1. Strategic Planning In Public Health: A Program Approach TH Tulchinsky MD MPH Braun School of Public Health Hebrew University-Hadassah, Jerusalem October 2003

2. Strategy A set of essential measures (preventive and therapeutic) believed sufficient to control a health problem ( Last J. Dictionary of Epidemiology, 3rd edition, 2000 ) A program or series of measures, stratagems and activities planned and carried out for the purpose of achieving specific objectives ( Webtser Dictionary )

3. 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.

4. How to Fight and Win Who is the enemy? What are the enemy’s objectives? What are our objectives? What are their resources/capabilities? 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

5. 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 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

10. Jack Maple’s Law, NYPD 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)

11. MVA Mortality and Mileage, United States, 1925-1997 Vehicle Miles Traveled Deaths

12. Cardiovascular Disease Mortality Rates, United States, 1900-1999

13. 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

14. Determinants of Population Health Health Services Income & Social Status Social Support Networks Education Employment & working conditions Physical environments Biology & genetic endowment Personal health practices & coping skills Healthy child development

15. 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

16. 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

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, 1900-1999

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 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 Deaths AIDS Prevalence 1993 Definition Implementation

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

26. Summary Define the problem Adopt program approach Develop an intervention program and budget Inter-sectoral cooperation 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