Basic Principles for Improving Health and Well-being
White Paper on Renewing Hungarian Public Health in the 21st Century
Based on an assessment of the most recent national and international literature, it is based on two fundamentally new approaches, systems thinking and participatory approaches. The emphasis on these two principles is justified by the diverse and deep social embeddedness of health.
Thus, in the future, public health will no longer carry out screenings, vaccinations, and individual counseling that can be linked to the social security system. Furthermore, health protection regulation and control are also separated from public health and made the responsibility of public authorities.
Based on a vision of the future and an analysis of recent problems and the impact of health determinants, identify priority areas for change and coherent main lines of intervention.
The change agents are health coalitions of stakeholders, supported by the expertise of public health organizations to achieve their objectives. The interventions are funded by the communities themselves, with the cost of professional support coming from the public health budget.
The proposed main lines of intervention are A) Development of training materials and training courses in line with modern approaches; B) Development and expansion of the national public health institutional system; C) Implementation of communication campaigns; D) Initiation and professional support of health coalitions at national, intermediate and local levels; E) Development of a regulatory environment adapted to the interventions.
Multisectoral cooperation, which is essential for improving the health of the population, is implemented in health coalitions, with the professional support of public health, i.e. direct cooperation with other sectors is limited to the delivery of up-to-date training materials.
According to the World Health Organization (WHO), public health is the area of health protection and improvement where community interventions and public action are justified rather than responses directed at individuals. Unfortunately, the expected results of public health, such as halting the spread of obesity, reducing health inequalities, or even tackling global diseases, remain far from what is expected. In addition to the lack of progress, new challenges to humanity's future, such as sustainability, biodiversity loss, ecosystem degradation, and the climate crisis, increasingly call for a renewal of public health, both in theory and practice. According to the WHO document adopted in Spring 2023, the key role of public health on the platform of health promotion is to ensure intersectoral collaboration, collective action through empowering communities to make decisions, and good governance essential for achieving individual and social well-being.
The authors intend this document to be a kind of white paper, providing readers with concise information on the complex issue of improving public health. It aims to help to understand the problem and to provide a sound theoretical basis for making the right decisions. The authors have sought to answer the following questions. What are the main directions of change that would bring the greatest health gains for the Hungarian population?" The answers in the document are not ready-made "prescriptions", but conceptual proposals based on scientific knowledge and proven practical experience.
The development of public health is not only a competence and responsibility of the health sector, precisely because of the deep and multifaceted social embeddedness of health. It is therefore essential to present the issue to professionals outside the health sector and to discuss it with representatives of other disciplines. A technical note: for the sake of brevity, the word 'health' is used in the text instead of "health and well-being".
For decades, the focus of public health in Hungary has been on communicable disease control and public health screening. In addition, training, research, and practice focus mainly on the individual's exposure to risk and health literacy. However, the factors that have the greatest impact on health, such as health behavior or the influence of the social environment, remain outside the scope of intervention.
The disappointing ineffectiveness of the activities is largely due to the knowledge-based and individualized nature of the interventions. The poor effectiveness of the public health system is due to a lack of modern expertise and approaches, a shortage of professionals and financial resources, and an institutional system that is ill-equipped to act effectively and serves countervailing interests.
Training, research, and practice lack complexity and a culture of health approach, i.e. the socio-cultural embeddedness and definition of behavior and environmental risks. Together, these are major obstacles to the cooperation with actors inside and outside the health sector that is essential for effectiveness.
After careful consideration of the domestic options, it can be concluded that five main lines of intervention can lead to results for public health to achieve the desired changes in the identified target areas: A) Development of training materials and implementation of training courses in line with modern approaches; B) Development and expansion of the national public health institutional system; C) Implementation of communication campaigns; D) Initiation and professional support of health coalitions at national, intermediate and local level; E) Development of a regulatory environment that is appropriate to the interventions.
Analyzing the coherence between the target areas and the interventions, it can be stated that the expected positive changes in the target areas can be achieved through the implementation of interventions in the main intervention directions. The list of intervention directions also indicates the order of their implementation, except for legislation, which may be necessary for each intervention area.
A) Development of training materials in line with modern approaches, implementation of training courses
Public health training should place much greater emphasis than hitherto on the complexity and culture of health approach, i.e. on the socio-cultural embeddedness of behavior and environmental risks, and participatory community action. Implementing this new approach makes it necessary to review and renew Hungarian public health education's educational materials and training methodology. Given the deep and multifaceted social embeddedness of health, the training of professionals not only in the health sector but also in other sectors needs to be complemented with modern health-related knowledge.
B) Development and expansion of the national public health institutional system
The primary task of public health in Hungary is to promote complex community interventions at different levels of social hierarchy aimed at improving the health of the whole population, population groups, and communities. To fulfill this task, it should facilitate the establishment of geographical or thematic whole-population coalitions and provide professional support for their operation. To carry out its tasks properly, public health must perform several basic activities, such as management, information collection and analysis, communication, the provision of human and material resources and the carrying out of research to provide a scientific basis for these activities. This will require the establishment and operation of a more complex and extensive institutional system than is currently the case.
The Hungarian public health system should be organized into at least three hierarchical levels: national, intermediate regional, and local. The highest level of leadership should optimally be a person under the head of government, who should ensure government-level representation and cross-sectoral management of health maintenance, protection, and development. At the next level of the system, the National Institute of Public Health is responsible for professional coordination, support, and organizational involvement in information collection and evaluation, health communication, and research at the national level. The National Institute coordinates the work of a professional network of public health professionals, consisting of relevant expert groups in universities and research institutes. The member organizations of the network support the work of the National Institute and other organizations involved in public health through research and related training and education in a specific field of expertise at the university level. At the sub-national level, intermediate regional and local public health organizations form horizontal cooperation networks similar to the national one. Vertical links between public health organizations ensure the coordinated activities of the system and the two-way flow of information and technical material.
C) Implementation of communication campaigns
Effective communication campaigns are based on a well-planned, long-term strategy, and deliver messages in a coordinated way through several communication channels, adapted to the specificities of the targeted social groups. Effective health communication is planned and implemented by a specialized department of the National Institute. In addition to this task, the central unit, which employs creative professionals, provides training and communication materials for the effective implementation of local media campaigns.
D) Initiating and supporting national, intermediate, and local health coalitions
Unlike in the past, the institutionalized actors for interventions to improve the health of the Hungarian population are not public health organizations but national, intermediate, and local level health coalitions. Their activities range from planning, preparation, and implementation of interventions to evaluation, and they coordinate their activities through vertical and horizontal networks. Health coalitions provide the space for multisectoral cooperation that is essential for improving the health of the population.
The professional support for decisions leading to effective interventions in the community's interest and the acquisition of the knowledge and skills needed to implement them are provided by experts from the public health organization at the relevant level. The financing of activities to improve the health of the population comes mainly from the community's resources or resources raised by the community, and the State is therefore mainly responsible for providing public health organizations with the financial resources needed to support the professional activities of the health coalitions.
E) Developing a regulatory environment appropriate to interventions
Act CLIV of 1997 on health provides a good starting point for the development of the legislative framework necessary for the implementation of the intervention orientations outlined above. At the same time, the public health chapter of the Act needs to be brought into line with the proposals in this document for the renewal of public health in Hungary. The governance, institutions, and organizations of the public health system need to be regulated in a significantly different way from the current one, as required by the implementation of the main lines of intervention. It should be emphasized that the development and operation of a well-functioning, expanded public health system requires the provision of budgetary resources, but that, apart from the costs of setting up and launching health coalitions, their operation and the implementation of their programs require the joint resources of the stakeholders. This model, as opposed to state-supported projects, could be a cost-effective and sustainable solution.
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