This article is written by José Chen-Xu, MD MSc PhD candidate, Medical Resident in Public Health, Public Health Unit, ULS Baixo Mondego, Figueira da Foz, Portugal.

  • The problem: Low investment in public health.
  • **Why it matters: **Public health focuses on health promotion and disease prevention among the population and tackling health determinants in a holistic way.
  • The solution: Governments need to shift focus to public health by increasing funding and resources in public health.

Health is a political choice. Working on public health requires us to reflect on the impact of public policies on health and what we, as public health practitioners, can do to improve the health of our populations.

For the past five years, I have worked in public health for the National Health Service in Portugal. A medical residency enables you to explore different areas of interest which has allowed me to develop meaningful work across sectors.

The pandemic was a catalyst. We were able to develop work at all levels. On a local level we worked on Covid-19 management and epidemiological surveillance in partnership with local authorities. On a regional level we contributed to effective reporting and data management. On a national level we collaborated with the national Directorate-General of Health on technical recommendations.

As the world started resuming its affairs, opportunities emerged in the field of policy and decision-making: firstly, the development of science diplomacy training for diplomats and researchers in the Ibero-American region, bringing academic and scientific perspectives to international relations; secondly, a contribution to the Organisation for Economic Co-operation and Development (OECD) in developing policy research and advice in environmental health; thirdly, a collaboration with the European Parliament in developing evidence-based policies in the field of public health. At the same time, I was able to develop research for my PhD through a research network funded by European funds, always to produce evidence for policymaking. All these experiences changed my perspective about how public health can serve its populations and the potential it holds to have a lasting impact truly and effectively.

Change: time to reassess and redirect

The organisation of public health services in Portugal is strongly oriented to the local level. Public health units close to the population, aim at achieving people-centred care and public health interventions tailored to the population it serves. This also enables public health to influence and partner with local authorities. However, there is one thing all public health practitioners must agree on: we are underfunded, understaffed and undervalued.

After a pandemic, we would assume we had learned our lesson: that it is important to invest in robust public health services that allow for better planning, preparedness and prevention, including strong surveillance systems. These investments would empower public health bodies to step up and have a stronger voice in health planning and public policy. This has not been the case: since Covid-19 the health system in Portugal has gone through several changes. Our National Directorate — a technical body — has been losing power in contributing to public health policies. Through the creation of a Secretary of State dedicated to it, there is a louder political voice for health promotion now. There has been a reform of the National Health Service (NHS), which puts the emphasis on hospitals instead of primary health care and public health.

The pandemic has shown us that every single citizen can be an agent for public health, and that health decisions must involve the populations that are affected by them.

One might think that these changes could strengthen the role of public health in policy- and decision-making. Instead, we have realised something we knew all along: a strong a strong health system is mainly dependent on political orientations that put aside the contribution from public health bodies which offer the best evidence for policymaking. This reinforces the stance that health is a political choice.

It is widely known that public health activities, including interventions, planning, and policymaking, can bring a unique perspective to governments. They can advise on priority setting, the best strategies for specific health issues, and evaluation of interventions, which have long been shown to originate health and socioeconomic gains in the long run. This was somewhat valued in Portugal, where we have the National Directorate-General of Health and local public health units.

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However, politics often interfere, as other priorities can generate political momentum for re-election, particularly due to the fact that public health outcomes are only noticeable decades after. Moreover, different political parties have distinct views on the role of healthcare provision (private vs public), often leaving public health in the background.

Show value to become a priority

Changes that have been implemented in the whole health system can only be beneficial if changes also occur in the way we do and perceive public health. We must shift the paradigm and ensure that the health focus is on disease prevention and health promotion instead of just financing downstream in treatment and palliative care.

This starts with public health professionals. We have the responsibility to show politicians and the population we serve that it is worth investing in our work and that our work will ensure that we move towards a more sustainable healthcare system. In this context, health literacy and public health communication are effective tools we can use. We can show good examples, achievements, and results of our work.

But that alone is not enough. The role of governments is paramount in this. Public health professionals require additional means to improve their work, including: a) skills and knowledge that allow for a well-trained public health workforce, which is essential for producing better public health policies and tailored interventions; b) a strong structure and platform which serves to guide and strategise our action, and make our voices heard; c) specific financing which allows us to conduct our work properly.

Lastly, but perhaps most importantly, civil society participation is crucial. The pandemic has shown us that every single citizen can be an agent for public health and that health decisions must involve the populations that are affected by them. At the same time, these must be informed with the best evidence in an understandable way to make their own decisions and contribute to their health. Thus, citizens, society-led and non-governmental organisations must be provided with funding and resources, which ultimately contribute to improving public health.

For public health to become a priority, we need to transition from cha(lle)nge to change: we must use the current changes as opportunities to show that public health is a valuable asset to keep and invest in, reinforcing our role as public health practitioners. The health of our families, friends, and everyone around us is safeguarded, and they can live healthier and longer lives because governments have worked together and invested in their citizens.

This will ensure that (public) health is present across all policies, guaranteeing that the public policies put forward are based on the best scientific evidence.

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