the institutionalisation of public health training and the health sciences 2002 jerusalén

8/17/2019 The Institutionalisation of Public Health Training and the Health Sciences 2002 Jerusalén

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collaboration beyond borders (the concept of regionality) is apt to support the achievement of

international standards of excellence for newly developing schools of public health.

Introduction

In the recent report on Macroeconomics and Health (1) a long established paradigm has beenreversed: It is now stated that without healthy people economic development is seriously

impaired. If on the other hand one of the central paradigms of Public Health is hold valid,

namely that the state of health is also determined by a number of ecological determinants

other than medical care as e.g. socio-cultural and socio-economic conditions of living, then it

becomes obvious that the population’s health cannot be improved following exclusively a

medical paradigm. However, around the world most training programs for public health

professionals - with the exception of the United States - are hosted within medical faculties

(2). This is especially true for the Former Socialist Economies, where as a rule the medical

discipline of “Social Medicine” is taken for “Public Health”. Under this narrow perspective it

is difficult to develop “Health Sciences” as an autonomous academic field (3). The following

text tries to lay out the framework of population health problems [I.] respectively why

independent institutes or “Schools” of public health are needed and how they should fulfill

their array of tasks (II). Then the contemporary trends [III.] of academic education in Europe

will be described and as a result of all of these a structural profile [IV.] of appropriate training

institutions.

I. THE PROBLEMS

The health status of a population is not an independent one of the historical conditions notably

their social, economic, and cultural dimension. Therefore the health sciences relate to the

societal development altogether, the health of the public is a political subject.

Public Health and the Society

The history of modern public health in Germany may serve as an example for the

interrelationship between the health of the public and the development of a society in general.

The origins of this contemporary discussion can be traced back to the analysis of the outbreak

of typhoid fever in Upper Silesia, published by Rudolf Virchow (1821-1902) in 1849 (4). He

accused the Prussian state of the negligence of basic needs of the Polish population in that

region and identified the lack of its political participation as a main social cause of the

epidemic. In the same period Salomon Neumann (1819-1902) postulated the obligation of the


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state to organize public health care and to protect the health of its people (5). The state should

inter alia ensure the basic human right to live a healthy life under suitable conditions, improve

care for the poor, establish health offices at all administrative levels, provide medical statistics

of the causes and effects of disease and last but certainly not least let the people participate in

the administration and guarantee the independence and freedom of physicians. In 1925Gottstein, Schlossmann & Teleky developed for the first time the concept of a health science

in their foreword to the “Manual of Social Hygiene and Health Care” (6). Even at that early

date they combined essential medical and social scientific disciplines under this term. The

upcoming of National Socialism (1934 legislation on the centralization of the health care

system) and later of socialism in East Germany blocked further advancement of this concept

(3). Not before half a century later public health was re-established as an academic discipline

of study and research when a faculty of health sciences was opened at the University of

Bielefeld in 1988/1994. With the Treaties on European Union of Maastricht and Amsterdam

(1993 ff) a renaissance of the health sciences developed also in Germany as well as in other

European countries, based on the new public health mandate of the European Commission

(e.g. article 129 in the Maastricht Treaty (7)). A few years earlier the Acheson Report defined

public health as the science and art of preventing disease, prolonging life, and promoting

health through organized efforts of society (8).

Public Health and Populations

Coined by the English cardiologist and epidemiologist Geoffrey Rose the terminology of a

“Population Strategy” as opposed to a “High Risk Strategy” (9) has gained worldwide

acceptance: “Traditional preventive strategy is concerned with identifying and helping

minorities with special problems, by treating their risk factors or seeking changes in their

behavior. The underlying aim is to truncate the risk distribution, eliminating the tail but not

interfering with the rest of the population. In practice such truncation proves hard or

impossible to achieve. As our results show, the spread of a distribution is not readily

compressed. The close link between mean and prevalence implies, that to help the minority

the "normal" majority must change.... The health of society is integral” (10). This implies that

the mean together with the entire distribution of risk in a population has to be shifted into the

direction of lower levels of potential harm; a reduction only of the prevalence of elevated

values of a risk factor will prove not to be sufficient. This has been confirmed also for

intervention studies (11). Interventions confined to the narrow medical system cannot reduce

the incidence of disease accruing from a number of ecological determinants.


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Public Health and the Health Care Deficits

Four main deficits can be identified with regard to modern systems of health care:

a)

The information deficit

b)

The prevention deficitc)

The social deficit

d) The regulation deficit.

The information deficit : Because of the obvious lack of sufficient and reliable information in

the health sector international as well as national initiatives have promoted the development

of indicator-based comprehensive monitoring systems (mostly although not exclusively

quantitative routine data) and their interpretation by experts published as reports to the

general public (health reporting). Usually health reports of this kind comprise the following

sections (see e.g. (12):

Demographic parameters of health care

The health of the population

Health behaviors

Environmental health risks

Institutions in health care

Utilization of services

Employees in health care

Professional education in health care

Expenditure and financing

Cost of health care.

Health surveillance is a prerequisite of intelligent decision making in health policy. Valid

indicators are the key to meaningful analysis. Health indicators should be relevant (regarding

priorities), valid (regarding determinants of health), measurable (in quantitative or qualitative

terms), sensitive (to change and differences), comparable (inter-territorial), repeatable (for

time series), affordable (in terms of relative costs), and useful (for intervention) (13). Meeting

these criteria obviously requires a permanent scientifically qualified institutional

infrastructure.


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The prevention deficit:

Given its great potential, the preventive sector of health services has not yet received

appropriate attention. Where this is obvious for infectious diseases it seems to be even more

relevant for chronic diseases which start to develop at early stages of an individual’s life.

Smoking, alcohol drinking and using of drugs, incorrect diet and overfeeding, too little physical exercise, insufficient hygiene and other health damaging behaviors are often

responsible especially for diseases of the circulatory system and cancer. Dangerous driving,

auto-aggressive behavior and unprotected sexual acts are major causes of increasing

morbidity and mortality rates as well as premature deaths. These are mainly behavior related

risk factors, in other words they are potentially under the control of an individual. However,

risk factors are based on behavioral patterns which are integrated with habitual patterns of

socio-cultural life styles and which are shaped in each case by various life situations (14). For

this reason, all preventive approaches must have behavioral and situational components.

Chronic diseases, for example, are very seldom curable once they have manifested

themselves, but they are – at least in principle – preventable. It would be logical if some of the

money allocated for and personnel involved in treatment could be diverted to preventive

activities. This could allow to alter the initial conditions which contribute to the development

of chronic-degenerative diseases by means of behavior-oriented prevention (health education,

behavioral modification etc.) and setting-oriented prevention (promotion of health at work,

housing, recreation, education, and medical services). I.e. in the future much greater

consideration has to be given to the multi-dimensional interrelationship of the causes of health

impairments both in etiological research and provision of medical services.

Acquired Immune Deficiency Syndrome (AIDS) is a good example which illustrates the need

for concerted efforts and actions, firstly, in the area of etiological research through a

combination of molecular biology and epidemiological studies, secondly, in the therapy and

diagnostics in clinical research and practical work, thirdly, in education of the public, focused

on behavioral patterns and life-styles oriented towards prevention, and finally, in nursing care

of patients. It is obvious that success can be only achieved by combining etiological research,

prevention, clinical practice, and nursing (3).

With regard to implementation a core issue is to keep the target group well informed, notably

the administrations, non-governmental organizations, citizen initiatives, and the individual


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people. WHO’s Declaration of Jakarta (15)has made it quite evident by launching five most

comprehensive and effective strategies:

1) build healthy public policy,

2)

create supportive environments,

3)

strengthen community action,4)

develop personal skills,

5) reorient health services.

It is added in the declaration that a so-called “Setting Approach” offers practical opportunities

(in cities, islands, local communities, markets, schools, workplaces, and health facilities),

people have to be at the center, access to education and information is essential, and health

promotion is a “Key Investment”.

The structural problems discussed here can only be managed by means of interdisciplinary

cooperation. This also applies to infra-structural and organizational problems faced by health

services.

The social deficit: Today a terminology has become widely accepted which uses the term

“inequality” for stating differences in health status determined by social variables like

educational grade, professional category and income level sometimes added up to one

integrated index of social status. By some this is called “vertical” inequality, whereas

“horizontal” inequality may refer to various dimensions of disparities connected with sex and

age or different ways of looking at a person’s position in the society, e.g. marital and family

status, ethnic group, whether one is a migrant or a native resident etc. Others prefer not to

make such a distinction but to think instead in terms of disadvantaged or vulnerable groups

such as migrating laborers, the unemployed, socially isolated elderly, and one parent families.

The value statement on inequalities most often is termed “inequity”, namely whether a

socially determined state of disadvantaged health is considered to be unfair, and unjust

because being unnecessary and avoidable (16). The interdisciplinary study of the determinants

and possible interventions to minimize health inequities may be summarized as “Social Public

Health” (17). Social Public Health then constitutes a core sector of the New Public Health

(18) approach which has been developed throughout the nineties


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Four different concepts have been discussed already in the Black Report (19) in order to

explain the differences in health status by social groups: [1] methodological artifacts, [2]

social selection, [3] living conditions, and [4] health behavior. The first explanation of social

gradients is deemed of little relevance: systematic methodological errors are unlikely, given

the almost universal and quite uniform existence of social gradients and health inequalities.The second and third explanation are mirrored in the slogan that “Poverty drives you sick and

sickness makes you poor”. Together they constitute a vicious circle effective in many regions

of the (third) world especially where the population is not sufficiently covered by health

insurance. As disease is more prevalent in the lower social strata, the economically

disadvantaged ones may have to pay more not only in relative but even in absolute terms.

Other researchers highlight the fact that at least some part of health inequalities have been

shown to arise from a higher prevalence of unhealthy behavior in lower socio-economic

groups and from differences in psychosocial work environment (20).

Two objectives have been set for interventions (21):

1) Mortality and morbidity should decline particularly for those causes of death

and age groups in which a defined population is lagging behind other

populations (“level objective”).

2) Socio-economic differences in mortality and morbidity should shrink, which

requires reductions faster than average among less fortunate groups

(“distribution objective”).

This requires scientific analysis of:

a) Socio-economic gradients in health: The distribution of total and specific mortality

and morbidity as well as risk factors according to social gradients,

b) Disadvantaged groups: The characterization - including intermediary factors - of

selected disadvantaged or vulnerable groups with regard to health inequity,

c) Social barriers to health care: Social selectivity in access to health care and delivery

of services including satisfaction with health services and their quality.

Disadvantaged or vulnerable groups are subpopulations being exposed to an

accumulation of unfavorable determinants of health and therefore at excess risk

for disease or ill health respectively. The terminology sometimes used for

underprivileged or disadvantaged groups stresses the external causation of


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reduced health chances, however, voluntary risk seeking behaviors may also

contribute and should not exclude such people from supportive action. This

applies even more to individuals with a limited ability to cope with strains. No

systematic classification of disadvantaged groups has yet been developed, but

the following for example have been suggested in varying contexts: the

migrating labor force, the traveling communities, the homeless, ethnic

minorities, asylum seekers and refugees, elderly females living alone and in

poverty, one parent families, children growing up in families on social

compensation, the unemployed, and the very poor. According to Wilkinson (22)

social dislocation and the disruption of social cohesion respectively may be a

common mechanism of vulnerability. Furthermore many researchers hold theview that during the last decade vulnerability has gained importance vis à vis the

classical vertical inequalities. On the other hand vulnerability is not necessarily

static or definite but may change during a lifetime, as is typically the case with

regard to many states of (intermediate) poverty. The tensions originating from

unacceptable differences in chances for healthy living can destroy the societal

web and lead to violence and war (23).

The regulation deficit: The decision making in health care is organized by a regulatory

framework which in most countries is characterized by a continuous shift from the old vertical

model to a more horizontal one with a moderating instead of a directive role of the

governmental agencies. A number of decision making centers acting more or less in parallel

have to be coordinated but cannot be directed.

Originally organized rather in a top-down model more and more the generation of decisions

follows a bottom-up approach. This requires a management that integrates several levels of a

formerly hierarchical pyramid in a round-table manner. A management approach of this type

may be named “Horizontal Management”. Arguments for an increasingly horizontal

management can be found in the following:


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1) For Europe and to a lesser degree other continents the processes of unification and

regionalization which take place in parallel make a centralized top-down coordination

difficult and complex.

2) Harmonization and decentralization as an essential prerequisite of the above.

3) The competence gap in the health administrations which seems to be increasing because ofthe growing complexity of management tasks as indicated above.

4) A management by moderation of conflict as a consequence of the loss of authority of the

central units.

5) The apparent shortage of tax based funding and in consequence privatization of services.

6) The necessity of smaller respectively lower units to develop a competitive profile given the

incapability of covering a complex and wide spectrum of services altogether.

7) The growing inter-disciplinary and multi-professional collaboration in order to find

solutions for modern multifaceted problems.

8) The wider understanding of health (including spiritual respectively cultural dimensions)

and the increasing role of non-governmental organizations.

9) The shift from clinical to ambulatory and primary health care with its less controllable

environment of service providers.

The health conferences as established in the federal state of North-Rhine-Westphalia,

Germany may serve as an example of the new instruments developed in this regard (24):

With the new health legislation of 1997 (§ 26 ÖGDG) health conferences have been

established as well at the state level, chaired by the Ministry of Health itself as at the

communal and county level, chaired by the head of the local health office which also has to

organize its proceedings. Members to be invited are among others: Medical Chambers,

Pharmacists’ Chambers, Hospital Association, Health Insurances, Social Insurances, State

Board of Counties & Cities, Employers’ Association, Trade Unions, Occupational Hazard

Insurances, Social Welfare Association, Self Help Associations, and Regional

Administrations.

Among other topics treated the state conference decreed 10 Health Objectives for North-

Rhine-Westphalia which are worked on at annual conferences:

I. Reduction of cardiovascular diseases

II. Reducing cancer


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FigureAn operational approach to improve the health of the people (from (23))

It is obvious that this outline applies only to open societies where interplay can develop

between the people and the administration. However, undemocratic closed societies do not

seem to have a competitive potential for dynamic development, at least not in the long run.

The task profile to be dealt with in this setting can be summarized from the outline of health problems (I.) as follows:

a)

Training for research and services b) Monitoring population health and setting of prioritiesc) Applied research on public healthd) Consulting the decision makerse) Intervention and public accountability

As for individual therapy and even diagnosis a code of medical ethics has to be obeyed the

implementation of population wide interventions in public health and even analytical studieshave to follow ethical rules which relate predominantly to the way of how decisions in this

regard are made.

However, the field of population ethics is not yet well developed or even recognized. As an

exemption one might consider the Skopje Declaration on Public Health, Peace & Human

Rights (26). Five basic principles can be identified:

1)

Equity

Administration[Top downApproach]

Information System People’s Health Decision Making Process

People[Bottom upApproach]

Public Information Public Information

Consultancy

Training

Technical Support

Interventions

Healthy management


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2) Participation

3)

Subsidiarity

4) Sustainability

5)

Efficiency

Equity: A long and healthy life is at the top of the agenda of almost every individual and

whereas some gradient in socio-economic welfare given equal chances may stimulate

dynamic development, inequity in health is considered to be unfair and unjust, being

unnecessary and avoidable (16). It causes social tension, and thereby in turn interferes also

with economics (1). Further more incapacitated individuals cannot fully participate in

decision making regarding societal issues, and in extremis even concerning their private lives.

In the European ethical tradition solidarity with the disadvantaged is a moral value throughout

the Christian middle-ages, the French revolution (“Liberté, Egalité, Fraternité”) and the

modern European welfare states, not to mention the original intentions of philosophers like

Marx and Engels. Thus it is a European heritage to think of health as a personal good but

under individual as well as collective responsibility (27).

Participation: Collective responsibility must not interfere with individual autonomy. The

principle of how to solve this seemingly antagonistic statement is substantiated by the term of

participation as coined by WHO in many publications (28): Participation in the societal

decision making processes which define our social and physical environment and therewith

our conditions of living. The formation of the “Settings” (15) we live in is to evolve as much

“bottom up” as possible, in other words in a most democratic way.

Subsidiarity: The principle of subsidiarity, which has been invented as a concept in the

Catholic social doctrine by the late Jesuit Nell-Breuning (29) and became a dominant

principle of the European unification process, is meant to protect against a preponderance of

higher hierarchical levels and in consequence to refer decisions as much as possible to

regional and local bodies. Subsidiarity equally relates to social welfare when it reads in the

Maastricht Treaty on European Union (7) that gradients in the quality of life between the

regions of Europe must be compensated for so that living conditions are comparable and

similar all-over Europe.


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Sustainability: The fourth ethical concept of relevance concerns sustainability which refers to

a development which ensures that the current use of resources does not compromise the health

of future generations (30). This is especially relevant to countries with economic difficulties,

such as post-communist countries in transition.

Efficiency: Finally resources for health are limited by principle as the desires for health

promotion and technological advances are always ahead of the financial capabilities. That

implies that any waste or sub-optimal use of money is unethical as it leads to even greater

restriction of resources elsewhere. Services financed from solidarity funds (taxes, obligatory

insurance fees) have to be compensated according to rational priorities which results in

limited provision of very expensive technologies.

III. THE TRENDS

The development of institutional profiles for training and research in public health cannot be

isolated from the contemporary trends of education. In Europe over the last decade we find

(31):

1) A quantitative explosion of specialized educational programs in various fields,

2) A dominant trend towards academization of existing and new programs,

3) A phenomenon of accidental specialization i.e. the accessory amendment of

existing programs for neighboring fields resulting in hybrid “Interdisciplinary

disciplines”,

4)

The growing importance of Continued Education,

5) The increasing relevance of Far Distance Learning,

6)

Demand that is mainly determined by supply.

More recently in the wake of the Bologna Declaration (32) additional trends can be observed:

7) An effort toward international compatibility,8) equal conditions for universities and polytechnics,

9)

shortening the period of study duration (< 5 years),10)

a more flexible organization of programs allowing for stepwise professionalqualification (no “dead ends”),

11) the chance for every student to meet the entrance criteria to doctoral degrees,12) modularisation and credits (European Credit Transfer System, ECTS),13)

establishment of agencies for the accreditation of training institutions.

With regard to the health sciences in Europe we find correspondingly a clear trend towards

academic settings for new programs and for academization of existing ones. In the academic


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environment public health is represented by a proto-typical “interdisciplinary discipline”, i.e.

the health sciences which are characterized by the “Double Paradigm” of medical respectively

biological and of the social sciences (33, 34) in so far as they comprise at least the four core

disciplines of applied epidemiology, health management, health promotion, and

environmental health. Beyond that a canon of health disciplines does not exist allowing eachinstitution to develop its own profile in relatedness to its societal environment. At least for the

example of Germany we see programs at universities as well as polytechnics (universities of

applied sciences). In addition to the classical postgraduate master programs more and more

undergraduate studies and doctoral programs are offered. Internationalization progresses

rapidly by consortial networks between schools of public health as e.g. for the European

Master of Public Health (EMPH), inaugurated by the Association of Schools of Public Health

in the European Region, ASPHER (35) and based on the ECTS system of credits.

IV. THE STRUCTURAL PROFILE

General characteristics

The health problems, the resulting tasks and the trends in modern education lead in

conclusion to an institutional profile for the “School of Public Health”, which can be

characterized as follows:

1) The institutional base should be in the university vs. being a part of the health

administration within or closely related (National Institutes of Public Health in many

countries) to the Ministry of Health (2). This guaranties the indispensable degree of autonomy

necessary to fulfill its tasks and secondly is the best way to make the required inter-

disciplinarity of the New Public Health functional.

Within the university different models of academic institutionalization can be found.

Probably the most appropriate is the establishment of a faculty in its own right. An example is

the Faculty of Health Sciences at the University of Bielefeld, which at the same time fulfills

all functions of a school of public health in terms of training for services including continued

education and a far distance learning program as well as executing a broad spectrum of public

health research. Another model is more frequently found: a department of public health

belonging to a faculty of Medicine. This implies the involvement in undergraduate medical

teaching (e.g. of Social Medicine) and may leave little space for expansion. Some universities

as for example the Palestinian Al Quds University in East Jerusalem have found another


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solution for the ambivalent though vital relationship between medicine and public health: The

Faculty of Health Sciences at Al Quds comprises with equal rights a School of Medicine, a

School of Nursing and a School of Public Health.

2) An institution under the paradigm of New Public Health must represent the medical as wellas the social sciences more or less as equally important (the double paradigm of public

health). From this two consequences derive:

a) Interdisciplinarity requires multiprofessionality of lecturers and

students as well which corresponds to the growing role of problem-

oriented task forces set up by governments requesting experts with

differing backgrounds to participate.

b) Interdisciplinarity creates innovative approaches merging relevant

knowledge from different traditional subjects. Typical for modern

development is the appearance of new hybrid disciplines

(“interdisciplinary disciplines”) where e.g. quantitative and qualitative

methods meet, termed “triangulation”. The health sciences are also an

example in themselves as well as the modern nursing science or the

environmental sciences.

3) Multiprofessionality and interdisciplinarity relate rather to postgraduate studies than to

undergraduate programs. Thus the typical training program in schools of public health is

organized as a Master of Public Health. However, the admission of undergraduate study

programs especially with a bachelor degree takes place more frequently during the last years,

usually specialized according to a format of e.g. a bachelor in health communication or in

health management etc. Many schools of public health prepare for a complete set of study

programs adding to the bachelor and master degrees a master of science and doctoral

programs as well as those of continued education.

A specific problem is posed where - especially in the post-communist countries - medical

academies are charged with continued education for medical specialization, usually of about 4

years. In order to avoid duplication the academic postgraduate master of public health

program of between one and two years should be fully recognized as an integral or even

mandatory part of the 4 years of specialization. Many teaching institutions especially in those

countries will be occupied throughout the years to come with the re-training of the public

health work force in preparation of the new task profile in a western type society.


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4) The international scale of modern health problems - whether we refer to the emergence of

new and the re-emergence of well-known infections like tuberculosis or to patient mobility

between different national insurance systems e.g. in the European Union – asks for an

international respectively even global perspective. This becomes very clear considering thecomplex causes of violence and terrorist acts. Beyond that a core principle of epidemiological

analysis is the comparison between populations being different for the factor in question.

Very often this requires international comparative studies, as gradients within one country

may be small. Finally in a global community of public health professional standards of

excellence are transmitted through working relationships. Therefore the Association of

Schools of Public Health in the European Region has inaugurated the scheme of a European

Master of Public Health (EMPH) requiring an international placement of the student for a

certain period of time during the study course. Also in addition to national accreditation a

European accreditation of schools of public health is under development (36).

5) The School of Public Health is set to train the public health work force and the future

academic lecturers and researchers, i.e. the institution has to train for services and research.

That implies a close working relationship with the government , especially with the ministries

of health as well as of higher education and research. Maintaining independence the school of

public health must relate to the issues relevant to health policies and pro-actively consult the

decision makers. In some institutions therefore a department of health policy analysis has

been established. In countries with a more federal structure semi-official and private health

institutions ask likewise for expertise and consultancy. Ideally the function as a “think tank”

for the executive agencies results in a more evidence-based policy than is common. In support

of this a well-developed system of health surveillance with indicator based monitoring and

reporting is essential, otherwise the definition of alternative priorities remains in a gray zone

of volatile opinions and prejudice. Setting firmly grounded priorities produces relevance, last

but not least, of the public health institution itself. The identification of relevant health

problems also may strengthen the argument for the funding of public health research, which

in turn helps to stabilize the teaching faculty.

6) The strong practice orientation of the modern school of public health makes a close

cooperation with health institutions in the local environment indispensable, especially with

the local institutes of public health. This not only means sending students into the field but


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also vice versa to invite practitioners from the field to lecture in the academic programs.

Regular meetings between representatives of the school of public health and of the institutions

outside the university are good practice. In several environments a contractual network has

been inaugurated between academic and service institutions. This in addition facilitates the

“active professionalization” of students who can inter alia perform their thesis work as anintroductory step to later employment and at the same time solve a research question for the

presumable employer. Given the limited means for research this has been proven to be a very

powerful arrangement in order to promote public health research and practical implementation

of research results. However, it also means a rather horizontal structure of a faculty in the

context of its environment with a certain amount of decision making in the periphery. This is

in line with the general trend to decentralize formerly hierarchical structures driven by the

modern complexity of issues (horizontal management as discussed above).

7) Given their multi-facetted functional profile schools of public health should be placed and

should go where the problems are. In addition to being responsible for training in public

health and a lot of the relevant research in this field, they provide the necessary expertise to

be fed into the administrative decision making processes. However, even more relevant may

be their serving as a “neutral” forum for the informed public debate. In an open society the

school of public health must not detach from the public opinion. Regular appearance in the

media is an essential requirement in modern societies.

8) Depending on the size of a country and its population the geographical scope of a school

of public health may differ. Notwithstanding international even global collaboration many

hold the position that each state needs at least one school of public health of the profile

described afore. Larger territories within a country even require their own institutions. On the

other hand it is unlikely that a small country of e.g. one or two million inhabitants can or even

should afford an expensive institution with the full spectrum of activities. The result in this

situation very often is an institution being too small, understaffed and sub standard in all

respects, especially if the small country is a developing one or in transition as e.g. the former

socialist economies. At least for Europe with her diminishing importance of the old national

borders a structured regional cooperation may offer the solution. “Regionality” in this context

does not refer to regions within a country but to collaboration with neighboring countries of

smaller size in a geographical region as is for example South Eastern Europe or in common

language the Balkans. Other examples include the long established Nordic School of Public


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course has to be supervised according to international criteria of quality

assurance.

There is a number of advantages accruing from this type of regional collaboration which can

be summarized under the slogan of a “Regional Ownership”:a)

It contributes to the rebuilding of professional relationships

after a period of violence and open war (e.g. the Yugoslavian

succession wars).

b) It allows for complementary sharing of scarce resources.

c) It has the potential to enhance the excellence of the overall

program

d) It induces competitive profiling of the institutions in the region

e)

It avoids the creation of incapable “Mini-Institutions”

f) It preempts to some degree a “Brain drain” to the West in

providing a re-entry structure at least for those (re-) trained in

the job.

g) It supports mutual quality assessment by the necessity to

mutually acknowledge study certificates from institutions in

neighboring countries.

h) It is affordable for students because of local price structure.

i)

It offers a chance for regional lecturers to contribute and to

develop their skills and competences.

j) It provides experts with a qualified knowledge of the region for

external evaluation (e.g. of research projects for funding

procedures)

k)

It facilitates a consortium approach for research proposals as for

example requested for EU funding programs.

l)

It broadens the scientific base and enhances wider

implementation and utilization of research and development

(R&D).

m) It supports last but not least the emergence of a professional

identity and collegiality in the region.


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Since 2000 the PH-SEE collaborative network ( 40) has created a common database for public

health in the region and works on a common set of teaching materials (37). An agreement on

mutual recognition of study certificates is under negotiation as well as a Minimum Indicator

set for health monitoring (13). A first teaching book in Albanian is in print (41).

SUMMARY AND CONCLUSION

In summary the key features of modern schools of public health are an independent academic

status outside the medical faculties or within and nevertheless a close and functional working

relationship with the relevant governmental institutions notably the ministries of health and

higher education. The agreements reached in the European Union for education in general and

for public health training in particular will become sooner or later standard for all European

countries inter alia the accession states in Central and Eastern Europe. These developments

can be enhanced by a well designed regional collaboration between neighboring countries.

The public health professional having encompassed education in schools of public health as

outlined may be described according to the following profile:

a) follow a professional code of ethics

b) accept accountability towards society

c) work for evidence-based action

d) aim at structural and stable solutions

e)

understand the global context of public health

f)

understand the multi-factorial determination of population health

g) be prepared for transnational management

h)

be qualified for trans-cultural, interdisciplinary & multi-professional

cooperation

i)

know assessment technologies

j) have acquired consulting competencies

k)

be trained in leadership for services

l)

be competent for research and development in the service environment

m) be knowledgeable in foreign languages, the use of the Internet, presentation

techniques, moderation skills, conflict management, and teamwork interaction.


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15) WHO, World Health Organization: The Jakarta Declaration on Leading Health Promotion into the

21st Century. World Health Organization, Geneva: 1997 (WHO/HPR/HEP/$ICHP/BR/97.4 and:

www.who.int/regions/euro/index.html).

16) Whitehead M.: The concepts and principles of equity and health. WHO-EURO, Copenhagen 1990

17) Laaser, U. (on behalf of the Working Group on Social Gradients and Health in Europe):

Social gradients in health. In: Weil O., McKee M, Brodin M, Oberlé D (eds.): Priorities for public

health action in the European Union. Societé Francaise de la Santé Publique, Paris 1999 (ISBN 2-

911489-06-3) : p. 14-20.

18) Frenk J. The New Public Health. Annual Review of Public Health 14 (1993): 469-490.

19) Townsend P, Davidson N: Inequalities in Health. The Black Report. Penguin, London 1982

20) Marmot MG, Bosma H, Hemingway, Brunner H, Stansfield S: Contribution of job control and

other risk factors to social variations in coronary heart disease incidence. The Lancet 350 (1997): 235-

239.

21) Valkonen T, Sihvonen A-P, E. Lahelma E: Health expectancy by level of education in Finland.Soc. Sci. Med. 1997;44/6:801-808.

22) Wilkinson R: Unhealthy Societies. The Afflictions of Inequality. Routledge, London 1996

23) Laaser, U., D. Donev, V. Bjegovic, Y. Sarolli: Public Health and Peace (editorial). Croatian

Medical Journal 43/2 (2002):107-113.

24) Laaser U: Gesundheitswissenschaften. In: Homfeldt HG, Laaser U, Prümel-Philippsen U,

Robertz-Grossmann Hrsg B): Soziale Differenz – Strategien – Wissenschaftliche Disziplinen.

Luchterhand, Berlin et al. 2002:195-231.

25) Laaser, U.: Directions of Further Research and Development on Important Health Related Issues.

In: Strohmeier KP, Köhler G, Laaser U (eds.): Urban Violence and Health. Determinants and

Management. A Study in Jakarta, Karachi and Conurbation Ruhrgebiet. Hans Jacobs-Verlag, Lage:

2001:273-279.

26) Donev D, Laaser U, Levett J: Skopje Declaration on Public Health, Peace & Human Rights.

Croatian Medical Journal 43/2 (2002):105-106.

27) Laaser, U, Wolters P: Das Gesundheitswissenschaftliche Graduiertenstudium an der Universität

Bielefeld im Rahmen vergleichbarer Bestrebungen. Soz Praeventivmed 34/5 (1989): 223-226

28) World Health Organisation (WHO). Ottawa Charta for Health Promotion. WHO, Geneva: 1986

29) Nell Breuning O.: Aktuelle Fragen der Gesellschaftspolitik. Bachem, Köln: 197030) Babic M, Zajtchuk R, Eckenfels E, Vuckovic-Krcmar M (eds.). Modern Health Care Glossary.

Cancer Foundation Yugoslavia, Belgrade & Chicago: 2000.

31) Deutsche Koordinierungsstelle Gesundheitswissenschaften: www.ruf.uni-

freiburg.de/medsoz/Dkgw. Modified from Kälble, K./J. v. Troschke (2001 unpublished).

32) European Ministers of Education: The Bologna Declaration on the European Higher Education

Area. Bologna, June 19, 1999: http://www.med-net.nl/topics/news/bologna.htm


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33) Hurrelmann K, Laaser U: Health Sciences as an Interdisciplinary Challenge; The Development of

a New Scientific Field. In: Laaser U, de Leeuw E, Stock C (Eds.): Scientific Foundations for a Public

Health Policy in Europe. Juventa-Verlag, Weinheim 1995, pps. 104-131.

34) Hurrelmann K, Laaser U, Bury J: Theory and Practice in Public Health. In: K. Hurrelmann and U.

Laaser (eds.): International Handbook of Public Health. Greenwood Press, Westport, Connecticut,

USA, 1996.

35) Association of Schools of Public Health in the European Region, ASPHER: www.ensp.fr/aspher.

36) Bury J, Gliber M: Quality Improvement and Accreditation of Training Programmes in Public

Health. Fondation Merieux 2001 (www.fond-merieux.org).

37) Public Health Collaboration in South Eastern Europe (PH-SEE): A project of the Stability Pact:

www.snz.hr/ph-see

38) Burazeri G: A Regional Master Program in Public Health (MPH) in order to meet specific needs

of the South Eastern European Countries (SEE). Oral presentation at the South Eastern European

Conference on Public Health and Peace, Skopje, Macedonia, December 6-8, 2001.39) Ramadani N.: Personal communication through J. Holst, February 22, 2002).

40) Kovacic L., Laaser U: Public health training and research collaboration in South Eastern Europe.

Med Arh 55/1 (2001), 13-15.

41) Burazeri GE, Roshi, N. Tavanxhi: Research Methods in Public Health, a “Starter” for Ambitious

Researchers. Hans Jacobs Editing Company, Lage: 2002.

SELECTED REFERENCES:

Websites:

1. Association of Schools of Public Health in the European Region (ASPHER), Paris:

www.ensp.fr/aspher/

2. Public Health Collaboration in South Eastern Europe (PH-SEE): A project of the Stability Pact:

www.snz.hr/ph-see/

Publications:

1) Commission on Macroeconomics and Health: Macroeconomics and Health: Investing in Health for

Economic Development. Website: www.cmhealth.org. WHO, Geneva: 2001.

2) Tulchinsky TH, Varavikova EA: The New Public Health: An Introduction for the 21 st Century.

Academic Press, San Diego: 2000.

3) Laaser U. (on behalf of the Working Group on Social Gradients and Health in Europe):

Social gradients in health. In: Weil, O., M. McKee, M. Brodin, D. Oberlé (eds.): Priorities for public

health action in the European Union. Societé Francaise de la Santé Publique, Paris 1999 (ISBN 2-

911489-06-3):14-20.


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4) WHO, World Health Organization: The Jakarta Declaration on Leading Health Promotion into the

21st Century. World Health Organization, Geneva: 1997 (WHO/HPR/HEP/$ICHP/BR/97.4 and:

www.who.int/regions/euro/index.html).

5) Hurrelmann K, Laaser U, Bury J: Theory and Practice in Public Health. In: K. Hurrelmann and U.

Laaser U (ed.): International Handbook of Public Health. Westport, Connecticut: Greenwood Press,

1996.

6) Hurrelmann, K, Laaser U: Health Sciences as an Interdisciplinary Challenge: The Development of a

New Scientific Field. International Journal of Occupational Medicine and Environmental Health 8/3

(1995): 195-214.

7) Leeuw, E. de: European Schools of Public Health in a state of flux. The Lancet 345 (1995): 1158-

1160.

8) Rose G, Day S: The population mean predicts the number of deviant individuals. Br Med J 301

(1990): 1031-1034.

9) Whitehead M.: The concepts and principles of equity and health. WHO-EURO, Copenhagen 1990.10) Townsend P., N. Davidson: Inequalities in Health. The Black Report. Penguin, London 1982.

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