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 18th 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 19th C war is continuation of
policy by other means – complete victory
• Alfred Mahan – influence of sea power on history
• Liddel Hart 1920s ‫ד‬direct 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
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Who (or what) is the enemy?
What are the enemy’s 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 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
“The Uboat 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 the Atlantic, 1939-45:
Shipsunk vs. Subsunk
1200
1000
800
S h ip s u n k
600
Subs unk
400
200
0
1
2
3
4
5
6
7
Battle of Atlantic Turning Point;
April-June 1943
Months
Merchant
Tonnage
Sunk
000s
Subsunk
Air
Subsunk
sea
Subsunk
total
March
515
7
4
12
April
242
8
6
15
May
199
18
12
40
June
22
9
6
17
47 ships
-
-
53
Oct-Dec
Churchill W
Perspective
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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 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)
MVA Mortality and Mileage, United
States, 1925-1997
Cardiovascular Disease Mortality Rates,
United States, 1900-1999
Expanded Host-Agent-Environment
Paradigm
• Host - genetic, nutritional, life style, personality,
psychosocial and other factors
• Agent - microbiologic, toxic, stress, work,
nutrient excess or deficiency
• Environment – vector, physical-societal context
• Intervention - clinical, preventive, environment
Host
Agent
Environment
Host
Environment
Agent
Intervention
Determinants of Population Health
Income &
Social
Status
Social Support
Networks
Employment &
working
conditions
Physical
environment
s
Personal health
practices & coping
skills
Healthy
child
development
Education
Biology &
genetic
endowment
Health Services
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)
A Comprehensive Health Services
Continuum: Manitoba
Promotion
Healthy Public
Policy
Prevention
Promotion
Protection
Community
Oriented
Services
Palliation
Hospitals
Support
Services
To
Seniors
Community
Health
Centres
Home Care
Outpatient
Rural
Urban
Ambulatory
Community Community
Care
Extended
Treatment &
Long Term Care
Tertiary
Palliation
Rehabilitation
Health Resources
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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
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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, 1900-1999
Maternal Mortality, United States,
1900-1999
Communicable Disease Control
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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 1981-2000
Safe Community Water Supplies
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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
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Comprehensive planning
Strategic goals
Specific targets
Operational planning
Steering group
Implementation team
Training, resources
Monitoring of input, process and outcomes
Summary
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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