Strategic Planning in Public Health: A Program Approach TH Tulchinsky MD MPH Braun School of Public Health Hebrew University-Hadassah, Jerusalem October 2004

Strategy A set of essential measures (preventive and therapeutic) believed sufficient to control a health problem (Last J. Dictionary of Epidemiology, 3rd edition, 2000) Strategy may be defined as the general scheme of the conduct of a war, tactics as the planning of means to achieve strategic objectives (Von Clausewitz 18 th C). A program or series of measures, stratagems and activities planned and carried out for the purpose of achieving specific objectives (Webster Dictionary)

Strategy and Tactics Strategy - A plan or method or series of maneuvers or stratagems for obtaining a specific goal or result. The art and science of planning and directing large scale use of resources with long range planning and development to ensure success in achieving objectives e.g. prevent or successfully combat disease in a population, plan a military campaign Tactics – use and deployment of resources in actual field conditions e.g. military, police, firefighting, public health.

War Theory: Military Strategy and Tactics Sun Tsu 166 BC – The Art of War - knowledge, deception, prevention Von Clausewitz 19 th C war is continuation of policy by other means – complete victory Alfred Mahan – influence of sea power on history Liddel Hart 1920s ד direct and indirect approaches Mao Tse Tung etc

Game Theory Distinct, interdisciplinary approach to the study of human behavior. Disciplines most involved are mathematics, economics, other social and behavioral sciences. Mathematical and neoclassical economics. Outcome depends on "market conditions," but also on the strategies chosen by others Rational choice of strategies is the problem Rational outcome as the "solution" Infectious disease modeling (Anderson and May)

How to Fight and Win Who (or what) is the enemy? What are the enemys objectives? What are their resources/capabilities? What are our objectives? What are our resources/capabilities? How best can we achieve our objectives? What are the most suitable methods of combat? Intelligence and modification of strategy and tactics

Case Study: Battle of the Atlantic Phase I, June 1939-April, 1943 –Convoy system, British codes broken –German wolf packs control of sea lanes increasing –Allies build quantitative strength, new technology –Air gap 800 miles Phase II May –Crisis April-May the tide turns –Allied quantitative and qualitative achievements –Air gap closed; convoys plus hunter-killer groups –Technological advances e.g. radar, squid, torpedoes –German innovations too late

The U- boat was the only thing I really feared in WWII. Winston Churchill

The Crisis of Battle of the Atlantic, Aug 1/42 to May 21/43 Winston Churchill, World War II, Vol 5

Battle of Atlantic Turning Point; April-June 1943 MonthsMerchant Tonnage Sunk 000s Subsunk Air Subsunk sea Subsunk total March April May June Oct-Dec47 ships--53 Churchill W

Perspective Stoker on merchant ship Captain of merchant ship Captain of convoy escort Commander of convoy Commander of naval sector Commander of air services First Sea Lord Prime minister Public opinion The enemy

Jack Maples Law, NYPD Objective – reduce crime and murder rates Methods –1. Accurate and timely intelligence –2. Rapid deployment –3. Effective tactics –4. Relentless follow-up –5. Continuous assessment and data Murders fell from 1,946 (1993) to 1,000 (1996)

MVA Mortality and Mileage, United States,

Cardiovascular Disease Mortality Rates, United States,

Expanded Host-Agent-Environment Paradigm HostHost - genetic, nutritional, life style, personality, psychosocial and other factors AgentAgent - microbiologic, toxic, stress, work, nutrient excess or deficiency EnvironmentEnvironment – vector, physical-societal context InterventionIntervention - clinical, preventive, environment Host AgentEnvironment HostEnvironment AgentIntervention

Determinants of Population Health Adopting the population health framework and collaborative approach as the basis for development of future health policies and strategies by governments has great potential to improve the health of Canadians... (Strategies for Population Health Investing in the Health of Canadians, 1994) Health Services Income & Social Status Social Support Networks Education Employment & working conditions Physical environment s Biology & genetic endowment Personal health practices & coping skills Healthy child development

A Comprehensive Health Services Continuum: Manitoba Healthy Public Policy Prevention Promotion Protection Community Oriented Services Support Services To Seniors Home Care Community Health Centres Extended Treatment & Long Term Care Outpatient Ambulatory Care Rural Community Urban Community Tertiary Rehabilitation Palliation Hospitals Promotion Palliation

Health Resources Political and public support Community and media expectations and support Manpower and training Money Facilities for in-patient care – acute and LTC Community care – clinics, outreach, home care Drugs Vaccines Education

Healthy Infants Healthy women in age of fertility e.g. iron and folate Good prenatal care and risk assessment Good care during delivery e.g. in hospital Good neonatal care e.g. vitamin K Good infant care e.g. immunization, Growth and development monitoring Breast feeding plus vitamins A, C, D, iron Formulas to one year Solid foods from 4 months Warmth, care, stimulus

Infant Mortality, United States,

Maternal Mortality, United States,

Communicable Disease Control Sanitation and hygiene Safe water and food Sewage collection and treatment Education - public, professional, patients Epidemiologic reporting, surveillance Training in PH, epidemiologic investigation Up to date immunization program Good programs for Social Diseases i.e TB, STDs, HIV, Hep B, Ca Cx Good primary and secondary care treatment Good laboratory support

Social Diseases: TB, STIs, HIV, Hepatitis, Cancer of Cervix Common risk groups and factors Noxious synergy Prevention and treatment strategies e.g. education, anti-retroviral drugs, immunization Ambulatory and community care Screening and case contact follow-up Community outreach Education Specialized tertiary care and terminal care Long term strategies for sustainable success

AIDS Incidence, Deaths and Prevalence, United States

Safe Community Water Supplies Safe water sources – contamination Coagulation Filtration Disinfection and residual chlorine - mandatory Routine testing – bacterial and chemical Routine chemical testing Sanitary engineering inspection Safe distribution and drainage systems Updated standards Epidemiologic monitoring of diseases

Non-Communicable Disease Control Primary prevention –Reduce CVD risk factors – BMI, exercise, smoking –Good nutrition e.g. much vegetables, little fat Secondary Prevention –Hypertension and diabetes control –Good treatment of AMI, stroke –Technology assessment and adoption Tertiary prevention –Good long term care in community –Hospital care in extremis

Motor Vehicle Trauma Control Primary prevention –Transport policy e.g. trains vs. cars –Laws and policing e.g. speed, seatbelts, helmets –Roads e.g. shoulders, roundabouts, lights –Alcohol control e.g. supply, taxation, –Education Secondary prevention –Emergency care at site –Good emergency transportation – trauma care in hospital –Good hospital care and training Tertiary prevention –Good rehabilitation care

A Program Approach Comprehensive planning Strategic goals Specific targets Operational planning Steering group Implementation team Training, resources Monitoring of input, process and outcomes

Summary Define the problem, and objectives Program Approach - strategy and tactics Intervention program – multi layered planning Budget and resources Inter-sectoral cooperation - networking Political support and resources Management group Technology - the state of the art Define realistic alternative approaches Implementation tactical program Intelligence i.e. continuous monitoring Reevaluation and revision Communicate what you are doing