The Future of Public Health (1988) / Chapter Skim
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5. Public Health As A Problem-Solving Activity: Barriers to Effective Action
5. Public Health As A Problem-Solving Activity: Barriers to Effective Action
Pages 107-137
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From page 107... ...
, the committee has identified some appreciable barriers to effective problem solving in public health. These barriers include: · lack of consensus on the content of the public health mission; · inadequate capacity to carry out the essential public health functions of assessment, policy development, and assurance of services; · disjointed decision-making without necessary data and knowledge; · inequities in the distribution of services and the benefits of public health; · limits on effective leadership, including poor interaction among the technical and political aspects of decisions, rapid turnover of leaders, and inadequate relationships with the medical profession; · organizational fragmentation or submersion; · problems in relationships among the several levels of government; 107
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From page 108... ...
THE LACK OF CONSENSUS ON MISSION AND CONTENT OF PUBLIC HEALTH Progress on public health problems in a democratic society requires agreement about the mission and content of public health sufficient to serve as the basis for public action. There is no clear agreement among public decisionmakers, public health workers, private sector health organizations and personnel, and opinion leaders about the translation of a broad view of mission into specific activities.
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From page 109... ...
This maternal and child health focus has been especially strong in a number of public health agencies in the South. The tension caused by attempting to provide personal medical care services without at the same time depriving other public health functions of an appropriate share of scarce funds is aggravated by overall changes in the financing of medical care, which force more of the burden of care of the indigent back on to public agencies.
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From page 110... ...
By contrast, in a Canadian city visited during the study, universal entitlement to medical care lifts the burden of indigent care from the public health agency, leaving that agency free to focus its resources on other priorities in public health, such as effects of industrial pollutants on cancer incidence, improving the health outcomes of high-risk infants, smoking cessation, monitoring health status, and organizing the community to combat particular health problems. RELATIONSHIP OF PUBLIC HEALTH TO ENVIRONMENTAL HEALTH Many of the early accomplishments in the prevention of infectious disease were accomplished through public health management of water supply and sewage disposal.
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From page 111... ...
At the federal level, mental health responsibilities remained within the Public Health Service, although mental health groups have advocated the maintenance of a separate identity for mental health programs both at the state and federal levels in order to assure sufficient attention to these important health problems. The trend in mental health services in the United States since World War II has been away from large custodial institutions and toward communitybased services, stimulated by the National Mental Health Act of 1946 and by the federal Community Mental Health Centers legislation in the 1960s.
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From page 112... ...
. The role of state or local public health agencies has often been relatively minor.
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From page 113... ...
Public health programs, to be effective, should move beyond programs targeted on the immediate problem, such as teen pregnancy, to health promotion and prevention by dealing with underlying factors in the social environment. To deal with these factors, the scope of public health will need to encompass relationships with other social programs in education, social services, housing, and income maintenance.
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From page 114... ...
Achieving and sustaining a comprehensive and integrated assessment and surveillance capacity is made more difficult by the fragmentation of the assessment function in many states where environmental health and mental health data are gathered by separate agencies. Meanwhile, the lack of direct federal encouragement and assistance to state efforts has limited the availability of good health data at the state and local levels.
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From page 115... ...
During the time we visited that state, the plight of an uninsured woman in need of a heart-lung transplant was monopolizing public dialogue, while severe stress-related problems among the state's farmers and their families alcoholism, family violence, accidents received little notice even among public health professionals. Another problem is the fragmentation of policy development because of governmental structure.
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From page 116... ...
The relationship between the public and private sectors for the accomplishment of public health objectives becomes particularly apparent when regulation is the mode of public health activity chosen through the policy development process. Here again, a clear identification of the public purpose in the policy development process is necessary, along with the technical underpinning that can be provided by a solid assessment function.
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From page 117... ...
In theory a good policy development process should be just as important for deciding on program reductions as it is for determining desirable program expansions. In practice, a ratchet effect is often observed in which it is much easier to consider program expansions on top of existing activities than it is to consider realignment of programs according to program priorities.
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From page 118... ...
The conflicts may erode support for effective public health actions, leaving gaps in access to benefits. A special problem in assuring access to the benefits of public health activity is the diversity of funding sources for public health activities.
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From page 119... ...
On the other hand, we observed that the technical experts may not understand or appreciate the appropriate and fundamental role for the political process in public policy-making, especially as it expresses society's values as criteria for selecting among options that have been defined with appropriate technical competence. CONTINUITY OF LEADERSHIP In many public health jurisdictions, rapid turnover of leadership has been a problem.
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From page 120... ...
Public Health Service Commissioned Corps in providing experts on assignment to state and local public health agencies. For decades, the Commissioned Corps provided a personnel system with retirement benefits that allowed assignment of corps officers to state and local positions, constituting a national cadre of trained public health personnel.
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From page 121... ...
represented a visible national leadership role in the establishment of public health objectives, working with state and local agencies and state and national nongovernmental health groups. The Environmental Protection Agency has played a major role in reducing environmental pollution.
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From page 122... ...
This capability requires appropriate leadership skills and techniques, as well as an attitude that the community itself is a source of public health actions. These skills include the ability to communicate important agency values to public health workers and to enlist their commitment to those values, the ability to sense and deal with important changes in the community that are the context for public health programs, the ability to communicate with diverse audiences and to understand their perspectives and needs, and the ability to find common pathways for action.
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From page 123... ...
Concern was also expressed that organizational fragmentation lessens desirable health-related technical input into the policy- and decision-making process especially for environmental health activities and for the Medicaid program when it is administered by a social services agency. For mental health programs, the organizational separation may reflect a continued emphasis within mental health on the provision of services for the mentally ill rather than a "public health" orientation, including epidemiological surveillance and prevention.
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From page 124... ...
. From the perspective of advancing a public health mission, the committee notes that both in the fragmentation model described above and the superagency model, the role of public health leadership founded on a technically competent assessment function is lessened.
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From page 125... ...
In the 1960s, the federal government deliberately bypassed official health agencies at the state and local levels in establishing certain federal health programs, such as neighborhood health centers and regional medical programs, to assure that federal objectives were met. Some environmental health problems raise complex questions of interstate or even international relationships in which a purely state or local focus of authority is insufficient for the problem.
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From page 126... ...
These capacities include the technical knowledge base and its application, well-trained and competent personnel, the generation and maintenance of adequate constituencies and political support, managerial competence sufficient for these complex public sector tasks, and adequate fiscal support for the agreed-upon public health mission. The committee has identified problems with each of these capacities.
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From page 127... ...
THE NEED FOR WELL TRAINED PUBLIC HEALTH PERSONNEL Many sections of this report have mentioned the need for well-trained public health professionals who can bring to bear on public health problems the appropriate technical expertise, management and political skills, and a firm grounding in the commitment to the public good and social justice that gives public health its coherence as a professional calling. The committee has identified a number of problems in meeting this need.
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From page 128... ...
The variation in public health practice noted earlier in this report and the limitations on employment opportunities in health agencies for welltrained professionals, restricting opportunities for graduates, have inhibited desirable responses by the educational institutions to the needs of practice. This situation is exacerbated by the fact that most public health workers have not had appropriate formal professional public health training.
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From page 129... ...
Such achievements as a safe water supply, the disappearance of many childhood infectious diseases, reduction of the incidence of stroke, fewer childhood poisonings, reductions in lead poisoning, and control of food-borne infections are taken for granted until a problem occurs. Also, the identification of public health programs with means-tested welfare programs adds to the perception that public health concerns are not an integral part of the entire community.
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From page 130... ...
Other important interest groups, such as the tobacco industry, may oppose public health actions and question the competence of public health agencies because those actions may interfere with the economic interests of the group. Although the broader medical community can and does identify with such public health issues as smoking, injury control, infectious disease control, and dietary change related to cardiovascular disease and cancer, many physicians look down on public health, as an organized activity, believing it to be second rate or meddlesome.
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From page 131... ...
However, we would note these special problems for public health as compared with other public functions: · an explicit reduction of federal support for public health activities; · the special financial problems faced by particular states as a result of declines in their economies; · the appearance of new challenges to public health such as AIDS or the hazardous by-products of modern economies; · the advance of our techniques both biological and epidemiological to identify risks to human health; · the changing demographics of American society (e.g., an aging population) ; · an interconnected world that shares health risks with increasing rapidity; · the need to maintain and replace expensive public infrastructures for health, such as water and sewage systems; · the rise in the costs of modern health care, which both add to the burden on public provision of health services and compete with funds for other public health functions; · the need to provide sufficient core support for a public health delivery system; and
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From page 132... ...
HOW THE PUBLIC HEALTH SYSTEM WORKS-AIDS AS AN EXAMPLE What are the problems public agencies are having in fulfilling their unique functions of assessment, policy development, and assurance? Is the statutory base adequate to cope with a new and compelling issue?
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From page 133... ...
Among the many groups and individuals, public and private, engaged in fighting AIDS, health agencies have not taken a clear initiative in supplying leadership, and the public is unclear about what level of government it should look to for guidance or what it can appropriately and realistically expect any
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From page 134... ...
The fiscal implications of caring for AIDS patients are poorly understood because estimates of the potential number of cases are in dispute. In some places where there are large numbers of AIDS patients, the private sector especially voluntary groups such as gay rights organizations-have taken the lead in providing treatment and counseling,
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From page 135... ...
Response to a highly publicized crisis like AIDS cannot serve as the model for a sustained and effective public health effort addressed to the many health problems that, in the aggregate, dwarf the health impact of AIDS. For example, the great increase in lung cancer took place more slowly and therefore lacked the dramatic impact of AIDS on the public consciousness, but it is a larger problem in terms of death and disability, and sustained public health effort cart affect the magnitude of the disease burden.
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From page 136... ...
Cir., 1987~. Office of Disease Prevention and Health Promotion, Public Health Service, U.S.
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From page 137... ...
737 U.S. Depar1meD1 of Health and Human Serv~es, ~bUc HeaRb Serv~e 1980.
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