Users Online: 732 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size
 

 

Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
     

 Table of Contents  
EDITORIAL
Year : 2011  |  Volume : 55  |  Issue : 4  |  Page : 241-245  

Defining public health


Professor of Public Health, International Institute of Global Health, The INCLEN Trust International, Chairman, Indian Academy of Public Health

Date of Web Publication30-Jan-2012

Correspondence Address:
F U Ahmed
Professor of Public Health, International Institute of Global Health, The INCLEN Trust International, Chairman, Indian Academy of Public Health

Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.92397

Rights and Permissions

How to cite this article:
Ahmed F U. Defining public health. Indian J Public Health 2011;55:241-5

How to cite this URL:
Ahmed F U. Defining public health. Indian J Public Health [serial online] 2011 [cited 2017 Sep 25];55:241-5. Available from: http://www.ijph.in/text.asp?2011/55/4/241/92397

The word "public health" is one of the most commonly used word by the policy makers, planners, health care providers and academicians. It is one of the most important tools to keep the nation healthy as well as for its overall development. Hence it has become essential that the entire stake holder understands the term and the scope of the discipline for addressing the health and other development needs. As we do not have a comprehensive definition based on the contemporary knowledge on health and its determinants and the well defined concepts and strategies of public health, the word public health is used by the policy makers, bureaucrats, social activists, clinicians, public health practitioners, academicians, researchers and many others engaged in decision/ policies making on health issues of any community to suit their ends. The first accepted definition was that of C.E.A. Winslow in 1887. The definition was based on the concept of health and determinants of that era. It was the era of "great sanitary awakening" followed by the spectacular achievements in the field of microbiology. Poor sanitary conditions and the germs discovered were thought to be the prime determinants of health. The first definition was based to address the same. It states that "public health is the science and the art of [1] preventing disease, [2] prolonging life, and organized community efforts for (a) sanitation of the environment, (b) control of communicable infections, (c) education of individuals in personal hygiene, (d) organization of medical and nursing services for early diagnosis and preventive treatment of disease, and (e) the development of social machinery to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birth right of health and longevity". The above definition has four sections in its opening part "public health" is the science and the art of [1] preventing disease. [2] "prolonging life" describes the discipline as a combination of science and arts (i.e. knowledge and skills) for two very specific purposes i.e. preventing disease and prolonging life. The second section depicts the specific interventions and the process/ strategy to prevent disease and prolonging life. The four specific interventions mentioned are "(a) sanitation of the environment, (b) control of communicable infections, (c) education of individuals on personal hygiene (d) organization of medical and nursing services for early diagnosis and preventive treatment of disease". The third section includes the objectives and aim of the discipline of public health. It states "to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birth right of health and longevity". The "bridging statements" viz. are "organized community efforts" and the sentence "the development of social machinery". These are crucial bridge statements linking the objectives and aims with the interventions and the knowledge and skill necessary for them. The conceptual background based on which the 1 st . definition is coined is relevant for that period. The domain mentioned in the definition is confined to preventing disease and prolonging life. In that period, promoting life was beyond the comprehension of the scientific community. In the first definition, we have added it. The interventions depicted are also limited to three specific activities. These are (a) sanitation of the environment, (b) control of communicable infections, (c) education of individuals on personal hygiene, (d) organization of medical and nursing services for early diagnosis and preventive treatment of disease. As we know, in the advent of "socialized medicine" or "social medicine" during that period in some countries like Europe the strategy includes two directives based on conceptual paradigm. They are "organized community efforts" and "the development of social machinery". It emphasizes the role of the society including the state, the community and the governance structure. The other part is also based on the concept that is the aim and the objective thereof. The statement "to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birth right of health and longevity" is based on the concept of social rights and responsibilities of the state and its citizens. The elements which are necessary in a definition of a discipline are clearly seen in Winslow's definition. The definition guides the users clearly what it aims for and how to achieve it. The definition is prescriptive; it prescribes the package of service needed and the strategy how it is to be delivered.

But after the World War II, with the advancement of scientific knowledge and an understanding of the greater role of societal, political, economic and ecological factors along with the conventional biological and environmental factors as the determinants of health, the focus of concern became broadened. With the formation of World Health Organization a platform of the committee of Nation to assist the nation's to look after the health evolved various concepts on health and health care delivery. These include the definition of health, setting the goal of health for all and identifying primary health care strategy as the key to achieve the same. At the same time, the scoping of public health problems and the consequent process of decision making on designing an intervention also drastically changed. The policy/decision makers on health issues gave equal or more emphasis on solving health issues with relevant community development package addressing the social and other determinants of health rather than depending solely on the medical care package. On the other hand, the ever increasing newer inventions in the field of diagnostic and therapeutic in an ever growing market economy made this life saving health care package costly beyond the reach of the common man. More so when the onus of delivering the personalized health care package gradually shifted from the state to the professional and private entrepreneurs the modern day wonders became out of reach of the common man and thus affecting the health of a major proportion of which constitutes a concern of "public health". On the above context, the term "public health" means different to each stakeholders. So the need of the hour is to have a new definition of public health. The members of the Indian Academy of Public Health, an academic platform under the aegis of Indian Public Health Association, agreed that a participatory process is called for to identify the main principles constituting the content of "public health". Accordingly, and as a basis for its discussions, the members decided to focus on the definition of basic concepts and terminologies relating to "public health", providing an in depth assessment of such concepts, how they have evolved and how they are used and applied. The members felt that definition of the concept and related terminologies would greatly benefit the academia at large and discussion in governmental processes as well as in the work of practitioners. As an initial step a core team of three was constituted to prepare a limited inventory and listing of definitions of concepts and terminologies used by different stake holders. The main purpose is to serve as a point of departure for the committee to find out the necessity of changing the existing definition in the context of the emerging scientific evidence as well changing societal and political concept of governance and its effect on the understanding of public health problems and interventions and formulate guidelines on the basis of which a new definition can be coined. The members deliberated on the issues and adopted the following to formulate a guideline. The definition should be based on the (i) current concepts of health and disease and the social goals as endorsed by the WHO and other world bodies, (ii) different levels of prevention accepted by the scientific community and being used effectively, (iii) delivered through an effective health system based on scientific evidence and matching with the available resources and needs and a delivery strategy mutually agreed upon by WHO, and the member states, professional bodies, academia, practitioners and civil society. The definition should help the policy makers and planners to effectively formulate policies and plans to be effectively implemented by the service providers by organizing a health care delivery system and defining the roles and responsibilities of a well trained health work force and make them accountable to carry out specific jobs assigned to them. This will also help the academicians to define the knowledge and skills to be developed in the different levels of public health workforce. It will also help the public i.e. citizens and groups to articulate their interest, their legal rights and meet their obligations and mediate their differences and ensures that each individual and or community irrespective of his/their ethnicity, gender, social class, and or any other discriminative factors existing or emerging receives the requisite package of services as per his/their actual needs through a process of good governance at a cost he/they can afford.

The process started with the circulation of one definition in the web site of the IPHA as well as of the academy. This is depicted below:


   Conceptual Background of the Definition 1 Top


In the revised definition, the current concept of health and disease and levels of prevention as well as the health goal set by WHO is considered. Besides the conventional areas like environmental sanitation and control of epidemic diseases, the other areas included are the newer domains identified in recent years under public health. Only those areas which are accepted by Public Health Professional Bodies and Academia are considered. The delivery of Integrated package of Patient care (Personal Health) and Public Health Care through a common Health Delivery system as outlined in Primary Health care Strategy of service delivery is also used.

Indian Academy of Public Health' definition of "Public Health": "Public health is the science and art of promoting health, preventing disease and prolonging life, to maintain a healthy and economically productive life so as to realize the birth right of each individual, by organizing a social machinery of community development to maintain a healthy environment, empower the people for maintaining a healthy life style and behavior, prevent epidemics, control communicable and non communicable diseases, addressing the social, economic and cultural determinants influencing health and disease, and also organizing a personal care and public health service for caring the sick and disabled specially during man made or natural calamities and epidemics." by evolving and organizing a health care delivery system, staffed with adequately trained appropriate health work force to deliver health promotion, prevention, early diagnosis, treatment and rehabilitation of diseases as a comprehensive package along with essential public health services which is to be universally available, equitably distributed and accessible to all the individuals and the community in need at an affordable cost, through intersectoral coordination, organized collective effort, community participation and ownership."

The definition has four distinctive sections. The first section depicts the goal or purpose of public health as "Public health is the science and art of promoting health, preventing disease and prolonging life, to maintain a healthy and economically productive life so as to realize the birth right of each individual" This is also the essence of the HFA goal which has been adopted by the parliament of India.

The second section includes the broad strategy of how to achieve the aim stated in section 1 "by organizing a social machinery of Community Development0". It is the responsibility of the state to look after the health of the Nation, which has been enshrined in the Indian constitution under the directive principles to the state.

The penultimate and the third section of the definition outlines the specific health intervention activities to "maintain a healthy environment, empower the people for maintaining a healthy life style and behavior, prevent epidemics, control communicable and non communicable diseases, addressing the social, economic and cultural determinants influencing health and disease, and also organizing a personal care and public health service for caring the sick and disabled and specially during man made or natural calamities and epidemics." These activities are described by most of the Public Health organization including WHO, APHA, PAHO, Australian Public Health association. It is also mentioned in our National Health policy document.

And the last and the fourth section depicts the process of evolving and organizing a health care delivery system, its package and salient features "by evolving and organizing a health care delivery system, staffed with adequately trained health work force to deliver health promotion, prevention, early diagnosis, treatment and rehabilitation of diseases as a comprehensive package along with other public health services which is to be universally available, equitably distributed and accessible to all the individuals and the community in need at an affordable cost, through intersectoral coordination and organized community effort, participation and ownership." The packages are already referred to in the Health care package defined by WHO and also the National Health Policy and the criteria of universal availability, equitable distribution and affordability is also well documented and to converge and deliver the health and non health personal care and public health packages to a community the strategy of intersectoral coordination and organized collective effort, community participation and ownership are already well established strategies as referred in the primary health care strategy, National Health policy of India as well as NRHM.

The first definition is comprehensive and it gives in details the specific domains of action and the specific intervention to be adopted as well the service delivery strategy. It is comprehensive and suitable for the current period but will need subsequent changes with the advancement of knowledge and understanding. So sustainability is in question. On the other hand, if the definition is based on the concept of health and disease it encompasses all the areas even for the time to come. The aim of providing health care will not be changed in future so also.


   Conceptual Background of the Definition 2 Top


Alternative definition (based on concepts):"Public Health is the science and arts of maintaining a synergy between health of a community and the ecological, environmental, social, cultural, economic, and political, status around it and aims to achieve the fullest attainment of health for all to lead a productive life by promoting health, preventing diseases, prolonging life and improving the quality of life, by formulating people oriented policies through a process of a social movement of community development and by evolving and organizing a health care delivery system based on the primary health care approach, to address the health needs of a community in normal as well as emergent situation; staffed with adequately trained health work force to deliver comprehensive personal care and public health services to the individuals and the community; based on the contemporary knowledge and appropriate technologies and approved by the scientific community."

The definition has four distinctive sections. The first section depicts the concepts of public health and also its aims in the following lines. "Public health is the science and arts of maintaining a synergy between health of a community and the ecological, environmental, social, cultural, economic, and political status around it and aims to achieve fullest attainment of health for all to lead a productive life". Fullest attainment of health" is referred to in Article III of the Alma Ata declaration.

The second section includes the means, the three domains and the process. It has two distinctive sections, the domains and the process. The domain part is depicted as "by promoting health, preventing diseases, prolonging life and improving the quality of life" and the last part "by evolving and organizing a health care delivery system, staffed with adequately trained health work force to deliver comprehensive personal care and public health services to the individuals and the community; based on the contemporary knowledge and appropriate technologies approved by the scientific community and specific policies" includes the process. Promoting health, preventing diseases and prolonging life with improved quality encompasses the five levels of prevention as follows:

  1. Health promotion which includes most of the community development activities, to address different social determinants of health, emerging environmental and ecological changes affecting health as well as empowering all the people in the community with knowledge so that they are responsible to change their life style, food habits, behavior and thinking and to participate in making the surrounding environment conducive to health. The relevant domain is promoting health.
  2. Specific protection for prevention of diseases viz. immunization, nutrition supplementation, specific personal and community protective measures voluntary or legislative sanitation measures, universal iodization, banning smoking in public places, seatbelts etc. This represents the domain of disease prevention.
  3. The third domain prolonging life with improved quality includes three remaining levels of preventions. They are early diagnosis and treatment, prevention of complication and rehabilitation. It includes early diagnosis and treatment and the objective of the same is to cut short the span of the natural history and revert back to health but in certain situation the complication is inevitable and may cause physical and or mental disability affecting the natural reversal to health. For these individuals, the level of prevention necessary is rehabilitation and the aim is to revert back to health and if not improve the quality of life as far as practicable.
The third section of the definition depicts the process of achieving the domains identified and stated as "by formulating people oriented policies through a process of a social movement of community development. This is the key element for an effective public health service. The India nation is committed to improve the public health as enshrined in the constitution; moreover, the Parliament has endorsed the Health for all Goal of WHO and also approved "primary health care as the key to achieve the same goal. The focus is on the people oriented policies and the civil societies as well as the policy makers are also heading toward that direction. The fourth section is prescriptive part. It specifies the type of service delivery system. It states that "and by evolving and organizing a health care delivery system based on the primary health care approach, to address the health needs of a community in normal as well as emergent situation; staffed with adequately trained health work force to deliver comprehensive personal care and public health services to the individuals and the community; based on the contemporary knowledge and appropriate technologies and approved by the scientific community. The process is formatted in a prescriptive and not a directive format for the ease of implementation. In the prescriptive format, the words "by evolving and organizing" is used to signify that according to the scope of public health needs and the societies resources the "health care delivery system" has to be evolved and organized for a community and it is not a straight jacket directive. The delivery system should also be based on "primary health care approach". It signifies that all the criteria like appropriate technology, universal availability, accessibility, equity, without any social and gender discrimination as well as at an affordable cost should be fulfilled. The prescription also outlines two distinct types of services to be delivered through the evolved and organized health care delivery system. They are "comprehensive personal care and public health services". The personal care services include the services under the five levels of prevention, health promotion, health protection, early diagnosis and treatment and the prevention of complication and rehabilitation and are to be provided as a comprehensive package. The focus of attention for this service package is individuals and their families. The public health package is focussed to the community and is a separate entity and should be delivered by a well trained staff. Current practice of implementing the public health programs by defining a multi skilling job responsibility of the peripheral health worker is one of the major causes of our dismal performance. The other major area of concern is desegregating the public health tasks from the parent health department to other ancillary department. However, there is a ray of hope as the Government is emphasizing the convergence of services for better health. It is easier to preach but it is difficult to practice. What we need now is a strong public health work force well trained with specific responsibility under a comprehensive health care delivery system. The definition of public health will at least clear the concepts on the basis of which the services are to be developed. The current exercise is the beginning. India Academy of Public Health under the aegis of Indian Public Health Association has started the process and now it is up to all the members and other stake holders to ponder over and come out with their views so that collectively we can define "public health" and work for improving the health of the people.

 
   References Top

1.Picket EG, Hanlon JJ. Public Health Administration and Practice. 7 th ed. St. Louis, Missouri- The C.V Mosby Co. 1979.  Back to cited text no. 1
    
2.Park K. Park's Text Book of Preventive and Social Medicine. 21 st ed. Jabalpur: Banarasidas Bhanot Publishers; 2011.  Back to cited text no. 2
    




 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Conceptual Backg...
    Conceptual Backg...
    References

 Article Access Statistics
    Viewed2882    
    Printed82    
    Emailed5    
    PDF Downloaded696    
    Comments [Add]    

Recommend this journal