End of life is a public health issue

Public health activities to prevent and control disease have produced an extraordinary decline in mortality rates during the last century. This phenomenon has widespread implications, not the least of which is that death often occurs at a later age and frequently after a protracted illness. With a prolonged death due to technological advances now common in developed countries, quality of life at the end of life has become a societal concern. It is logical that public health should embrace the end of life as an area worthy of study and intervention. After all, the end of life has three characteristics of other public health priorities: high burden, major impact, and a potential for preventing the suffering associated with illness. In this paper, we propose three initial roles for the public health profession and a process for developing a public health agenda for the end of life.     

Bucking the trend? Health care expenditures in low-income countries 1990-1995

Health care expenditures in low-income countries are analysed for the years 1990 and 1995 using four key indicators. Key findings include a substantial reduction in public spending per capita across low-income countries between 1990-95; a significant shift towards private expenditures, which appears increasingly to be substituting rather than supplementing public expenditures; a fall in total and public health spending in many countries despite growth in national income, contradicting the relationship found in other studies. Two possible explanations are put forward. First that the patterns found are a direct result of the structural adjustment policies adopted by many low-income countries, which aim to control and often cut public financing, whilst promoting private health expenditures. Secondly, that following the wave of privatization of state industries, many governments are finding problems adapting to their new role as a tax collector, and are thus not benefiting from economic growth to the extent that might be expected.     

Getting Australia more active: challenges and opportunities for health promotion

A growing body of evidence demonstrates that regular physical activity promotes health and assists in the prevention of noncommunicable diseases but this is presently curtailed by low and unhealthy participation rates in Australia and comparable industrialised countries. Compounding the problem is knowledge that physical inactivity is independently associated with poor health outcomes. Despite physical activity being described as public health's ‘best bet’ or ‘best buy’, motivating individuals and groups to adopt and maintain physical activity continues to be a major challenge for health professionals. Global advocacy for prevention efforts must be operationalised through national to local strategies to promote and support physical activity in multiple settings including the home, schools and workplace. The Australian health promotion community has and continues to play a leadership role in physical activity promotion. However, there is an urgent need to continue to promote the importance of physical activity, along with its pivotal role in the prevention of non‐communicable diseases, alongside related agendas including healthy diets, tobacco control and environmental sustainability. This commentary overviews the contemporary status of physical activity promotion in Australia and identifies key challenges and opportunities moving forward.     

Rickettsial diseases in Brazil and Portugal: occurrence, distribution and diagnosis

The present study is an update review on the occurrence and diagnosis of rickettsial diseases in Brazil and Portugal, aiming at promoting their epidemiological surveillance in both countries. A literature review was carried out and unpublished data of laboratories and surveillance systems were presented. The results described the occurrence of rickettsial diseases and infections in Brazil and Portugal, including other new and still poorly understood rickettsial infections. Current diagnostic methods were discussed. As in many other countries, rickettsial diseases and infections seem to be an emerging public health problem. Treated as a minor problem for many decades, the interest in these infections has increased in both countries but further studies are needed to establish their role as a public health problem.     

当代公共卫生面临的主要挑战

一场新型冠状病毒感染疫情让公共卫生从幕后走到台前。在世界逐渐从疫情中恢复的今天，需要清醒地认识到当代公共卫生仍存在许多挑战。传染病和慢性病的双重疾病负担依旧严峻；精神心理健康、伤害防护是重大健康问题，但缺乏足够的重视；环境健康问题、食品药品安全问题是疾病负担的重要来源，亟需进一步管理和干预；以上健康问题对不同生命阶段人群的影响不同，构成了生命全过程人口健康问题。当前现状距联合国“可持续发展目标”或我国“健康中国2030”制定的目标仍存在较大距离。各国政府及相关部门应携起手来，落实将健康融入所有政策的宗旨，共同应对当代公共卫生的重大挑战。     

Survey in sub-Saharan Africa shows substantial support for government efforts to improve health services

Public opinion can play an important role in shaping health policy alternatives and outcomes. However, little is known about how citizens in developing countries evaluate government performance in the health sector. Through a survey conducted in 2008 in twenty sub-Saharan African countries, we examined public priorities and perceptions of government efforts to improve health services. In sixteen of these countries, health was one of the top five priorities the public thought the government should address. A staggering proportion of citizens in most of the sampled countries reported having gone without medicines or medical treatment in the previous year, and going without health care was most strongly correlated with views on health services. By contrast, greater access to health care was associated with more positive impressions of government efforts to improve health services. Population health indicators, such as life expectancy and childhood mortality, were not correlated with citizens' evaluation of government efforts. Results suggest that improving access to health care will be a key factor in improving perceptions of government performance.     

Exploring health care reform in a changing Europe: Lessons from Greece

Abstract

The economic crisis is the major theme in the Eurozone and its impact on public health and outcomes is largely discussed. Under this pressure, concerns of further inequalities exist that may have an impact on the burden of several diseases in certain European countries. In this context, Greece is currently an issue of top interest in any international economic discussion. Although the background of the recession has been largely discussed as a political crisis, its health effects on the population, as well as the key role of primary care and general practice/family medicine in health care reform remain to be explored. Serving both the worldwide trend of orienting health care systems towards strengthened primary care and the inner need for minimizing the demand and lessening the burden from the dysfunctional and costly hospital-care system, the economic crisis sets the perfect timing for prioritizing primary health care. In this article a unique window of opportunity for health care reform in Greece is examined, attempting to establish the axes of an example of how health care system can be reshaped amidst the economic crisis. Equity, quality, value framework, medical professionalism, information technology and decentralization emerge as topics of central interest. There is no doubt that Europe is transitioning under challenging social, economic and public health perspectives. However, taking Greece as an example, the current economic situation sets a good timing for health care reform and the key messages of this paper could be used by other countries facing similar problems.     

Legal strategies to improve physical activity in populations

The World Health Assembly has adopted the World Health Organization’s (WHO) recommended target of achieving a 15% reduction in physical inactivity by 2030. The WHO Global Action Plan on Physical Activity provides a framework for countries to achieve this, using a systems-based approach to address the social and environmental determinants of physical inactivity. Lack of progress in many countries indicates a need to identify new ways of addressing this public health priority. WHO continues to highlight the importance of legislative and regulatory measures within the multicomponent and multisectoral action needed to reduce physical inactivity. Yet research into the role of law for addressing physical inactivity has been limited, in contrast to the legal approaches to other major noncommunicable disease risk factors such as smoking and alcohol use. Conceptual frameworks for public health law offer a method for mapping and understanding the determinants, mechanisms and outcomes of law-making for the promotion of physical activity within populations. We describe the development and application of a framework that aligns legal strategies with the WHO Global Plan policy objectives. This new framework – the Regulatory Approaches to Movement, Physical Activity, Recreation, Transport and Sport – can help policy-makers to use the untapped potential of legal interventions to support or strengthen a whole-system response for promoting physical activity. The framework illustrates the role of legal interventions to improve physical activity and identifies opportunities for research to advance understanding, implementation and evaluation of legal responses to this issue.     

Health care financing in Asia: key issues and challenges

This article examines the major elements of health care financing such as financial risk protection, resource generation, resource pooling, and purchasing and payment; provides key lessons; and discusses the challenges for health care financing systems of Asian countries. With the exception of Japan, Korea, Taiwan, and Thailand, most health care systems of Asia provide very limited financial risk protection. The role of public prepaid schemes such as tax and social health insurance is minimal, and out-of-pocket payment is a major source of financing. The large informal sector is a major challenge to the extension of population coverage in many low-income countries of Asia, which must seek the optimal mix of tax subsidy and health insurance for universal coverage. Implementation of effective payment systems to control the behavior of health care providers is also a key factor in the success of health care financing reform in Asia.     

全球卫生治理面临的困境、原因及应对：以新型冠状病毒肺炎疫苗实施计划为例

新型冠状病毒肺炎威胁着人民的生命健康和财产安全。新型冠状病毒肺炎疫苗是建立人群免疫屏障、实现疫情全球卫生治理的关键公共品,WHO、全球疫苗免疫联盟和流行病防范创新联盟于2020年创建新型冠状病毒肺炎疫苗实施计划（COVAX）,旨在让世界各国,尤其是中、低收入国家也能公平接种疫苗。尽管COVAX通过协调全球供应链加速了疫...     

Private health insurance: implications for developing countries

Private health insurance is playing an increasing role in both high- and low-income countries, yet is poorly understood by researchers and policy-makers. This paper shows that the distinction between private and public health insurance is often exaggerated since well regulated private insurance markets share many features with public insurance systems. It notes that private health insurance preceded many modern social insurance systems in western Europe, allowing these countries to develop the mechanisms, institutions and capacities that subsequently made it possible to provide universal access to health care. We also review international experiences with private insurance, demonstrating that its role is not restricted to any particular region or level of national income. The seven countries that finance more than 20% of their health care via private health insurance are Brazil, Chile, Namibia, South Africa, the United States, Uruguay and Zimbabwe. In each case, private health insurance provides primary financial protection for workers and their families while public health-care funds are targeted to programmes covering poor and vulnerable populations. We make recommendations for policy in developing countries, arguing that private health insurance cannot be ignored. Instead, it can be harnessed to serve the public interest if governments implement effective regulations and focus public funds on programmes for those who are poor and vulnerable. It can also be used as a transitional form of health insurance to develop experience with insurance institutions while the public sector increases its own capacity to manage and finance health-care coverage.     

Evidence-based public health: what does it offer developing countries?

The global burden of disease and illness is primarily situated in developing countries. As developing countries have limited resources, it is particularly important to invest in public health and health promotion strategies that are effective. Systematic reviews are central to evidence-based public health and health promotion practice and policy. This paper discusses issues surrounding the relevance of evidence-based public health and systematic reviews to the health of developing countries. It argues that there is a lack of systematic reviews relevant to the health priorities of developing countries; many interventions reviewed can not be implemented in resource-poor situations; and, a limited amount of primary research is conducted in developing countries. The paper further argues that improvements in public health are determined not only by effective health services and interventions, but through an approach that includes other sectors and influences broader structural and systematic barriers to health. Given the social complexity of human development, and the inter-sections amongst different development goals, there is no question that gains in developing country public health are unlikely to emerge from systematic reviews alone, but will require decisions about inter-sectoral collaboration and social policy initiatives. Nonetheless, evidence around intervention effectiveness has an important role to play in addressing health priorities in developing countries and resource-poor areas. The public health evidence base urgently needs strengthening, with dedicated effort towards increasing the relevance of primary evidence and systematic reviews.     

Community gardens: lessons learned from California Healthy Cities and Communities

Community gardens enhance nutrition and physical activity and promote the role of public health in improving quality of life. Opportunities to organize around other issues and build social capital also emerge through community gardens. California Healthy Cities and Communities (CHCC) promotes an inclusionary and systems approach to improving community health. CHCC has funded community-based nutrition and physical activity programs in several cities. Successful community gardens were developed by many cities incorporating local leadership and resources, volunteers and community partners, and skills-building opportunities for participants. Through community garden initiatives, cities have enacted policies for interim land and complimentary water use, improved access to produce, elevated public consciousness about public health, created culturally appropriate educational and training materials, and strengthened community building skills.     

Health care expenditure and life expectancy in Australia: how well do we perform?

Abstract: The Australian health care system consists of mixed public and private financing underpinned by Medicare, a universal government-run insurance scheme paid through taxation (and levy) on income. Australia has improved its ranking for life expectancy (at birth) since 1960, and in 1990 ranked ninth and seventh of 24 countries for females and males respectively; this is ahead of the United States and United Kingdom, and approximately equal to Canada. Australian hospital bed supply and utilisation are average, after deletion of day-only cases. The proportion of gross domestic product (GDP) spent on health, in relation to GDP per capita (adjusted for purchasing power), in Australia in 1990 was average, and the prices for health care from 1975 to 1990 did not increase when adjusted for inflation. Although 68 per cent of health expenditure emanates from public sources in Australia, this is lower than in the majority of European countries and Canada. Some countries are doing poorly (such as the United States, with lower than average life expectancy and higher than predicted health expenditure) and some countries are doing well (with higher than average life expectancy and lower than predicted health expenditure; for example, Japan). Australia has higher than average life expectancy and only slightly higher than predicted health expenditure per capita. Although the Australian system could be improved, there are no indications that radical changes are required. The relatively high life expectancy in Australia can be attributed to favourable social and economic conditions, successful public health programs, and the availability of universal quality health care.     

Health workforce attrition in the public sector in Kenya: a look at the reasons

Background  

Kenya, like many other countries in sub-Saharan Africa, has been affected by shortages of health workers in the public sector. Data on the rates and leading reasons for health workers attrition in the public sector are key in developing effective, evidence-based planning and policy on human resources for health.     

Obesity and risk knowledge

Obesity is an epidemic health problem in many developed countries, and it is an emerging public health concern in developing, transitional, and newly developed countries. The purpose of this research is to investigate the relationship between individuals' knowledge concerning the health risks of obesity and their tendency to be obese (as measured by the "body mass index"). Instead of assuming that obesity is a pure physiological problem as in previous studies, we allow an individual's cost/benefit evaluation to play a role. Based on survey data from Taiwan, we investigate the relationship with the quantile regression technique. The results suggest that such a relationship does exist and it is different for males and females.     

Introduction. Symposium: Obesity in developing countries: biological and ecological factors

Over the past decade there has been an increasing concern about the impact of chronic, noncommunicable diseases on the health of developing world populations. Traditionally, major causes of illness and death in developing countries have been linked to infectious diseases and undernutrition, and these are still major public health problems in several regions of the world. But recent projections indicate that in 20 y noncommunicable diseases will account for over 60% of the disease burden and mortality in the developing world. Obesity is recognized as an underlying risk factor for many of these chronic conditions. As in developed societies, the risk for obesity in developing countries is also strongly influenced by diet and lifestyle, which are changing dramatically as a result of the economic and nutrition transition. This symposium discusses key aspects of the phenomenon of obesity in the developing world and provides some specific examples from countries facing increasing prevalence of that condition.     

Holistic Self-Management Education and Support: A Proposed Public Health Model for Improving Women's Health in Zimbabwe

The primary health care model of public health has been implemented in many countries around the globe since the Declaration of Alma Ata in 1978, without pilot testing the primary health care model. Therefore, many public health researchers have sought methods of improving primary health care by creating evidence-based models. Many of these researchers recognize the role of behavioral models in public health. These offshoots of primary health care include the ecological, care, central human capabilities, and the SPECIES models. Holistic self-management education and support is a capacity-building philosophy that ensures active involvement of consumers of health care in the planning and implementation and evaluation of health care services. It helps consumers of health care to achieve the desired improved quality of health and life in managing and sustaining their health at the grassroots level. The care model addresses disease management ideals of the in the original primary health care model. The SPECIES model addresses those aspects of the primary health care model that include the cultural and social factors, as well as individual health education and support in the original primary health care model. The ecological model offers an improvement of the socioeconomic ideal in the original primary health care model. Improving the health of individuals will prevent illness, thereby reducing health care costs and lessening the current strain on an overburdened health care system in Zimbabwe. Holistic self-management education and support links health care delivery systems with social processes. It is a best practices model that could better serve Zimbabwean girls and women by contributing positively to the national challenges in health care, thereby meeting the Zimbabwean primary health care and safe motherhood goals. It is here recommended that holistic self-management education and support must be pilot tested before being adopted as the most appropriate model for ensuring population health.     

Holistic self-management education and support: a proposed public health model for improving women's health in Zimbabwe

The primary health care model of public health has been implemented in many countries around the globe since the Declaration of Alma Ata in 1978, without pilot testing the primary health care model. Therefore, many public health researchers have sought methods of improving primary health care by creating evidence-based models. Many of these researchers recognize the role of behavioral models in public health. These offshoots of primary health care include the ecological, care, central human capabilities, and the SPECIES models. Holistic self-management education and support is a capacity-building philosophy that ensures active involvement of consumers of health care in the planning and implementation and evaluation of health care services. It helps consumers of health care to achieve the desired improved quality of health and life in managing and sustaining their health at the grassroots level. The care model addresses disease management ideals of the in the original primary health care model. The SPECIES model addresses those aspects of the primary health care model that include the cultural and social factors, as well as individual health education and support in the original primary health care model. The ecological model offers an improvement of the socioeconomic ideal in the original primary health care model. Improving the health of individuals will prevent illness, thereby reducing health care costs and lessening the current strain on an overburdened health care system in Zimbabwe. Holistic self-management education and support links health care delivery systems with social processes. It is a best practices model that could better serve Zimbabwean girls and women by contributing positively to the national challenges in health care, thereby meeting the Zimbabwean primary health care and safe motherhood goals. It is here recommended that holistic self-management education and support must be pilot tested before being adopted as the most appropriate model for ensuring population health.     

Community pharmacy and public health in Great Britain, 1936 to 2006: how a phoenix rose from the ashes

The pharmacy profession in Great Britain has identified public health as a key area for future development; at the same time the government has been keen to make full use of pharmacists in pursuing its public health goals. To date, pharmacy has focused on microlevel activities such as health promotion, medicines management and prescribing advice, rather than on wider public health issues such as health inequalities. The role in health promotion has its origins in the traditional advisory role of the pharmacist, which largely died out following the establishment of the National Health Service in 1948, and was resurrected only following ministerial intervention in 1981. This article traces the origins of the pharmacist's role in public health, illustrating both shifting definitions of public health and changes in pharmacy practice. It describes how the profession was able to re-establish its advisory role and to develop it into a wider contribution to public health, indicating that this process came about as a result of convergence between a professional imperative to develop its role, on the one hand, and state recognition of the need to draw a broader range of health professionals and lay people into public health activities, on the other. Convergence required the securing of government support, confirmed in policy documents; the recognition by pharmacy's professional body that embracing public health is a desirable activity; incentives for community pharmacists to carry out such activities; and support from the wider public health community. This article describes how each of these was achieved.