The Future of the Public's Health in the 21st Century (2003) / Chapter Skim
Currently Skimming:
3. The Governmental Public Health Infrastructure
3. The Governmental Public Health Infrastructure
Pages 96-177
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 96... ...
Weaknesses in the nation's governmental public health infrastructure were clearly demonstrated in the fall of 2001, when the once-hypothetical threat of bioterrorism became all too real with the discovery that many people had been exposed to anthrax from letters sent through the mail. Communication among federal, state, and local health officials and with political leaders, public safety personnel, and the public was often cumbersome, uncoordinated, incomplete, and sometimes inaccurate.
|
From page 97... ...
The chapter then examines some of the most critical shortcomings in the public health infrastructure at the federal, state, and local levels: the preparation of the public health workforce, inadequate information systems and public health laboratories, and organizational impediments to effective management of public health activities. The committee recommends steps that must be taken to respond to these challenges so that governmental public health agencies can meet their obligations within the public health system to protect and improve the population's health.
|
From page 98... ...
The report also contained recommendations for a review of the statutory basis for public health, the establishment of the governmental public health infrastructure as the clear organizational hub for public health activities, better linkages to other government agencies with health-related responsibilities, and strategies to strengthen the capacities of public health agencies to perform the core functions. A complete listing of the recommendations from that report can be found in Appendix C
|
From page 99... ...
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)
|
From page 100... ...
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)
|
From page 101... ...
. 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.
|
From page 102... ...
Constitution.i 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.
|
From page 103... ...
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 servlces. Role of the Federal Government in Assuring Population Health The federal government acts in six main areas related to population health: (1)
|
From page 104... ...
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.
|
From page 105... ...
Whereas the venereal disease statute simply empowers compulsory examination whenever health officials cleem 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 clanger to public health (Gostin et al., 1999~.
|
From page 106... ...
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.
|
From page 107... ...
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.
|
From page 108... ...
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.
|
From page 109... ...
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)
|
From page 110... ...
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.
|
From page 111... ...
THE FEDERAL PUBLIC HEALTH INFRASTRUCTURE In contrast to state and local public health agencies, the federal government has a limited role in the direct delivery of essential public health services. Nevertheless, it plays a crucial role in protecting and improving the health of the population by providing leadership in setting health goals, policies, and standards, especially through its regulatory powers.
|
From page 112... ...
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.
|
From page 113... ...
One of the leading examples in public health is the Healthy People initiative, which establishes national goals and objectives for health Promotion and disease Prevention. The Healthy People ~n~t~at~ve Is lea cy tne ~~ Ace or Disease Prevention and Health Promotion and now involves all DHHS operating divisions, other federal departments, and partnerships with state and local public health officials, as well as more than 350 national membership organizations, nongovernmental organizations, and corporate sponsors.
|
From page 114... ...
These include national vital and health statistics, household surveys on health and nutrition, health care delivery cost and utilization information, and reporting requirements for programs funded by federal grants or assistance. The National Center for Health Statistics within CDC is the primary agency collecting and reporting health information for the federal government.
|
From page 115... ...
In terms of the public health infrastructure, this includes striving for effective collaboration within DHHS, between DHHS and other cabinet departments for domestic and international health policy, and between DHHS and state and local public health departments. With more than 200 categorical public health programs in DHHS and a variety of health-related programs in other federal agencies, the alignment of policies and strategies is challenging.
|
From page 116... ...
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.
|
From page 117... ...
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.
|
From page 118... ...
Public Health Nurses ~ 28% Environmental Specialists 21% 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)
|
From page 119... ...
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.
|
From page 120... ...
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.
|
From page 121... ...
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
|
From page 122... ...
Such a process would complement efforts to establish national public health performance standards for state and local public health systems based on the essential public health services framework and the related objectives of Healthy People 2010 (Objective 23-11)
|
From page 123... ...
The commission should be charged with determining if a credentialing system would further the goal of creating a competent workforce and, if applicable, the manner and time frame for implementation by governmental public health agencies at all levels. The dialogue should include representatives from federal, state, and local public health agencies, academia, and public health professional organizations who can represent and discuss the various perspectives on the workforce credentialing debate.
|
From page 124... ...
The lack of information from DHHS was also frustrating to other federal, state, and local leaders and governmental public health officials, some of whom learned about new cases and contamination in their states though network and cable television newscasts (Connolly, 2001~. The lesson from these and other communication breakdowns is evident: clear and effective communication, both internal and external, is a critical service of the governmental public health infrastructure.
|
From page 125... ...
Given the tremendous potential of the mass media and evolving information technologies, such as the Internet, to influence the knowledge, normative beliefs, and behavior patterns of individuals and groups, governmental public health agencies must be prepared to use these communication tools. The public health workforce must have sufficient expertise in communications to be able to engage diverse audiences with public health information and messages and to work with the media to ensure the accuracy of the health-related information they convey to the public.
|
From page 126... ...
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.
|
From page 127... ...
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)
|
From page 128... ...
Ideally, these comprehensive disease registries and surveillance networks would be accessible to and used by state and local public health agencies to better understand and monitor the health status of the communities they serve. Additionally, these registries would have the potential to be linked with registries from private health care delivery organizations
|
From page 129... ...
THE GOVERNMENTAL PUBLIC HEALTH INFRASTRUCTURE 129 :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ~ ~ X~ ~ J- ~ JI ~ _- rat M~ ~ a~-l- ~ 1~ l -- a - -I -- - thou -- vu-l- -- 1-~-~ Eye- mu- ~.~ .................................................
|
From page 130... ...
Although no national syndrome surveillance network is in operation, some state and local public health agencies are beginning to test and implement such systems. For example, New York City has had an active syndrome surveillance system since the l990s (LLGIS, 2001)
|
From page 131... ...
is working with state and local health departments and information systems contractors to develop real-time syndrome surveillance and analytical methods (CDC,20013~. During special events, ESP sites monitor data on emergency department visits at sentinel hospitals.
|
From page 132... ...
. By 1997, 14 states had begun INPHO projects, some combining their INPHO resources with other CDC grant funds to build statewide networks linking state and local public health departments.
|
From page 133... ...
. A public health information network is under consideration at CDC to serve as a vehicle, with an effective governance mechanism, to ensure the integration of existing public health information systems within CDC and coordinated development of future ones with state and local public health agencies.
|
From page 134... ...
Congress to increase the levels of funding devoted to improving the nation's public health information infrastructure. The recommendations in CDC's review of this infrastructure specifically emphasized the need to ensure that health departments at all levels have access to modern means of rapid electronic data exchange and communication (CDC, 2001c)
|
From page 135... ...
It would allow the public health system and others to address concerns such as public health emergencies, medical errors, and health disparities in a more timely and comprehensive fashion (NCVHS, 2002~. The links to data from the health care delivery system are critical to state public health agency efforts to monitor the quality of health care.
|
From page 136... ...
This would be a combination of federal, state, local, and private-sector funds ramping up to a peak investment of $1.7 billion per year in 2007 and flattening out for the remaining years; the amounts needed to sustain the system after that period were not estimated. Public Health Laboratories Public health laboratories are a critical component of the disease surveillance resources of the public health infrastructure, providing essential capacity to detect, identify, and monitor the presence of infectious or toxic agents in populations and the environments in which those populations live.
|
From page 137... ...
.l° GAO (1999a) also recommended that the CDC director lead an effort by federal, state, and local public health officials to establish a consensus on the core laboratory capacities needed at each level of government.
|
From page 138... ...
The limitations of existing laboratory capacity were clearly demonstrated by the 1999 outbreak of West Nile virus in New York State. Even with a relatively small outbreak in an area served by one of the nation's largest local public health agencies, the investigations taxed federal, state, and local laboratory resources (GAO, 2001b)
|
From page 139... ...
and the Working Group on Bioterrorism Preparednessl2 estimated that approximately $200 million was needed as an initial investment to improve state and local preparedness with regard to laboratory capacity. This funding would support · Further development and implementation of the Laboratory Response Network, which is a multilevel laboratory network composed of federal, state, county, and city public health laboratories designed to receive and analyze specimens from a range of sources; · Full implementation of the National Laboratory System, which is a communications system designed to rapidly share laboratory information among public health, hospital, and commercial laboratories; · Integration of chemical terrorism preparedness into laboratory improvements; and · Improved diagnostic testing and identification of potential agents of bioterrorism by animal and wildlife laboratories and improved communications among human, animal, and wildlife laboratories.
|
From page 140... ...
Given the important role of public health laboratories in assuring the health of the population and in protecting the nation's security, the committee believes that federal, state, and local public health agencies should have access to a strong, state-of-the-art public health laboratory system. Furthermore, the committee believes that these public health laboratories are an essential part of a robust and stable surveillance capability necessary to identify emerging threats, natural or intentional, to the health of the public and to track the effectiveness of interventions at multiple levels.
|
From page 141... ...
Readiness of Local Public Health Agencies Until recently, the degree to which public health departments were actually prepared for bioterrorist attacks or other emergencies was unknown. Determining the level of state and local health departments' emergency preparedness and response capacities is crucial because public health officials are among those, along with firefighters, emergency medical personnel, and local law enforcement personnel, who serve on "rapid response" teams when large-scale emergency situations arise.
|
From page 142... ...
Survey results indicated that local public health officials played a variety of roles in response to the September 11 terrorist events, including communicating with various community-level partners; working with response partners to develop, update, and review emergency response protocols and plans; and providing information to the media and the concerned public. Of the inquiries received by local health officials, most concerned vaccination and the availability of medicines.
|
From page 143... ...
These individual competencies are complementary to the organizational capacities for bioterrorism response developed by CDC (2001b) , the standards for state and local public health performance (CDC, i3 At the time that this report was drafted, legislation for a Department of Homeland Security was under debate.
|
From page 144... ...
Because frontline health care providers (i.e., those in urgent care and emergency room facilities) are often the first to see unusual illnesses or injuries, they must constantly be vigilant to notice trends that seem out of the ordinary and must report these trends to local public health departments (ASTHO, 1999; CDC, 2000a)
|
From page 145... ...
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)
|
From page 146... ...
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 onthe-spot epidemiological investigation, developing local-level bioterrorism preparedness plans, and administering mass vaccinations)
|
From page 147... ...
Doing so is crucial in assuring the safety and preparedness of all of the nation's communities. FINANCING THE PUBLIC HEALTH INFRASTRUCTURE State and local governments traditionally have had financial responsibility for basic governmental public health services, such as workforce training, the development of information systems and the organizational capacity to conduct disease surveillance and prevention programs, the management of public health laboratories, the implementation of populationbased prevention and health education programs, and other protections such as water and air quality management, waste disposal, and pest control.
|
From page 148... ...
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~.
|
From page 149... ...
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.
|
From page 150... ...
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.
|
From page 151... ...
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.
|
From page 152... ...
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
|
From page 153... ...
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~.
|
From page 154... ...
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.
|
From page 155... ...
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~.
|
From page 157... ...
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.
|
From page 158... ...
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.
|
From page 159... ...
. Many local public health departments also lack even the most basic tools necessary for rapid communication and access to information (GAO, 1999b)
|
From page 160... ...
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.
|
From page 161... ...
Centralization versus Decentralization: Models for Managing DHHS The committee's discussion of key federal functions policy making, financing, infrastructure development, and the like illustrate how the problems of fragmentation in federal public health activities affect the functioning of state and local public agencies. Such problems are related to histori
|
From page 162... ...
The regional offices are also seen as aids in convening state leadership in health and human services in those regions and in convening local leaders to help them find ways to increase their access to federal programs or to collaborate with others in the public and private sectors to make DHHS programs effective. Although others prefer that DHHS agencies work directly with state and local governments and grantees, such agency-by-agency linkages can add to the fragmentation of efforts to address population health.
|
From page 163... ...
Another area for greater collaboration and coordination is with nongovernmental entities. This can be particularly challenging in the area of health care delivery because of the government's role as regulator and payer.
|
From page 164... ...
A final challenge is the integration of federal standard setting and regulation with the equally varied jurisdictions of state and local health departments or other health-related agencies. Again, creative and sustained mechanisms to develop collaborative relationships and to harmonize regulations within DHHS, across federal agencies, and among federal, state, and local governments are critical to effective action for protecting the population's health.
|
From page 165... ...
DHHS has only limited authority from Congress to spend money on international health activities. Coordination across all these agencies is critical to assuring a coordinated strategy for international health.
|
From page 166... ...
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.,
|
From page 167... ...
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.
|
From page 168... ...
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)
|
From page 169... ...
This National Public Health Council would bring together the Secretary of DHHS and state health commissioners at least annually to A, A, . A, · 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 incentivebased 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)
|
From page 170... ...
Testimony of David R Johnson, MD, MPH, Deputy Director for Public Health and Chief Medical Executive, Michigan Department of Community Health, on behalf of the Association of State and Territorial Health Officials, to the U.S.
|
From page 171... ...
2002. Assessment of the validity of the National Public Health Performance Standards: the local public health performance assessment instrument.
|
From page 172... ...
2001. Local public health competency for emergency response.
|
From page 173... ...
1999. Information technology and local health departments.
|
From page 174... ...
2000. Stabilizing the rural public health infrastructure.
|
From page 175... ...
2001d. Local public health agency infrastructure: a chartbook, October.
|
From page 176... ...
Report and recommendations from the Work Group on the National Health Information Infrastructure, Washington, DC, November 15, 2001. Available online at http://ncvhs.hhs.gov.
|
From page 177... ...
Mending gaps in the public health infrastructure. National Health Policy Issue Brief No.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.