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Editorial: Developing the Public Health Workforce in Europe: Association of Schools of Public Health in the European Region (ASPHER)

The population health situation in Europe is one of the substantial cross-country variation. Low and slowly developing gross national products, widespread poverty, and substantial exposure to well-known health risks (such as smoking, excessive alcohol consumption, malnutrition, unemployment, environmental exposures, including also poor basic hygiene) characterise large parts of European populations. The interaction between poverty and its consequences in terms of poor health form a vicious circle, leading to more poverty and more ill health. This has resulted in short life expectancy and short healthy life expectancy, high infant mortality, and, in adult life, in high incidences of "classic" chronic diseases, that constitute central elements of the disease pattern in Eastern and Central Europe as well as in Western Europe. Examples include ischemic cardiovascular disease, cancer, and mental disease, especially alcoholism, depression, and suicide. The populations of Europe are further threatened by new increases in chronic diseases, including the upcoming obesity epidemic with its consequences: hypertension, ischemic heart disease, and diabetes mellitus. Infectious pandemics such as SARS are also examples.

If we want to avoid the likelihood of these new and old threats to millions of people's health running their own "natural" course, we will need target-oriented policies and strategies. These will need adequate resources, including scientific research and sufficient numbers of trained Public Health professionals who can identify, forecast, and handle the threats in timely manner, using up-to-date, scientifically based methods.

Until now, health systems have been attuned to tackling population needs by caring for ill persons using medical and nursing care, demanding large numbers of medical staff. Accordingly, most resources are spent on hospital services and fewer than 5–10% of resources on disease prevention and health promotion – despite the fact that major increases in life expectancy can be ascribed to changes in exposure to causes of disease. Curative interventions play more limited and less certain roles. Cure is not a relevant overall means to address the challenges of most diseases caused by tobacco smoking, or to handle the obesity epidemic. Prevention and health promotion, when understood in their broadest sense, are crucial to success.

To assure that health services address population needs more effectively, intervention strategies will need to be professionally planned, implemented, financed, managed, and evaluated. We have a huge need for training of students to become high-quality, scientifically based Public Health professionals, so that they can develop, operate, and evaluate Public Health strategies. Accordingly, major disciplines in scientific, professional Public Health training curricula must include:

• methods, including epidemiology, statistics, and qualitative methods;
• health policy; health strategy development and evaluation; management;
• organisation and health economics;
• physical, chemical and biological environment, and health;
• social and psychological environment, and health;
• methods for health promotion and disease prevention;
• cross-disciplinary themes, including ethics;

– all with a scientific base in order to be able to reach at the desired results.

I am sad to report that the number of Public Health professionals is extremely low – actually very close to zero in most European countries. Especially in the last half of the 20th century an increase has resulted from establishment of Schools of Public Health in many European countries. Recently WHO Europe addressed the shortage of personnel in the diagnostic, curative, and caring professions across Europe. But the shortage of personnel with professional Public Health backgrounds needs serious attention now. That is, we need to concentrate greater emphasis on sufficiently long-term, formalised training in the planning, organisation, management, evaluation and economic assessment of health promotion and disease prevention.

For more than 40 years, the ASPHER has been occupied with the development of programmes for the training of Public Health professionals. At present, ASPHER includes 75 Schools of Public Health in 34 European countries. ASPHER's core mission is to:

• assist schools and university departments of Public Health to achieve their missions of professional and graduate education, research, and service;
• build coalitions with other programmes and public health organisations to increase public awareness, appreciation, and support of Public Health.

To fulfil its mission, ASPHER has a series of programmes, including:

• evaluation and development of the quality of Public Health training programmes;
• accreditation of Public Health training programmes;
• development of lists of competencies achieved in Public Health training;
• organising and coordinating the European Master of Public Health;
• summer schools in Public Health;
• collaboration with international organisations – like WHO, EU, EUPHA, EHMA – and with sister organisations in other parts of the world.

ASPHER seeks to motivate Public health stakeholders, among them Ministries of Health, to establish and increase training of Public Health professionals. Mutual communication is, of course, of fundamental importance. Thus, at present, ASPHER organises – together with a Public Health stakeholder, the Central Denmark Region – a European conference on the development of lists of core competencies needed in Public Heath training in order to meet population health challenges and those related to the future development of health systems. European Ministries of Health, international organisations, and sister organisations will be invited to participate to contribute with stakeholders' views on components in Public Health training necessary to the meet challenges, both short and long term.

Alliances are needed among many – including Public Health stakeholders, international organisations (including WHO and EU DG SANCO), the association for Public Health training, ASPHER, and Public Health scientists and practitioners. Let us hope for strongly intensified communication and collaboration.

Contact:

Professor Anders Foldspang, M.D., Ph.D., D.M.Sc.

ASPHER Past President

Head, Department of Health Services Research

Institute of Public Health

Faculty of Health Sciences

Aarhus University, Building 1264

Vennelyst Boulevard

DK-8000 Aarhus C, Denmark

Phone: +45 89 42 31 81 (stat.)

Phone: +45 21 25 45 69 (mobile)

E-mail: af@mph.au.dk

Homepage: www.mph.au.dk

ASPHER: www.aspher.org

Special Reports

The 57th Session of the WHO Regional Committee for Europe Belgrade, Serbia, 17–21 September 2007

The 57th session with 53 member states in attendance was chaired by Professor T. Milosavljevic, Minister of Health of Serbia, and addressed by the Regional Director Mark Danzon. Later the new Director-General of WHO, Dr. Margaret Chan, highlighted key issues of global health development. She observed that some of the so-called luxury items, like obesity or health needs of the elderly in this century, have become global problems, saying "More and more, health problems all around the world are being shaped by the same powerful forces". The Millennium Development Goals (MDGs) are an important step but progress is too slow and unequal: "Europe has areas and subgroups where mortality rates for mothers and babies are just as serious as those in sub-Saharan Africa or southern Asia". Therefore, country averages are not suitable for the measurement of the MDGs. The universal and regional shortage of appropriately trained, motivated, and skilled health workers has to be addressed together with the consequences of a globalised labour market. She added that "Good health contributes to stability, and is a foundation for prosperity". Dr. Chan defined three fronts around the world where public health is engaged: (1) we struggle against the constantly changing microbial world; (2) we struggle to change human behaviours; and (3) we struggle for attention and resources. She also underlined European leadership in these struggles at various moments, and referred to the high expectations towards Europe in other parts of the world.

A concept of regional cooperation has been stressed repeatedly. The European Stability Pact for the region of Southeastern Europe (the successor states of former Yugoslavia, Albania, Bulgaria, Romania, and Moldova) has been proposed as a role model (see e.g. www.who.int/euro or www.snz.hr/fph-see) for example, for the southern Caucasus. In this context, issues of cross-border collaboration in health care, including patient mobility, gained attention. A relatively new topic concerned the protection of intellectual property, the copyright of new drugs. It also relates to a problem of fake medicines sold via the Internet. Traditional problems like tuberculosis re-emerged on the agenda together with the ever-returning question on how to integrate most efficiently horizontal and vertical programmes.

The MDGs occurred as a crosscutting topic during the debates as their achievement depends on progress in health systems development, health outcomes, and wealth – economic development. Some countries including Sweden made a strong point that the MDGs cannot be reached without gender equality. Valid measurement of the MDG goals depends on improvements of the health information systems. For the time being, such improvements remain questionable in many countries, especially for administrative data. It was the president of the Association of Schools of Public Health in the European Region (ASPHER) who pointed to the essential role of training public health professionals as a backbone of health development (see the editorial just above in this issue).

Contact:

Professor Dr. med. Ulrich Laaser, DTM&H, MPH

Delegate of the World Federation of Public Health Associations (WFPHA)

Faculty of Health Sciences, University of Bielefeld, Germany

E-mail: Ulrich.laaser@uni-bielefeld.de