Responding to Disarray

The Future of Public Health provided the public health community with a common language and a focus for reform, and progress has been made. In Washington, Illinois, and Michigan, for example, revisions of the state public health codes resulted in the inclusion of mandatory provisions for funding and the distribution of services to all communities “no matter how small or remote,” as recommended by the Institute of Medicine (IOM) (1988). In 1994, the Public Health Functions Working Group, a committee convened by the Department of Health and Human Services (DHHS) with representatives from all major public health constituencies, agreed on a list of the essential services of public health. This list of services translates the three core functions into a more concrete set of activities, called the 10 Essential Public Health Services (see Box 3–1). These essential services provide the foundation for the nation's public health strategy, including the Healthy People 2010 objectives concerning the public health infrastructure (DHHS, 2000) (see Appendix D) and the development of National Public Health Performance Standards (CDC, 1998) for state and local public health systems.

BOX 3–1

The 10 Essential Public Health Services. Assessment Monitor health status to identify community health problems

At least four subsequent National Academies reports have made a strong case for sustained federal action both domestically and internationally to strengthen the public health infrastructure (IOM, 1992, 1997a, 1997b; NRC, 2002). The federal government has yet to take the initiative to develop a comprehensive, long-term plan to build and sustain the financing for this infrastructure at the state and local levels to ensure the availability of the essential health services to all people, and this is a critical concern. The federal government has, however, developed and funded various new programs and organizational units, which, if effectively coordinated, could serve as important components of a more systematic program. The Centers for Disease Control and Prevention (CDC) established (in 1989) the Public Health Practice Program Office and strengthened university-based Centers for Prevention Research (initiated in 1983). CDC also developed Public Health Leadership Institutes (initiated in 1992) at the national and regional levels and the National Public Health Training Network (initiated in 1993). Both programs respond to recommendations to improve the overall leadership competencies of public health practitioners. In 1993, CDC began discussions of a modern and uniform approach to public health surveillance, and it has moved forward with the development of a National Electronic Disease Surveillance Network. More recently, CDC has worked with states to establish the Health Alert Network (initiated in 1999) to improve information and communication systems for both routine and emergency use and the Centers for Public Health Preparedness (launched in 2000) to improve linkages between local health agencies and academic centers. These programs provided important services in the aftermath of September 11, 2001.

Many units within CDC have contributed to strengthening the public health infrastructure. The National Center for Chronic Disease Prevention and Health Promotion, for example, has led the effort to develop statewide population-based cancer registries, a tracking system for cardiovascular disease, and a program for the early detection of breast and cervical cancer (CDC, 2002). The National Center for Environmental Health also contributed to the improvement of public health monitoring and assessment functions when it developed a biomonitoring program to measure people's exposures to 27 different chemicals by analyzing human blood and urine samples. This program offers the first national assessment of people's exposure to 24 chemicals for which exposures were not previously assessed and 3 for which exposures were previously assessed. In 2002, the center began developing a nationwide environmental public health tracking network in response to a Pew Environmental Health Commission report entitled America's Environmental Health Gap: Why the Country Needs A National Health Tracking Network (Pew Environmental Health Commission, 2000; www.cdc.gov/nceh/tracking/background.htm). Among CDC initiatives are the development of immunization registries and a guide to community preventive services (www.cdc.gov).

Limited Progress

Despite this progress, the committee found that in many important ways, the public health system that was in disarray in 1988 remains in disarray today. Many of the recommendations from The Future of Public Health have not been put into action. There has been no fundamental reform of the statutory framework for public health in most of the nation. Funding for the public health infrastructure has recently increased to support the infrastructure that relates to bioterrorism and emergency preparedness but may still be insufficient. Furthermore, governmental and nongovernmental support (both political and financial) and advocacy for the report's recommendations have been limited. Progress is mixed in strengthening public health agencies' capacities to address environmental health problems, in building linkages with the mental health field, and in meeting the health care needs of the medically indigent. In addition, new information and technological challenges face the system today. In a recent review of the nation's public health infrastructure for the U.S. Senate Appropriations Committee, CDC (2001d) pointed to the need for further efforts to address gaps in workforce capacity and competency, information and data systems, and the organizational capacities of state and local health departments and laboratories.

Finding continued disarray in the public health system is especially disturbing because the nation faces increasingly diverse threats and challenges. The early detection of and the response to these threats will depend on capacity and expertise within the public health system at every level. The gaps in the system warrant urgent remediation. Many of these basic reforms also require actions from agencies that are outside the direct control of governmental public health agencies but whose policies and programs can have important health consequences, such as the Environmental Protection Agency (EPA) (environment) and the Departments of Agriculture (nutrition and food safety), Labor (working conditions), and Treasury (economic development). This support has not been forthcoming from elected or appointed government officials (including those in control of budgets), and stakeholders in the broader public health system—who should have been partners in the vision of creating a healthier nation—have yet to be effectively mobilized in this effort.

In the next section, the committee provides an overview of the special role of governmental public health agencies (at the federal, tribal, state, and local levels). The section addresses the legal framework for governmental responsibility and its authorities for protecting the health of the people as well as the organization of the governmental public health infrastructure.

Role of State and Local Governments in Assuring Population Health

States and their local subdivisions retain the primary responsibility for health under the U.S. Constitution.¹ To fulfill this responsibility, state and local public health authorities engage in a variety of activities, including monitoring the burden of injury and disease in the population through surveillance systems; identifying individuals and groups that have conditions of public health importance with testing, reporting, and partner notification; providing a broad array of prevention services such as counseling and education; and helping assure access to high-quality health care services for poor and vulnerable populations. State and local governments also engage in a broad array of regulatory activities. They seek to ensure that businesses conduct themselves in ways that are safe and sanitary (through the institution of measures such as inspections, licenses, and nuisance abatements) and that individuals do not engage in unduly risky behavior or pose a danger to others (through the provision of services such as vaccinations, directly observed therapy, and isolation), and they oversee the quality of health care provided in the public and private sectors.

Role of Tribal Governments in Assuring Population Health

Although their legal status varies, tribal governments have a unique sovereignty and right to self-determination that is often based on treaties with the federal government. Under these treaties, the federal government has an obligation to provide tribes with certain services, including health-related services. In addition, American Indians and Alaska Natives are eligible as individual citizens to participate in state health programs. However, in some instances, tribal–state relations are strained, and there are often misunderstandings about the relative responsibilities of states and tribes for the financing of health care and population-based public health services. Until the mid-1970s, the federal government directly provided health care services to American Indians living on reservations and to Alaska Natives living in villages through the Indian Health Service (IHS), an agency within DHHS. In 1975, the Indian Self-Determination and Education Assistance Act (P.L. 93–638) established two other options for obtaining these services: (1) tribal governments can contract with IHS to provide the services or (2) administrative control, operation, and funding for the services can be transferred to a tribal government (IHS, 2001c). In the mid-1970s, legislation also authorized funding health services for American Indians living in urban areas.² The operation of IHS programs depends on annual discretionary appropriations, which are generally considered inadequate (Noren et al., 1998; IHS, 2001a). Some tribes are able to supplement IHS funding, but many cannot. Many tribes have health directors and operate extensive public health programs that include environmental safety and community health education, as well as direct curative and preventive services.

Role of the Federal Government in Assuring Population Health

The federal government acts in six main areas related to population health: (1) policy making, (2) financing, (3) public health protection, (4) collecting and disseminating information about U.S. health and health care delivery systems, (5) capacity building for population health, and (6) direct management of services (Boufford and Lee, 2001). For most of its history, the U.S. Supreme Court has granted the federal government broad powers under the Constitution to protect the public's health and safety. Under the power to “regulate Commerce . . . among several states” and other constitutional powers, the federal government acts in areas such as environmental protection, occupational health and safety, and food and drug purity (Gostin, 2000). The federal government may set conditions on the expenditure of federal funds (e.g., require adoption of a minimum age of 21 for legal consumption of alcoholic beverages to receive Federal-Aid Highway Funds), tax commodities whose use results in risky behavior (e.g., cigarettes), reduce taxes for socially desirable behaviors (e.g., for voluntary employer provision of health care), and regulate persons and businesses whose activities may affect interstate commerce (e.g., manufacturers of pharmaceuticals and vaccines so that they are safe and effective).

The judicial branch also can shape federal health policy in many ways. It can interpret public health statutes and determine whether agencies are acting within the scope of their legislative authority. The courts can also decide whether public health statutes and regulations are constitutionally permissible. The Supreme Court has made many decisions of fundamental importance to the public's health. The court has upheld the government's power to protect the public's health (e.g., require vaccinations), set conditions on the receipt of public funds (e.g., set a minimum drinking age), and affirmed a woman's right to reproductive privacy (e.g., a right to contraception and abortion). Gostin (2000) notes that although the courts generally have been permissive on matters of public health, stricter scrutiny has come when there is any appearance of discrimination against a suspect class or invasion of a fundamental right, such as bodily integrity.

Public Health Law: The Need for State Reforms

Because primary responsibility for protection of the public's health rests with the states, their laws and regulations concerning public health matters are critical in determining the appropriateness and effectiveness of the governmental public health infrastructure. At present, however, the law relating to public health is scattered across countless statutes and regulations at the state and local levels and is highly fragmented among the states and territories. Furthermore, public health law is beset by problems of antiquity, inconsistency, redundancy, and ambiguity that make it ineffective, or even counterproductive, in advancing the population's health.

The most striking characteristic of state public health law, and the one that underlies many of its defects, is its overall antiquity. Much of public health law contains elements that are 40 to 100 years old, and old public health statutes are often outmoded in ways that directly reduce their effectiveness and their conformity with modern legal norms in matters such as protection of individual rights.³ These laws often do not reflect contemporary scientific understandings of health risks or the prevention and treatment of health problems. For example, laws aimed at preventing casual transmission of airborne diseases such as influenza and measles have little relevance for control of the sexually transmitted and blood-borne pathogens that are major concerns of health authorities today (Gostin et al., 1999). When many of these statutes were written, the science of public health, in fields such as epidemiology and biostatistics, and of behavior and behavioral interventions, such as client-centered counseling, was in its infancy.

Related to the problem of antiquity is the problem of multiple layers of law. The law in most states consists of successive layers of statutes and amendments, built up over more than 100 years in some cases, in response to changing perceptions of health threats. This is particularly troublesome in the area of infectious diseases, which forms a substantial part of state health codes. Colorado's disease control statute, for example, has separate sections for venereal diseases, tuberculosis, and HIV. All three sections authorize compulsory control measures, but they vary significantly in the procedures required and the public health philosophy expressed. Whereas the venereal disease statute simply empowers compulsory examination whenever health officials deem it necessary, the HIV section sets out a list of increasingly intrusive options (requiring use of the least restrictive) and places the burden of proof on the health department to show a danger to public health (Gostin et al., 1999).

Because health codes in each state and territory have evolved independently, they show profound variations in their structures, substance, and procedures for detecting, controlling, and preventing injury and disease. In fact, statutes and regulations among American jurisdictions vary so significantly in definitions, methods, age, and scope that they defy orderly categorization. There is, however, good reason for greater uniformity among the states in matters of public health. Health threats are rarely confined to single jurisdictions, instead posing risks across regions or the entire nation.

State laws do not have to be identical. There is often a justification for the differences in approaches among the states if there are divergent needs or circumstances. There is also a case for states' acting as laboratories to determine the best approach. Nevertheless, a certain amount of consistency is vital in public health. Infectious diseases and other health threats do not confine themselves to state boundaries but pose regional or even national challenges. States must be able to engage in surveillance and respond to health threats in a predictable and consistent fashion, using similar legal structures. Consistent public health statutes would help facilitate surveillance and data sharing, communication, and coordinated responses to health threats among the states. Consider the coordination that would be necessary if a biological attack were to occur in the tristate area of New York, New Jersey, and Connecticut. Laws that complicate or hinder data communication among states and responsible agencies would impede a thorough investigation and response to such a public health emergency.

To remedy the problems of antiquity, inconsistency, redundancy, and ambiguity, the Robert Wood Johnson and W. K. Kellogg Foundations' Turning Point initiative launched a Public Health Statute Modernization Collaborative in 2000 “to transform and strengthen the legal framework for the public health system through a collaborative process to develop a model public health law” (Gostin, 2002). The model public health law focuses on the organization, delivery, and funding of essential public health services, as well as the mission and powers of public health agencies. It is scheduled for completion by October 2003, and current drafts are available on the Turning Point website, at http://www.turningpointprogram.org.

The process of law reform took on new urgency after the events of September 11, 2001, and the subsequent intentional dispersal of anthrax through the postal system. In response, the Center for Law and the Public's Health at Georgetown University and Johns Hopkins University drafted the Model State Emergency Health Powers Act (MSEHPA) at the request of CDC (www.publichealthlaw.net). DHHS recommends that each state review its legislative and regulatory needs and requirements for public health preparedness. MSEHPA offers a guide or checklist for governors and legislatures to review their current laws. As of September 2002, three-quarters of the states had introduced a version of MSEHPA, and 19 states had adopted all or part of the act (Gostin et al., 2002). The model act, under review by federal and state officials, defines the purpose of the legislation as giving the governor and other state and local authorities the powers and ability to prevent, detect, manage, and contain emergency health threats without unduly interfering with civil rights and liberties. The legislation would address matters including reporting requirements, information sharing, access to contaminated facilities, medical examination and testing, and procedures for isolation and quarantine (Center for Law and the Public's Health, 2001).

CDC is facilitating the law reform process through its internal Public Health Law Collaborative. Efforts are in place to improve scientific understanding of the interaction between law and public health and to strengthen the legal foundation for public health practice. Through the Public Health Law Collaborative, CDC is joined in its work in public health law by a growing number of partners. These include public health practice associations, academic institutions and researchers, and public policy organizations (www.phppo.cdc.gov/PhLawNet).

The committee finds that the problems of antiquity, inconsistency, redundancy, and ambiguity render many public health laws ineffective or even counterproductive in improving population health. A set of standards and procedures would add needed clarity and coherence to legal regulation. Therefore, the committee recommends that the Secretary of the Department of Health and Human Services, in consultation with states, appoint a national commission to develop a framework and recommendations for state public health law reform. In particular, the national commission would review all existing public health law as well as the Turning Point ⁴ Model State Public Health Act and the Model State Emergency Health Powers Act ⁵ ; provide guidance and technical assistance to help states reform their laws to meet modern scientific and legal standards; and help foster greater consistency within and among states, especially in their approach to different health threats. It is essential that any reform of public health legislation address the powers needed to deal effectively with bioterrorism and other public health emergencies that pose significant threats across state boundaries. Each state could adapt the commission's recommendations to its unique legal structures and particular needs for public health preparedness. Public health is traditionally a state function, so the commission would provide guidance to the states rather than impose standards.

The following section provides a description of the federal, state, and local governmental agencies that are responsible for protecting the health of the public. Later in the chapter, the committee examines certain aspects of the state and local public health infrastructures that are of special concern.

The State and Local Governmental Public Health Infrastructure

Although the states carry the primary constitutional responsibility and authority for public health activities in the United States, public health administration first began in cities in the late eighteenth century (Rosen, 1993). The burgeoning social problems of industrial cities convinced legislatures to form more elaborate and professional public health administrations within municipal governments (Duffy, 1990). City boards of health were established to obtain effective agency supervision and control of health threats facing the population. Only after the Civil War did states form boards of health. County and rural health departments emerged in the early twentieth century (Ferrell and Mead, 1936). Today, there are more than 3,000 local public health agencies, 3,000 local boards of health, and 60 state, territorial, and tribal health departments (CDC, 2001b).

Structure and Governance of State and Local Public Health Agencies

The organization and authority granted to state and local public health agencies vary substantially across the country. Every state has an agency with responsibility for public health activities. That agency may be an independent department or a component of a department with broader responsibilities, such as human services programs. In 31 states, the state health officer is also the head of the larger health and human services agency (Turnock, 2000). Physicians and nurses often lead state public health agencies. At the local level, however, general managers with business training rather than formal training in public health or medicine may lead public health agencies.

States differ in terms of the relationship between the state agency and the agencies serving localities within the state. In some states (e.g., Arkansas, Florida, Georgia, and Missouri), the state public health infrastructure is centralized, meaning that the state agency has direct control and authority for supervision of local public health agencies. In other states (e.g., California, Illinois, and Ohio), local public health agencies developed independently from the state agency, in that they are run by counties or townships (rather than the state) and report directly to local boards of health or health commissioners or are governed by cooperative agreements. Still other states (e.g., Iowa and North Dakota) have no local public health agencies and the state public health agency is preeminent (Fraser, 1998).

In a recent report on the local public health agency infrastructure, the National Association of County and City Health Officials (NACCHO) (2001d) identified five types of local public health agencies (see Figure 3–1).

FIGURE 3–1

Types of local public health agencies (LPHAs) across the United States.

The most common arrangement is a local public health agency (LPHA) serving a single county, ranging from small rural counties (e.g., Issaquena County, Mississippi, with a population less than 1,000) to large metropolitan counties (e.g., Los Angeles County, with a population approaching 10 million). LPHAs may also serve single cities of various sizes (e.g., Kansas City, Missouri, and New York City). A combined city–county local public health agency is also found (e.g., Seattle-King County, Washington). Township local public health agencies are common in states with strong “home-rule” political systems⁶ (e.g., Connecticut, Massachusetts, and New Jersey). City or township health agencies may operate within counties that are also served by county health agencies.

Multicounty local public health agencies often span large geographic areas in the western United States. For example, the Northeast Colorado Health District serves six counties, an area roughly equivalent in size to that of the state of Vermont. In these local public health agencies, health directors may be accountable to multiple county boards of health or to a combined board of health whose membership represents the counties or other units covered by the local public health agency. The multicounty local public health agency category also includes state health department regional offices that act as local public health agencies, an arrangement found in several states (e.g., Alabama, New Mexico, Tennessee, and Vermont).

The governance of state and local public health agencies generally fits one of three models. In a cabinet model, the head of the agency is appointed by and answers to the governor, mayor, or other executive authority. Under a board-of-health model, the state or local health director reports to an appointed board representing constituencies served by the department. In many cases, however, a board of health functions in a strictly advisory capacity, with no oversight authority. Under an “umbrella” model, the public health agency is part of a larger agency, and the health director either heads the agency or reports to its head. There are considerable variations within these three models.

Even with this great variability in governance at both the state and local levels, there are no data to suggest what an “ideal” state and local agency governance structure might be. Thus, it would be important for state agencies to examine their present governance structures and evaluate mechanisms to make these structures more effective. Doing so should serve to build and strengthen relationships with local public health agencies, coordinate efforts for the delivery of the essential public health services and crisis response services, integrate essential health information, and respond to the changing health needs of the population.

Scope of Agency Responsibilities and Activities

At both the state and local levels, there are differences among public health agencies in terms of the scope of their authority, responsibilities, and activities. At the state level, activities such as immunization, infectious disease control and reporting, health education, and health statistics are common to most public health agencies. States are also responsible for licensing and regulating the institutional and individual providers that deliver health care services. However, states differ in whether the public health agency has responsibility for programs such as mental health and substance abuse, environmental health, and Medicaid. These organizational differences make it more complicated to frame and pursue a coherent national agenda concerning changes and improvements in the governmental public health infrastructure.

A recent NACCHO (2001e) survey of local public health agency infrastructures has helped document the variation in services provided at the local level. Among county health departments, for example, 98 percent provided childhood immunizations (directly or through contract services), 76 percent were responsible for restaurant inspections and licensing, and 31 percent provided dental services. City and township local public health agencies were often less likely to offer services that other types of local public health agencies provided. The most common services provided by local public health agencies include those most associated with traditional public health practice: adult and childhood immunizations, communicable disease control, community assessment, community outreach and education, environmental health services, epidemiology and surveillance, food safety, health education, restaurant inspections, and tuberculosis testing. Services provided by a smaller percentage of local public health agencies included treatment for chronic disease, behavioral and mental health services, programs for the homeless, substance abuse services, and veterinary public health (NACCHO, 2001d).

One widespread change in the scope of local public health agency activities is a reduction in the direct delivery of health care services, especially to Medicaid participants. This is consistent with a national effort to have governmental public health agencies return their attention to the more population-based public health services that had been weakened by the pressing need to provide safety-net services to uninsured individuals. Although some have been unable to do so, many state and local public health agencies now have contracts with managed care organizations and other private providers to serve those populations. A substantial transfer of service delivery from health departments to private providers has also occurred for childhood immunizations under federal and state programs for the purchase and distribution of vaccines (IOM, 2000a). Some researchers have found the partnership between managed care and local public health agencies to be positively associated with the overall scope and perceived effectiveness of local public health activities in terms of their ability to meet population-based community needs (Mays et al., 2001). (See Chapter 5 for additional discussion of the role of health care services providers in the public health system.) However, some local public health agencies have found it difficult to compensate for the loss of revenue that had previously come from the delivery of health care services that have now been transferred to managed care organizations (Wall, 1998; Keane et al., 2001).

Organization of the Federal Public Health Infrastructure

At the federal level, the lead entity responsible for public health activities is DHHS. Several key agencies in DHHS comprise the U.S. Public Health Service (PHS): the Agency for Healthcare Research and Quality, CDC, the Agency for Toxic Substances and Disease Registry (ATSDR), the Food and Drug Administration (FDA), the Health Resources and Services Administration (HRSA), IHS, the National Institutes of Health (NIH), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition, various White House agencies such as the Office of Science and Technology Policy and the Office of National Drug Control Policy, 14 cabinet-level departments and agencies (e.g., Department of Agriculture, Department of Transportation, EPA, Department of Veterans Affairs [VA], and Department of Defense [DOD]), and more than 10 public corporations and commissions and subcabinet agencies are responsible for certain health programs.

The U.S. Congress oversees the activities of federal agencies through committees that review the authorization of programs and the appropriation of funds. Multiple committees in both the House of Representatives and the Senate have jurisdiction over DHHS programs and health-related activities in other departments. These multiple authorities and congressional jurisdictions are an important reason for the “disarray” noted in previous IOM reports.

Scope of DHHS Responsibilities and Activities

Although activities and responsibilities related to public health are spread throughout the federal government, the committee focused its attention on DHHS and its agencies as the principal federal component of the nation's governmental public health infrastructure and as the principal point of contact for other federal agencies with health or health-related programs and for state and local public health agencies. Reviewed briefly here are DHHS activities related to the previously noted functions of policy making, financing of public health activities, public health protection, collection and dissemination of information about U.S. health and health care delivery systems, capacity building for population health, and direct management of services. Some of these activities are considered in more detail later in this chapter, in conjunction with the discussion of specific concerns regarding weaknesses in the nation's governmental public health infrastructure.

The Public Health Workforce

The governmental public health infrastructure at the federal, state, and local levels consists of physical resources (e.g., laboratories), information networks, and human resources (the public health workforce). An adequately sized and appropriately trained workforce performing competently is an essential element of the public health infrastructure. The public health workforce at the federal, state, and local levels must be prepared to respond to an array of needs, such as the assurance of health-related environmental safety, the interpretation of scientific data that can influence health outcomes, or the clarification of vast amounts of highly technical information after a community emergency. In addition to meeting the scientific and technical requirements of public health practice, state and local public health officials are often expected to provide community leadership, manage community reactions, and communicate about risk, protection, and prevention.

Current estimates indicate that approximately 450,000 individuals are working in salaried public health positions, with many more contributing to this mission through nongovernmental organizations or on a voluntary basis (HRSA, 2000). Public health practitioners have training in a variety of disciplines, including the biological and health sciences, psychology, education, nutrition, ethics, sociology, epidemiology, biostatistics, business, computer science, political science, law, public affairs, and urban planning.

Recent studies have shown, however, that the current public health workforce is unevenly prepared to meet the challenges that accompany the practice of public health today. An estimated 80 percent of the current workforce lacks formal training in public health (CDC-ATSDR, 2001). Moreover, the major changes in technology, biomedical knowledge, informatics, and community expectations will continue to challenge and redefine the practice of public health, requiring that current public health practitioners receive the additional, ongoing training and support they need to update their existing skills (Pew Health Professions Commission, 1998).

Training and Education for the Public Health Workforce

Competency-Based Training

Given that early public health efforts in the United States were aimed at improving sanitation, controlling infectious diseases, assuring the safety of food and water supplies, and immunizing children, it is hardly surprising that public health workers at that time were predominantly graduates of schools of medicine, nursing, and the biological sciences. Today, however, the public health workforce has broader responsibilities and must be much more diverse. For example, as part of the performance of essential services, members of the public health workforce must be prepared to engage the community in effective actions to promote mental, physical, environmental, and social health. Advances in biomedical and genomics research and technologies have the potential to change the way public health practitioners think about population-level disease risk and how disease prevention and health promotion activities might be practiced. Moreover, rapidly evolving computer and information technologies and the use of mass media and social marketing have the potential to revolutionize health departments' access to up-to-date surveillance information, disease databases, and communications networks as well as to enhance worker productivity.

The need to strengthen the public health workforce was recognized by IOM in 1988 and has been the focus of a variety of efforts since then. Some of these activities will be discussed in the chapter on the role of academia in the public health system (Chapter 8). A few key efforts focusing on the current workforce (rather than training new workers) are also covered here. In particular, the report The Public Health Workforce: An Agenda for the 21st Century (USPHS, 1997) called for greater leadership on workforce issues from national, state, and local public health agencies; use of a standard taxonomy to better assess and monitor workforce composition; competency-based curriculum development; and greater use of new technologies for distance learning. The Taskforce for Public Health Workforce Development, established in 1999 by CDC and ATSDR, recommended six broad strategies for a national public health workforce development agenda (CDC, 2000e):

1.

Monitor current workforce composition and project future needs.

2.

Identify competencies and develop curricula.

3.

Design integrated learning systems.

4.

Use incentives to promote public health practice competencies.

5.

Conduct and support evaluation and research.

6.

Assure financial support for a lifelong learning system in public health.

An almost universal priority for workforce development is ensuring that all public health practitioners have mastery over a basic set of competencies involving generalizable knowledge, skills, and abilities that allow them to effectively and efficiently function as part of their public health organizations or systems (CDC-ATSDR, 2000; DHHS, 2000; CDC, 2001d) (see Appendix E for an extended list of competencies for public health workers). Many experienced public health professionals require a variety of cross-cutting competencies to help them meet the routine and emergent challenges of public health, as well as specialized skills and abilities in areas such as maternal and child health, community health, and genomics. In addition, a recent survey of the local public health infrastructure found that several specific public health occupations are projected to be the most needed in the coming 5 years (NACCHO, 2001e). These occupations included public health nurses, epidemiologists, and environmental specialists (NACCHO, 2001e) (see Figure 3–2).

FIGURE 3–2

Public health occupations most needed in 5 years.

The Council on Linkages between Academia and Public Health Practice ⁸ has developed a list of 68 core public health competencies in eight domains (see Box 3–2), with different levels of competency expectations for frontline public health workers, senior professional staff, program specialists, and leaders (Council on Linkages between Academia and Public Health Practice, 2001). An expert panel convened by CDC, ATSDR, and HRSA has recommended adoption of this list as the basis for competency-based training of the public health workforce (CDC, 2000e). Use of this list as the basis for training and continuing education for the public health workforce was recommended, regardless of the programmatic or categorical focus of the training (CDC, 2000e). Efforts are under way in the various public health training networks to establish models that will contribute to a systematic approach to competency-based training that is linked to the essential services framework and grounded in prior competency validation efforts (CDC, 2000e).

BOX 3–2

The Core Public Health Competencies. Analysis and assessment Policy development and program planning

Meeting the Needs for Workforce Development

The issue of workforce training and competency is central to the success of any public health system. Governmental public health agencies have a responsibility to identify the public health workforce needs within their jurisdictions and to implement policies and programs to fill those needs. In addition, an assessment of current competency levels and needs is essential to develop and deliver the appropriate competency-based training, as well as to evaluate the impact of that training in practice settings. Workforce training and education efforts may be conducted in partnership with academia and other relevant and appropriate community partners, and ideally, a percentage of public health employees should be targeted annually for continuing education (DHHS, 2000). These and other issues are discussed in the 2003 IOM report Who Will Keep the Public Healthy: Educating Public Health Professionals for the 21st Century.

Training resources for the public health workforce are expanding, spurred by modest funding by HRSA for Public Health Training Centers and by CDC for Public Health Preparedness Centers. By mid-2002, there were 14 Training Centers and 15 Preparedness Centers, which form the backbone of a national public health training network. Both types of centers promote a variety of general workforce development strategies, although the CDC-funded centers place a heavier emphasis on bioterrorism preparedness.

Given the importance of the workforce in carrying out the mission of public health, the committee finds that education and development of the current workforce must continue to be a fundamental priority within the broader efforts to improve the state and local public health infrastructure. Therefore, the committee recommends that all federal, state, and local governmental public health agencies develop strategies to ensure that public health workers who are involved in the provision of essential public health services demonstrate mastery of the core public health competencies appropriate to their jobs. The Council on Linkages between Academia and Public Health Practice should also encourage the competency development of public health professionals working in public health system roles in for-profit and nongovernmental entities.

To facilitate ongoing workforce development, the committee encourages public health agencies to engage in training partnerships with academia to ensure the availability of coordinated, continuous, and accessible systems of education. These systems should be capable of addressing a variety of workforce training needs, ranging from education on the basic competencies to continuing education for individuals in the specialized professional disciplines of public health science.

Furthermore, the committee recommends that Congress designate funds for CDC and HRSA to periodically assess the preparedness of the public health workforce, to document the training necessary to meet basic competency expectations, and to advise on the funding necessary to provide such training.

Preparing Public Health Leaders

Senior public health officials must have the preparation not only to manage a government agency but also to provide guidance to the workforce with regard to health goals or priorities, interact with stakeholders and constituency groups, provide policy direction to a governing board, and interact with other agencies at all levels of government whose actions and decisions affect the population whose health they are trying to assure (Turnock, 2000). These tasks require a unique and demanding set of talents: professional expertise in the specific subject area; substantive expertise in the content and values of public health; and competencies in the core skills of leadership. Those who have mastery of the skills to mobilize, coordinate, and direct broad collaborative actions within the complex public health system must lead in implementing the actions outlined in this report. They require the skills for vision, communication, and implementation. Although many of these skills are innate for most professionals and other leaders, they need constant refinement and honing.

CDC has pioneered the development and funding of a national Public Health Leadership Institute, and in the intervening dozen years, more than 500 leaders in public health have been exposed to leadership training and skill building (described in more detail in the Academia chapter). Furthermore, a similar network of State and Regional Public Health Leadership Institutes has been funded and, over time, has developed the capacity to work collaboratively through a national network, which permits institutes to benchmark and share best practices and continue the process of learning needed to help with state-of-the art curriculum and educational training efforts. Equally notable has been the development of the Management Academy for Public Health, a joint effort of the major public health philanthropies. Although effort is still at an early stage, this academy has already generated graduates who work hand in glove with senior leadership in public health organizations. Furthermore, the Turning Point Initiative devotes efforts to increasing collaborative leadership across all sectors and at all levels (Larson et al., 2002)

Another key to leadership is continuity in office long enough to exert the leadership and to provide the institutional memory to defend public health agencies and the public health sector from the political winds of the moment. Yet, the committee finds there has been great difficulty in recruiting, developing, and retaining the leaders so vital to the job.

A state health official's term, if that official is a political appointee, is tied to the governor's term. Health officials must work with legislators who operate on 2-year terms. Given that the average tenure of a state health officer is relatively short (an average of 3.9 years and a median of 2.9 years) (ASTHO, 2002), many state health officials find it difficult to create longer-term plans for achieving health goals on shorter-term time frames (Meit, 2001). Additionally, because state health officers report to many governing bodies, they generally have less direct access to policy makers, and state health officials must prioritize the issues that they think deserve the most attention (Meit, 2001). Political factors at the state level can also have a significant impact on the abilities of public health leadership to influence policy. To address the specific issues of discontinuity occasioned by the rapid turnover, particularly of state health officials, the Robert Wood Johnson Foundation has funded a unique State Health Leadership Initiative administered by the National Governors Association to immerse newly appointed officials in a curriculum for political leadership and provide a network of resources and mentors.

Governmental public health leadership is a critical component of the infrastructure that must be strengthened, supported, and held accountable by all of the partners of the public health system and the community at large. For this reason, the committee recommends that leadership training, support, and development be a high priority for governmental public health agencies and other organizations in the public health system and for schools of public health that supply the public health infrastructure with its professionals and leaders.

Information Networks

Information and the systems through which it is produced are critical tools that enable public health agencies to meet their responsibilities for monitoring health status and for identifying health hazards and risks to the populations they serve. Public health agencies also rely on information and information systems to assess communities' resources and their capacity to respond to health needs and problems. Such assessments inform the interventions and policies designed to address the community's health needs (Keppel and Freedman, 1995). It is essential that the governmental public health infrastructure have a system that is capable of supporting the collection, analysis, and application of myriad forms of health-related data and information.

The committee uses the term “information” in its most general form, referring to three distinct terms in information science: data, information, and knowledge. Data are the essential elements of information; that is, data are the measurements and facts about an individual, an environment, or a community. Information is what is generated when data are placed in context via the tool of analysis. When rules are applied to the information, knowledge is generated (Lumpkin, 2001). All of these elements—data, information, and knowledge—are critical products of public health information networks.

Of particular concern for the public health infrastructure are interrelated weaknesses in the nation's disease surveillance systems and inadequate access to information systems and communication tools. The committee emphasizes the need for an integrated information infrastructure to overcome many of these problems.

Fragmentation of Surveillance Systems

Fragmentation has developed in surveillance systems in part because legal authority for surveillance rests with states and localities and they have not developed uniform standards for data elements, collection procedures, storage, and transmission. The lack of uniformity has made it difficult for states and localities to work collaboratively among themselves or with the private sector to develop more effective surveillance systems. Although The Future of Public Health recommended the development of a uniform national health data set (IOM, 1988), progress has been limited.

Requirements under the Health Insurance Portability and Accountability Act (HIPAA; P.L. 104–191) for the development and use of comprehensive new standards for the electronic transmission of health information may result in greater consistency of certain types of data. However, there is uncertainty about the scope of the rules under HIPAA, and state and local health departments must determine what portion of their electronic health information might be subject to the requirements established by HIPAA (ASTHO, 2001a, 2001b).

Another key factor shaping the development of surveillance systems is that, historically, investment in these systems has been largely categorical, resulting in fragmentation of surveillance efforts across the spectrum of infectious disease threats and other programs for other specific diseases and populations. An inventory of public health data projects and systems identified more than 200 separate DHHS data systems in seven broad programmatic areas (Boufford and Lee, 2001). The multiplicity of surveillance systems for food-borne illnesses illustrates the problem (see Box 3–3).

BOX 3–3

An Example of Fragmentation in Disease Surveillance Systems. A recent study—based on a survey of public health officials in all 50 states, the District of Columbia, and New York City—of the Centers for Disease Control and Prevention's (more...)

A lack of integration in federal data systems helps drive fragmentation at the state and local levels. Data collected in accordance with the specifications of separate federal programs often cannot be accessed at the local level because of differences in formats, definitions, classification systems, personal identifiers, or sampling strategies (Lumpkin et al., 1995). The fragmentation means that state and local public health agencies inevitably must spend time on duplicative data-reporting activities that drain already scarce staff resources (GAO, 1999a). The current combination of system incompatibility and lack of integration hinders the ability of program managers to know what information exists and how to access that information and hinders the ability of local health agencies to provide integrated care to their communities (Lumpkin et al., 1995). CDC's National Electronic Disease Surveillance System (NEDSS) is working to electronically integrate a number of surveillance activities; details can be found in the discussion of information systems later in this chapter.

Special Role of the Governmental Public Health Infrastructure in Emergency Preparedness and Response

In the wake of the events of September 11, 2001, federal, state, and local public health agencies—and indeed, the nation as a whole—have been grappling with the crucial question of whether the public health system is prepared to cope with future terrorist attacks. Even before the events of 2001, the threat of chemical terrorism had grown more real in the United States because of developments in the mid-1990s such as the discovery of the Iraqi biological weapons program and the release of sarin nerve gas in the Tokyo subway by the Aum Shinrikyo cult (Henderson, 1998). Resources put into the improvement of the public health system's ability to respond to bioterrorism will yield benefits that go far beyond that specific concern, but only if adequate funds are made available to strengthen the public health infrastructure's ability to detect and combat natural disease outbreaks, such as E. coli and other food-borne pathogens, and to work with other vital partners in the public health system to provide the protection necessary for the assurance of public health.

Investing in Infrastructure Improvements

If the United States is going to be appropriately prepared for a terrorist attack (biological, chemical, or otherwise), one of the top priorities must be to strengthen the public health infrastructure at all levels so that it is strong enough, flexible enough, and capable enough to respond to emergency situations of this nature (CDC, 2000a).

An estimated initial investment of approximately $400 million is needed to improve state and local preparedness with regard to personnel, training, epidemiology, and surveillance capacity (Center for Infectious Disease Research and Policy and Workgroup on Bioterrorism Preparedness, 2001). This level of investment would cover the integration of bioterrorism preparedness activities into existing communicable disease prevention and control programs such as CDC's emerging infections program, the training of public health practitioners, and the hiring of designated public health veterinarians for states that do not have one. An estimated additional $200 million was also recommended to begin to improve state and local preparedness with regard to information and communication systems (e.g., Health Alert Network, NEDSS, Epi-X, and rapid communication systems). It was also noted that additional funds would be needed to sustain these systems effectively over time.

Progress toward these estimated needs has been addressed by some of the new resources for infrastructure improvement made available through bioterrorism-related appropriations. A report on the FY 2002 appropriations makes reference to infrastructure improvements such as those authorized by the Public Health Improvement Act of 2000 (P.L. 106–505). Furthermore, in 2002, Congress authorized a variety of bioterrorism-related activities in the Public Health Security and Bioterrorism Preparedness and Response Act of 2002 (OMB, 2002) (see Table 3–1).

TABLE 3–1

FY 2002 DHHS Bioterrorism Funding.

Following the passage of the Public Health Threats and Emergency Act of 2000, there were plans to develop two separate grant programs—one for basic public health infrastructure and the other for bioterrorism preparedness. These were subsequently combined with a stronger emphasis on specific preparation for bioterrorism and other such emergencies.

CDC staff (Office of Terrorism Preparedness and Emergency Response) provided information on funding for the state and local public health infrastructure from FY 1999 to FY 2002 as a subset of total appropriations for bioterrorism. Of total appropriations of $124 million (FY 1999), $156 million (FY 2000), and $182 million (FY 2001), $55 million, $57.6 million, and $67.8 million, respectively, were allocated to state and local capacity building prior to the FY 2002 DHHS bioterrorism funding. The bulk of the funding was for the Health Alert Network; and smaller amounts were allocated for public health laboratory infrastructure and other needs, such as staff development and epidemiology and detection systems. For FY 2002, and prior to September 11, 2001, states were to receive $75 million; however, this amount was supplemented with $915 million. The following seven “capacity areas” (along with the estimated funding levels), deemed necessary for bioterrorism preparedness, were identified for allocation of these funds:

1.

Preparedness planning and readiness assessment ($183 million, including $65 million for the pharmaceutical stockpile)

2.

Surveillance and epidemiology capacity ($183 million)

3.

Laboratory capacity, biological agents ($118.9 million)

4.

Laboratory capacity, chemical agents ($0)

5.

Health Alert Network/communication and information technology ($109.8 million)

6.

Communicating health risks and health information dissemination ($46.7 million)

7.

Education and training ($91.5 million)

The total represents about 42 percent of CDC's total appropriations for bioterrorism and emergency preparedness.

Although the overall resources for the improvement of state and local public health department capacities have increased substantially because of these allocations, it should be noted that the local public health infrastructure provides other important functions that are not covered by the improvements made as a result of these appropriations (e.g., conducting active syndrome surveillance, performing on-the-spot epidemiological investigation, developing local-level bioterrorism preparedness plans, and administering mass vaccinations) (NACCHO, 2001c). For these reasons, it is important to ensure that the improvements that will be made to state and local infrastructures are based on comprehensive data about what is needed to ensure the delivery of the 10 essential public health services at the community level. Furthermore, it is important to ensure that funding levels are sustained over time to maintain these improvements. Most importantly, however, the improvement of public health preparedness capabilities will require the sustained involvement and commitment of policy makers at all levels of government, with ample attention being given to ensuring appropriate accountability (Salinsky, 2002). Doing so is crucial in assuring the safety and preparedness of all of the nation's communities.

Can an appropriate balance be struck between responding to the threat of bioterrorism and ensuring an effective public health response to the health problems facing the nation on a daily basis, such as HIV/AIDS and heart disease?

Eileen Salinsky

National Health Policy Forum

Assessing Infrastructure Costs and the Need for Federal Investment

As the committee has noted, there are vast differences across the country in the scope of activities, the resources available, and the organization of the governmental public health infrastructure at the state and local levels and in the sizes of the populations served. This complicates the task of assessing the cost of public health services and the appropriate investment in the governmental infrastructure that delivers these services or ensures that they are provided. In 1997, the DHHS Office of the Assistant Secretary for Planning and Evaluation commissioned the Lewin Group¹⁴ to develop a comprehensive data strategy to characterize the state of the nation's public health infrastructure. The report urged a collective effort with ASTHO, NACCHO, and PHF to study the status of the public health infrastructure and respond with a sustained investment plan to address the needs identified (The Lewin Group, 1997).

Assessing the funds and expenditures for the public health infrastructure at the local level is complex. Data from NACCHO (2001d) illustrate some of this complexity. The average annual expenditure of the 630 local public health agencies reporting was $4.5 million (1999 dollars), but 50 percent of these agencies had expenditures of $621,000 or less. By contrast, 25 percent of the agencies serving large populations of 500,000 or more had annual expenditures of more than $46 million. On average, local public health agencies reported receiving 44 percent of their funding from local government, 30 percent from state government (including funds passed through federal programs), 19 percent from reimbursements for services, 3 percent from the federal government, and 4 percent from other sources.

ASTHO, NACCHO, the National Association of Local Boards of Health (NALBOH), and PHF, in various collaborative efforts supported by DHHS, have been exploring ways to measure actual expenditures at the state and local levels for each of the 10 essential public health services (Barry et al., 1998; Public Health Foundation, 2000). Feasibility studies show promise, but no systematic accounting of this sort is being done on a regular basis.

Almost no data are available on how much would be needed to adequately build and sustain the necessary public health infrastructure to support the nationwide provision of the essential public health services at the local level. One jurisdiction—Bergen County, New Jersey—conducted a detailed analysis of the funding needed for the public health infrastructure to be able to meet new state public health practice standards. Its estimate of $5.1 million per year translates into about $6.61 per capita and represents the county's best current judgment of the total, ongoing investment in infrastructure required to support the provision of the 10 essential public health services throughout the county (National Partnership for Social Enterprise, 2002). Various IOM reports (IOM, 1988, 1992, 1997a, 1997b, 2000a) have made a case for sustained action, both domestically and internationally, to strengthen the public health infrastructure. A detailed examination of infrastructure needs specifically in support of the nation's immunization system produced a recommendation for annual federal funding of $200 million for the next 5 years, along with an overall increase in funding from state governments of $100 million (IOM, 2000b). That report also emphasized the importance of stability in infrastructure funding, documenting the adverse impact at the state and local levels of rapid increases followed by rapid decreases in federal funding during the 1990s.

As policy makers and the public health community contemplate substantial increases in funding to improve the ability of the public health system to respond to threats of bioterrorism, the committee urges them to consider the lessons that the experience of the immunization program offers. Congress responded to the national measles outbreak in 1989–1991, in part, by increasing funding for state immunization infrastructure grants from $37 million in 1990 to $261 million in 1995, but the appropriations were reduced by about $80 million in 1996 and had fallen to $111 million by 1999. A variety of barriers (e.g., the requirements of state budget cycles and the administrative constraints of a 1-year grant period) had made it difficult for states to absorb the initial influx of grant funds, but funding was cut just as states had begun to build program capacity (IOM, 2000b). Moreover, the influx of federal funding had led state legislatures to cut state funding for infrastructure activities (Freed et al., 2000). Both stable and sustained funding is needed for the effective performance of the public health infrastructure.

On the basis of available data, the committee was unable to conclude what level of federal funding may be warranted as an ongoing, governmental investment in the development and maintenance of the public health infrastructure to ensure that it can provide the essential public health services to all Americans. It is expected that funding for the Public Health Improvement Act of 2000 will enhance the public health infrastructure, but it is unclear to what extent these additional investments would further improve the ability of the public health infrastructure to meet its broad day-to-day responsibilities for protecting and improving the health of the population. A commitment for sustained public health infrastructure financing (unrelated to bioterrorism-related activities) is clearly needed.

Prior efforts at systematic nationwide studies of financing for public health have failed because of their exclusive focus on the budgets of state and local governmental public health agencies rather than the funding of the public health system, thus preventing appropriate benchmarking for communities that have various approaches to the allocation of roles and responsibilities within the system. For example, in the late 1960s, Congress became increasingly aware of the need for accountability pertaining to state expenditures and performance as the amount of funding allocated to state health departments was increasing under Section 314(d) of the Public Health Service Act. As a result, the PHS agencies allocated funds to create the National Public Health Program Reporting System (NPHPRS). Started in 1970 and operated by the Public Health Foundation, all states routinely participated in this voluntary reporting system. Data were collected and verified for items such as federal and nonfederal expenditures by program areas, the organizational structures of health departments, and revenue amounts and sources. This was the only data source of this type in the nation. While discussions were occurring around health care reform in the early 1990s, PHF worked with state and local public health agencies to improve NPHPRS, using the Healthy People 2000 objectives as the basis for performance measures and the 10 essential services as the framework for collecting expenditure data. In 1995, PHS discontinued funding because NPHPRS could not provide program management data for federal agencies. Nearly a decade later, no reporting system exists and no data on state public health expenditures and programs are available. Although different methods of categorizing and cataloging expenditures have been studied, the research indicates that use of the 10 essential public health services for collection of expenditure data is feasible, reliable, and beneficial to the public health community. In addition, the National Public Health Performance Standards Program's Local Public Health System Performance Assessment Instrument appears to be effective in assessing the capabilities of local public health agencies to provide essential public health services.

There is still a great need for an expenditure reporting system for public health agencies based on the framework of the essential public health services and consistent with the newly implemented National Public Health Performance Standards Program to produce a needs assessment and expenditures data as a basis for estimating the investments needed. To begin this process, the committee recommends that DHHS be accountable for assessing the state of the nation's governmental public health infrastructure and its capacity to provide the essential public health services to every community and for reporting that assessment annually to Congress and the nation. The assessment should include a thorough evaluation of federal, state, and local funding for the nation's governmental public health infrastructure and should be conducted in collaboration with state and local officials. The assessment should identify strengths and gaps and serve as the basis for plans to develop a funding and technical assistance plan to assure sustainability. The public availability of these reports will enable state and local public health agencies to use them for continual self-assessment and evaluation.

Organizational Impact of Federal Grant Funding

The ways in which funds are transmitted have an impact on program effectiveness. At present, most discretionary funding distributed by DHHS to states and some local entities is allocated through block grants, formula grants, and categorical programs. According to the White House's Blueprint for New Beginnings accompanying the FY 2002 budget, DHHS manages hundreds of discrete public health activities. For these activities, states receive about $4 billion in formula grants and about $3 billion through block grants. The Blueprint for New Beginnings (White House, 2001) notes that potential reform of formula and block grant programs is a priority of the administration. The administration is considering increasing state flexibility to address public health needs through expanded transfer authorities and other mechanisms to remove barriers to effective targeting of public health resources at the state and local levels. The Blueprint does not address the need to increase the flexibility of categorical grants.

Formula grants are characterized by the allocation of funds to states in accordance with a distribution formula prescribed by law or administrative regulation. Two examples of formula grants can be found under Title I and Title II of the Ryan White CARE Act. Formula-driven grants have been difficult to modify on the basis of new variables influencing a particular issue or changes in the demographics of affected populations. The political process often prevents formula revisions that would negatively affect significant numbers of states, even if the expressed purposes of funding would be better realized by shifts to more needy populations or to other geographic areas.

Block grant programs are a subset of formula allocation programs in which the recipient has broad discretion in the application of funds received in support of broad program areas (e.g., Prevention and Treatment of Substance Abuse and Preventive Health and Health Services Block Grants). Block grant programs have various reporting requirements.

One of the questions that has been long asked is about the effectiveness of the block grant mechanism in targeting funding to a particular purpose or need. Michael Rich (1993) conducted highly regarded studies of this issue, in the area of funding for the poor. After significant empirical analysis of the distribution of Community Development Block Grants, he drew several broad conclusions about this funding vehicle:

• State and local officials play an important role in determining the degree to which federal grants are used to balance income and resources in resource-poor areas.
• The capacity and will of governments to target federal grant funds to the poor vary widely. Government officials tend to spread benefits widely as opposed to concentrating them where the need is the greatest.
• Strong coalitions are more effective in influencing federal program decisions, including targeting areas of greatest need. However, local coalitions need a strong federal partner to make explicit targeting more acceptable locally.

A literature review of different models for federal funding conducted by the DHHS Office of the Inspector General in 1994 noted that states report that block grants increased administrative efficiency and integration and did not replace state funds.

Categorical grants provide states and other recipients with funding for specific programs. CDC provides a significant amount of funding to state government departments of health through categorical grants (e.g., for HIV/ AIDS prevention, sexually transmitted disease control, tuberculosis control, and chronic disease). They are highly restrictive in terms of how the recipients may use the funding, may add administrative costs and complexities, and may worsen fragmented program management and service delivery, as federal prohibitions against mixing funds create programmatic “stove-pipes.” The result can be separation and gaps in services, because even related program areas become insulated and isolated from each other and lack the flexibility to respond to changes at the recipient level. Furthermore, measuring their real effectiveness has been difficult at times because of the large number of individual grants and the lack of resources for effective performance monitoring (Boufford and Lee, 2001).

The DHHS Performance Partnership initiative and the Oregon Option are examples of efforts to use a more performance-oriented approach to categorical funding by integrating multiple categorical programs under larger umbrella categories. Under the Performance Partnership initiative, DHHS and its partners worked together to reach consensus on the results to be achieved by the program and develop performance measures to monitor progress toward the stated results. The Oregon Option tested the proposition that multiple levels of government can align their efforts to achieve results that matter to people. Both initiatives involved signing memoranda of understanding (MOU) that committed them to work cooperatively to both determine the results to be achieved and to get the job done. The question of creating linkages of funding to benefit coalitions demands another role for governments in partnering with key local stakeholders.

This situation should be remedied. Expanded transfer authorities and other mechanisms to remove barriers and facilitate, rather than hinder, the alignment of resources and policy for the actualization of national health objectives should be considered. Thus, the committee recommends that the federal government and states renew efforts to experiment with clustering or consolidation of categorical grants for the purpose of increasing local flexibility to address priority health concerns and enhance the efficient use of limited resources.

Financial Implications of a Changing Mission for Governmental Public Health Agencies in Providing Health Care Services

Essential public health service number 7 (see Box 3–1) charges state and local governmental public health agencies to “link people to needed personal health services and assure the provision of health care when otherwise unavailable” (Public Health Functions Steering Committee, 1994). Thus, state and local governmental public health agencies are responsible for providing a safety net to guarantee that personal health care services are available to all members of the communities they serve. As noted earlier, since 1988, state and local governments have turned increasingly to the private sector, particularly managed care organizations, to provide health care services for Medicaid beneficiaries and others, many of whom were once served directly by local public health departments. In addition, an increasing number of employees (approximately 85 percent) (Kuttner, 1999) are covered by private health insurance, reducing their need for services from public health departments. These changes seemed to provide great promise that local public health agencies would be able to shift their focus from the provision of personal health care services to previously neglected population-based public health functions (IOM, 1996). In some states and communities, however, services to Medicaid patients had offered an important revenue stream that subsidized the population health programs of governmental public health agencies (Keane et al., 2001).

Thus, these agencies find themselves in a difficult relationship with managed care plans: on the one hand, encouraging their active partnership in the public health system, while, on the other, competing with them for revenues for some of these services (Lumpkin et al., 1998). A study of state public health agencies found that 16 of 47 states had some kind of collaboration between their public health departments and managed care groups (DHHS, 1999). In most cases, the managed care organizations were contracted to provide direct patient care (e.g., primary care and clinical preventive services). Other studies of this collaboration reported similar findings.

Although there is great potential benefit from collaborations between public health agencies and managed care plans, current economic trends for managed care programs are not optimistic. In 1997, 67 percent of managed care plans sponsored by safety-net providers lost money, and only 8 percent indicated that they broke even (Gray and Rowe, 2000). In recent years, managed care organizations have been withdrawing from collaborative contracts with governmental public health agencies, once again leaving these agencies with the pressure of having to deliver personal health care services including primary care services to the uninsured or vulnerable populations rejected by the medical care system. This instability in service delivery is also contributing to the disruption of individuals' continuity and availability of care (IOM, 2000a).

Of potential assistance to safety-net providers is the reemerging interest in federal support for “a doubling” of community health centers, operated either by traditional governmental public health agencies or by nongovernmental organizations. Congress recently awarded DHHS with funding to add 1,200 new and expanded health center sites over a 5-year period. At the end of 2002, DHHS will have invested $165 million in 260 new and expanded health centers capable of serving an additional 1.25 million people (HRSA, 2002). As these centers redevelop, the lessons of the past must be kept in mind. The allocation of federal and state resources to communities for these facilities and other health-related programs should be coordinated in a process that ensures the involvement and approval (or at least acknowledgment) of local public health agencies. Moreover, coordination with state and local public health authorities and other community resources is essential (IOM, 1988).

The committee finds that, as in 1988, the continued lack of a nationwide strategy to ensure adequate financing of personal medical, preventive, and health promotion services will continue to place undue burdens on the public health system and to fragment the provision of personal health care services to those most in need of comprehensive integrated approaches. Also, if the number of uninsured continues to increase, the diversion of resources urgently needed for population health efforts to the health care assurance component of the governmental public health system may be required.

The recent downturn in in-state revenues due to the national economic slump will exacerbate problems of sustaining the state share of Medicaid funding and lessen the likelihood of increased or, perhaps, even sustained state funding for the governmental public health infrastructure.

Improving the Operation and Management of the Governmental Public Health Infrastructure

Successfully implementing health policy based on multiple determinants of health and their impact on the health of communities and populations will depend on the effective performance of public health agencies at all levels of government. The committee has discussed the need to strengthen specific aspects of the governmental public health infrastructure at the federal, state, and local levels—the competency of the workforce, the integration and enhancement of information and communication networks, and the improvement of the laboratory and organizational capacities to ensure that the essential public health functions are available to all Americans. Another important priority is to improve the management and coordination of the work of public health agencies as they support this goal of protecting and improving the health of the population.

Public Health Performance Standards and the Accreditation of State and Local Health Departments

Performance measurement has become an essential tool for guiding quality improvement efforts and for holding organizations in the public and private sectors accountable for meeting specified responsibilities. The National Public Health Performance Standards Program (NPHPSP), initiated in 1998, is an effort to use the ideas of performance measurement to promote the organization of state and local public health practice around delivery of the essential public health services (see Box 3–4).

BOX 3–4

The National Public Health Performance Standards Program. Started in 1998, the National Public Health Performance Standards Program (NPHPSP) is a collaborative effort between the Centers for Disease Control and Prevention (CDC) and a variety of national (more...)

In a national partnership, CDC, ASTHO, NACCHO, NALBOH, APHA, and PHF are working together to establish measurable performance standards for state and local public health systems, to develop tools to assess performance against these standards, and to create incentives for states and localities to use such tools. Some of these measures could be used in a “report card” or as standards in a national program that accredits public health agencies.

The performance standards effort is seen as one way to help move the state and local components of the nation's public health system closer to the system envisioned in The Future of Public Health (IOM, 1988). Separate sets of tools for governance have been developed and tested. The instruments are available via CDC's NPHPSP website (www.phppo.cdc.gov/nphpsp), the ASTHO website for the state instrument (www.astho.org/phiip/performance.ht-ml) (ASTHO, 2001d), the NACCHO website for the local instrument (www.naccho.org/project48.cfm) (NACCHO, 2001f), and the NALBOH website for the governance instrument (www.nalboh.org/perfstds/perfstds.htm) (NALBOH, 2001). Although the program is aimed at assessing the performance of the public health system as a whole, it recognizes that governmental public health agencies have key responsibilities for leading, coordinating, and supporting the efforts of various contributors.

The interest in measuring the performance of the public health system extends to the possibility of establishing a formal process of accreditation to certify that governmental public health agencies are meeting specified levels of performance. Several states have developed or are developing state-specific performance requirements for local governmental public health agencies, but interest has also emerged in the development of nationally standardized, systematic performance evaluations for state and local public health agencies.

No agreement has been reached on the appropriate criteria or process for accreditation. One of the key challenges is to create a system that is flexible enough to accommodate the wide variety of public health department structures and circumstances across states. Given the resource constraints that state and local governmental public health agencies currently face, it is unclear how performance standards can be met or accreditation can be achieved when the resources to provide even the most basic services are often lacking. Linking federal funding to accreditation based on public health performance standards has been proposed, but there may not be adequate incentives for states and localities that do not receive significant portions of their overall funding from federal agencies. The promise of a long-term federal investment at the state and local levels linked to such a system could change the situation considerably.

To address these and other concerns, NACCHO has convened the Voluntary Accreditation Committee, which consists of eight local health officers who are charged with maintaining an ongoing discussion of the advantages and disadvantages of voluntary accreditation of local health departments. They are currently researching lessons that might be learned from other voluntary accreditation efforts, such as those for hospitals, managed care organizations, and law enforcement agencies. The Voluntary Accreditation Committee is also taking into account the work of states such as Florida, Illinois, Michigan, Missouri, Ohio, and Washington that are already active in the development of state-specific accreditation or performance standards for their local public health agencies.

Despite the controversies concerning accreditation, the committee believes that greater accountability is needed on the part of state and local public health agencies with regard to the performance of the core public health functions of assessment, assurance, and policy development and the essential public health services. Furthermore, the committee believes that development of a uniform set of national standards leading to public health agency accreditation could provide such a mechanism, but only if adherence to such standards is linked to a commitment of sustained federal investment in the state and local public health infrastructure to assure that resources are available. Moreover, such a mechanism could serve to increase levels of accountability among state and local elected officials in whose jurisdictions these agencies operate. The breakthrough concepts of NPHPSP provide a way to conceptualize the system as the unit of accreditation and, from there, to evaluate the role of the agencies in facilitating the work of the system.

Accreditation is a useful tool for improving the quality of services provided to the public by setting standards and evaluating performance against those standards. Accreditation mechanisms have helped to ensure the robustness of the health care delivery system (hospitals, clinics, programs) and medical and other educational programs. Accreditation processes also provide information to the public about the quality of the services they receive (e.g., National Committee for Quality Assurance report cards on health plans) (IOM, 2001). Governmental public health agencies currently have no such framework, and the communities they serve have little information on the quality of the services they receive. An accreditation process could provide a structure for establishing quality assurance and improvements in governmental public health agencies. Therefore, the committee recommends that the Secretary of DHHS appoint a national commission to consider if an accreditation system would be useful for improving and building state and local public health agency capacities. If such a system is deemed useful, the commission should make recommendations on how it would be governed and develop mechanisms (e.g., incentives) to gain state and local government participation in the accreditation effort. Membership on this commission should include representatives from CDC, ASTHO, NACCHO, and nongovernmental organizations.

This commission should focus on the development of a system that will further the efforts of NPHPSP. The work of this commission should be closely linked to that of the commission whose creation the committee has recommended to examine issues related to the credentialing of public health workers, because it is conceivable that these mechanisms could be linked. In both efforts, the relationship of the official public health agency to its role in the larger public health system will be key to accreditation.

Special Concerns About the Capacity to Meet Local Public Health Needs

In The Future of Public Health (1988), the IOM committee concluded that “no community, no matter how small or remote, should be without identifiable and realistic access to the benefits of public health protection, which is possible only through a local component of the public health delivery system” (IOM, 1988: 144). The rationale behind this finding is clear: If a community is going to be able to meet its own health needs, it must have access to an identifiable public health infrastructure to provide the essential public health services. Today, concerns remain about the availability of an adequate local public health infrastructure, particularly in terms of staffing and communications systems, to provide these services.

Despite the presence of some 3,000 local public health agencies throughout the country, these agencies are not equally distributed across states or across rural and urban areas. For example, Bergen County, New Jersey, with a population of approximately 884,000 and an area of 234 square miles (Census Bureau, 2001a), is served by a strong county health department, 55 local boards of health, and 22 independent public health agencies that serve different and occasionally overlapping communities (T. Milne, NACCHO, personal communication, October 31, 2001). By contrast, the state of Maine, with a population of about 1.3 million distributed over 30,862 square miles (Census Bureau, 2001b), has two local public health agencies (T. Milne, NACCHO, personal communication, October 31, 2001). Challenges come from both an abundance of local public health agencies and their scarcity. When multiple public health departments serve the same geographic area, they may experience difficulties coordinating activities and aligning priorities. However, rural areas, with little or no local public health presence, may suffer from inadequate public health capacity or resources to address local needs and a paucity of educational and training support (Johnson and Morris, 2000).

Data from NACCHO (2001e) also point to substantial differences in the workforce available to local public health agencies. NACCHO's 1999– 2000 survey found that 50 percent of all local public health agencies responding had 17 or fewer full-time employees or contract staff, but for those serving metropolitan areas, 50 percent had at least 28 full-time employees or contract staff. Some local public health agencies, however, currently have only one half-time employee as their entire public health agency staff. Staffing levels have shown little change over the past decade. A 1997 survey found that the median number of full-time employees was 16 (NACCHO, 1998), and in 1992–1993, NACCHO (2001e) reported that 42 percent of local public health agencies had less than 10 full-time staff members. Given the many responsibilities and wide-ranging duties inherent in the assurance of population health, the committee is concerned that these low numbers do not bode well for the core capacity of some local public health agencies to provide the 10 essential public health services to their communities.

Simply increasing the size of the local public health agency workforce appears problematic, however. The committee is concerned about reports by 68 percent of local public health agencies that budget restrictions prevent them from hiring needed staff, including public health nurses, environmental specialists, health educators, epidemiologists, and administrative personnel (NACCHO, 2001d). In addition, local public health agencies in smaller, nonmetropolitan jurisdictions indicated that they could not hire the necessary staff because of a lack of qualified candidates in their areas and difficulty attracting other candidates to their locations. Only 19 percent of the local public health agencies indicated that they needed new staff because of projected expansions of their programs and services (NACCHO, 2001d).

Many local public health departments also lack even the most basic tools necessary for rapid communication and access to information (GAO, 1999b). For example, a 1999 survey of 1,200 local public health departments found that 19 percent did not have the capacity to send and receive e-mail via the Internet (Fraser, 1999). The most common barriers cited by the departments without Internet access were prohibitive costs (64 percent), the need for hardware (64 percent), and the need for staff training (63 percent). Additionally, only 48 percent of the health departments surveyed indicated that the director had continuous, high-speed Internet access at work, and only 44 percent indicated that the department had broadcast fax capabilities (Fraser, 1999). In all cases, public health agencies in smaller and more remote jurisdictions had the least access to information and communications technologies, even though these agencies may actually have the greatest need for such technologies.

Given the evidence concerning the local public health workforce and communication capacity as well as related observations made throughout this chapter, the committee finds that too little has been done to support and strengthen the local public health infrastructure. Over the past 14 years, governmental public health agencies have made great efforts in response to the recommendations concerning local public health agencies in The Future of Public Health (1988) (see Appendix C). Unfortunately, until recently, progress has been slow because of the lack of political and financial support that was needed long ago to fully realize the vision of the 1988 report. Recent increases in infrastructure support in connection with bioterrorism preparedness are somewhat encouraging, but there is concern that such efforts may reinforce the complex problems created by prior categorical funding if excellent specific services (e.g., surveillance are informatics) are built on the foundation of a crumbling infrastructure. For these reasons, the committee believes that every community, no matter how small or remote, should have identifiable and realistic access to the essential public health services, and that it is the responsibility of the states to ensure that such services are available. However, for states to meet this obligation, the committee recommends that DHHS develop a comprehensive investment plan for a strong governmental national public health infrastructure with a timetable, clear performance measures, and regular progress reports to the public. State and local governments should also provide adequate, consistent, and sustainable funding for the governmental public health infrastructure. This investment is crucial to assure the preparedness of public health departments and the protection of communities, regardless of their size or location.

Some communities provided comments to the committee noting that a more precise description of an essential minimum level of local official agency capacity would aid their efforts to obtain public health services. In an effort to be responsive to these requests, the committee struggled with the challenge to be more explicit with regard to the level of public health capacity that should be present in these small and remote communities. Not surprisingly, some familiar problems were encountered. For example, there are questions involving the proper definition of a “community” for this purpose and the appropriate response if a community has too small an economic base to sustain a formal public health agency with the necessary presence and capacity to provide public health protections.

The most robust approach to assessing need seems to be the use of a functional analysis based on the ability to provide the essential public health services, as recommended above. The committee recognizes the potential value of a recommendation regarding the development of a formula to determine the “critical mass” of services and population (e.g., a ratio of one of each of the critical professions per 50,000 or 100,000 population), the geographic accessibility of services, and the workforce capacity necessary for the effective development of local public health agencies to serve small or remote communities. Before such a recommendation can be made, however, solid, practice-oriented research must be conducted to provide the evidence on which to base a formula or other criteria.

The committee had hoped to be able to provide specific guidance to assist the nation in its efforts to rebuild and finance its public health infrastructure. However, a comprehensive search of the published literature and extensive information gathering yielded very little firm, generalizable evidence on which to structure public health practice recommendations like those noted. To remedy this situation, the committee recommends that CDC, in collaboration with the Council on Linkages between Academia and Public Health Practice and other public health system partners, develop a research agenda and estimate the funding needed to build the evidence base that will guide policy making for public health practice.

Strengthening the Management Capacity of DHHS

From 1993 to 1997, DHHS, like all federal government departments, conducted a reinvention exercise to determine what work it should do and how it could do that work more effectively and responsively. A recent monograph on DHHS and the impact of departmental reinvention efforts in the late 1990s identified two issues of particular significance: (1) the effect of the balance between centralization and decentralization on the management of departmental activities and (2) the relationship of the department with other agencies (Boufford and Lee, 2001).

Federalism and a National Public Health Policy

The relationships among various levels of government have always been complex and hotly contested. In most spheres of public health (e.g., injury prevention, clean air and water, and infectious disease surveillance and control), federal, state, and local governments all have a presence. As in all essential government endeavors, good communication and cooperation among the various levels of government are vital. Federalism functions as a sorting device for determining which government, federal or state, may legitimately respond to a public health threat. Often, the national and state governments exercise public health powers concurrently, but the Supremacy Clause gives Congress the authority to preempt state public health regulation, even if the state is acting squarely within its police powers (Gade v. National Solid Waste Management Association, 505 U.S. 88, 98 [1992]). Federal preemption occurs in many areas of public health regulation, including labeling and advertising of cigarettes, self-insured health care plans, and occupational health and safety.

Although there may be debates over the constitutional roles of the federal and state governments, a more fundamental concern is that each level of government operates effectively in assuring the conditions for the public's health. First, strong public health leadership is essential. This means that where the various levels of government are operating at the same time, clear understanding of who is in charge and who has responsibility for which tasks must exist. During the anthrax outbreak, for example, it was often unclear which level of authority was in charge: the Secretary of DHHS, the local public health commissioners in Florida, New York, and Washington, D.C., or the Department of Justice (FBI). Second, no significant gaps in public health protection should exist. This means that at least one level of government should be actively involved in dealing with important health problems.

Because the major interactions of the federal and state governments in recent years have related to issues of health care financing through the Medicaid program (or through welfare programs), they have tended to focus on arguments over money and degrees of freedom to spend it. States have often been reduced to being just another interest group. If a mechanism could be developed to engage the states as potential partners in a larger national strategy such as the health agenda that clearly depends on collaborative action for success, it could change these relationships.

Direct relationships between the federal government and local governments constitute a complicated issue. In the American system, local governments are the creatures of state governments, from which they get their authority and resources (or the authority to raise revenues). There are more than 90,000 units of local government in the United States; 90 percent have populations of less than 10,000 and 80 percent have populations of less than 5,000 (Cigler, 1998). Their policy-making and managerial capacities are highly variable, as are their capacities and resources in health. It is clear that some units of local government look to the federal government to correct the inequities that they experience at the hands of state governments; others are in tense relations with their state counterparts, and direct federal connections may exacerbate tensions. Ways to manage relationships that engage local governments but that respect the rights of the state governments in terms of their relationships to local governments must be considered in any long-term partnership-building process.

The committee believes that a more comprehensive and coordinated approach to health policy is necessary to improve the alignment of federal, state, and local governmental authorities and financial resources to support effective action in improving population health. This kind of coordination is critical to creating a true public health system from the multiple, often disconnected, and somewhat competitive organizations that must work together to promote and protect the health of the public. As one step toward better coordination, DHHS should be looking to new ways to collaborate more effectively with governmental public health agencies at the state and local levels.

This is not a new problem for DHHS. In 1960, then Surgeon General Leroy Edgar Burney convened an external expert group to “study the present and future mission of the public health service and design the best possible structure to deal with its multiple new functions.” It found that PHS needed to develop mechanisms to allow it to work “with, rather than through state agencies” (Study Group on the Mission and Organization of the Public Health Service, 1960). During the Nixon administration, there was similar recognition of the importance of improving relationships between federal, state, and community organizations to serve the populations in greatest need. This led to strengthening of the regional offices of DHHS and establishing an office on intergovernmental affairs. As discussed earlier, the department's policy and structures for dealing with state and local governments have varied over the years, but the mechanisms within the department are weak at present.

One way to achieve better communication is through formal links with the national organizations representing state and local health officials, ASTHO and NACCHO, which often collaborate with the department in activities such as the Healthy People (2010) initiative and the development of National Public Health Performance Standards. The department could also enhance its efforts to seek state and local perspectives on public health policy through the National Governors Association and the U.S. Conference of Mayors, which have staff who work on health issues.

The committee believes that a more formal entity could facilitate the link between the Secretary of DHHS and state public health officers for the purpose of improving communication, coordination, and collaborative action on a national health agenda. In considering the form of such an effort, it is important to recognize that the U.S. health care system is highly devolved, and as noted earlier, historically, the major responsibility for the essential public health services has rested with state governments, but with that responsibility subject to federal regulations and with the public health services partially supported by federal revenues (more revenues are provided for health care delivery than for the public health infrastructure). Because governments have a unique role in assuring the conditions for health of the population and because health is a public good, the high level of interdependence of federal and state governments in achieving national health goals such as those articulated in Healthy People 2010 (DHHS, 2000) requires effective communication and collaboration.

In a 1997 report on the principles of state–federal relations, the National Governors Association, while noting the importance of state autonomy and the preservation of the ability of the states to address local circumstances, agreed that there was a need for a federal role in certain domestic issues—when issues are national in scope and the national interest is at risk and to help states meet the needs of special populations. It also reaffirmed its support for a federal role in assuring equality of access, addressing the issues beyond the capacities of individual states, and ensuring that all states have the fiscal capacity to meet the requirements of federal goals. It further cites the critical importance of close working relationships with “our federal partners” (NGA, 1997). Although this discussion did not specifically address collaboration in public health, the principles would seem to apply and call for direct interaction between the governmental public health leadership of states and the DHHS rather than through annual meetings of representative organizations or interest groups.

Therefore, the committee recommends that Congress mandate the establishment of a National Public Health Council. This National Public Health Council would bring together the Secretary of DHHS and state health commissioners at least annually to

• Provide a forum for communication and collaboration on action to achieve national health goals as articulated in Healthy People 2010 ;
• Advise the Secretary of DHHS on public health issues;
• Advise the Secretary of DHHS on financing and regulations that affect the governmental public health capacity at the state and local levels;
• Provide a forum for overseeing the development of an incentive-based federal–state-funded system to sustain a governmental public health infrastructure that can assure the availability of essential public health services to every American community and can monitor progress toward this goal (e.g., through report cards);
• Review and evaluate the domestic policies of other cabinet agencies for their impacts on national health outcomes (e.g., through health impact reports) and for their impacts on the reduction and elimination of health disparities; and
• Submit an annual report on their deliberations and recommendations to Congress.

The Council should be chaired by the Secretary of DHHS and cochaired by a state public health director on a rotating basis. An appropriately resourced secretariat should be established in the Office of the Secretary to ensure that the council has access to the information and expertise of all DHHS agencies during its deliberations.

The committee believes that public health exists within a sphere of political and policy-making activity, from which it cannot and should not be separated. Thus, public health must operate within the boundaries of democracy and must take place in a rational, evidence-based political process. Therefore, the proposed Council may change with changes in administration.