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![]() ![]() Tracking Changes in the Public Health System:What Researchers Need to Know to Monitor and Evaluate These ChangesIssue Brief No. 02
The Tradition of Public Health
The popular image of a local health department is represented by New York City, Detroit, Los Angeles County, and other large metropolitan areas. But big city or county public health agencies represent only 4 percent of the nation’s local public health departments. Most are in small cities, towns, and rural areas; half serve fewer than 25,000 people and two-thirds fewer than 50,000. It is on the local level, in large and small communities alike, that decisions made by public health departments are most likely to affect the public’s health. Changes in Public Health Services
Foremost among the pressures on the system are the diminished levels of state and local funding and the increased fragmentation of public health responsibilities among nontraditional partners in the community. As a result of these and other pressures, the tools and strategies used to address the delivery of public health in the past may not be adequate or appropriate today or in the future. For example, with the increased fragmentation public health departments find it increasingly challenging to coordinate and be held accountable for the services they are responsible for. Primary health care facilities and hospitals can take care of patients with tuberculosis, but the local health department remains responsible for overseeing contact tracing to find other people in the community with the disease. The proliferation of health and safety programs in non-public health government agencies further challenges the coordination of public health functions. Many states have environmental health programs that are managed by their environmental protection agency. Food safety often comes under the direction of the state agriculture department. Drug awareness programs are housed in education offices. And highway safety programs are run by the department of transportation. Each of these agencies or departments tends to look at health problems from its own perspective. For example, when an environmental agency handles asbestos removal from buildings, the problem is seen primarily as an environmental one with environmental solutions, and not as a public health problem. Dwindling Resources
Not only is less money available for public health, but also much of it is categorical, or set aside for specific programs or services. This makes it difficult to handle local emergencies or unexpected disease outbreaks, such as food poisoning or cryptosporidiosis from infectious agents in food or water. State and local health department administrators want more discretionary funding to give them flexibility in transferring money among public services when the needs arise. Compounding the problem of dwindling resources is an increase in the number of uninsured people -- including those with complex health problems such as AIDS and drug-resistant tuberculosis -- who rely on public health facilities for their medical care. For people with inadequate or no health insurance, local health departments are among the few places in the community where they can go for health care. As an example, half the patients at one public health clinic for the indigent in Missouri have no health insurance, and most of the rest are on Medicaid.
Managed Care
Managed care has the potential to be more involved in providing these and other population-based services; however, it cannot be expected to replace completely the population-based functions of public health departments. For example, an HMO can identify a child with lead poisoning, but it is not responsible for removing lead paint from an apartment or school, monitoring other children in the neighborhood, or enforcing building codes. The relationship between public health and managed care varies from place to place. In Los Angeles County, for example, the public health department competes with private health care providers to offer managed care under Medicaid. In San Diego County, however, the public health department only monitors care delivered in the private sector; it does not bid on or undertake contracts to provide managed health services. The impact of losing income that Medicaid patients once provided to public health departments is significant in some areas because it supported vital public health services and programs that brought in little or no money. In fact, Medicaid reimbursements were 10 percent of the annual budget for some state health departments. The loss of this business has had a particularly large impact in states where Medicaid reimbursement is highest. Where there are savings from Medicaid managed care, public health departments want to make sure they are used to fund population-based work. There is widespread concern that the money will be allocated elsewhere in state and local government agencies.
New Partnerships
In Texas, for example, Wendy’s has instituted an MBA program -- Mop, Bucket, and Attitude -- to help protect food safety and prevent outbreaks of food poisoning. A Columbus, Ohio, business coalition developed a strategic plan that closely follows the public health department’s plan. Called Community Health 2010, the coalition plan calls for improving the health status of residents by facilitating education and behavioral changes and providing access to basic health care and preventive health services. In other communities across the country, local health departments are building linkages with private hospitals, managed care organizations, business groups, and others in the private sector to enhance public health services. For this to work well, the groups need to work as partners, not as competitors. Looking at public sector partnerships, 98 of Missouri’s 115 local health agencies have signed contracts with the state health department to assess their communities’ health status and needs. In most cases, the local public health agency will act as a leader in convening teams of community health officials from the public and private sectors. Another public sector partnership is the Centers for Disease Control and Prevention program to develop sentinel networks across the country, which will serve as early warning systems for potential public health problems. With a broader number of public and private sector partners, local health departments find it more challenging to coordinate and be accountable for the services delivered. Accountability
Public health activities are not the only determinants of public health outcomes, however. Rates of infant mortality, for example, are affected not only by the delivery of prenatal services, but also by Medicaid eligibility, the rate of employment in a community, whether a pregnant woman is homeless, and so on. A public health department cannot accept the credit -- or blame -- for all measures involved in a community’s infant mortality statistics. In any case, health goals are needed to measure outcomes and ensure the accountability of public health programs. In some cities, public health goals include an increased awareness of sexually transmitted diseases and improved immunization rates. These goals are a clear reflection of the ultimate public health outcome of reducing disease in the population. Public health agencies can develop a series of indicators to track whether the goals are being met and, if so, how they affect medical outcomes in the community. In doing so, however, they should be aware of which indicators are most likely to change and how those changes are likely to affect the delivery of public health services. Measuring Public Health Functions
Since 1989, the National Association of County and City Health Officials (NACCHO) has sponsored the National Profile of Local Health Departments. The latest profile will look at changes in how many dollars go into public health, what those dollars cover, and who is providing public health services. Another NACCHO project, APEX, is designed to assess a public health agency’s organizational capacity and work with local residents to assess and improve the community’s health status. About 45 percent of local health departments have used APEX. Under the Illinois Process for Local Assessment of Needs (IPLAN), every local health department in Illinois has examined its community needs and organizational capabilities. The study provides a score for specified public health indices. North Carolina has been tracking changes in public expectations of services performed by local public health agencies. Researchers are tracking these agencies’ progress toward meeting the goal of 90 percent of the public being served by a local health department as set out in Healthy People 2000. Traditional methods and tools for tracking public health functions have focused on describing and assessing the local health department’s infrastructure, capacity, and organization. As public health activities move outside the walls of the local health department, these tools are falling short in their ability to track public health activities in the community. New methods and tools need to be developed that can:
Looking Ahead
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