BOX 4-1
A Fundamental Challenge to Estimating Financing
Needs: How to Define Public Health

Many organizations and researchers have attempted to determine how much money is spent on all public health activities combined and how much money public health needs to address its charge successfully. One factor that reduces the ability to interpret the estimates is the lack of common definitions. International entities (such as the Organisation for Economic Co-operation and Development [OECD] and the World Health Organization [WHO]), national entities (such as the CMS Office of the Actuary and the Centers for Disease Control and Prevention [CDC]), state entities, and local entities define public health (and its overlap with prevention) in different ways. Some include only population-based health services, others take a broader look and include personal healthcare delivered by governments in the category of public health. Other domains in which different inclusions exist are environmental monitoring by government agencies, food and drug safety, mental health, medical transportation, and emergency disaster services. The lack of consistency in the scope of public health and its role and even in which federal agencies to include within the boundaries of public health (such as the Environmental Protection Agency and the National Highway Traffic Safety Administration, which have important public health roles) add to the difficulty of providing reliable estimates.a

The NHEA is limited in its measurement of U.S. spending on public health because there is no universally accepted definition of what constitutes public health activity and no uniformity in existing public health classifications (Honoré, 2011; Sensenig, 2007). For example, Honoré (2011) noted that different states classified tobacco control activities under primary care, under “enhanced public health services,” and under “health promotion.”

Public health data in NHEA include epidemiologic surveillance, immunization

the cost of a defined “package” of public health services for every state and locality requires both an agreement on what the package is and a better understanding of how the governmental public health infrastructure will shape itself to deliver the package. Some of those difficulties were described by the committee that authored the 2003 Institute of Medicine report The Future of the Public’s Health in the 21st Century.

Efforts are being made to address these difficulties. The National Association of County and City Health Officials (NACCHO) and the Association of State and Territorial Health Officials (ASTHO) produce periodic reports that include financial information from local and state public health departments, and a continuous data harmonization activity could improve the quality and standardization of the survey data collected (Jones, 2011). In addition, an expanding public health systems and services research agenda and endeavor is under way. However, more effort is needed to facilitate stan-

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