Introduction

This chapter sets out the conceptual framework used for the study of public health services. It clarifies what is meant by the terms “public health”, “public health operations” and “public health services”.

Public health

What is public health? Although the term is widely used, the meaning attributed to it in different circumstances is not always clear. Crucially, understandings of public health vary among countries in Europe and the term is difficult to translate into some European languages (Kaiser & Mackenbach 2008; Tragakes et al., 2008). Although there is no generally accepted definition, a concept paper of the WHO European Region concluded in 2011 that the definition of public health put forward in 1988 by Sir Donald Acheson, and based on an earlier definition by Winslow (1920), serves as a useful point of departure (Marks et al., 2011). Acheson defined public health as “the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson, 1988).

Public health operations

The next question then is what kinds of actions are needed to achieve these goals. What are the most important public health activities? A number of “essential public health functions” have been suggested in different parts of the world (WHO, 2009), including the United States (US Department of Health and Human Services, 1995) and the United Kingdom (Faculty of Public Health Medicine, 2001). An international Delphi study conducted in 1997 came up with another set of essential public health functions (Bettcher et al., 1998), which were subsequently modified by the Pan American Health Organization and the WHO Regional Office for the Western Pacific (WHO, 2002; WHO, 2003).

An adaptation of these “essential public health functions” has been put forward by the WHO Regional Office for Europe in the form of 10 “essential public health operations” (EPHOs). EPHOs can guide assessments of public health capacities and services, as well as the actions required to strengthen them (WHO, 2012). They also have the benefit of identifying horizontal activities across the whole political and administrative spectrum of policy-making, rather than focusing on the activities of specific institutions (Koppel et al., 2009).

The latest iteration of EPHOs was published by WHO in 2015 as part of the self-assessment tool for the evaluation of essential public health operations in the WHO European Region (WHO, 2015):

1. Surveillance of population health and well-being;
2. Monitoring and response to health hazards and emergencies;
3. Health protection including environmental, occupational, food safety and others;
4. Health promotion, including action to address social determinants and health inequity;
5. Disease prevention, including early detection of illness;
6. Assuring governance for health;
7. Assuring a competent public health workforce;
8. Assuring organizational structures and financing;
9. Information, communication and social mobilization for health;
10. Advancing public health research to inform policy and practice.

EPHOs can be divided into core and enabling operations (WHO, 2003). EPHOs 1–5 can be thought of as core public health operations, while EPHOs 6–10 are overarching operations that enable the delivery of public health activities (Fig. 2.1).

Fig. 2.1

The 10 essential public health operations. Source: Adapted from WHO, 2015 Note: EPHO: essential public health operation.

This volume focuses on the two enabling EPHOs concerned with assuring sustainable organizational structures and financing and assuring a sufficient and competent public health workforce.

Public health services

The term “public health services” is problematic because it is ambiguous. “Services” can refer to processes that are undertaken or to the organizations that undertake them. However, with public health, the organizations involved vary widely, sometimes even within the same country. They often reflect decisions about how particular responsibilities should be distributed among ministries or tiers of government, and cultural and professional norms, such as whether an activity should be undertaken by the medical profession or not. Consequently, given that the structures that deliver public health processes are so culturally embedded, it makes little sense to try to compare them. Instead, the focus has been on those processes, and the totality of actors in any setting that provide them, that are considered to be the “public health system”. This, in turn, can be defined as “all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction” (CDC, 2017).

The conceptualization of public health services as processes that take place has the advantage of ensuring contributions by all relevant entities. It has the disadvantage of precluding any attempt, at least in respect of the overall system, to make comparisons about budgets, staffing and the like, given that many of these organizations will do things other than public health and it is often impossible to differentiate their public health budgets and workforces from their other roles.

An example of a public health system given by the United States Centers for Disease Control and Prevention is shown in Fig. 2.2.

Fig. 2.2

A public health system. Source: CDC, 2017 Note: EMS: Emergency medical services; CHC: Community health centres.

Despite the logic of this approach, there is often a desire to focus on structures or agencies involved, which can be considered the public health delivery systems. This is particularly the case when the term “public health service” is used in the singular. It then tends to refer to a defined structure, usually in the public sector. While there is thus only one English expression with two very different meanings, in some other languages this distinction comes out more clearly. In German, for example, there is a clear difference between Gesundheitsdienst (the structure providing public health services) versus Gesundheitsdienstleistungen (the public health services being provided).

In the current volume “public health services” are understood as the services that are being provided, rather than the structures that provide these services. In the country studies that underpin the analysis presented here (Rechel et al., 2018a), the main focus was on public health delivery systems, mainly public sector organizations with a clear mandate for public health.

Financing for public health

The changing way that expenditure on public health is captured in official statistics can further illuminate the issues at stake, as will be discussed in more detail in Chapter 4. In the System of Health Accounts, used by OECD, WHO, and the European Union (EU) to capture health expenditure in a uniform way, there has been a shift in thinking of “public health services” away from the organizations providing them and towards the services being provided. In an earlier version of the System of Health Accounts, SHA 1.0, expenditure categories were based on a mix of criteria: “public” referred at the same time to government-financed services, place of delivery (publicly owned services) and the beneficiaries involved (population groups). According to the newest, 2011, edition of the System of Health Accounts, “prevention and public health services” are defined as “services designed to enhance the health status of the population as distinct from curative services, which are seen as repairing health dysfunction. Typical public health services are vaccination campaigns and programs” (OECD/Eurostat/WHO, 2011). Subcomponents include maternal and child health, school health services, prevention of communicable or noncommunicable diseases, and occupational health care (see Chapter 4 Financing of public health services).

Conclusion

This chapter has explored some of the key terms used in this volume. While there have been considerable efforts by international and national agencies working in public health to clarify the terms used to describe public health activities and structures, there remains much uncertainty and ambiguity. This challenge can only partly be resolved by definitional exercises and expert consensus. What matters at least as much, if not more, is how public health activities and structures are conceptualized and perceived at the national and local level in the vastly differing countries that comprise Europe. The remaining chapters of this book aim to shed more light on these issues.

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