menting current and future realizations of the BioWatch monitoring system; and (2) research into the costs of “the current and a potential ‘enhanced national surveillance system’ to provide a basis for a rapid response to bioterrorist attacks or other biothreats, including initiation of pre-infection prophylaxis and expedited response and recovery.”1 This memo focuses on IEc’s efforts to acquire and analyze cost data on the public health system both as it currently exists and for cutting-edge programs aimed at improving surveillance and response capabilities. Note that this memorandum is not intended to provide information about the merits of the current or “enhanced” public health system or provide a snapshot of current public health surveillance capabilities nationwide. Furthermore, for the reasons detailed below, IEc and the committee have concluded that the available data do not support a comprehensive cost analysis of either current or enhanced public health activities related to biosurveillance and outbreak response. Thus, this memo does not present such an analysis; instead, it describes the major challenges to performing a cost analysis of public health programs, describes IEc’s effort to obtain cost data for example programs operating at the state or local level that match key biosurveillance and response activities identified by the committee, and discusses IEc’s observations regarding the limited data set we were able to obtain.

We include example costs for specific state and local programs in Table C-2.

OBSTACLES TO COST ANALYSIS

Significant obstacles preclude our ability to generate a comprehensive cost estimate for the current or an enhanced U.S. public health system’s biosurveillance and response efforts. The primary problem is a general lack of financial transparency and accountability across the U.S. public health system. A number of papers and reports have documented this issue (e.g., Hebert et al., 2007; Honoré et al., 2007; TFAH, 2008). In part, this lack of transparency reflects differences in the organization of the public health system from state to state, where some have a more centralized system of public health responsibilities and others spread those responsibilities across multiple agencies. More importantly, there is no uniformly recognized classification system for expenditures on public health, leading to confusion about what constitutes public health spending. The report from the Trust for America’s Health (TFAH, 2008) presents examples of inconsistencies in cost accounting for specific public health initiatives both across states and

1

“Statement of Task” provided to the committee by the Institute of Medicine and the National Research Council.



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