pdf proefschrift mjambroes

THE PUBLIC HEALTH WORKFORCE - AN ASSESSM

ENT IN THE NETHERLANDS

M

ARIELLE JAMBROES

THE PUBLIC HEALTH WORKFORCE AN ASSESSMENT IN THE NETHERLANDS

MARIELLE JAMBROES

UITNODIGINGvoor het bijwonen van de openbare verdediging van

het proefschrift

The public health workforce

An assessment in the Netherlands

door

Marielle Jambroes

[email protected]

op 10 december 2015 om 10:00 uur

in de Agnietenkapel te Amsterdam

Na afloop van de verdediging bent u van harte uitgenodigd voor de receptie ter plaatse

Paranimfen:Jelle Doosje

[email protected]

Anneke [email protected]

The public health workforce is a key resource of population health. How many people work in public health in the Netherlands, what are their characteristics and who does what? Remarkably, such information about the size and composition of the public health workforce in the Netherlands is lacking. A standardized system to collect these data is also unavailable.

This thesis introduces a new methodology to enumerate the public health workforce. By applying it to environmental public health and preventive youth health care, our insight in the quantity and quality of the current and future public health workforce in the Netherlands has increased.

The studies described in this thesis are among the first scientific studies into public health workforce enumeration in the Netherlands and the results contribute to an empirical base for public health workforce planning and development.

Stellingen behorende bij het proefschrift

The public health workforce; an assessment in the Netherlands

1. Het is onbekend hoeveel mensen er in Nederland in de publieke gezondheidszorg

werken, hoe zij zijn opgeleid en wat ze doen. (dit proefschrift)

2. De kerntaken van publieke gezondheidszorg vormen een goede basis om het

werkveld van de publieke gezondheidszorg te omschrijven, onafhankelijk van

professies of organisaties. (dit proefschrift)

3. Regionale verschillen in de capaciteit voor jeugdgezondheidszorg in Nederland

hangen niet samen met het aantal kinderen in een regio. (dit proefschrift)

4. Inzicht in de capaciteit voor de publieke gezondheidszorg is noodzakelijk

voor effectieve sturing op die capaciteit en daarmee voor de kwaliteit en

doelmatigheid van de publieke gezondheidszorg. (dit proefschrift)

5. Veranderingen in het concept van gezondheid kunnen aanleiding geven

tot veranderingen in de prioriteiten voor de publieke gezondheidszorg.

(dit proefschrift)

6. De koppeling van de financiering voor sociaal-geneeskundige opleidingen

aan de wet publieke gezondheid belemmert de opleiding van sociaal-

geneeskundige professionals op terreinen die niet in deze wet staan.

7. Als epidemiologische ontwikkelingen richtinggevend zijn voor de prioriteiten

in de publieke gezondheidszorg, moet preventieve zorg voor ouderen een

belangrijk onderdeel van de publieke gezondheidszorg worden.

8. Het opleiden van toekomstbestendige artsen vereist integratie van

sociale geneeskunde in de basisartsopleiding, de huisartsopleiding en in

medisch-specialistische vervolgopleidingen.

9. Meer fietsforensen is goed voor de volksgezondheid en de natuur.

10. You cannot escape the responsibility of tomorrow by evading it today. (Abraham

Lincoln)

Marielle Jambroes



Marielle Jambroes



ACADEMISCH PROEFSCHRIFT

ter verkrijging van de graad van doctor

aan de Universiteit van Amsterdam

op gezag van de Rector Magnificus

prof. dr. D.C. van de Boom

ten overstaan van een door het College voor Promoties ingestelde commissie,

in het openbaar te verdedigen in de Agnietenkapel

op donderdag 10 december 2015, te 10:00 uur

door

Marielle Jambroes

geboren te Amsterdam

© Marielle Jambroes, Amsterdam 2015

Layout: Tara Kinneging, Persoonlijk Proefschrift

Printed by: Ipskamp Drukkers, Enschede

Beeld: Mea Jambroes-ten Doesschate

Fotografie: Dinger Knoop

Copyright by Marielle Jambroes, Amsterdam, the Netherlands. All rights

reserved. No part of this publication may be reproduced, stored on a retrieval system, or

transmitted in any form or by any means, without permission of the author.

CONTENTS

1. General introduction 7

2. Enumeration of the public health workforce in the Netherlands;

insight in the size and composition is limited 21

3. What is public health? A definition and essential public health operations

in the Netherlands 37

4. How to characterize the public health workforce based on essential public

health operations? Environmental public health workers in the Netherlands

as an example 55

5. Enumerating the preventive youth health care workforce: size, composition

and regional variation in the Netherlands 75

6. Implications of health as ‘the ability to adapt and self-manage’ for public

health policy: a qualitative study 93

7. General discussion 109

Summary 129

Samenvatting 137

Dankwoord 147

About the author 151

Promotiecommissie

Promotores: Prof. dr. M.L. Essink-Bot Universiteit van Amsterdam

Prof. dr. K. Stronks Universiteit van Amsterdam

Overige leden: Dr. N. van Dijk Universiteit van Amsterdam

Prof. dr. N.S. Klazinga Universiteit van Amsterdam

Dr. W.J.M. Scholte op Reimer Hogeschool van Amsterdam

Prof. dr. S.A. Reijneveld Rijksuniversiteit Groningen

Prof. dr. D. Ruwaard Maastricht University

Faculteit der Geneeskunde

CHAPTER 1General Introduction

98

General IntroductionChapter 1

1

plan was a list with priority research topics. On top of that list was and still is ‘monitoring

the size and composition of the workforce’. In the USA, the CDC strategic plan has been

a driver for the growth of public health workforce research.

Insight in the public health workforce is also lacking in Europe. A study into the public

health capacity in the EU performed in 2010-2011 showed that a clearly distinguishable

workforce for public health has neither been defined nor formally established in the vast

majority of the EU Member States. (19) Because of the limited data on the availability

and distribution of the public health workforce in Europe, the World Health Organisation

Europe (WHO Europe) launched an action plan to strengthen public health capacities and

services in 2012. (20) Defining, assessing and strengthening the public health workforce

are among the key priority areas.

Both the US and WHO Europe documents stress that more research is needed to be

able to monitor the size and composition of the public health workforce. There are

still a number of unsolved issues that complicate this monitoring. The first is related

to the often indistinct boundaries of the public health sector. Public health, as part

of the health care sector, has many interlinks with the medical care workforce. Part

of the services delivered by medical care professionals in fact constitutes delivery of

public health services, for e example general practitioners executing the national

influenza vaccination program. Outside the health care sector, also sectors such as

the social welfare or the educational sector are involved in public health with social

workers and teachers providing health promotion or other public health services.

The multidisciplinary nature of the public health workforce constitutes again a factor

that complicates workforce enumeration. Due to the many factors influencing health

different professional disciplines are involved in public health. (19, 12, 21-23) Only for a

few disciplines, like physicians, dentists and sometimes nurses, compulsory professional

registers exist. Other disciplines, for example dieticians or health promotion specialists

do not have such registries.

Public health workforce enumeration

Previous efforts to enumerate the public health workforce were using existing data

sources. However, the limitations of using existing databases for public health workforce

enumeration are known and have been emphasized. (15, 24-26) For instance, different

job titles of public health professionals for the same kind of jobs are a drawback, and

not all job titles are accurately labelled as ‘public health’ in the different data sources.

(27) Also, registers use different definitions of public health workers, different disciplines

are often registered in different registries and not all disciplines or workplace settings

are represented in the databases. (28, 29) A recent study into the federal workforce at

the CDC combined the data of two different data sources to characterize the public

health workforce. An additional shortcoming of this method was that the existing data

sources do not contain demographic information or education and professional training

characteristics of the workforce. (30)

INTRODUCTION

This introductory chapter first provides background information on public health, the

public health workforce, essential public health operations and public health in the

Netherlands. The aim and outline of this thesis are presented at the end of this chapter.

PUBLIC HEALTH

Public health is often defined as ‘the science and art of preventing disease, prolonging

life, and promoting health through the organised efforts of society’. (1) The focus on

preventive measures through collective interventions distinguishes public and preventive

care (public health) from providing medical care (curative sector). Public health is an

essential part of the healthcare system and concentrates on the health of the population

as a whole. As all patients are part of the population in fact medical care occurs within the

context of public health. (2, 3)

In many high income countries, the rising burden of chronic diseases, ageing populations,

increasing health inequalities and growing health care costs poses challenges for health

systems to improve and maintain population health. (4-6) The health of populations and

the individuals within that population is influenced by a range of factors both within and

outside the individual’s control (7, 8), as described by the so-called rainbow model of

Dahlgren and Whitehead (D&W), see Figure 1. (9) Starting from the inner layer, the model

shows: 1) fixed factors, such as age and gender, 2) individual lifestyle factors, 3) social

and community factors, 4) living and working conditions, and 5) general socioeconomic,

cultural and environmental factors. This model illustrates that health is not only influenced

by individual lifestyle choices and an individual’s ability to adapt and self-manage, but also

by collective factors that determine the context of an individual, as reflected by layers 3, 4

and 5. For example, the 2008 economic crisis in Europe has pronounced and unintended

effects on public health; the number of suicides and infectious disease outbreaks has

increased since. (10) So, improving or maintaining population health requires medical

care as well as public health interventions.

To deliver effective public health services, a qualified public health workforce and

appropriate allocation of that workforce are necessary. Therefore there is a need to

understand the composition and trends in the public health workforce. (11-14)

Public health workforce

In several high income countries, e.g. the United States of America (USA) and Australia,

insight in the public health workforce is limited. (15, 16) Limited insight in the total public

health workforce makes workforce planning impossible. To provide evidence on which

to base decisions for workforce planning and development, appropriate data on the size

and composition of the workforce and the services provided are needed. Around 2000,

the Centers for Disease Control and Prevention in the USA (CDC) and national partners

developed a strategic plan for public health workforce development.(17, 18) Part of that

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Table 1 | Essential public health operations, WHO Europe

Description Example

1 Surveillance of population health and wellbeing; to feed information to health needs assessments, health impact assessments and to planning for health services

Surveillance systems and registries for (non)communicable diseases

2 Monitoring and response to health hazards and emergencies; in order to monitor health hazards so that risks can be assessed.

Preparing for emergencies like prevention of health effects of heat-waves

3 Health protection, including environmental occupational, food safety and others; to use monitoring data to protect health from diseases and environmental risks and hazards.

Legislation for assessing food safety

4 Health Promotion, including action to address social determinants and health inequity; to promote population health and well-being by addressing inequalities and the broader social and environmental determinants

The development, implementation and evaluation of policies to promote healthy diets and to prevent overweight and obesity

5 Disease prevention, including early detection of illness; to prevent disease through preventive actions.

Provision of vaccination programmes

6 Assuring governance for health and wellbeing; to ensure that public health services are well governed and maintain accountability, quality and equity.

Mobilizing action for health and health equity in local policies

7 Assuring a sufficient and competent public health workforce; to ensure that there is a relevant and competent public health workforce sufficient for the needs of the population.

Education, training, development and evaluation of the public health workforce.

8 Assuring sustainable organisational structures and financing; to ensure sustainable organisations and financing for public health to provide efficient, effective and responsive services.

Ensuring services are responsive and sustainable

9 Advocacy communication and social mobilisation for health; to support leadership and advocacy for community engagement and empowerment.

Improving health literacy and health status of individuals and populations.

10 Advancing public health research to inform policy and practice; to ensure that research findings are used to improve evidence-informed policy and practice.

Development of new research methods or innovative solutions in public health

Complementary to local public health services, other local and national organisations

provide public health services, including academic research groups conducting public

health research and thus providing the scientific basis of public health practice (EPHO

10). The National Institute for Public Health and Environment (‘RIVM’) contributes

significantly to public health by conducting public health research and advising the

national government on public health policy. National training and education institutes

such as the Netherlands School of Public and Occupational Health, contribute to public

health by developing public health curricula and offering training programmes (EPHO 7).

Innovation and knowledge institutes support the health of specific population groups

Essential public health operations

To overcome the indistinct boundaries and the multidisciplinary nature of the public

health workforce as drawbacks for public health workforce studies, the services provided

by public health professionals have been used to define the workforce. In 1994, the USA

defined ten essential public health services, as a framework for public health activities

that should be undertaken. (31) In 2012 the World Health Organisation in Europe (WHO

Europe) followed and defined ten essential public health operations (EPHOs). (20) EPHOs

describe the main tasks of public health and can be used as a unifying and guiding basis

to monitor and evaluate policies, strategies and actions for reforms and improvement in

public health. EPHOs have also been used to support the development of public health

curricula. (32)

In most public health workforce studies the EPHOs were the basis to define the public

health workforce as “all those responsible for providing any of the 10 essential services of

public health”. Selections of the organizations in which they work and of specific job titles,

such as public health nurse or public health manager, were used to further operationalise

the definition of the public health work force for research purposes. The ten EPHOs are

shown in Table 1.

PUBLIC HEALTH IN THE NETHERLANDS

Public health organisation

The Dutch minister of Health, Welfare and Sport is responsible for public health. By law,

the Public Health Act, all Dutch municipalities have the obligation to provide pre-specified

public health services and to support a local public health service. (33) There are about

400 municipalities in the Netherlands which are served by 25 local public health services.

All local public health services have a number of uniform tasks, as specified in the law.

Examples of those tasks include preventive youth health care, infectious disease control,

health promotion and environmental public health. From the perspective of the EPHOs

this means that local public health services take care of ‘surveillance of population health

and wellbeing’ (EPHO 1), ‘health promotion’ (EPHO 4), ‘disease prevention’ (EPHO

5), ‘monitoring and response to health hazards and emergencies’ (EPHO 2), ‘assuring

sustainable organisational structures’ (EPHO 8) and ‘assuring governance for health and

wellbeing’ (EPHO 6).

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Table 3 | Ranking determinants of health and their contribution to the burden of disease in the Netherlands in 2011*

Determinants of health % causing the disease burden

1 Smoking 13,1

2 Overweight 5,2

3 Sedentary behavior 3,5

4 Excessive alcohol use 2,5

* RIVM, Volksgezondheid Toekomst Verkenning 2014

Public health workforce in the Netherlands

The above mentioned trends in population health and the corresponding public health

needs will impact the public health services and the public health workforce. Therefore,

also in the Netherlands, there is a need to understand the size and composition of the

public health workforce, in order to secure sufficient qualified and appropriate allocation

of that workforce to maintain and improve population health.

Like in other countries, total size and composition of the public health workforce in the

Netherlands is unknown and a standardized system for regularly and systematically

collecting public health workforce data is lacking. This is remarkable because public health

contributes significantly to population health, and public health is a public service with

a high societal impact. The lack of evidence based public health workforce governance

limits the potential to optimize population health in the Netherlands.

The main aim of the research in this thesis is to contribute to increasing insight in

the quantity and quality of the current and future public health workforce in the

Netherlands, in order to support workforce planning and policy development for better

population health. The public health workforce is in this thesis defined as all workers

involved in prevention, promotion and protection of population health, as distinct from

activities directed to medical care. We use the Netherlands as a case study to develop

and test methodologies that are also internationally applicable to collect public health

workforce data.

or public health topics. The national center for youth health care (NCJ) can serve as an

example. The NCJ supports youth health care practice by developing guidelines and

aggregating knowledge.

Population health status

Public health has contributed significantly to population health in the Netherlands.

Noteworthy successful public health interventions over the past 40 years include the

national child immunisation programme (RVP), prevention of HIV/AIDS, anti-smoking

measures, safety belts in cars, prevention of burns and the implementation of national

organised screening programmes for breast, cervical and colorectal cancer. (34)

Nevertheless, the current state of population health in the Netherlands offers important

challenges for public health. The current life expectancy of Dutch men of 79 years is

among the highest in the European Union. With 83 years, the life expectancy of Dutch

women is in the middle range in the EU and the life expectancy will probably continue

to rise in the coming years in the Netherlands. (35) However, the wide inequalities in

life expectancy across socio-economic classes are persistent. Life expectancy of Dutch

people with low levels of education is around 6 years less than the life expectancy of

people with high levels of education. In terms of life expectancy in self-perceived good

health, the difference between the lowest and the highest educational groups is 19 years

and this difference has been quite constant over the years. Reduction of socioeconomic

gaps in health has remained a major challenge for public health.

Chronic diseases such as mental disorders, cardiovascular conditions and cancer caused

the largest burdens of disease in 2011 in the Netherlands, see Table 2. Half of this burden

can be attributed to unhealthy behaviour, like smoking, excessive alcohol use, sedentary

behaviour and overweight and may thus essentially / theoretically be preventable. Among

these, smoking remains the major cause of death and illness by far (causing 13% of the

disease burden), see Table 3. (35) To reduce the burden of chronic diseases, healthier

behaviours and environments need to be promoted and supported, which substantiates

again the importance of public health for population health.

Table 2 | Ranking diseases causing the largest burden of disease in the Netherlands , 2011*

Burden of disease

1 Mental disorders

2 Cardiovasculare disease

3 Cancer

4 Injuries

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OVERVIEW OF THE STUDIES PRESENTED IN THIS THESIS

Ch Topic Study methodsData/Study population

Focus of study

Current situation

2 Enumeration of the Dutch public health workforce

Document analysis

Existing data and reports on the Dutch public health workforce

Enumeration of the Dutch public health workforce making use of existing data sources and information

Strategy development

3 Operationalisation of EPHOs for the Netherlands

Literature review Articles and reports on public health essential operations

Developing a new strategy to assess the Dutch public workforce using Essential Public Health Operations

4 Enumeration of the Dutch environmental public health workforce

National cross-sectional study with online questionnaires

Organisations that provide Environmental public health (n=24)

Implementation of the new strategy to assess the public health workforce, environmental public health as example

5 Enumeration of the Dutch Youth health care workforce

National cross-sectional study with online questionnaires

Organisations that provide Youth public health (n=43)

Assessement of the national youth health care workforce and

Future public health priorities

6 Assessing the implications of the new concept of health for public health

Secondary qualitative data-analysis of group-interviews

Group interviews (n=28), participants (n=277)

Assessing implications of the new concept of health for public health with regard to the EPHOs

RESEARCH QUESTIONS OF THIS THESIS

The studies presented here address public health workforce enumeration at three levels:

the current situation, strategy development to enumerate the public health workforce and

future public health needs. We address the following research questions:

1. What is currently known about the public health workforce in the Netherlands?

In the first part of the thesis we aim to assess the public health workforce in the Netherlands

using existing data sources and to identify potential data gaps. The research question is:

What is the quantity and quality of the Dutch public health workforce, using existing

data sources? (Chapter 2)

2. How to enumerate the multidisciplinary public health workforce systematically?

We developed a strategy for empirical workforce enumeration based on EPHOs. In this

part of the thesis we first define the essential public health operations for public health in

the Netherlands. Subsequently we develop and test a new strategy based on EPHOs to

assess the capacity of parts of the Dutch public health workforce. This part of the thesis

addresses the following research questions:

a. What are the scope and essential public health operations or EPHOs of public health

in the Netherlands, based on international examples? (Chapter 3)

b. What is the feasibility and validity of an EPHO based strategy to measure the size,

composition and qualifications of the environmental public health workforce in the

Netherlands? (Chapter 4)

c. What is the quantity and quality of the preventive youth health care

(“jeugdgezondheidszorg” in Dutch) workforce in the Netherlands and can regional

differences in workforce be understood in terms of indicators of preventive youth

health care need? (Chapter 5)

3. How are public health priorities affected by a new conceptualization of health?

In the third part of the thesis we used the EPHOs as a framework for analysis to assess the

consequences of application of a new conceptualization of health in terms of adaptation

and self-management for public health policy. We used qualitative analysis of existing

data from group interviews with stakeholders in Dutch public health and health care. This

part addresses the following research question:

What are the implications of application of a new conceptualization of health for

public health policy? (Chapter 6)

Finally, in chapter 7, the main findings of the thesis are summarized and discussed in

the light of various methodological considerations and previous research. Furthermore,

implications and recommendations for practice, research and policy are analysed.

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CHAPTER 2Enumeration of the public health workforce in the Netherlands; insight in the size and composition is limited

Marielle Jambroes, Marie-Louise Essink-Bot,

Thomas Plochg and Karien Stronks

This chapter was published as:

Capaciteit van de beroepsgroepen in de publieke

gezondheidszorg; Beperkt inzicht in omvang en samenstelling.

[Enumeration of the public health workforce in the Netherlands;

insight in the size and composition is limited]

NED TIJDSCHR GENEESKD. 2012;156:A4529.

2322

Enumeration of the public health workforce in the Netherlands; insight in the size and composition is limitedChapter 2

2

INTRODUCTION

In the Netherlands, preventive care as delivered by public health has provided an

important contribution to population health. Examples include organised programs to

prevent infectious diseases, preventive youth health care, municipal health policies, and

programs for early detection of cancer. Bearing in mind the importance of public health for

population health, it is noteworthy that important data are still lacking on this sector, e.g.

how many people work in public health, and the types and levels of their competencies.

It is known that the Dutch registry of healthcare professionals in 2011 included 38,677

health care physicians, of whom 2122 were occupational health physicians, 1050

insurance physicians and 934 were public health physicians (in comparison: there were

11,870 registered general practitioners). Whether these public health physicians actually

work in public health and which and how many other professionals (e.g. health promotion

specilists and epidemiologists) are active in this sector is unknown.

This is remarkable because the workforce is one of the five relevant parts that define

the quality of public health. (1) Insight into the size and composition of the public health

workforce is necessary to support public health workforce planning and development

and to improve the quality and appropriateness of public health services. For physicians

such guidance has been available for some time: for example, the Advisory Committee

on Medical Manpower Planning (‘Capaciteitsorgaan’) estimates the expected need

for physicians and, based on this estimate, makes recommendations for the required

training inflow of physicians. Unfortunately, other occupations in public health lack such

systematic guidance.

In the Netherlands, the Public Health Act [‘Wet Publieke Gezondheid’] describes public

health as ‘…the health protecting and health promoting measures for the population or

specific groups thereof, including disease prevention and early detection of diseases’. (2)

The focus on preventive measures through collective interventions distinguishes public

and preventive care (public health) from providing medical care (curative sector).

The need to gain insight into the public health workforce (and their competencies) and

what the future demand of public health professionals will be, has increased considerably

over the last 10 years. This resulted in the production of 7 inventories, each from different

parts of public health, for example a specific professional group such as health promotion

specialists, or a specific organization, e.g. the municipal health service.

This study examines whether these inventories, when combined, provide sufficient insight

into the size and composition of the public health workforce.

ABSTRACT

Objective

To gain insight into the size and composition of the public health workforce in the

Netherlands, to guide development and improve the future quality and provision of

public health.

Design

Document analysis.

Method

Analysis of the estimates presented in 7 reports published between 2003 and 2010 in the

Netherlands, presenting workforce descriptions, occupations and roles, definitions, and

total numbers.

Results

Based on our comparison of the data in the reports, we estimated the total size of the Dutch

public health workforce at 12,000 fte. However, this estimate is inaccurate because the

definition of the workforce, the occupations selected and the methods of data collection

differed between the reports. Moreover, definitions of the workforce ranged from all

municipal health services to a broad selection of related facilities and organizations. The

number of roles/occupations in each report ranged from 1-15. A registry exists only for

public health physicians.

Conclusion

Despite 7 reports covering 7 years, we still have limited insight into the size and composition

of the public health workforce in the Netherlands. Therefore, it is not possible to assess

whether the capacity is sufficient now and in the future to fulfil the required quality and

provision of public health services.

2524


2

The

Neth

erla

nds

orga

nisa

tion

for

heal

th re

sear

ch a

nd

deve

lopm

ent:

pub

lic

heal

th k

now

ledg

e in

frast

ruct

ure

(Zon

Mw

)

The

Neth

erla

nds

orga

nisa

tion

for

heal

th re

sear

ch

and

deve

lopm

ent

(Zon

Mw

)

2010

Asse

ssm

ent o

f the

cur

rent

pub

lic

heal

th k

now

ledg

e in

frast

ruct

ure

in

orde

r to

supp

ort d

istri

butio

n an

d im

plem

enta

tion

of p

ublic

hea

lth

know

ledg

e

Publ

ic h

ealth

nur

ses,

phy

sici

ans,

soc

ial

wor

kers

, psy

chia

tric

nurs

es, h

ealth

pr

omot

ion

spec

ialis

ts, h

ealth

sci

entis

ts,

epid

emio

logi

sts,

spe

cial

ists

in e

mer

genc

y ca

re, p

reve

ntiv

e yo

uth

heal

thca

re,

envi

ronm

enta

l pub

lic h

ealth

Exis

ting

data

sou

rces

Capa

cite

itspl

an 2

010,

su

b-re

port

Soci

al

Med

icin

e

The

Advi

sory

Co

mm

ittee

on

Med

ical

M

anpo

wer

Pla

nnin

g (C

apac

iteits

orga

an)

2010

Estim

atio

n an

d ad

vice

on

train

ing

inflo

w o

f pub

lic h

ealth

phy

sici

ans,

oc

cupa

tiona

l hea

lth p

hysi

cian

s an

d in

sura

nce

phys

icia

ns

Profi

le-p

hysi

cian

s o

f the

Roy

al D

utch

M

edic

al A

ssoc

iatio

n. (K

NMG)

, pub

lic h

ealth

ph

ysic

ians

, occ

upat

iona

l hea

lth p

hysi

cian

s,

insu

ranc

e ph

ysic

ians

Com

puls

ory

regi

stry

of

Profi

le-

phys

icia

ns o

f the

Roy

al D

utch

M

edic

al A

ssoc

iatio

n. (K

NMG)

, pu

blic

hea

lth p

hysi

cian

s,

occu

patio

nal h

ealth

phy

sici

ans,

in

sura

nce

phys

icia

ns

Role

s, o

ccup

atio

ns

en tr

aini

ng in

pub

lic

heal

th

Boar

d fo

r the

Pr

ofes

sion

s an

d Tr

aini

ng in

Hea

lth

Care

(CBO

G)

2010

List

of c

urre

nt ro

les,

occ

upat

ions

an

d ed

ucat

iona

l pro

gram

mes

in

publ

ic h

ealth

, in

orde

r to

expl

ore

futu

re n

eeds

Profi

le-p

hysi

cian

s o

f the

Roy

al D

utch

M

edic

al A

ssoc

iatio

n. (K

NMG)

, pub

lic h

ealth

ph

ysic

ians

, occ

upat

iona

l hea

lth p

hysi

cian

s,

insu

ranc

e ph

ysic

ians

, pub

lic h

ealth

nur

ses,

M

aste

rs o

f Pub

lic H

ealth

, epi

dem

iolo

gist

s,

heal

th p

rom

otio

n sp

ecia

lists

Exis

ting

data

sou

rces

, or

gani

satio

ns o

f pro

fess

iona

ls a

nd

web

site

s

Tabl

e 1

| Cha

ract

eris

tics

of th

e 7

repo

rts s

how

ing

the

size

and

com

posi

tion

of th

e oc

cupa

tiona

l gro

ups

in p

ublic

hea

lth c

are

in th

e Ne

ther

land

s in

the

perio

d 20

03-2

009.

Title

Orga

nisa

tion

Year

Desc

riptio

nRo

le o

r fun

ctio

nSo

urce

Know

ledg

e in

frast

ruct

ure

publ

ic

heal

th

Advi

sory

Cou

ncil

on H

ealth

Res

earc

h (R

GO)

2003

Inve

ntor

y of

the

Dutc

h pu

blic

he

alth

kno

wle

dge

infra

stru

ctur

e

Rese

arch

ers

Ques

tionn

aire

stu

dy a

mon

g un

iver

sitie

s, o

ther

rese

arch

in

stitu

tions

and

mun

icip

al h

ealth

se

rvic

es

Wor

kfor

ce p

lann

ing

publ

ic h

ealth

Neth

erla

nds

Publ

ic

Heal

th F

eder

atio

n (N

PHF)

2007

Deve

lopm

ent o

f too

l to

asse

ss th

e pu

blic

hea

lth w

orkf

orce

to s

uppo

rt pu

blic

hea

lth w

orkf

orce

pla

nnin

g

Heal

th p

rom

otio

n sp

ecia

lists

, pub

lic

heal

th n

urse

s, in

spec

tora

te c

hild

car

e,

epid

emio

logi

sts

Ques

tionn

aire

stu

dy a

mon

g or

gani

satio

ns o

f pub

lic h

ealth

pr

ofes

sion

als

Futu

re d

evel

opm

ents

he

alth

pro

mot

ion

and

prev

entio

n

The

Neth

erla

nds

Inst

itute

for H

ealth

Pr

omot

ion

and

Dise

ase

Prev

entio

n (N

IGZ)

2008

Anal

ysis

of f

utur

e de

velo

pmen

ts

for h

ealth

pro

mot

ion

and

prev

entio

n

Heal

th p

rom

otio

n sp

ecia

lists

Onlin

e qu

estio

nnai

re d

istri

bute

d am

ong

heal

th p

rom

otio

n sp

ecia

lists

wor

king

with

in s

elec

ted

orga

nisa

tions

Benc

hmar

k da

ta

mun

icip

al h

ealth

se

rvic

es

Natio

nal A

ssoc

iatio

n of

Loc

al P

ublic

He

alth

Ser

vice

s (G

GD

Nede

rland

)

2008

List

ing

of a

ll em

ploy

ees

wor

king

at

mun

i cip

al h

ealth

ser

vice

s in

th

e Ne

ther

land

s

Nurs

es, s

uppo

rting

sta

ff, p

hysi

cian

s,

ambu

lanc

e dr

iver

s, p

olic

y ad

viso

rs, h

ealth

pr

omot

ion

spec

ialis

ts, s

peec

h th

erap

ists

, ep

idem

iolo

gist

s, s

ocia

l wor

kers

, am

bula

nce

staf

f, en

viro

nmen

tal p

ublic

hea

lth

spec

ialis

ts, m

edic

al te

chni

cal w

orke

rs,

info

rmat

ion

offic

ials

, psy

chol

ogis

ts,

qual

ity

offic

ers,

pre

vent

ive

dent

al c

are

offic

ers,

oc

cupa

tiona

l the

rapi

sts,

oth

er ro

les

Ques

tionn

aire

dis

tribu

ted

amon

g hu

man

reso

urce

dep

artm

ents

of a

ll m

unic

ipal

hea

lth s

ervi

ces

2726


2

Table 2 | Overview of the criteria of the descriptions in the field of Public Health in several reports published in the period 2003-2009, used to determine the size and composition of the workforce in the public health sector in the Netherlands.

Organisation Description of the public health sector or focus of the inventory

RGO Definition of the workforce of the public health sector based on the American definition of Acheson, applied to Dutch situation: collective interventions for health promotion and disease prevention such as sewers, health education, preventive health care, social facilities and policy, while aimed at improvement of population health. Or: public health includes health protection, health promotion and disease prevention.

NPHF The workforce is defined with the term ‘public health’ and operationalised by a selection of organisations and roles and occupations within those organisation. The Dutch Public Healthcare Act (WPG) and the tasks mentioned therein were an important guide.

NIGZ The inventory includes all persons working within the selected organisations who provide > 50% of their time on health promotion activities. This means: the development and performance of campaigns, improvement of expertise or research in the field of health promotion. Employees with secretarial, administrative or logistic support jobs are not included.

GGD NL The inventory includes all employees of the municipal health service in the Netherlands.

ZonMw The workforce is described by the term ‘openbare gezondheidszorg’ (public health) and includes tasks, task fields and roles that are associated with the Dutch Public Health Act.

Capaciteitsorgaan The inventory includes all registered public health physicians and so-called profile physicians.

CBOG The workforce is described by domains. The report is limited to a formal domain, the Dutch Public Health Act: health protection and health promotion activities aiming for the population or specific groups thereof, including disease prevention and early detection of diseases.

Inclusion criteria

The Advisory Committee on Medical Manpower Planning [Capaciteitsorgaan] considered

a registration in the registry of the Public Health Physicians Registration Commission,

to be a criterion for inclusion in their public health workforce inventory. In contrast, the

Institute for Health Promotion and Disease Prevention [NIGZ] used a combination of the

job description, > 50% of the working hours working on health promotion, and a selection

of organizations. In 5 of the 7 inventories, the occupations and roles were not defined

beforehand.

Total Numbers

Table 3 presents an overview of the combined data from the reports in which the

occupations/roles are shown for each report. The reports did not always result in

numerical estimates of the quantities of the occupations and roles. The occupations/roles

without numerical estimates of the quantities are not shown in Table 3. In general, each

report provided a different estimate of the total public health workforce, ranging from

731 reported by the Advisory Council on Health Research [RGO] up to 9807 reported by

the Board for the Professions and Training in Health Care [CBOG]. A combined estimate

amounted to a total public health workforce of approximately 12,000 fte.

METHODS

Due to the lack of a central registration of all roles/occupations in the public health sector,

we searched for inventories made during the last 10 years. We used (internet) search

engines and also asked members of the Netherlands Public Health Federation for existing

data. Inventories were selected that specifically addressed public health, or the areas of

expertise mentioned in the Dutch Public Health Act, i.e. social medicine, epidemiology

and health promotion. From the periodically updated inventories, the most recent data

were selected. Of all available inventories we examined how the workforce was described,

which definitions or descriptions of the roles/occupations were used, and the numbers

of persons associated with each of these occupations. Subsequently, an estimate was

made of the total size of each occupation recorded in full-time equivalents (fte). To do this,

all data from all the available documents were pooled, grouped by role or occupation, and

analyzed for accuracy and comparability.

In order for this research (and possible follow-up) to have adequate representation

within the field of public health, the Public Health Federation assigned an advisory board

consisting of representatives from the broad field of public health. Prior to starting this

research, the advisory board evaluated and approved the study. It also contributed to

evaluation of the available documents, and commented on the results.

RESULTS

The 7 available inventories compiled by different organizations were published between

2003 and 2010. (3-9) Table 1 presents details of these documents and the methods

by which their data were collected. The inventories differed in their selection of roles/

occupations, ranging from 1 professional group up to 15 functions and/or occupations.

Four of the 7 inventories included multiple occupations or roles and, in total, more than

40 different roles and occupations were reported.

Definition of the public health workforce

Table 2 presents an overview of the descriptions of the public health workforce, as used

in the inventories. Of the 7 documents, 4 referred to the description of public health

as stated in the Public Health Act. Two documents did not describe the workforce but,

instead, described a specific occupational group (e.g. public health physicians) or a

specific organization (e.g. municipal health organizations). The Netherlands Institute

for Health Promotion and Disease Prevention [NIGZ] chose a selection of organizations

which include employees that perform work that fits a job description that aims for

health promotion.

2928


2

Prev

entiv

e yo

uth

heal

thca

re

35

00

Hygi

ene

care

340

- 38

0

Fore

nsic

med

icin

e

10

0 -

150

Envi

ronm

enta

l pub

lic h

ealth

100

Publ

ic m

enta

l hea

lth c

are

750

Epid

emio

logy

120

Heal

th p

rom

otio

n

80

0

Heal

thy

publ

ic p

olic

y ad

vise

100

Med

ical

Em

erge

ncy

Prep

ared

ness

and

Pl

anni

ng

30

0

Othe

r

Envi

ronm

enta

l med

ical

offi

cer

66

Assi

stan

t phy

sici

an

96

0

Heal

th p

rom

otio

n sp

ecia

list

89

911

1925

5

1433

Epid

emio

logi

st

86

120

11

00

Mas

ter o

f pub

lic h

ealth

76

Polic

y ad

viso

r

22

0

Med

ical

tech

nica

l offi

cer

116

Spee

ch th

erap

ist

187

Ambu

lanc

e st

aff

32

Info

rmat

ion

offic

ial/

docu

men

talis

t

88

Prev

entiv

e de

ntal

car

e of

ficer

8

TOTA

L73

129

7511

1966

0068

60-6

950

4427

9807

*Num

ber o

f wor

king

phy

sici

ans

Tabl

e 3

| Ove

rvie

w o

f the

size

and

com

posi

tion

of p

rofe

ssio

nals

incl

uded

in s

even

repo

rts

Advi

sory

Co

unci

l on

Hea

lth

Rese

arch

(R

GO)

Neth

erla

nds

Publ

ic H

ealth

Fe

dera

tion

(NPH

F)

The

Neth

erla

nds

Inst

itute

for

Heal

th P

rom

otio

n an

d Di

seas

e Pr

even

tion

(NIG

Z)

Natio

nal

Asso

ciat

ion

of

Loca

l Pub

lic

Heal

th S

ervi

ces

(GGD

NL)

The

Neth

erla

nds

orga

nisa

tion

for

heal

th re

sear

ch

and

deve

lopm

ent

(Zon

Mw

)

The

Advi

sory

Co

mm

ittee

on

Med

ical

M

anpo

wer

Pla

nnin

g (C

apac

iteits

orga

an)

Boar

d fo

r the

Pr

ofes

sion

s an

d Tr

aini

ng

in H

ealth

Car

e (C

BOG)

fte

ftefte

ftefte

nn

Phys

icia

ns

Phys

icia

ns

670

Profi

le-p

hysi

cian

pre

vent

ive

Yout

h he

alth

care

43

140

3

Profi

le-p

hysi

cian

Infe

ctio

us d

isea

se c

ontro

l

1313

Profi

le-p

hysi

cian

For

ensi

c m

edic

ine

91

85

Profi

le-p

hysi

cian

Tub

ercu

losi

s co

ntro

l

22

Profi

le-p

hysi

cian

Env

ironm

enta

l pub

lic h

ealth

01

Profi

le-p

hysi

cian

indi

catio

n &

advi

se

40

47

Profi

le-p

hysi

cian

pol

icy

& ad

vise

35

43

Publ

ic h

ealth

phy

sici

an*

914

965

Occu

patio

nal h

ealth

phy

sici

an*

1968

2167

Insu

ranc

e ph

ysic

ian*

933

1072

Nurs

es

Publ

ic h

ealth

nur

ses

19

90

1500

24

00

Rese

arch

ers

Rese

arch

er p

ublic

hea

lth, u

nive

rsity

152

Rese

arch

er o

ther

, uni

vers

ity12

0

Re

sear

cher

pub

lic h

ealth

, oth

er re

sear

ch

inst

itutio

n40

5

Rese

arch

er m

unic

ipal

hea

lth s

ervi

ce54

Dom

ains

Infe

ctio

us d

isea

se c

ontro

l

75

0

3130


2

Examples of this include the preventive activities carried out by general practitioners,

and the health counselling and screening of pregnant women by midwives. The roles

and organizations outside the public health sector were not consistently included in the

registries that took the ‘traditional’ working fields within public health as a starting point.

Many of the differences between the registries can be traced back to differences in

definition of the public health work field. For example, the report of the Advisory Council

on Health Research (RGO) was aimed at researchers and included researchers in the

broad domain of public and occupational health, while other reports, such as that from

the Netherlands Institute for Health Promotion and Disease Prevention (NIGZ), ignored

medical care as a sector in which health promotion specialist may work.

Policy functions within local or national government, the Health Care Inspectorate and

health insurers were not included in the registries, unless these employees are qualified

and registered as public health physicians, a qualification that is not necessarily required

for working in these roles.

Selection of occupations and roles

The registries differed in the selection of occupations and roles; a total of over 40 different

roles and occupations were mentioned. Also, because for very few occupations where

the definitions were specified beforehand, it is unclear whether the same names for

certain roles were used and if they were used to describe the same roles and tasks. For

example, it remains unclear whether the task description ‘epidemiologist’ in the registry

of the municipal health services is the same as or similar to the ‘epidemiologist’ as used

in the report of the Board for the Professions and Training in Health Care (CBOG). Also,

several names of occupations and educational titles are used interchangeably, such as

public health policy advisor and ‘Master of Public Health’. Without specific criteria or

definitions it is impossible to establish whether the categories are in fact distinct or, to

some extent, overlap each other.

Data collection

The lack of proper registration of occupations and roles in the public health care is

another barrier to proper sizing of the public health workforce. A compulsory register is

only available for physicians, public health physicians and so-called profile physicians of

the Royal Dutch Medical Association (KNMG).

Limitations

A limitation of our approach is the selection of documents that are explicitly related to

public health or specific areas of expertise mentioned in the Public Health Act. Therefore,

it is possible that data of professionals working in, for example, occupational health,

e.g. occupational health nurses or occupational health psychology have been missed.

If this information was not included in the documents (although it was available) then

our estimated 12,000 fte is probably an underestimation of the actual size of the public

health workforce.

We arrived at this estimate through the following steps:

1. The sum of all researchers (from the registry of the Advisory Council on Health

Research, RGO), plus public health physicians (from the registry of the Advisory

Committee on Medical Manpower Planning, Capaciteitsorgaan) plus health

promotion specialists (from the registry of the Institute for Health Promotion and

Disease Prevention, NIGZ);

2. The municipal health service benchmark, [GGD NL] mapped all their employees,

including physicians and health promotion specialists. After subtraction of these

latter two categories from the total number of employees in the municipal health

services, the estimate of the number of municipal health workers was added to the

result of step 1;

3. The Board for the Professions and Training in Health Care (CBOG) used the numbers

of the above-mentioned registries, but also presented numbers of ‘masters of public

health’; this latter group was added to the result of step 2.

Data from the Netherlands Organization for Health Research and Development (ZonMw)

were not used in the calculations, as this inventory only made use of data derived from

other documents.

The documents from the Advisory Committee on Medical Manpower Planning

(Capaciteitsorgaan) and the Board for the Professions and Training in Health Care (CBOG)

reported only absolute numbers instead of ftes; these absolute numbers were used to

compile the total estimate.

DISCUSSION

By combining data from the 7 documents published between 2003 and 2010, we

estimated the size of the public health workforce at 12,000 fte. However, this is an

inaccurate estimate due to lack of similarities in: i) definition of the workforce, ii) the

selection of occupations/roles and their descriptions, and iii) differences in the methods

of data collection between the registries.

Definition of the work field

The considerable variation in registries illustrates the difficulty in defining the public health

workforce. Of the 7 inventories, 4 used the Public Health Act to define the workforce.

However, in this Act, the description of public health does not translate to specific

occupation or roles, or to specific organizations. The ‘traditional’ working fields within

public health (e.g. preventive youth healthcare, infectious disease control, and health

promotion), and their roles and organizations, are another optional starting point for

defining the workforce. Although some registries used this as a starting point, this resulted

in insufficient insight, as some public health tasks are organized within the curative sector.

3332


2

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ca tienr 2003/39. Den Haag: Raad voor gezondheidsonderzoek; 2003.

4. Eindrapport Beroepskrachtenplanning Public Health: Een pleidooi voor systematische

en integrale beroepskrachtenplanning in de public health. Utrecht: Nederlandse Public

Health Federatie; 2007.

5. Fransen G, Molleman G, Hekkink C, Keijsers J. Trendonderzoek Gezondheidsbevordering

en Preventie [rapport]. Woerden: Nationaal Instituut voor Gezondheidsbevordering en

Ziektepreventie; 2008.

6. Benchmark GGD’en 2008. Utrecht: GGDNL; 2008.

7. Vaandrager L, Driessen Mareeuw van den F, Naaldenberg J, Klerks L, Molleman G, Regt de

W et al. De kennisinfrastructuur van de Openbare Gezondheidszorg: vorm en functioneren

[rapport]. Den Haag: ZonMw; 2010.

8. Capaciteitsplan 2010: Deelrapport 4: Sociaal Geneeskundigen. Utrecht:

Capaciteitsorgaan; 2010.

9. Butterman O, Waal van der M. Functies, beroepen en opleidingen in de publieke

gezondheidszorg: een kwalitatief overzicht van de stand van zaken en een blik

op de toekomst. Utrecht: College voor de Beroepen en Opleidingen in de

Gezondheidszorg; 2010.

10. Corso, L. C., et al. “Using the essential services as a foundation for performance

measurement and assessment of local public health systems.” J.Public Health Manag.

Pract. 6.5 (2000): 1-18.

11. Turnock, B. J. and A. S. Handler. “From measuring to improving public health practice.”

Annu.Rev.Public Health 18 (1997): 261-82.

12. Public Health Functions Steering Committee (1994). Public Health in America. Washington,

DC: U.S. Public Health Services

Requirements for a realistic assessment

Our research shows that 7 existing reports (and all the data combined) do not provide

sufficient insight into the capacity of the public health workforce. To assess the public

health workforce properly, a clear definition of the public health work field is needed. A

few Anglo-Saxon countries have defined the work field by identifying essential public

health operations (or core functions) for public health. (10-15) Core functions are services

that necessarily belong to public health and are essential to achieve the aims of public

health. In the various countries involved, the idea of defining core functions was based on

consensus among a relatively large group of professionals.

Core functions can be translated into core competencies; these can be applied for several

purposes, such as assessing the quality of local health services and the development of

public health education programs. American and English studies on the ‘public health

workforce’ show that essential public health operations can also be used as basis for

workforce assessment. (10,16)

RECOMMENDATIONS

In the Netherlands, essential public health operations have not yet been defined.

Defining the essential public health operations, based on consensus of large groups of

professionals from the workforce, will probably be a good starting point for assessing

the public health workforce. In this way, the workforce will be defined based on content

characteristics, i.e. separately from specific occupations or roles, and irrespective of the

institute or organization in which they are performed.

CONCLUSIONS

Despite analysis of 7 reports covering 10 years, we have limited insight into the size

and composition of the public health workforce in the Netherlands. Therefore, it is not

possible to assess whether the current capacity, in relation to the required quality and

performance of public health, will be sufficient now and in the future.

Therefore, we advise to take first steps to acquire this insight by clearly defining the scope

and essential public health operations.

3534


2

13. Shifting the Balance of Power within the NHS: Securing Delivery, Department of Health,

27 July 2001

14. Public health renewal in britisch Columbia: an overview of core functions in public health.

Population health and wellness, ministry of health services, March 2005

15. Public health practice in Australia today, the Australian Health Ministers’ Advisory Council

in June 2000

16. Tilson, H. and K. M. Gebbie. “The public health workforce.” Annu.Rev.Public Health 25

(2004): 341-56.

CHAPTER 3What is public health? A definition and essential public health operations in the Netherlands

Marielle Jambroes, Marie-Louise Essink-Bot, Thomas

Plochg, Boukje Zaadstra and Karien Stronks

This chapter was partly published as:

De Nederlandse publieke gezondheidszorg? 10 kerntaken en

een nieuwe definitie. [What is public health? A definition and

essential public health operations in the Netherlands.]

NED TIJDSCHR GENEESKD. 2013;157: A6195

3938

What is public health? A definition and essential services of public health in the NetherlandsChapter 3

3

ABSTRACT

Public health is an important part of any healthcare system. However, the boundaries

of public health are indistinct. The current challenges to public health and medical care

require a closer collaboration between public health and medical care. We present the

working field of public health to health professionals according to international examples.

Our study shows that a general consensus exists internationally on the overall role of

public health in terms of scope and core functions. Public health aims at promoting

health and reducing inequalities in health, through the organized efforts of society. Based

on this aim, we defined the aim and ten essential public health operations (EPHOs)

for the Netherlands. The EPHOs go beyond institutional and professional boundaries,

are provided within and outside the healthcare system and can be translated into core

competencies for public health professionals.

INTRODUCTION

Public health is an essential part of the healthcare system and focuses on the health of

populations. Over the past 150 years, public health has made a significant contribution to

population health in the Netherlands, and successful public health interventions include

collective intervention programmes like the national child immunisation programme, anti-

smoking measures, prevention of HIV/AIDS, safety belts in cars, and promotion of healthy

workplaces. (1)

Nevertheless, the current state of population health in the Netherlands still presents major

challenges for public health and the healthcare system. The future contribution of public

health is underlined by several policy documents which advocate for a change in the

focus of the healthcare system, i.e. from ‘care for disease and illness’ towards ‘health

and healthy lifestyles’. (2,3,4) Recent policy documents on future health developments

published by the association of medical specialists ‘The Medical Specialist 2015’ (‘De

Medisch Specialist 2015’) and by the association of general practitioners ‘Future Vision

for General Practice Care 2022’ (‘Toekomstvisie Huisartsenzorg 2022’) support this trend

and advocate for more prevention in the medical sector, including primary care. (5,6)

Although public health and medical care are currently separate sectors, the above-

mentioned policy documents suggest there could be a closer collaboration or even

integration in the future.

Public health in the Netherlands

During the past centuries, public health has evolved into a broad and diverse working field,

focusing on the prevention of disease and health hazards, including the determinants of

health both within and outside the healthcare sector. (7) Disciplines included in public

health are, for example, preventive youth healthcare, infectious disease control, public

health emergency control, environmental public health, and health promotion. The

public health services are provided by many different professionals and a wide range of

organizations, e.g. local public health services, local municipalities, occupational health

services, and national knowledge institutes. Within the group of specifically trained and

registered public health physicians different disciplines exist, e.g. occupational health

physicians, insurance physicians (‘Verzekeringsgeneeskundigen’), and public health

physicians (‘Artsen Maatschappij & Gezondheid’). The wide range of factors influencing

health is reflected in the multidisciplinary nature of the public health workforce and is

the main reason for the rather indistinct boundaries of the public health sector. A clearly

distinguishable workforce for public health has not been defined or formally established,

neither in the Netherlands nor in the majority of EU Member States. (8)

As a result, insight in the availability and distribution of the public health workforce in

other countries and in the Netherlands is limited. Public health workforce governance

is important to support future developments towards more integration of public health,

4140


3

medical care and long-term care.[9] Insufficient data on both the size and the composition

of the public health workforce hampers evidence-based decision-making on public health

workforce governance.


In addition to descriptions of public health in terms of definitions, some countries defined

essential public health functions as a framework for public health activities that should

be undertaken. The USA did so in 1994. In 2012, he World Health Organisation in Europe

(WHO EUR) followed and defined 10 essential public health operations (EPHOs) (10,11).

EPHOs describe the main functions of public health. The EPHOs have successfully been

used to monitor and evaluate the quality of public health services and to assess the

public health workforce. (12,13,14)

In the Netherlands, EPHOs have not yet been defined. Therefore, we analysed international

examples of EPHOs and subsequently propose the aims and 10 EPHOs for public health

in the Netherlands. We expect that the Dutch EPHOs will contribute to the development

of the sector and to the training of public health professionals in the Netherlands.

METHODS

We searched the websites of relevant international organisations (e.g. the World Health

Organisation (WHO), the Association of Schools of Public Health in the European Region,

the European Public Health Association, and national public health organisations) for

definitions of public health and for descriptions of essential public health functions; we

primarily aimed for white papers, or similar authoritative reports. The reference lists of the

identified documents were also scrutinised and further searches were made in Medline,

Google Scholar and the internet.

International definitions of public health and operations were then clustered, arranged

according to common topics, and analysed with regard to differences and commonalities.

Based on the outcomes, the generic set of public health operations that we developed

was extrapolated to public health in the Netherlands. Whether or not the public health

operations were actually delivered in the Netherlands was assessed according to the

Dutch Public Health Act, existing professional profiles, policy documents and existing

practice guidelines (e.g. the basic duties package (‘Basistakenpakket’) for preventive

youth healthcare). (15,16,17,18,19)

RESULTS

International documents

The search yielded 7 international definitions of public health and associated descriptions

of EPHOs (Table 1); three from the WHO and one each from Australia, New Zealand,

the UK and the USA. In the USA some individual states defined their own public health

operations, but we did not include these as they were derived from the overall USA

document. The most recent set of public health operations was defined in 2012 by WHO

Europe (WHO EUR). All documents consist of a definition or aim of public health and

include a range of 5-11 public health operations.

Although the countries from which the selected documents originated have different

healthcare systems, the definition of public health and the essential public health

operations (EPHOs) were highly comparable (Table 1). Commonalities between the

definitions of public health were: 1) focus on population health, 2) focus on prevention,

and 3) a collective approach towards interventions to address risk factors and causes of

disease.

The public health operations of the different documents could be divided into nine

main topics, see Table 1, first column. Five of these topics could be clustered as core

operations: monitoring health status, disease prevention and control, health promotion/

empowering communities, health protection and public health emergency response. The

remaining four could be clustered as enabler operations: healthy public policies, research

and development, a competent workforce and quality assurance of public health services.

The latter four operations more or less support the delivery of the core operations.

In some documents, some of the operations were not addressed as a specific operation.

For example, ‘public health emergency response’ was defined as a separate operation in

two of the documents, whereas in the USA this particular operation was part of ‘disease

prevention and control’. The USA document was the only document that mentioned

‘Link people to needed personal health services and assure the provision of health care

when otherwise unavailable’ as an EPHO. was mentioned as a public health operations.

Therefore we did not label this operation as a generic operation.

In four of the international documents, reducing inequalities in health was explicitly

addressed as an operation or integrated in the aim of public health. The UK addressed

the topic ‘reduce inequalities’ in three of the EPHOs, and the WHO EUR in one of the

operations. The WHO Western Pacific region and New Zealand included ‘reduction of

inequalities in health/health disparities’ within the aim of public health.

To summarise, the aims and EPHOs reported in the seven international documents were

very similar. In these seven examples, we used the commonalities, i.e. the generic EPHOs

derived from the international examples, as a framework to propose the aims and public

health operations for the Netherlands.

4342


3

Tabl

e 1

| In

tern

atio

nal s

yste

ms

of d

efini

tions

or a

ims

of p

ublic

hea

lth a

nd e

ssen

tial p

ublic

hea

lth o

pera

tions

USA,

199

4 10

Aust

ralia

, 200

0 20

UK, 2

001

21PA

HO/ W

HO *

, 200

2 22

WHO

, WPR

O**

2003

23Ne

w Z

eala

nd, 2

011

24W

HO E

urop

e, 2

012

11

Visi

on: w

hat w

e,

as a

soc

iety

, do

col

lect

ivel

y to

ens

ure

the

cond

ition

s in

w

hich

peo

ple

can

be h

ealth

y (h

ealth

y pe

ople

in h

ealth

y co

mm

uniti

es)

Mis

sion

: to

prom

ote

phys

ical

an

d m

enta

l hea

lth

and

prev

ent

dise

ase,

inju

ry, a

nd

disa

bilit

y

The

orga

nise

d re

spon

se b

y so

ciet

y to

pro

tect

an

d pr

omot

e he

alth

, and

to

prev

ent i

llnes

s,

inju

ry a

nd d

isab

ility

The

scie

nce

and

art o

f pro

mot

ing

heal

th, p

reve

ntin

g di

seas

e,

prol

ongi

ng li

fe a

nd

impr

ovin

g qu

ality

of

life

thro

ugh

the

orga

nize

d ef

forts

of

soc

iety

“Pub

lic h

ealth

is a

n or

gani

zed

effo

rt by

so

ciet

y, pr

imar

ily

thro

ugh

its p

ublic

in

stitu

tions

, to

impr

ove,

pro

mot

e,

prot

ect

and

rest

ore

the

heal

th

of th

e po

pula

tion

thro

ugh

colle

ctiv

e ac

tion.

”

The

art o

f app

lyin

g sc

ienc

e in

the

cont

ext

of p

oliti

cs s

o as

to

redu

ce in

equa

litie

s in

he

alth

whi

le e

nsur

ing

the

best

hea

lth fo

r the

gr

eate

st n

umbe

r

The

key

prin

cipl

es o

f Pu

blic

Hea

lth a

re:

a) fo

cusi

ng o

n th

e he

alth

of c

omm

uniti

es

rath

er th

an in

divi

dual

s,

b) in

fluen

cing

hea

lth

dete

rmin

ants

, c)

prio

ritis

ing

impr

ovem

ents

in M

aori

heal

th, d

) red

ucin

g he

alth

dis

parit

ies,

e)

basi

ng p

ract

ice

on th

e be

st a

vaila

ble

evid

ence

, f)

build

ing

effe

ctiv

e pa

rtner

ship

s ac

ross

the

heal

th s

ecto

r and

oth

er

sect

ors,

g) r

emai

ning

re

spon

sive

to n

ew a

nd

emer

ging

hea

lth th

reat

s.

Publ

ic h

ealth

is th

e sc

ienc

e an

d ar

t of

prev

entin

g di

seas

e,

prol

ongi

ng li

fe a

nd

prom

otin

g he

alth

th

roug

h th

e or

gani

zed

effo

rts o

f soc

iety

Gene

ric

oper

atio

nsEs

sent

ial p

ublic

he

alth

ser

vice

sCo

re fu

nctio

ns fo

r pu

blic

hea

lthSc

ope

of a

m

oder

n pu

blic

he

alth

sys

tem

Es

sent

ial p

ublic

he

alth

func

tions

Core

pub

lic h

ealth

fu

nctio

nsEs

sent

ial p

ublic

he

alth

ope

ratio

ns

1. M

onito

r he

alth

sta

tus

Mon

itor h

ealth

st

atus

to id

entif

y co

mm

unity

hea

lth

prob

lem

s

Asse

ss, a

naly

ze

and

com

mun

icat

e po

pula

tion

heal

th n

eeds

an

d co

mm

unity

ex

pect

atio

ns

Heal

th

surv

eilla

nce,

m

onito

ring

and

anal

yses

Mon

itorin

g, e

valu

atio

n,

and

anal

ysis

of h

ealth

st

atus

Heal

th s

ituat

ion

mon

itorin

g an

d an

alys

isHe

alth

ass

essm

ent a

nd

surv

eilla

nce

Surv

eilla

nce

of

popu

latio

n he

alth

and

w

ell-b

eing

2. D

isea

se

prev

entio

n an

d co

ntro

l

Diag

nose

and

in

vest

igat

e he

alth

pr

oble

ms

and

heal

th h

azar

ds in

th

e co

mm

unity

Prev

ent a

nd c

ontro

l co

mm

unic

able

and

no

n-co

mm

unic

able

di

seas

es a

nd

inju

ries

thro

ugh

risk

fact

or

redu

ctio

n,

educ

atio

n,

scre

enin

g,

imm

uniz

atio

n an

d ot

her i

nter

vent

ions

Inve

stig

atio

n of

di

seas

e ou

tbre

aks,

ep

idem

ics

and

risks

to h

ealth

Surv

eilla

nce,

rese

arch

, an

d co

ntro

l of t

he ri

sks

and

thre

ats

to p

ublic

he

alth

Epid

emio

logi

cal

surv

eilla

nce/

dise

ase

prev

entio

n an

d co

ntro

l

Prev

entiv

e in

terv

entio

nsDi

seas

e pr

even

tion,

in

clud

ing

early

de

tect

ion

of il

lnes

s

3. H

ealth

pr

omot

ion,

em

pow

erin

g co

mm

uniti

es

Info

rm, e

duca

te,

and

empo

wer

pe

ople

abo

ut

heal

th is

sues

Prom

ote

and

supp

ort h

ealth

y lif

esty

les

and

beha

viou

rs

thro

ugh

actio

n w

ith in

divi

dual

s,

fam

ilies

, co

mm

uniti

es a

nd

wid

er s

ocie

ty

Esta

blis

hing

, de

sign

ing

and

man

agin

g he

alth

pr

omot

ion

and

dise

ase

prev

entio

n pr

ogra

ms

Heal

th p

rom

otio

n He

alth

pro

mot

ion,

so

cial

par

ticip

atio

n an

d em

pow

erm

ent

Heal

th p

rom

otio

nHe

alth

pro

mot

ion

incl

udin

g ac

tion

to a

ddre

ss s

ocia

l de

term

inan

ts o

f he

alth

ineq

uity

M

obili

ze

com

mun

ity

partn

ersh

ips

to

iden

tify

and

solv

e he

alth

pro

blem

s

Prom

ote,

dev

elop

, su

ppor

t and

in

itiat

e ac

tions

w

hich

ens

ure

safe

and

hea

lthy

envi

ronm

ents

Enab

ling

and

empo

wer

ing

com

mun

ities

an

d ci

tizen

s to

pr

omot

e he

alth

an

d re

duce

in

equa

litie

s

Soci

al p

artic

ipat

ion

in

heal

th

Ad

voca

cy,

com

mun

icat

ion

and

soci

al m

obili

satio

n fo

r he

alth

Prom

ote,

dev

elop

an

d su

ppor

t he

alth

y gr

owth

an

d de

velo

pmen

t th

roug

hout

all

life

stag

es

4544


3

USA,

199

4 10

Aust

ralia

, 200

0 20

UK, 2

001

21PA

HO/ W

HO *

, 200

2 22

WHO

, WPR

O**

2003

23Ne

w Z

eala

nd, 2

011

24W

HO E

urop

e, 2

012

11

Stre

ngth

en

com

mun

ities

an

d bu

ild s

ocia

l ca

pita

l thr

ough

co

nsul

tatio

n,

parti

cipa

tion

and

empo

wer

men

t

Pr

omot

e, d

evel

op

and

supp

ort

actio

ns to

impr

ove

the

heal

th s

tatu

s of

Abo

rigin

al

and

Tor

es

Stra

it Is

land

er

peop

le a

nd o

ther

vu

lner

able

gro

ups.

4. H

ealth

y pu

blic

pol

icy

Deve

lop

polic

ies

and

plan

s th

at

supp

ort i

ndiv

idua

l an

d co

mm

unity

he

alth

effo

rts

Prom

ote,

dev

elop

an

d su

ppor

t he

alth

y pu

blic

po

licy,

incl

udin

g le

gisl

atio

n,

regu

latio

n an

d fis

cal m

easu

res

Crea

ting

and

sust

aini

ng c

ross

-go

vern

men

tal

and

inte

r-se

ctor

al

partn

ersh

ips

to

impr

ove

heal

th

and

redu

ce

ineq

ualit

ies

Deve

lopm

ent

of p

olic

ies

and

inst

itutio

nal c

apac

ity

for p

ublic

hea

lth

plan

ning

and

m

anag

emen

t

Deve

lopm

ent o

f po

licie

s an

d pl

anni

ng in

pu

blic

hea

lth

As

surin

g go

vern

ance

fo

r hea

lth a

nd w

ell-

bein

g

5. H

ealth

pr

otec

tion

Enfo

rce

law

s an

d re

gula

tions

that

pr

otec

t hea

lth a

nd

ensu

re s

afet

y

Prom

ote,

dev

elop

an

d su

ppor

t he

alth

y pu

blic

po

licy,

incl

udin

g le

gisl

atio

n,

regu

latio

n an

d fis

cal m

easu

res

Ensu

ring

com

plia

nce

with

re

gula

tions

and

la

ws

to p

rote

ct

and

prom

ote

heal

th

Stre

ngth

enin

g of

pub

lic h

ealth

re

gula

tion

and

enfo

rcem

ent c

apac

ity

Regu

latio

n an

d en

forc

emen

t to

prot

ect

publ

ic h

ealth

Heal

th p

rote

ctio

nHe

alth

pro

tect

ion

incl

udin

g en

viro

nmen

tal.

occu

patio

nal,

food

sa

fety

and

oth

ers

Cont

inua

tion

of T

able

1

6. R

esea

rch

and

deve

lopm

ent

Rese

arch

for

new

insi

ghts

an

d in

nova

tive

solu

tions

to h

ealth

pr

oble

ms

Re

sear

ch,

deve

lopm

ent,

eval

uatio

n an

d in

nova

tion

Rese

arch

in p

ublic

he

alth

Rese

arch

, dev

elop

men

t an

d im

plem

enta

tion

of

inno

vativ

e pu

blic

hea

lth

solu

tions

Ad

vanc

ing

publ

ic

heal

th re

sear

ch to

in

form

pol

icy

and

prac

tice

7. C

ompe

tent

w

orkf

orce

Assu

re a

co

mpe

tent

pu

blic

hea

lth a

nd

pers

onal

hea

lth

care

wor

kfor

ce

Plan

, fun

d, m

anag

e an

d ev

alua

te

heal

th g

ain

and

capa

city

bui

ldin

g pr

ogra

ms

desi

gned

to

ach

ieve

m

easu

rabl

e im

prov

emen

ts

in h

ealth

st

atus

, and

to

stre

ngth

en s

kills

, co

mpe

tenc

ies,

sy

stem

s an

d in

frast

ruct

ure

Deve

lopi

ng a

nd

mai

ntai

ning

a

wel

l-edu

cate

d an

d tra

ined

, mul

ti-di

scip

linar

y pu

blic

he

alth

ser

vice

Hum

an re

sour

ces

deve

lopm

ent a

nd

train

ing

in p

ublic

he

alth

Hum

an re

sour

ces

deve

lopm

ent a

nd

plan

ning

in p

ublic

he

alth

Publ

ic h

ealth

cap

acity

de

velo

pmen

tAs

surin

g a

suffi

cien

t an

d co

mpe

tent

pub

lic

heal

th w

orkf

orce

8. Q

ualit

y as

sura

nce

of

publ

ic h

ealth

se

rvic

es

Eval

uate

ef

fect

iven

ess,

ac

cess

ibili

ty, a

nd

qual

ity o

f per

sona

l an

d po

pula

tion-

base

d he

alth

se

rvic

es

Plan

, fun

d, m

anag

e an

d ev

alua

te

heal

th g

ain

and

capa

city

bui

ldin

g pr

ogra

ms

desi

gned

to

ach

ieve

m

easu

rabl

e im

prov

emen

ts

in h

ealth

st

atus

, and

to

stre

ngth

en s

kills

, co

mpe

tenc

ies,

sy

stem

s an

d in

frast

ruct

ure

Qual

ity a

ssur

ing

the

publ

ic h

ealth

fu

nctio

n

Eval

uatio

n an

d pr

omot

ion

of e

quita

ble

acce

ss to

nec

essa

ry

heal

th s

ervi

ces

Stra

tegi

c m

anag

emen

t of

hea

lth s

yste

ms

and

serv

ices

for p

opul

atio

n he

alth

gai

n

As

surin

g su

stai

nabl

e or

gani

zatio

nal

stru

ctur

es a

nd

finan

cing

4746


3

USA,

199

4 10

Aust

ralia

, 200

0 20

UK, 2

001

21PA

HO/ W

HO *

, 200

2 22

WHO

, WPR

O**

2003

23Ne

w Z

eala

nd, 2

011

24W

HO E

urop

e, 2

012

11

En

surin

g th

e ef

fect

ive

perfo

rman

ce o

f NH

S se

rvic

es to

m

eet g

oals

in

impr

ovin

g he

alth

, pr

even

ting

dise

ase

and

redu

cing

in

equa

litie

s

Qual

ity a

ssur

ance

in

per

sona

l and

po

pula

tion-

base

d he

alth

ser

vice

s

Ensu

ring

the

qual

ity

of p

erso

nal a

nd

popu

latio

n-ba

sed

heal

th s

ervi

ces

9. P

ublic

he

alth

em

erge

ncy

resp

onse

Re

duct

ion

of th

e im

pact

of e

mer

genc

ies

and

disa

ster

s on

he

alth

Mon

itorin

g a

nd

resp

onse

to h

ealth

ha

zard

s an

d em

erge

ncie

s

10.

Link

peo

ple

to

need

ed p

erso

nal

heal

th s

ervi

ces

and

assu

re

the

prov

isio

n of

hea

lth c

are

whe

n ot

herw

ise

unav

aila

ble

* PA

HO/W

HO: P

an A

mer

ican

Hea

lth O

rgan

isat

ions

/ Wor

ld H

ealth

Org

anis

atio

n

** W

HO W

PR: W

orld

Hea

lth O

rgan

isat

ion

in th

e W

este

rn P

acifi

c Re

gion

The Netherlands

In Table 2, the first column presents the generic EPHOs that resulted from the comparison

of the international examples; the second presents the proposal for EPHOs in the

Netherlands, the third gives examples of these tasks in daily practice and the last column

shows organisations that deliver those services.

We compared the generic EPHOs with the Dutch Public Health Act and the existing

practice guidelines of preventive youth healthcare and infectious disease control, to

assess the validity for the Netherlands. We also used existing professional profiles and

the position paper of public health physicians that was published in 2012. [25] These

comparisons showed that the generic EPHOs are also valid for the Netherlands. The main

operations provided by Dutch public health professionals fitted within the framework of

generic operations, as did the organisations that deliver these operations. However, one

public health service did not fit within the framework, i.e. providing a ‘health safety net’

is an important operations of Dutch local public health services but did not appear in

the generic operations that emerged from the comparison of the international examples.

However, it does fit with the USA operation ‘Link people to needed personal health

services and assure the provision of health care when otherwise unavailable’. ‘Providing

a health safety net’ includes the care for vulnerable and fragile groups who are not

reached by regular healthcare services or for whom regular health services are difficult

or impossible to access; an example of this operation is the care for homeless people.

Therefore, we extended the generic operations with the additional operation ‘providing a

health safety net’.

Table 2 (fourth column) provides an overview of organisations that provide the public

health operations. It is noteworthy that some operations are also provided by organisations

outside public health: e.g. operation 2, ‘disease prevention’, is also carried out by general

practitioners when, for example, they provide the yearly influenza vaccinations. EPHO

3, ‘health promotion’, is also provided by e.g. midwives who promote a healthy lifestyle

among pregnant women. Some operations are delivered in collaboration with medical

care, for example preparedness for a public health emergency. Although local public

health services are basically responsible for this service, in case of emergencies there

is close collaboration with, for example, general practitioners, ambulance services, and

emergency departments of hospitals.

In view of these results, the question remains: what is the overall definition or aim of public

health? The Dutch Public Health Act defines public health as: …health protection and

health promotion activities addressing the population or parts of the population, including

disease prevention. This definition contains two of the three common elements of the

aim of public health that resulted from the international analysis: a population focus and

disease prevention. However, because the collective approach is missing, we propose to

add this element to the definition.

Cont

inua

tion

of T

able

1

4948


3

Tabe

l 2 |

Publ

ic h

ealth

in th

e Ne

ther

land

s, i

n Ne

derla

nd: k

ernt

aken

en

wer

kvel

d

Gene

ric E

PHOs

Prop

osed

EPH

Os fo

r the

Net

herla

nds

Exam

ples

in th

e Ne

ther

land

s (1

)Or

gani

satio

ns p

rovi

ding

the

EPHO

s (1

)

1M

onito

r hea

lth s

tatu

sM

onito

ring

popu

latio

n he

alth

and

wel

lbei

ng; t

o fe

ed in

form

atio

n to

hea

lth n

eeds

ass

essm

ents

, he

alth

impa

ct a

sses

smen

ts a

nd p

lann

ing

for

heal

th s

ervi

ces

Surv

eilla

nce

syst

ems

and

regi

strie

s fo

r (no

n)co

mm

unic

able

dis

ease

sLo

cal p

ublic

hea

lth s

ervi

ces,

occ

upat

iona

l hea

lth

serv

ices

, you

th h

ealth

org

anis

atio

ns, N

atio

nal

inst

itute

for p

ublic

hea

lth a

nd th

e en

viro

nmen

t (R

IVM

)

2Pu

blic

hea

lth e

mer

genc

y re

spon

se

Publ

ic h

ealth

em

erge

ncy

resp

onse

; in

orde

r to

mon

itor h

ealth

haz

ards

so

that

risk

s ca

n be

as

sess

ed.

Prep

arin

g fo

r em

erge

ncie

s lik

e pr

even

tion

of

heal

th e

ffect

s of

hea

t-w

aves

Loca

l pub

lic h

ealth

ser

vice

s, g

ener

al

prac

titio

ners

, am

bula

nce

care

, em

erge

ncy

care

de

partm

ent h

ospi

tals

3He

alth

pro

tect

ion

Heal

th p

rote

ctio

n; to

pro

tect

hea

lth fr

om

dise

ases

and

env

ironm

enta

l ris

ks a

nd h

azar

ds.

Legi

slat

ion

for a

sses

sing

food

saf

ety

Natio

nal g

over

nmen

t; M

inis

tery

of H

ealth

, W

elfa

re a

nd S

port,

Min

istr

y of

Soc

ial A

ffairs

an

d Em

ploy

men

t, Th

e Ne

ther

land

s Fo

od a

nd

Cons

umer

Pro

duct

Saf

ety

Auth

ority

4He

alth

pro

mot

ion,

em

pow

erin

g co

mm

uniti

esHe

alth

Pro

mot

ion

incl

udin

g em

pow

erin

g co

mm

uniti

es; t

o pr

omot

e po

pula

tion

heal

th a

nd

wel

l-bei

ng

The

deve

lopm

ent,

impl

emen

tatio

n an

d ev

alua

tion

of p

olic

ies

to p

rom

ote

heal

thy

diet

s an

d to

pre

vent

ove

rwei

ght a

nd o

besi

ty,

or im

prov

ing

heal

th li

tera

cy a

nd h

ealth

sta

tus

of in

divi

dual

s an

d po

pula

tions

.

Loca

l pub

lic h

ealth

ser

vice

s, o

ccup

atio

nal h

ealth

se

rvic

es, h

ealth

pro

mot

ing

inst

itute

s, m

idw

ives

5Di

seas

e pr

even

tion

and

cont

rol

Dise

ase

prev

entio

n an

d co

ntro

le, i

nclu

ding

ear

ly

dete

ctio

n of

dis

ease

; to

prev

ent d

isea

se th

roug

h pr

even

tive

actio

ns.

Prov

ide

vacc

inat

ion

prog

ram

mes

, org

anis

ed

scre

enin

g pr

ogra

mm

esLo

cal p

ublic

hea

lth s

ervi

ces,

occ

upat

iona

l he

alth

ser

vice

s, y

outh

hea

lth c

are

orga

nisa

tions

, Na

tiona

l ins

titut

e fo

r pub

lic h

ealth

and

the

envi

ronm

ent (

RIVM

), ge

nera

l pra

ctiti

oner

s,

hosp

itals

, scr

eeni

ng o

rgan

isat

ions

6He

alth

y pu

blic

pol

icy

Heal

thy

publ

ic p

olic

ies

and

to e

nsur

e th

at p

ublic

he

alth

ser

vice

s ar

e w

ell g

over

ned

and

mai

ntai

n ac

coun

tabi

lity,

qual

ity a

nd e

quity

.

Mob

ilizi

ng a

ctio

n fo

r hea

lth a

nd h

ealth

equ

ity

in lo

cal p

olic

ies

Loca

l gov

ernm

ents

, nat

iona

l gov

ernm

ent,

loca

l pu

blic

hea

lth s

ervi

ces

7Co

mpe

tent

wor

kfor

ceAs

surin

g a

suffi

cien

t and

com

pete

nt p

ublic

he

alth

wor

kfor

ce; t

o en

sure

that

ther

e is

a

rele

vant

and

com

pete

nt p

ublic

hea

lth w

orkf

orce

su

ffici

ent f

or th

e ne

eds

of th

e po

pula

tion.

Educ

atio

n, tr

aini

ng, d

evel

opm

ent a

nd

eval

uatio

n of

the

publ

ic h

ealth

wor

kfor

ce.

Univ

ersi

ties,

pub

lic h

ealth

trai

ning

inst

itute

s,

asso

ciat

ions

of p

rofe

ssio

nals

, Cap

acite

itsor

gaan

/ V

WS

8Qu

ality

of h

ealth

ser

vice

sEn

forc

emen

t of t

he q

ualit

y of

pub

lic

heal

th s

ervi

ces

and

assu

ring

sust

aina

ble

orga

nisa

tiona

l stru

ctur

es; t

o en

sure

sus

tain

able

or

gani

satio

ns a

nd fi

nanc

ing

for p

ublic

hea

lth

to p

rovi

de e

ffect

ive,

acc

essi

ble,

and

qua

litat

ive

se

rvic

es.

Effe

ctiv

e en

forc

emen

t of t

he q

ualit

y of

hea

lth

serv

ices

by

the

heal

th c

are

Insp

ecto

rate

Heal

th c

are

Insp

ecto

rate

, ass

ocia

tions

of

prof

essi

onal

s, lo

cal o

rgan

isat

ions

9Re

seac

h an

d de

velo

pmen

tAd

vanc

ing

publ

ic h

ealth

rese

arch

to in

form

po

licy

and

prac

tice;

to e

nsur

e th

at re

sear

ch

findi

ngs

are

used

to im

prov

e ev

iden

ce-in

form

ed

polic

y an

d pr

actic

e.

Deve

lopm

ent o

f new

rese

arch

met

hods

or

inno

vativ

e so

lutio

ns in

pub

lic h

ealth

Un

iver

istie

s, re

sear

ch in

stitu

tes,

loca

l pub

lic

heal

th s

ervi

ces

10 A

dded

: hea

lth s

afet

y ne

tPr

ovid

ing

a he

alth

saf

ety

net

Heal

th c

are

for h

omel

ess

peop

leLo

cal p

ublic

hea

lth s

ervi

ces

1. M

acke

nbac

h JP

, Stro

nks

K. V

olks

gezo

ndhe

id e

n ge

zond

heid

szor

g (6

e dr

.). H

fdst

k 8.

Am

ster

dam

: Ree

d Bu

sine

ss; 2

012.

5150


3

We also propose to add a focus on ‘inequalities in health’. Health inequalities have

traditionally always been a major concern of public health. For example, in the 19th

century Virchow (in Prussia) and Sarphati (in Amsterdam) were well-known public

health figures who addressed the social determinants of health and the resulting health

inequalities. (26,27) Although population health status has dramatically improved since

then, large differences in health still exist between people with a high or a low educational

level, which supports the need to add an extra focus on health inequalities, as in other

international examples. (28,29) Therefore, we propose the following definition as the aim

of public health in the Netherlands: ‘To promote health and an equal distribution of health

through population-based interventions aimed at protecting and promoting health and

preventing disease’.

DISCUSSION

The international comparison revealed many similarities between the aims and EPHOs

in different countries. This implies that these core functions are largely independent of

the health system or country in which they are performed. Therefore, we can use it to

formulate a definition and core functions for public health in the Netherlands. Important

principles of public health include the population-oriented, prevention-oriented and

collective approach. The international framework was useful to describe public health in

the Netherlands but we added the provision of a ‘health safety net’ function. In line with

the international examples we also propose to include the aim ‘equal opportunities in

health’ in the definition of public health in the Netherlands.

EPHOs are independent of the position of public health in the healthcare system, and of

the professional who performs them and raises the question as to who may best perform

these EPHOs. Our study showed that the answer to this question extends beyond the

traditional boundaries of the field of public health and supports that there is an inherently

strong association between public health and medical care physicians, i.e. their work aims

at the realisation of (partly) the same tasks. (30) General practitioners who comply with

the guidelines of cardiovascular risk management can serve as an example. Therefore

we emphasise the importance of adequate attention being paid to public health during

medical education, so that all healthcare professionals are sufficiently trained in the

content and tasks of public health.

Our approach also had some limitations. For example, in the international comparison

we may have missed some goals and/or examples of core tasks. However, due to the

considerable degree of similarity between the different systems and the large number

of countries represented in the WHO documents, this is not likely to have an important

impact on our results.

Because of our background in the working field of public health physicians [artsen

maatschappij & gezondheid], the examples provided in this paper were mainly derived

from the working field of public health physicians, however, the definition and essential

operations of public health are also applicable to the working field of insurance- and

occupational health physicians. [Verzekerings- en Bedrijfsartsen]

CONCLUSIONS

We presented a definition of public health and of essential public health operations

for The Netherlands. Public health focuses on promoting population health, an equal

distribution of health, and is based on collective interventions. The EPHOs extend beyond

the recognised institutions or professional domains, e.g. EPHOs are also provided by

professionals working in medical care. EPHOs provide a basis for the development of

public health in the Netherlands, and support the provision of adequate public health

operations and the training of sufficient numbers of adequately trained professionals to

deliver them.

ACKNOWLEDGEMENTS

The authors thank the professional workforce planning team of the Netherlands Public

Health Federation for their contribution to the design of the analyses and interpretation

of the results.

5352


3

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2010 Van gezond naar beter. Bilthoven: RIVM; 2010. www.vtv2010.nl



87(7):837-839.

CHAPTER 4How to characterize the public health workforce based on essential public health operations? Environmental public health workers in the Netherlands as an example

M. Jambroes, R. van Honschooten, J. Doosje,

K. Stronks, M.L. Essink-Bot

This chapter was published as:

How to characterize the public health workforce based on

essential public health operations? environmental public health

workers in the Netherlands as an example.

BMC Public Health 2015, 15:750

5756

How to characterize the public health workforce based on essential public health operations? Chapter 4

4

ABSTRACT

Background

Public health workforce planning and policy development require adequate data on

the public health workforce and the services provided. If existing data sources do not

contain the necessary information, or apply to part of the workforce only, primary data

collection is required. The aim of this study was to develop a strategy to enumerate

and characterize the public health workforce and the provision of essential public health

operations (EPHOs), and apply this to the environmental public health workforce in the

Netherlands as an example.

Methods

We specified WHO’s EPHOs for environmental public health and developed an online

questionnaire to assess individual involvement in these. Recruitment was a two-layered

process. Through organisations with potential involvement in environmental public health,

we invited environmental public health workers (n=472) to participate in a national survey.

Existing benchmark data and a group of national environmental public health experts

provided opportunities for partial validity checks.

Results

The questionnaire was well accepted and available benchmark data on physicians

supported the results of this study regarding the medical part of the workforce. Experts

on environmental public health recognized the present results on the provision of EPHOs

as a reasonable reflection of the actual situation in practice.

All EPHOs were provided by an experienced, highly educated and multidisciplinary

workforce. 27% of the total full-time equivalents (FTEs) was spent on EPHO ‘assuring

governance for health’. Only 4% was spent on ‘health protection’. The total FTEs were

estimated as 0.66 /100,000 inhabitants.

Conclusions

Characterisation of the public health workforce is feasible by identification of relevant

organisations and individual workers on the basis of EPHOs, and obtaining information

from those individuals by questionnaire. Critical factors include the operationalization of

the EPHOS into the field of study, the selection and recruitment of eligible organisations

and the response rate within organisations.. When existing professional registries are

incomplete or do not exist, this strategy may provide a start to enumerate the quantity

and quality of the public health within or across countries.

BACKGROUND

Recently, the review of the public health capacity in Europe in 2013 by the European

Commission Directorate General for Health and Consumers showed uncertainty regarding

the capacity of the public health workforce in Europe. (1) Adequate data on the size and

composition of the actual workforce are needed to support workforce planning and policy

development, in order to guarantee sufficient and competent workers in the future. (2-4)

Measuring the public health capacity is hence an important but challenging task.

Strategies to enumerate the public health workforce have been subject of scientific

debate for many years. (5-10) Efforts to develop information about the public health

workforce encountered major obstacles, including uncertain boundaries of the field of

public health, and the multidisciplinary workforce in combination with the absence of

credential requirements for most of the disciplines involved. (1, 11, 12)

Until now, most efforts to enumerate the public health workforce are based on existing

data sources, see for example the USA centers of excellence in public health workforce

studies focusing on the governmental public health workforce, and the recently published

study on characterization of the federal workforce at the Centers of Disease Control and

Prevention. (13-16)

However, the limitations of using existing databases for public health workforce

enumeration are known and have been emphasised. (1, 17, 18) For instance, disparate

job titles of public health professionals are a drawback, because not all job titles are

accurately labelled as ‘public health’ in the different data sources. (19) Also, registrations

use different definitions of public health workers, different disciplines are often registered

in different registries and not all disciplines or workplace settings are represented in the

databases.

If existing data sources do not contain the necessary information, or apply to part of the

workforce only, primary data collection is essential for accurate characterization of the

workforce. To date, no standard strategy for this primary data collection exists.

Therefore we developed a strategy aiming to 1) assess the size and composition of

the multidisciplinary public health workforce across different organisations, and 2) to

assess the services provided. We applied our strategy to the environmental public health

workforce in the Netherlands as an example.

Environmental public health focuses on the interactions with and effects of the environment

on health, e.g. indoor and outdoor pollution and chemical safety. Environmental public

health is a relatively small discipline within the public health working field in the Netherlands

and is mainly but not exclusively performed through local public health services (see

Textbox 1) by a very multi-disciplinary workforce, among which physicians. The total size

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4

and composition of this workforce is unknown. However, there is a compulsory registry for

physicians and the total number of environmental public health workers working at local

public health services is known. Additional data relevant for workforce planning about

age, educational background, job function and provision of services are not available.

The aim of the present study was to examine the feasibility and validity of our newly

developed strategy to enumerate the public health workforce and the services provided,

by applying it to environmental public health workforce as an example.

METHODS

General study design

A national cross-sectional survey was conducted using an online questionnaire.

To assess the services provided by the workforce we used the recently defined essential

public health operations (EPHOs) by the World Health Organisation in Europe (WHO Eur).

(20) The EPHOs describe the main tasks of public health and can be used as a unifying

and guiding basis to monitor and evaluate policies, strategies and actions for reforms and

improvement in public health.

The environmental public health workforce was defined as all workers who contribute

to the delivery of environmental public health. We made this definition operational

as: all those who consider environmental public health as part of their job and who

are responsible for providing any of the EPHOs for (on average) ≥ 0.5 h/week. This

small number of hours per week was chosen to capture all disciplines and services

provided. For example, the work of the health care inspectorate includes promotion

of public health and responsible care through effective enforcement of the quality of

health services. For environmental public health these services are delivered only 2-3

weeks per year.

As the EPHOs are not yet implemented in public health practice in the Netherlands,

we operationalized the EPHOs to environmental public health using existing policy

documents, e.g. from the professional organisation of environmental public health

physicians, guidelines on the size of the environmental public health workforce and

the most recent advice of the Advisory Committee on Medical Manpower planning

(‘Capaciteitsorgaan’) on the training inflow of environmental public health physicians. (21)

We also involved a group of 5 national environmental public health experts who agreed

on the resulting specifications. Based on the documents and the expert opinions, we

made some changes to the EPHOs: EPHO ‘advocacy communication and mobilisation

for health’ was combined with EPHO ‘health promotion’. We decided to combine these

two EPHOs as ‘advocacy communication and mobilisation for health’ according to WHO

eur contains improving health literacy and enhancing population’s capacity to access,

understand and use information to reduce risk or prevent disease. (22) These kind of

activities are part of health promotion in the Netherlands. ‘Regional consultation and

support’ was added as EPHO as some local public health services fulfil this specific role

for other local public health services. A description of environmental public health and the

EPHOs is presented in Table 1.

According to Dutch law, formal ethical approval was not required, but we took every effort

to effectively inform the respondents and protect their privacy.

Development of the questionnaire

The questionnaire was developed based on a review of literature, interviews with public

health experts and consultation with other researchers and contained 20 items divided

into three parts:

1. Eligibility and socio-demographic variables: Is environmental public health part of

your job and do you spend more than 0.5 hours per week on average on environmental

public health tasks? The questionnaire ended if a respondent did not fulfil these

criteria. Items on age, gender and educational background (level and discipline,

specific training in environmental public health) completed this section.

2. Job characteristics: Type of organisation, job title, and number of years of work

experience in the current job.

3. EPHOs: For each separate EPHO, respondents were asked to indicate explicitly if

they delivered this operation, and if yes, the average time spent on each of them

per week. To facilitate completing this part of the questionnaire examples of

daily environmental public health practice were added to each of the EPHOs, see

Table 1. Finally, respondents were asked whether they had enough time to perform

these operations.

Testing of the practicality of the questionnaire among all employees of a local public

health service (n=217) resulted in some modification of the wording and the order of

some items For the present study the adapted version was used. After some adaptations

based on a pre-test of this questionnaire among 5 environmental public health workers,

the questionnaire took about 10 min to complete.

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4

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4

Recruitment of participants

Potential respondents were selected in a two-layered recruitment strategy. First we

identified all organisations likely to conduct environmental public health tasks and

second, within these, we invited all workers considered to be performing environmental

public health.

To enhance recruitment across organisations and of as many employees and disciplines

substantially involved in environmental public health, we composed two complementary

mailing lists. In the first mailing list (core group; n=182), we included all workers of the

departments of environmental public health of the local public health services. Then,

we explored who might also be likely performing environmental public health EPHOs

outside the department of environmental public health of the local public health services,

and included those addresses in the second mailing list (peripheral group; n=290). For

example, in order to recruit respondents involved in EPHOs ‘surveillance’ and ‘health

promotion’ we approached all workers from the divisions of epidemiology and health

promotion of the local public health services. Similarly, we approached direct network

contacts, like employees of the Ministry of Health, Welfare and Sport, environmental

public health workers from the National Institute for Public Health and the Environment

and departments of public health of two universities in order to recruit workers involved in

EPHO ‘advancing public health research’ and EPHO ‘governance for health’.

Both mailing lists were composed in collaboration with environmental public health

experts and the national association organisation of all local public health services

(GGDGHOR-Netherlands, textbox 1). This organisation supports environmental public

health practice, policy and research from a national perspective and maintains a good

overview of the national environmental public health network.

Data collection strategy

The survey was performed in March 2013. The invitation to participate in the survey was

distributed by e-mail to 472 workers. The invitation emphasized voluntary participation

and responses would be confidential. The e-mail contained a link to a secured website

where they could complete the electronic questionnaire. (23) In the week after the

invitation, two reminders were sent to the non-responders. After two weeks the database

was closed, data were downloaded, and the analyses were performed with SPSS 14.0.

Analysis

Feasibility

The feasibility of the measurement strategy was assessed by:

- The complete response rate;

- The number of partial respondents (defined as respondents who started the

questionnaire without completing it);

- Remarks added by respondents.

Validity checks

External data provided the opportunity to check aspects of the validity of the strategy.

a) Existing benchmark data for specific groups: environmental public health physicians

and the total capacity of environmental public health workers at the local public health

departments:

- The assessment of the capacity of environmental public health physicians in 2010

by the Advisory Committee on Medical Manpower Planning; the total capacity was

14 physicians. (21)

- The total capacity of environmental public health workers within local public health

departments was enumerated in 2011; the total capacity was 75.5 FTEs.

b) Feedback on the results from national experts on environmental public health, as a test

of face validity.

The group of 5 national experts consisted of representatives of the medical environmental

public health professional organisations, the national association of all local public health

services and two managers of departments of environmental public health from two

local public health services. We organised a group session with the experts and after we

presented the results we asked the experts to give feedback on:

- Whether they recognized the data on the size and composition of the workforce;

- Whether the EPHO profile was a reasonable reflection of the actual situation

in practice.

Size, composition and services provided

Characteristics of the composition of the workforce included, gender, educational level

and background, specific training in environmental public health, work setting, job title,

and years of work experience in the current job title.

The size of the workforce was calculated in full-time equivalents (FTEs): In the Netherlands,

36 working hours/week constitutes 1 FTE.

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4

For a tentative estimation of the total FTEs of the national environmental public health

workforce, we assumed that:

- All non-responders from the peripheral group were not involved in environmental

public health for more than 0.5 h/week

- The proportion of environmental public health workers among the respondents of the

core group was the same as among the non-responders of the core group

Environmental public health workers among the non-responders of the core group spent

a similar number of working hours on environmental essential public health operations

as respondents of the core group. To gain insight into the services provided by the

professionals, we assessed which of the EPHOs they provided and for how many hours

per week. The distribution of FTEs over the EPHOs was calculated as the sum of all the

hours spent per EPHO, divided by 36.

RESULTS

Feasibility

The response rate among the local public health services was 100%. Within the

organisations, the response rate of individual workers was 70% (127/182) in the core

group and 28% (81/290) in the peripheral group. After exclusion of respondents who

reported not to be involved in environmental public health or who reported spending ≤

0.5 h/week (n=59), and double (n=26) and partial respondents (n=14), 129 questionnaires

were available for analysis: 112 from the core and 17 from the peripheral group. As the

characteristics of both respondent groups were similar for educational background, job

titles and involvement on EPHOs, we combined the data from these two groups.

Of all respondents, 26 added remarks to the questionnaire. Of these, 6 indicated that the

number of hours spent per EPHO was difficult to estimate and 3 reported not to recognize

the EPHOs as a reflection of their daily practice. The other comments were personal

additions to the answers.

Validity checks

Existing benchmark data:

- Our data showed that 28 respondents were physicians, of which 10 had been

trained and registered as environmental public health physicians. Data from the

Advisory Committee on Medical Manpower Planning (‘Capaciteitsorgaan’) showed

14 registered environmental public health physicians in 2010. As all 14 environmental

public health physicians were included and invited in the core group, we assumed

that the difference was explained by non-response of 4 physicians in our survey,

corresponding with the 70% response rate in the core group.

- Local public health services: The total number of 97 FTEs in our study exceeded the

number of 75.5 FTEs from existing reference data. According to the expert group,

this could partly be explained because the reference study focused on employees

working at the environmental public health department of the local public health

services only, whereas our study also included employees from other departments

of the local public health services and other organisations.

National experts in the field of environmental public health indicated that the data

were recognizable as a reasonable reflection of the actual situation with regard to

educational background, employment setting, task differentiation and the provision

of EPHOs.

- The experts recognized that the majority of the workforce was trained at university

level or higher.

- They also found that the amount of FTEs provided outside the local public health

services was plausible. The finding that respondents with a lower educational

background spent more time on the EPHOs ‘surveillance’, ‘disease prevention’

and ‘health promotion’, whereas physicians spent more time, e.g., on ‘assuring

governance for health’ and ‘advancing research’ was, according to the experts a

valid reflection of the situation in daily practice.

- Finally, the distribution pattern of the FTEs over the EPHOs was in line with the

expectations of the experts. The results showed more capacity for the EPHOs

focusing on daily environmental public health problem-solving, like ‘assuring

governance for health’, ‘disease prevention’ and ‘health promotion’, than on the

more supportive EPHOs like ‘assuring sustainable organisational structures’ and

‘assuring a competent workforce’. According to the experts this is in line with the

actual situation, although the experts had expected more capacity spent on ‘assuring

governance for health’.

Composition of the environmental public health workforce

Of all respondents, the mean age was 46 years (SD 10.2), 64% was female, 71% had

special training for environmental public health, 59% had ≥ 5 years working experience

in their current job, and 80% was educated at university level (or higher) with various

disciplinary backgrounds (e.g. medicine, nursing, toxicology, biology, and environmental

hygiene) (Table 2). Respondents had multiple different job titles. Of the primary job titles

79% could be classified in 5 main categories (policy advisor, environmental public health

physician, environmental public health nurse, environmental public health advisor, and

environmental public health emergency expert); the remaining 21% consisted of 22

different job titles.

28 Respondents were physician, 10 were trained as environmental public health physician,

10 were trained as public health physician and 8 were physicians ‘other’, of which 6 were

in training for environmental public health physician.

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4

Of all respondents, 92% were working in local public health services, 13% worked outside

the local public health services (e.g. university, Ministry, or research institute), some had

multiple work settings, and 45% were working in environmental public health and in other

domains (e.g. infectious disease control).

Table 2 | Characteristics of the environmental public health workforce in the Netherlands

Total (n=129)

Gender, female N (%) 83 (64)

Age, yrs (SD) 46.1 (±10.2)

Number of years in current job (%)

< 1 yr 6 (5)

1 - 5 yrs 47 (36)

6 - 10 yrs 42 (33)

> 10 yrs 34 (26)

Working hours/week hrs (SD) 30 (±7.1)

Working hours/week environmental public health hrs (SD) 22 (±11.4)

Education N (%)

≤Senior secondary vocational education and training 2 (2)

Professional eduction, applied science 24 (19)

University level 65 (50)

Post university level 38 (29)

Physicians N (%) 28 (22)

Environmental public health physician 10 (8)

General public health physician 10 (8)

Physician 8 (6)

Organizational setting N (%)*

Local public health service 118 (92)

National 8 (6)

Municipality 4 (3)

University 3 (2)

Other 3 (2)

Special training for Environmental Public Health n (%)

Yes 92 (71)

No 37 (29)

Services provided by the environmental public health workforce

Figure 1 shows the distribution of the capacity across the 10 EPHOs. All EPHOs were

provided; most FTEs were spent on the essential operations ‘Surveillances of (the

determinants of) population (environmental) health and wellbeing’ and ‘assuring

governance for health’ and the least FTEs were spent on the EPHOs ‘health protection’ and

‘assuring sustainable organisational structures’. See table 3 for the specific percentages

and the average hours per week spent per EPHO.

Compared to environmental public health physicians, environmental public health nurses

were less often involved in performing the EPHOs , ‘Advancing research’ and ‘regional

consultation and support’ (table 3).

Table 3 | Specification of percentage FTE-, time of physicians and nurses and, hours per week per essential environmental

public health operation

% total

FTEAverage hrs/wk

(SD)% time

physician% time nurse

1Surveillances, evaluation, and analysis of (the determinants of) environmental health and wellbeing

15 4.4 (5.1) 8.8 22

2Monitoring and response to environmental health hazards and emergencies

7 1.9 (2,7) 8.4 3.3

3Health protection, enforce laws and regulations that protect environmental health and ensure safety

4 1.9 (2.5) 5.6 1.5

4Health promotion, including action to address social determinants, health inequity and health literacy

6 1.8 (1.9) 4.8 10.2

5Disease prevention, diagnosis and investigation of environmental health problems and health hazards

14 4.6 (5.7) 8.9 34.3

6Assuring governance for health, support environmental health public policy

27 8.4 (4.5) 26.2 9,6

7Assuring a sufficient and competent environmental public health workforce

6 1.8 (1.9) 9.6 5.9

8Assuring sustainable organisational structures, enforcement of the quality of health services

4 1.3 (1.3) 2.8 8.9

9Advancing research and development on environmental public health

9 3.5 (5.3) 11.4 2.4

10 Regional consultation and support 9 3.9 (5.0) 13.5 1.8

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4

Figure 1 | Percentage of full time equivalents per environmental essential public health operation

1 Surveillance, evaluation, and analysis of (the determinants of) environmental health and wellbeing

2 Monitoring and response to environmental health hazards and emergencies

3 Health protection, enforce laws and regulations that protect environmental health and ensure safety

4 Health promotion including empowering communities

5 Disease prevention, diagnosis and investigation of environmental health problems and health hazards

6 Assuring governance for health, support environmental health public policy

7 Assuring a sufficient and competent environmental public health workforce

8 Assuring sustainable organisational structures, enforcement of the quality of (public) health services

9 Advancing research and development on environmental public health

10 Regional consultation and support

Total size of the environmental public health workforce

The total capacity of the environmental public health workforce was estimated at 110

FTEs (range 79-152 FTEs) or 0.66 FTE per 100,000 inhabitants. Of the total FTEs, 97%

(96 FTEs) was provided through the local public health services and 13 FTEs through

other organizations.

DISCUSSION

We developed and applied a strategy to enumerate the size and composition of the general

public health workforce and the services provided, on the basis of actual involvement

in EPHOs. Quantitative estimates of self-reported individual respondents’ actual

involvement in EPHOs collected through an online survey proved to be a useable source

for national estimates of the environmental public health workforce. The questionnaire

was well accepted and available benchmark data on physicians and the total number

of environmental public health professionals working at local public health services

supported the validity of the results emerging from the present study. In the Netherlands,

the total size of the environmental public health workforce was estimated at 0.66/100,000

inhabitants. The EPHOs were provided through different organizations and performed by

an experienced, highly educated and multidisciplinary workforce.

Our strategy started by specifying the EPHOs to environmental public health, followed

by identifying the organizations and individuals considered to be involved in delivery of

environmental public health. Because this resulted in inclusion of workers outside local

public health service and from other disciplines than environmental public health as well,

the estimation of the total capacity for environmental public health was – as expected

- higher than previously estimated on the basis of registries. Furthermore the reference

data were from 2011, and might explain a difference in workforce size as well.

In addition, our strategy resulted not only in data on the number of workers, but also

in additional data on the composition of the workforce, educational background and

the provision of EPHOs. Our study clearly demonstrates the multi-disciplinarity of the

workforce in terms of educational degree as well as in background. Only 22% of the

respondents was physician and the remainder had various educational backgrounds. The

current health human resource planning model used in the Netherlands by the Advisory

Committee on Medical Manpower planning (‘Capaciteitsorgaan’) is a mono-professional

model to estimate the training inflow of physicians, including environmental public health

physicians. Taking our results into account, implies that central workforce planning is only

targeting 22% of the total workforce. (21) To address the whole workforce health human

resource planning should be integrated.

Our study also revealed data on the EPHOs provided, by whom and for how many hours.

A next step to support workforce planning would be to examine whether corresponding

competencies are sufficiently addressed in the different curricula. (24, 25)

Whereas we demonstrated the feasibility of this new strategy for enumerating public

health workforce for one specific example - the environmental public health workforce

– we believe that this strategy can be applied to other public health sectors as well. The

universal applicability is the result of the fact that this strategy has been based on EPHOs.

Our approach is therefore also applicable to assess the capacity of the total public health

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4

workforce in the Netherlands or abroad, as WHO’s EPHOs were considered valid for all

WHO Eur countries. (20)

Although the feasibility of our measurement strategy was demonstrated and resulted in

more insight in the size and composition of the environmental public health workforce

than was available before from registry data, this first application brought some limitations

to light that need to be addressed in further development. These include the selection

of the environmental public health organisations; workers who were not used to classify

their work according to the EPHOs; and the response rates.

Our estimation of the total capacity was dependent on proper identification of organizations

harbouring people belonging to the environmental public health workforce. We explored

per EPHO who or which organizations potentially perform that service, and decided to

compose a core group and a peripheral group. The core group was identified through

organisations who were likely to be involved in delivering environmental public health

EPHOs and the peripheral group of those who might be involved in environmental public

health. It could be that our selection was incomplete and in that case the total available

capacity estimated in this study may be an underestimation of the real capacity. However,

overestimation is also possible.

Workers were asked to classify there daily tasks according to the EPHOs and were asked

to estimate the average time they spent on each of EPHOs per week. As the EPHOs were

only recently introduced in Europe, workers are not yet familiar with linking their daily work

to the EPHOs. This may have resulted in misclassification. For example some workers

might have classified a specific task to a certain EPHO whereas it should have been

classified to another EPHO. To prevent misclassification and to shape workers’ mental

image of the tasks to be assessed, we added examples from daily practice to each of the

EPHOs. As the group of environmental health experts recognized the overall results of the

study as being in line with the provision of EPHOs in daily practice, we assume workers

were able to classify there daily tasks to each of the EPHOs properly. However, further

validation of the correctness of the classification and quantitative estimation of hours

spent is required in further studies.

CONCLUSION

We developed and applied a novel strategy to enumerate the public health workforce

based on assessment of individual workers’ involvement in EPHOs. We identified

relevant organisations and individuals on the basis of EPHOs and obtained information

from those individuals by using online questionnaires. Critical factors include the

selection and recruitment of eligible organisation and the response rate. When existing

professional registries are incomplete or do not exist, this strategy may provide a start

to enumerate the quantity and quality of the public health within or across countries.

TEXTBOX 1

National Association of Local Public Health Services.

‘GGDGHOR Nederland’ is the national Association of Local Public Health Services

(‘GGD’en’) and GHOR( Regional Medical Emergency Preparedness and Planning) offices

in the Netherlands. By law, all Dutch municipalities have the obligation to protect, control

and promote the health of their inhabitants. Each municipality is associated with a local

public health service to carry out these tasks. There are about 400 municipalities in the

Netherlands and they are served by 25 local public health services. This means that

one local public health service is often jointly directed by several municipalities. Local

public health services are responsible for preventive health care. All local public health

services have a number of uniform tasks, as specified in the law: the Public Health Act.

Examples of those tasks are Youth health, Infectious disease control, Health promotion

and Environmental public health. Environmental public health focuses on the interactions

with and effects of the environment on health, e.g. indoor and outdoor pollution and

chemical safety.

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20. European Action Plan for Strengthening Public Health Capacities and Services.


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CHAPTER 5Enumerating the preventive youth health care workforce: size, composition and regional variation in the Netherlands

M. Jambroes, M. Lamkaddem, K. Stronks, M.L. Essink-Bot

In press:

Enumerating the preventive youth health workforce: size,

composition and regional variation in the Netherlands

Health policy 2015 [Epub ahead of print]

7776

Enumerating the preventive youth health care workforce: size, composition and regional variation in the NetherlandsChapter 5

5

ABSTRACT

Objectives

The progress in workforce planning in preventive youth health care (YHC) is hampered by

a lack of data on the current workforce. This study aimed to enumerate the Dutch YHC

workforce. To understand regional variations in workforce capacity we compared these

with the workforce capacity and the number of children and indicators of YHC need per

region.

Methods

A national survey was conducted using online questionnaires based on WHO essential

public health operations among all YHC workers. Respondents (n=3220) were recruited

through organisations involved in YHC (participation: 88%).

Results

The YHC workforce is multi-disciplinary, 62% had > 10 years working experience within

YHC and only small regional variations in composition existed. The number of children

per YHC professional varied between regions (range 688-1007). All essential public health

operations were provided and could be clustered in an operational or policy profile. The

operational profile prevailed in all regions. Regional differences in the number of children

per YHC professional were unrelated to the indicators of YHC need.

Conclusion

The essential public health operations provided by the YHC workforce and the regional

variations in children per YHC professional were not in line with indicators of YHC needs,

indicating room for improvement of YHC workforce planning. The methodology applied

in this study is probably relevant for use in other countries.

INTRODUCTION

The services provided by the preventive youth health care (YHC) workforce are pivotal

to current youth and future population health. (1, 2) A recent study reported an inverse

association between public health staffing and provision of preventive services to women

and children on the one hand and infant mortality rates on the other (3); this finding

confirmed similar results from earlier research. (4, 5) Insight into the capacity of the YHC

workforce, and the services provided in relation to youth health needs, is required to

support health human resource planning and to maintain and/or improve youth health.

This also applies to countries with relatively good youth health. Although the health of

youth in the Netherlands is among the best in Western Europe, promoting youth health

remains a continuous challenge for the YHC workforce. Adverse trends over time in

behavioural risk factors (e.g. overweight, and an uneven distribution of health across

socioeconomic groups) may affect youth health and warrant continuous attention. (6)

YHC is preventive care focusing on the growth and development of the child to prevent

severe health problems, and is the largest discipline within the public health field in

countries in Western Europe. (7)

Workforce planning, or health human resource planning, consists of activities to bring

the quantity and/or quality of the health human resources to a desired level. (8, 9). Most

countries in the WHO European region (WHO Eur), except for Albania, Spain and the

Netherlands, make use of guidelines on the size of the YHC workforce in terms of a

desired ratio between the numbers of children per YHC professional: ranging from e.g. 1

nurse per 350 children in Armenia to 1 nurse per 2000 children in Cyprus. (10) However,

standards on the appropriate size and composition of the YHC workforce in relation to

youth health needs are absent in WHO Eur countries. Also lacking is adequate insight

into the size and composition of the YHC workforce and the services provided, also in

the Netherlands.

It is essential to fill this gap in knowledge to support YHC health human resource planning

and policy development. Therefore, this study enumerates the YHC workforce and

services provided in the Netherlands. In the absence of standards on the appropriate

size of the YHC workforce, we examine whether regional variations in the workforce

capacity can be understood in terms of the number of children per region and variations

in indicators of youth health care need. We assumed to find more YHC workers in regions

with more children and more YHC workers in regions with e.g. a higher prevalence of

children with overweight, as indicator of youth health care need.

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METHODS

General study design

In 2013 we assessed the environmental public health workforce in the Netherlands using

a newly developed strategy. This strategy showed that characterisation of the public

health workforce and the services provided is feasible by 1. identification of relevant

organisations and individual workers, and 2. obtaining information from those individuals

via a questionnaire addressing the essential services provided. As this 2-step approach

earlier appeared to be feasible and valid, we used this same strategy to assess the YHC

workforce. (11)

For the essential services we used the 10 essential public health operations (EPHOs) as

defined by WHO Eur in 2012. (12)

For the present study, a national cross-sectional survey was performed. The YHC

workforce was defined as all workers who contribute to the delivery of YHC. This

definition was operationalised as all those who consider YHC as part of their job and who

are responsible for providing any of the EPHOs. We specified the WHO’s EPHOs for YHC

and assessed the individual respondent’s involvement in these by means of an online

questionnaire.

Every effort was made to adequately inform all participants and to protect their privacy.

According to Dutch law, formal ethical approval was not required for this study.

Development of the questionnaire

For specification of the EPHOs to YHC existing policy documents were used, e.g. from

the professional organisation of YHC physicians and documentation on the basic duties

package which municipalities have to fulfil according the Public Health Act.(13) We also

involved a group of 7 national YHC experts who agreed on the resulting specifications.

Based on the documents and the expert opinions, we added two services: ‘management

and team leadership’ and ‘providing a youth health safety net’ as this is a specific public

health operation in the Netherlands.

Table 1 presents a description of youth public health and the related EPHOs in the

Netherlands. The YHC questionnaire contained 20 items divided into three sections: i)

Eligibility and socio-demographic variables, ii) job characteristics, and iii) EPHOs.

After some adaptations based on a pre-test of this questionnaire among 30 YHC workers,

the questionnaire took about 10 min to complete.

Table 1 | Essential public health operations and Essential youth health care operations in the Netherlands

Essential public health operations , WHO* Essential youth health care operations

YHC is preventive care which concentrates on the growth and development of healthy children. It is the largest discipline within the public health working field in Western Europe. The target group of the Dutch YHC are all children aged 0-19 years. Basic services are provided by local governments, through child health centres, schools or local public health services or at home, by a highly multi-disciplinary workforce, including physicians.

1 Surveillance of population health and wellbeing 1 Surveillance of youth health and wellbeing

2Monitoring and response to health hazards and emergencies

2Monitoring and response to psycho-social incidents and emergencies

3Health protection including environmental occupational, food safety and others

3 Youth health protection

4Health promotion including action to address social determinants and health inequity

4**

Youth health promotion, addressing social determinants, health inequity and including advocacy communication and social mobilisation for health

9Advocacy communication and social mobilisation for health

5Disease prevention, including early detection of illness

5Disease prevention, including early detection of illness

6 Assuring governance for health and wellbeing 6Promote, develop and support youth health public policy

7Assuring a sufficient and competent public health workforce

7Assuring a sufficient and competent YHC workforce

8Assuring sustainable organisational structures and financing

8 Assuring access to YHC and quality of YHC

10Advancing public health research to inform policy and practice

9Advancing YHC research to inform policy and practice

10 Assuring a YHC safety net

11 Management and team leadership

YHC: preventive youth health care

* European Action Plan for Strengthening Public Health Capacities and Services. Malta: World Health Organisation, regional office for Europe, 2012.** EPHO ‘Health promotion’ and ‘Advocacy communication and social mobilisation for health’ in the Netherlands were for YHC combined into ‘Youth health promotion’

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Recruitment of participants

All organisations likely to conduct YHC tasks were identified, i.e. all local public

health services, other local YHC organisations, national public health organisations,

and universities. Within these, we invited all workers considered to be involved in

youth EPHOs.

To enhance recruitment of as many employees substantially involved in YHC, e.g. to

recruit respondents involved in EPHOs ‘monitoring’ and ‘health promotion’ outside the

departments of YHC, all workers from the divisions of epidemiology and health promotion

of the local public health services were approached. Similarly, all workers from specific

research institutes and departments of public health of universities were approached

to recruit workers involved in EPHO ‘advancing public health research’ and ‘assuring a

sufficient and competent public health workforce’.

The mailing list was composed in collaboration with YHC experts and with support from

the national association of organisations of the local public health services and one other

national YHC organisation. This latter organisation supports YHC practice, policy and

research from a national perspective and maintains a good overview of the national YHC

networks.

Data collection strategy

The survey was performed in May 2014. The invitation to participate in the survey was

distributed by e-mail to all organisations that agreed to participate, i.e. all local public

health services (n=26) and 73% of the other YHC organisations (n=16) and, within these

organisations, to >7000 workers. The invitation emphasised voluntary participation and

confidentiality. The e-mail contained a link to a secured website where participants could

complete the electronic questionnaire. In the week after the invitation, two reminders

were sent to the non-responders. After two weeks the database was closed, data were

downloaded, and the analyses were performed with SPSS 14.0.

Analysis

1. Composition and size of the YHC workforce

We characterised the composition of the workforce in terms of age, gender, educational

level and medical or non-medical training, years of working experience in the current

job title, and skills mix. The skills mix was expressed by the ratio physicians/nurses per

region. This was calculated based on the educational background of the respondents

(medical or nursing training completed).

The size of the workforce was characterised as the absolute number of full-time equivalents

(FTEs), number of children to be treated per YHC professional, and the number of children

aged < 5 years per YHC professional.

For a tentative estimation of the total FTEs of the national and regional YHC workforce,

we assumed that YHC workers among the non-responders spent a similar number of

working hours on youth EPHOs as the respondents. In the Netherlands, 36 working

hours/week constitutes 1 FTE.

To assess regional differences in size and composition of the workforce, the country was

divided in 4 regions to assure the anonymity of individual organisations: North (provinces

of Groningen, Friesland, Drenthe; approx. 1.7 million inhabitants), East (provinces of

Flevoland, Gelderland, Overijssel; approx. 3.5 million inhabitants), South (provinces

of Noord-Brabant, Limburg; approx. 3.5 million inhabitants) and West (provinces of

N-Holland, Z-Holland, Utrecht, Zeeland; approx. 7.9 million inhabitants). Each YHC

organisation was assigned to one of the regions. When organisations provided services

in two or more regions, the organisation was assigned to the dominant service region (this

was the case for only one organisation).

For analysis of regional variations in the size and composition of the YHC workforce, we

selected the workforce of the local YHC organisations and excluded the workforce in

national institutions (n=29 respondents or 0.9% of the total number of respondents), as

these institutions are located in one specific region but support the total workforce. The

total FTE per region was calculated as the sum of the estimated FTEs per youth health

organisation allocated to that region.

2. Essential Public Health operations provided

To gain insight into the services provided by the professionals, we assessed which

EPHOs they provided and for how many hours per week. The distribution of FTEs over

the EPHOs per region was calculated as the sum of all the hours spent per EPHO, per

region, divided by 36.

Principal component analysis (PCA) was used to identify EPHO patterns among the

respondents. PCA was performed with 11 components (EPHOs) and we used a Kaiser-

Meyer-Olkin measure of 0.8, an eigenvalue >1 and orthogonal rotation (varimax).

Distribution of EPHO profiles per region was calculated based on the outcomes of the

PCA analysis.

3. Association between the size of the workforce, services provided and indicators of

youth health care needs

Dutch YHC professional guidelines recommend frequent scheduled contacts with the

YHC organization, and routine screenings and vaccinations for all children aged < 5

years. For children aged 5-19 years, much less frequent visits are scheduled. Therefore,

the number of children aged <5 years can be considered a need indicator for YHC. Our

hypothesis was that there would be an association between regional variations in the

numbers of children aged < 5 years and the size of the YHC workforce, expressed in the

number of children aged < 5 years per YHC professional. (13)

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Reducing inequalities in the distribution of determinants of health and child health is

one of the tasks of the YHC workforce. Therefore, the percentages of children 1) living

in deprived areas, 2) being referred to youth care, 3) living in poverty, 4) lagging behind

at school and 5) with overweight, can be considered as need indicators for YHC. An

association was assumed between indicators of YHC need per region and the size of the

workforce expressed as the number of children per YHC professional.

We examined whether regional variation in indicators of need are in concordance with

regional variations in workforce size.

RESULTS

Of the 48 YHC organisations throughout the Netherlands, 42 (88%) participated

in this study. Within the organisations, the response rate was 51%. In total, data

from 3220 YHC employees could be used for the analysis, of which 29 were from

national institutions.

Size and composition of the workforce

Table 2 shows the composition and the size of the workforce. About 2/3 of the workers

had > 10 years of working experience within YHC. Workers had different educational

backgrounds: 19% had secondary school or intermediate vocational education, 44%

were trained as a professional nurse, and 24% were university trained as physician. In

the North workers were older and the percentage of workers with education to secondary

school or intermediate vocational education was higher. For the other characteristics, no

or only small differences were found between the regions. In all regions, the number of

nurses is about two times the number of physicians, reflecting the skills mix.

The total size of the workforce was estimated at 7000 YHC workers, corresponding to

4934 FTEs. The absolute number of YHC workers ranged from 524-2649 per region. The

number of children per professional ranged from 688-1007. The absolute and relative

workforce size was highest in the West of the Netherlands. Similar to the pattern of the

number of children per professional, the number of children per professional for children

aged < 5 years ranged between regions from 163-223, with the lowest number of children

aged < 5 years per professional in the North (Table 2).

Tabl

e 2

| Cha

ract

eris

tics,

com

posi

tion

and

size

of t

he Y

HC w

orkf

orce

Tota

l (r

espo

nden

ts =

319

1)No

rth

(res

pond

ents

= 3

28)

East

(r

espo

nden

ts =

667)

Wes

t (r

espo

nden

ts =

155

7)So

uth

(res

pond

ents

= 6

39)

Gend

er, f

emal

e (%

)30

74 (9

6)

308

(94)

64

2 (9

6)

1502

(97)

622

(97)

Age,

yea

rs (S

D)

48 (1

0.2)

50

.3 (9

.6)

47.

5 (1

0.2)

46.9

(10.

2)

47.5

(10.

4)

>10

yea

rs in

sam

e jo

b (%

)19

69 (6

2)23

4 (7

1)42

0 (6

3)32

2 (5

7)43

1 (6

7)

Wor

king

hou

rs/w

eek

(SD)

23

.7 (7

.3)

23

.4 (7

.1)

23

.2 (7

.0)

23.0

(7.2

)

Educ

atio

nal l

evel

(%)

Seco

ndar

y sc

hool

/inte

rmed

iate

voc

atio

nal e

duca

tion

621

(19)

89 (2

7)12

4 (1

9)26

5 (1

7)14

3 (2

2)

Prof

essi

onal

edu

catio

n: o

ther

220

(7)

27 (8

) 5

9 (9

) 1

17 (7

)17

(3)

Prof

essi

onal

edu

catio

n: n

urse

1418

(44)

129

(39)

309

(46)

681

(44)

299

(46)

Univ

ersi

ty e

duca

tion:

oth

er20

0 (6

) 2

0 (6

)43

1 (4

)11

8 (8

)31

(6)

Univ

ersi

ty e

duca

tion:

phy

sici

an73

1 (2

4)

328

(19)

144

(22)

375

(24)

149

(23)

Phys

icia

n/nu

rse

ratio

0.48

0.

440.

43

0.52

0.47

Type

of E

PHO

profi

le, p

erce

ntag

e

Polic

y pr

ofile

27.4

26

.526

.1

27.8

28.6

Prac

tice

profi

le51

47

.653

.1

50.7

51.6

No s

peci

fic p

rofil

e21

.6

25.9

20.8

21

.519

.8

Estim

ated

tota

l FTE

4934

.4

523.

899

1.4

26

4977

0.2

Estim

ated

no.

of c

hild

ren

per p

rofe

ssio

nal*

779.

4

742.

386

6.3

68

8.1

1007

.3

Estim

ated

no.

of c

hild

ren

aged

<5

year

s pe

r pro

fess

iona

l* 1

81.9

16

2.5

19

4.9

16

8.9

22

3.1

YHC=

prev

entiv

e yo

uth

heal

th c

are

F

TE=

full-

time

equi

vale

nt

* CB

S –

Stat

istic

s Ne

ther

land

s, 2

013

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5

Services provided

Figure 1 shows the distribution of the total FTEs across the different EPHOs. All EPHOs

were provided; most FTEs were spent on the essential operations ‘Surveillance’, ‘Health

promotion’ and ‘Disease prevention’ and the least FTEs were spent on the EPHOs ‘Health

protection’ and ‘Psycho-social health incidents’. As the EPHO patterns were almost the

same in all regions, only the overall picture is presented here.

Figure 1 | Percentage of full time equivalents per YHC essential public health operation

1. Surveillance of youth health and wellbeing

2. Monitoring and response to psycho-social incidents and emergencies

3. Youth health protection

4. Youth health promotion, addressing social determinants, health inequity and including advocacy communication and social mobilisation for health

5. Disease prevention, including early detection of illness

6. Promote, develop and support youth health public policy

7. Assuring a sufficient and competent YHC workforce

8. Assuring access to YHC and quality of YHC

9. Advancing YHC research to inform policy and practice

10. Assuring a YHC safety net

11. Management and team leadership

PCA identified two EPHO profiles (Table 3). The first indicates involvement in preventive

and other operational services (EPHO 1 monitoring, 4 health promotion, 5 prevention, 7

assuring a competent workforce, and 10 health safety care net). The second profile is

characterised by employees involved in governance for health and management (EPHO

6 governance for health, 9 research and development, 8 assuring access and quality, 11

management and team leadership, 3 health protection). Of all respondents, 78% could be

assigned to either one of the EPHO profiles, about 50% to the prevention or ‘operational’

profile, about 25% to the governance for health or ‘policy profile’; nearly 25% could

not be assigned to a specific profile, with only small variations between regions. The

operational profile was slightly more prevalent in the East, corresponding to the higher

percentage of nurses in the East.

Table 3 | Principal component analysis (Varimax rotation) - components and factor loadings of Essential Public Health Services

Practice profile Policy profile

1 Disease prevention 0.83

4 Health promotion, advocacy communication 0.73

5 Health safety net 0.72

7 Assuring competent workforce 0.70

10 Surveillance, monitoring of youth health 0.58

6 Promote, develop public policy 0.74

2 Advancing Research & Development 0.70

3 Assuring access to and quality of YHC 0.59

9 Management and team leadership 0.54

11 Health protection 0.46

8 Psycho-social incidents - -

YHC= preventive youth health care

Variation in indicators of preventive youth health care needs

The regional variation in the proportion of children with overweight was small. Because the

other indicators of YHC need also showed small regional variation (children in deprived

areas, referral to youth care, lagging behind at school), the regional variations in workforce

size were not reflected in regional variations in need. However, in the North, the percentage

of children living in poverty was high and the workforce size relatively low.

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Table 4 | Indicators of youth health care needs per region

North East West South

% Overweight (child 4-20 years)* 12.3 13.4 13.8 12.3

% Children in deprived areas (child 0-18 years)** 38.3 13.9 13.4 19.3

% Children referred to youth care (child 0-18 years)** 1.6 1.4 1.4 2.6

% Children in poverty (child 0-18 years)** 5.8 5.1 5.5 5.3

% Children lagging behind at school (child 4-12 years)** 9.1 10.5 12.1 11.3

* CBS – Statistics Netherlands, percentage children with overweight per region, 2008-2011

** Children in Tel, databoek 2012, http://www.verwey-jonker.nl/doc/jeugd/KIT%202012light.pdf

DISCUSSION

Preventive YHC in the Netherlands is performed by a multi-disciplinary workforce

with many years of experience in YHC. Overall, regional variations in the composition

of the workforce were small. All EPHOs were provided and could be clustered into an

operational profile and a policy profile. We found regional variations in the size of the

YHC workforce, as indicated by the number of children per professional, ranging from

688-1007. These variations in the size of the YHC workforce were not in concordance

with regional variations in the indicators of YHC need, because there was little variation

in indicators of YHC need.

Strengths/limitations

This is the first study in the Netherlands to provide insight into the size and composition of

the YHC workforce, as well as in the operations provided. We conducted a national study

and invited all organisations involved in YHC to participate, with a high response rate

(88%) among the organisations. However, the study has some limitations. The response

rate among organisations was high but the response rate among the workers was lower

(51%). Such a response rate is a well-known limitation of online questionnaire studies.

(14) We did not conduct a non-response analysis, but we do know that time-restrictions

were an important reason for non-participation for organisations as well as workers. If

the participating YHC organisations cannot be regarded as representative for all the YHC

organisations that we a priori selected for participation, the estimate of the totally available

capacity in this study may be an underestimation of the real capacity. We cannot assess if

the responders within YHC organisations differed with respect to the variables of interest

from the non-responders. Selective non-response within YHC organisations may have

resulted in under- or overestimation of total workforce capacity. We statistically adjusted

the total number of workers in YHC according to the participation rates, assuming that

the non-participation at organisational and workers level was not selective. However,

further study, comparing age-, sex and educational profiles of respondents and non-

respondents per organisation, or preferably comparing the profiles of EPHOs provided

and hours spent per EPHO of respondents and non-respondents is recommended. The

second limitation is that the data are self-reported; therefore, it is unknown whether

the outcomes, e.g. the average time spent per EPHOs, reflect the actual time spent on

EPHOs at individual level.

Third, classification into four regions might have diluted a possible association between

higher YHC needs in the larger cities, e.g. due to more ethnic diversity, and the services

delivered. Unfortunately it was not possible to perform the analysis on smaller regions

as we had to guarantee the anonymity of individual organisations. We recommend to

analyse possible associations between workforce capacity and indicators of youth health

care needs in smaller regions, for example at the level of YHC organisations.

Finally, our results did not provide evidence for an explanation of regional differences in

YHC workforce by corresponding differences in YHC needs, but the internal validity of

this finding is limited by uncertainty about the quality of the data on indicators of need. To

improve the validity of this analysis, we strongly recommend implementing a standardized

national data collection with epidemiologic data on youth health, for example by pooling

the standardized data collected by YHC organisations. Furthermore, empirical evidence

on the relation between health needs and requirements of the workforce is lacking

and also needs further study. However, the indicators used are relevant determinants

for population health needs. Moreover, the epidemiological and socio-cultural factors

we used are elements of the health human resource planning model applied in the

Netherlands to estimate the training inflow of YHC physicians. (15-17)

Interpretation

Our study clearly demonstrates the multi-disciplinarity of the workforce. About half of the

workforce consisted of YHC nurses, about a quarter was YHC physician and the remainder

had various educational backgrounds, such as dieticians, medical assistants, and speech

therapists. The current health human resource planning model used in the Netherlands

by the Advisory Committee on Medical Manpower planning (‘Capaciteitsorgaan’) is a

mono-professional model to estimate the training inflow of physicians, including YHC

physicians. (17) Taking our results into account, implies that central workforce planning

is only targeting 25% of the total YHC workforce. To address the whole workforce and

to include the dynamics of e.g. task-shifting policies, health human resource planning

should be integrated and, at least, include YPH nurses in the workforce planning. (9)

No regional variations were found in the EPHO patterns. This could be a reflection of

the existing practice guidelines for YHC, i.e. the basic duties package. This package is

offered to all children and includes schedules on the number of YHC visits and health

checks that should be performed (13). We observed regional variations in the size of

the workforce that could not be explained by regional variations in the indicators of

YHC need. Wide variations in staffing levels across local public health systems have

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been reported and might be explained by differences in the size of the public health

organisation. (18, 19) However, our data do not support a relationship between YHC

organisational size and workforce size, as three large YHC organisations are located in

the West where the highest workforce size was found. Ideally, we would expect the levels

of YHC need in the youth population to be congruent with the YHC workforce in terms of

size, composition and services provided. (8, 20, 21) However, our study does not support

this expectation, which suggests that some youth populations are under-served or over-

served, indicating room for improving YHC workforce planning. The present study used

a strategy that was previously developed and tested. Despite some limitations, we think

the use of this strategy to enumerate the public health workforce is an improvement

on current practice and can support YHC workforce planning. Central and structured

workforce planning in the Netherlands is limited to the estimation of training inflow of

qualified public health physicians, including YHC physicians. However, our results on

the YHC workforce revealed that about a quarter of the YHC workforce consists of YHC

physicians. Examples of other disciplines within the workforce were public health nurses,

speech therapists, health promotion specialists and policy makers. For these disciplines

no registers and no central workforce planning exist. Previous work on human resource

planning in health care, addressed the shortcomings of mono professional planning. (9)

Integration of different occupations into health workforce planning was mentioned as

a need to improve health human resource planning. A change from mono-professional

public health workforce planning to planning of the whole workforce, is necessary to

optimize the contribution to population health. A first step towards integrated workforce

planning and development is the assessment of the whole public health workforce in

terms of size, composition and services provided. Our strategy for empirical enumeration

of the public health workforce supports this, but requires further development

and implementation.

Because of obvious differences in (public) health systems between EU member states,

the results on the size and composition of the preventive youth health care workforce

cannot just be extrapolated to other EU member states. However, as our strategy is

based on EPHOs, and WHO’s EPHOs are considered valid for all WHO Eur member

states, the strategy we developed for public health workforce assessment might also

be applicable in other EU member states. Nevertheless, further research is required to

develop the international applicability of our strategy. A strength of this strategy is that

it allows enumeration across different organisations and among different professional

disciplines. (7, 10) Another strength is that the strategy allows to assess not only the size

and composition of the workforce but also the services provided. However, as YHC is

organised differently within the EU countries, existing standards on the required children-

to-provider ratio are difficult to compare.

CONCLUSIONS

This study provides insight into the national YHC workforce and regional variations in the

size, composition and services provided. The essential public health operations provided

by the YHC workforce and the regional variations in children per YHC professional

were not in line with indicators of YHC needs, indicating room for improvement of YHC

workforce planning. Insight in the public health workforce is an important condition

for improvement of public health workforce planning. Our strategy, based on essential

public health services offers promising results to enumerate the public health workforce

in general, as a starting point to improve the empirical basis for workforce planning and

development. However further development and validation of our strategy to characterize

the public health workforce are needed. Additional research is needed to elucidate the

associations between workforce size, composition and YHC needs, to support workforce

planning to optimally promote, prevent and protect youth health.

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Canadian Public Policy 2007; 33:S1-S16.

CHAPTER 6Implications of health as ‘the ability to adapt and self-manage’ for public health policy: a qualitative study

Marielle Jambroes, Trudi Nederland, Marian Kaljouw,

Katja van Vliet, Marie-Louise Essink-Bot, Dirk Ruwaard

In press:

Implications of health as ‘the ability to adapt and self-manage’

for public health policy: a qualitative study

The European Journal of Public Health 2015

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Implications of health as ‘the ability to adapt and self-manage’ for public health policyChapter 6

6

ABSTRACT

Background

To explore the implications for public health policy of a new conceptualisation of

health as ‘The ability to adapt and to self-manage, in the face of social, physical and

emotional challenges’.

Methods

Secondary qualitative data analysis of 28 focus group interviews, with 277 participants

involved in public health and health care, on the future of the Dutch healthcare system.

WHO’s essential public health operations (EPHOs) were used as a framework for analysis.

Results

Starting from the new concept of health, participants perceived health as an individual

asset, requiring an active approach in the Dutch population towards health promotion

and adaptation to a healthy lifestyle. Sectors outside health care and public health

were considered as resources to support individual lifestyle improvement. Integrating

prevention and health promotion in healthcare is also expected to stimulate individuals

to comply with a healthy lifestyle. Attention should be paid to persons less skilled to

self-manage their own health, as this group may require a healthcare safety net. The

relationship between individual and population health was not addressed, resulting in

little focus on collective prevention to achieve health.

Conclusions

The new concept of health as a basis for changes in the healthcare system offers

opportunities to create a health-promoting societal context. However, inequalities in

health within the general population may increase when using the new concept as an

operationalisation of health. For public health the main challenge is to maintain focus on

the collective socioeconomic and environmental determinants of health and disease and,

thereby, preserve collective prevention.

INTRODUCTION

In 2011 Huber and colleagues challenged the WHO definition of health, formulated in

1948 as “A state of complete physical, mental and social well-being and not merely the

absence of disease or infirmity” by introducing a new concept of health as “The ability to

adapt and to self-manage, in the face of social, physical and emotional challenges” (1, 2).

The WHO definition has been criticised with regard to: 1) the static nature of the definition,

i.e. health as a state, 2) the changing patterns of morbidity, and 3) the operationalisation

of the definition. Operationalisation of health as a state of ‘complete physical, mental and

social well-being’ is difficult because it is not easy to either define or measure ‘complete’.

Moreover, critics said, the requirement of complete well-being has contributed to the

medicalisation of society (3-6). Patterns of population morbidity have changed since

1948 and the numbers of persons living with one or more chronic diseases has increased

worldwide (7-9). According to WHO’s definition all these individuals are considered to be

‘ill’, without taking into account their level of functioning or well-being.

The new conceptualisation may meet some limitations of the WHO definition, as it

is more dynamic and emphasises the resilience and capacity of people to cope with

chronic disease. From the point of view of the new concept, people can be ‘healthy’

while living with chronic disease; therefore, compared to the WHO definition of

health, more people can be considered to be ‘healthy’. Moreover, the new concept

addresses the opportunities available to the individual, rather than focusing on their

disabilities (10, 11).

The new concept has also received criticism, some related to public health. Public health

is defined as the science and art of preventing disease, prolonging life and promoting

health, through the organised efforts of society (9). The critical comments focused on the

risk of reactive instead of proactive actions for health by individuals and professionals,

since challenges to be faced in life are unknown until they occur. Others mentioned

that the new concept is only applicable in circumstances that are within one’s control,

whereas some social determinants of health may preclude the ability of individuals and

communities to adapt to their circumstances (12-14).

We conducted a qualitative directed content analysis of data from group interviews with

stakeholders in Dutch public health and healthcare to analyse the implications of the

new conceptualisation of health as the ability to adapt and self-manage for public health

policy.

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METHODS

Study design

The new conceptualisation of health is one of the pillars supporting the recent formal

advice to the Dutch Minister of Health intended to prepare healthcare professions and

health education to effectively cope with future challenges in healthcare (15). The pros

and cons of the new concept of health were the subject of a qualitative study based on

focus group interviews with stakeholders in Dutch public health and healthcare. We used

these data for a secondary data analysis.

Sample

A purposive sampling strategy was used to recruit focus group participants

representing different stakeholder groups in the public health and healthcare sectors,

as well as different organisations in the field of practice, research, education and policy

(Attachment 1).

The 28 group interviews included 8 persons on average (277 participants in total) and

each group session lasted ± 1.5 h.

Table 1 | The WHO’s essential public health operations (EPHOs).


1 Surveillance of population health and wellbeing

2 Monitoring and response to health hazards and emergencies

3 Health protection including environmental occupational, food safety and others

4 Health promotion including action to address social determinants and health inequity

5 Disease prevention, including early detection of illness

6 Assuring governance for health and wellbeing

7 Assuring a sufficient and competent public health workforce

8 Assuring sustainable organisational structures and financing

9 Advocacy communication and social mobilisation for health

10 Advancing public health research to inform policy and practice

Data collection

Data were collected during September through November 2013. Focus groups discussed

four open-ended questions: 1) Reflect on the new concept of health, 2) What does a

future healthcare system based on the new concept of health mean for citizens and their

networks, 3) What support do citizens need in such a system, and 4) What should be

done to achieve such a system?

The focus groups were moderated by skilled facilitators with a background in public health

or healthcare. An additional person was present to take notes. All discussions were tape-

recorded, anonymised and transcribed into summary reports. Later, the reports were sent

to the participants to be checked for accuracy.

Ethics Statement

Every effort was made to effectively inform the participants and protect their privacy.

According to Dutch law, no formal ethical approval was required for this study.

Framework for analysis

For the analysis, we operationalized public health according to the aim of our study to

assess the implications of a new conceptualisation of health for public health policy as

well as according to 10 essential public health operations (EPHOs) WHO Europe (WHO

EUR) defined in 2012. (16) A systematic direct content analysis was conducted, using

WHO EUR EPHOs as initial coding categories (Attachment 1). We added ‘health safety

net’ as a category as this is a specific public health operation in the Netherlands (17).

This analysis involves a systematic process of sifting, charting and sorting material

according to the EHPOs, going through the following stages: familiarisation with the

data, identification of the thematic framework, indexing, charting and mapping, and

interpreting (18, 19).

The familiarisation stage provided an overview of the richness and diversity of the data.

Notes on the responses on EPHOs and on additional and recurrent public health themes

and issues that appeared to be important to participants were used to develop a thematic

framework of the EPHOs extended with key public health themes.

Subsequently the framework was systematically applied to the material and all data were

re-read and annotated accordingly. The coding was done manually by MJ and checked

by TN, who organised the focus group discussions.

Finally, the tables with headings and subheadings for each theme of the framework were

used to describe patterns and connections through an iterative, comparative process of

searching, reviewing, and comparing the data. Potential discrepancies were identified

and solved in discussions among MJ, DR, MLEB and TN.

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Table 2 | Quotations of the focus groups

1. The new definition is related to the fact that, nowadays, we value having control over our own lives more than just the absence of disease. “The goal of self-realization and a resilient and responsible life is definitely preferable to dealing with the illness or the disability model.”

2.We’re always talking about the responsible citizen, but the question is whether it’s possible for all groups to take control. “In the new concept the responsibility lies with the citizen, who needs to have certain abilities or skills. However, there is a considerable ‘range’ in ability - people differ considerably”.

Also, there is such a thing as a hierarchy in the possibilities of being able to take responsibility for restoring health.

The premise is that people are able to take control. However, not everyone can participate according to the ideal of the new concept: for example, people aged 85+, the frail elderly, and those with mild intellectual disabilities. Not everyone can get involved and we as a society have a responsibility to support these people.

3. “If you’re not healthy, or if you fail to find a balance, is that your own fault? “

4. “First of all, a situation is created in which vulnerable people are easily told that it’s their own fault and that they’re to blame and remain in default: i.e. “blaming the victim.”

5.“If we consider how infant care is provided, then that’s a good example of outreach care. Child health clinics are fully incorporated into our healthcare culture and we see that it works very well - especially the preventive side of health care. We shouldn’t throw outreach care overboard.”

6.“When we mastered the infectious diseases, we didn’t suddenly abolish that approach. Good things that occur nowadays shouldn’t suddenly be abolished, we need to maintain them and develop new things.”

7.In Sweden, in the primary schools children learn that if they have stomach ache then they should try and think where it comes from - did I eat something wrong, or am I nervous? This makes children more resilient so that later on, also with more serious conditions, they can ask the same questions.

8.“I have a friend who’s 60 years old and much too fat. He’s already had two hip operations and now has a problem with his knee. Not one of the professionals has ever mentioned his being overweight - and my friend never talks about it himself. What a missed opportunity! “

9. “The funding system needs to assume that you pay for your good health and not for sickness. The incentive between treatment and payment should be removed.”

10.“You can’t bring about a change in citizens, unless you also properly scrutinize the funding system. There is no funding for a good conversation with a patient, which is not directly aimed at delivering a healthcare product.”

11.

I live in Maastricht, where a lot of people who regret leaving are coming back again. These are people who moved away from the city, but have now decided to return. Between friends and acquaintances we say: “Come and live within ‘walking frame’ distance!” We already have 10 friends who live close by and, later on, if there’s a problem we can help each other.”

12.We should aim for smaller residential communities to encourage living together - people who are in the same situation, who are willing to support each other.

RESULTS

Key themes emerging

Overall, participants supported the new concept of health. Four key patterns emerged

regarding implications for public health: 1) health as an individual asset, 2) health as a

healthy lifestyle, 3) health as focus of the healthcare system, and 4) health in the context

of social support.

1. Health as an individual asset

Starting from the new concept of health, participants perceived health as an individual

asset. According to the participants the new concept places emphasis on people’s own

responsibility for health and implies an individual and active approach towards health and

a healthy lifestyle, Table 2, quotation 1.

Respondents also pointed out potential side-effects of the new concept, including i) the

inability of certain groups to adapt and self-manage, ii) the risk of ‘blaming the victim’,

and iii) the neglect of certain public health services.

1.1 Ability to adapt and to self-manage across the population

In the new conceptualisation, adaptation and self-management are considered

prerequisites to be healthy. Participants indicated that several groups might be unable

to fulfil these requirements as individuals differ in their inherent capacity to adapt and

to self-manage. For example, frail older people, or persons with mild mental disorders,

are less able to manage their own health. People who are less advantaged in terms of

education, income, or social position, might have lower health literacy skills which may

also impair their ability to adapt and self-manage. In terms of the new concept of health,

these persons would be labelled as ‘unhealthy’ and would probably never be able to

achieve the status ‘healthy’.

When applying the new concept of health some participants expected that the above-

mentioned groups would become more vulnerable, possibly leading to an increase in

inequalities in health. As a result, more people would need help from the healthcare safety

net. One focus group indicated that supporting the health of less skilled persons should

be considered a societal responsibility, Table 2, quotation 2.

1.2 Blaming the victim

Several respondents indicated the risk of ‘blaming the victim’ as an inherent side-effect

when individuals are considered to be responsible for their own health. When health

problems occur these might be seen as a result of their own choice for unhealthy behaviour.

Vice versa, people with sufficient ability to adapt and self-manage their health may

be less willing to pay for the healthcare costs of people who ‘chose’ for an unhealthy

lifestyle. In turn, this may affect the financial solidarity of our healthcare system. Table 2,

quotation 3, 4.

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1.3 Public health services

Some participants acknowledged that the emphasis on individual responsibility to

adapt and self-manage could lead to neglect of important population-based public

health services that contribute to our current population health status. Preventive youth

healthcare was proposed as a representative example, see Table 2, quotation 5, 6.

2. Health as a healthy lifestyle

Participants interpreted being responsible for your own health as adopting a healthy

lifestyle. They considered choosing for healthy behaviour to be the best option to take

this responsibility and to prevent health problems. Participants stressed that people

would need support to adapt to a healthy lifestyle and suggested that such support

should also come from sectors outside healthcare. Several strategies were mentioned

that might increase a person’s adaptability, including education, health protection and

(within healthcare) health promotion.

2.1 Education

Participants believed that people need health education to become more health literate

and health education should start early in life;. primary schools could play an important

role in educating children in health literacy and self-control. Also secondary schools

and sports clubs could contribute to teaching children about health promotion. Table 2,

quotation 7.

2.2 Health protection

Respondents indicated that authorities need to be supportive in creating a healthy (i.e.

an adapting and self-managing) population. They mentioned various health protective

options that might help, such as rules, regulations and legislation. For example, legislation

on age restrictions for buying cigarettes, or regulations on the use of salt in food products.

2.3 Health promotion

Participants indicated that health promotion within the healthcare sector, offered by

healthcare providers, could play a role in supporting people to adapt and self-manage. For

example, care providers should not restrict consultations to treatment alone, but should

also address options for health promotion and prevention to support people in making

responsible and informed choices about their health. According to the participants, health

promotion should be a key competence for all health professionals, as illustrated with the

following example, Table 2, quotation 8.

3. Health as focus of the healthcare system

Some participants indicated that health as the ability to adapt and to self-manage

requires a change in the focus of the healthcare system: health as the ability to adapt

and self-manage should become the outcome measure. Adapting the current financial

model of health care was mentioned as a strategy to change incentives in the direction

of the desired outcome of the healthcare system: prevention of disease and maintenance

of good health should be reimbursed instead of solely treatment of diseases. Table 2,

quotation 9, 10.

4. Health in the context of social support

Although participants approached prevention mainly as health promotion and measures

to support adaptation to a healthy lifestyle, other aspects to support individual health

were also discussed. Social mobilisation for health (through social and community care

networks) was suggested as an aspect of prevention that would become increasingly

important, i.e. participants believed that social support through community networks

would help individuals to take responsibility for their own health and to support others in

this aim. Table 2, quotation 11, 12.

DISCUSSION

Our findings reveal that a new conceptualisation of health as ‘The ability to adapt and

self-manage’ may stimulate an active approach of individuals towards health promotion

and adaptation to a healthy lifestyle. The new concept also provides support for creating

a health- promoting society that helps individuals to adapt and self-manage. Health

promotion should become a competence of all healthcare providers. Our findings

did not show that the new conceptualisation encourages a focus on the relationship

between individual and population health; this resulted in a low priority among the

participants for collective prevention to achieve health. Moreover, the results show the

new conceptualisation may result in an increase of socio-economic inequalities in health

because not all individuals are equally capable of taking care of their own health.

Interpretation of the findings

The results show that a different conceptualisation of health may result in a change of

priorities for public health operations and thus in the EPHOs to be delivered. The observation

that focus group participants perceived health as an individual asset requiring an active

approach in the population towards health promotion and adaptation to a healthy lifestyle

will lead to an increase in the need and delivery of EPHO ‘health promotion’, which may

impact training needs. Furthermore, an increase of health promotion within the curative

sector offered by medical care providers, implies that health promotion must be a key

competence for all physicians, including medical specialists and general practitioners.

With regard to public health policy and training needs, this implies an extension of public

health training needs towards professionals in the curative sector as well. The need for

incorporation of health promotion and public health competencies within the curricula

of all physicians has been advocated before, by the Lancet committee on Education

of health professionals for the 21st century and also by Levy and Wegman, Plochg and

Essink-Bot. (20, 23). Layers 2 and 3 were clearly addressed by the participants of the

focus groups. Our outcomes suggest that innovations in the healthcare system starting

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The fact that ‘health as an individual asset’ and ‘health as a healthy lifestyle’ were

addressed in more detail than ‘health as focus of the healthcare system’ and ‘health

in the context of social support’ may be a result of the methodology. It might be that

participants of the focus groups address issues regarding a personal level easier than on

a social- or healthcare system level. However, this requires further research.

Earlier comments, that the new conceptualisation of health would stimulate a reactive

attitude towards health, were not confirmed in this study.(12) This unexpected finding

might be explained by the context of the health policy in the Netherlands. The current

national government strongly advocates holding people responsible for their own health.

As part of this policy, and during the period in which the focus group interviews took

place, the government was preparing the decentralisation of several national healthcare

and public health services to local governments. However, participants in the focus

groups were explicitly asked to provide their views on the future healthcare system in

2030, starting from the new concept of health. Whether the new conceptualisation of

health would stimulate an active approach towards health in other European countries as

well requires further research, as public health systems are different among the European

member states.

Our study also revealed some potentially serious threats for public health. The most

important is the possible neglect of socio-economic, cultural and environmental

determinants of health (24). The WHO definition also fails to address these determinants,

and our findings suggest that this is not likely to improve when using the new concept

of health. Ignoring those determinants and, thus, collective prevention programs for

health, will not only negatively affect population health but may lead to increasing health

inequalities which can in turn negatively influence individual health (25).

Known causes of persisting inequalities in health include inequalities in education, income

and social position. The creation of equal opportunities of health requires action within

the healthcare system, as well as on the conditions in which people are born, develop,

work and age, and on the drivers of these conditions (26), (27) Interventions to improve

these conditions not only need strong governance for health through the collective effort

of society, but also need support from society itself.

Persons with lower health literacy skills are more likely to have a lower health status

than individuals with good health literacy skills (29). Our results suggest that health

conceptualised in terms of adaptation and self-management challenges equal opportunities

for health even more, because several groups may lack sufficient ability to adapt and self-

manage. In a society and a healthcare system of increasing complexity, these groups may

become even more vulnerable (25). Therefore, the new conceptualisation of health may

lead to an increase of health inequalities.

Strengths and limitations of the study

An important strength is the large number of focus groups held and the variety of

stakeholders and organisations represented. Nevertheless, all focus group participants

were invited because they either work in public health or health care, or they are patients;

this means that citizens from the general population and stakeholders working in sectors

other than (public) health care were not represented in the focus groups. This may have

led to underrepresentation of persons with less health literacy skills and of sectors outside

the healthcare sector. However, both the vulnerable position of persons with low health

literacy skills and the role of sectors other than healthcare, were extensively addressed.

Another limitation was that the implications of the new concept of health for public

health were not the primary focus of the groups. That may partly explain why some

aspects of public health were not addressed during the interviews. However, by means

of the various items included in the topic list, respondents were invited to mention

the relevance of collective prevention and the wider determinants of health as part of

the new system.

Implications for public health policy

In making changes in the healthcare system based on the new concept of health, we

recommend to integrate support of adaptation and self-management of individuals into

the whole healthcare system. Second, at a population level, we strongly recommend to

nurture, maintain and improve collective prevention. Finally, we recommend to combat

health inequalities and promote the health of disadvantaged groups by integrated

approaches that reach beyond the healthcare sector.

Future research on the conceptualisation of health as adaptation and self-management

should focus on monitoring the effects on population health, and on further exploration

of how to increase the opportunities for public health and how to integrate public health

and health care.

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CONCLUSIONS

The new concept of health offers opportunities to create a health-promoting societal

context; however, some inequalities in health within the population may increase. For

public health, the main challenge is to maintain the focus on the collective socioeconomic

and environmental determinants of health and disease and, thereby, preserve collective

prevention. Individuals who are less able to take care of their own health will need our

continuous support and the presence of an effective healthcare safety net.

ACKNOWLEDGEMENTS

The authors thank Prof. Dr. K. Stronks (Dept of Public Health, University of Amsterdam)

for her review of earlier versions of this article.

ATTACHMENTS

Attachment Table 1 | Overview groups of participants in the focus groups

Focus groups

Institutions for health care education and training

University medical centres 1

University medical centres 2

Life Long Learning, post-graduate education

Inspectorate of Health Care

Pharmacy

Municipal Health Services

Healthcare entrepreneurs

Professionals mental health care

Social workers

Physiotherapists

Nursing

Midwifery care

Primary care

Medical specialists

Institutes for Research and Development

Dental hygienists

Patients 1

Patients 2

Patients 3

Professional organisations

Ministry of Health, Welfare and Sports

Dutch organisation of volunteer work

Representatives from patient, educational and health care organisations in Amsterdam

Representatives from patient, educational and health care organisations in province Friesland

Care for disabled persons

Institutions of Mental Healthcare

Welfare organisations

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7. Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. Aging

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8. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of


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9. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional

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11. Ogwido MO. Re:WHO definition of health does not remain fit for purpose. Bmj.

2011;343:d4163.

12. Becker CM. Re:How should we define health? Bmj. 2011;343:d4163.

13. Popay J. WHO definition of health does remain fit for purpose. Bmj. 2011;343:d4163.

14. Macaulay AC. Re:How should we define health? Bmj. 2011;343:d4163.

15. Kaljouw M, Vliet Kv. Towards new health and health professions, the outline. Diemen:

National Healt Care Institute, 2015.

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World Health Organisation, regional office for Europe, 2012.

17. Jambroes M, Essink-Bot ML, Plochg T, Zaadstra B, Stronks K. [Public health in the

Netherlands --a definition and 10 essential functions]. Nederlands tijdschrift voor

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18. Pope C, Ziebland S, Mays N. Qualitative research in health care. Analysing qualitative

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19. Rabiee F. Focus-group interview and data analysis. The Proceedings of the Nutrition

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20. Essink-Bot ML. Population healthcare including patients 2013. Available from: http://

issuu.com/ellenwiggemansen/docs/population_healthcare__including_pa.

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23. Plochg T, Klazinga NS, Starfield B. Transforming medical professionalism to fit changing

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Stockholm, Sweden: Institute for Futures Studies, 1991.

25. Arah OA. On the relationship between individual and population health. Medicine, health

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CHAPTER 7General Discussion

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General DiscussionChapter 7

7

INTRODUCTION

In this chapter the results of the studies presented in this thesis will be summarised

by answering the research questions (paragraph 7.1), followed by a discussion of

methodological issues (paragraph 7.2) and a discussion of the results in light of findings

from other studies and of public health practice (paragraph 7.3). The chapter ends with

a general conclusion (paragraph 7.4) and implications and recommendations for future

research, policy and practice (paragraph 7.5)

ANSWERS TO THE RESEARCH QUESTIONS

Here we summarize the contribution of the main findings of the studies presented in this

thesis to the answers to the research questions of this thesis.

What is the quantity and quality of the Dutch public health workforce, using existing

data sources?

Pooling the available workforce data from 7 reports resulted in a ‘best estimate’ of the

total Dutch public health workforce of 12,000 FTE. The point estimate of 12,000 FTE is

inaccurate, mainly because of the different definitions of the public health work field that

were used in the various documents. For example, in one report the public health work

field was defined as “all municipal health services”, whereas in another report it was

defined as “a diverse mix of organizations”. Moreover, the number of functions or roles

assessed in the different reports varied between 1 and 15. We concluded that insight

in the quantity and quality of the current Dutch public health force is limited and that

planning future workforce numbers and educational needs based on the current capacity

of the public health workforce in the Netherlands is not possible using the currently

existing data.

What are the scope and Essential Public Health Operations of public health in the

Netherlands, based on international examples?

Analysis of several authoritative international examples of defined essential public health

operations (EHPOs) on country level showed general consensus on the overall role of

public health in terms of scope and core functions. This consensus justified definition

of the scope of public health in the Netherlands in accordance with the international

examples as: ‘To promote health and an equal distribution of health through population

based interventions aiming at protecting and promoting health and preventing disease’.

Based on the international consensus on nine core functions of public health we adopted

essential public health operations for the Netherlands and added ‘providing a health

safety net’ as a typically Dutch EPHO. The ten proposed EPHOs for the Netherlands are:

1.monitoring population health, 2. disease prevention and control, 3. health promotion,

4. health protection, 5. public health emergency response, 6. health safety net, 7. healthy

public policies, 8. public health research and development, 9. competent workforce, 10.

sustainable organisational structures, quality of (public) health services.

These specifications of the scope of public health and of essential public health operations

were the basis to develop a strategy to empirically enumerate the public health workforce.

This strategy consists of 1. selection of organisations that provide public health; 2. within

these organisations, assessment of educational qualifications and the hours spent on

EPHOs by individual workers using an online questionnaire. The online questionnaire was

developed based on a review of the literature on workforce enumeration, interviews with

public health experts and consultation with other researchers.

What is the feasibility and validity of an EPHO-based strategy to measure the size,

composition and qualifications of environmental public health workforce in the

Netherlands?


to the delivery of environmental public health. We identified organisations involved in

providing environmental public health. The questionnaire was distributed among all

potential environmental public health workers within the selected organisations in the

Netherlands and resulted in data on the environmental public health workforce.

The questionnaire was well accepted and available benchmark data on environmental

public health physicians supported the results of this study regarding the medical part

of the workforce. Experts on environmental public health recognized the present results

on the provision of EPHOs as a reasonable reflection of the actual situation in practice.

All EPHOs were provided by an experienced, highly educated and multidisciplinary

workforce. 27% of the total full-time equivalents (FTEs) was spent on EPHO ‘assuring

governance for health’. Only 4% was spent on ‘health protection’. The total FTEs were

estimated as 0.66 /100,000 inhabitants.

We concluded that characterisation of the public health workforce was feasible by

identification of relevant organisations and individual workers on the basis of EPHOs, and

obtaining information from those individuals by questionnaire. Critical factors include the

operationalization of the EPHOS into the field of study, the selection and recruitment of

eligible organisations and the response rate within organisations.

What is the quantity and quality of the preventive youth health care [jeugd-

gezondheidszorg] workforce in the Netherlands and can regional differences in

workforce be understood in terms of indicators of youth health care need?

The questionnaire we developed to assess the environmental public health workforce

was adapted to preventive youth health care, which basically means that we adapted

the accompanying examples of daily practice of each EPHO to preventive youth health

care. Distribution among all potential youth health care professionals in the Netherlands

resulted in data on the youth health care workforce in total and per region. The preventive

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youth health care workforce is multi-disciplinary, 62% had > 10 years working experience

within preventive youth health care and only small regional variations in composition

existed. The number of children per youth health care professional varied between regions

(range 688-1,007). All EPHOs were provided and could be clustered in an operational or

policy profile. The operational profile prevailed in all regions. Regional differences in the

number of children per preventive youth health care professional were unrelated to the

percentage of children with overweight, living in poverty, referred to youth care or living

in deprived areas. The regional differences in size of the preventive youth health care

workforce were thus not in line with indicators for preventive youth health care needs.

What are the implications of application of a new conceptualization of health for

public health policy?

We performed a secondary qualitative data analysis of 28 focus group interviews with

277 participants involved in public health and healthcare on the future of the Dutch

healthcare system. Starting from the conceptualisation of health in terms of adaptation

and self-management, participants perceived health as an individual asset, requiring

an active approach in the Dutch population towards health promotion and adaptation

to a healthy lifestyle. Sectors outside healthcare and public health were considered as

resources to support individual lifestyle improvement. Integrating prevention and health

promotion in healthcare is also expected to stimulate individuals to comply with a healthy

lifestyle. Attention should be paid to persons less skilled to self-manage their own health,

as this group may require a healthcare safety net. We conclude that a new concept of

health as a basis for changes in the healthcare system offers opportunities to create

a health-promoting societal context. However, inequalities in health within the general

population may increase when using the new concept as an operationalisation of health.

For public health the main challenge is to maintain focus on the collective socioeconomic

and environmental determinants of health and disease and, thereby, preserve

collective prevention.

METHODOLOGICAL ISSUES

This section offers an overview of the main strengths and limitations of these studies for

the internal and external validity of our findings.

A strength of this thesis is the combination of methods used in the various studies. We

used quantitative as well as qualitative research methods, which resulted in numbers

on the public health workforce as well as in qualitative perspectives on future public

health needs. Another strength is that we conducted nationwide studies, which offered

the opportunity not only to study the total public health workforce within environmental

public health and preventive youth health care, respectively, but also to assess regional

variations in capacity for preventive youth health care. A third strong point is the high

participation rate of the public health organisations in the enumeration studies (chapter 4

and 5) and the large number of focus groups in the qualitative study (chapter 6).

Internal validity

Enumeration strategy

As existing data sources appeared to be incomplete and did not cover the whole public

health workforce, we developed a strategy to collect primary data on the public health

workforce. Although these provide more insight in the workforce and the services

provided by that workforce than was available before, the internal validity of the proposed

strategy may be affected by 1. the selection of organisations, 2. the response rates within

organisations, 3. the use of EPHOs and 4. the self-report character of the data.

First the selection of public health organisations. Our estimation of the total capacity was

dependent on proper identification of organisations harbouring workers belonging to the

public health workforce. In the studies presented in chapters 4 and 5, we explored per

EPHO who or which organizations potentially perform that service. If, as an example, the

selection of preventive youth health care organisations in Chapter 5 was incomplete, or if

the participating organisations cannot be regarded as representative for all the preventive

youth health care organisations that we a priori selected for participation, the estimate of

the totally available capacity estimated in this study may be an underestimation of the real

capacity. However, in de environmental public health study (Chapter 4) we showed that the

results on the estimated number of workers were in line with available benchmark data,

a finding that supports the validity of our estimate. The number of organisations involved

in preventive youth health care (chapter 5) was much higher than in environmental public

health (chapter 4). We did our utmost best to include all the preventive youth health

care organisations, for example by ensuring support for the study of the professional

associations for preventive youth health care physicians, nurses and assistants, which

resulted in participation of almost 90% of the organisations. We corrected the total number

of workers in environmental public health and preventive youth health care according to

the participation rates, assuming that the non-participation at organisational level was

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not selective and we assume this has not resulted in significant under- or overestimation.

However, further research is needed to confirm if our assumption is correct, for example

by verifying the actual number of preventive youth health care employees in the missing

organisations.

Second, non-response within organisations. The two enumeration studies we

performed showed non-response (30-50%). Non-response is a well-known limitation

of questionnaire studies. We cannot assess if the responders within preventive

youth health care or environmental public health organisations significantly

differed with respect to the variables of interest from the non-responders, e.g.

selective non-response. Selective non-response within preventive youth health

care or environmental public health organisations may have resulted in under- or

overestimation of total workforce capacity. Further study, for example comparing

age-, sex and educational profiles of respondents and non-respondents per organisation,

or preferably comparing the profiles of EPHOs provided and hours spent per EPHO of

respondents and non-respondents is recommended.

Third, we used public health domain specific EPHOs as the basis of our questionnaires.

We asked workers to classify their daily tasks according to these EPHOs and to estimate

the average time spent on each of these EPHOs per week. Misclassification of tasks by

individual workers may have occurred, because of unfamiliarity of public health workers

with EPHOs. The EPHOs were only recently introduced in Europe, and not yet in the

Netherlands, so workers were not familiar with linking their daily work to the EPHOs yet.

Some workers may have classified a specific task to a certain EPHO whereas others

classified it to another EPHO. To prevent misclassification at individual level and to shape

workers’ mental image of the tasks to be assessed, we added domain-specific examples

from daily practice to each of the EPHOs. Eligible examples were selected with help of

domain-specific experts and professionals organisations for environmental public health

and preventive youth health care. As the EPHO profiles resulting in Chapters 4 and 5

were recognized as reflections of daily practice in environmental public health as well as

in preventive youth health care by experts, we assume that significant misclassification

was not present at group level. We conducted a pilot study in which we assessed among

a small group (n=30) of preventive youth health care workers whether a list of frequently

provided tasks within this sector was classified similarly by all the participants. The results

showed no substantial misclassification at group level, but the numbers were too small to

allow for meaningful statistical analysis. Further study, for example by repeating the pilot

study with more participants is required.

Fourth, the data on delivery of EPHOs and the time spent per EPHO were based on self-

report. Self-reported data are relatively easy to obtain, however, the disadvantage is that

we cannot check whether the reported average time spent per EPHO reflects the actual

time spent on this EPHO at individual level. Checks of the total number of working hours

reported as spent on separate EPHOs with the total number of working hours per week

for individual respondents did not show large discrepancies. Therefore we assume the

self-reported data to reflect the actual time spent per EPHO quite accurately at aggregate

level. However, validation by empirical evaluations is recommended.

The analysis of preventive youth health care needs

The assessment of the associations of regional differences in preventive youth health care

needs and regional differences in the number of preventive youth health care workers was

based on available national data on youth health indicators with regional specification.

Data on youth health indicators were scarce and insufficient, which may have influenced

the internal validity of the results of this analysis. Our results did not provide evidence for

an explanation of regional differences in the preventive youth health care workforce by

corresponding differences in preventive youth health needs, but the internal validity of

this finding is limited by uncertainty about the quality of the data on indicators of need. To

improve the validity of this analysis, we strongly recommend to implement a standardized

national data collection with epidemiological data on youth health, for example by pooling

the standardized data that are collected by youth health care organisations (‘Basis

Data set JGZ’).

Public health consequences of a new conceptualisation of health (Chapter 6)

We used focus group data to assess the implications of the new conceptualisation of

health for public health. A limitation of this study was that we performed secondary data

analysis; the implications of the new concept of health for public health were not the

primary focus of the interviews. That may partly explain why some aspects of public

health were not addressed during the interviews. However, by means of the various items

included in the topic list, respondents were invited to mention the relevance of collective

prevention and the wider determinants of health as part of the future health system.

External validity

Generalizability of the results of the enumeration studies to the whole public health workforce

Although we studied different public health domains, i.e. environmental public health

and preventive youth health care, the total picture of the public health workforce in the

Netherlands is still patchy. In other words, our studies did not provide complete insight

in the total public health workforce. The results of the studies into environmental public

health and preventive youth health care showed that the workforce in both domains

is assessable by using the same strategy. However, the outcomes in terms of training

qualifications or EPHO profiles are really different, suggesting that the results of the

studies presented in this thesis cannot be extrapolated to estimate the total Dutch public

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health workforce capacity. As the first studies showed promising results with regard to

the application of the strategy, we first recommend further development and validation

of this strategy, including the studies recommended in the internal validity section.

Subsequently the other parts of the public health workforce can be assessed using our

strategy to complete the national public health workforce picture.

Generalizability of our strategy to the health care workforce

The use of EPHOs has proven to allow for workforce enumeration across different

organisations and among different professional disciplines within public health. However,

the medical care or curative sector also provides public health services. Our strategy

offers the opportunity to assess contributions from other healthcare sectors to public

health, for example primary care. However, we have not yet applied the methodology to

other healthcare sectors. We recommend to start with a pilot study, for example among

a group of general practitioners. A first step would be to adjust the examples of daily

practice per EPHO to examples of daily practice of general practitioners, as general

practitioners are probably less acquainted with the essential operations of public health.

Generalizability of the results to other countries

Because of obvious differences in (public) health systems between EU member states,

the results on the size and composition of the environmental public health and preventive

youth health care workforce cannot automatically be extrapolated to other EU member

states. However, as our strategy is based on EPHOs, and WHO’s EPHOs are considered

valid for all WHO European member states, the strategy we developed for public health

workforce assessment can also be used in other EU member states. WHO Europe

launched an action plan for strengthening public health capacities and services in

2012.[1] This action plan proposed the ten EPHOs as unifying and guiding framework

for any European health authority to set up, monitor and evaluate policies, strategies

and actions for reforms and improvement in public health. The Association of School of

Public Health in the European Region (ASPHER), that assessed the exit competences of

public health graduates across a diverse European landscape in 2011, used the EPHOs

as a framework to group the competencies.[2] Both projects illustrate the applicability

of the EPHOs at different levels; for policy as well as training purposes across Europe.

Further research is required to develop the international applicability of our strategy. We

recommend to start assessing the use of the strategy in a pilot study before applying it to

the country wide public health workforce. First, the selection of organisations providing

public health services might be different from that in the Netherlands because public

health systems differ between member states. Second, it may be that several questions

in the questionnaire need some adjustment in wording in order to align with country

specific circumstances. An internationally applicable strategy for public health workforce

enumeration provides a basis for cross-national comparison of workforce data.

Sustainability of EPHOs over time

We proposed EPHOs for the Netherlands on the basis of international examples and

by assessing the international examples with the Dutch public health system. EPHOs

describe the main tasks of current public health. Whether the EPHOs are sustainable

and are still valid when future changes in the health care system are implemented, e.g. a

new conceptualisation of health, we do not know. We recommend to evaluate the validity

of the EPHOs every several years, for example by assessing the EPHOs with timely

policy documents, literature review and interviews with public health and health care

professionals.

REFLECTION ON AND DISCUSSION OF THE RESULTS

In the following paragraph we reflect on the current public health workforce and public

health workforce governance in the Netherlands in the light of our research findings

and we discuss the implications of the findings for improving public health workforce

governance. We will first give a short overview of the governance of public health

workforce in the Netherlands.

Public health workforce planning in the Netherlands: a short overview

Public health workers deliver services that contribute to the overall aim and goals of

public health. As argued in the introductory chapter of this thesis, a knowledgeable,

competent and prepared workforce is essential to achieve the aim and goals.( 3-6)

Workforce planning, in this case public health human resource planning, tries to anticipate

how many and what type of human resources will be necessary in order to maintain and

improve the quality, quantity, availability and effectiveness of the public health services

provided. (7-9)

Public health workforce planning and development in the Netherlands is governed at

different levels: a. the organisations providing public health services, b. the public health

physicians, organised within organisations of professionals for physicians [e.g. KAMG]

and c. the National government through the Advisory Committee on Medical Manpower

planning [Capaciteitsorgaan].

In the Netherlands, the Ministry of Health, Welfare and Sports is responsible for public

health. Many public health tasks are decentralized to local governments and provided

through local public health services (GGD’en). (10) Besides local public health services,

also other local and national organizations provide public health tasks, like academic

research groups and the National Institute for Public Health and Environment (RIVM). The

delivery of public health services is legally founded in the Public Health Act, but there is

no central human resource policy regarding the provision of public health services. (10)

In addition, in the Netherlands but also internationally, hardly any standards or guidelines

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are available on the appropriate public health workforce size and composition with regard

to public health needs and population health outcomes.(11) In The Netherlands, each

local public health organisation is responsible for its own human resource management.

The public health physicians, organised in the organisation of professionals for public

health physicians [KAMG] are involved in workforce governance regarding the quality and

quantity of the group of public health physicians. Examples of tasks of this governance

by professionals include to maintain and develop professional practice standards, to

contribute to the training of new public health physicians by development of general

education plans and to advise the Ministry of Health, Welfare and Sports on the national

distribution of training positions for public health physicians.

By government order, the Advisory Committee on Medical Manpower planning

[Capaciteitsorgaan], assesses the required training inflow of public health physicians at

a national level, every four years.[12] The Advisory Committee on Medical Manpower

planning uses a simulation model that basically uses the current number of trained

public health physicians within a specific domain as input, and produces estimations

on the required inflow of public health physicians within that same domain as output.

(12) One of the determinants of the required inflow within the model is the expected

public health need. The public health need is operationalized in this model by several

indicators, like projected demographic and epidemiological changes in the Dutch general

population, task-shifting policies and socio-economic developments in the general

population. After confirmation of the estimated training inflow by the Ministry of Health,

Welfare and Sports, financial resources are made available for the professional training of

public health physicians. However, there is no instrument to ensure that sufficient training

positions become available to fulfil the required training inflow of public health physicians.

In 2013 the actual training inflow was 37% lower than the advised inflow by the Advisory

Committee. (13)

Reflections on public health workforce governance in the Netherlands from

the perspective of our results on the environmental and preventive youth health

care workforce

Reflection on public health workforce governance from the perspective of our results

of the two enumeration studies illustrate three main problems of the current system

of public health workforce governance in the Netherlands; 1. the mono-disciplinary

approach, 2. lack of insight into the number of physicians working in public health,

and 3. lack of insight in the background of the distribution of the workforce across

the country.

First, estimations on the required expertise or training inflow for public health professionals,

as executed by the Advisory Committee of Medical Manpower Planning, are restricted

to public health physicians. Our data in Chapter 4 and 5 show that about 22% of the

environmental public health workforce and 24% of the preventive youth health care

workforce consists of public health physicians. The other professionals are a very multi-

disciplinary group, including, among others, public health nurses, speech therapists,

toxicologists and policy makers. These disciplines are not included in the estimations of

required training inflow. The shortcomings of mono-professional workforce governance

have been addressed in previous studies on health human resource planning. (14) We

therefore recommend to extend public health workforce governance and integrate all

occupations or disciplines into the forecasts of required public health expertise. Broadening

this focus is especially relevant when the consequences of recent health policies and

changes in the health care system are included in the workforce governance. For example,

task shifting from public health physicians to nurses, the shift of specific (public) health

care services to local governments, or the other way around, the shift from local services

to a national level, e.g. for tuberculosis control. A first step towards integrated workforce

planning and development is assessment of the whole public health workforce in terms

of size, composition and services provided. Our strategy for empirical enumeration of

the public health workforce (Chapter 4 and 5) provides an initial step and can be of

great value towards this goal. However, the strategy requires further development and

implementation, as described in section 7.2. Important issues that need further study are

the operationalization of EPHOs and possible misclassification, and the use of our strategy

to assess the contribution of other sectors within the health system to public health.

Second, our data elucidate that only part of the physicians working in public health are

formally trained and registered as public health physician within their discipline: about

60% of the physicians who are professionally active in environmental public health and

preventive youth health care. Part of the services are currently provided by formally

unqualified public health physicians (‘basisartsen’). The numbers of unqualified public

health physicians working in public health were previously unknown; our strategy

delivered insight in the numbers and we also showed that these positions are being held

for many years.

The presence of unqualified public health physicians is not exclusive for public health

and happens in medical care as well, but in medical care physicians without a registration

as medical specialist or general practitioner can by law only work under supervision of

a registered medical specialist / general practitioner, and these positions are usually

temporary. In public health it is legally allowed to deliver public health services as a non-

trained public health physician without supervision. Whether this situation guarantees a

high quality medical contribution to public health is questionable. Despite the general

fact that competencies may develop ‘on the job’, unqualified public health physicians

have only limited basic knowledge on public health, also because public health is an

underrepresented topic in the basic training of physicians at Dutch universities. (15)

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Our findings underpin the second shortcoming of the current system of public health

workforce governance. The estimation of the training inflow of public health physicians is

restricted to formally qualified public health physicians, and does not take into account

the delivery of services by formally unqualified physicians (‘basisartsen’). Without data

on the contribution of all physicians working in public health, workforce governance on

the required quality and quality of medical contribution to public health is insufficient.

We therefore recommend to enumerate the public health workforce beyond the existing

registries for qualified public health physicians, as a basis for public health workforce

governance. Our strategy for empirical enumeration of the public health workforce

(Chapter 4 and 5) can be used to assess the whole public health workforce, including

training qualifications.

Third, with regard to the distribution of the total capacity of the public health workforce

(physicians and other disciplines) across the country, our preventive youth health care

study revealed regional differences in workforce capacity across the country (north, east,

south, west). These differences were not related to regional differences in population

size. In addition, these results did not provide evidence for an explanation of regional

differences in the preventive youth health care workforce by corresponding differences

in preventive youth health care needs. Regional differences may occur as a result of the

governance structure. Each public health organisation is responsible for its own health

human resource management. No guidelines exist on the minimum level of FTEs (or

competency or profession) required to deliver all services. So, local governments can

decide what the population health priorities in their region are and have the possibility

to align the public health workforce capacity with local health needs. It might be that for

example other health problems than youth health are more pronounced in their region,

which may result in relatively less capacity for youth health, compared to other regions

with equal youth health status. However, assessing whether regional variations in public

health workforce capacity are in line with regional variations in public health needs is

not possible without proper data on the public health workforce. Our data provided the

opportunity for such comparisons. The so far unexplained regional variations in youth

health care workforce (chapter 4) suggest that the regional governance on the preventive

youth health care workforce may result in under-serving or over-serving of some

youth health populations, however this is a finding that deserves further exploration.

Underserving is difficult to accept from an equity point of view, as preventive youth

health care should aim for providing equal chances of optimal health to all children in the

Netherlands. Overcapacity is also difficult to accept because of opportunity costs and

potential waste of resources. To monitor the background of the distribution of the public

health workforce across the country, we recommend to first enumerate the national public

health workforce. Our strategy showed to be useful for such enumeration. And second to

assess whether regional difference in public health workforce capacity can be justified by

regional differences in public health need.

Whether regional differences in capacity also occur in other public health domains is not

known, however for some domains, like infectious disease control, guidelines exist on

the advisable number of public health physicians and nurses. Whether these guidelines

result in regional comparable workforce numbers for infectious disease control requires

further study. A recently conducted European study revealed regional differences in the

overall quality of public health service delivery in various countries, which was linked to

the inadequate availability of public health workforce capacity in general. (16) Another

European study showed differences in the capacity for preventive youth health care

between the different countries. (17) We recommend to develop national guidelines with

regional specifications on the required quality and quantity of the public health workforce.

Evaluating the existing guidelines on infectious disease control for general use would be

a first step.

Reflection on workforce governance from the perspective of the implications of a

new concept of health for public health.

We analysed the implications of a new conceptualisation of health as the ability to adapt

and self-manage for public health policy, as an example of assessing future public health

priorities. We used the EPHOs as a predefined thematic framework for analysis.

The results in Chapter 6 show that a different conceptualisation of health may result in a

change of priorities for public health services and thus in the EPHOs to be delivered. The

observation that focus group participants perceived health as an individual asset requiring

an active approach in the population towards health promotion and adaptation to a healthy

lifestyle will lead to an increase in the need and delivery of EPHO ‘health promotion’,

which may impact training needs. Furthermore, an increase of health promotion within

the curative sector offered by medical care providers, implies that health promotion

must be a key competence for all physicians, including medical specialists and general

practitioners. With regard to workforce governance and training needs, this implies an

extension of public health training needs towards professionals in the curative sector

as well. The need for incorporation of health promotion and public health competencies

within the curricula of all physicians has been advocated before, by the Lancet committee

on Education of health professionals for the 21st century and also by Levy and Wegman,

Plochg and Essink-Bot. (18-21) We recommend to bring public health training for all

physicians into practice at universities and follow-up training. We also recommend to

include changing public health needs, for example as a result of a new conceptualisation

of health, into the public health workforce planning process as this provides important

information regarding priorities for public health services and subsequently public health

training needs. (9, 22-24) To translate these changes into training needs, the translation

of EPHOs into public health competencies would be an important step to support public

health workforce planning and training.

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The largest burden of disease expressed in years lived with disability in the coming

years in the Western world will be attributable to elderly having one or more chronic

illnesses. (25-28) The results in Chapter 6 illustrate that these changes may impact the

need for public health operations and the corresponding expertise regarding elderly and

chronic diseases. However, elderly or chronic diseases are currently not addressed in the

existing public health physician domains and the current model for estimating the training

inflow for public health physicians addresses only the existing domains (e.g. physician

infectious disease control, physician environmental public health). For ‘new’ domains in

public health, it is up to the organisations delivering public health services whether they

develop new expertise or invest in new domains. We recommend to investigate how

future ‘new’ public health needs can be translated into required public health expertise

and public health operations, to better support workforce planning for the total public

health workforce.

Reflections on public health workforce governance in the Netherlands from the

perspective of our results in general

The studies described in this thesis are among the first scientific studies into public health

workforce enumeration in the Netherlands and the results contribute to an empirical base

for public health workforce planning and development. These studies supported the

importance of insight in the quantity and quality of the public health workforce and trends

in this workforce in order to improve public health workforce governance to contribute to

maintaining and improving population health. However, public health workforce research

is not a common research area in the Netherlands. Therefore we emphasize the need for

structural research into the development and innovation of the public health workforce in

general. Quite some public health research is performed on how to improve population

health with regard to specific health topics, like overweight, infectious disease control

or socioeconomic inequalities in health. Other groups focus on improving public health

practice, for instance by innovations in public health service delivery (‘academische

werkplaatsen’). However, research into the more supporting services like ‘assuring a

competent workforce’ or health services research of the public health sector is lagging

behind and needs further development. Research priorities include further development

and validation of our strategy to characterize the public health workforce, and studies

into the relationship between public health workforce interventions and population

health. These and other studies are needed for providing the evidence on which to

base planning and policy decision making both for workforce development and for

addressing uncertainties regarding organizing, financing, and delivering effective public

health strategies.

CONCLUSION

Insight in the public health workforce in the Netherlands is limited. Increasing insight is an

important condition for improvement of public health workforce governance. We showed

that multidisciplinary enumeration of the public health workforce is feasible, and that a

new concept of health may lead to changes in public health priorities.

Based on our results we identified three recommendations for improvement of the

current public health workforce governance in the Netherlands. First, to extend workforce

governance from the mono-disciplinary estimation of required public health physicians

into workforce governance of the whole multidisciplinary public health workforce. Second,

to include public health needs into workforce governance. And third, to develop public

health workforce research as an area of scientific research to contribute to the empirical

basis for workforce planning and development and thus to population health.

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SUMMARYThe public health workforce; An assessment in the Netherlands

131130

SummarySummary

INTRODUCTION

Public health is often defined as ‘the science and art of preventing disease, prolonging

life, and promoting health through the organised efforts of society’. (1) The focus on

preventive measures through collective interventions distinguishes public and preventive

care (public health) from providing medical care (curative sector). Public health is an

essential part of the healthcare system and concentrates on the health of the population

as a whole. As all patients are part of the population, medical care occurs in fact within

the context of public health. (2, 3)

To deliver effective public health services, a qualified public health workforce and

appropriate allocation of that workforce are necessary. Therefore there is a need to

understand the composition and trends in the public health workforce.

Data on the availability and distribution of the public health workforce in Europe are limited

because a clearly distinguishable workforce for public health has neither been defined

nor formally established in the vast majority of the EU Member States. This is partly

due to the often indistinct boundaries of the public health sector. The multidisciplinary

nature of the public health workforce constitutes another factor that contributes to limited

data on the public health workforce. For most disciplines working in the public health no

registries exists.

Like in other countries, total size and composition of the public health workforce in the

Netherlands are unknown and a standardized system for regularly and systematically

collecting public health workforce data is lacking.

THE STUDIES IN THIS THESIS

The main aim of the research in this thesis was to provide insight in the quantity and

quality of the public health workforce in the Netherlands, in order to support public

health workforce planning and development. We used the Netherlands as a case study

to develop and test methodologies that are also internationally applicable to collect

public health workforce data. The three central themes were: the current situation,

strategy development to enumerate the public health workforce and future public

health priorities.

1. The current situation in the Netherlands

In the first part of the thesis we assessed the public health workforce in the Netherlands

using existing data sources and identified potential data gaps. Pooling the available

workforce data from 7 reports resulted in the total sum of the Dutch public health workforce

of 12,000 FTE (estimates in the separate reports ranged from 731 – 9807). This estimation

was inaccurate due to the different definitions of the public health work field that were

used in the various documents. The reports yielded different functions or roles and used

different methods of data collection. For example, in one report the public health work

field was defined as “all municipal health services”, whereas in another report it was

defined as “a diverse mix of organizations”. Moreover, the number of functions or roles

assessed in the different reports varied between 1 and 15. We concluded that planning

future workforce numbers and educational needs according to the current capacity of the

public health workforce is not possible using the currently existing data.

2. Strategy development to enumerate the PH workforce

In the second part of this thesis we developed a strategy for empirical workforce enumeration

based on essential public health operations (EPHOs). The scope and main public health

services have been defined by the World Health Organisation Europe into ten EPHOs, in 2012.

We first proposed essential public health operations for public health in the Netherlands.

Subsequently we applied the new strategy to assess the capacity of parts of the Dutch public

health workforce.

We assessed the scope and essential public health operations or EPHOs of public

health in the Netherlands, based on international examples. The international examples

showed a general consensus on the overall role of public health in terms of scope and

core functions. Therefore we defined the aim of public health in the Netherlands as: ‘To

promote health and an equal distribution of health through population based interventions

aiming at protecting and promoting health and preventing disease’.

Based on the international consensus on core functions and assessment of the validity

of the outcomes for public health in the Netherlands, we formulated essential public

health operations for the Netherlands and we added ‘providing a health safety net’ as a

function. The ten proposed essential public health operations for the Netherlands include:

1.monitoring health status, 2. disease prevention and control, 3. health promotion, 4.

health protection, 5. public health emergency response, 6. healthcare safety net, 7. healthy

public policies, 8. research and development, 9. competent workforce, 10. sustainable

organisational structures, quality of (public) health services.

This scope and essential public health operations were the basis for our new strategy

to enumerate the public health workforce. This strategy consists of 1. selection of

organisations that provide public health; 2. within these organisations, assessment of

educational qualifications and the hours spent on EPHOs by individual workers using an

online questionnaire. We tested the feasibility and validity of our EPHO based strategy

to measure the size, composition and qualifications of the public health workforce, by

applying it to environmental public health workforce in the Netherlands.


to the delivery of environmental public health. The questionnaire was distributed among

133132

SummarySummary

all potential environmental public health workers in the Netherlands and resulted in data

on the environmental public health workforce. The questionnaire was well accepted and

available benchmark data on physicians supported the results of this study regarding

the medical part of the workforce. Experts on environmental public health recognized

the present results on the provision of EPHOs as a reasonable reflection of the actual

situation in practice. All EPHOs were provided by an experienced, highly educated and

multidisciplinary workforce. The total FTEs were estimated as 0.66 /100,000 inhabitants.

We concluded that characterisation of the public health workforce is feasible by

identification of relevant organisations and obtaining information from individual workers

on the EPHOs provided by questionnaire. Critical factors include the operationalization of

the EPHOS into the field of study, the selection and recruitment of eligible organisations

and the response rate within organisations.

In the next study we built on the results of the previous study and we enumerated the

preventive youth health care workforce. The questionnaire we developed to assess the

environmental public health workforce was adapted to preventive youth health care,

which basically means that we adapted the examples of daily practice of each EPHO to

preventive youth health care. Distribution of the questionnaire among all potential youth

health care professionals in the Netherlands resulted in data on the youth health care

workforce. The preventive youth health care workforce is multi-disciplinary, 62% had >

10 years working experience within youth health care and only small regional variations

in composition existed. The number of children per youth health care professional varied

between regions (range 688-1007). All EPHOs were provided and could be clustered in

an operational or policy profile. The operational profile prevailed in all regions. Regional

differences in the number of children per preventive youth health care professional were

unrelated to the percentage of children with overweight, living in poverty, referred to youth

care or living in deprived areas and thus not in line with youth health needs.

3. Future public health priorities

In the final study we used the EPHOs as a framework for analysis to assess the

consequences of application of a new conceptualization of health in terms of adaptation

and self-management for public health policy. We used qualitative analysis of data from

group interviews with stakeholders in Dutch public health and medical care. A secondary

qualitative data analysis of 28 focus group interviews, with 277 participants, on the future

of the Dutch healthcare system was performed. The aim was to explore future public

health priorities in order to support workforce planning and policy development.

Starting from the conceptualisation of health in terms of adaptation and self-

management, participants perceived health as an individual asset, requiring an active

approach in the Dutch population towards health promotion and adaptation to a

healthy lifestyle. Sectors outside medical care and public health were considered as

resources to support individual lifestyle improvement. Integrating prevention and health

promotion in medical care was also expected to stimulate individuals to comply with a

healthy lifestyle. Attention should be paid to persons less skilled to self-manage their

own health, as this group may require a healthcare safety net. The new concept of

health as a basis for changes in the healthcare system offers opportunities to create

a health-promoting societal context. However, inequalities in health within the general

population may increase when using the new concept as an operationalisation of health.

For public health the main challenge is to maintain focus on the collective socioeconomic

and environmental determinants of health and disease and, thereby, preserve collective

prevention.

GENERAL DISCUSSION

In Chapter 7, the general discussion, we discussed the main results and the strengths

and limitations of the studies. We placed the findings in perspective and we end with

implications for research, practice and policy with regard to improving public health

workforce governance.

Public health workforce planning and development in the Netherlands is governed at

different levels: a. the organisations providing public health services, b. the public health

physicians, organised within organisations of professionals for public health physicians

[e.g. KAMG] and c. the National government through the Advisory Committee on Medical

Manpower planning [Capaciteitsorgaan].

Our data provide insight in some parts of the public health workforce and supported the

importance of this insight for workforce planning and development.

Reflection on public health workforce governance from the perspective of the results

of the two enumeration studies illustrates three main problems of the current system

of public health workforce governance in the Netherlands; 1. the mono-disciplinary

approach, 2. lack of insight into the number of physicians working in public health,

and 3. lack of insight in the background of the distribution of the workforce across

the country.

- The central workforce planning as executed through the Advisory Committee on

Medical Manpower planning (Capaciteitsorgaan) addresses only part of the public

health workforce, i.e. the qualified public health physicians. Our data showed that

the public health workforce is very multidisciplinary and that more than half of the

workforce consists of other professionals, including, among others, public health

nurses, speech therapists, toxicologists and policy makers. These disciplines are not

included in the Capaciteitsorgaan’s estimations of required training inflow.

135134

SummarySummary

- We showed that only part of the physicians working in public health are formally

trained and registered as public health physician within their discipline. Part of the

services are currently provided by formally unqualified public health physicians

(‘basisartsen’). The estimation of the training inflow of public health physicians

is restricted to formally qualified public health physicians, and does not take into

account the delivery of services by formally unqualified public health physicians

(‘basisartsen’). Without data on the contribution of all physicians working in public

health, workforce governance on the required quality and quality of medical

contribution to public health is insufficient.

- With regard to the distribution of the total capacity of the public health workforce

(physicians and other disciplines) across the country, our preventive youth health

care study revealed regional differences in workforce capacity across the country

(north, east, south, west). These differences could not be understood in terms of

regional differences in population size nor in regional differences in preventive youth

health care needs. Regional differences may occur as a result of the governance

structure. Local governments can decide what the population health priorities in their

region are and have the possibility to align the public health workforce capacity with

local health needs. Verifying whether regional variations in public health workforce

capacity are in line with regional variations in public health needs is not possible

without proper data on the public health workforce. The strategy we developed

allows for collecting such data.

Reflection on workforce governance from the perspective of the implications of a new

concept of health for public health showed that a different conceptualisation of health

may result in a change of priorities for public health services and thus in the EPHOs to be

delivered. Including public health needs into the public health workforce planning process

provides information regarding the need for public health services and subsequently

public health training needs.

Overall reflection on our results revealed that better insight in the public health workforce

in the Netherlands is an important condition for improvement of public health workforce

governance. We end with three main recommendations for improving public health

workforce governance:

1. To address the whole public health workforce (multidisciplinary) in workforce

governance.

A change from mono-professional public health workforce planning to workforce planning

of the whole workforce, integrated planning, is necessary to optimize the contribution to

population health. A first step towards integrated workforce planning and development

is assessment of the whole public health workforce in terms of size, composition and

services provided. Our strategy for empirical enumeration of the public health workforce

shows promising results, but requires further development and implementation.

2. To include public health needs into public health workforce governance

A change in the priorities for public health services results in a change in the delivery

of EPHOs (for example a change in the way EPHOs are delivered), or in the need for

a specific EPHO, or in delivery by other professionals. To translate these changes into

training needs, the translation of EPHOs into public health competencies would be an

important step to support public health workforce planning and training.

3. To develop public health workforce research as an area of scientific research.

Research into the supporting EPHOs like ‘assuring a competent workforce’ or ‘health

services research of the public health sector’ is lagging behind and needs further

development. The same holds for studies into the relationship between public health

workforce interventions and population health outcomes. These studies are needed for

providing the evidence on which to base planning and policy decision making both for

workforce development and for addressing uncertainties regarding organizing, financing,

and delivering effective public health strategies.

SAMENVATTING

139138

SamenvattingSamenvatting

INTRODUCTIE

Publieke gezondheidszorg, internationaal synoniem met public health, beoogt het

bevorderen van volksgezondheid en gelijke kansen op gezondheid door collectieve

maatregelen gericht op gezondheidsbescherming, gezondheidsbevordering en

ziektepreventie. De focus op preventieve maatregelen en collectieve interventies

onderscheidt het vakgebied van de curatieve zorg. De publieke gezondheidszorg is een

belangrijk onderdeel van het gezondheidszorgsysteem en richt zich op de gezondheid

van de Nederlandse bevolking. Omdat patiënten onderdeel zijn van de bevolking vindt de

curatieve zorg in feite plaats in de context van de publieke gezondheidszorg.

Om de taken van de publieke gezondheidszorg goed uit te voeren zijn voldoende en

goed gekwalificeerde professionals noodzakelijk. Vanwege de breedte en diversiteit in

activiteiten en beroepen is de publieke gezondheidszorg in de meeste EU lidstaten een

slecht afgebakend werkveld. Het ontbreken van een heldere afbakening van het werkveld

heeft onder meer tot gevolg dat er onvoldoende inzicht is in de beschikbare expertise voor

publieke gezondheidszorg. Gerichte sturing op de ontwikkeling van de beroepsgroepen

en daarmee op de kwaliteit en doelmatigheid van publieke gezondheidszorg is hierdoor

onvoldoende mogelijk.

Net als in de meeste EU lidstaten is ook in Nederland onvoldoende inzicht in de

omvang en samenstelling van de groep beroepsbeoefenaren werkzaam in de publieke

gezondheidszorg. Bovendien ontbreekt een methode om deze gegevens systematisch

te verzamelen.

DIT PROEFSCHRIFT

De belangrijkste doelen van het onderzoek dat in dit proefschrift wordt beschreven zijn

om inzicht te verkrijgen in de beschikbare expertise voor de publieke gezondheidszorg

in Nederland en om sturing op de benodigde expertise te bevorderen. We gebruikten

Nederland als casus voor het ontwikkelen en testen van een methode die ook internationaal

toegepast kan worden. De beschreven onderzoeken adresseren drie thema’s: de huidige

situatie, methode ontwikkeling om het werkveld in kaart te brengen, en de toekomstige

behoefte aan expertise voor de publieke gezondheidszorg.

1. De huidige situatie in Nederland

In het eerste deel van dit proefschrift beschrijven wij aan de hand van bestaande

rapporten wat er bekend is over de omvang en samenstelling van de groep

beroepsbeoefenaren in de publieke gezondheidszorg in Nederland. Door gegevens van

zeven rapporten te combineren konden wij de totale omvang van de beroepsgroepen

in de publieke gezondheidszorg schatten op 12.000 FTE (tellingen in de afzonderlijke

rapporten varieerden van 731 – 9807). Dit is een onnauwkeurige schatting omdat de

afbakening van het werkveld, de geselecteerde beroepen en functies en de methoden

van dataverzameling in de inventarisaties niet overeenkwamen. De afbakening van

het werkveld liep per inventarisatie uiteen van “alle GGD’en” tot een brede selectie

van instellingen en organisaties. Het aantal functies dat geïncludeerd werd varieerde

van 1 tot meer dan 15. Wij concludeerden dat er beperkt inzicht is in de omvang en

samenstelling van de beroepsgroepen in de publieke gezondheidszorg. De beschikbare

gegevens zijn ontoereikend voor een bruikbare inschatting van de benodigde expertise

en opleidingsbehoefte voor de publieke gezondheidszorg in Nederland.

2. Methode ontwikkeling om het werkveld in kaart te brengen

In het tweede deel van dit proefschrift ontwikkelden wij een methode voor de

empirische inventarisatie van beroepsbeoefenaren werkzaam in de publieke gezond-

heidszorg, gebaseerd op de internationale kerntaken van public health. Een aantal

Angelsaksische landen en recent ook de Wereldgezondheidsorganisatie – Europa,

hebben public health omschreven in een de doelstelling en kerntaken. Wij deden eerst

een voorstel voor kerntaken voor de publieke gezondheidszorg in Nederland. Vervolgens

hebben wij onze strategie toegepast om onderdelen van het werkveld van de publieke

gezondheidszorg in Nederland in kaart te brengen.

Wij analyseerden de doelstelling en kerntaken van publieke gezondheidszorg in Nederland

aan de hand van internationale voorbeelden. De doelstelling van publieke gezondheidszorg

komt in verschillende landen grotendeels overeen, en kan voor Nederland geformuleerd

worden als: ‘Bevorderen van volksgezondheid en gelijke kansen op gezondheid door

collectieve interventies gericht op gezondheidsbescherming, gezondheidsbevordering of

ziektepreventie’.

Op basis van de internationale consensus over negen kerntaken van publieke

gezondheidszorg, en een analyse van de toepasbaarheid van deze kerntaken in

Nederland, formuleerden wij tien kerntaken voor publieke gezondheidszorg in Nederland;

het verzorgen van een vangnetfunctie werd als tiende kerntaak toegevoegd. De kerntaken

die wij formuleerden zijn: 1. Monitoren en rapporteren (van determinanten) van gezondheid,

2. Opsporen en preventie van ziekten of gezondheidsrisico’s, 3. Gezondheidsbevordering,

4. Gezondheidsbescherming, 5. Geneeskundige hulp, oefening en preventie van rampen,

6. Vangnetfunctie voor (kwetsbare) groepen, 7. Integraal gezondheidsbeleid, 8. Onderzoek

en ontwikkeling, 9. Waarborgen van voldoende competente beroepsbeoefenaren,

10. Kwaliteit van de (publieke) gezondheidszorg.

Het doel en de kerntaken vormden de basis voor een nieuwe empirische methode

om in kaart tebrengen hoeveel en wat voor mensen er werkzaam zijn in de publieke

gezondheidszorg en welke taken zij uitvoeren. Onze methode bestaat uit: 1. Selectie

van organisaties die een bijdrage leveren aan de publieke gezondheidszorg en 2.

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Binnen deze organisaties individuele medewerkers bevragen over hun opleidingsniveau

en werkzaamheden (hoeveel tijd besteden zij aan welke kerntaken), met behulp van

een digitale vragenlijst. Wij hebben de toepasbaarheid en validiteit van deze methode

onderzocht door het werkveld van de medische milieukunde in Nederland in kaart te

brengen (hoofdstuk 4).

Het werkveld van medische milieukunde definieerden wij als alle organisaties en

medewerkers die een bijdrage leveren aan de medische milieukunde. De vragenlijst

werd verspreid onder alle potentiele werkers in de medische milieukunde. Het onderzoek

resulteerde in gegevens over de beroepsbeoefenaren in de medische milieukunde. De

vragenlijst werd goed ingevuld en de resultaten met betrekking tot de artsen in de medische

milieukunde kwamen overeen met bestaande referentiegegevens. De resultaten met

betrekking tot het uitvoeren van kerntaken was volgens een groep medisch milieukundige

experts een goede reflectie van de situatie in de dagelijkse praktijk. Alle kerntaken werden

uitgevoerd door een ervaren en hoogopgeleide multidisciplinaire groep professionals. Het

totaal aantal FTE voor medische milieukunde in Nederland kon geschat worden op 0,66

/ 100.000 inwoners.

Wij concludeerden dat het in kaart brengen van de capaciteit voor publieke gezondheidszorg

mogelijk is door het identificeren van organisaties die een bijdrage leveren aan de publieke

gezondheidszorg en het verzamelen van informatie van medewerkers die binnen deze

organisaties kerntaken van publieke gezondheidszorg uitvoeren. Kritische factoren hierbij

zijn het operationaliseren van de kerntaken voor het betreffende werkveld, de selectie van

de juiste organisaties en de bereidheid van medewerkers binnen deze organisaties om de

vragenlijst in te vullen.

In de studie daarna brachten wij het werkveld van de jeugdgezondheidszorg in

kaart (hoofdstuk 5). Wij pasten de vragenlijst aan voor jeugdgezondheidszorg, wat

betekende dat wij bij elk van de kerntaken voorbeelden uit de dagelijkse praktijk van de

jeugdgezondheidszorg toevoegden. Verspreiding van de vragenlijst onder alle potentiele

beroepsbeoefenaren in de jeugdgezondheidszorg in Nederland resulteerden in gegevens

over professionals werkzaam in de jeugdgezondheidszorg. De jeugdgezondheidszorg

is een heel multidisciplinair werkveld. Een meerderheid (62%) van de respondenten

had meer dan 10 jaar werkervaring binnen de jeugdgezondheidszorg. Er bestonden

slechts kleine regionale verschillen in leeftijd en opleidingsniveau van de werkers in de

jeugdgezondheidszorg. Het aantal kinderen per beroepsbeoefenaar varieerde tussen

regio’s van 688 tot 1007 kinderen per beroepsbeoefenaar. Alle kerntaken werden

uitgevoerd en konden geclusterd worden in een uitvoerend of een beleidsprofiel. Het

uitvoerende profiel kwam in alle regio’s het meest voor. Regionale verschillen in het aantal

kinderen per beroepsbeoefenaar waren niet gerelateerd aan het percentage kinderen

met overgewicht, die in armoede leven, die doorverwezen zijn naar jeugdzorg of die

woonachtig zijn achterstandswijken, en konden dus niet toegeschreven worden aan

verschillen in indicatoren voor de behoefte aan preventieve zorg.

3. Toekomstige behoefte aan expertise voor de publieke gezondheidszorg

In de laatste studie gebruikten we de kerntaken als een kader voor analyse van de

consequenties van het gebruik van een nieuw concept van gezondheid voor de publieke

gezondheidszorg (hoofdstuk 6). Het nieuwe concept van gezondheid luidt: ‘het vermogen

van mensen zich aan te passen en eigen regie te voeren, in het licht van fysieke, emotionele

en sociale uitdagingen van het leven’. We analyseerden 28 groepsinterviews over de

toekomst van het Nederlandse zorgstelsel, met in totaal 277 deelnemers werkzaam in

de publieke of de curatieve gezondheidszorg. Het doel van onze analyse was om de

toekomstige prioriteiten voor de publieke gezondheidzorg te onderzoeken ten behoeve

van sturing op de benodigde expertise voor de publieke gezondheidszorg.

Uitgaande van gezondheid in termen van het vermogen van mensen om zich aan te

passen en eigen regie te voeren, beoordeelden de deelnemers aan de groepsinterviews

gezondheid als een individuele verantwoordelijkheid. Die visie impliceert een actieve

houding van mensen ten aanzien van gezondheidsbevordering en een keuze voor gezond

gedrag. Sectoren buiten de gezondheidszorg, zoals het onderwijs of het bedrijfsleven

kunnen in de visie van de deelnemers aan de groepsinterviews bijdragen aan het

bevorderen van gezond gedrag. Meer aandacht voor preventie en gezondheidsbevordering

in de curatieve gezondheidszorg werd ook genoemd als mogelijkheid om een gezonde

levensstijl te stimuleren. Extra aandacht is nodig voor mensen die minder goed in staat

zijn tot aanpassen en het voeren van eigen regie ten aanzien van hun gezondheid. Voor

deze groep is een vangnet nodig. Het nieuwe concept van gezondheid als basis voor

veranderingen in de gezondheidszorg biedt mogelijkheden voor het creëren van een

maatschappij die meer dan nu gericht is op gezondheidsbevordering. Echter, het is

zeer wel denkbaar dat gezondheidsverschillen in de bevolking toenemen als gevolg van

toepassing van het nieuwe concept van gezondheid in het gezondheidszorgsysteem.

Voor publieke gezondheidszorg zijn de belangrijkste uitdagingen om effectief aandacht

te behouden voor de sociaal-economische en omgevings determinanten van gezondheid

en ziekte, en daarnaast voor het behoud collectieve preventie.

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ALGEMENE DISCUSSIE

In hoofdstuk 7, de algemene discussie, bespreken we de belangrijkste resultaten, de sterke

punten en de beperkingen van onze studies. We plaatsen de bevindingen in perspectief

en we eindigen met implicaties voor onderzoek, beleid en praktijk, ten behoeve van het

verbeteren van de sturing op de benodigde expertise voor de publieke gezondheidszorg.

Sturing op de omvang en samenstelling van beroepsgroepen in de publieke

gezondheidszorg in Nederland vindt plaats op verschillende niveaus: a. de organisaties

in de publieke gezondheidszorg, b. de artsen, georganiseerd in de beroepsverenigingen;

bijvoorbeeld de Koepel Artsen Maatschappij en Gezondheid (KAMG) en c. de nationale

overheid via het Capaciteitsorgaan.

Reflectie op de sturing op de omvang en samenstelling van beroepsbeoefenaren in de

publieke gezondheidszorg vanuit het perspectief van de resultaten van de twee studies

naar de medische milieukunde en de jeugdgezondheidszorg illustreren drie belangrijke

problemen in de huidige beroepskrachtenplanning:1. de monodisciplinaire aanpak, 2.

gebrek aan inzicht in het aantal artsen dat werkzaam is in de publieke gezondheidszorg

en 3. gebrek aan inzicht in de achtergrond van de spreiding van beroepsbeoefenaren over

het land.

- De capaciteitsramingen zoals uitgevoerd door het Capaciteitsorgaan hebben alleen

betrekking op de artsen werkzaam in de publieke gezondheidszorg. Ons onderzoek

laat zien dat het werkveld van de publieke gezondheidszorg heel multidisciplinair is en

voor meer dan de helft bestaat uit andere beroepsbeoefenaren dan artsen, waaronder

verpleegkundigen, logopedisten, toxicologen en beleidsmakers. Voor deze disciplines

bestaat geen raming van de benodigde expertise.

- We lieten zien dat slechts een deel van de artsen die werkzaam zijn in de publieke

gezondheidszorg is opgeleid en geregistreerd als arts maatschappij & gezondheid

of profielarts. Een deel van de werkzaamheden wordt uitgevoerd door basisartsen.

De schatting van de benodigde opleidingsbehoefte voor artsen beperkt zich tot de

geregistreerde artsen maatschappij & gezondheid en profielartsen en houdt geen rekening

met de werkzaamheden die door basisartsen worden uitgevoerd. Zonder gegevens over

de bijdrage van alle artsen die werkzaam zijn in de publieke gezondheidszorg, is sturing

op de benodigde kwantiteit en kwaliteit van medische expertise voor goede publieke

gezondheidszorg inadequaat.

- De resultaten van het jeugdgezondheidszorg onderzoek toonden aan dat regionale

verschillen in de capaciteit v van beroepsbeoefenaren niet verklaard konden worden

door regionale verschillen in het aantal kinderen of door regionale verschillen in de

behoefte aan jeugdgezondheidszorg. Regionale verschillen kunnen optreden als

gevolg van de bestuursstructuur. Lokale overheden kunnen hun beleid ten aanzien

van jeugdgezondheidszorg en daarmee de capaciteit voor jeugdgezondheidszorg

afstemmen op de lokale zorgbehoefte. Of regionale verschillen in de capaciteit voor

jeugdgezondheidszorg in lijn zijn met de regionale verschillen in de behoefte aan

jeugdgezondheidszorg wordt niet op nationaal niveau gemonitord. De methode die wij

ontwikkeld hebben om omvang en samenstelling van de beroepsgroepen in de publieke

gezondheidszorg in kaart te brengen maakt het mogelijk om de gegevens te verzamelen

die noodzakelijk zijn voor dergelijke monitor.

Reflectie op de sturing op de omvang en samenstelling van de groep beroepsbeoefenaren

in de publieke gezondheidszorg vanuit het perspectief van een nieuw concept van de

gezondheid liet zien dat een andere conceptualisering van gezondheid kan leiden tot een

verandering van prioriteiten voor de publieke gezondheidszorg.

Beter inzicht in de capaciteit voor de publieke gezondheidszorg in Nederland is een

belangrijke voorwaarde voor het verbeteren van sturing op de benodigde capaciteit. We

eindigen met drie belangrijke aanbevelingen voor de verbetering van de sturing op de

omvang en samenstelling van de totale capaciteit aan beroepsbeoefenaren in de publieke

gezondheidszorg in Nederland:

1. Betrek alle beroepsbeoefenaren in de publieke gezondheidszorg in de raming van de

toekomstige behoefte aan capaciteit voor de publieke gezondheidszorg (van mono- naar

multidisciplinair)

Sturing op de omvang en de ontwikkeling van alle beroepsgroepen in de publieke

gezondheidszorg is noodzakelijk voor een optimale kwaliteit en doelmatigheid van

publieke gezondheidszorg. Een eerste stap in de richting van multidisciplinaire sturing

op de capaciteit is het in kaart brengen van de van omvang en samenstelling van de

beroepsgroepen werkzaam in de publieke gezondheidszorg en de taken die zij uitvoeren.

Onze strategie voor het empirisch in kaart brengen van de capaciteit voor publieke

gezondheidszorg is hiervoor in principe bruikbaar en veelbelovend, maar vereist verdere

ontwikkeling en implementatie.

2. Includeer de behoefte aan publieke gezondheidszorg in het bepalen van de benodigde

capaciteit voor de publieke gezondheidszorg

Een verandering in de prioriteiten van de publieke gezondheidszorg kan leiden tot een

verandering in het uitvoeren van kerntaken (bijvoorbeeld een verandering in de manier

waarop kerntaken uitgevoerd worden), of de behoefte aan een specifieke kerntaak,

of het uitvoeren van kerntaken door andere professionals. De vertaling van kerntaken

in competenties is een noodzakelijke stap om deze veranderingen in opleidings-

behoeften vertalen.

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3. Faciliteer wetenschappelijk onderzoek gericht op het ontwikkelen van de evidence voor

evidence-based arbeidsmarktbeleid in de publieke gezondheidszorg

Onderzoek naar de ondersteunende kerntaken zoals ‘het waarborgen van

voldoende competente professionals voor de publieke gezondheidszorg’ en

‘gezondheidszorgonderzoek binnen de publieke gezondheidszorg’ blijft achter en

moet verder worden ontwikkeld. Hetzelfde geldt voor studies naar de relatie tussen

interventies in de capaciteit voor de publieke gezondheidszorg en de effecten op de

volksgezondheid. Dergelijke studies zijn nodig voor het onderbouwen van beslissingen ten

aanzien van sturing op de omvang en samenstelling van beroepsgroepen in de publieke

gezondheidszorg, maar ook beleid met betrekking tot het organiseren, financieren, en

het implementeren van effectieve strategieën voor het bevorderen van volksgezondheid.

DANKWOORD

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DankwoordDankwoord

Dhr. Sjaak de Gouw, ik wil je bedanken voor het vertrouwen en de mogelijkheid die je me hebt gegeven om de aller eerste pilot in jouw GGD in Leiden uit te voeren. Die studie heeft veel betekend voor de studies in dit proefschrift.

Alle organisaties en medewerkers in de publieke gezondheidszorg die meegewerkt hebben aan de onderzoeken. Zonder alle medewerking van de organisaties én de medewerkers was er geen proefschrift geweest.

Mijn collega’s van de afdeling sociale geneeskunde en in het bijzonder met ex-kamergenoten: Mirjam, Conny en Majda, Boukje en het secretariaat: Noor, Nita en Henriette.

De collega’s van de NSPOH. Bij de NSPOH is de inspiratie ontstaan voor het onderzoeken van de public health workforce.

De leden van de NPHF werkgroep Beroepskrachtenplanning, voor de feedback op de onderzoeksresultaten en input vanuit de praktijk.

Het Zorginstituut Nederland, in het bijzonder Marian Kaljouw, Katja van Vliet en Mary van der Linde. Wat als stage begon groeide uit tot een twee jaar lange samenwerking die verzilverd is in een mooi artikel.

Dhr. Victor Slenter, ik wil je bedanken voor de jaarlijkse reflectie op de tussentijdse resultaten van de onderzoeken en het delen van je kennis over beroepskrachtenplanning.

Mijn zwager Ruud Emous, voor de tips en adviezen over de communicatie.

Mijn PHned intervisie groep, voor alle goede tips tijdens mijn promotiedips.

Corine de Kruijk en Diana Hell van de Huisartsenopleiding in het AMC, het proefschrift is af en de katoenen lap is inmiddels een wol/zijden promotiejurk geworden.

Mijn ouders en broer, voor jullie betrokkenheid, steun en bijdrage aan dit werk. Tijs, ik kijk uit naar jouw promotie!

Thuis: Arnoud, Janne en Else. Arnoud, voor het trouwe meelezen. Er zijn weinig huisartsen die zoveel van public health weten als jij. Jij bent nu al de huisarts van de toekomst. Janne en Else, wat was het bijzonder dat wij vaak samen aan tafel zaten te werken. Daardoor was het werken in de avond en het weekend nog gezellig ook. Wat een luxe dat jullie straks bij de verdediging op de eerste rij zitten.

En nu is mijn proefschrift klaar!

LAST BUT NOT LEAST….

Het dankwoord van mijn proefschrift. Lang heb ik gedacht: als de laatste studie maar afgerond is, dan komt het wel goed met mijn proefschrift. Maar dan volgt er nog een inleiding, discussie, Engelse en Nederlandse samenvatting en tot slot het dankwoord; het allerlaatste maar zeer belangrijke stuk van dit proefschrift. Zonder de medewerking van heel veel mensen was dit proefschrift niet tot stand gekomen. Ik wil in het bijzonder bedanken:

Allereerst mijn promotoren, professor Stronks en professor Essink-Bot. Beste Karien, jij was mijn promotor vanaf de start en hebt mij gestimuleerd om aan een proefschrift te beginnen. Dank voor je geduld, je betrokkenheid en vooral je kritische opmerkingen die mij uitdaagden om harder na te denken en het onderzoek beter op te schrijven. Nu kan de hele wereld ons werk lezen en er zijn voordeel mee doen.

Beste Marie-Louise, mijn promotor én opleider. Dat maakt jouw rol heel bijzonder en ik wil je bedanken dat je mij in beide rollen hebt willen begeleiden. Samen hebben we het terrein van de publieke gezondheidszorg , beroepskrachten planning en opleidingen onderzocht. Dat was inspirerend en ik heb veel van je geleerd, niet alleen op het terrein van onderzoek doen maar ook van onze discussies over de rol van publieke gezondheidszorg in de gezondheidszorg. Ik hoop dat er nog veel AIOS-en de opleiding arts maatschappij & gezondheid gaan volgen en dat meer hoogleraren jouw voorbeeld volgen. Dat is een verrijking voor de publieke gezondheidszorg.

Leden van de promotiecommissie prof. dr. N.S. Klazinga, prof. dr. S.A. Reijneveld, prof. dr. D. Ruwaard, dr. W.J.M. Scholte op Reimer en dr. N. van Dijk wil ik graag bedanken voor het beoordelen van mijn proefschrift en de bereidheid zitting te nemen in de commissie. Prof. dr. L.J. Gunning-Schepers, beste Louise, wat fijn dat jij tijdens de verdediging zitting wil nemen in de commissie, dank daarvoor.

Paranimfen, Jelle en Anneke. Jullie hebben allebei een belangrijke rol gespeeld in de vertaling van mijn academische onderzoeksplannen naar de praktijk. Zonder jullie had ik het MMK en JGZ onderzoek niet uit kunnen voeren. Daarom vind ik het bijzonder dat jullie naast mij staan tijdens de verdediging. Dat symboliseert de verbinding tussen de academie en de praktijk en natuurlijk ook onze jarenlange vriendschap.

Mijn kamergenoot, Ines. Wat was het gezellig om samen te reflecteren op ons werk en onze gezinnen. Ik mis je nu al. Gelukkig komen we elkaar in het IOSG nog regelmatig tegen.

Thomas Plochg, ex-collega. Dank voor je bijdrage als mede-auteur, maar vooral ook voor de vele gesprekken die wij hebben gevoerd over de publieke gezondheidszorg in Nederland en hoe die te verbeteren.

ABOUT THEAUTHORCurriculum Vitae

Portfolio

153152

About the authorAbout the author

CURRICULUM VITAEMarielle Jambroes, geboren 1 maart 1970, te Amsterdam

Opleiding:

PhD: Start maart 2011

Arts M&G io: Start augustus 2013, vrije richting.

Verwachte einddatum 31 december 2015

MPH: Master of Public Health, Netherlands School of Public Health,

Utrecht (1993 – 1995)

Basisarts: Geneeskunde aan de Universiteit van Amsterdam (1989 – 1997)

Werkervaring

2015 - Assistant professor, afdeling Public Health, Julius Centrum,

Universitair Medische Centrum Utrecht

2013 - 2015 Beleidsmedewerker innovatie zorgberoepen en opleidingen,

detachering, Zorginstituut Nederland, afdeling Beroepen en

Opleidingen, Diemen.

2009 – Senior beleidsmedewerker Academische Opleidings Werkplaats

Arbeid, Maatschappij & Gezondheid (AMC/NSPOH), Academisch

Medisch Centrum, Universiteit van Amsterdam.

2006 – 2009 Teamleider en research physician Unilever R&D Vlaardingen

(Nutrition intervention studies)

2001 – 2006 Projectmedewerker Infectieziektebestrijding, GGD Nederland,

Utrecht

1997- 2001: Studie-coördinator bij het Nationaal Aids Therapie Evaluatie

Centrum (NATEC), Academisch Medisch Centrum, Universiteit

van Amsterdam.

1994-1995 Stagiaire bij het Instituut Sociale Geneeskunde. Academisch

Medisch Centrum, Universiteit van Amsterdam.

155154

About the authorAbout the author

PORTFOLIO

PhD candidate: Marielle Jambroes

PhD period: 2011 - 2015

PhD supervisors: Prof. dr. M.L. Essink-Bot, Prof. dr. K. Stronks

Year Workload

1. Courses, master classes, and training

General and specific courses

BKO certificate 2014 0,1

Governance in public health, NSPOH 2015 5

Didactical skills, 2 AMC courses 2012 0,2

Seminars and workshops (selection)

Seminars at AMC Dept. of Public health (every other week) (several A21oral presentations)

2009 - 2015 3,2

Monthly meetings research group ‘diversity in health care’ (several oral presentations)

2010 - 2015 3,2

Masterclass academische werkplaats Amsterdam+A7 2009 - 2015 0,3

(International) conferences and presentations

EUPHA, Amsterdam, Malta, Glasgow, Milan (oral and poster presentations)

2009 - 2015 2,3

Formal leave oral presentation, Toon Voorham 2014 0,1

Academy Health, oral presentation 2013 0,5

NCVGZ 2010 - 2015 2,8

Other

Member of working group educational program public health, Dept of public health, AMC

2010 - 2013 1

Member of ‘writing group’ Dept of public health, AMC 2013 0,5

2. Teaching and education

Tutoring, mentoring

Practical ‘Cultural diversity in medical practice’ (BSc Medi-cine, UvA)

2012 - 2015 1

Evaluation of nursing internship (BSc Medicine, UvA) 2009 - 2012 0,5

Assessment nursing intership reports 2009 - 2012 0,5

Practical ‘Health literacy in medical practice’(MSc Medicine, UvA)

2012 - 2015 1

Lecturing

EPHOs NSPOH(4x) 2014 - 2015 0,3

Education development

Programme development and preparing accreditation pro-cess, Master of Public Health programme NSPOH

2010 - 2013 3

Supervising

Bachelor thesis medical Informatics, 2x 2013 - 2014 2

Supervisor paper-writing, 2 years 2012 - 2013 0,5

Total (Recommended no of ECTS = 20 - 30) 27,9

pdf proefschrift mjambroes

Documents

Transcript of pdf proefschrift mjambroes