Workshop on Developing New Schools of Public Health

Jerusalem, 17-21 March, 2002

THE INSTITUTIONALISATION OF PUBLIC HEALTH
TRAINING AND THE HEALTH SCIENCES
Prof. Dr. med. Ulrich Laaser DTM&H, MPH 1
Keywords:
Schools of Public Health, Health Sciences, Training, Structures, Regional Consortia

Abstract:
The health of the population is determined by a number of ecological determinants in addition
to medical care. Therefore a close relationship exists with the social and political context in a
society. With regard to the health care system schools of public health as institutions for
training, research and services have to focus on four main deficits in the area of information,
prevention, social gradients and the regulation of health care delivery. A task profile derives
which comprises (a) training for research and services, (b) monitoring population health and
setting of priorities, (c) applied research on public health, (d) consulting the decision makers,
and (e) intervention and public accountability. How to perform in these areas has to be related
to basic ethical principles notably equity, participation, subsidiarity, sustainability, and
efficiency. Furthermore international trends in modern education have to be considered as for
the European Union in the Bologna Declaration of 1999, with reference to academization and
internationalization of advanced studies. The resulting institutional profile of modern schools
of public health is characterized by their academic basis, inter-disciplinarity and multiprofessionality, the paradigm of the New Public Health with an equal merger of medical and
social sciences, a predominantly postgraduate study program, an international scope, close
links to the government, local networks with service institutions, and a focus on contemporary
health issues. In the former socialist economies of Central and Eastern Europe a regional
1.

Section of International Public Health, Faculty of Health Sciences
University of Bielefeld, POBox 10 01 31, D 33501 BIELEFELD, Germany
TEL, AM, FAX: +49-521-450116
Email: ulrich.laaser@uni-bielefeld.de

1

1

collaboration beyond borders (the concept of regionality) is apt to support the achievement of
international standards of excellence for newly developing schools of public health.
Introduction
In the recent report on Macroeconomics and Health (1) a long established paradigm has been
reversed: It is now stated that without healthy people economic development is seriously
impaired. If on the other hand one of the central paradigms of Public Health is hold valid,
namely that the state of health is also determined by a number of ecological determinants
other than medical care as e.g. socio-cultural and socio-economic conditions of living, then it
becomes obvious that the population’s health cannot be improved following exclusively a
medical paradigm. However, around the world most training programs for public health
professionals - with the exception of the United States - are hosted within medical faculties
(2). This is especially true for the Former Socialist Economies, where as a rule the medical
discipline of “Social Medicine” is taken for “Public Health”. Under this narrow perspective it
is difficult to develop “Health Sciences” as an autonomous academic field (3). The following
text tries to lay out the framework of population health problems [I.] respectively why
independent institutes or “Schools” of public health are needed and how they should fulfill
their array of tasks (II). Then the contemporary trends [III.] of academic education in Europe
will be described and as a result of all of these a structural profile [IV.] of appropriate training
institutions.
I. THE PROBLEMS
The health status of a population is not an independent one of the historical conditions notably
their social, economic, and cultural dimension. Therefore the health sciences relate to the
societal development altogether, the health of the public is a political subject.

Public Health and the Society
The history of modern public health in Germany may serve as an example for the
interrelationship between the health of the public and the development of a society in general.
The origins of this contemporary discussion can be traced back to the analysis of the outbreak
of typhoid fever in Upper Silesia, published by Rudolf Virchow (1821-1902) in 1849 (4). He
accused the Prussian state of the negligence of basic needs of the Polish population in that
region and identified the lack of its political participation as a main social cause of the
epidemic. In the same period Salomon Neumann (1819-1902) postulated the obligation of the
2

2

3 3 . The state should inter alia ensure the basic human right to live a healthy life under suitable conditions. Schlossmann & Teleky developed for the first time the concept of a health science in their foreword to the “Manual of Social Hygiene and Health Care” (6). In practice such truncation proves hard or impossible to achieve.. improve care for the poor.g. a reduction only of the prevalence of elevated values of a risk factor will prove not to be sufficient. eliminating the tail but not interfering with the rest of the population. The upcoming of National Socialism (1934 legislation on the centralization of the health care system) and later of socialism in East Germany blocked further advancement of this concept (3). This has been confirmed also for intervention studies (11). The health of society is integral” (10). the spread of a distribution is not readily compressed. As our results show. Not before half a century later public health was re-established as an academic discipline of study and research when a faculty of health sciences was opened at the University of Bielefeld in 1988/1994. Interventions confined to the narrow medical system cannot reduce the incidence of disease accruing from a number of ecological determinants. In 1925 Gottstein. establish health offices at all administrative levels. Even at that early date they combined essential medical and social scientific disciplines under this term. based on the new public health mandate of the European Commission (e. A few years earlier the Acheson Report defined public health as the science and art of preventing disease. The close link between mean and prevalence implies.state to organize public health care and to protect the health of its people (5). prolonging life. Public Health and Populations Coined by the English cardiologist and epidemiologist Geoffrey Rose the terminology of a “Population Strategy” as opposed to a “High Risk Strategy” (9) has gained worldwide acceptance: “Traditional preventive strategy is concerned with identifying and helping minorities with special problems.. With the Treaties on European Union of Maastricht and Amsterdam (1993 ff) a renaissance of the health sciences developed also in Germany as well as in other European countries. The underlying aim is to truncate the risk distribution. that to help the minority the "normal" majority must change.. This implies that the mean together with the entire distribution of risk in a population has to be shifted into the direction of lower levels of potential harm. by treating their risk factors or seeking changes in their behavior. article 129 in the Maastricht Treaty (7)). and promoting health through organized efforts of society (8). provide medical statistics of the causes and effects of disease and last but certainly not least let the people participate in the administration and guarantee the independence and freedom of physicians.

Health indicators should be relevant (regarding priorities). Meeting these criteria obviously requires a permanent scientifically qualified institutional infrastructure. and useful (for intervention) (13). comparable (inter-territorial). Health surveillance is a prerequisite of intelligent decision making in health policy. Usually health reports of this kind comprise the following sections (see e. (12): Demographic parameters of health care The health of the population Health behaviors Environmental health risks Institutions in health care Utilization of services Employees in health care Professional education in health care Expenditure and financing Cost of health care. valid (regarding determinants of health). sensitive (to change and differences). 4 . repeatable (for time series). Valid indicators are the key to meaningful analysis.g. measurable (in quantitative or qualitative terms).Public Health and the Health Care Deficits Four main deficits can be identified with regard to modern systems of health care: a) The information deficit b) The prevention deficit c) The social deficit d) The regulation deficit. affordable (in terms of relative costs). 4 The information deficit: Because of the obvious lack of sufficient and reliable information in the health sector international as well as national initiatives have promoted the development of indicator-based comprehensive monitoring systems (mostly although not exclusively quantitative routine data) and their interpretation by experts published as reports to the general public (health reporting).

and medical services). It is obvious that success can be only achieved by combining etiological research. non-governmental organizations. I. behavioral modification etc. incorrect diet and overfeeding. and nursing (3). clinical practice. secondly. auto-aggressive behavior and unprotected sexual acts are major causes of increasing morbidity and mortality rates as well as premature deaths. These are mainly behavior related risk factors. in the future much greater consideration has to be given to the multi-dimensional interrelationship of the causes of health impairments both in etiological research and provision of medical services. in other words they are potentially under the control of an individual. in education of the public. and the individual 5 5 . too little physical exercise. thirdly. in the therapy and diagnostics in clinical research and practical work. all preventive approaches must have behavioral and situational components. However. recreation. Where this is obvious for infectious diseases it seems to be even more relevant for chronic diseases which start to develop at early stages of an individual’s life. alcohol drinking and using of drugs. in the area of etiological research through a combination of molecular biology and epidemiological studies. Dangerous driving. prevention. in nursing care of patients. education. but they are – at least in principle – preventable. Chronic diseases. With regard to implementation a core issue is to keep the target group well informed. citizen initiatives. It would be logical if some of the money allocated for and personnel involved in treatment could be diverted to preventive activities. insufficient hygiene and other health damaging behaviors are often responsible especially for diseases of the circulatory system and cancer. the preventive sector of health services has not yet received appropriate attention. housing. risk factors are based on behavioral patterns which are integrated with habitual patterns of socio-cultural life styles and which are shaped in each case by various life situations (14). are very seldom curable once they have manifested themselves. focused on behavioral patterns and life-styles oriented towards prevention.) and setting-oriented prevention (promotion of health at work. This could allow to alter the initial conditions which contribute to the development of chronic-degenerative diseases by means of behavior-oriented prevention (health education.e. notably the administrations. for example. and finally. firstly.The prevention deficit: Given its great potential. For this reason. Smoking. Acquired Immune Deficiency Syndrome (AIDS) is a good example which illustrates the need for concerted efforts and actions.

This also applies to infra-structural and organizational problems faced by health services. 5) reorient health services. 3) strengthen community action. ethnic group. e. Others prefer not to make such a distinction but to think instead in terms of disadvantaged or vulnerable groups such as migrating laborers. The interdisciplinary study of the determinants and possible interventions to minimize health inequities may be summarized as “Social Public Health” (17). marital and family status. By some this is called “vertical” inequality.g. schools. The value statement on inequalities most often is termed “inequity”.people. The social deficit: Today a terminology has become widely accepted which uses the term “inequality” for stating differences in health status determined by social variables like educational grade. 2) create supportive environments. markets. local communities. 6 It is added in the declaration that a so-called “Setting Approach” offers practical opportunities (in cities. and health facilities). socially isolated elderly. islands. The structural problems discussed here can only be managed by means of interdisciplinary cooperation. Social Public Health then constitutes a core sector of the New Public Health (18) approach which has been developed throughout the nineties 6 . whereas “horizontal” inequality may refer to various dimensions of disparities connected with sex and age or different ways of looking at a person’s position in the society. and unjust because being unnecessary and avoidable (16). 4) develop personal skills. WHO’s Declaration of Jakarta (15)has made it quite evident by launching five most comprehensive and effective strategies: 1) build healthy public policy. the unemployed. namely whether a socially determined state of disadvantaged health is considered to be unfair. professional category and income level sometimes added up to one integrated index of social status. people have to be at the center. and one parent families. workplaces. whether one is a migrant or a native resident etc. and health promotion is a “Key Investment”. access to education and information is essential.

Other researchers highlight the fact that at least some part of health inequalities have been shown to arise from a higher prevalence of unhealthy behavior in lower socio-economic groups and from differences in psychosocial work environment (20). This requires scientific analysis of: a) Socio-economic gradients in health: The distribution of total and specific mortality and morbidity as well as risk factors according to social gradients. Together they constitute a vicious circle effective in many regions of the (third) world especially where the population is not sufficiently covered by health insurance. and [4] health behavior. [2] social selection. The first explanation of social gradients is deemed of little relevance: systematic methodological errors are unlikely.Four different concepts have been discussed already in the Black Report (19) in order to explain the differences in health status by social groups: [1] methodological artifacts. which requires reductions faster than average among less fortunate groups (“distribution objective”). Two objectives have been set for interventions (21): 1) Mortality and morbidity should decline particularly for those causes of death and age groups in which a defined population is lagging behind other populations (“level objective”). As disease is more prevalent in the lower social strata.of selected disadvantaged or vulnerable groups with regard to health inequity. b) Disadvantaged groups: The characterization . [3] living conditions.including intermediary factors . the economically disadvantaged ones may have to pay more not only in relative but even in absolute terms. The second and third explanation are mirrored in the slogan that “Poverty drives you sick and sickness makes you poor”. Disadvantaged or vulnerable groups are subpopulations being exposed to an accumulation of unfavorable determinants of health and therefore at excess risk for disease or ill health respectively. 2) Socio-economic differences in mortality and morbidity should shrink. c) Social barriers to health care: Social selectivity in access to health care and delivery of services including satisfaction with health services and their quality. given the almost universal and quite uniform existence of social gradients and health inequalities. The terminology sometimes used for underprivileged or disadvantaged groups stresses the external causation of 7 7 .

The tensions originating from unacceptable differences in chances for healthy living can destroy the societal web and lead to violence and war (23). one parent families. This requires a management that integrates several levels of a formerly hierarchical pyramid in a round-table manner. asylum seekers and refugees. and the very poor.reduced health chances. On the other hand vulnerability is not necessarily static or definite but may change during a lifetime. The regulation deficit: The decision making in health care is organized by a regulatory framework which in most countries is characterized by a continuous shift from the old vertical model to a more horizontal one with a moderating instead of a directive role of the governmental agencies. the homeless. but the following for example have been suggested in varying contexts: the migrating labor force. the unemployed. A management approach of this type may be named “Horizontal Management”. ethnic minorities. Arguments for an increasingly horizontal management can be found in the following: 8 8 . Furthermore many researchers hold the view that during the last decade vulnerability has gained importance vis à vis the classical vertical inequalities. No systematic classification of disadvantaged groups has yet been developed. Originally organized rather in a top-down model more and more the generation of decisions follows a bottom-up approach. elderly females living alone and in poverty. the traveling communities. According to Wilkinson (22) social dislocation and the disruption of social cohesion respectively may be a common mechanism of vulnerability. A number of decision making centers acting more or less in parallel have to be coordinated but cannot be directed. This applies even more to individuals with a limited ability to cope with strains. children growing up in families on social compensation. however. voluntary risk seeking behaviors may also contribute and should not exclude such people from supportive action. as is typically the case with regard to many states of (intermediate) poverty.

Among other topics treated the state conference decreed 10 Health Objectives for NorthRhine-Westphalia which are worked on at annual conferences: I. chaired by the Ministry of Health itself as at the communal and county level. The health conferences as established in the federal state of North-Rhine-Westphalia. Hospital Association. Social Welfare Association. 6) The necessity of smaller respectively lower units to develop a competitive profile given the incapability of covering a complex and wide spectrum of services altogether. 2) Harmonization and decentralization as an essential prerequisite of the above. 3) The competence gap in the health administrations which seems to be increasing because of the growing complexity of management tasks as indicated above. 8) The wider understanding of health (including spiritual respectively cultural dimensions) and the increasing role of non-governmental organizations. chaired by the head of the local health office which also has to organize its proceedings. Reducing cancer 9 . Germany may serve as an example of the new instruments developed in this regard (24): With the new health legislation of 1997 (§ 26 ÖGDG) health conferences have been established as well at the state level. Reduction of cardiovascular diseases II.1) For Europe and to a lesser degree other continents the processes of unification and regionalization which take place in parallel make a centralized top-down coordination difficult and complex. 7) The growing inter-disciplinary and multi-professional collaboration in order to find solutions for modern multifaceted problems. Occupational Hazard Insurances. Social Insurances. Health Insurances. Employers’ Association. Trade Unions. 4) A management by moderation of conflict as a consequence of the loss of authority of the central units. 9) The shift from clinical to ambulatory and primary health care with its less controllable environment of service providers. Self Help Associations. and Regional Administrations. Members to be invited are among others: Medical Chambers. Pharmacists’ Chambers. 9 5) The apparent shortage of tax based funding and in consequence privatization of services. State Board of Counties & Cities.

III. the bottom up approach. Management of environmental hygiene VI. Support through health information. Research & development for health X. qualified participation depends on good information in order to: - identify support - build consensus (acceptance) - satisfy the people (the electorate) 10 10 . serving more action-oriented programs (25). Promoting healthy settings IV. including technical support and training. and provide decision makers with sound analyses. the top down approach. Hospital care VIII. Citizen orientation of health services IX. in this way e.g. how (valid) information is fed into the decision-making processes namely top down via the responsible agencies and municipal administrations (advisory or consultative function). In a first strategy. The full range of these issues can only be successfully treated in a close cooperation between well established independent institutions for research and training in public health and the governmental agencies. The administration is to build a solid information system. II. THE TASKS The figure below delineates the task setting for public health. good governance depends on good information in order to identify: - health problems as far upstream as possible - effective interventions - most cost-effective interventions - explicit priorities In a second strategy. Primary health care VII. Combating drugs V. and/or bottom up via local initiatives and round tables (public information).

However. Peace & Human Rights (26).) as follows: a) Training for research and services b) Monitoring population health and setting of priorities c) Applied research on public health d) Consulting the decision makers e) Intervention and public accountability As for individual therapy and even diagnosis a code of medical ethics has to be obeyed the implementation of population wide interventions in public health and even analytical studies have to follow ethical rules which relate predominantly to the way of how decisions in this regard are made. the field of population ethics is not yet well developed or even recognized. undemocratic closed societies do not seem to have a competitive potential for dynamic development. As an exemption one might consider the Skopje Declaration on Public Health. Five basic principles can be identified: 1) Equity 11 .Figure An operational approach to improve the health of the people (from (23)) Administration [Top down Approach] Consultancy Training Technical Support Information System Interventions Healthy management 11 People’s Health Public Information Decision Making Process Public Information People [Bottom up Approach] It is obvious that this outline applies only to open societies where interplay can develop between the people and the administration. at least not in the long run. The task profile to be dealt with in this setting can be summarized from the outline of health problems (I. However.

Fraternité”) and the modern European welfare states. and thereby in turn interferes also with economics (1). Egalité. The principle of how to solve this seemingly antagonistic statement is substantiated by the term of participation as coined by WHO in many publications (28): Participation in the societal decision making processes which define our social and physical environment and therewith our conditions of living. in other words in a most democratic way. 12 12 . not to mention the original intentions of philosophers like Marx and Engels. Subsidiarity: The principle of subsidiarity. the French revolution (“Liberté. and in extremis even concerning their private lives. inequity in health is considered to be unfair and unjust. Further more incapacitated individuals cannot fully participate in decision making regarding societal issues. which has been invented as a concept in the Catholic social doctrine by the late Jesuit Nell-Breuning (29) and became a dominant principle of the European unification process. Subsidiarity equally relates to social welfare when it reads in the Maastricht Treaty on European Union (7) that gradients in the quality of life between the regions of Europe must be compensated for so that living conditions are comparable and similar all-over Europe. being unnecessary and avoidable (16). In the European ethical tradition solidarity with the disadvantaged is a moral value throughout the Christian middle-ages. The formation of the “Settings” (15) we live in is to evolve as much “bottom up” as possible. Thus it is a European heritage to think of health as a personal good but under individual as well as collective responsibility (27).2) Participation 3) Subsidiarity 4) Sustainability 5) Efficiency Equity: A long and healthy life is at the top of the agenda of almost every individual and whereas some gradient in socio-economic welfare given equal chances may stimulate dynamic development. Participation: Collective responsibility must not interfere with individual autonomy. It causes social tension. is meant to protect against a preponderance of higher hierarchical levels and in consequence to refer decisions as much as possible to regional and local bodies.

6) Demand that is mainly determined by supply. With regard to the health sciences in Europe we find correspondingly a clear trend towards academic settings for new programs and for academization of existing ones. THE TRENDS The development of institutional profiles for training and research in public health cannot be isolated from the contemporary trends of education. In the academic 13 13 .Sustainability: The fourth ethical concept of relevance concerns sustainability which refers to a development which ensures that the current use of resources does not compromise the health of future generations (30). 5) The increasing relevance of Far Distance Learning. 4) The growing importance of Continued Education. III. 3) A phenomenon of accidental specialization i. the accessory amendment of existing programs for neighboring fields resulting in hybrid “Interdisciplinary disciplines”. 12) modularisation and credits (European Credit Transfer System. 10) a more flexible organization of programs allowing for stepwise professional qualification (no “dead ends”). More recently in the wake of the Bologna Declaration (32) additional trends can be observed: 7) An effort toward international compatibility. That implies that any waste or sub-optimal use of money is unethical as it leads to even greater restriction of resources elsewhere. obligatory insurance fees) have to be compensated according to rational priorities which results in limited provision of very expensive technologies. 9) shortening the period of study duration (< 5 years). This is especially relevant to countries with economic difficulties. Services financed from solidarity funds (taxes.e. 8) equal conditions for universities and polytechnics. In Europe over the last decade we find (31): 1) A quantitative explosion of specialized educational programs in various fields. such as post-communist countries in transition. 2) A dominant trend towards academization of existing and new programs. 13) establishment of agencies for the accreditation of training institutions. Efficiency: Finally resources for health are limited by principle as the desires for health promotion and technological advances are always ahead of the financial capabilities. ECTS). 11) the chance for every student to meet the entrance criteria to doctoral degrees.

g. Probably the most appropriate is the establishment of a faculty in its own right. Another model is more frequently found: a department of public health belonging to a faculty of Medicine. the resulting tasks and the trends in modern education lead in conclusion to an institutional profile for the “School of Public Health”. Within the university different models of academic institutionalization can be found. This implies the involvement in undergraduate medical teaching (e. At least for the example of Germany we see programs at universities as well as polytechnics (universities of applied sciences). THE STRUCTURAL PROFILE General characteristics The health problems.environment public health is represented by a proto-typical “interdisciplinary discipline”. which at the same time fulfills all functions of a school of public health in terms of training for services including continued education and a far distance learning program as well as executing a broad spectrum of public health research. health promotion. An example is the Faculty of Health Sciences at the University of Bielefeld. ASPHER (35) and based on the ECTS system of credits. Beyond that a canon of health disciplines does not exist allowing each institution to develop its own profile in relatedness to its societal environment. for the European Master of Public Health (EMPH). This guaranties the indispensable degree of autonomy necessary to fulfill its tasks and secondly is the best way to make the required interdisciplinarity of the New Public Health functional.e. inaugurated by the Association of Schools of Public Health in the European Region. Internationalization progresses rapidly by consortial networks between schools of public health as e. and environmental health. being a part of the health administration within or closely related (National Institutes of Public Health in many countries) to the Ministry of Health (2). 34) in so far as they comprise at least the four core disciplines of applied epidemiology. which can be characterized as follows: 1) The institutional base should be in the university vs. In addition to the classical postgraduate master programs more and more undergraduate studies and doctoral programs are offered. i. IV.g. of Social Medicine) and may leave little space for expansion. health management. the health sciences which are characterized by the “Double Paradigm” of medical respectively biological and of the social sciences (33. Some universities as for example the Palestinian Al Quds University in East Jerusalem have found another 14 14 .

A specific problem is posed where . The health sciences are also an example in themselves as well as the modern nursing science or the environmental sciences. usually of about 4 years. quantitative and qualitative methods meet. Typical for modern development is the appearance of new hybrid disciplines (“interdisciplinary disciplines”) where e. Many teaching institutions especially in those countries will be occupied throughout the years to come with the re-training of the public health work force in preparation of the new task profile in a western type society.g. In order to avoid duplication the academic postgraduate master of public health program of between one and two years should be fully recognized as an integral or even mandatory part of the 4 years of specialization. b) Interdisciplinarity creates innovative approaches merging relevant knowledge from different traditional subjects. a School of Nursing and a School of Public Health.g. However. termed “triangulation”. 3) Multiprofessionality and interdisciplinarity relate rather to postgraduate studies than to undergraduate programs. usually specialized according to a format of e. the admission of undergraduate study programs especially with a bachelor degree takes place more frequently during the last years. Thus the typical training program in schools of public health is organized as a Master of Public Health. From this two consequences derive: a) Interdisciplinarity requires multiprofessionality of lecturers and students as well which corresponds to the growing role of problemoriented task forces set up by governments requesting experts with differing backgrounds to participate. 15 15 .medical academies are charged with continued education for medical specialization. a bachelor in health communication or in health management etc.solution for the ambivalent though vital relationship between medicine and public health: The Faculty of Health Sciences at Al Quds comprises with equal rights a School of Medicine.especially in the post-communist countries . Many schools of public health prepare for a complete set of study programs adding to the bachelor and master degrees a master of science and doctoral programs as well as those of continued education. 2) An institution under the paradigm of New Public Health must represent the medical as well as the social sciences more or less as equally important (the double paradigm of public health).

Finally in a global community of public health professional standards of excellence are transmitted through working relationships. This not only means sending students into the field but 16 16 . Ideally the function as a “think tank” for the executive agencies results in a more evidence-based policy than is common. as gradients within one country may be small. the institution has to train for services and research. Setting firmly grounded priorities produces relevance. in the European Union – asks for an international respectively even global perspective. otherwise the definition of alternative priorities remains in a gray zone of volatile opinions and prejudice. Also in addition to national accreditation a European accreditation of schools of public health is under development (36). 6) The strong practice orientation of the modern school of public health makes a close cooperation with health institutions in the local environment indispensable. The identification of relevant health problems also may strengthen the argument for the funding of public health research. last but not least. i. which in turn helps to stabilize the teaching faculty. In support of this a well-developed system of health surveillance with indicator based monitoring and reporting is essential. That implies a close working relationship with the government. especially with the local institutes of public health. Beyond that a core principle of epidemiological analysis is the comparison between populations being different for the factor in question. of the public health institution itself.g. Very often this requires international comparative studies. especially with the ministries of health as well as of higher education and research. In some institutions therefore a department of health policy analysis has been established. This becomes very clear considering the complex causes of violence and terrorist acts. Therefore the Association of Schools of Public Health in the European Region has inaugurated the scheme of a European Master of Public Health (EMPH) requiring an international placement of the student for a certain period of time during the study course.whether we refer to the emergence of new and the re-emergence of well-known infections like tuberculosis or to patient mobility between different national insurance systems e.4) The international scale of modern health problems .e. 5) The School of Public Health is set to train the public health work force and the future academic lecturers and researchers. In countries with a more federal structure semi-official and private health institutions ask likewise for expertise and consultancy. Maintaining independence the school of public health must relate to the issues relevant to health policies and pro-actively consult the decision makers.

Given the limited means for research this has been proven to be a very powerful arrangement in order to promote public health research and practical implementation of research results. On the other hand it is unlikely that a small country of e. especially if the small country is a developing one or in transition as e. In several environments a contractual network has been inaugurated between academic and service institutions. The result in this situation very often is an institution being too small. it also means a rather horizontal structure of a faculty in the context of its environment with a certain amount of decision making in the periphery. understaffed and sub standard in all respects. the former socialist economies. This is in line with the general trend to decentralize formerly hierarchical structures driven by the modern complexity of issues (horizontal management as discussed above).g. At least for Europe with her diminishing importance of the old national borders a structured regional cooperation may offer the solution. However. Larger territories within a country even require their own institutions. However. 7) Given their multi-facetted functional profile schools of public health should be placed and should go where the problems are. one or two million inhabitants can or even should afford an expensive institution with the full spectrum of activities. Notwithstanding international even global collaboration many hold the position that each state needs at least one school of public health of the profile described afore. 8) Depending on the size of a country and its population the geographical scope of a school of public health may differ. “Regionality” in this context does not refer to regions within a country but to collaboration with neighboring countries of smaller size in a geographical region as is for example South Eastern Europe or in common language the Balkans. This in addition facilitates the “active professionalization” of students who can inter alia perform their thesis work as an introductory step to later employment and at the same time solve a research question for the presumable employer. they provide the necessary expertise to be fed into the administrative decision making processes. Regular meetings between representatives of the school of public health and of the institutions outside the university are good practice. Regular appearance in the media is an essential requirement in modern societies.g.also vice versa to invite practitioners from the field to lecture in the academic programs. In an open society the school of public health must not detach from the public opinion. In addition to being responsible for training in public health and a lot of the relevant research in this field. even more relevant may be their serving as a “neutral” forum for the informed public debate. Other examples include the long established Nordic School of Public 17 17 .

the Swiss consortium of Departments of Preventive Medicine and the recently inaugurated International Baltic School of Public Health. Kosova (39). 4) The conditions of public health training described above require accordingly a modularization of the knowledge and skill base into rather small units which fit into the small training periods and also can be linked more easily to a heterogeneous lecturing faculty. The consequence is a “Sandwich”. 5) It is understood that the quality potential of this scheme is limited which means that after a basic training the future public health leadership has to be sent for advanced training to well established institutions as in the European Union and the USA. However. This requires first of all re-training not only “on the job” but “in the job” as these professionals cannot leave their positions for longer periods of study. (37) is used to explain some features of a concept of “Regionality” with special consideration of the situation of transition countries in Central and Eastern Europe (38).Health for the Scandinavian countries. 1) Many if not all countries in South Eastern Europe have similar difficulties to adapt their inherited communist structures of health care to Western European standards. 6) Following the model of the European Master of Public Health degree of ASPHER this may lead to a Regional Master of Public Health which off 18 18 . a political goal of all governments in the region. very often a prerequisite for later accession to the European Union. 3) The public health workforce currently in the field is characterized by advanced age. low salaries and lack of high levels of professional qualification.training of 2-3 days every 2-3 weeks for 2-3 years as for example offered by the new School of Public Health in Prishtina. 2) The weakness of the economies enforces a slow even delayed build up of infrastructure including reliable provision of resources and manpower development. a regional collaboration opens the alternative to achieve excellence at least for some of the health sciences in each institution and to exchange lecturers as well as students to study specific subjects at the most renowned institutes of the region. The concept of “Regionality” In the following the example of the Public Health Collaboration in South Eastern Europe (PHSEE.

19 . m) It supports last but not least the emergence of a professional identity and collegiality in the region.g.g. c) It has the potential to enhance the excellence of the overall program d) It induces competitive profiling of the institutions in the region e) It avoids the creation of incapable “Mini-Institutions” f) It preempts to some degree a “Brain drain” to the West in providing a re-entry structure at least for those (re-) trained in the job.course has to be supervised according to international criteria of quality assurance. g) It supports mutual quality assessment by the necessity to mutually acknowledge study certificates from institutions in neighboring countries. j) It provides experts with a qualified knowledge of the region for external evaluation (e. There is a number of advantages accruing from this type of regional collaboration which can be summarized under the slogan of a “Regional Ownership”: a) It contributes to the rebuilding of professional relationships after a period of violence and open war (e. the Yugoslavian succession wars). of research projects for funding procedures) k) It facilitates a consortium approach for research proposals as for example requested for EU funding programs. i) It offers a chance for regional lecturers to contribute and to develop their skills and competences. l) It broadens the scientific base and enhances wider implementation and utilization of research and development (R&D). h) It is affordable for students because of local price structure. 19 b) It allows for complementary sharing of scarce resources.

conflict management. SUMMARY AND CONCLUSION In summary the key features of modern schools of public health are an independent academic status outside the medical faculties or within and nevertheless a close and functional working relationship with the relevant governmental institutions notably the ministries of health and higher education. The public health professional having encompassed education in schools of public health as outlined may be described according to the following profile: a) follow a professional code of ethics b) accept accountability towards society c) work for evidence-based action d) aim at structural and stable solutions e) understand the global context of public health f) understand the multi-factorial determination of population health g) be prepared for transnational management h) be qualified for trans-cultural. moderation skills. The agreements reached in the European Union for education in general and for public health training in particular will become sooner or later standard for all European countries inter alia the accession states in Central and Eastern Europe. 20 20 . These developments can be enhanced by a well designed regional collaboration between neighboring countries. An agreement on mutual recognition of study certificates is under negotiation as well as a Minimum Indicator set for health monitoring (13). A first teaching book in Albanian is in print (41). the use of the Internet. presentation techniques. interdisciplinary & multi-professional cooperation i) know assessment technologies j) have acquired consulting competencies k) be trained in leadership for services l) be competent for research and development in the service environment m) be knowledgeable in foreign languages. and teamwork interaction.Since 2000 the PH-SEE collaborative network ( 40) has created a common database for public health in the region and works on a common set of teaching materials (37).

14) Laaser U. However.) Krankheitsverhütung und Früherkennung. 6) Gottstein A.: Salomon Neumann (1819-1908). 77-90. Düsseldorf 1991. Handbuch der Prävention. Flatten. de: European Schools of Public Health in a state of flux. International Journal of Occupational Medicine and Environmental Health 8/3 (1995): 195-214. Day S: The population mean predicts the number of deviant individuals. Ethische Fragen in der Prävention. Gesundheit und Soziales NRW: Gesundheitsreport 1990 & 1994. S. Band 1-5.cmhealth.It will be a long and never ending way to achieve this with the limited resources available.): Handbuch der Sozialen Hygiene und Gesundheitsfürsorge.. 4) Virchow R: Mitteilungen über die in Oberschlesien herrschende Typhus-Epidemie.nrw. Berlin 1993. 9) Rose G: Sick individuals and sick populations. Laaser U: Health Sciences as an Interdisciplinary Challenge: The Development of a New Scientific Field. Hoffmann B: Can a decline in the population means of cardiovascular risk factors reduce the number of people at risk? J Epidemiol Commun Health 55 (2001). REFERENCES: 1) Commission on Macroeconomics and Health: Macroeconomics and Health: Investing in Health for Economic Development. 13) Bardehle D. Breckenkamp J. P. Leipzig: 1983. 3) Hurrelmann K. 12) Ministerium für Arbeit.): Scientific Foundations for a Public Health Policy in Europe. K. Laaser (Hrsg. 8) Committee of Inquiry into the Future Development of the Public Health Function: Public Health in England. training for research and services to serve the health of populations is a mission well worth the effort. WHO.: Minimum Health Indicator Set for South Eastern Europe. In: Laaser. Juventa-Verlag. Cmnd 289. 1988. Teleky L (eds. Croatian Medical Journal 43/2 (2002): 170-173. London: HMSO. Int J Epidemiol 14 (1985): 32-38 10) Rose G. Website: www. Berlin: 1849 5) Karbe. The Lancet 345 (1995): 11581160. U. G. Springer-Verlag.-H. The Contribution of the Schools of Public Health to Public Health in Europe. 11) Laaser U. 7) Laaser U.de). 21 21 .loegd. 1995 (see also website: www. Evelyne de Leeuw. Schloßmann A. U. Berlin: 1925-1927.. Johann Ambrosius Barth.org. Christiane Stock (Eds. Br Med J 301 (1990): 1031-1034. Weinheim 1995: 162-172. Ausgewählte Texte. In: Allhoff. Ullrich A. 179-184. Geneva: 2001 2) Leeuw E.

Laaser U. Robertz-Grossmann Hrsg B): Soziale Differenz – Strategien – Wissenschaftliche Disziplinen. U. Lahelma E: Health expectancy by level of education in Finland. Modified from Kälble. Karachi and Conurbation Ruhrgebiet. V.: The concepts and principles of equity and health.unifreiburg. Luchterhand. Geneva: 1997 (WHO/HPR/HEP/$ICHP/BR/97. Laaser U. U. 2002:195-231. Soz Praeventivmed 34/5 (1989): 223-226 28) World Health Organisation (WHO). (on behalf of the Working Group on Social Gradients and Health in Europe): Social gradients in health. The New Public Health. Bologna. Annual Review of Public Health 14 (1993): 469-490. Peace & Human Rights. In: Weil O. Zajtchuk R. U. Lage: 2001:273-279.).15) WHO. 21) Valkonen T. World Health Organization: The Jakarta Declaration on Leading Health Promotion into the 21st Century. Wolters P: Das Gesundheitswissenschaftliche Graduiertenstudium an der Universität Bielefeld im Rahmen vergleichbarer Bestrebungen. Modern Health Care Glossary. 1999: http://www. Stansfield S: Contribution of job control and other risk factors to social variations in coronary heart disease incidence.who. 31) Deutsche Koordinierungsstelle Gesundheitswissenschaften: www. 27) Laaser. Penguin. Köln: 1970 30) Babic M. June 19. Determinants and Management. Prümel-Philippsen U. World Health Organization. 22) Wilkinson R: Unhealthy Societies.: Aktuelle Fragen der Gesellschaftspolitik. Brunner H. Med. Sci. In: Homfeldt HG. Berlin et al. 19) Townsend P. The Lancet 350 (1997): 235239.: Directions of Further Research and Development on Important Health Related Issues. Geneva: 1986 29) Nell Breuning O. Köhler G. 14-20. Soc. 25) Laaser. Donev. Croatian Medical Journal 43/2 (2002):107-113. D. The Black Report. 24) Laaser U: Gesundheitswissenschaften.med-net. Hemingway. McKee M.nl/topics/news/bologna./J. Laaser U (eds. Societé Francaise de la Santé Publique. E. Sarolli: Public Health and Peace (editorial).): Priorities for public health action in the European Union. London 1996 23) Laaser. 1997. Davidson N: Inequalities in Health. Copenhagen 1990 17) Laaser. A Study in Jakarta. Brodin M. 26) Donev D.htm 22 22 .. 18) Frenk J. Routledge. Ottawa Charta for Health Promotion. Vuckovic-Krcmar M (eds.44/6:801-808. Eckenfels E. Bosma H.. Croatian Medical Journal 43/2 (2002):105-106. Sihvonen A-P. Bjegovic.de/medsoz/Dkgw.int/regions/euro/index.4 and: www. Oberlé D (eds. U.): Urban Violence and Health. Troschke (2001 unpublished). Cancer Foundation Yugoslavia. v.html). In: Strohmeier KP. Levett J: Skopje Declaration on Public Health. 16) Whitehead M. Paris 1999 (ISBN 2911489-06-3) : p. WHO. 32) European Ministers of Education: The Bologna Declaration on the European Higher Education Area. K. The Afflictions of Inequality.ruf. Hans Jacobs-Verlag. Bachem. Y. London 1982 20) Marmot MG. Belgrade & Chicago: 2000. WHO-EURO.

cmhealth. Paris: www. Societé Francaise de la Santé Publique. M.hr/ph-see/ Publications: 1) Commission on Macroeconomics and Health: Macroeconomics and Health: Investing in Health for Economic Development. Paris 1999 (ISBN 2911489-06-3):14-20. 40) Kovacic L. 13-15.: Personal communication through J. 35) Association of Schools of Public Health in the European Region. Brodin. December 6-8. Greenwood Press. 2002). Med Arh 55/1 (2001). In: Laaser U. In: Weil. Fondation Merieux 2001 (www. 2) Tulchinsky TH. 34) Hurrelmann K. de Leeuw E. 1996.fr/aspher/ 2.ensp.ensp.): International Handbook of Public Health. O.33) Hurrelmann K. Website: www. Laaser (eds. Skopje. Stock C (Eds. In: K. Roshi. February 22. Laaser U: Health Sciences as an Interdisciplinary Challenge. Gliber M: Quality Improvement and Accreditation of Training Programmes in Public Health. Varavikova EA: The New Public Health: An Introduction for the 21st Century.): Priorities for public health action in the European Union. Hans Jacobs Editing Company. 23 23 . Oral presentation at the South Eastern European Conference on Public Health and Peace. M. 39) Ramadani N. N. USA. SELECTED REFERENCES: Websites: 1. San Diego: 2000. 36) Bury J. Oberlé (eds. ASPHER: www. WHO.. 3) Laaser U. McKee.snz.org). Academic Press.snz. Association of Schools of Public Health in the European Region (ASPHER). 41) Burazeri GE. Public Health Collaboration in South Eastern Europe (PH-SEE): A project of the Stability Pact: www. Connecticut.): Scientific Foundations for a Public Health Policy in Europe. Laaser U: Public health training and research collaboration in South Eastern Europe. 37) Public Health Collaboration in South Eastern Europe (PH-SEE): A project of the Stability Pact: www. The Development of a New Scientific Field. 104-131.fr/aspher. Juventa-Verlag.hr/ph-see 38) Burazeri G: A Regional Master Program in Public Health (MPH) in order to meet specific needs of the South Eastern European Countries (SEE). Holst. Geneva: 2001. Macedonia.fond-merieux. Westport. a “Starter” for Ambitious Researchers. Laaser U. (on behalf of the Working Group on Social Gradients and Health in Europe): Social gradients in health. D. pps. 2001. Hurrelmann and U.org. Bury J: Theory and Practice in Public Health.. Tavanxhi: Research Methods in Public Health. Lage: 2002. Weinheim 1995.

E.int/regions/euro/index. de: European Schools of Public Health in a state of flux. 1996. Br Med J 301 (1990): 1031-1034. The Black Report. World Health Organization. 6) Hurrelmann. 8) Rose G. WHO-EURO.html).who.. 9) Whitehead M. 10) Townsend P. Bury J: Theory and Practice in Public Health. International Journal of Occupational Medicine and Environmental Health 8/3 24 (1995): 195-214.: The concepts and principles of equity and health. 7) Leeuw. The Lancet 345 (1995): 11581160. In: K. Westport.): International Handbook of Public Health.4 and: www. Laaser U: Health Sciences as an Interdisciplinary Challenge: The Development of a New Scientific Field.4) WHO. Davidson: Inequalities in Health. Connecticut: Greenwood Press. Laaser U (ed. Geneva: 1997 (WHO/HPR/HEP/$ICHP/BR/97. 5) Hurrelmann K. Laaser U. London 1982. World Health Organization: The Jakarta Declaration on Leading Health Promotion into the 21st Century. Copenhagen 1990. Hurrelmann and U. Penguin. Day S: The population mean predicts the number of deviant individuals. N. ***/*** 24 . K.