Health promotion in local government: a British experience.

Historically, the development of health promotion work in Britain centred largely upon the activities of elected local authorities. From the mid-nineteenth century onwards, these authorities were primarily responsible both for major interventions in the physical environment, such as improved housing and sanitation, and for the development of community-based preventive and primary care services, such as ante-natal care, health-visiting and district nursing. The importance attached to such work was underlined by the statutory requirement that local authorities should appoint a Medical Officer of Health who could not be dismissed without specific Ministerial approval. Yet in recent decades, this long-standing tradition has been undermined, with both public health doctors and the community health services being displaced from their historical local authority base and placed instead within the the National Health Service, where they are substantially outnumbered by their hospital-based colleagues. As a result, a major political and administrative focus for developing public health approaches has largely disappeared. This loss of a health focus has become a matter of concern to a growing number of local authorities in Britain; a concern which reflects their public health tradition and newer policy issues and approaches which began to affect British local authorities from the late 1970s onwards. This paper considers the example of one such authority, the London Borough of Greenwich, where the author was employed during the early 1980s. In particular, it examines the political and practical problems faced when attempting a systematic review of the authority's role and potential for promoting health through its policies on housing. In the light of this experience, some tentative suggestions are made about the kinds of structures which will be needed if local authorities are to revitalise their public health tradition in a political and economic climate hostile even to existing levels of State intervention.     

INGO在缅甸特区政府卫生责任倡导中的作用

由于特殊的历史和政治原因，缅甸特区政府一直以来忽略了老百姓的健康问题或者无力做更多的投入，而国际非政府组织（INGO）在推动和倡导当地政府承担更多的民众健康责任方面起到了很大的作用。以无国界卫生（英国）组织在缅甸的卫生项目为例，在提升政府卫生意识、支持INGO卫生工作，建立面向民众的卫生服务与管理体系，提高特区自我卫生管理能力，支持特区开发卫生发展规划和加强特区政府与中方联控项目合作等六个方面，促进了特区政府增加卫生投入提升其对民众健康责任承担。     

Public health medicine and the district health authority

The 1991 National Health service reforms have greatly changed the role of district health authorities. These bodies employ most public health physicians in England and thus the focus of public health departments has changed with the reforms. Presents the results of a series of semi-structured interviews with the board members of two health authorities about the role of public health. Board members outlined several roles for the specialty including defining key issues, interpreting technical issues, intelligence gathering, developing links with clinicians and legitimizing health authority decisions. There were some concerns about the corporacy of public health departments. There was a great deal of support for health promotion, but some reluctance to be drawn into political issues. Also explored were alternative sources of advice on health policy, such as the views of general practitioners.     

Chemical incident management: gaseous emissions from a stockpile of coal

Spontaneous combustion of coal releases a wide range of airborne pollutants which, in high concentrations, may be hazardous to health. Little is known about how the effects on health change in relation to the release of multiple substances. This article reports an incident in which a stockpile of coal released potentially harmful gases into the environment. Although the resultant health effects reported were few, the co-ordinated response by local authorities and health authorities highlighted the advantage of a multidisciplinary approach. Public health departments need to be aware of major chemical hazards within their district. Prompt environmental monitoring and exposure measurement needs to be arranged as this is crucial to making an appropriate response. Updated registers are needed from private companies and public bodies; who can provide timely measurements of chemical hazards. Health districts with more than one local authority may benefit from pooling resources and knowledge in order to prepare for such an incident.     

Community participation and health care priorities: reflections on policy, theatre and reality in Britain

In recent years, the British government has attempted to make the finite nature of publicly funded health care explicit and to involve the 'public' in discussions about which treatments (or indeed patients) should be given priority over others. This article considers the nature of the new political emphasis upon local participation through analysis of policy and illustrative reference to a system of participatory forums in the field of mental health planning developed in an area of southern England. The tendency by the health authority in question not to respond to many of the issues raised by the forums illustrates two characteristics of the health service in Britain. Firstly, there continues to exist a political , managerial and clinical hegemony within the service such that health authorities tend not to have to account for the weight they attach to local views or the manner in which such preferences are measured against other imperatives and considerations. In a second respect, the simplistic notion of the 'purchase' of health care by health authorities on behalf of local populations is problematic. Health authorities are faced with a panoply of political, statutory and bureaucratic requirements that preclude activity in accordance with 'market forces'. This in turn renders the idea of local 'advice' to purchase considerably more complex than the associated political rhetoric intimates.     

Public participation for women's health: strange bedfellows or partners in a cause?

A major focus of health system reform in Canada has been the regionalization of health services administration. With a goal of bringing decision-making closer to the community, there has been a commitment to public participation in planning by some health authorities. Women, however, often feel that their participation is minimal or their needs are not addressed. During regionalization of the Alberta health system, the Calgary Health Region (CHR) negotiated an agreement with the Salvation Army to provide women's health services through the Grace Women's Health Centre, a major part of the region's women's health program. We present a case study exploring the process and final agreement and the impact of this agreement on women's participation in health policy development. The historical context and the nature and impact of the agreement are described and several participation strategies that occurred within the partnership are discussed. The development of a formal partnership agreement, a governance model, was a success for public participation in this case; however, the greatest success for women was maintenance of a political space in which women's health as a priority could be discussed in a context where the forces against gender equity talk are strong.     

Integrating health and social services for older adults: a case study of interagency collaboration

As public housing residents age in place, they require health and social services outside of those traditionally offered by housing authorities. A promising response to these emerging needs is for housing authorities to collaborate with local public health departments to deliver coordinated services to older adult residents. Aging residents' health needs include health promotion activities, preventive health services, health education, and mental health services, among others. From 2001-2004 the New York City Department of Health and Mental Hygiene (DOHMH) and the New York City Housing Authority (NYCHA) collaborated to implement the Senior Wellness Project. This outreach program integrated health and social services provided by DOHMH and NYCHA, and delivered these services to older adult residents on site in 21 New York City public housing developments. Services were rendered at senior centers located in the housing developments and in residents' apartments. The program also referred residents to community healthcare providers to address special needs such as addiction. This article retroactively applies a formal model for interagency collaboration, the Stages of Collaboration, to describe and analyze the process of collaboration between DOHMH and NYCHA. It identifies the successes and shortcomings of the collaborative process, and explores the theory that successful collaboration leads to inherent challenges for implementation. Recommendations are then made for other public housing and public health agencies that have considered collaborating to address the needs of public housing residents who are aging in place.     

Rethinking public health: new training for new times

The new public health agenda will require major changes in the way health authorities, local authorities, Trusts and Primary Care Groups organise and manage their activities. The requirement is for inter-agency co-ordination and inter-professional and inter-sectoral working to a shared agenda, yet the human and resources development planning to achieve these goals has not been done. This paper summarises the key training issues and argues for a collaborative, decentralised and quality assured approach to multidisciplinary public health management education and training. Only with such a joined up human resources plan can Our Healthier Nation succeed where The Health of the Nation signally failed.     

Public Participation for Women's Health: Strange Bedfellows or Partners in a Cause?

A major focus of health system reform in Canada has been the regionalization of health services administration. With a goal of bringing decision-making closer to the community, there has been a commitment to public participation in planning by some health authorities. Women, however, often feel that their participation is minimal or their needs are not addressed. During regionalization of the Alberta health system, the Calgary Health Region (CHR) negotiated an agreement with the Salvation Army to provide women's health services through the Grace Women's Health Centre, a major part of the region's women's health program. We present a case study exploring the process and final agreement and the impact of this agreement on women's participation in health policy development. The historical context and the nature and impact of the agreement are described and several participation strategies that occurred within the partnership are discussed. The development of a formal partnership agreement, a governance model, was a success for public participation in this case; however, the greatest success for women was maintenance of a political space in which women's health as a priority could be discussed in a context where the forces against gender equity talk are strong.     

Public health, private concern: The organizational development of public health in the Netherlands at the beginning of the twentieth century

This article outlines an important period in the developmentof public health in the Netherlands. It starts with the developmentof a more active government policy, in the middle of the centuryand ends with the political decision to develop a public healthsystem, based on private initiatives and funded by the centralgovernment and local authorities. In 1933 this decision wasmade implicitly. In that year a Health Services Bill was rejected,in which the suggestion was made that municipal health servicesshould be established. To understand this development, the roleof both the central government and local authorities is sketched,as well as that of private organizations. In parallel with theincreased Involvement of governments, private initiatives developed.Cross societies are considered crucial in this development.It was not until the second decade of this century that it becameclear which way the Dutch health care system would develop.Private organizations were insecure about their role and governmentinstitutions were thought to be inadequate and expensive. Thedebate on the Health Services Bill illustrates this. The periodin which this bill was discussed can be seen as a decisive onefor the field of public health in the Netherlands.     

Surveillance of drinking water supply with a geographic information system: a pilot project of the of the Iogd NRM and the Hoxter district

Drinking water surveillance includes the use of spatial data. A geographic information system (GIS) is a practicable tool for work with spatial data in the health sector as well. Co-operation between the Institute of Public Health for North Rhine Westphalia, the local health authority of the Hoexter district and the Institute for Geoinformatics of the University of Muenster started a project testing the use of GIS for drinking water surveillance. A special application was programmed. It includes functions of retrieval and classification of the measured values of drinking water wells, in order to show time trends in a diagram and to visualise the location of the wells and the analysis data in a map. The members of the Public Health Office accepted the method and started using it regularly. In addition, the collaboration between the health authority and other local authorities was strengthened. Several data sets were included in the GIS, such as wells and results of water analysis, water protection areas, land use data, and topographical maps. Basing on to the experiences with this project, the development of a standard application is planned that is supposed to be communicated to all local health authorities in North Rhine Westphalia.     

The National Public Health Performance Standards Program: will it strengthen governance of local public health?

Governing bodies such as local boards of health are the government authority ultimately accountable for public health at the local level. The National Public Health Performance Standards Program (NPHPSP) provides governing bodies guidance in their oversight of the public health system and the provision of essential public health services. Using the NPHPSP's standard guidelines and criteria, local public health governing boards can identify assets and needs for public health improvements, coordinate existing services and programs, and target their advocacy for public health resources. The NPHPSP provides governing boards a means for ensuring that local public health systems coordinate their efforts to improve accountability, quality, and evidence for community health.     

What impact do annual public health reports have?

Each district health authority is required to produce an annual report on the health of their population. Although they consume considerable resources, there is little evidence as to their impact on their intended audiences. We describe the results of a postal survey of how these reports are viewed by health authority and local government managers in one region. Eighty-nine out of 139 responded (64%). Over half of the managers had read the reports in their entirety. Most were discussed by health authorities but few by relevant local government committees. There was some disagreement between directors of public health and other health authority managers about the impact of the reports on commissioning. The paper discusses the difficulties in evaluating the impact of annual public health reports. The survey reveals a fundamental disagreement about whether the intended audience should be health care purchasers or the public. This reflects an underlying tension about the role of public health and the debate about its independence.     

Facing the cuts: a health authority's experience of rate-capping.

Health and social services in Britain are both publicly funded, but health care is provided centrally by the National Health Service while social services are provided by local government. Central government has sought to limit overall public spending by limiting the income of local authorities from rates (property taxes)--a policy known as rate-capping. In the face of this policy, one inner London local authority was forced to cut its social services budget in 1988/89 by 17%. We have compared the actual social service reductions with the perceptions, expressed in semi-structured interviews, of 69 health and social services staff. There was a perceived deterioration in social service provision, and indicators were suggested which would help health service staff to monitor these changes. There were also recent and more long-standing difficulties of communication between the two services, which limited joint working. The increasing emphasis on community care requires health authorities to cooperate more closely with social services at the local level.     

Clinical governance for public health professionals

This paper examines the issues specific to clinical governance for public health professionals. It highlights three levels at which public health is capable of promoting clinical governance: within the specialty of public health, across other National Health Service (NHS) organizations and as part of the public health responsibilities of health authorities. Current work is reviewed, and its focus on hospital and community NHS Trusts is noted. Current thinking on the introduction of clinical governance into clinical practice is interpreted to provide a framework for its development in public health professional practice.     

Local leadership in public health: the role of the medical officer of health in Britain, 1872-1974

The recent policy focus in British public health on the importance of local action invites consideration of historical precedent. The role and achievements of the medical officer of health (MOH), the local government official charged with public health responsibilities, is discussed. The gradual accretion of duties is traced in the first section: the mid-Victorian concern with urban sanitation; the preventive strategies adopted after the bacteriological revolution; the extension of personal health services in the early 20th century; and the more diminished role under the National Health Service (NHS), when infectious diseases retreated. The historical verdicts passed on the MOsH are reviewed in the second section. The leading role of the MOsH in the late 19th-century mortality decline has been reasserted, and although there is some justification in the argument that in the 20th century public health lost its focus, it is important to recall that the extension of personal health services under MOH direction signified a major extension of access to care. Similarly, the charge that MOsH did not redefine their role in the period before their final demise in 1974 is not entirely justified. The emphasis of the NHS on curative rather than preventive medicine, and the economic constraints on local authority health service expansion limited their room for manoeuvre. The history of local leadership in public health may offer some enduring lessons. These include the importance of monitoring local population health, acting as a public interface between medicine and the community, facilitating joined-up working and confronting vested interests.     

Through a glass darkly: what should public health observatories be observing?

BACKGROUND: Eight regional public health observatories were launched in England in February 2000, to strengthen the availability and use of health information and to support efforts to tackle health inequalities at local level. This qualitative study was carried out by the Merseyside and Cheshire Zone of the North West Public Health Observatory to assess the needs of local users and producers of public health information. METHODS: Semi-structured in-depth interviews were carried out with 42 representatives of three major groups in Merseyside and Cheshire: community groups, public-health-related professionals in the local statutory and academic sectors, and information specialists within the National Health Service. RESULTS: Different groups of users and producers encountered different problems in accessing health information. Community groups had significant problems accessing and interpreting health information and were concerned about tokenism and the failure of professionals to recognize lay knowledge. Professionals experienced difficulties in accessing local information from outside their agency and had concerns over partnerships failing to work together to share information. The health information specialists stressed the danger of providing information without supporting intelligence, the difficulty of keeping track of the many local sources, and the importance of having access to local authority data sources. All three groups relied on their own networks in their search for information, and these should not be overlooked in any dissemination strategy. CONCLUSION: Information requires skilled interpretation to become policy-relevant public health intelligence. This research identified major problems in the communication of lay health knowledge and in the accessibility of public health intelligence.     

Respiratory conditions: effect of housing and other factors.

The public health movement has been concerned with the relation between housing and health for well over a century. Nevertheless the Black Report still identified housing as one of the major causes of ill-health and suggested, on one indicator at least, that council housing is the least healthy form of tenure. An exploratory study concerning housing and health in a north eastern local authority area is described. It was found that smoking, work experience, and age were the most important determinants of self assessed respiratory conditions. When the background factors were held constant people in areas of 'bad' housing were found to report more respiratory symptoms than those in 'good' housing areas. Respiratory conditions were affected by the age of housing, and flats were found to be worse than houses. High rise flats were worse than low or medium rise flats.     

Socio-political aspects of toxoplasmosis epidemic in Santa Isabel do Ivaí, Paraná State, Brazil

In 2002, due to a toxoplasmosis epidemic Santa Isabel do Ivaí, Paraná State, was the focus of sanitary investigations. Four hundred and twenty six individuals had serology suggestive of acute T. gondii infection (IgM reactor), considered the largest outbreak of toxoplasmosis ever reported in the world. This research was meant to identify actions carried out by the sanitation and health services sector at that time, highlighting the political conflicts that took place during the process and identifying the measures taken by the sanitary authorities during and after the epidemic period. This is an interdisciplinary study aimed at understanding major problems of public health like this one. The investigation was based on the contents of documents--press and institutional--and interviews. According to official data, the epidemic was caused by the contamination of one of the water reservoirs that supply the city. This research showed that political and social factors, as the party instability and the level of political dependence of local society, were largely responsible for the occurrence of the epidemic and for the difficulties faced by the health agents during such crisis.