1. The Big Picture: Strategic Planning in Public Health TH Tulchinsky MD MPH Braun School of Public Health Hebrew University-Hadassah, Jerusalem Skopje, Macedonia 25 Oct 2010 25 Oct 2010

2. 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 or plan a military campaign Last JM. Dictionary Epidemiology - A set of essential measures (preventive and therapeutic) believed sufficient to control a health problem (2001) Tactics – use and deployment of resources in actual field conditions e.g. military, police, firefighting, public health.

3. Game Theory Interdisciplinary approach to the study of human behavior Disciplines most involved : mathematics, economics, 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)

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

5. 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 – crucial factor Phase II May 1943-1945 –Crisis April-May 1943 -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

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

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

9. Battle of Atlantic Turning Point; April-June 1943 MonthsMerchant Tonnage Sunk 000s Subsunk Air Subsunk sea Subsunk total March5157412 April2428615 May199181240 June229617 Oct-Dec47 ships--53 Churchill W

10. 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

11. NYPD: Jack Maple’s Law, 1993-96 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)

12. Changes in a Time Trend: The “Tipping Point” Organization Monitoring Funding Concentration of forces Training Technology Experience Innovation Adaptation

13. Cardiovascular Disease Mortality Rates, United States, 1900-99

14. 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

16. Health Resources Resources are limited and must be used wisely Political, public, media expectations and support Manpower and training Money and how it is allocated Facilities for in-patient care – acute and ambulatory Home care and Long Term Care Community care – clinics, outreach, Education, motivation Drugs Vaccines Education

17. 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

18. Infant Mortality, United States, 1900-1999

19. Maternal Mortality, United States, 1900-99

20. 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

21. 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

22. AIDS Incidence, Deaths and Prevalence, United States 1981-2000

23. 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

24. 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

25. 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 – Good trauma care in hospital –Good hospital care and training Tertiary prevention –Good rehabilitation care

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

27. Summary Define the problem, and objectives Program Approach - strategy and tactics Intervention program – multi layered planning Budget and resources Intersectoral 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 Reevaluate, revise and adapt Communicate what you are doing