European Journal of Public Health, Vol. 25, No. 3, 361–362 ß The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckv007
.........................................................................................................
Editorials
.........................................................................................................
Towards a public health profession: the roles of essential public health operations and lists of competences Anders Foldspang Department of Public Health, Aarhus University, Aarhus, Denmark Correspondence: Anders Foldspang, Department of Public Health, Aarhus University, Aarhus, Denmark, e-mail: [email protected]
.........................................................................................................
Public health methods;
Population health and: Its social and economic determinants, and: Its material environmental determinants; Man-made interventions and systems, namely Health policy, health economics, organizational theory, health legislation, and public health leadership and management; Health promotion—health education, health protection, disease prevention; public health ethics. This should form the central part of the basis for all public health professionals. Moreover, linking EPHOs and competences does not only define the public health professional but will also constitute a sound basis for the planning of public health systems.2 Individual specialization can be further developed on this comprehensive basis—in epidemiology and statistics, health promotion and disease prevention, health economics and leadership, health sociology, ethics, etc.—unified under the comprehensive public health umbrella. This approach will contribute to the prevention of silo thinking and isolated, particularistic action. Conversely, just thinking in and engaging specialists or experts without the necessary comprehensive background will to a less marked extent have the potential to meet public health challenges adequately. It will leave decisions about what questions to pose to decision makers often without a public health background, when such decisions and the subsequent analyses should be made by public health professionals able to consider and analyse the coherent comprehensiveness of population health challenges. The public health discipline and movement has got the historical tradition as well as the prerequisites for forming a unified public health profession—a long-lasting educational and training legend, exceptional achievements, flourishing research—often up-hill and against the wind, actually. In each country, we should discuss the shaping of an authorized profession—and about what that means in concrete terms, including, for example, the development of agreed public health professional standards and ethical rules. Furthermore, the creation of national systems for authorisation as such depends on our ability to persuade the authorities to be willing to sustain that. Finally, the creation of an authorised profession will lead to visibility in national and international statistics. This cannot be over-estimated. Let’s bring our Babylonian voyage to an end now. Let’s unite. We have got the challenges, the responsibility—and the tools. Conflicts of interest: None declared.
References 1
Bjegovic-Mikanovic V, Czabanowska K, Flahault A, et al. Addressing needs in the public health workforce in Europe. Copenhagen: World Health Organization, Regional Office for Europe, Policy Summary 10, 2014.
Downloaded from http://eurpub.oxfordjournals.org/ by guest on April 13, 2016
oday, public health is characterized by an increasingly number of kingdoms with each their language and indispensable self-identity and sets of concepts. The numbers of partial educational programmes and vocations are high.1 So, who are we—and to whom shall then decision makers turn for advice? To traverse this question, it is necessary to acknowledge the two fundamental challenges, which European public health is up to in its own organization. The first challenge is the need for the creation and authorization of a public health professional as a central person in public health2—the focus of this editorial. The second challenge is the need to develop coherent and comprehensive national, regional and local public health organizational structures, able to shape the appropriate, costeffective framework for public health professionals and their staff. I will leave that for now. In my view, it is easy to prophecy that if these two challenges are not met, public health will continue to be weak and under-funded. Invisible in public statistics, as its workforce is now, public health will remain a just too easy target for opponents in the quest for resources. If so, the shaping of a unified and authorised profession thus should have high priority among public health workers and their societies, academies and associations—for example, EUPHA—and the WHO, as it is for the Association of Schools of Public Health in the European Region, ASPHER, whose institutional members are responsible for the graduation of future professionals. A bachelor or a master degree in comprehensive public health or, among medical doctors and nurses, a specialization in comprehensive public health, possibly including a MPH degree, seems to offer themselves as a straightforward basis for professional acknowledgement. In addition there will be seniors with a background in public health theory and practice, however not necessarily with formal public health education or training. In accordance with the composite nature of most population health challenges, the principle of comprehensiveness must be reflected in the theoretical as well as the practical potential of the public health professional. Thus, he and she must be able to perform, what WHO Europe has developed as Essential Public Health Operations (EPHOs).3 This, in turn, implies that the public health professional possesses the set of intellectual (knowledge) as well as practical (skills) competences stated in ASPHER’s comprehensive list of public health core competences.4 The lists have, since 2006, been developed with the participation of public health researchers, practitioners and decision makers and in conferences and workshops. In 2012, they were endorsed by WHO Europe’s member states as the basis for the public health education in Europe.5 The sections of the lists include:
TBabylonian
362 2
3
European Journal of Public Health
Foldspang A, Otok R, Czabanowska K, Bjegovic-Mikanovic V. Developing the Public Health Workforce in Europe: The European Public Health Reference Framework (EPHRF): It’s Council and Online Repository. Concepts and Policy Brief. Brussels: ASPHER, 2014. Available at: http://www.aspher.org/repository/index. php?get_action=open_file&repository_id=0&file=%2FASPHER%2FASPHER%20 Positions%2FEPHRF_Concept_and_Policy_Brief.pdf. Martin-Moreno JM. Self-Assessment Tool for the Evaluation of Essential Public Health
4
Birt C, Foldspang A. European Core Competences for Public Health professionals. ASPHER’s European Public Health Core Competences Programme. ASPHER Publication No. 5. Brussels: ASPHER, 2011. Available at: http://www.aspher.org/ repository/#2.
5
The European Action Plan for Strengthening Public Health Capacities and Services. Copenhagen: World Health Organization, Regional Office for Europe, 2012.
Operations in the WHO European Region. Copenhagen: World Health Organization, Regional Office for Europe, 2014.
......................................................................................................... European Journal of Public Health, Vol. 25, No. 3, 362–363 ß The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cku144
.........................................................................................................
Will European Reference Networks herald a new era of care for patients with rare and complex diseases? Natasha Azzopardi-Muscat1,2, Helmut Brand1
Correspondence: Natasha Azzopardi Muscat, Department of Health Services Management, Faculty of Health Sciences, University of Malta, Mater Dei Hospital, Tal-Qroqq Msida MSD2080, Malta. Tel: +356 234 018 40, Fax: +356 234 018 42, e-mail: [email protected]
......................................................................................................... he patients’ rights and cross-border care directive is widely seen
Tas the beginning of a new era for European action in health
services.1 While cross-border care only affects a small percentage of European Union citizens, an important section of the directive provides for a series of collaborative initiatives between Member States. It is this part of the directive that is likely to be highly influential in shaping the manner future health services across the European Union. One such initiative is the establishment of European Reference Networks (ERNs). Earlier this year, the decisions regulating the setting up and management of ERNs were adopted.2,3 These decisions serve to lay down the framework within which ERNs will operate. Much preparatory work has gone into the development of the framework, and there is a general expectation that ERNs will have to meet rigorous standards both to be initially approved as well as on an ongoing basis. European citizens aspire to have knowledge about where the ‘best’ care for their condition exists within the European Union and increasingly expect to access such care.4 In this sense, the establishment of ERNs appeals to a populist objective in terms of cross-border care. ERNs undoubtedly also appeal to health-care professionals involved in cutting-edge research and medical education and could place the European Union in a stronger leadership position in medical research.5 There remain, however, several issues that need to be addressed and challenges to be overcome to ensure that this important project actually achieves its potential impact throughout the European Union. ERNs are theoretically based on the literature surrounding volume, concentration of expertise and patient outcomes, albeit the fact that the literature does not illustrate a linear relationship between these parameters across all disciplines.6 One of the guiding principles for the ERN initiative is that ERNs should be established only where there is clear added value at European level. This assessment will vary depending on whose yardstick is used, as added value at European level is likely to be perceived differently by Member States depending on their population size and level of economic development. As the spirit of the directive is that of
enhancing cooperation between Member States, there should be sufficient flexibility and openness to allow networks to be formed where there is sufficient demand for them rather than engaging in protracted theoretical or political discussions on whether this will bring European added value. The setting up of ERNs is likely to continue to accentuate a concentration of centres within the larger and richer European Union Member States. While this is not unexpected, the actual setting up of ERNs should serve as a stimulus for centres that initially start out as ‘affiliated’ to the network to develop fully particularly if they can improve access to high-quality services for an underserved geographic region of the European Union. European structural and investment funds could be usefully applied to such developments. The concept of setting up networks of centres of reference is interesting partly also because it tends to go against the market concept of competition between centres of excellence to attract patients towards mutual collaboration and support. Another innovative perspective is that while in medical sciences, excellence has usually been clinically driven and emerged through a bottom-up approach, the development of ERNs as contemplated seems to be far more centrally driven than emergent. The sustainability of ERNs will also depend on the funding for these networks. This is possibly the most serious threat to the project, as there is presently no secure sustainable form of funding available at European level. The stringent budgetary frameworks being applied to health systems at national levels, partly due to pressure being applied through the European semester mechanism, indicate that Member States will find it difficult to spare funds for the maintenance of ERNs. The impact on equity and health inequalities is another issue meriting close attention. The mechanisms for reimbursement under the cross-border directive pose a barrier for access to care for the following reasons. There is a good possibility that the intervention/treatment sought from a centre of reference may not be provided in the Member State’s package of health-care services. Second, even if the Member State does agree to provide the authorization given the rarity or complexity of the patient’s
Downloaded from http://eurpub.oxfordjournals.org/ by guest on April 13, 2016
1 Department of International Health, Maastricht University, Faculty of Health, Medicine and Life Sciences, CAPHRI School of Public Health and Primary Care, The Netherlands 2 Department of Health Services Management, Faculty of Health Sciences, University of Malta, Msida, Malta
.........................................................................................................
Editorials
.........................................................................................................
Towards a public health profession: the roles of essential public health operations and lists of competences Anders Foldspang Department of Public Health, Aarhus University, Aarhus, Denmark Correspondence: Anders Foldspang, Department of Public Health, Aarhus University, Aarhus, Denmark, e-mail: [email protected]
.........................................................................................................
Public health methods;
Population health and: Its social and economic determinants, and: Its material environmental determinants; Man-made interventions and systems, namely Health policy, health economics, organizational theory, health legislation, and public health leadership and management; Health promotion—health education, health protection, disease prevention; public health ethics. This should form the central part of the basis for all public health professionals. Moreover, linking EPHOs and competences does not only define the public health professional but will also constitute a sound basis for the planning of public health systems.2 Individual specialization can be further developed on this comprehensive basis—in epidemiology and statistics, health promotion and disease prevention, health economics and leadership, health sociology, ethics, etc.—unified under the comprehensive public health umbrella. This approach will contribute to the prevention of silo thinking and isolated, particularistic action. Conversely, just thinking in and engaging specialists or experts without the necessary comprehensive background will to a less marked extent have the potential to meet public health challenges adequately. It will leave decisions about what questions to pose to decision makers often without a public health background, when such decisions and the subsequent analyses should be made by public health professionals able to consider and analyse the coherent comprehensiveness of population health challenges. The public health discipline and movement has got the historical tradition as well as the prerequisites for forming a unified public health profession—a long-lasting educational and training legend, exceptional achievements, flourishing research—often up-hill and against the wind, actually. In each country, we should discuss the shaping of an authorized profession—and about what that means in concrete terms, including, for example, the development of agreed public health professional standards and ethical rules. Furthermore, the creation of national systems for authorisation as such depends on our ability to persuade the authorities to be willing to sustain that. Finally, the creation of an authorised profession will lead to visibility in national and international statistics. This cannot be over-estimated. Let’s bring our Babylonian voyage to an end now. Let’s unite. We have got the challenges, the responsibility—and the tools. Conflicts of interest: None declared.
References 1
Bjegovic-Mikanovic V, Czabanowska K, Flahault A, et al. Addressing needs in the public health workforce in Europe. Copenhagen: World Health Organization, Regional Office for Europe, Policy Summary 10, 2014.
Downloaded from http://eurpub.oxfordjournals.org/ by guest on April 13, 2016
oday, public health is characterized by an increasingly number of kingdoms with each their language and indispensable self-identity and sets of concepts. The numbers of partial educational programmes and vocations are high.1 So, who are we—and to whom shall then decision makers turn for advice? To traverse this question, it is necessary to acknowledge the two fundamental challenges, which European public health is up to in its own organization. The first challenge is the need for the creation and authorization of a public health professional as a central person in public health2—the focus of this editorial. The second challenge is the need to develop coherent and comprehensive national, regional and local public health organizational structures, able to shape the appropriate, costeffective framework for public health professionals and their staff. I will leave that for now. In my view, it is easy to prophecy that if these two challenges are not met, public health will continue to be weak and under-funded. Invisible in public statistics, as its workforce is now, public health will remain a just too easy target for opponents in the quest for resources. If so, the shaping of a unified and authorised profession thus should have high priority among public health workers and their societies, academies and associations—for example, EUPHA—and the WHO, as it is for the Association of Schools of Public Health in the European Region, ASPHER, whose institutional members are responsible for the graduation of future professionals. A bachelor or a master degree in comprehensive public health or, among medical doctors and nurses, a specialization in comprehensive public health, possibly including a MPH degree, seems to offer themselves as a straightforward basis for professional acknowledgement. In addition there will be seniors with a background in public health theory and practice, however not necessarily with formal public health education or training. In accordance with the composite nature of most population health challenges, the principle of comprehensiveness must be reflected in the theoretical as well as the practical potential of the public health professional. Thus, he and she must be able to perform, what WHO Europe has developed as Essential Public Health Operations (EPHOs).3 This, in turn, implies that the public health professional possesses the set of intellectual (knowledge) as well as practical (skills) competences stated in ASPHER’s comprehensive list of public health core competences.4 The lists have, since 2006, been developed with the participation of public health researchers, practitioners and decision makers and in conferences and workshops. In 2012, they were endorsed by WHO Europe’s member states as the basis for the public health education in Europe.5 The sections of the lists include:
TBabylonian
362 2
3
European Journal of Public Health
Foldspang A, Otok R, Czabanowska K, Bjegovic-Mikanovic V. Developing the Public Health Workforce in Europe: The European Public Health Reference Framework (EPHRF): It’s Council and Online Repository. Concepts and Policy Brief. Brussels: ASPHER, 2014. Available at: http://www.aspher.org/repository/index. php?get_action=open_file&repository_id=0&file=%2FASPHER%2FASPHER%20 Positions%2FEPHRF_Concept_and_Policy_Brief.pdf. Martin-Moreno JM. Self-Assessment Tool for the Evaluation of Essential Public Health
4
Birt C, Foldspang A. European Core Competences for Public Health professionals. ASPHER’s European Public Health Core Competences Programme. ASPHER Publication No. 5. Brussels: ASPHER, 2011. Available at: http://www.aspher.org/ repository/#2.
5
The European Action Plan for Strengthening Public Health Capacities and Services. Copenhagen: World Health Organization, Regional Office for Europe, 2012.
Operations in the WHO European Region. Copenhagen: World Health Organization, Regional Office for Europe, 2014.
......................................................................................................... European Journal of Public Health, Vol. 25, No. 3, 362–363 ß The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cku144
.........................................................................................................
Will European Reference Networks herald a new era of care for patients with rare and complex diseases? Natasha Azzopardi-Muscat1,2, Helmut Brand1
Correspondence: Natasha Azzopardi Muscat, Department of Health Services Management, Faculty of Health Sciences, University of Malta, Mater Dei Hospital, Tal-Qroqq Msida MSD2080, Malta. Tel: +356 234 018 40, Fax: +356 234 018 42, e-mail: [email protected]
......................................................................................................... he patients’ rights and cross-border care directive is widely seen
Tas the beginning of a new era for European action in health
services.1 While cross-border care only affects a small percentage of European Union citizens, an important section of the directive provides for a series of collaborative initiatives between Member States. It is this part of the directive that is likely to be highly influential in shaping the manner future health services across the European Union. One such initiative is the establishment of European Reference Networks (ERNs). Earlier this year, the decisions regulating the setting up and management of ERNs were adopted.2,3 These decisions serve to lay down the framework within which ERNs will operate. Much preparatory work has gone into the development of the framework, and there is a general expectation that ERNs will have to meet rigorous standards both to be initially approved as well as on an ongoing basis. European citizens aspire to have knowledge about where the ‘best’ care for their condition exists within the European Union and increasingly expect to access such care.4 In this sense, the establishment of ERNs appeals to a populist objective in terms of cross-border care. ERNs undoubtedly also appeal to health-care professionals involved in cutting-edge research and medical education and could place the European Union in a stronger leadership position in medical research.5 There remain, however, several issues that need to be addressed and challenges to be overcome to ensure that this important project actually achieves its potential impact throughout the European Union. ERNs are theoretically based on the literature surrounding volume, concentration of expertise and patient outcomes, albeit the fact that the literature does not illustrate a linear relationship between these parameters across all disciplines.6 One of the guiding principles for the ERN initiative is that ERNs should be established only where there is clear added value at European level. This assessment will vary depending on whose yardstick is used, as added value at European level is likely to be perceived differently by Member States depending on their population size and level of economic development. As the spirit of the directive is that of
enhancing cooperation between Member States, there should be sufficient flexibility and openness to allow networks to be formed where there is sufficient demand for them rather than engaging in protracted theoretical or political discussions on whether this will bring European added value. The setting up of ERNs is likely to continue to accentuate a concentration of centres within the larger and richer European Union Member States. While this is not unexpected, the actual setting up of ERNs should serve as a stimulus for centres that initially start out as ‘affiliated’ to the network to develop fully particularly if they can improve access to high-quality services for an underserved geographic region of the European Union. European structural and investment funds could be usefully applied to such developments. The concept of setting up networks of centres of reference is interesting partly also because it tends to go against the market concept of competition between centres of excellence to attract patients towards mutual collaboration and support. Another innovative perspective is that while in medical sciences, excellence has usually been clinically driven and emerged through a bottom-up approach, the development of ERNs as contemplated seems to be far more centrally driven than emergent. The sustainability of ERNs will also depend on the funding for these networks. This is possibly the most serious threat to the project, as there is presently no secure sustainable form of funding available at European level. The stringent budgetary frameworks being applied to health systems at national levels, partly due to pressure being applied through the European semester mechanism, indicate that Member States will find it difficult to spare funds for the maintenance of ERNs. The impact on equity and health inequalities is another issue meriting close attention. The mechanisms for reimbursement under the cross-border directive pose a barrier for access to care for the following reasons. There is a good possibility that the intervention/treatment sought from a centre of reference may not be provided in the Member State’s package of health-care services. Second, even if the Member State does agree to provide the authorization given the rarity or complexity of the patient’s
Downloaded from http://eurpub.oxfordjournals.org/ by guest on April 13, 2016
1 Department of International Health, Maastricht University, Faculty of Health, Medicine and Life Sciences, CAPHRI School of Public Health and Primary Care, The Netherlands 2 Department of Health Services Management, Faculty of Health Sciences, University of Malta, Msida, Malta
