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Public Health in a National Accounting FrameworkNational Health Accounts (NHA) are a management monitoring and a policy assessment tool, whose construction requires classifications and identities. The classifications are typically created through a blend of institutional descriptors, product nomenclatures, lists of purposes. Among sizeable hurdles facing the build-up of comparative NHA are :
Pertinent classifications help to overcome these. A forthcoming OECD Manual on NHA proposes rules of this kind across the full spectrum of individual and collective (consumption) functions, delivery institutions and products. When pre-existing international classifications fitted the task, these have been "borrowed" (with attribution) in order to reduce the compliance and interpretation burden facing statisticians and analysts. Among the WHO classifications imported in the OECD draft Manual, the adequacy of the Essential Public Health Functions (EPHF) -- which is the only classification found relating to that field -- has been questioned. This is notably because the WHO itself and its constituency -- the health ministries - do not use EPHF as an accounting instrument [it was not intended for that purpose] and because the boundaries of EPHF overlap with those of other classifications. It may be recalled that the EPHF list was established as a tool in support of the broad Health for All policy and that it was finalised after a consultation of eminent scholars and senior civil servants from 67 countries -- which conferred immediately to the instrument a high degree of respectability -- but that the vast majority of the experts consulted had a public health background. Less weight was attached to the needs of other constituencies of the health services research and of the decision-making community than might have been the case if different demands had been placed on the set-up of EPHF. Furthermore, the revival of interest in setting cross-nationally boundaries to the domain of public health occurred at a time when the Soviet Union was breaking-up and at a time when Health for All paths and outcomes were re-evaluated; this led to a considerable concern to define the appropriate roles of health authorities at the regional level and to issues surrounding the devolution of power to various groups in the community, leading to a greater concern to define strategic functions than operating functions and performance assessment tools. Concerns evolve like societies. EPHF served an important purpose and still serves many goals of health policy. For the evaluation of performance, there is a legitimate question as to whether public health functions should not be re-appraised in terms of the challenges that have emerged in the past few years, including those of better monitoring the development of health systems ? Public Health is a more important instrument of health policy attainment in the middle- and lower-income countries than it is in the OECD area and must consequentially be defined and measurable for most purposes on the WHO agenda. Whatever the rationale and the opportunity question, the OECD Manual is likely to be used in middle- and lower-income countries until such time as appropriate "world" guidelines see the day of light. These guidelines may not be dramatically different from the OECD set, subject to some interim conceptual and reporting adaptations. The public health classification will thus be carried over in several dozen countries, else ignored if not relevant for performance evaluation and replaced by heterogeneous national classifications. Given the propensity of the accounting profession not to publish sources and methods, for a sizeable component of expenditure on health and expenditure on non-medical determinants of health recorded outside the boundaries of health, the outcome would be an inkpot. The desirability of an operational accounting classification of public health functions is not one of political appreciation, it is a methodological requirement to measure inputs, throughputs and evaluate outcomes. As it is, measurement already minimises cross-national comparability, battered by a wide range of cultural factors affecting medical and by varying uses of identical medical and non-medical terminology in several branches and in the many loci of Health Information systems. The advocacy of an "accounting" version of WHO’s classification of Public Health Functions rests on the grounds that it is more likely to be comprehensive and consistent than many national endeavours because it would result from monitoring developments in nearly 200 countries and it would be more operationally used than the broader EPHF list has been. For the convenience of readers, the EPHF list as publicly released ("Essential Public Health Functions : results of the international Delphi study", World Health Statistics Quarterly vol. 51 n°1, 1998) is presented in table 1. A preliminary proposal of a substitute classification of public health functions prepared in EIP/GPE/OHS is presented in Table 2. Both centre around what Public Health "does", but reflect somewhat different approaches, respectively a more research-oriented one and a more action-oriented one. The two classifications pursue both ends but give them different weights. Broadly stated, public health action starts with an identification of "need" and an assessment of potential action, which is a kind of "research subfunction" preceding action, incorporated by public health "professionals" as a "core" of their intervention; other students of public policy consider that the planning, monitoring and evaluation dimensions are cross-sectional. Without denying a substantial investment of experts in public health to establish the pre-condition of intervention, they view this as a cross-sectional function that relates to all other "domains" of health policy and interventions, that cannot be "appropriated" by any one of them, lest it be a cross-sectional function, labelled "government" or "administration and management". The latter function oversees in addition to public health the "domains" that aim at satisfying individualised needs, such as the bulk of primary-, much of secondary- and part of the tertiary-care activities, other health delivery and financing institutions, investment in facilities and in human resources, the establishment of regulations and the monitoring of the system with a total population or a population segment dimension. Neither the EPHF nor the Accounting approaches confines public health to an old fragmentary dichotomy which characterised it in the past, a confrontation of "personal" services and "environmental" services, of preventive actions and curative activities, of public and of private responsibilities". Both approaches seek to overcome a weakness of past governmental budgeting practices that failed to properly account for
Public Health is "concerned" with all these services and with the entire finality of a health system (including those dealing with the management of pain, actions against disease, other interventions enhancing productive lives), but it is deemed not to be accountable stricto sensu for services whose primary purpose is therapeutic or a preventive intervention on individuals, that is acute hospital care, a range of long-term care services, primary care, optical and prosthetic assistance. The WHO budget programme and many health ministries also list under the public health heading :
Their reality is acknowledged conceptually but not operationally under NHA. NHA (and other disciplines of knowledge) which allocate these essential attributes of what Public Health is "concerned" with respectively to Capital Formation and to Health Administration and Insurance. Administration is not only bookkeeping, but includes the three dimensions of accountabilty : planning, monitoring of implementation and evaluation. Another classificatory difference relates to non-medical determinants of health gain, notably in the "environmental" domain. Health gain has little meaning if sources of pollution and other diseconomies are not under control. Since more than two decades, the United Nations Classification of Government Functions (COFOG) treats most "sanitation" subfunctions as a separate category of amenities even though the intent comprises health enhancement. Other societal goals, such as aesthetic considerations, guide the classification of waste disposal; the same applies to recreational purposes concerning efforts to clean rivers and lakes, to consumer protection and international trade incentives regarding food safety and veterinary controls. "Joint products" abound in national accounting. These are often arbitrated using a convenience rule. When the primary intent, the largest part of value added and the bulk of the benefits accrue more to one category of agents than to the others, the transaction is fully allocated to the principal domain, activity or agent. In practice, this leads to a "narrower" environmental function in the putative NHA classification than under EPHF, without prejudice that a greater respect of environmental concerns is essential to health but with a recognition that society values it as a goal independently of its public health contribution. Two classifications may thus co-exist, responding to different constituencies. The attributes retained for the proposed NHA classification of public health functions have been found in a few seminal articles, in several contributions to the Oxford Textbook of Public Health (third edition, 1997), in White Papers and in government budgets. Only a few are cited :
A difficulty inherent to any classificatory exercise is the constant flux of the parameters determining the notions of health status, health priorities, health interventions, etc. This is illustrated by the acceptance in many high-income communities that the costs of screening programmes for congenital chromosomic anomalies should be born by a third-party payer; a medical intervention that has a very strong individual content is thereby propelled into a Public Health intervention dealing with the prevalence of mental retardation in a society. The attributes and criteria listed attempt to be comprehensive of what should count as Public Health, but that review may not be exempt from deficiencies and should accordingly be complemented with criteria that may have been omitted. The candidate public health accounting classification attempts to identify the main clusters of interventions reported in several WHO’s work programmes and in the main policy statements of its 192 Member States, except with respect to the separate allocation of activities pertaining to governance and management and to capital formation, in part also with respect to environmental concerns. Table 2 is at this stage only a preliminary proposal whose entries can be increased or reduced, whose labels can be shortened or enlarged : would-be accountants are only the penholders of the health systems’ decision-makers and analysts. To facilitate this process of creative destruction, each function has been broken below into subfunctions or discrete building blocks (some to be chopped if a consensus emerged that they are not pertinent, others to be added if important omissions were singled out) risk assessment and risk management, inherent in many EPHF functions and sub- functions, are not specifically identified but joint products of a subfunctiuon of Health administration much international health flows through other Public Health programmes, dispensing from a specific entry. A number of experts on middle- and low-income countries imply that external assistance programmes constitute a genuine addition to public health strategies and should be reported outside of the programmes they facilitate (avoiding double counting, however). When agreed to, a classification of public health functions for NHA will require in addition to the summary descriptive content exacting definitions so as to reduce further the discrepancies arising from multiple uses of the same terminology. It may be observed that the precision of the literature regarding the territory of Public Health and the width of the definitions regarding the skills to become a consultant in public health is an accountant’s challenge. The following citation remarkable for its concision (never mind the order of qualifications) cannot be commended for its operational character. This person needs to know : epidemiology, economics, cost accounting, nursing, pharmacy, medicine/surgery, communicable disease control, informatics/computing, statistics, report writing, research skills, option appraisal skills, disease registration, medical complaints, medical discipline, other medico-legality, dental and optical health, health needs assessment, survey design, nutrition, primary and community care, awareness of local health related groups (voluntary groups, CHCs and so on, assessing scientific evidence, health care management medical ethics, diplomacy, political awareness, health education/promotion, public relations, environmental science, medical genetics, agriculture, town and country planning (housing and transport policy), medical sociology, monitoring outcomes, chairing meetings, awareness off up-to-date scientific literature, awareness of sources of data and information, public speaking, rationing, equity, modelling skills, strategic planning ….. there are undoubtedly others" [from Suzy Lessof, Carol Dumelow & Klim Mc Pherson Feasability Study of the Case For National Standards for Specialist Practice in Public Health London School of Hygiene and Tropical Medicine ]
Table 1. Essential Public Health Functions
2. Monitoring the health situation
3. Health promotion
4. Occupational health
5. Protecting the environment
6. Public health legislation and regulation
7. Public health management
8. Specific public health services
9. Personal health care for vulnerable and high risk populations
Table 2. Public Health Functions in an Accounting perspective
.*** *** *** *** *** *** ******* *** *** *** *** *** *** Notes : (1) a large part of functions 2 6 and 7 under EPHF are allocated to Administration under NHA (2) a fair part of function 5 under EPHF is allocated to sanitation, not to health under COFOG rules (3) mental health, an orphan of the public health literature, but an explicit line in most Member States budgets, is given here a status of a distinct function. There is a case, however, to treat it instead as a distinct entry under 2 "Promotion and protection of specific population segments". The same case exist for the proposed function 4 : palliative and rehabilitation care and activities.
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