Challenges of the Public Health System

After decades of inadequate funding, there is broad consensus that today’s public health system is not equipped to meet modern-day challenges. In the aftermath of 9-11 and Katrina, and as we continue to watch the spread of avian flu and worry about the potential for bioterrorism, it is clear that this country’s public health system will take on increasing importance and increasing burden.  Yet the core public health functions such as tuberculosis control and childhood immunizations remain critical.

Research which provides a greater understanding of the organizational structures, the economic needs, and evaluation tools for the public health system is needed to inform policymakers and to assist them in creating an efficient structure with an optimal allocation of resources. The Robert Wood Johnson Foundation’s Health Care Financing and Organization (HCFO) Program has recently awarded several grants studying the challenges of the public health system.

Organization of Public Health Systems

While at is essential to coordinate federal, state and local efforts in the development of an effective public health system, the most immediate action happens on the ground - - at the front lines - - in the community.  Accordingly, much of the critical framework for the public health system will grow out of local and regional innovations.1 Secretary of Health and Human Services Michael Leavitt acknowledged this fact in a recent comment on the development of new information systems in New Orleans to monitor health threats and transmit information among providers.  Leavitt explained that it was important to compare “the principles for such a system we have devised up here with the principles that they have developed for themselves.  I have a pretty clear picture in my mind, but it has to evolve from them.”2

HCFO grantee Susan Zahner, Ph.D. from the University of Wisconsin is examining the factors that influence the performance of small local public health agencies in Wisconsin.  These agencies often support rural, sparsely populated areas and often do not have the infrastructure and resources to meet high quality performance standards. A better understanding of the workings of local public health agencies will be useful to state and local policymakers as they allocate resources and consider the types of technical assistance needed to build capacity in these agencies.

Public health crises, including natural disasters and disease outbreaks, often expand beyond geopolitical borders.  Accordingly, the development of regional public health structures which cross state lines may generate the greatest response capacity.  HCFO grantee Michael Stoto, Ph.D. from RAND is conducting a series of case studies examining the effect of regionalization of public health structures. 

Public Health Systems Funding

Funding for public health preparedness is insufficient.3  As new public health threats appear, the need for greater financial investment to stem these threats will increase.  Moreover, a strategic allocation of limited resources will be necessary to ensure that monies are put to the best use.

An important corollary to the shift in funds toward high priority public health needs is the potential to undermine other local programs.  Policymakers must keep in mind that without an influx of new dollars, shifting funds to support public health programs may have unintended consequences, including cuts in other essential programs.4

HCFO grantee Glenn Mays, Ph.D. from the University of Arkansas for Medical Sciences is exploring local public health spending, with a focus on identifying the factors that precipitate changes in spending and the consequences of such change.  Findings from the study will assist policymakers and public health administrators in a better understanding of the adequacy and equity of current investment in public health services.

As monies are directed toward disaster relief and legislation is passed to fund various public health programs, a sentiment often expressed is, “are these dollars making a difference?” Fair question, but not always easy to provide an answer.  In the public health environment, accountability is an important component to ensure that funding is making a difference and that the infrastructures being created are working.5  Measuring the value of public health services is necessary to determine where resources will have the most impact and whether adjustments are needed.  HCFO grantee Peter Jacobson, J.D. from the University of Michigan is exploring how best to incorporate value measures into the examination of public health systems, and how measuring value will affect important dimensions of public health systems, such as accountability.  His goal is to inform policymakers about the importance of demonstrating measurable contributions in the public health system and to allocate resources to those public health functions which are likely to achieve maximum value.

In sum, HCFO grantees are working to better inform the organizational, financial and strategic planning associated with the current public health system. While the findings from these projects will not resolve the universe of public health challenges, they are likely to assist policymakers in making important inroads to strengthen the system.

HCFO Funded Research:

Title:  Regionalization in Local Public Health Systems: Variation in Rationale, Implementation, and Impact of Public Health Preparedness
Institution: RAND
Time: February 2006 – January 2007
Principal Investigator: Michael Stoto, Ph.D.

What is the effect of regionalization of public health structures? The researchers will use four comparative case studies to 1) document the variation in the rationale for creating regional public health structures, 2) understand how these structures have been organized, implemented, and governed, and 3) assess the current and likely impact of regional structures on public health preparedness and public health systems more generally. The case studies will address coordination, standardization, and developing regional capacity. The objective of the study is to provide a better understanding of the regionalization of pubic health systems in order to inform the many state and local health departments currently developing regional structures.

http://www.hcfo.net/grantees/grant.asp?GrantNo=56470&searching=Yes

Title: Structural Capacities, Processes and Performance of Essential Public Health Services by Small Local Public Health Systems
Institution: University of Wisconsin
Time: February 2006 – January 2008
Principal Investigator: Susan Zahner, Ph.D.

What factors influence the performance of small local public health agencies (LPHA) in Wisconsin? The researchers will identify key factors by determining the contributions of specific structural capacities and processes in providing three public health services: 1) monitoring health status, 2) mobilizing community partnerships, and 3) developing policies and plans. The objective of the study is to gain insight into specific factors that can improve the quality of small local public health systems in order to assist policymakers and administrators with targeting resources and technical assistance.

http://www.hcfo.net/grantees/grant.asp?GrantNo=56471&searching=Yes

Title: Causes and Consequences of Change in Local Public Health Spending
Institution: University of Arkansas for Medical Sciences
Time: March 2006 – February 2007
Principal Investigator: Glenn Mays, Ph.D.

What are the causes and consequences of changes in local public health spending?  The researchers will study cross-sectional variation and longitudinal change in public health spending levels and funding sources, including an examination of disparities in spending levels for different types of communities. The researchers will also investigate the extent to which changes in spending levels are associated with changes in local population health status. The objective of the study is to provide insight into the effects of changes in local public health spending in order to assist policymakers craft desirable strategies to correct existing gaps and disparities in resources for local public health services.

http://www.hcfo.net/grantees/grant.asp?GrantNo=56469&searching=Yes

Title: Measuring the Value of Public Health Systems
Institution: The University of Michigan
Time: March 2006 – February 2007
Principal Investigator: Peter Jacobson, J. D.

How can the value of governmental public health systems (GPHSs) be defined and measured? The GPHS is a state and local governmental apparatus designed to assess and respond to threats to the public’s health through population-based and individual health services. The researchers will examine how other public or quasi-public entities define and measure value; the methodologies used to measure value; the criteria for determining and measuring value; and how measuring the value of these services will affect other important dimensions of public health systems, such as accountability. The objective of this study is to develop ways for policymakers to incorporate value measures for governmental public health system activities into resource allocation decisions. 

http://www.hcfo.net/grantees/grant.asp?GrantNo=56782&searching=Yes

1 See, Profiles in Public Health, The Robert Wood Johnson Foundation.  http://www.rwjf.org/newsroom/featureDetail.jsp?featureID=1028&type=3
2 Broder, David S., “Hope for Health Care? HHS’s Leavitt Sees an Opportunity in New Orleans,” The Washington Post, February 23, 2006.
3 Issue Report, “Ready or Not? Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism,” Executive Summary, Trust for America’s Health (supported in part with a grant from The Robert Wood Johnson Foundation).
4 Lurie, N, Wasserman J, Stoto, M, et al., “Local Variation in Public Health Preparedness: Lessons from California,” Health Affairs Web Exclusive, June 2, 2004.
5 Issue Report, “Ready or Not? Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism,” Executive Summary, Trust for America’s Health (supported in part with a grant from The Robert Wood Johnson Foundation).

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