The Big Picture: Strategic Planning The Big Picture: Strategic Planning in Public Healthin Public Health

TH Tulchinsky MD MPHTH Tulchinsky MD MPHBraun School of Public HealthBraun School of Public Health

Hebrew University-Hadassah, JerusalemHebrew University-Hadassah, Jerusalem

Skopje, MacedoniaSkopje, Macedonia

25 Oct 201025 Oct 2010

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.

Game TheoryGame 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)

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

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

“The U-boat 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

B a ttle o f th e A tla n tic , 1 9 3 9 -4 5: S h ip su n k vs. S u b su n k

0

200

400

600

800

1000

1200

1 2 3 4 5 6 7

Shipsunk

Subsunk

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

Oct-Dec 47 ships - - 53

Churchill W

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

NYPD: Jack Maple’s Law, 1993-96NYPD: 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)

Changes in a Time Trend: The “Tipping Point”

• Organization• Monitoring• Funding• Concentration of forces• Training• Technology• Experience• Innovation• Adaptation

Cardiovascular Disease Mortality Rates, United States, 1900-99

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

HostHost

AgentAgent EnvironmentEnvironment

HostHost EnvironmentEnvironment

AgentAgent InterventionIntervention

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

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

Infant Mortality, United States, 1900-1999Infant Mortality, United States, 1900-1999

Maternal Mortality, United States, 1900-99

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

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, AIDS Incidence, Deaths and Prevalence,

United States 1981-2000United States 1981-2000

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

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– Good trauma care in hospital– Good hospital care and training

• Tertiary prevention– Good rehabilitation care

A Program Approach

• Comprehensive planning• Strategic goals• Specific targets• Operational planning• Steering group• Implementation team• Training, resources• Monitoring of input, process and outcomes

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