Transcript Strategic Planning in Public Health

The Big Picture: Strategic Planning
in Public Health
TH Tulchinsky MD MPH
Braun School of Public Health
Hebrew University-Hadassah, Jerusalem
Skopje, Macedonia
25 Oct 2010
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 or plan a military campaign
• Last JM. Dictionary Epidemiology - A set of essential
measures (preventive and therapeutic) believed
sufficient to control a health problem (2001)
• Tactics – use and deployment of resources in actual
field conditions e.g. military, police, firefighting,
public health.
Game Theory
• Interdisciplinary approach to the study of human
behavior
• Disciplines most involved : mathematics, economics,
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 and capabilities?
What are our objectives?
What are our resources and 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 – crucial factor
• 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 Uboat 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
Battle of the Atlantic, 1939-45:
Shipsunk vs. Subsunk
1200
1000
800
S h ip s u n k
600
Subs unk
400
200
0
1
2
3
4
5
6
7
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
47 ships
-
-
53
Oct-Dec
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
NYPD: Jack Maple’s Law, 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)
Changes in a Time Trend:
The “Tipping Point”
•
•
•
•
•
•
•
•
•
Organization
Monitoring
Funding
Concentration of forces
Training
Technology
Experience
Innovation
Adaptation
Cardiovascular Disease Mortality Rates,
United States, 1900-99
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
Agent
Environment
Host
Environment
Agent
Intervention
Health Resources
•
•
•
•
•
•
•
•
•
•
•
Resources are limited and must be used wisely
Political, public, media expectations and support
Manpower and training
Money and how it is allocated
Facilities for in-patient care – acute and ambulatory
Home care and Long Term Care
Community care – clinics, outreach,
Education, motivation
Drugs
Vaccines
Education
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
Infant Mortality, United States, 1900-1999
Maternal Mortality, United States, 1900-99
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
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
AIDS Incidence, Deaths and Prevalence,
United States 1981-2000
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
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
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
– Good 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
Summary
•
•
•
•
•
•
•
•
•
•
•
•
•
Define the problem, and objectives
Program Approach - strategy and tactics
Intervention program – multi layered planning
Budget and resources
Intersectoral 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
Reevaluate, revise and adapt
Communicate what you are doing