have moved from being outsiders to
being informed insiders in influencing policy processes.
25.
Elected representatives in local bodies have responsibilities for health and there is a need for
innovative training to enable this group to improve the governance of the public health system.
26.
Self-help groups, especially of women, are an increasingly important development force in
the region. Adding a health and social dimension to their activities has been effective in some
countries of the region and could be more widely used.
27.
Experience across the region has shown the value of involving communities in public health
through a variety of means that increase community ownership and management of health institutions.
Those means include the following:
•
Grass-roots-level health committees;
•
Mechanisms for maintaining and enforcing accountability;
•
Local bodies or elected representatives with specific constitutional responsibilities for the
governance of health institutions and programmes;
•
Mechanisms for the participatory management of health institutions that articulate
community views for action to be taken on community health issues.
28.
Governments and CSOs could proactively use information and communication technology
(ICT) to bridge the knowledge gap in public health. A community participatory model of the Health
InterNetwork project being piloted by the World Health Organization has shown that the sharing of
health information with communities, health workers and government health personnel using a mix of
communication methods, including ICT, improved information services for public health.
29.
Community participation has been successful in action research on developmental
determinants of health, such as those from industrial pollution, use of pesticides and mining.
Community involvement in monitoring water and air quality has enabled communities to gather
evidence and become agents for change.
30.
Public campaigns on health-related issues have become increasingly common in the region as
well as globally. The women’s movement has been effective in increasing gender sensitization in
health policies, promoting reproductive rights and raising gender concerns in health research and
medical education. One of the current campaigns is to increase women’s access to primary health
care and reduce violence against women. The People’s Health Movement has been campaigning for a
revitalization of the spirit and principles of primary health care. The pulse of people can be felt and
responded to by listening to the issues raised by people’s campaigns and movements.
/...
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Conclusion
31.
To achieve good health in the region, a paradigm and operational shift in public health is
necessary. Public health needs to respond to the social, economic and environmental determinants of
health that have not been sufficiently addressed thus far.
32.
Capacity-building in public health enables health systems to address the determinants of
health. It needs to take into consideration the rapid growth in knowledge and the context-specific
changes that are constantly occurring. It also needs to be developed across sectors to deepen the
understanding of health as a multisectoral issue. Communities are a rich resource of skills and
knowledge, playing a key role in serving the health and health-related needs of the community.
33.
The challenges that countries in the region are experiencing in improving their health systems
are, to a large extent, the result of long-term neglect in the planning and management of capacity
building in public health. For the region to achieve the Millennium Development Goals, public health
capacity has to be improved in quality and in coverage.
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