and vaccination,b disease prevention programs, public health laboratories, and similar population-based health services (Catlin, 2011). NHEA does not include the following in the definition of public health: publicly financed personal health care services, government-funded health research, government investment in medical structures and equipment, public works, environmental protection, sanitation and sewage treatment, and emergency planning (Catlin, 2011). Therefore, spending on nonclinical, prevention, and health promotion–oriented services (that could be classified as public health activities) by the Substance Abuse and Mental Health Services Administration and spending on environmental health services and on maternal and child health services by any level of government are not counted in the public health expenditure category in NHEA.

The International Classification for Health Accounts does not distinguish between personal health care services provided by governments and population-based health services (Sensenig, 2011). And the OECD’s System of Health Accounts category of “prevention and public health services” does not distinguish between population-based and individual-based preventive activities. At the local level, nurse home visiting programs illustrate one definitional challenge: whether they are population-based services or individual-based services.


aFor example, the National Association of State Budget Officials report on 2002 and 2003 state health spending contained a definition of population health services as including “promotion of chronic disease control and encouragement of healthy behavior and the protection against environmental hazards” (NASBO, 2005). The CMS Office of the Actuary classification system defines a roughly but not completely equivalent budget category of “governmental public health activity” as “publicly provided health services such as epidemiological surveillance, inoculations, immunization/vaccination services, disease prevention programs, the operation of public health laboratories, and other such functions” (CMS, 2011).

bImmunizations given in a physician’s office are not included in public health data; if they are administered through a public health department, they are included. However, this is complicated by the fact that some of the vaccines given in non–public health facilities may be government-funded, and this could distort the cost data.

dardization in data collection and in the current definitions of public health and related activities at all levels of government in which public health financial data are collected. That would enable the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary National Health Expenditure Accounts (NHEA) to provide a more accurate and uniform picture of governmental public health spending (Catlin, 2011; Sensenig, 2011).

This chapter discusses current public health funding, estimates of the level of funding that public health needs, and some potential sources of adequate, stable, sustainable, and dedicated funding for public health.


Public health spending may be reported as a percentage of national health spending (used by NHEA), as a percentage of national gross do-

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