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| Copyright © 2009. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
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OCR for page 43
Revisiting The Future of Public Health
In the course of its discussions about current public health issues, the
Committee on Public Health had the opportunity to readdress the findings and
conclusions of The Future of Public Health, and to assess the impact that the
report has had on the field. If not begun directly in response to The Future of
Public Health, then many of the following activities were at least informed and
energized by it.
BETTER DEFINITIONS OF PUBLIC HEALTH
One of the most valuable aspects of The Future of Public Health was the
articulation of the mission and functions of governmental public health agencies
(see Introduction). Specifying the functions of public health enabled federal,
state, and local health departments to begin a dialogue and assessment about what
they do and whether it was appropriate and adequate. This clarification of the
roles for public heal agencies was part of a larger movement to reinvent and
reorganize governmental public health programs to make them more efficient and
effective and to build support from public officials and the general public
(University of Illinois, 1994~.
From the core functions identified in The Future of Public Health, experts
developed more specific frameworks of public health processes. Miller and
colleagues developed 10 public health practices, each linked to one of the core
functions thriller, 1995; see also Box 13~. This framework was then used to assess
the performance of local health departments (Miller et al., 1994~.
43
OCR for page 44
44
HEALTHY COMMUNITIES
BOX 13. Public Health Practices
ASSESSMENT PRACTICES
(The regular systematic collection, assembly, analysis, and dissemination of
information on the health of the community.)
1. Asses the health needs of the community by establishing a systematic needs
assessment process that periodically provides information the health status and health
needs of the community.
2. Investigate the occurrence of adverse health effects and health hazards in the
community by conducting timely investigations that identify the magnitude of health
problems including their duration, trends, location, and populations at risk.
3. Analyze the determinants of identified health needs to identify etiologic and
contributing factors that place certain segments of the population at risk for adverse
health outcomes.
POLICY DEVELOPMENT PRACTICES
(The exercise of the responsibility to serve the public interest in the development of
comprehensive public health policies by promoting the use of the scientific knowledge
base in decision making.)
4. Advocate for public health, build constituencies and identify resources in the
community by generating supportive and collaborative relationships with public and
private agencies and constituent groups for the effective planning, implementation and
management of public health activities.
5. Set priorities among health needs based on the size and seriousness of the
problems, the acceptability, economic feasibility and effectiveness of interventions.
6. Develop plans and policies to address priority health needs by establishing goals
and objectives to be achieved through a systematic course of action that focuses on local
community needs and equitable distribution of resources and involves the participation
of constituents and other related governmental agencies.
ASSURANCE PRACTICES
(The assurance to constituents that services necessary to achieve agreed-on goals are
provided by encouraging actions of others (private or public), requiring action through
regulation, or providing service directly.)
7. Manage resources; develop organizational structure through the acquisition,
allocation, and control of human, physical, and fiscal resources; and maximize the
operation functions of the local public health system through coordination of community
agencies' efforts and avoidance of duplication of services.
OCR for page 45
REVISITING THE FUTURE OF PUBLIC HEALTH
45
8. Implement programs and other arrangements ensuring or providing direct
services for priority health needs identified in the community by taking actions that
translate plans and policies into services.
9. Evaluate programs, provide quality assurance in accordance with applicable
professional alla regulatory standards to ensure that programs are consistent with plans
and policies, and provide feedback on inadequacies and changes needed to redirect
programs and resources.
10. Inform and educate the public on public health issues of concern in the
community, promote art awareness about public health services' availability, and health
education initiatives that contribute to individual and collective charges in health
knowledge, attitudes, and practices achieve a healthier community.
| SOURCES: Miller et al., 1994; Turnock and Handler, 1995 l
The National Association for County and City Health Officials, working from
the goal of healthy people in healthy communities, developed a paradigm for a
community's health system. The paradigm incorporates ten elements, each of
which must be present for a health system in a community to be considered
complete (NACHO and CDC, 1994~. In this framework, the role of the
governmental public health agency is to assess whether the elements are present
either on its own or in partnership with others; to develop legal or financial
incentives for the ten elements; or through its own efforts to provide the ten
elements or a subset of the elements, based on local priority setting, if others
cannot be found to provide, will not provide, or are unable to provide elements of
a high quality to meet community benchmarks.
The maternal and child health (MCH) community also expanded upon the list
of ten essential services to develop an MCH Functions Framework (Graven and
Guyer, 1995~. This framework details MCH program functions and provides
examples of local, state, and federal activities for implementing MCH program
functions. It has been used as a strategic planning, evaluation, and educational tool
by state and local MCH programs and schools.
While The Future of Public Health has had an important impact on public
health professionals, health officials have not yet found the correct formula for
informing the public about the importance of public health. Finding better ways to
inform the public and elected officials of the substance and importance of public
health clearly deserves more attention.
OCR for page 46
46
HEALTHY COMMUNITIES
PUBLIC HEALTH CAPACITY
By clarifying goals within the profession and supplying tools for advocacy,
The Future of Public Health provided a stimulus for activities to strengthen the
capacity of public health. Although there is still tremendous variability in capacity
among state and local public health agencies, over the past eight years, there have
been many targeted areas in which public health capacity has improved. Two
important areas have been in response to the resurgence of tuberculosis and the
increase in childhood vaccine-preventable disease, both occurring in the late 1980s
and early 1990s. A heavy infusion of federal funds and a reorganized
operationally focused tuberculosis program enabled New York City to reverse the
increase in cases (Frieden et al., 1995~. In response to outbreaks of measles,
mumps, and other childhood diseases, the federal government dramatically
increased appropriations for immunization, and immunization action planning
projects were initiated in cities and states across the country (Woods and Mason,
1992~. Another important area has been in small rural communities. Some local
health departments find that The Future of Public Health report is valuable in
helping to direct public health activities (Box 14~.
At the state level, The Future of Public Health spawned a series of activities
intended to clarify and strengthen the core functions of public health. These
include the State of Washington's Public Health Improvement Plan (Washington
State Department of Health, 1994) and the Illinois public health improvement plan
(Illinois Department of Public Health, 1990, 1993, and 1994~.
Currently, 69% of the expenditures of state and local health departments are
used to provide personal health care services (Eilbert et al., 19961. Funding for
these personal services from federal and state sources such as Medicaid help pay
for administrative and other functions. Thus, as revenue streams for services to
vulnerable populations shift from public health departments to managed care
organizations, the financial base for governmental public health agencies could
shrink. In light of new roles for public health agencies to work with managed care
organizations and the community as outlined above, some states have begun to
explore ways to reinvest in local public heals agencies (Re-Invesunent Work
Group, 19951. This will require public health officials and their allies to inform
state legislatures about what public health agencies do in the state and community
and their contributions to the public's health.
PRACTICE GUIDELINES FOR PREVENTION
It became clear to public health professionals that to improve the public's
health further, it was necessary to develop guidelines for practice and prevention.
OCR for page 47
REVISITING THE FUTURE OF PUBLIC HEALTH
47
BOX 14. Barron County Health Department, Wisconsin
Barron County is a rural community in Wisconsin that is distant from any
metropolitan area. Because it is difficult to get current public health information, Barron
County has relied on The Fixture of Public Health. The report has provided valuable
information that the County Health Department has used in managing the community's
public health activities.
Some recent activities in Wisconsin and Barron County demonstrate the relevance
of The Future of Public Health. The State of Wisconsin has used many of the report's
recommendations. It has published its own version of Healthier People in Wisconsin:
An Agenda for the Year 2000. It recently revised Wisconsin Public Health Statutes 1993
to define a health planning arid leadership role for local health departments that is
fundamental to the protection of the health of the community. The three core functions
of a local health department identified in the statutes are assessment, policy development,
and assurance.
In 1995, these documents provided the Barron County Health Department the
impetus to assume the lead in a countywide process to assess the health of Barron County
using the National Association for County and City Health Officials' APEXPH
(Assessment Protocol for Excellence in Public Health). The goal was to assess the
county's health needs, develop policies to meet those needs, and to ensure that quality
services (including personal health services) that are necessary for the protection of
public health are available and accessible to all persons in Barron County.
The APEXPH process has been successful. The community has renewed
confidence in the Barron County Board of Health. Since the completion of the Barron
County Health Plan 2000 in December 1995, the Board has passed two county
ordinances to protect the public's health, and it continues to involve the community by
requesting input from other government agencies and community organizations on health
concerns, department programs, and fiscal matters.
SOURCE: Based on information provided by Kathy Newman, director of the Barron
County Health Department, 1996; NACCHO, 1991.
The Council on Linkages, with support from the W. K. Kellogg Foundation,
sponsored a "Guideline Development Project for Public Health Practice." The
goals of this project were to assess the desirability and feasibility of practice
guidelines and to test a methodology for evaluating the scientific evidence on
which such guidelines could be built. Four public health problems were chosen
for study: (1) immunization of children, (2) treatment for tuberculosis, (3)
prevention of cardiovascular disease, and (4) prevention of lead poisoning. This
project found that the development of public health practice guidelines is feasible
and should be pursued (Council on Linkages, 1995), and efforts are underway to
develop prototype guidelines.
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48
HEALTHY COMMUNITIES
The CDC has also begun to assess the effectiveness of community-based
prevention guidelines. They have collected these guidelines into a "Prevention
Guidelines Database," available to practitioners though CDC's PC Wonder (Friede
et al., 1993), an on-line electronic communication system, and the Internet
(Gordon et al., 1996~. The CDC is providing staff support to a newly established
U.S. Task Force on Community Preventive Services intended to complement the
U.S. Preventive Services Task Force Guide to Clinical Preventive Services
(DHHS, 1989, 1996), which is designed for practitioners to use with individual
patients. The proposed new guide will focus on community-based prevention and
control strategies.
TRAINING OF PUBLIC HEALTH PROFESSIONALS
the couture of Public Health identified needs and gaps in the training of public
health professionals, which were further addressed at an IOM Conference on
Education, Training, and the Future of Public Health held in 1987 (IOM, 1991~.
The F?vt?are of Public Health called for strengthening the links between schools of
public health and public health agencies. In 1988, the Health Resources and
Services Administration and the CDC established a "Public Health Faculty/
Agency Forum" to develop universal and discipline-specific competencies and
recommendations (Sorensen and Bialek, 1991~. These competencies are now
being used by public health schools and programs to guide the development of
curriculums and by agencies to assess needs for training.
The forum's work led to formation of the "Council on Linkages Between
Academia and Public Health Practice." The council is working to improve
practice in public health agencies and education by refining and implementing the
recommendations of the Public Health Faculty/Agency Forum, establishing links
between academia and the agencies of the public health community, and creating a
process for continuing public health education throughout one's career (Sorensen
end Bialek, 1991~.
DEVELOPING STRONGER LEADERS AND PRACTITIONERS
The Future of Public Health identified serious gaps in the leadership skills of
governmental public health leaders and others interested in improving the public's
health, including difficulty with the interaction of technical expertise and political
accountability, lack of management skills, a high turnover and lack of continuity
of leaders, inadequate national leadership, a lack of supportive relationships with
the medical community, and insufficient capability in working with the
OCR for page 49
REVISITING THE FUTURE OF PUBLIC HEALTH
49
community (IOM, 1988). Roper (1994) notes that public health leaders must
understand and deal with multidimensional problems. The straightforward
challenges of the past (e.g., developing a vaccine for an uncomplicated infectious
disease) have given way to problems such as teen pregnancy, drug abuse, and
STDs that are intertwined with seemingly intractable social and economic
problems. Even active and experienced public health professionals, Roper reports,
are not prepared for current and future challenges and, worse yet, suffer from
problems of morale, skills, and systems. These conditions demand that today's
leaders in public health be equipped differently than the leaders of yesterday.
Since the IOM's report was released, leadership institutes have been
developed at the federal, regional, and state levels. The CDC and the Western
Consortium for Public Health established a training institute for state and local
public health practitioners at the national level. Regional leadership institutes have
been organized at the University of Washington, University of North Carolina, and
St. Louis University Schools of Public Health and in the states of Florida, Illinois,
Michigan, Missouri, Ohio, and Texas (Gordon et al., 1996~.
The CDC has developed an "Information Network for Public Health
Officials" (INPHO). This federal-state partnership is designed to connect public
health professionals so that they may have access to current data and information
to make informed decisions and to provide a vehicle for data exchange. INPHO
computer networks and software link organizations eliminate geographic and
bureaucratic barriers to communication and information exchange. Georgia was
the first state to join the network, and INPHO projects are underway in 13 states.
The CDC has also developed a "Public Health Training Network," a distance
learning system comprising public, private, and academic partnerships. This
network will use computers and satellite systems to train public health
professionals and health care providers in the latest issues in public health, such as
managed care (Baker et al., 1994; Gordon et al., 1996~.
CONCLUSIONS
Through its analysis of the interactions between managed care organizations
and the role of governmental public health agencies in enhancing the health of the
community and through its discussions about the many responses to The Future of
Public Health, the committee found that the constructs of He mission and
substance of governmental public health agencies envisioned in that report have
been extraordinarily useful in revitalizing the infrastructure and rebuilding He
federal, state, and local public health system in the United States. These agencies
continue to be a fundamental building block in efforts to improve He public's
health for the future. However, although clear progress has been made, some of
OCR for page 50
50
HEALTHY COMMUNITIES
the recommendations of that report have not yet been achieved. In light of this, the
committee's analysis shows that the concepts in The Future of Public Health
remain vital and essential to current and future efforts to energize and focus
the efforts of public health. These concepts need to be advanced, applied, and
taught to all health professionals.
The committee also found that the concepts of assessment, policy
development, and assurance, while useful in the public health community itself,
have been difficult to translate into effective messages for key stakeholders,
including elected officials and community groups. These concepts need to be
translated into a vernacular that these groups understand.
In conclusion, the committee found that the public health enterprise in the
United States, as embodied in governmental public health agencies, is necessarily
diverse in organization and function, but operates within the common framework
set out in The Future of Public Health. The committee's discussions, however,
revealed continuing evidence of inadequate support for governmental public health
in many communities. Now, as nearly a decade before, society must reinvest in
governmental public health agencies, with resources, commitments, and
contributions from government, private, and nonprofit sectors and
substantial legal authorities, if the public's health is to improve. The
partnerships that are the focus of this report between governmental public health
agencies and managed care organizations, and between public health and the
community-can provide both political support and a vehicle for this
reinvestment.
Representative terms from entire chapter:
governmental public
