disease control, community assessment, community outreach and education, environmental health services, epidemiology and surveillance, food safety, health education, restaurant inspections, and tuberculosis testing. Services provided by a smaller percentage of local public health agencies included treatment for chronic disease, behavioral and mental health services, programs for the homeless, substance abuse services, and veterinary public health (NACCHO, 2001d).

One widespread change in the scope of local public health agency activities is a reduction in the direct delivery of health care services, especially to Medicaid participants. This is consistent with a national effort to have governmental public health agencies return their attention to the more population-based public health services that had been weakened by the pressing need to provide safety-net services to uninsured individuals. Although some have been unable to do so, many state and local public health agencies now have contracts with managed care organizations and other private providers to serve those populations. A substantial transfer of service delivery from health departments to private providers has also occurred for childhood immunizations under federal and state programs for the purchase and distribution of vaccines (IOM, 2000a). Some researchers have found the partnership between managed care and local public health agencies to be positively associated with the overall scope and perceived effectiveness of local public health activities in terms of their ability to meet population-based community needs (Mays et al., 2001). (See Chapter 5 for additional discussion of the role of health care services providers in the public health system.) However, some local public health agencies have found it difficult to compensate for the loss of revenue that had previously come from the delivery of health care services that have now been transferred to managed care organizations (Wall, 1998; Keane et al., 2001).

THE FEDERAL PUBLIC HEALTH INFRASTRUCTURE

In contrast to state and local public health agencies, the federal government has a limited role in the direct delivery of essential public health services. Nevertheless, it plays a crucial role in protecting and improving the health of the population by providing leadership in setting health goals, policies, and standards, especially through its regulatory powers. It also contributes operational and financial resources: to assure financing of health care for vulnerable populations through Medicare, Medicaid, Community and Migrant Health Centers, and IHS programs; to finance research and higher education; and to support development of the scientific and technological tools needed to improve the effectiveness of the public health infrastructure at all levels.



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