Who does the work of public health?

Frequently, we take the "public" out of public health and allow the practice to become extremely narrow, limited to experts telling the public what's best for them.     

Are public health physicians fading out of management?

BACKGROUND: Recent developments in health services in the local arena in Norway have challenged the theoretical and applied scientific basis for both public health medicine and management. During the 1990s although public health physicians in Norway increased in number, they worked less with public health, as well as public health management. The effects of these developments on public health management are largely unknown. We studied public health physicians' involvement in management and their self-reported managerial competence. METHODS: Cross-sectional study of physicians working in local public health medicine in all Norwegian municipalities, using a mail-back questionnaire. RESULTS: Public health physicians reduced their administrative tasks and evaluated their own managerial competence rather conservatively and somewhat lower in 1999 than in 1994. Many had supplementary training in management in addition to their medical education and specialty training. CONCLUSIONS: Public health physicians may be fading out of management. To address this there is a need for development of both public health management training programmes and provision of adequate resources for managerial activities.     

Why feminism in public health?

The issues raised in this editorial and exemplified within a number of the studies reported in this issue indicate new directions for public health, directions which take feminist scholarship, both outside and within the medical framework, into account. The changing potential of feminist public health, as derived from the articles in this issue, can be summarised within the following issues: new research areas, positioning women as actors, development of theoretical frameworks, reflexive theory of science, interplay between sex and gender, gender-sensitive methods, diversities among women/men, pro-feminist research on men's health and using the results for change. Thus, feminist public health represents a shift towards the new public health, with holistic and multidisciplinary activities, based on theoretical pluralism, multiple perspectives and collective actions with the aim of improving the health of gender-subordinated groups.     

Reducing social inequalities in health: public health, community health or health promotion?

While the Consortium on 'Community Health Promotion' is suggesting a definition of this new concept to qualify health practices, this article questions the relevance of introducing such a concept since no one has yet succeeded in really differentiating the three existing processes: public health, community health, and health promotion. Based on a literature review and an analysis of the range of practices, these three concepts can be distinguished in terms of their processes and their goals. Public health and community health share a common objective, to improve the health of the population. In order to achieve this objective, public health uses a technocratic process whereas community health uses a participatory one. Health promotion, on the other hand, aims to reduce social inequalities in health through an empowerment process. However, this is only a theoretical definition since, in practice, health promotion professionals tend to easily forget this objective. Three arguments should incite health promoters to become the leading voices in the fight against social inequalities in health. The first two arguments are based on the ineffectiveness of the approaches that characterize public health and community health, which focus on the health system and health education, to reduce social inequalities in health. The third argument in favour of health promotion is more political in nature because there is not sufficient evidence of its effectiveness since the work in this area is relatively recent. Those responsible for health promotion must engage in planning to reduce social inequalities in health and must ensure they have the means to assess the effectiveness of any actions taken.     

Economics and ethics in public health?

The topic suggests a conflict between ethics and economy in medical care. It is often argued that today's welfare state in affluent societies with their social insurance systems makes it easier for the doctor to translate ethical demands into reality without being hampered by economic restrictions. Both doctors and patients took advantage of this system of medical care by mingling social guarantees for health with the doctor's income. Hence, medical expenses expanded rapidly, additionally promoted by technical progress in medicine. This entailed a proportionate increase in medical expenses in relation to personal income, especially wage income. Budgets of state authorities were streamlined or deficits became larger. This state of affairs was promoted further by mechanisms of distribution of national income in accordance with the slogan "less state, more market". While national income continued to grow, although at a slower rate, the number of jobless persons grew continually and thus also the social expenses, this was not due, as is usually assumed and pretended, to an economic crisis. Society and economy are facing a crisis of distribution of national income under conditions of technical progress as a job killer, making economic production more productive and efficient. Not taking into account the new challenge of social market economy--the German innovation in market economy creating the economic miracle after World War II--reforms of the system of medical care took place and are still continuing along market principles, particularly the latest German reform law leading to individual contracts between patients and their doctors in respect of cost charging. However, marketing principles promote economy in medicine, but they do not promote medical ethics. Further German guidelines for medical care should take stock of past experiences. There will be more competition in the "growing market of medical care" (private and public) and this will need--as economic experience has shown and economists have affirmed--new organisational devices to ensure better outcomes for the individual patient as a consumer and the doctors as suppliers. More responsibility should be given to the different suppliers of collective security in medical care (private or social systems of insurance). No individual patient as a mere consumer has a genuine chance in handling contracts with doctors carefully who are considered to be "gods in white" according to a popular German saying. These consumers have only a slight chance when arguing in courts of justice for the performance of contracts. Diagnosis and therapy, the system of doctors who treat members of statutory social insurance schemes (National Health general practitioners in the U.K.) and doctors as "free entrepreneurs" in the growing market of medical care should be separated due to the different rules of charging costs and offering medical care. "Classless medical care" does not have a better chance by applying market principles. The same is true for ethics versus economy. Doctors as "free entrepreneurs" must learn that markets will not guarantee reimbursement of costs but react to supply and demand. Hence, regulation of medical care by economic instruments creates better chances even for ethics in medical care against economy.     

Managing the work–life roller-coaster: Private stress or public health issue?

Although research has established the importance for health of a sense of personal control at work, the implications of this for women have not been adequately studied. Using quantitative data from the Australian Longitudinal Study on Women's Health and qualitative data from an associated study, here we examine women's health and sense of control in relation to family and employment commitments. In line with other research, 'demand over-load' is found to be important for sense of control, but both 'over-load' and 'control' prove complex, as illustrated by the finding that good mental health is associated with satisfaction with, rather than actual, hours of employment. In the contemporary western context of longer working hours, increasing time strain, and gender relations shaped within a neo-liberal, individualised social environment, the findings suggest that as life speeds up, 'control' and the health effects of 'busyness', need to be understood not merely as personal matters, but rather as potentially important public health issues.     

Whither public health?

This paper examines the future of Schools of Public Health in the United States. The history of Schools of Public Health is developed by tracing the history of the philanthropies which supported scientific medicine and public health in the early decades of the twentieth century. The role of the theory of disease in shifting the focus of public health from the community to the laboratory is explored. This paper argues that Schools of Public Health have lost their legitimacy and no longer have any content area or discipline for which they alone are responsible. The declining public image of public health is explored in light of the recent swine flu and legionnaire disease episodes. The current tendencies of Schools of Public Health as miniature business schools or as departments of medical schools are explored and criticized and a revitalized curriculum for Schools of Public Health is posited.     

More physicians: improved availability or induced demand?

A number of empirical studies have shown that there is a negative association between population:physician ratio and utilization of medical services. However, it is not clear whether this relationship reflects supplier-inducement, the effect of lower prices on patient demand, a supply response to variation in health status, or improved availability. In Norway, patient fees and state reimbursement fees are set centrally. Therefore, the correlation between utilization and population:physician ratio either reflects supplier-inducement, a supply response or an availability effect. We applied a theoretical model which distinguished between an inducement and an availability effect. The model was implemented on a cross-sectional data set which contained information about patient visits and laboratory tests for all fee-for-service primary care physicians in Norway. Since population:physician ratio is potentially endogenous, an instrumental variable approach is used. We found no evidence for inducement either for number of visits or for provision of laboratory services. © 1998 John Wiley & Sons, Ltd.     

Funding for public health in Europe in decline?

Concerns have been raised in recent years in several European countries over cutbacks to funding for public health. This article explores how widespread the problem is, bringing together available information on funding for public health in Europe and the effects of the economic crisis. It is based on a review of academic and grey literature and of available databases, detailed case studies of nine European countries (England, France, Germany, Italy, the Netherlands, Slovenia, Sweden, Poland, and the Republic of Moldova) and in-depth interviews. The findings highlight difficulties in establishing accurate estimates of spending on public health, but also point to cutbacks in many countries and an overall declining share of health expenditure going to public health. Public health seems to have been particularly vulnerable to funding cuts. However, the decline is not inevitable and there are examples of countries that have chosen to retain or increase their investment in public health.     

Can public health and medicine partner in the public interest?

The dominant issues for health and health care today can be effectively engaged only if public health and medicine work together as better partners. Yet historical, professional, organizational, operational, and financial barriers exist to closer relationships. Fostering the necessary collaboration will require changes for both public health and medicine in leadership styles, professional education, practice incentives, accountability measures, and financing structures.