For the Public's Health Investing in a Healthier Future (2012) / Chapter Skim
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Appendix C: Financing Mission-Critical Investments in Public Health Capacity Development--Eileen Salinsky
Appendix C: Financing Mission-Critical Investments in Public Health Capacity Development--Eileen Salinsky
Pages 153-204
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From page 153... ...
The committee commissioned this paper to inform its deliberations regarding optimal mechanisms for financing the governmental public health infrastructure in a manner that will best support the needs of the public during and after health care reform. Based on guidance from the committee, this paper seeks to • i dentify and describe priority investments in public health capacity that promise to strengthen the ability of state and local public health agencies to adopt an ecologically oriented, population-based ap proach to disease prevention and health promotion that addresses the broad socioenvironmental determinants of health; • e xplore the extent to which categorical financing mechanisms have influenced the capacity deficits observed in these mission-critical areas; and • e xamine the funding sources that have been successfully used by in novative public health agencies at the state and local level to finance these capacity-development priorities.
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. This paper focuses specifically on capacity within governmental public health agencies at the state and local level, while recogniz Clinical care Community delivery system Government Governmental Employers agencies Public Health (other than and business Infrastructure public health)
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Respondents were selected based on their broad expertise in public health agency capacity, performance, and financing, as well as their experiences implementing innovative practices. Many interview respondents were directly identified by workgroup members, and additional respondents were identified during initial interviews with these public health leaders.
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The following identifies capacity-development priorities for state and local public health agencies based on the expert opinion of committee
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underdeveloped in many, if not most, state and local health agencies, and (3) difficult to develop adequately given the current level and structure of public health funding.
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The few issues characterized by explicitly divergent viewpoints are noted in the following narrative. Surveillance and Epidemiology Surveillance and epidemiology are the foundation of public health practice, and deficits in this capacity domain can fundamentally undermine the effectiveness of governmental public health agencies.
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A wide variety of data sources administered by state health agencies (e.g., claims data for public health insurance programs, hospital discharge databases, emergency department data, vital statistics, and disease and immunization registries) can be used to monitor rates of disease, injury, and health care utilization.
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. Interview respondents noted that local health officials face similar (and perhaps more daunting)
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. However, state and local public health agencies have struggled to adapt public health surveillance systems to leverage these advances in health information technology and do not appear to have the capacity necessary to shape the development of EHRs in clinical settings to optimize their potential for surveillance purposes.
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. Although similar epidemiology workforce requirements are not available for local health agencies, NACCHO reports that a minority of local health departments engages in surveillance and epidemiology activities for noninfectious diseases.
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Deficits were observed in all three stages of community health improvement planning identified above, with development needs cited related to public health agencies' capacity to • c onduct comprehensive community health assessments (CHAs) , • f acilitate participatory priority setting involving multiple stakehold ers, and • i dentify cost-effective, community-based interventions to prevent disease, injury, and disability.
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From page 164... ...
Over the past two decades, many states have enacted policies that mandate the completion of community health assessments by local health agencies, and a variety of trainings and tools have been developed to assist these efforts.6 These activities have supported the implementation of community health assessments throughout the country and facilitated the use of health data in planning and policy development. In 2008, NACCHO found that the majority of local health agencies led or contributed to a collaborative process to conduct a community health assessment at some point within the prior 3-year period (NACCHO, 2009)
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. These staffing constraints within state and local health agencies decrease the likelihood that actionable health improvement plans will emerge from these assessment efforts.
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While these private-sector efforts promise to support improvements in the reach and quality of community health assessments, this growth may increase, rather than dimin ish, the need for additional public-sector involvement. Many state and local health agencies are working proactively to ensure appropriate public–private partner ships.
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, improve the timeliness of available data, expand epidemiology-support capacity provided at the state level, and augment the analytic skills of local health officials (Friedman and Parrish, 2006; Love and Shah, 2006)
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Facilitating a prioritization process that engages a broad variety of stakeholders with diverse interests and perspectives will almost certainly lead to some degree of conflict and disagreement. Public health leaders interviewed for this paper identified a number of underdeveloped capacities related to priority setting in the context of community health improvement planning, including the need for improved leadership skills related to conflict mediation and group facilitation, more and better models for communicating community health assessment findings in actionable formats that can be easily understood by a lay audience, and additional evaluation and research related to effective methods for priority setting in a community context.
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Partnership Building Community health improvement plans often feature ecologically oriented public health interventions that must be implemented through intersectoral partnerships. Traditionally, state and local public health agencies have focused on the implementation of disease prevention and health promotion activities that these agencies have direct responsibility and operational control over (e.g., lead abatement, vector control, sanitation, food service inspections, and health education)
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. Interview respondents cited a variety of capacity deficits that currently limit the ability of state and local health agencies to build effective partnerships, including the capacity to • a ssess the interests, priorities, culture, and operating processes of partner organizations,
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is often seen as a primary responsibility of leadership personnel. Agency leaders frequently serve as the "public face" of state and local health departments, presenting at governance functions, participating in intergovernmental cabinets and workgroups, serving as the main liaison to private-sector groups, and engaging with media outlets.
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A few respondents were somewhat more pessimistic and expressed concern that leaders in many public health agencies have not yet embraced a more expansive, collaborative role. Limited political support for public health efforts to promote social and environmental change was cited as a major factor discouraging public health leaders from pursuing innovative forms of partnership (Libbey and Miyahara, 2011)
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Public health agencies can devolve into information silos with limited coordination across programs (Merrill et al., 2008)
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To optimize partner contributions and model collaborative action, local and state health agencies may need to revisit their own strategic position within the broader health system and restructure governmental activities and service offerings accordingly. Interview respondents raised concerns regarding the ability of state and local health agencies to significantly reorient their operational activities in order to support strategic goals.
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States have established a variety of approaches to organizing public health activities and distributing operational responsibilities among state agencies, local health departments, and health system partners (Mays et al., 2010)
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. Interview respondents noted several underdeveloped capacities that may hinder state and local health agencies' ability inform the broad range of legislative, regulatory, and administrative policies that affect community health, including deficits in the capacity to • i dentify policy change opportunities in nonhealth sectors, • a nticipate the information needs of policymakers,
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efforts are viewed as key ingredients for improving community health, demonstrating accountability, and securing policy makers' support for the governmental infrastructure. Although most state and local public health agencies engage in some type of performance monitoring and quality improvement, the nature and scope of these activities appear to vary substantially (Beitsch et al., 2010; Madamala et al., 2010)
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. Funding limitations have perhaps been the dominant factor hindering growth of PHSSR, but interview respondents also noted the need to promote academic partnerships in order to more actively engage public health agencies in practice-based research.
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Public health messages must compete for attention in this crowded, highly stylized, and sophisticated information landscape. Many public health practitioners have recognized the magnitude of this challenge and are increasingly using social marketing techniques to educate the public about health risks and promote healthy behaviors (Grier and Bryant, 2005)
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Although respondents generally concurred that capacity for paid media communications is underdeveloped in state and local public health agencies, some expressed skepticism that political support for capacity development in this area could be mustered. Improved Ability to Customize Health Messages to Specific Target Audiences Despite funding limitations, public health agencies are increasingly using mass media to promote healthy behaviors, sometimes in partnership
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However, interview respondents expressed some differences of opinion regarding the extent to which categorical funding has limited investments in the capacity-development priorities described in the preceding section of this paper. Respondents generally agreed that categorical funding discourages coordination across programs; fosters a fragmented, inefficient deployment of public health resources; perpetuates a narrow view of the role of public health agencies; and hinders adaptation to changing population health needs and scientific advancements.
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Department of Agriculture (USDA) to state and local health agencies for information system development related to the WIC program was frequently cited as particularly restrictive.
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Explicit restrictions may be incorporated into formal grant guidance or contractual agreements, but less formal program management practices may also constrain the use of program funds. For example, contentious negotiations surrounding the establishment of agreements and contracts, as well as a difficult history of expenditure disallowances after a grant has been awarded, may dissuade public health agencies from investing categorical funds in cross-cutting capacities that could benefit other program areas.
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However, few clear patterns emerged regarding the financing strategies most commonly pursued or the relative importance of each type of funding source. The lack of a clear typology for these financing strategies likely reflects the diverse fiscal policies that characterize public health finance across the nation, differences in the nature and level of the development investments described by interview respondents, and, to some degree, limitations in the qualitative methods used to gather information for this paper.
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Flexible Funds from Local Government Funds provided to local health departments by local governments were frequently cited as an important source of flexible dollars that can be invested in mission-critical capacities. Relative to state and federal funding sources, local health officials appear to have more discretion over the use of local funds and may be able to use this flexibility to address priority capacity-development needs.
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. More specific data on per capita spending of local funds by local health departments have not been reported publicly.
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Respondents with current or prior experience working in local health agencies generally acknowledged the broad systemic benefits of investments in state health agency capacity, but they often focused their remarks on the usefulness of direct financial support from state government. Several respondents indicated that state funding had been used to build local capacity in mission-critical areas, using both categorical and noncategorical funds.
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From page 188... ...
Respondents cautioned, however, that that noncategorical support provided to local health departments by state government has been significantly reduced in recent years due to both the fiscal pressures facing states and increased adoption of performance-based budgeting. These anecdotal reports are difficult to document nationally given limited information regarding state investments in local health agencies specifically and in public health more broadly.
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Numerous issues surrounding state financing for public health are not well documented, including • t he level of resources invested by states in the public health infrastructure, • t he proportion of state investments distributed respectively to local health departments, state agencies, and private-sector organizations, • t he nature of the mechanisms used to distribute these funds, • t he source of revenue used to fund these investments, and • t he financing mechanisms used to generate these revenues. Preliminary data from the ASTHO 2010 Profile indicates that in 2009 state health agencies' total expenditures averaged $98 per capita in 2009, and approximately 40 percent of total agency revenues were derived from state general funds or other state-financed funds15 (Sellers, 2011)
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However, the interviews did yield some interesting observations that may be valuable in identifying issues for future study. Some agencies have benefited from federal grants and cooperative agreements specifically focused on capacity development in the mission-critical areas identified, such as CDC's Assessment Initiative and more recently the National Public Health Improvement Initiative.
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Respondents also expressed concerns that federal categorical programs largely target funds at the state level, and because of the modest size of these awards, limited amounts of federal categorical funding trickle down to local agencies. ASTHO reports that of the $14 billion in federal funds received by state health agencies in fiscal year 2009, approximately 60 percent was directly distributed to local and regional health departments (Sellers, 2011)
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Public health agencies' ability to influence payment rates for revenuegenerating services appears limited. Local health departments have little influence in setting reimbursement rates for Medicaid and Medicare.
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. Policy Change Proposals Based on their experiences using existing funding opportunities to finance capacity development in mission-critical areas, respondents were asked to share suggestions for policy changes that would enhance the ability of public health agencies to adopt an ecologically oriented, populationbased approach to disease prevention and health promotion that addresses the broad socioenvironmental determinants of health.
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CONCLUSION A clear consensus emerged from the respondent interviews regarding the need for improved and expanded capacity in state and local health agencies related to surveillance and epidemiology, community health improvement
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Categorical funding streams have also contributed to ossification within the governmental public health infrastructure, limiting agencies' ability to use scientific advancements and adapt to evolving population health needs. Perhaps most importantly, the dominance of these restrictive funding mechanisms has perpetuated a narrow vision for the potential role and contributions of state and local public health agencies -- implying that their mission is merely the sum of categorical parts, rather than a comprehensive, holistic strategy to prevent disease and promote health.
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2010. Achieving Population Health Through Meaningful Use: How Do Governmental Public Health Agencies View the Process to Date?
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2008. Involving local health departments in community health partnerships: Evaluation results from the Partnership for the Public's Health Initiative.
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2008. The performance of local health departments: A review of the literature.
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2011. The effects on population health status of using dedicated property taxes to fund local public health agencies.
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2006. Using local health information to promote public health.
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2005. Building geo graphic information system capacity in local health departments: Lessons from a North Carolina project.
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2004. Local public health agency capacity and its relationship to public health system performance.
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2011. Making the case for using financial indicators in local public health agencies.
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Phred Pilkington, Director Cabarrus Health Alliance (NC) Doug Scutchfield University of Kentucky School of Public Health Kathy Vincent Former Staff Assistant to the State Health Officer, Alabama Department of Public Health
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