Strategic Planning in Public Health: Strategic Planning in Public Health: A Program ApproachA Program Approach

TH Tulchinsky MD MPHTH Tulchinsky MD MPHBraun School of Public HealthBraun School of Public Health

Hebrew University-Hadassah, JerusalemHebrew University-Hadassah, Jerusalem

October 2004October 2004

StrategyStrategy

• 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)

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.

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

Game TheoryGame 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)

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

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

“The U-boat was the only thing I really

feared in WWII.”Winston

Churchill

The Crisis of Battle of the Atlantic,

Aug 1/42 to May 21/43

Winston Churchill, World War II, Vol 5

B a ttle o f th e A tla n tic , 1 9 3 9 -4 5: S h ip su n k vs. S u b su n k

0

200

400

600

800

1000

1200

1 2 3 4 5 6 7

Shipsunk

Subsunk

Battle of Atlantic Turning Point; April-June 1943

Months Merchant Tonnage Sunk

000s

Subsunk Air

Subsunk sea

Subsunk total

March 515 7 4 12

April 242 8 6 15

May 199 18 12 40

June 22 9 6 17

Oct-Dec 47 ships - - 53

Churchill W

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

Jack Maple’s Law, NYPD 1993-96Jack 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)

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

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

Expanded Host-Agent-Environment Expanded Host-Agent-Environment ParadigmParadigm

• HostHost - genetic, nutritional, life style, personality, psychosocial and other factors

• AgentAgent - microbiologic, toxic, stress, work, nutrient excess or deficiency

• EnvironmentEnvironment – vector, physical-societal context• InterventionIntervention - clinical, preventive, environment

HostHost

AgentAgent EnvironmentEnvironment

HostHost EnvironmentEnvironment

AgentAgent InterventionIntervention

Determinants of Population HealthDeterminants of Population Health

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)

Health ServicesHealth Services

Income & Social Status

Social Support Networks

Education

Employment &working

conditions

Physical environments

Biology &genetic

endowment

Personal healthpractices & coping

skills

Healthy child

development

A Comprehensive Health Services A Comprehensive Health Services Continuum: ManitobaContinuum: Manitoba

Healthy Public PolicyPreventionPromotionProtection

CommunityOrientedServices

SupportServices

ToSeniors

Home Care

CommunityHealth Centres

ExtendedTreatment &

Long Term Care

OutpatientAmbulatory

Care

RuralCommunity

UrbanCommunity Tertiary

Rehabilitation

Palliation

HospitalsPromotionPromotion PalliationPalliation

Health ResourcesHealth 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

Healthy InfantsHealthy 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

Infant Mortality, United States, 1900-1999Infant Mortality, United States, 1900-1999

Maternal Mortality, United States, Maternal Mortality, United States, 1900-19991900-1999

Communicable Disease ControlCommunicable 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

Social Diseases: TB, STIs, HIV, Social Diseases: TB, STIs, HIV, Hepatitis, Cancer of CervixHepatitis, 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

AIDS Incidence, Deaths and Prevalence, AIDS Incidence, Deaths and Prevalence,

United States 1981-2000United States 1981-2000

Safe Community Water SuppliesSafe 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

Non-Communicable Disease ControlNon-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

Motor Vehicle Trauma ControlMotor 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

A Program Approach

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

SummarySummary

• 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