Docfan Academy

1. Key concepts

• Population: all people who live in a defined area or share a defined characteristic (for example all children under five in Ethiopia). Populations are what we count and compare.
• Community: a group of people who share a place, interests, identity or institutions and who interact (a kebele, a school, a congregation, an online group). A population becomes a community when people feel a link and can act together.
• Public: the people as a whole, including the people who are not patients and who may not know they are at risk. ‘Public’ also means shared: public goods such as clean air and herd immunity benefit everyone and cannot be fully bought by individuals.
• Health: the WHO Constitution (1948) defines it as complete physical, mental and social well-being and not merely absence of disease. Critics say ‘complete’ is unrealistic, so many now stress the ability to adapt and self-manage and the idea of well-being across the life course. The Ottawa Charter (1986) calls health a resource for everyday life, not the object of living.
• Wellness: an active process of making choices toward a healthy and fulfilling life; it is wider than the absence of illness and includes physical, emotional, social, spiritual and environmental dimensions.

2. What is public health?

Definitions differ in wording but share three ideas: prevention, population and organised collective effort. Winslow’s (1920) definition is the best known: public health is the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society. The Institute of Medicine (1988) added that public health is what we do together to assure the conditions in which people can be healthy.

Related terms are used in different settings, with overlap: community health (health of a defined community, often delivered locally), preventive medicine (the clinical specialty), social medicine, population health (outcomes of a group and their distribution), health promotion, international or global health (health across borders, see Chapter 6) and primary health care (a whole-of-society approach, see below).

3. Unique features of public health

• The population is the patient; the community is the unit of diagnosis and treatment.
• Emphasis on prevention at all levels (primordial, primary, secondary, tertiary).
• Equity: attention to who is left behind, and to the causes of unfair differences.
• Multisectoral: health is affected by water, education, roads, agriculture and trade, so health workers need to work with other sectors.
• Government and community carry the main responsibility, with law, policy and financing as tools.
• Evidence-driven: surveillance, epidemiology and evaluation guide decisions.
• Benefits are often invisible: a successful prevention programme shows as ‘nothing happened’, so public health is easy to underfund.

4. Core functions, essential services and essential functions

The Institute of Medicine (1988) named three core functions of public health: assessment (monitor and diagnose the health of the community), policy development (plan and make evidence-informed policy) and assurance (make sure that services are available, the workforce is competent and people can access them).

These were expanded to the 10 Essential Public Health Services, revised in 2020 with equity placed at the centre: (1) assess and monitor population health; (2) investigate, diagnose and address health hazards; (3) communicate effectively to inform and educate; (4) strengthen, support and mobilise communities and partnerships; (5) create, champion and implement policies, plans and laws; (6) use legal and regulatory actions; (7) enable equitable access to care and services; (8) build and support a diverse, skilled workforce; (9) improve and innovate through evaluation, research and quality improvement; (10) build and maintain strong organisational infrastructure.

WHO has its own list of Essential Public Health Functions (EPHFs). After COVID-19, WHO and partners renewed the list to a set of 12 functions that cover surveillance and monitoring, emergency preparedness and response, health protection, disease prevention and early detection, health promotion, governance and financing, workforce, and community engagement EPHF 2023 WHO EPHF paper. The aim is that every country can check how strong each function is and invest where it is weak.

5. Disciplines and competencies

Core competencies for public health practitioners are usually grouped into: analytical and assessment skills; policy development and programme planning; communication; cultural competency; community dimensions of practice; public health sciences; financial planning and management; and leadership and systems thinking. Competency is the ability to apply knowledge, skills and attitudes to real tasks, and it is assessed by what you can do, not only by what you know.

6. Primary health care: Alma-Ata (1978) and Astana (2018)

The Declaration of Alma-Ata (1978) said that health is a human right, that gross inequality in health is unacceptable, and that governments are responsible for the health of their people. It proposed Health for All through primary health care (PHC) based on equity, community participation, intersectoral action, appropriate technology and a focus on prevention. It listed essential elements: health education; promotion of food supply and nutrition; safe water and sanitation; maternal and child health including family planning; immunisation; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and essential drugs.

In 2018 the Declaration of Astana renewed the commitment and linked PHC to universal health coverage and the SDGs. It has three components: (1) primary care and essential public health functions as the core of integrated services; (2) multisectoral policy and action; (3) empowered people and communities. The 2020 WHO-UNICEF operational framework turns this into 14 levers for countries, and the 2023 UN high-level meeting on UHC again placed PHC at its centre.

7. Ethics and values in public health

Public health actions often restrict choice (quarantine, mandatory notification, tobacco taxes) to protect others, so ethical reasoning is part of the job. The usual starting principles are:

• Respect for autonomy: people decide about their own lives, with accurate information and without coercion, unless others are harmed.
• Beneficence and non-maleficence: do good and avoid harm, including the harms of public health measures.
• Justice and equity: fair distribution of benefits and burdens; special attention to the disadvantaged.
• Solidarity and reciprocity: we share risks; those who bear burdens for the public (for example health workers) deserve support.
• Proportionality, necessity and least restrictive means: the benefit must justify the restriction, the measure must really be needed, and the least intrusive effective option should be used.
• Transparency, participation and accountability: explain decisions, involve communities, and report results.
• Privacy and confidentiality: collect only the data you need, protect it, and use it for stated purposes.

The Nuffield intervention ladder helps judge how intrusive a measure is, from least to most: do nothing or monitor; provide information; enable choice; guide choice through changing the default; guide choice through incentives; guide choice through disincentives; restrict choice; eliminate choice. The higher you climb, the stronger the justification needed.

8. Intercultural competence and ways of knowing

Public health works across languages, faiths and traditions. Cultural humility means listening, asking about the person’s own explanation of illness, and not assuming that your way is the only way. In Ethiopia more than 80 languages are spoken and many communities use traditional healers and holy water; ignoring these beliefs can reduce trust and uptake, and working with respected local people can increase it.

Public health also recognises several ways of knowing: empirical (measurement and experiments), authoritative (guidelines and experts), traditional (inherited community knowledge), and experiential (lived experience of patients and practitioners). Good practice values scientific evidence, and also listens to community knowledge; the two are brought together in community-based participatory methods.