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I Pan American Conference of Public Health Education and XVI Conference of the Latin American and Caribbean Association of Public Health Education (ALAESP)
 Contemporary Reforms
in the Field of Health: Challenges for Public HeatlhPractice in Public Health:
Challenges for EducationTheory in Public Health:
Challenges for EducationDeclaration of the I Pan American Conference on Education in Public Health Equity, Sustainability, Democracy: Health and Public Health Education for the XXI Century The I Pan American Conference of Public Health Education and the XVI Conference of the Latin American and Caribbean Association of Public Health Education (ALAESP) were held 14-27 August 1994 in Rio de Janeiro, Brazil. The Conference was organized by ALAESP and the American Association of Schools of Public Health (ASPH) on the occasion of the 40th anniversary of the founding of the National Public Health School/FIOCRUZ. The event, sponsored by the Pan American Health Organization (PAHO/WHO), was held to discuss the role of the schools of public health in the Hemisphere in light of current health conditions and the recent transformations in the health systems in almost all the countries of the Region. The intensive program planned for the event and the contributions of the nearly 120 participants made it possible to achieve the proposed objectives. The panels and group discussions were organized around the main topics of the conference: Contemporary Experiences and proposed Reforms in the Field of Health and Current Approaches to the Theory and Practice of Public Health. At the conclusion of the conference, a declaration was issued and cooperation was proposed between the organizing institutions and the entities associated with them to strengthen one another and carry out joint activities in response to the enormous technical, social, and political changes that must be faced as the millennium draws to a close. The principal debates and most significant outcomes are summarized in the Final Report, which includes the Declaration of Rio de Janeiro on Public Health Education and the Consolidated Reports of the Panels and Working Groups. The Organizing Committee will publish a document containing the complete texts of the presentations made during the Conference as a contribution to the intense debate taking place among institutions, investigators, public health professionals, and students throughout the Hemisphere on the present and future of this theoretical and applied field, its educational institutions, and its past, present, and future contributions to the progress of our societies. Presented below are summaries of only the discussions of the main items on the Conference agenda, the Declaration of Rio, and the proposal for ALAESP/ASPH collaboration. Contemporary Reforms in the Field of Health: Challenges for Public Heatlh Definition of the basic criteria for health reform requires a prior definition of the two terms that make up that expression. The issue of health transcends the sectoral dimension and, hence, cannot simply be reduced to the organization of the health services, health care, or the medical profession. Proposals for reform thus admit differing forms and contents in accordance with the specific context of each country and may be either regressive or progressive, depending on the relative strength of the health sector and the correlation of political forces. The right to health may be considered an adequate parameter for distinguishing reforms that foster fragmentation. Heterogeneity, and discrimination in the provision of health care, on the one hand, from those that seek a healthy public policy, on the other—one that is decentralized, democratic, and typified by community participation. The discussion of criteria suggests the need to reflect on the values that are capable of stirring people to action through campaigns and to study the ability of society to devise strategies to reduce the gap between principles and reality. The defense of life and the quality of life, social solidarity, day-to-day democracy, and freedom are indispensable for important social actors. Principles such as universality, equity, opportunity, decentralization, participation, efficiency, effectiveness, and flexibility were widely agreed upon in the discussions, in spite of some differences about their meaning. Concerning the role of the State and the right to health, mention must be made of the State’s functions of providing and ensuring the delivery of services, formulating policies, responding to organized pressure from civil society, and, above all, regulating the relationship between the public and private sectors. The emphasis on the intersectoral approach, the search for new health practices, the need for democratically incorporating the users into health care (making them aware of their rights and responsibilities regarding lifestyles, self-care, health promotion), and, finally, the defense of ethics in health policy and health management are all guidelines that should be considered when implementing health reforms. Although this set of proposals is tantamount to postulating the need for a new public health, it is fitting to determine to what extent the classical categories of public health, associated with the conceptual basis of social medicine, can deal with the matter. At the theoretical level, the frame of reference provided by the classical approach has perhaps been confused with the shortcomings of a practice that has not been up to the demands of the conceptual framework. The response capability of the health sector to the demand for reform is, in many instances, limited. This is especially true when health reform is conceived outside the sector as part of the reform of the State and its relationship to society, particularly in the context of structural adjustment policies. Preserving capital at all costs, reducing mortality without combating poverty and misery, and providing of a "package" of basic health services while ignoring diverse needs and values of the different social groups, have been the prevailing features of health reform in the 1990s. Faced with this trend, there are some who advocate the need for the health sector to learn to act at the political level, to employ the language of economics, to emphasize extrasectoral considerations (such as schooling, information, and the environment), to encourage community organization, and to foster political culture through a democratization of the relationship between government and society. Others, in contrast, criticize the economic approach and the references to "the population" or to "homogeneous masses" that were and are employed in traditional planning methods, ignoring the diversity and sociocultural values that would help achieve "the best possible life for all." These sectors understand that the response capability of the health sector depends on tackling headlong the intrinsic complexity of this problem, and this will not be possible if the scope of the approach is persistently reduced. Without ignoring the aspect of health recovery, both health promotion and disease prevention should be the guiding principles for action. There is a high degree of idealism about the responsibilities of public health, where what should be prevails over what is. This may lead to an unwitting concealment of the setbacks that occur in the health of different social groups. The recognition of the meager creativity of the current public health system and the lack of constructive criticism compromise the health reforms, as does the unquestioning acceptance of policies, whether those of the international technical cooperation organizations or of the financing agencies, which are often responsible for the structural adjustment policies that are imposed. The need to monitor and anticipate changes in the epidemiological profile should be stressed, with particular attention to the diseases responsible for the greatest mortality. Morbidity, living conditions and lifestyle, and well-being, as the shared responsibility of public health, should be permanent concerns of the health services system. In order to overcome some of the sector’s current weaknesses, it will be necessary to develop adequate information systems—particularly of the type that organizes the data so as to emphasize the situation of particular social groups—in addition to intensifying the reporting of morbidity to support actions geared toward the achievement of universal coverage, equity, and quality. Other proposals are linked to the reform, advocacy, and defense of health. In this regard, one of the functions of the schools of public health would be to assist society in making informed decisions. Three areas of activity have been identified in this respect: 1) Research to document the nature of the problems and needs. Opposing positions regarding the role of the schools of public health in political action and advocacy became evident in the discussions. Some participants felt that his was largely a role that private individuals in the schools should assume on their own, at the same time emphasizing that in certain areas, such as discouraging smoking in the United States or sanitary reform in Brazil, his role is now the norm. The lack of consensus and political organization with regard to the reform of the health system have impeded the effective defense of health. The schools of public health should endow their students with the political capacity and ability to perform policy analysis that will enable them to be effective in such activities. The goal is to create a system grounded in the concept of health to replace the current system which is grounded in the concept of disease.
Practice in Public Health: Challenges for Education The discussion centered on reformulating the object of work of the schools of public health in its broadest possible sense as a field for the generation and dissemination of knowledge, the training of human resources, and the creation of intervention instruments to deal with the problem at hand. The point of departure is that the crisis poses problems to public health that can only be solved by redefining, expanding, refining, and reformulating its object of work. The first issue is linked to the constraints that such institutions come up against in attempting to identify the key changes that must be made to respond to the new demands. One of these constraint has been identified by some groups as the close ties between the health sector and the ministries of health or schools of medicine. In the first case, the schools of public health are essentially devoted to training workers for the health institutions; in the second, they are dominated by the power of the physicians. In both situations, the operative and ideological authority is in the hands of the medical establishment. Other participants considered it more logical for the schools of medicine to form part of the schools of public health. With respect to teaching, it was generally recommended that the subject of public health be dealt with from a dialogical and problem-based perspective that extends beyond the narrow limits of specific disciplines, fostering a transdisciplinary approach more suitable to the multiple dimensions of the topic. It is necessary to move beyond the false dichotomies so that theory goes hand-in-hand with practice and practice becomes capable of generating theory. With regard to the conflict of the generalist versus the specialist, a strategy was recommended that starts with the specialist, reaching the generalist through a variety of activities. Likewise, broader utilization of health services personnel in teaching activities was proposed, in addition to a practice guided by the notion of thinking globally and acting locally. The problem of the relationship between the schools of public health and social needs is linked to different stages in the evolution of public health issues, at one time concerned about the demands deriving from the expectations placed on development and, currently obliged to tale charge of administrative and managerial problems. Throughout history, health has been a crossroads where disciplines and approaches come together. The multiple viewpoints expressed during the debates may be summed up in three main lines of change proposed by various participants as possible strategies for responding to the emerging challenges of the crisis. The first strategy proposed is based on differentiating the role of the health professionals. In the broadest sense, as citizens, they participate in the public debate on the social and political issues linked with health conditions. In their particular areas of intervention, related to their role as specialist, they must concentrate on the struggle against disease. As faculty or administrators in the schools of public health, their best contribution would be to explain the factors that produce disease and help foster the conditions for its prevention and treatment. The second strategy seeks to reinforce the work of public health through the incorporation of other disciplines that can enhance its capacity to address the issue of health and disease. The linkage between health and development remains very important in this strategy. A complex matter, it should employ multiple approaches in analyzing the problems at hand and in laying out new paths for health reform that demand the shared contributions of various fields of knowledge. The construction of a new field to approach the health-disease in development issue requires interdisciplinary efforts and the creation of health teams that will step back from the prevailing curative/biological paradigm and expand the sphere of action of public health. The third strategy consists of defining a new object of work. This new object of work will be formulated on the basis of a radical departure from the traditional concern of public health, abandoning even the word public in order to attend to something that is recognized as part of health ad is basically defined as capacity for its comprehensive development. This is a new way of generating and using knowledge, based on the collective construction of genuine health reform It is not an alternative strategy but the opening of a new field that does not conflict with other, no doubt essential fields, such as those related to the organization of the social response to disease. A perspective of complementarity or mutual reinforcement may be envisaged if both areas are constructed with sufficient autonomy. This new interdisciplinary field should preferably be developed in an academic setting to enable it to take advantage of the opportunities that the University provides for generating and disseminating knowledge. Health promotion, continuing education, and cost/benefit analyses should figure among its chief concerns, but its main responsibility should be to function as a mediator between:
Theory in Public Health: Challenges for Education One problem universally recognized by the participants was the meager research being carried out in the schools of public health, a situation that is related both to the lack of resources and the total lack of field experience among the majority of educators. There is no tradition of research. The faculty lacks the training required for investigation and, consequently, is also unable to direct research. The need for strengthening both the provision of resources and training in research methodologies and techniques was a major concern of the representatives of the schools. It was concluded that the foundations for the production of knowledge are not adequate, either from an epistemological, theoretical, or methodological standpoint or from the standpoint of infrastructure, financing, or the science and technology policies of many countries of the Region the schools of public health, a situation that is related both to the lack of resources and the total lack of field experience among the majority of educators. There is no tradition of research. The faculty lacks the training required for investigation and, consequently, is also unable to direct research. The need for strengthening both the provision of resources and training in research methodologies and techniques was a major concern of the representatives of the schools. It was concluded that the foundations for the production of knowledge are not adequate, either from an epistemological, theoretical, or methodological standpoint or from the standpoint of infrastructure, financing, or the science and technology policies of many countries of the Region. It must be pointed out, however, that this situation. It must be pointed out, however, that this situation varies from country to country. In some countries, public health research has shown substantive development, even in operations research. As to how research should be channeled, it was agreed that it should be adapted to the changes that are taking place. Hence, the schools should introduce research plans, in both the services and the other areas of practice related to health, and on the basis of these plans, continue to reformulate their output of knowledge, considering the objective of health/disease/care and the mobilization of the personnel committed to the realization of that object. Another of the problems highlighted is the gap that has arisen between the theoretical approach, related in particular to epistemology, philosophy, sociology, history, and policy, on the one hand, and the daily needs that must be satisfied by health workers, on the other. This leads to a demand for practical knowledge, that is not always satisfied, and to a tendency to establish the contents of the teaching programs from analyzing health problems and their determinants. This detracts from the teaching of social and economic disciplines related to the emergence of problems related to health and disease and their solution, as well as the articulation of these disciplines with the specified organizational and managerial needs of the different agents working in the sector. The crisis began outside the health sector and was then transferred to its interior. Two major areas in which the demands of the sector should be resolved can therefore be defined: the macrospace, which, particularly in Latin America, is linked to democratization, the reform of the State and the health sector, and the problems associated with equity and governance; and the microspace, no less important and characterized by urgent demands related to the delivery of individual or collective health services. Articulating both spaces while assigning each the importance it demands is one of the imperatives I constructing a new theory of public health. One of the important knowledge-related problems whose solution would make a positive contribution to public health is the study of poverty. The advances in political economy and other social sciences in this regard could be very useful, since their natural correlate is the area of human development. Articulation of this kind presupposes a short-term strategy, in addition to a medium-term one that would encompass larger scenarios than the sectoral sphere. It also assumes that both time-framed levels are strategic in nature and enjoy reciprocal legitimacy, and as a result, have been mutually strengthened. Another consideration to be emphasized is that the articulation between academia, the services, and the population must include the participation of all actors as protagonists in building public opinion. The participants in the First Pan American Conference on Education in Public Health, held in Rio de Janeiro, Brazil, from 14-18 August 1994: Consider: • Health is a fundamental resource from human development, but inequities in accessing its basic prerequisites—in social, economic, political, environmental and health care terms—result in an enormous waste of human capabilities. • Changes taking place in the majority of countries generally favor the achievement of health objectives and expectations, but may also deepen the deficiencies of society’s system of responses to health needs. • Health reform, comprises both the reform for health—involving the basic health prerequisites—and the reform of the public health and medical care systems, as a means to ensure full coverage of the population. • The achievement of higher level of equity, the assurance of an economic activity that is ecologically sustainable for the present and future generations, and the promotion of participatory democracy ion which those making decisions about health are accountable to those whose health is affected, are essential elements for all-inclusive health promotion. Declare: • The role of public health is to strengthen the capability of society to build its own health and realize its full human potential. • To this end, a real coalition for health must be developed to lead and sustain the public health dialogue involving communities in a comprehensive effort to create healthier conditions, with society’s resources directed at supporting local development and propitiating the decentralization of power to local governments. • With respect to the reform of public health and medical care systems, the efficiency of the organization of services aiming to offer universal access must be critically examined as well as the efficacy and quality of practice for improving the health of the people. Purpose: • Public health education must support the public health field in its tasks of pursuing reform for health, and must focus first on the determinants of health and on the combination of policies, programs and activities at all levels that will best promote health and lead to the highest possible level of human development, guided by the values of equity, sustainability and democracy. • A network of education must support the public health field in its tasks of pursuing reform for health, and must focus first on the determinants of health and on the combination of policies, programs and activities at all levels that will best promote health and lead to the highest possible level of human development, guided by the values of equity, sustainability and democracy. • In order to effectively contribute to reform for health and reform of the public health and medical care services, and to participate effectively in public health education, institutions and programs involved will have to address a number of challenges:
Recommend that: • Recognizing the profound philosophical, social and practical challenges posed by the need for a renewed public health education and research that can address the crisis in public health and the need for reform for health and reform of the public health and medical care systems, we commit ourselves to further the debate about these issues, as well as the necessary developments, at the national, sub-regional and regional levels. • We encourage all constituencies involved to continue to support the exchange of ideas and experience in the field of public health education and research throughout the Americas. Joint Proposal for Collaboration between ASPH and ALAESP
• Facilitating the exchange of students and professors between the member institutions. • Jointly organizing workshops for the training of professors. • Promoting individual and institutional collaborative research.
Source: Division of Health Systems and Services Development, Human Resources Development Program, HSP/HSR, |
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