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The Future of the Public’s Health in the 21st Century C Recommendations from The Future of Public Health* Objective: To provide a set of directions for public health that can attract the support of the total society, the committee made three basic recommendations dealing with: The mission of public health The governmental role in fulfilling the mission The responsibilities unique to each level of government THE PUBLIC HEALTH MISSION, GOVERNMENTAL ROLE, AND LEVELS OF RESPONSIBILITY Mission The committee defines the mission of public health as fulfilling society’s interest in assuring conditions in which people can be healthy. The Governmental Role in Public Health The committee finds that the core functions of public health agencies at all levels of government are assessment, policy development, and assurance. * Institute of Medicine. 1988. The Future of Public Health. Washington, DC: National Academy Press.
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The Future of the Public’s Health in the 21st Century Assessment The committee recommends that every public health agency regularly and systematically collect, assemble, analyze, and make available information on the health of the community, including statistics on health status, community health needs, and epidemiologic and other studies of health problems. Policy Development The committee recommends that every public health agency exercise its responsibility to serve the public interest in the development of comprehensive public health policies by promoting use of the scientific knowledge base in decision making about public health and by leading in developing public health policy. Agencies must take a strategic approach, developed on the basis of a positive appreciation for the democratic political process. Assurance The committee recommends that public health agencies assure their constituents that services necessary to achieve agreed upon goals are provided, either by encouraging action or by other entities (private or public sector), by requiring such action through regulation, or by providing services directly. The committee recommends that each public health agency involve key policymakers and the general public in determining a set of high-priority personal and communitywide health services that governments will guarantee to every member of the community. This guarantee should include subsidization or direct provision of high-priority personal health services for those unable to afford them. Levels of Responsiblity States The committee believes that the states are and must be the central force in public health, They bear primary public sector responsibility for health. The committee recommends that the public health duties of states should include the following: Assessment of health needs within the state based on statewide data collection;
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The Future of the Public’s Health in the 21st Century Assurance of an adequate statutory base for health activities in the state; Establishment of statewide health objectives, delegating power to localities as appropriate and holding them accountable; Assurance of appropriate organized statewide effort to develop and maintain requisite personal, educational, and environmental health services; provision of access to necessary services; and solution of problems inimical to health; Guarantee of a minimum set of essential health services; and Support of local service capacity, especially when disparities in local ability to raise revenue and/or administer programs require subsidies, technical assistance, or direct action by the state to achieve adequate service levels. Federal The committee recommends the following as federal public health obligations: Support of knowledge development and dissemination through data gathering, research, and information exchange; Establishment of nationwide health objectives and priorities, and stimulation of debate on interstate and national public health issues; Provision of technical assistance to help states and localities determine their objectives and to carry out action on national and regional objectives; Provision of funds to states to strengthen state capacity for services, especially to achieve an adequate minimum capacity, and to achieve national objectives; and Assurance of actions and services that are in the public interest of the entire nation such as control of AIDS and similar communicable diseases, interstate environmental actions, and food and drug inspections. Localities The committee recommends the following functions for local public health units: Assessment, monitoring, and surveillance of local health problems and needs and of resources for dealing with them; Policy development and leadership that foster local involvement and a sense of ownership, that emphasize local needs, and that advocate
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The Future of the Public’s Health in the 21st Century equitable distribution of public resources and complimentary private activities commensurate with community needs; and Assurance that high-quality services, including personal health services, needed for the protection of public health in the community are available and accessible to all persons; that the community receives proper consideration in the allocation of federal and state as well as local resources for public health; and that the community is informed about how to obtain public health, including personal health, services, or how to comply with public health requirements. FULFILLING THE GOVERNMENT ROLE: IMPLEMENTING RECOMMENDATIONS Statutory Base The committee recommends that states review their public health statutes and make the revisions necessary to accomplish the following two objectives: Clearly delineate the basic authority and responsibility entrusted to public health agencies, boards, and officials at the state and local levels and the relationships between them; and Support a set of modern disease control measures that address contemporary health problems such as AIDS, cancer, and heart disease, and incorporate due process safeguards (notice, hearings, administrative review, right to counsel, standards of evidence). Structural/Organizational Steps States The committee recommends that each state have a department of health that groups all primarily health-related functions under professional direction—separate from income maintenance. Responsibilities of this department should include disease prevention and health promotion, Medicaid and other indigent health care activities, mental health and substance abuse, environmental responsibilities that clearly require health expertise, and health planning and regulation of health facilities and professions. The committee recommends that each state have a state health council that reports regularly on the health of the state’s residents, makes health policy recommendations to the governor and legislative [branch], promulgates public health regulations, reviews the work of the state health department, and recommends candidates for director of the department.
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The Future of the Public’s Health in the 21st Century The committee recommends that the director of the department of health be a cabinet (or equivalent-level) officer. Ideally, the director should have doctoral-level education as a physician or in another health profession, as well as education in public health itself and extensive public-sector administrative experience. Provisions for tenure in office, such as a specific term of appointment, should promote needed continuity of professional leadership. The committee recommends that each state establish standards for local public health functions, specifying what minimum services must be offered, by what unit of government, and how services are to be financed. States (unless providing local services directly) should hold localities accountable for these services and for addressing statewide health objectives. Localities The committee finds that the larger the population served by a single multipurpose government, as well as the stronger the history of local control, the more realistic the delegation of responsibility becomes: for example, to a large metropolitan city, county, or service district. Two attributes of such a locally responsible system are strongly recommended: To promote clear accountability, public health responsibility should be delegated to only one unit of government in a locality. Where sparse population or scarce resources prevail, delegation to regional single-purpose units, such as multicounty health districts, may be appropriate. The committee recommends that mechanisms be instituted to promote local accountability and assure the maintenance of adequate and equitable levels of service and qualified personnel. The committee finds that the need for a clear focal point at the local level is as great as at the state level, and for the same reasons. Where the scale of government activity permits, localities should establish public health councils to report to elected officials on local health needs and on the performance of the local health agency. Federal The committee recommends that the federal government identify more clearly, in formal structure and actual practice, the specific officials and agencies with primary responsibility for carrying out the federal public health functions recommended earlier. The committee recommends the establishment of a task force to consider what structure or programmatic changes would be desirable to
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The Future of the Public’s Health in the 21st Century enhance the federal government’s ability to fulfill the public health leadership responsibilities recommended in this report. Special Linkages Environmental Health The committee recommends that state and local health agencies strengthen their capacities for identification, understanding, and control of environmental problems as health hazards. The agencies cannot simply be advocates for the health aspects of environmental issues, but must have direct operational involvement. Mental Health The committee recommends that those engaged in knowledge development and policy planning in public health and in mental health, respectively, devote a specific effort to strengthening linkages with the other field, particularly in order to identify strategies to integrate these functions at the service delivery level. The committee recommends that a study of the public health/mental health interface be done in order to document how the lack of linkages with public health hampers the mental health mission. Social Services The committee recommends that public health be separated organizationally from income maintenance, but that public health agencies maintain close working relationships with social service agencies in order to act as effective advocates for, and to cooperate with, social service agency provision of social services that have an impact on health. Care of the Indigent The committee endorses the conclusion of the President’s Commission for the Study of Ethical Problems in Medical Care and Biomedical and Behavioral Research that the ultimate responsibility for assuring equitable access to health care for all, through a combination of public- and private-sector action, rests with the federal government. The committee finds that, until adequate federal action is forthcoming, public health agencies must continue to serve, with quality and respect and to the best of their ability, the priority personal health care needs of uninsured, underinsured, and Medicaid clients.
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The Future of the Public’s Health in the 21st Century Strategies for Capacity Building Technical The uniform national data set should be established that will permit valid comparison of local and state health data with those of the nation and of other states and localities and that will facilitate progress toward national health objectives and implementation. There should be an institutional home in each state and at the federal level for development and dissemination of knowledge, including research and the provision of technical assistance to lower levels of government and to the academic institution and voluntary organizations. Research should be conducted at the federal, state, and local levels into population-based health problems, including biological, environmental, and behavioral issues. In addition to conducting research directly, the federal government should support research by states, localities, universities, and the private sector. Political Public health agency leaders should develop relationships with and educate legislators and other public officials on community health needs, on public health issues, and the rationale for strategies advocated and pursued by the health department. These relationships should be cultivated on an ongoing basis rather than being neglected until a crisis develops. Agencies should strengthen the competence of agency personnel in community relations and citizen participation techniques and develop procedures to build citizen participation into program implementation. Agencies should develop and cultivate relationships with physicians and other private-sector representatives. Physicians and other health professionals are important instruments of public health by virtue of such activities as counseling patients on health promotion and providing immunizations. They are important determinants of public attitudes and of the image of the public health. Public health leaders should take the initiative to seek working relationships and support among local, state, and national medical and other professional societies and academic medical centers. Agencies should seek stronger relationships and common cause with other professional and citizen groups pursuing interests with health implications, including voluntary health organizations, groups concerned with improving social services or environment, and groups concerned with economic development. Agencies should undertake education of the public on community health needs and public health policy issues.
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The Future of the Public’s Health in the 21st Century Agencies should review the quality of “street-level” contacts between department employees and clients and where necessary conduct in-service training to ensure that members of the public are treated with cordiality and respect. Managerial Greater emphasis in public health curricula should be placed on managerial and leadership skills, such as the ability to communicate important agency values to employees and enlist their commitment; to sense and deal with important changes in the environment; to plan, mobilize, and use resources effectively; and to relate the operation of the agency to its larger community role. Demonstrated management competence as well as technical/professional skills should be a requirement for upper-level management posts. Salaries and benefits should be improved for health department managers, especially health officers, and systems should be instituted so that they can carry retirement benefits with them when they move among different levels of jurisdictions of government. Programmatic The committee recommends that public health professionals place more emphasis on factors that influence health-related behavior and develop comprehensive strategies that take these factors into account. Fiscal The committee recommends the following policies with respect to intergovernmental strategies for strengthening the fiscal base of public health: Federal support of state-level health programs should help balance disparities in revenue-generating capacities and encourage state attention to national health objectives. Particular vehicles for such support should include “core” funding with appropriate accountability mechanisms, as well as funds targeted for specific uses. State support of local-level health services should balance local revenue-generating disparity, establish local capacity to provide minimum levels of service, and encourage local attention to state health objectives; support should include “core” funding. State funds could be furnished with strings attached and sanctions available for noncompliance, and/or general support could be provided with appropriate accountability requirements
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The Future of the Public’s Health in the 21st Century built in. States have the obligation in either case to monitor local use of state funds. Education for Public Health Schools of public health should establish firm practice links with state and/or local public health agencies so that significantly more faculty members may undertake professional responsibilities in these agencies, conduct research there, and train students in such practice situations. Recruitment of faculty and admission of students should give appropriate weight to prior public health experience as well as to academic qualifications. Schools of public health should fulfill their potential role as significant resources to government at all levels in the development of public health policy. Schools of public health should provide students an opportunity to learn the entire scope of public health practice, including environmental, educational, and personal health approaches to the solution of public health problems; the basic epidemiological and biostatistical techniques for analysis of those problems; and the political and management skills needed for leadership in public health. Research in schools of public health should range from basic research in fields related to public health, through applied research and development, to program evaluation and implementation research. Schools of public health should take maximum advantage of training resources in their universities, for example, faculty and courses in schools of business administration, and departments of physical, biological, and social sciences. Schools of public health should extend their expertise to advise and assist with the health content of the educational programs of other schools and departments of the university. Schools of public health should undertake an expanded program of short courses to help upgrade the competence of these personnel. In addition, short course offering should provide opportunities for previously trained public health professionals, especially health officers, to keep up with advances in knowledge and practice. Schools of public health should encourage and assist other institutions to prepare appropriate, qualified public health personnel for positions in the field. When educational institutions other than schools of public health undertake to train personnel for work in the field, careful attention to the scope and capacity of the educational program is essential. Schools of public health should strengthen their response to the needs for qualified personnel for important, but often neglected aspects of public health such as the health of minority groups and international health.
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The Future of the Public’s Health in the 21st Century Schools of public health should help develop, or offer directly in their own universities, effective courses that expose undergraduates to concepts, history, current context, and techniques of public health to assist in the recruitment of able future leaders into the field. Education programs for public health professionals should be informed by comprehensive and current data on public health personnel and their employment opportunities and needs.
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