The Future of Public Health (1988) / Chapter Skim
Currently Skimming:
4. An Assessment of the Current Public Health System: A Shattered Vision
4. An Assessment of the Current Public Health System: A Shattered Vision
Pages 73-106
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From page 73... ...
"Public health" in the United States is defined not only by the scope of health problems and their interventions in each area, but also by the values * In the United States, government responsibility to protect the public's health is represented by public health agencies, state and local health departments, and by the federal Department of Health and Human Services.
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From page 74... ...
The areas visited within the states were chosen to reflect a variety of geographical locations, urban-rural mix, health problems, population mix and economic status, public health agency organization, and array of public health services. (See Appendix D for a fuller description of the selection process and the plan for the site visits.)
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From page 75... ...
At each site, committee members and committee staff spoke with state and local health officers; state and local health department directors and program administrators; state and local environmental, social service, and mental health agency personnel; representatives of local and state government; representatives of hospital, medical, and nursing professional associations and of citizen organizations; health professionals; administrators and board members in private and public hospitals and clinics; journalists; and professors of medicine and of public health. The committee conducted a total of more than 350 interviews.
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From page 76... ...
More than 350 people, including citizens of 39 states, the District of Columbia, and Canada, attended these meetings. Attendees included state health commissioners and state health agency officials; local health officers; deans and professors of medical schools, schools of public health, nursing schools, and schools of public administration; federal health officials; consumer representatives; physicians, nurses, social workers, health educators, and mental health professionals; representatives of state medical associations, state nurse's associations, and state social worker's associations; directors of public hospitals and community health centers; members of state boards of health; and representatives from nonprofit associations.
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From page 77... ...
Some state health agency directors are required to be physicians with public health experience, and some are administrators with management experience. (American Medical Association, 1984)
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From page 78... ...
A more detailed description of state health agencies and their leadership, organization, activities, and resources is presented in Appendix A Local Local health agencies are the critical components of the public health system that directly deliver public health services to citizens.
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From page 79... ...
(Executive Office of the President, Office of Management and Budget, 1987) State health agencies spent nearly 75 percent of their funds on personal health services, about $4 billion, while spending less than 1 percent on planning activities, about 3 percent on laboratory analysis and research, and about 9 percent on all resources development.
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From page 80... ...
While aggregate state health agency spending increased at about 4 percent annually between 1976 and 1984, the proportion of their finances spent on personal health services increased from 48 to 58 percent. (Public Health Foundation, 1987)
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From page 81... ...
Organization of Health Agencies Among the six states, two state health agencies were divisions of superagencies. One state health agency was also the mental health authority; two were also the state Medicaid agency.
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From page 82... ...
For example, in one state the state health agency was part of a superagency combined with social services, but separate from mental health and environmental services. The local health agency visited in this state was independent from the social services agency but had mental health and environmental divisions.
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From page 83... ...
In one state, substance abuse programs were handled by the state health agency, but mental health services were the responsibility of the social services agency. Almost no communication took place between the programs.
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From page 84... ...
The first was a trend toward more directors of health agencies with backgrounds in general administration. In two of the states, the health officers were former directors of the health agency and had been repositioned to report to an administrator heading the agency.
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From page 85... ...
A local health agency official criticized the state agency, "Some of us are frustrated by a sit-on-your-hands health department." Yet many public health workers expressed satisfaction with their jobs. The image of public health agencies also suffers because the job is a difficult one.
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From page 86... ...
Health agencies also suffer from lack of visibility. "The public visibility of the state health service is nil," was a frequent sentiment.
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From page 87... ...
All of the state agencies were involved in assessment, policymaking, and assurance of access to educational, environmental, and personal health services. The two largest local health agencies also conducted activities in each function.
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From page 88... ...
Policy Goals Developed Through Health Assessments 1 Standards for Local Health Agencies 5 B Health Planning State Health Plan ning 2 Categorical Plans 5 Certificate of Need 5 III.
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From page 89... ...
The emergency medical system, over which the examiner had authority, was operating a surveillance system. One local health agency was testing private homes for indoor air pollution.
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From page 90... ...
" Conversely, a state health official in a different state said, "We can detect more than we can do anything about." Frequently, people in states mentioned the need to collect their own data on particular issues. Several local areas reviewed studies of problems by hospitals or universities in the area.
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From page 91... ...
Initiatives came from state and local government, from citizen groups, and from health agencies. In one state, legislative staff were working on legislation restricting smoking in public buildings, while the health agency staff were designing and implementing health education programs in smoking prevention and cessation.
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From page 92... ...
Some agencies would seek the support of legislators and county executives, and they would contact the press to gain publicity for new programs and policies. As one state health officer said, "Part of our job is to sell this stuff." Another state agency was regularly contacted by the state legislature for information to back legislative proposals.
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From page 93... ...
One state health officer said, "Now we can do what we want instead of the feds dictating to us." A local health officer in the same state said, "The silver lining in the loss of federal funds is that now people realize they'll have to set priorities themselves, rather than wait for some planner with money to do it." But officials in another agency said, "When the president adopted new federalism, he also threw the problems back to the local level what's happening here is that we're trying to step into a void." Some states still felt restricted by federal spending policies. One state agency official decried the state's inability to provide services for mental health and alcoholism, while spending more than justifiable on maternal and child health.
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From page 94... ...
The local health agencies in this state were run by the state health agency. A variety of personal health services were offered by local health agencies, including
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From page 95... ...
Some private home health services and not-forprofit community health centers existed, but the public health agency provided personal health care for a majority of the low-income citizens. Specific illustrations of health programs in which the states and local agencies were involved are numerous.
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From page 96... ...
Several other strategies for state support of indigent care were discussed during open meetings of the committee. Despite all of these various programs, there were many examples of health problems for which services were not being offered by health agencies or by other participants.
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From page 97... ...
" The extent of unmet need in many areas caused agencies to be concerned about their responsibility to meet all needs, particularly those of indigent populations. In several of the local areas, other resources for personal services were abundant in the form of nonprofit clinics, public hospitals, and private practitioners and the health agency relied on these sources to carry out personal health activities.
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From page 98... ...
Many state and local health officials at open meetings described the need for public health agencies to become more involved in health promotion and the difficulty of doing so while maintaining other programs. Intergovernmental and Interorganizational Relationships It is evident in the examples of health agency leadership, assessment, policy-making, and assurance of educational, environmental, and personal health services observed during the site visits that the ability of health agencies to carry out their responsibilities relies in part on their relationships with other participants in the public health system.
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From page 99... ...
Some health officials even described their relationships as dictatorial. A representative anecdote concerns the state health officer who instituted new regulations defining local health departments without consulting local health departments.
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From page 100... ...
In one state, the state health agency felt hampered in its efforts to enforce rules on individual water supply, because responsibilities were split with the state environmental agency. Officials also described overlap problems with personal health programs.
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From page 101... ...
(Association of State and Territorial Health Officials, National Public Health Program Reporting System, 1981; Public Health Foundation, 1986) In 1984, total state and local health agency funding derived from federal contracts and grants ranged from 10 to 60 percent in the six states.
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From page 102... ...
(Public Health Foundation, 1986) Finances from health agencies were not the only source of funding for health programs.
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From page 103... ...
In most of the areas, the populace relied on private health care professionals to provide services as well as on health agency staff. The number of public health professionals and health care professionals in the states and localities working outside of the public health agencies varied; physicians per 1,000 population ranged from 107 to 230 in the six states.
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From page 104... ...
A state health official said, "First you define a problem, and then you decide if you can afford it." A local health official in an area with high infant mortality rates told the committee, "The high-risk pregnancy program is limited in number due to funds." And a public health agency clinic administrator confided, "We constantly prescribe less expensive medications or put off tests." Many health officials and providers mentioned concern about increasing indigent care and uncompensated care in their states. Some officials feared further cutbacks.
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From page 105... ...
1985. Staffs of State Health Agencies.
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From page 106... ...
1987. Public Health Agencies, 1987.
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