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The Future of the Public’s Health in the 21st Century
are questions involving the proper definition of a “community” for this purpose and the appropriate response if a community has too small an economic base to sustain a formal public health agency with the necessary presence and capacity to provide public health protections.
The most robust approach to assessing need seems to be the use of a functional analysis based on the ability to provide the essential public health services, as recommended above. The committee recognizes the potential value of a recommendation regarding the development of a formula to determine the “critical mass” of services and population (e.g., a ratio of one of each of the critical professions per 50,000 or 100,000 population), the geographic accessibility of services, and the workforce capacity necessary for the effective development of local public health agencies to serve small or remote communities. Before such a recommendation can be made, however, solid, practice-oriented research must be conducted to provide the evidence on which to base a formula or other criteria.
The committee had hoped to be able to provide specific guidance to assist the nation in its efforts to rebuild and finance its public health infrastructure. However, a comprehensive search of the published literature and extensive information gathering yielded very little firm, generalizable evidence on which to structure public health practice recommendations like those noted. To remedy this situation, the committee recommends that CDC, in collaboration with the Council on Linkages between Academia and Public Health Practice and other public health system partners, develop a research agenda and estimate the funding needed to build the evidence base that will guide policy making for public health practice.
Strengthening the Management Capacity of DHHS
From 1993 to 1997, DHHS, like all federal government departments, conducted a reinvention exercise to determine what work it should do and how it could do that work more effectively and responsively. A recent monograph on DHHS and the impact of departmental reinvention efforts in the late 1990s identified two issues of particular significance: (1) the effect of the balance between centralization and decentralization on the management of departmental activities and (2) the relationship of the department with other agencies (Boufford and Lee, 2001).
Centralization versus Decentralization: Models for Managing DHHS
The committee’s discussion of key federal functions—policy making, financing, infrastructure development, and the like—illustrate how the problems of fragmentation in federal public health activities affect the functioning of state and local public agencies. Such problems are related to histori-