Strategic Planning in Public Health: A Program Approach

1. Strategic Planning in Public Health: A Program Approach TH Tulchinsky MD MPH Braun School of Public Health Hebrew University-Hadassah, Jerusalem October 2004

2. Strategy • A set of essential measures (preventive and therapeutic) believed sufficient to control a health problem (Last J. Dictionary of Epidemiology, 3rd edition, 2000) • Strategy may be defined as the general scheme of the conduct of a war, tactics as the planning of means to achieve strategic objectives (Von Clausewitz 18th C). • A program or series of measures, stratagems and activities planned and carried out for the purpose of achieving specific objectives (Webster Dictionary)

3. Strategy and Tactics • Strategy - A plan or method or series of maneuvers or stratagems for obtaining a specific goal or result. • The art and science of planning and directing large scale use of resources with long range planning and development to ensure success in achieving objectives e.g. prevent or successfully combat disease in a population, plan a military campaign • Tactics – use and deployment of resources in actual field conditions e.g. military, police, firefighting, public health.

4. War Theory: Military Strategy and Tactics • Sun Tsu 166 BC – The Art of War - knowledge, deception, prevention • Von Clausewitz 19th C war is continuation of policy by other means – complete victory • Alfred Mahan – influence of sea power on history • Liddel Hart 1920sד direct and indirect approaches • Mao Tse Tung etc

5. Game Theory • Distinct, interdisciplinary approach to the study of human behavior. • Disciplines most involved are mathematics, economics, other social and behavioral sciences. • Mathematical and neoclassical economics. • Outcome depends on "market conditions," but also on the strategies chosen by others • Rational choice of strategies is the problem • Rational outcome as the"solution" • Infectious disease modeling (Anderson and May)

6. How to Fight and Win • Who (or what) is the enemy? • What are the enemy’s objectives? • What are their resources/capabilities? • What are our objectives? • What are our resources/capabilities? • How best can we achieve our objectives? • What are the most suitable methods of combat? • Intelligence and modification of strategy and tactics

7. Case Study: Battle of the Atlantic • Phase I, June 1939-April, 1943 • Convoy system, British codes broken • German wolf packs control of sea lanes increasing • Allies build quantitative strength, new technology • Air gap 800 miles • Phase II May 1943-1945 • Crisis April-May 1943 -the tide turns • Allied quantitative and qualitative achievements • Air gap closed; convoys plus hunter-killer groups • Technological advances e.g. radar, squid, torpedoes • German innovations too late

8. “The U-boat was the only thing I really feared in WWII.”Winston Churchill

9. The Crisis of Battle of the Atlantic, Aug 1/42 to May 21/43Winston Churchill, World War II, Vol 5

11. Battle of Atlantic Turning Point; April-June 1943 Churchill W

12. Perspective • Stoker on merchant ship • Captain of merchant ship • Captain of convoy escort • Commander of convoy • Commander of naval sector • Commander of air services • First Sea Lord • Prime minister • Public opinion • The enemy

13. Jack Maple’s Law, NYPD 1993-96 • Objective – reduce crime and murder rates • Methods • 1. Accurate and timely intelligence • 2. Rapid deployment • 3. Effective tactics • 4. Relentless follow-up • 5. Continuous assessment and data • Murders fell from 1,946 (1993) to 1,000 (1996)

14. MVA Mortality and Mileage, United States, 1925-1997

15. Cardiovascular Disease Mortality Rates, United States, 1900-1999

16. Expanded Host-Agent-Environment Paradigm • Host- genetic, nutritional, life style, personality, psychosocial and other factors • Agent - microbiologic, toxic, stress, work, nutrient excess or deficiency • Environment – vector, physical-societal context • Intervention - clinical, preventive, environment Host Host Environment Agent Environment Agent Intervention

17. Determinants of Population Health Income & Social Status Social Support Networks Education Physical environments Biology & genetic endowment Employment & working conditions Healthy child development Personal health practices & coping skills Health Services • Adopting the population health framework and collaborative approach as the basis for development of future health policies and strategies by governments has great potential to improve the health of Canadians... • (Strategies for Population Health Investing in the Health of Canadians, 1994)

18. A Comprehensive Health Services Continuum: Manitoba Promotion Palliation Hospitals Healthy Public Policy Prevention Promotion Protection Support Services To Seniors Community Health Centres Outpatient Ambulatory Care Rural Community Urban Community Tertiary Palliation Community Oriented Services Home Care Extended Treatment & Long Term Care Rehabilitation

19. Health Resources • Political and public support • Community and media expectations and support • Manpower and training • Money • Facilities for in-patient care – acute and LTC • Community care – clinics, outreach, home care • Drugs • Vaccines • Education

20. Healthy Infants • Healthy women in age of fertility e.g. iron and folate • Good prenatal care and risk assessment • Good care during delivery e.g. in hospital • Good neonatal care e.g. vitamin K • Good infant care e.g. immunization, • Growth and development monitoring • Breast feeding plus vitamins A, C, D, iron • Formulas to one year • Solid foods from 4 months • Warmth, care, stimulus

21. Infant Mortality, United States, 1900-1999

22. Maternal Mortality, United States, 1900-1999

23. Communicable Disease Control • Sanitation and hygiene • Safe water and food • Sewage collection and treatment • Education - public, professional, patients • Epidemiologic reporting, surveillance • Training in PH, epidemiologic investigation • Up to date immunization program • Good programs for “Social Diseases” i.e TB, STDs, HIV, Hep B, Ca Cx • Good primary and secondary care treatment • Good laboratory support

24. Social Diseases: TB, STIs, HIV, Hepatitis, Cancer of Cervix • Common risk groups and factors • “Noxious synergy” • Prevention and treatment strategies e.g. education, anti-retroviral drugs, immunization • Ambulatory and community care • Screening and case contact follow-up • Community outreach • Education • Specialized tertiary care and terminal care • Long term strategies for sustainable success

25. AIDS Incidence, Deaths and Prevalence, United States 1981-2000

26. Safe Community Water Supplies • Safe water sources – contamination • Coagulation • Filtration • Disinfection and residual chlorine - mandatory • Routine testing – bacterial and chemical • Routine chemical testing • Sanitary engineering inspection • Safe distribution and drainage systems • Updated standards • Epidemiologic monitoring of diseases

27. Non-Communicable Disease Control • Primary prevention • Reduce CVD risk factors – BMI, exercise, smoking • Good nutrition e.g. much vegetables, little fat • Secondary Prevention • Hypertension and diabetes control • Good treatment of AMI, stroke • Technology assessment and adoption • Tertiary prevention • Good long term care in community • Hospital care in extremis

28. Motor Vehicle Trauma Control • Primary prevention • Transport policy e.g. trains vs. cars • Laws and policing e.g. speed, seatbelts, helmets • Roads e.g. shoulders, roundabouts, lights • Alcohol control e.g. supply, taxation, • Education • Secondary prevention • Emergency care at site • Good emergency transportation • trauma care in hospital • Good hospital care and training • Tertiary prevention • Good rehabilitation care

29. A Program Approach • Comprehensive planning • Strategic goals • Specific targets • Operational planning • Steering group • Implementation team • Training, resources • Monitoring of input, process and outcomes

30. Summary • Define the problem, and objectives • Program Approach - strategy and tactics • Intervention program – multi layered planning • Budget and resources • Inter-sectoral cooperation - networking • Political support and resources • Management group • Technology - “the state of the art” • Define realistic alternative approaches • Implementation tactical program • Intelligence i.e. continuous monitoring • Reevaluation and revision • Communicate what you are doing

31. Working Toward Goals