The Legal Landscape for People Living with Chronic Hepatitis B in Australia: : A Consensus-Based View of Priority Justiciable Issues from Sector Leaders.

The emerging field of public health ethics

Advancing the Science of Delivery

Despite widespread acceptance that public health decisions should be based on evidence the reality is that the use of research evidence in public health policy and practice has been low. Studies investigating the factors that act to limit the implementation of research evidence in public health practice often point to the gap between the research and its use in practice. This gap is thought be a function of the availability and quality of the evidence, individual and organisational capabilities and the context in which it is interpreted. The direct transfer of research evidence in the public health domain is complicated by uncertainty about the effectiveness of interventions when transferring what works in one community to another; problems of attributing causal mechanisms when it is known that other policy decisions also impact on health outcomes and the long time delays before the results of a public health intervention can be observed. In addition public health decision making is subject to other factors such as political influences, financial and resources constraints, public pressure and the views of the community. This thesis used Actor Network Theory (ANT) as a framework to determine how the use of evidence by public health organisations was influenced by the quality of the evidence itself and by contextual factors identified by ANT. Six case studies covering a number of public health issues; climate change, tobacco control, syndromic surveillance for outbreak detection, health needs assessments and health literacy, were used in the analysis. ANT revealed the mechanism by which many of the barriers previously identified in the literature impacted on the translation of evidence into public health policy and practice. The model showed the role that external factors such as the media and public opinion play in the decision making process. It also showed how competing networks, such as lobby groups, can act to influence policy decisions. The quality of the evidence was pivotal in mobilising the policy idea in these case studies; where it was weak or surrounded by considerable uncertainty the policy ideas did not garner support. Finally ANT was able to demonstrate how features of the organisation may impact on the use of evidence in public health practice and how the forging of alliances may provide a mechanism to overcome these limitations. The ANT framework has assisted our understanding of how research evidence is translated into policy and practice. This knowledge should improve the translation process, lead to greater use of evidence in public health practice and ultimately to more robust public health interventions.

In the fields of public health policy and public health care, advanced educational programs are an important strategy in dealing with public health crises. The COVID-19 pandemic has exposed the global need for skilled public health leaders and managers to address complex public health challenges, which requires the strengthening of public health education at the highest levels. This paper is a qualitative case study of a special educational program for doctors of public health in China. The program's educational objectives are in line with epidemic prevention and control. With the goal of developing the world's leading national public health management system, the Chinese government established an advanced academic program for public health crisis management. The program offers doctoral students a multidisciplinary degree based upon the theoretical knowledge of crisis management, supported by advanced training in the foundational concepts, theories, and practices of public health, and the study of basic medicine which provides the theoretical support for developing essential clinical skills. Program graduates develop the theoretical, practical, and leadership-related capabilities required for the management of national emergencies. The program introduced in this paper meets current epidemic prevention and control needs and should be considered by public health policy makers, leaders, and scholars in the discussion of advanced public health policy and health care education in China, including the development of an internationally recognized Doctor of Public Health program.

The use of information to guide public health practice extends back to John Graunt’s pioneering work in the 17th century. It has been only in the past 2 decades that dramatic advances in information technology, including the nearly universal access to computers, the immediacy of instantaneous global communications, and the capacity to manage vast amounts of information have brought new and powerful tools to the desks (and the airborne tray-tables) of the public health practitioner and managers. Advances have enabled major information systems to share information. Today, the management of electronic information now underlies nearly all aspects of public health practice, research, and policy development. A basic understanding of how the major information systems work is essential. Those who are unable to maneuver in the world of information and information technology become marginalized. The Institute of Medicines (IOM) 2002 report, The Future of the Public’s Health, declares the “emphasis on communication as a critical core competency of public health practice.” The companion IOM report, Who Will Keep the Public Healthy? Education of Public Health Professionals for the 21st Century, calls for informatics as a core area in graduate-level public health education. The present book is most timely. It builds on a prior initiative, duly cited in the book. In 1995, the Centers for Disease Control and Prevention and the University of Washington School of Public Health developed training materials in public health informatics, then a new field. This book is very much grounded in the specifics of the disciplines unique to public health, starting with its core functions, and admirably fills an important niche that is not otherwise addressed, such as the literature on medical informatics. Public health informatics is defined in the opening chapter as “the systematic application of information and computer science and technology to public health practice, research and learning.” The book is organized into five parts: The Context for Public Health Informatics; The Science of Public Health Informatics; Key Public Health Information Systems; New Challenges, Emerging Systems; and Case Studies: Applications of Information Systems Development. Examples of covered topics include the historical roots of public health informatics, the public health framework, the legislative context, information systems in the contexts of organization, systems management, program development, critical competency areas, data standards, privacy, confidentiality, and ethics. Also included are descriptions of the major data systems presently in use as well as newly emerging applications in such areas as surveillance, registries, networking, and international health. Sixty authors have contributed to the book’s 34 well-referenced chapters. The editors have done a creditable job in smoothing differences in writing styles and in providing coherence, flow, and internal crossreferences, which keeps repetitions to an acceptable level. Most chapters move into their subject matter deliberately, so that the material becomes readily accessible for the informatics novice. The formatting is excellent, with clear section and subsection headings that allow for self-pacing through areas of greater or lesser interest. People already comfortable in the world of informatics will be able to move quickly across the breadth of topics to areas of specific interest. The book serves best as an overall introduction and orientation to the field for the student or those in careers who feel overtaken, bewildered, or intimidated by the explosion of information technology. The presentation is not at all technical. Rather, the book lays out the conceptual breadth of the field, showing how the pieces fit together and are used across the many aspects of public health. Readers new to informatics will find elements that are familiar, and will learn how these fit in a broader context of basic concepts, components of a system, issues, opportunities, and limitations. Hoping to be of benefit in the classroom, each chapter starts with a brief list of learning objectives and closes with questions for review. (The publisher provides a separate instructor’s manual, retrievable in portable document format [pdf] online.) While well indexed, the book does not work particularly well as an off-the-shelf reference. This is an important book that can serve a wide audience, including public health practitioners and managers as well as students and teachers. Even the experienced information technologist will benefit from its clear framing of issues around the principles of public health and the contexts of public health practice.

In Denmark, Norway and Sweden, the municipal and regional administrative levels are in charge of implementing public health policies and measures on behalf of the state. In fact, both in Denmark (Waldorff, 2010; Vrangbaek and Sorensen, 2013) and in Norway (Report to the Storting no. 47, 2008–2009; Rommetveit et al., 2014; Torjesen and Vabo, 2014), recent reforms have emphasized the role of the municipalities in carrying out public health policies. In this chapter, we investigate the challenges of managing organizational change processes, in order to create changes in practices within the field of public health in the case of Norway. We study the relationship between changes in national policies and legislation and implementation at the municipal level. Our main question concerns how national public health policies are put into local practice. To answer this, we need to (1) investigate which ideas about the government of public health are articulated in national policies, (2) study how these policies are received and acted upon locally and (3) explain local choices regarding public health practices. Furthermore, in this chapter we present a theoretical framework focusing on major ideas on public health management and on the relation between ideas and practice in a neo-institutional perspective. This is followed by a brief presentation of the material and methods, as well as an explanation on how the empirical data are analysed. Then the analysis of the empirical data is presented, concluding the chapter with a discussion.

At the UN Millennium Summit in September 2000, the 191 Member States of the UN reaffirmed commitments to work towards a world in which elimination of poverty and sustainable development are the highest priorities. Governments, health development agencies, nongovernmental agencies and WHO are committed to an unprecedented global effort to work towards the health-related Millennium Development Goals (MDGs) as their corporate mandates. Although significant progress has been made for most of the goals, the most recent evaluation indicates uneven achievements within and across countries.1 It is apparent that some countries in south Asia and sub-Saharan Africa need to channel special efforts through multisectoral actions to achieve maternal and HIV/AIDS mortality, and underweight targets. Poor health taxes productivity and undermines poverty reduction efforts. Given the MDG stakes, international evidence indicates that low-cost, effective interventions do exist2 but countries in south Asia and sub-Saharan Africa have failed to scale up these interventions to address the significant burden of diseases. Failure to scale up cost-effective interventions is the result of fragile health system capacity, lack of political commitment and weak public health capacity. Public health education and competency at various levels are needed to translate evidence into policy, and to implement and evaluate programmes.3 In addition to the public health aspects of the MDGs, the emergence of new infectious diseases, and multidrug and extensive drug resistance pose serious demands for scaling up surveillance as a key public health competency,4,5 especially in the light of avian influenza threat and implementation of the International Health Regulations (2005). The countries around the Asia Pacific rim are perceived as the potential epicentre of future influenza pandemics. A review of public health education in the WHO South-East Asia Region6 in 2005 showed mixed results. Despite the existence of several postgraduate courses in India, Indonesia and Thailand, and undergraduate courses in other countries, there is a great variation in institutes and courses offered in the region. Challenges include quality assurance, teaching standards and faculty members’ competency in practical field experience, especially in public health management and outbreak control. The absence of policy-relevant research or publication of staff in public health faculties indicates the weakness of public health education and its dissociation with real-life public health policies and practices.7 At a political level, it is doubtful that those in senior policy-making positions are competent in public health. Yet these are leaders who will play a vital role in stewardship of health systems and in translating evidence into policy and programme implementation. However, there are some positive developments in this bleak situation. In Australia, public health competencies are fostered by on-the-job in-service training, context-specific continuing education programmes and short courses, distance and self-directed learning packages, and postgraduate university-level courses.8 Experience of Field Epidemiology Training Programmes (FETPs) is worth mentioning. By 2007, 34 countries had established FETP programmes. FETP in Thailand,9 established in 1980, has applied the concept of “linking education and practice” in its programme which has recently developed into a training course for other countries in the region. Trainees spend 25% of their time in the classroom and 75% in the field and “learning by doing”. For example, they conduct outbreak investigation and control. They have become the backbone of epidemiological surveillance and broader public health responses in Thailand. The programme was a key player in the Ministry of Public Health in response to both the outbreak of SARS in 2003 and to AIDS epidemics. More recently, FETP trainees and graduates were able to detect several new avian influenza cases through the review of clinical signs and symptoms, which were subsequently confirmed by reference laboratories. In response to avian influenza threats, the programme played a vital role in coordinating 1070 surveillance and rapid response teams nationwide, which was triple the number of national and international trainees. Public health education that is irrelevant to national health priorities and divorced from public health practice is useless and constitutes a lost opportunity. Given the MDG stakes, challenges of re-emerging infectious diseases and the increasing complexity of chronic non-communicable diseases, it is the right time to revisit public health education. A regional network such as the South-East Asia Public Health Initiative can serve as a platform for public health education reform.6 ■

The term public health is well known. However, there are many meanings and competing ideas about what public health practice, public health policies and public health services are, should be or could be. There are different understandings of public health's main concepts (e.g., health protection and health promotion), diverse underlying basic normative assumptions (e.g., regarding paternalism or justice), and competing views on how public health policies should be developed (e.g., through top down or deliberative/participatory approaches).Different theories and ideologies frame the debate. They refer to the value of privacy and spheres of personal decision-making, the image of human beings as social or political animals, and the role of the liberal-democratic state. Those theories also reflect different historical developments and institutionalized experiences underlying differences in “political cultures” and related understandings of “public”, and consequently, of “public health”. However, we as a “public health community” do not often reflect on the different understandings of “public” in “public health”. E.g., what is the meaning of “public” and what is “public” about public health services? The need to make and evaluate COVID-19 public health policies and practices underlines the necessity for an ongoing reflection to identify good answers. Against this background, the workshop addresses the following questions: What different kinds of understanding of key concepts of “public health” - including the concept of “public” itself - underlie different kinds of interventions, measures and policies to tackle the ongoing public health emergency / the Covid 19 pandemic? What are the ethical lessons from the pandemic and implications for public health policies and activities? The roundtable workshop will start with a key contribution by John Coggon (Chair in Law and Director of Centre for law and Society, University of Bristol), reflecting some core messages of his seminal book “What Makes Health Public?” and recent research on the issue in the light of COVID-19-policies. Together with three further panelists key messages and reflections will be discussed from the different disciplines of political science, ethics, social science and policy / practitioner perspectives, drawing out implications for policy, research and practice. This will be followed by reflections and discussion with the workshop participants and their reflections and insights on these critical questions.Speakers/Panelists John Coggon University of Bristol, Bristol, UK Kai Michelsen Fulda University of Applied Sciences, Fulda, Germany Peter Schröder-Bäck University of Applied Sciences for Police and Public Administration in North Rhine-Westphalia, Aachen, Germany Sadie Regmi Public Health Registrar, University College London, London, UK Key messages In theory, different conceptions of the normativity of the key term “public” lay different foundations for the role of the state and the scope of the policies initialised to advance PH aims.In practice, PH policies are strongly driven by political and economic interests of “the ruling classes”, but modified by civil society and institutionalised historical experiences.

Effectively leading people engaged in the practice of public health has never been more critical than in the early years of the twenty-first century. Likewise, effectively managing the organizations in which these individuals practice the various professional disciplines of public health has become increasing important and difficult. Taken together, leading the people and managing public health organizations requires well educated and appropriately trained public health leaders and managers. Although leadership is often viewed as one of the key attributes of management, not every great manager will be a great leader and vice versa. While some leaders may be born with the inherent skills to lead, most effective leaders develop the requisite skills through education, additional training, and practice. Our aim is to focus the attention of public health practitioners on the importance of effectively leading public health organizations. Public health managers should recognize that their most valuable resource is the people they lead. The articles comprising the eBook on Leading People – Managing Organizations is composed of articles expressing the opinion of their authors of the need for effective public health leaders; perspective articles establishing their authors’ understanding of how leadership may be applied in various situations; methods articles that demonstrate how public health leadership may be applied, and original research articles that establish the role of public health leadership research studies.

<h3>Background</h3> Progress in the use of secondary data to inform public health practice and healthy public policy has been inconsistent and slow, despite its promise for understanding the social, political, environmental, and economic determinants of health. This is especially pertinent in the context of whole-systems approaches to public health, yet little is known about the perspectives of decision-makers across the public health system on secondary data sharing and linkage. <h3>Methods</h3> We undertook three sequential stakeholder workshops with participants from local and central government, NHS public health teams, Health &amp; Social Care Partnerships, the third sector, organisations with a remit for supporting data-intensive research, and public representatives. The workshops were informed by a scoping review on use of evidence – and particularly secondary data – in public health policy and practice, searching Medline, Scopus, SSCI, and key institutional websites, and by three case studies of existing cross-sectoral linkage projects. Findings were synthesised using thematic analysis. We focused on the use of public and third sector data by organisations in those sectors, given additional complexities associated with the use of data by, or from, commercial entities. <h3>Results</h3> The scoping review (61 included studies) highlighted that evidence serves diverse purposes in public health policy and practice and may be understood in different ways. It identified a range of barriers and facilitators to the use of evidence derived from secondary data in decision-making, which were used to guide workshop discussion around the case studies and the shaping of recommendations. From the workshop discussions with 19 participants, we identified a set of six guiding principles for cross-sectoral data sharing and linkage, and a series of specific practical actions. The guiding principles proposed that cross-sectoral data sharing and linkage should be pragmatic; participatory; ambitious; fair; iterative; with holistic and proportionate governance. The practical actions included a strategic approach to identifying and sharing key datasets; streamlining governance processes (e.g., through standardised data sharing agreements; central data repositories; and a focus on re-usable data resources) and building workforce capacity. To make these possible, participants identified a need for strong political and organisational leadership as well as a transparent and inclusive public conversation. <h3>Conclusion</h3> Stakeholders from healthy public policy and practice support greater use of cross-sectoral data sharing and linkage to inform decision-making. Our findings provide a practical set of actions that together can be used to address current barriers and constraints, and realise this potential.

The ethical obligations of those who work for health are as old as the health professions themselves; indeed, the commitment to place the interests of clients above all else is one of the hallmarks of professionalism. Ethical prescriptions are found in many cultures, such as the oath and associated writings of Hippocrates in ancient Greece and the writings of the medieval Jewish philosopher Maimonides. Though originating with the professions, ethical duties are of concern to society in general, and their violation – as by the doctors who conducted experiments in the Nazi prison camps – can constitute human rights as well as ethical violations. In response to the tremendous expansion of the powers of medicine and biomedical science in the 20th century, the new field of bioethics emerged in the 1960s, first in North America and western Europe and eventually around the world. With contributions not only from moral philosophers but also from physicians, nurses and other health professionals, social and natural scientists and lawyers, bioethics has become a field of major concern. Health professionals, health authorities and the public debate the issues raised by organ and tissue transplantation, unequal access to life-saving medicines, new reproductive technologies and vast increases in the numbers and types of clinical trials. While abundant analysis and official guidelines have been produced on most of the ethical issues in health care and research, until recently the field of public health received relatively little attention among ethicists. Similarly, while ethical questions have always been an implicit part of public health practice, the idea of incorporating a formal process of ethical deliberation into public health policy-making remains relatively new. As the ethics of public health receives greater attention, new paradigms and methods of ethical analysis will have to be developed. In particular, whereas medical ethics has traditionally aimed to protect individual interests in the context of the physician–patient relationship, public health ethics focuses on the design and implementation of measures to monitor and improve the health of broader populations. In addition, public health ethics must look beyond health care per se to consider the structural conditions, and social and economic determinants that promote or inhibit the development of healthy societies. Incorporating ethical analysis into public health raises many challenging questions. For example, what does ethical analysis add to public health beyond legal or public policy analysis? Is the law itself subject to a process of ongoing ethical scrutiny? When ethicists appeal to “values”, who gets to decide which values are worthy of protection or how these values should be prioritized in cases of conflict? How should ethical analysis address the tension between universal principles and culturally specific values, and find common ground among individuals from diverse cultural backgrounds? Such questions have practical implications for how public health policies are designed, implemented and evaluated. For example, when public health authorities make decisions about allocating limited resources, they will implicitly or explicitly determine which principles and values underlie those decisions. Such decisions also vary according to the processes by which they are made and to what extent the public, nongovernmental and international organizations, and national or regional governments participate in these processes. A Bulletin theme issue, to be published in August 2008, will provide a forum for examining these and related issues. The goal of this theme issue is to explore how ethical considerations have been and should be incorporated into decision-making about public health issues. The Bulletin encourages the submission of papers covering practical examples that illustrate how ethical questions have been addressed at the domestic and international levels. For example, how have governments or professional associations used ethical analysis to evaluate health-care workers’ obligations during influenza pandemics? What does ethics have to say about the use of financial incentives to increase the supply of organs for transplantation? In general, we seek to publish specific examples of structures and processes that have been used for ethical deliberation, combined with a candid examination of these options’ advantages and drawbacks. Contributions from authors from developing countries are particularly welcome. It is hoped that the papers in this issue will help national policy-makers reflect on the need to consider ethics in formulating and implementing health policies, while also providing best practices that can be adapted to specific national contexts. The issue will provide a forum for units at WHO headquarters and regional offices that have engaged in ethical analysis of their programmes to share their work. Finally, the empirical basis of the papers will provide much-needed data about global efforts to address ethical issues and the impact these efforts are having on the health of populations. The deadline for submissions is 11 January 2008. All submissions will go through the Bulletin’s peer review process. ■

Essential to achievement of the public health mission is a knowledgeable, competent, and prepared workforce; yet, there is little application of science and technical knowledge to ensuring the effectiveness of that workforce, be it governmental or private. In this article, I review the evidence for effective workforce development and argue for an increased emphasis on an evidence-based approach to ensuring an effective workforce by encouraging the generation of the evidence base that is required. To achieve this, I propose the appointment of an independent Task Force on Public Health Workforce Practice to oversee the development of a Guide for Public Health Workforce Research and Practice (Workforce Guide), a process that will generate and bring together the workforce evidence base for use by public health practitioners.

Good Governance and effective management are critical to the performance of health systems and of public health programs. Public health governance and management have to be understood as a whole to appreciate the rich, dynamic interactions and complexities that characterize it. A systems framework provides a theoretical basis for studying and understanding the complex mechanisms and processes of public health governance and is used for the structure of the discussion. Public health governance can be conceived as a complex system of the interactions of the institutions of the state, private-for -profit sector and civil society in collectively seeking to assure the conditions under which populations can live with the highest possible level of health and wellbeing. These three entities are the horizontal components or systems in this framework, each having distinct structures, institutions, organizations, instruments and tools of influence, and mechanisms and processes for interactions within and between components. The interactions and interdependencies of these three entities and how they inter-digitate in a second hierarchical dimension of either the national or supranational levels is described. The organizational context of governance within the three component entities is a third dimension of the system framework. The second part of the chapter discusses how good effective management in public health organizations is critical for success in developing and implementing strategies and programs to improve the health of populations and the key characteristics that create the context in which the governance and management in public health organizations should be considered. Management and governance are integral aspects of organizations and need to be understood as interdependent and interrelated components in the continuum of systems and processes of organizations. Management science is applied in the management of 'Public health organizations', the management of the health governance function in 'Public health management' and in the 'Program management in public health'.

Has traditional medicine had its day? The need to redefine academic medicine

Studies on the epidemiology of hepatitis B and C virus infections are still needed