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3
Informing Investment in Health
Public health leaders have sufficient information to take action in im-
portant sectors of population health. However, the public health system
at all levels of government requires better information about the level of
resources expended and how they are being used, what system character-
istics are most closely linked with achieving desired outcomes, and what
methods are most effective and efficient in improving population health. In
this chapter, the committee first discusses the administrative changes needed
to support the uniform collection and reporting of public health financial
information (revenues and expenditures). Better information will help gov-
ernment officials to make evidence-based management decisions to generate
and allocate resources for public health activities that maximize population
health gains and minimize the costs of treating preventable diseases and
injuries. And improved information will allow leaders of public health agen-
cies to make better management decisions about organizing, staffing, and
implementing public health activities that maximize the efficiency, reach,
and effects of their operations. Research is also needed to generate objec-
tive information about the costs and outcomes of public health activities—
information that would facilitate assessments of the comparative effective-
ness of public health and social interventions and medical approaches, and
allow decision makers in government and the private sector to identify better
ways of allocating limited resources across the spectrum of health-related
investment (Teutsch and Fielding, 2011b).
75
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76 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE
A NEED FOR FINANCIAL ANALYSIS AND RESEARCH
As mentioned in Chapter 1 and discussed in more detail in Chapter
4, the information available about public health funding has considerable
limitations. Many governmental public health programs were established in
response to specific health threats or as results of new interventions, such as
the creation of a specific vaccine or the implementation of new smoking in-
terventions to reduce cancer deaths. The collection of public health program
activities has become what a governmental public health department does.
But in many locales, public health departments have not been allowed the
“luxury” of organizing activities into a coherent whole in which essential
capabilities exist to support all programs or in which funding from one
program is leveraged in a systematic manner to benefit other programs. The
combination of that historical circumstance in funding, a lack of national
standards in recording and reporting funding and expenditure data, and
variations in the definitions of public health challenges any attempt to obtain
accurate expenditure estimates.
Because financial information on public health is difficult to obtain at all
levels of government, there is considerable uncertainty about current invest-
ment in public health activities in the United States and about the sources of
revenue for this investment and the relative contributions of federal, state,
local, and private bodies. It is also unclear what those sources purchase in
terms of the spectrum of public health activities and infrastructure, how
resources are allocated among different geographic areas and population
groups, and, perhaps most important, how investment compares with the
outcomes of public health activities. Poor financial information systems can
breed poor performance because a lack of data and measurement makes it
more difficult to evaluate, manage, and improve (Kaplan and Porter, 2011).
Without better financial information, policymakers cannot assess the value
realized from public health spending, nor can they clearly identify the health
and economic consequences of underinvestment. Public health managers
are unable to link cost data to their organizational structures, staffing pat-
terns, and service delivery models. This limits their ability to enhance the
productivity and efficiency of their operations. Because of a lack of adequate
financial information, effective and efficient public health departments go
unrewarded, and inefficient agencies face few incentives to improve (Honoré
and Costich, 2009; Honoré et al., 2007).
In the United States, the Centers for Medicare and Medicaid Services
Office of the Actuary develops the annual National Health Expenditure
Accounts (NHEA) on the basis of data from federal and state governments
and international standards. Some limitations of the NHEA, including
definitional and methodological issues (Sensenig, 2011), are discussed in
Chapter 4. Ballinger (2007) and Sensenig (2007, 2011) have shown that
NHEA in Canada and the United States, respectively, do not usefully re-
flect the level of spending on public health, because there are no uniform,
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INFORMING INVESTMENT IN HEALTH
universally accepted definitions of public health activity across levels of
government (or internationally). The Association of State and Territorial
Health Officials (ASTHO) and the National Association of County and City
Health Officials (NACCHO) attempt to bridge that gap by conducting peri-
odic surveys and other kinds of data collection to measure and understand
public health department revenues and expenditures at the state and local
levels, respectively (see, for example, ASTHO and NACCHO 2011 profiles
of state and local public health departments). The value of the data on state
and local governmental public health revenues is greatly limited by the lack
of a uniform chart of accounts used among health departments, which
makes it impossible for health department personnel around the United
States to report data on expenditures consistently (Gans et al., 2007). In
addition, the variation in scope of work among public health agencies and
the fragmented and idiosyncratic1 nature of public health funding make it
infeasible for the national associations to collect granular data on program-
specific revenues and expenditures. Although knowing the level of funding
by funding sources is a key to understanding the outcomes of investments
in governmental public health programs, NACCHO found that “collecting
these data nationally seems unrealistic given the difficulty of some [local
health departments] in providing accurate data even on total revenues and
expenditures” (NACCHO, 2011, p. 91).
Charts of Accounts
Honoré and colleagues observed that “[p]ublic health lacks an opera-
tional framework for basic levels of financial analysis and research” (2007,
p. 121). The key element of such a framework is a standardized chart of
accounts to enable public health to gather uniform data and conduct com-
parisons between jurisdictions. Charts of accounts are accounting records
that organizations—including nonprofit organizations, health care entities,
and universities—use to track expenditures and revenue (Honoré et al.,
2007; see also University of Minnesota, 2010; Urban Institute National
Center for Charitable Statistics, 2009). Charts of accounts generally match
the financial structure of an organization and use categories or classifications
for each type of expenditure. The information on a chart of accounts gives
an organization an overview of financial activities and can be used for such
purposes as fund accounting, reporting or demonstrating accountability to
funders and stakeholders, development of financial reports, management,
comparative analysis, and benchmarking. The lack of a uniform chart of
accounts is a crucial gap for public health services research, in which a clear
1One reason for this is that there has never been a consistent federal funding stream for
public health infrastructure as there has been for hospital infrastructure (the Hill–Burton Act
of 1946 aimed to strengthen the nation’s hospitals and to reach a specific ratio of hospital
beds per population) and for the National Institutes of Health biomedical research enterprise.
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78 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE
understanding of the effectiveness and efficiency of investment in programs,
personnel, and interventions is a necessity. The adoption of a uniform chart
of accounts would enable public health departments at all levels to better
ensure accountability for resources and outcomes. Accountability would
be facilitated through uniform reporting of revenue and expenditures, and
ultimately through establishing how financial inputs and outputs are associ-
ated with long-term outcomes.
The financial accounting systems used by public health agencies are
highly idiosyncratic, varying from one jurisdiction to another, and they
are generally fashioned on a local or state government’s template rather than
being customized to meet the needs of public health departments.2 They are
designed for budget management and fund accounting rather than for over-
all financial and program management, that is, understanding the linkages
between resources, processes, outputs, and outcomes (see Figure 3-1, a logic
model first introduced in the committee’s report For the Public’s Health: The
Role of Measurement in Action and Accountability and outlining the steps
to population health improvement from inputs to outcomes3). Thus, there
2Several states have undertaken efforts to develop charts of accounts. Florida has a compre-
hensive public health dataset and has begun to develop a chart of accounts (Honoré, 2011).
It has begun to tackle the difficult issues of definitions (What is core public health? What are
clinical care services “alone”?) and has developed a financial information reporting system.
The system can be used to compare staffing, workload, population, budget, and full-time
employees and can provide revenues and expenditures by program. It can measure revenue
per capita, expenditure per capita, and the ratio of revenue to expenditures. This program is
still in its testing phase but aims to be used at the state and local levels (Dillion, 2010). Ac-
cording to a state health official, objectives include enabling comparisons among jurisdictions
and informing “sound business decisions relative to public health.” Georgia has also begun to
develop local charts of accounts for its local governments that include some aspects of public
health (categories include maternal and child health services, adult health services, health
centers, and general clinics). However, each jurisdiction can adapt the template to its needs,
and it is not a comprehensive uniform chart of accounts for public health. Other states have
begun comprehensive cost analyses as part of a broader process of thinking about revenues,
expenditures, and outcomes (Honoré, 2011).
3In its first report on population health measurement, “the committee adapted a simple
structure–process–outcome logic model (Donabedian, 1988) to illustrate both the sequence
of steps between inputs and outputs in population health and the multiple categories for
measurement” (IOM, 2011, pp. 50-51). The figure was originally provided to help in thinking
about the types of data and indicators available and needed at each step in the process. The
figure ranges from resources and capabilities to intermediate outcomes and indicators and
distal outcomes. The “determinants of health” box in the figure “is intended to refer largely
to determinants that can be modified by the actions of various agencies and organizations in
the health system” (IOM, 2011, p. 51). “Arrows between the determinants of health and many
of the boxes represent the feedback loops between determinants and system inputs or outputs.
For example, broader societal values and priorities influence the availability of resources for
population health activities. Population health interventions, such as policy changes, are often
designed to influence particular determinants of health. After evaluation and research to assess
the effectiveness of an intervention on a given determinant, the intervention may be modified
or replaced” (IOM, 2011, p. 51).
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INFORMING INVESTMENT IN HEALTH
In the context of the social and environmental determinants of health
Processes,
Processes/
Needs Intermediate Health
Planning and interventions,
interventions/
Resources Capacities
assessment outcomes
outcomes
priority setting policies
Across different geographic levels and including public health
agencies and stakeholders, and with attention to
equity and disparities among population groups
FIGURE 3-1 Logic model: from inputs to outputs and outcomes.
SOURCE: IOM, 2011.
Figure 3-1 from old pub, with modifications
is a dearth of comprehensive and consistent financial data on the nation’s
health departments. A standard chart of accounts would ensure that expen-
ditures were recorded consistently among jurisdictions and would support
management, permit comparisons between jurisdictions, and allow more ac-
curate estimates of public health spending by states, regions, and the nation.
A uniform chart of accounts would also provide a reliable basis for studying
how variability in use of resources leads to differences in processes and in-
terventions and how they lead to differences in outputs. It would help local
health departments to make more informed decisions on allocating their
resources. The minimum package of public health services introduced in
Chapter 2 to ensure a standard level of capacity in all jurisdictions could also
serve as a framework for developing a chart of accounts, that is, preparing
sets of accounts for each domain of foundational capabilities and each basic
program. Steps toward creating a unified chart of accounts would include
• S
tudying the accounting structures now in place.
• B
uilding a model chart of accounts.
• C
omparing the model with existing accounting practices used by
local and state agencies.
• E
xamining how well accounting structures accommodate funding
flows.
Once it were developed and endorsed, the Department of Health and Hu-
man Services (HHS) could require use of a chart of accounts for reporting
as a condition of receipt of federal funds, as is the case with the Medicare
Cost Report that all health care providers must submit.4
4See, for example, Hospital Cost Report (CMS, 2012).
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80 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE
The characteristics of a useful chart of accounts include
• A
mutually exclusive set of expense accounts to ensure that pro-
gram expenses are not double-counted.
• A
uniform record that captures all work activity that creates
expenses.
• S
ufficient detail to link resources to specific processes that affect
intermediate and final outcomes.
• T
he management information needed to enable improvement of
performance of public health systems on a local, statewide, and
national basis.
A chart of accounts also needs to support management accounting of a
specified set of items, beginning with the minimum package of services
consisting of foundational capability domains and required programs; fund
accounting; and financial reporting. And a process will be needed to ensure
that the public health chart of accounts is not static but evolves to suit the
financial reporting and management needs of the field.
Uniform charts of accounts have been used successfully in other sectors,
including medical care and education. Examples in the medical care sector
include those used by the Healthcare Financial Management Association
(HFMA) and charts of accounts for hospitals (Nowicki and Berger, 2006). In
the education sector, the National Center for Education Statistics Common
Core of Data surveys administered to school districts and schools leads to
the publication of an annual report on school revenues and expenditures.
Financial reporting standards and frameworks also guide colleges and uni-
versities (Honoré et al., 2007).
Charts of accounts are linked with what Honoré and colleagues describe
as “exemplary practices” used in the clinical care and educational sectors
(2007). These practices include (1) uniform classifications for expenses and
revenues, (2) infrastructures for electronic data reporting, (3) standardized
system-wide financial analysis practices, (4) extensive reporting of financial
results, and (5) professional associations for the accounting workforce.
Implementation of these practices in some fields has been driven by private
sector market forces that demand accountability, whereas in other fields it
has evolved as a result of statutory mandates and stakeholder demands for
information (Honoré et al., 2007, p. 125).
Over the last several years, NACCHO and the University of Southern
Mississippi have partnered to develop a Web-based Public Health Uniform
Data System for local health departments (a project funded by the Robert
Wood Johnson Foundation). The system, projected to be available in 2012,
is expected to have the capacity to collect data and provide immediate
feedback to health departments on financial and operational performance,
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INFORMING INVESTMENT IN HEALTH
benchmarking, program sustainability, and other measures. Its purpose is to
make available a uniform set of account definitions to promote the collec-
tion and analysis of valid, reliable, and uniform public health data. It will
be the closest thing yet to a uniform chart of public health accounts.5 The
committee views the HHS and NACCHO effort as a step in the right direc-
tion. However, the committee notes that the type of classification described
in the draft template appears to be based on the array of expense categories
that are typically seen in health departments and does not appear to create
mutually exclusive expense accounts as typical charts of accounts do. Ad-
ditional work is needed to develop charts of accounts that fully meet the
needs of public health departments.
Adopting a uniform chart of accounts in all public health departments
will not be easy or rapid. An ideal chart of accounts would assign expen-
diture codes to a hierarchic cascade of activities that begins with the broad
functions and the minimum package of public health services. Each broad
category would divide into more granular categories, which would even-
tually lead to codes that describe discrete tasks associated with the broad
category.
Several barriers potentially stand in the way of adoption of a uniform
chart of accounts. For example, the committee acknowledges that it will be
difficult to assign a uniform accounting code structure that all health depart-
ments would be required to adopt. However, if agreement can be reached
on the highest levels of accounting aggregation, health departments could
reshape their existing charts of accounts to align with the highest levels of
definitions. In time, health departments could progressively refine their sub-
codes to comport with the national model chart of accounts. In the interval
before an agency reaches complete compliance with the model chart of ac-
counts, it could submit data to a nationally operated information utility that
would translate local codes into nationally compliant codes. For example, a
purpose of health information exchange organizations is to take health care
encounter data encoded in a hospital or provider office idiosyncratically and
translate them to nationally standardized codes that can be interpreted and
used by other health care organizations. A similar translation process could
serve as a transitional step for public health accounting data and lead to the
development of a structure to which each public health department would
“map,” for example, its way of coding. The cost of adoption of a chart of
accounts is another barrier. It includes investment needed to familiarize
health department personnel with new systems and the cost of implementing
a new infrastructure, which could be substantial.
As an example of how sets of accounts are developed, all immunization-
5Personal Communication, Peggy Honoré, December 1, 2011. For more information, see
http://publichealthfinance.org/research-and-analysis/2292.
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82 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE
related activities would be grouped in a set of immunization accounts. The
generic “immunization” can be separated into codes for “routine vaccine
clinic administration,” “routine vaccine supply management,” “emergency
mass immunization clinic,” and so on. During an influenza pandemic or oth-
er emergency mass immunization event, the codes for those activities would
be linked to the “emergency preparedness” set of accounts. Staff conduct-
ing immunization activities would recognize the work as vaccination clinic
work, and administrators may also need to define it as a component of a
specific emergency response. A thorough chart of accounts would categorize
program expenses to show actual expenditures involved in doing the work
and offer the flexibility of associating expenses to lines of revenue (such
as insurance or Medicaid reimbursement for vaccinations administered or
funding from Section 317 of the Public Health Services Act, which provides
support for vaccines and vaccination infrastructure). Once standard defini-
tions and a uniform chart of accounts have been adopted, it will be pos-
sible to capture reliable specific data on public health spending patterns in
existing federal surveys, such as the U.S. Census Bureau’s periodic Census
of Governments, which is the primary source of data used in NHEA. That
survey currently asks state and local governments to report their public
health expenditures in one large lump-sum category that is poorly defined.
The Census Bureau could ask governments for much more detailed report-
ing on public health expenditures if it were assured that governments would
provide this information in a consistent format. Table 3-1 shows a sample
portion of a hypothetical and highly simplified chart of accounts.
Recommendation 5: The committee recommends that a technical
expert panel be established through collaboration among govern-
ment agencies and organizations6 that have pertinent expertise to
develop a model chart of accounts for use by public health agencies
at all levels to enable better tracking of funding related to program-
matic outputs and outcomes across agencies.
The adoption of a uniform chart of accounts could be made a Public Health
Accreditation Board (PHAB) requirement in addition to being made a pre-
requisite for federal and state funding. The process of developing a chart of
accounts needs to take place with consideration of the broader management
needs of public health departments and the more difficult work of measuring
and accounting for nonclinical services.
6Agencies
and organizations would include HHS, public health departments, ASTHO, NAC-
CHO, PHAB, and the National Association of State Budget Officers.
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INFORMING INVESTMENT IN HEALTH
TABLE 3-1 Excerpt of a Hypothetical, Highly Simplified Public Health
Chart of Accounts
Account
Category Account
(Programs) Code Account Title Definition/Linked to
Immunization All funds spent on
immunizations
3000 Routine vaccine clinic
administration
3010 Routine vaccine supply
management
3020 Emergency mass immunization Linked to preparedness
clinic category
3030 Communication on immunization
Environmental
Health
6000 Healthy Homes and Lead Hazard Linked to prevention
Prevention Program programs category
6000.1 Public service announcements
6000.2 Staff training
6010 Compliance and enforcement, Air
6010.1 Outreach and education
6010.2 Permits
6020 Compliance and enforcement,
Water
Chronic Disease
9000 Asthma Linked to environmental
health
Obesity Linked to chronic disease
Prevention and category
Control
9010.1 Data collection, obesity (all ages) Linked to data collection
category
9010.2 Program evaluation, obesity Linked to research and
data collection categories
9010.3 Mass media campaigns and social Linked to communication
marketing
9010.4 Nutrition education and counseling Linked to general
education and counseling
continued
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84 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE
TABLE 3-1 Continued
Account
Category Account
(Programs) Code Account Title Definition/Linked to
9010.5 Physical education and counseling Linked to general
education and counseling
9010.6 Restaurant menu labeling
inspection and enforcement
9010.7 Planning
9010.8 Policy development
Asthma
9020.1 Data collection, asthma (all ages)
9020.2 Program evaluation, asthma
Account Category
(Administrative)
Workforce 1000 Total salaries
1010 Total liability days for unused
vacation
1020 Total fringe benefits
1030 Professional development
Infrastructure
2000 Utilities
2010 Computers
2010.1 Information technology support
DATA AND INFORMATION TO SUPPORT PRACTICE
This section discusses the research and evaluation needed to inform
and support evidence-based and best practices in the funding of public
health. Research, for example prevention-effectiveness and comparative-
effectiveness research, and evaluation are relevant to funding because they
inform the continuum of public health practice, including decisions about
what population-based interventions are funded, and the field’s knowledge
about what works best in public health financing, administration, and or-
ganization (PHSSR, 2012). The committee outlines below the thin evidence
base that supports many areas of public health practice, the funding imbal-
ances and the siloed nature of health research and development, and some
specific needs.
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INFORMING INVESTMENT IN HEALTH
The Evidence Base
The committee has noted before that the evidence base on the effective-
ness of health interventions is growing, but it remains particularly sparse
with respect to population-based interventions. The work of the Centers
for Disease Control and Prevention Task Force on Community Preventive
Services has led the way in establishing the effectiveness of interventions,
but there are areas where much remains to be done to show what is ef-
fective.7 Health systems research, including public health services and sys-
tems research, is an expanding field (AcademyHealth, 2012; RWJF, 2012).
However, efforts to improve population health are hampered by the many
uncertainties and evidence gaps concerning how to promote health and
prevent disease and disability on a populationwide basis.
The nation’s local, state, and federal public health agencies—with their
peers and partners in the private and public sectors—constitute a vast but
diffuse delivery system charged, to greater or smaller degrees, with imple-
menting public health and prevention strategies (Teutsch and Fielding,
2011a). But evidence on the most effective and efficient ways of organiz-
ing, financing, and deploying the strategies through the delivery system is
inadequate (Coffman, 2003/2004; IOM, 2011). Public health leaders have
few research-tested guidelines, protocols, and decision supports to inform
their choices about funding, staffing, and managing public health activi-
ties. Similarly, policy leaders have relatively little empirical guidance on the
most effective ways to exercise taxing, spending, and regulatory authorities
for the public’s health. The dearth of evidence promotes wide variation in
public health practices among communities, creating missed opportunities
for improving population health, waste and inefficiencies in resource use,
and inequities in health protection (Culyer and Lomas, 2006). The scientific
fields of prevention research and, more recently, public health services and
systems research (PHSSR) have mobilized to address those information
needs and build the evidence needed for improved decisionmaking in pub-
lic health practice. Thacker and colleagues (2005, p. 227) found that “[i]n
addition to the relatively young state of the field, there is little funding for
population-based effectiveness research in public health compared with
basic and patient-oriented clinical research. This situation might reflect the
analytic challenges of this kind of research or the absence of societal com-
mitment to invest resources in such research.” Expanded investments in the
applied fields of research are needed to produce information with which
policy officials and public health professionals can drive improvements in
7The Cochrane Collaboration, the Campbell Collaboration, and others are building the
evidence base of systematic reviews of population-based interventions (Sweet and Moynihan,
2007).
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90 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE
lation health information system, conducts some of the nation’s primary
surveys on population health, including the Health Interview Survey and
the National Health and Nutrition Examination Survey. However, the
agency’s role has been seriously limited by funding constraints, and the
committee believes that NCHS can play a broader leadership role in the
population health information system by expanding its analytic capabili-
ties, its research activities, its ability to collaborate with those who use its
data, and its ability to help to modernize and integrate the system. Doing
so would increase the usefulness of NCHS data and facilitate and guide the
“translation” of data into information and knowledge that decisionmakers
and communities can use.
Public health organizations receive inadequate research support to
address the leading causes of premature death and disease in American
communities. Considerable uncertainty remains in the policy and practice
domains about the array of public health services that every community
should offer, the level of investment required to provide those services, and
the health and economic benefits that can be expected from the investment
over various timeframes—including the potential for downstream offsets in
medical care spending. The nation’s current public health knowledge and
capabilities are inadequate to address some of the most pressing threats to
population health, such as those related to obesity and social determinants
of health. Where evidence-based strategies are lacking, the development
of new knowledge and efficacious public health strategies is imperative. It
takes a strong research infrastructure to produce the evidence needed for
optimizing the nation’s portfolio of investment in public health and the na-
tion’s health expenditures on health in general, but, as noted by an earlier
Institute of Medicine (IOM) committee (IOM, 2003), there is still little
infrastructure and support for this type of research.
The Guide to Community Preventive Services provides evidence-based
recommendations and identifies important gaps in knowledge regarding
the effectiveness of interventions and thus contributes to a research agenda
(TFCPS et al., 2005). On the service delivery side, a research agenda for
public health services research has recently been developed (PHSSR, 2011).
More and better evidence is needed to inform policy and managerial deci-
sions about resource allocation in public health and to ensure accountability
for current and future investment in the public health system.
Types of Research Needed
The discovery of new and better prevention strategies and delivery
system approaches requires a continuum of research activities, including
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INFORMING INVESTMENT IN HEALTH
• escriptive research to understand the distribution of population
D
health measures at national, state, and community levels; to detect
variation in health measures among communities; and to detect
changes in health measures.
• pidemiologic and etiologic research to identify causal mechanisms
E
and pathways that determine population health and explain why
health varies among communities and why it changes.
• fficacy trials and effectiveness studies to identify the prevention
E
strategies (programs, policies, and interventions) that improve
population health.
• conomic studies to determine the cost, efficiency, cost effective-
E
ness, and economic impact of prevention strategies (such as those
for obesity) and thus to inform the decisions of policymakers, com-
munities, and individuals.
• issemination and implementation research to determine the best
D
ways to organize, finance, and deliver effective prevention strategies
to population groups that can benefit.
• omparative effectiveness research and priority-setting studies to
C
determine which prevention strategies work best in which commu-
nity and institutional settings and in which population groups.
In addition to those traditional scientific approaches to learning what
works, the public health field needs to seek knowledge from newly emerg-
ing avenues of inquiry, including the application of behavioral economics
principles and complex systems analysis to study how environmental, social,
and economic conditions and patterns of interaction combine to influence
population health (see Box 3-2 for an example). Research in public health
also needs to embrace “realistic” methods of inquiry that rely on cumula-
tive, rapid-cycle learning from experience and that are designed to elucidate
how complex, multicomponent public health strategies and prevention
interventions interact with different social, environmental, and institu -
tional contexts to produce community-level outcomes. The nontraditional
approaches, termed realistic evaluation by Pawlson and Tilley in the social
research literature and called the science of improvement by Berwick in
the clinical research literature, offer methods that “are not compromises
in learning how to improve; they are superior” (Berwick, 2008, p. 1183;
Pawson and Tilley, 1997).
A strong infrastructure is needed to support each part of the research
continuum described above. Specific needs include
• R
obust data collection at state and community levels.
• M
ethods for constructing meaningful indicator sets—valid, reliable,
sensitive, specific, and actionable.
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92 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE
• I
nfrastructure for accessing and linking with new and diverse
sources of data relevant to population health, including electronic
health data, place-based data sources (such as the food environment
and the physical environment), and commercial data on purchas-
ing, consumption, travel, work, and recreational behavior (also
discussed in IOM, 2011).
• R
esearch on analytic methods and a variety of techniques, includ-
ing complex system modeling, structural equation modeling, and
qualitative methods to shed light on causal mechanisms and the
effectiveness of interventions.
• T
raining and development for the public health research workforce.
According to a social scientist (Coffman, 2003/2004, p. 7), evaluation
and research can be contrasted as follows: Evaluation “determines the merit,
worth, or value of things” through a process that “identifies relevant val-
ues or standards that apply to what is being evaluated, performs empirical
investigation using techniques from the social sciences, and then integrates
conclusions with the standards into an overall evaluation or set of evalu-
ations.” Research does not seek to formulate evaluative conclusions but
rather “is restricted to empirical (rather than evaluative) research, and bases
BOX 3-2
Obesity and Information Needs
In the case of obesity, little is known about the types of population-based inter-
ventions that can stem the tide of obesity that is leading to diabetes and other
costly health conditions. As discussed in Chapter 1, complex adaptive systems
are involved in causing obesity, and action on multiple levels is needed to solve
this serious public health problem (Bar-Yam, 2006; Leischow and Milstein, 2006;
Leischow et al., 2008). There are many gaps in public health knowledge about
obesity. For example, although it is understood that obesity is in part the result
of preventable risky behavior, such as inactivity and poor nutrition, there is not
enough knowledge to guide the selection of interventions or combinations thereof.
Is adding a supermarket a key requirement? What types of school-based interven-
tions work? What about increasing the walkability of neighborhoods, and what
elements of the built environment make the most difference? What combination
of sidewalks, traffic lights, crosswalks, and bicycle and walking paths is needed?
Little is known about how to select the best metrics to show improvement or to
define what combination of individual-based and population-based interventions
would make a difference. Food–environment data are becoming available, city
planners are increasingly versed in public health, and several HHS agencies are
targeting obesity, including through the study of policy interventions, but more
research is needed, as is funding to support it.
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BOX 3-3
Examples of Where Research and Evaluation Can Help
Considerable uncertainty remains in the policy and practice communities about
the basic package of critical public health services that are needed in every com-
munity, the level of investment that is required to support the availability of the
package of services, and the health and economic benefits that can be expected
from the investment and over what timeframe, including the potential for down-
stream savings in medical care spending.
More and better evidence is needed to inform policy and managerial decisions
about resource allocation in public health and to ensure accountability for current
and future investment in the public health system. Implementing a standard chart
of accounts as recommended in this chapter is a prerequisite.
The nation’s current public health knowledge and capabilities must be strength-
ened to address some of the most pressing threats to population health, such as
those related to obesity and the effects of the social determinants of health. Where
evidence-based strategies are lacking, the discovery of new knowledge and ef-
ficacious public health strategies is imperative. A robust research infrastructure
is required to produce the evidence needed for optimizing the nation’s portfolio
of investment in public health, but, as noted in the 2003 IOM report, there is still
little infrastructure and support for this type of research. Research on public health
services and systems is still in its adolescence (Scutchfield and Ingram, 2011).
its conclusions only on factual results—that is, observed, measured, or cal-
culated data” (Coffman, 2003/2004). In the field of public health, research
has several different purposes: on a practice level,10 to demonstrate the ef-
fectiveness and comparative effectiveness of population-based interventions;
and on an administrative or management level, to inform the organization,
administration, and financing of public health department activities. At each
level, the committee has identified gaps in the knowledge available to inform
decision making. That is pertinent to a report on funding both because of
the need for research funding and because of the need for additional research
on public health administration and financing (for example, research on the
optimal size of a health department, discussed above; see also Box 3-3).
Not enough is known about how health departments can become learn-
ing organizations and acquire an adaptive systems perspective that would
enable them to function productively in the self-organizing partnerships that
10Much public health research is not practice-oriented, such as etiologic research, behavioral
science, and laboratory science; but little research is aimed at closing the gap between research
and practice, for example, research useful to those in the field who need to implement the best
intervention for a given issue (Glasgow and Emmons, 2007).
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are becoming the norm, as opposed to the traditional management setting
(Leischow et al., 2008).
Translation of Research for Decisionmaking and Action
Building the research infrastructure that the committee proposes will
allow policymakers to make informed resource allocation decisions that
are based on societal or community values and on estimated health and
economic impacts of prevention and public health strategies (including use
by the National Prevention, Health Promotion, and Public Health Coun-
cil as recommended in Chapter 2). It will help to develop evidence-based
implementation strategies, guidelines, protocols, and checklists for use by
the public health practice community. The evidence can be used to establish
and update accreditation standards and performance expectations for public
health agencies as accreditation becomes more widely adopted by public
health agencies. Finally, the information that is generated would be used
to support rapid-cycle innovation, quality improvement, and learning by
public health agency administrators.
Cycle time in learning what works in public health needs to be reduced
through research and development designed to “fail fast and often” to pro-
duce a steady stream of innovative results that do work well. Policymakers
and public health decision makers need to be able to learn what works in
public health, for what population, in what contexts, and at what cost.
Whereas “steady-state” industries devote 2-3 percent to research and de-
velopment, pharmaceutical, biotechnology and medical technology, and
software industries all spend about 15 percent of their budgets on these
endeavors (Cutler, 2011). Public health is most similar to industries that face
pressures to grow, adapt, and improve and that rely heavily on research and
development investments to generate the innovations that sustain them. Yet,
of every $100 in federal health research spending, less than $1 is devoted
to research on how to deliver (and finance) interventions, and most of that
small amount is spent on delivery system research focused on medical care
and only a minuscule portion on public health systems and services research
(Woolf, 2007, 2008).
Public health has not been able to innovate, adapt, and respond quickly
enough to contemporary health threats—particularly those associated with
chronic disease. If it maintains a steady-state approach, public health and
the larger health system will not be able to contain the rising health conse-
quences and costs of chronic disease or address the changing needs of popu-
lation health. With respect to large-scale chronic disease prevention, there
are some good ideas but not a lot of evidence on whether and how they can
be implemented effectively populationwide. Given the economic magnitude
of the population health problem (75 percent of the nation’s $2.6 trillion
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annual health care expenditures are due to chronic disease [CDC, 2011]),
it seems prudent to invest in the research and development needed to learn
how to avoid the preventable elements of that cost. For example, 15 percent
of the current NHEA estimate of total federal public health spending ($11.5
billion) would be $1.7 billion. That amount, if devoted to public health
research and development, would equal less than 0.1 percent of what the
United States spends each year on health care for chronic disease treatment.
If such an investment led to interventions that had only a modest impact on
the growth of costs related to chronic disease, such as lowering the growth
in cost by 1 percent as suggested by Roehrig and Rousseau (2011), it would
yield a saving of more than $11 for every $1 invested—a highly favorable
return on investment. The “value of information” associated with learning
what works in public health seems to be very high according to its cost-
saving potential.
The field must find ways to reach more of the populations that are at
great risk for preventable disease and injury and must seek out new and
more effective prevention strategies. The committee believes that knowing
what works in population health is critical for the future of our nation, and
the rate of spending on research and development in public health needs to
be similar to that in the industries mentioned above—perhaps up to 15 per-
cent of total public health expenditures. Funding of research, development,
and dissemination in public health must be seen as a critical investment in
the nation’s economic growth and competitiveness.
The ACA authorized a program of research related to many of the issues
raised in this chapter (Section 4301, “Research on Optimizing the Delivery
of Public Health Services”), but funding and infrastructure development
for this program are not yet available. The committee recommends steps to
achieve the needed research infrastructure.
Recommendation 6: The committee recommends that Congress
direct the Department of Health and Human Services to develop
a robust research infrastructure for establishing the effectiveness
and value of public health and prevention strategies, mechanisms
for effective implementation of these strategies, the health and
economic outcomes derived from this investment, and the compara-
tive effectiveness and impact of this investment. The infrastructure
should include
• A dedicated stream of funding for research and evaluation.
• A national research agenda.
• Development of data systems and measures to capture research-
quality information on key elements of public health delivery,
including program implementation costs.
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• Development and validation of methodologies for comparing the
benefits and costs of alternative strategies to improve population
health.
The recommended research infrastructure would be shared among three
HHS agencies—the National Institutes of Health, the Agency for Healthcare
Research and Quality, and the Centers for Disease Control and Prevention—
and a national research agenda needs to include a priority-ordered list of
topics to be addressed by the research. Development of data systems and
measures to capture research-quality information (and training of needed
staff) is needed at the national, state, and community levels and would
include information on expenditures, workforce size and composition, and
the volume, intensity, and mix of activities produced.11
There are many data systems for studying medical care delivery, such as
the Medical Expenditure Panel Survey, the Healthcare Cost and Utilization
Project with its National Inpatient Sample, and the National Ambulatory
Medical Care Survey. Analogous data systems for public health delivery are
needed. The development and validation of methods to improve popula-
tion health need to include strategies from outside the health sector. The
current research paradigm—randomized clinical trials as the gold standard
for intervention research—needs to be expanded to include other empirical
study designs and the use of modeling and microsimulation for comparing
treatment strategies with prevention strategies, including strategies aimed
at underlying determinants of health and combinations of strategies. As
discussed in the committee’s report on measurement, system dynamics and
other types of modeling are useful in a context of great complexity, such
as one in which health problems are caused by multiple, interacting factors
and requiring action by multiple stakeholders on many dimensions (see, for
example, Homer and Hirsch, 2006; Homer et al., 2007, 2010; Jones et al.,
2006; Leischow and Milstein, 2006; Leischow et al., 2008; Milstein, 2008;
Milstein et al., 2011). Enhancing the research capacity of public health
departments is consistent with the idea of public health departments as
knowledge organizations described in Chapter 2.
On the basis of what is known about what public health agencies can
and cannot afford to do and in light of the imbalance in national spending
on clinical care and on population-based health services, the committee
believes that the nation does not invest sufficiently in public health. The
information available, however, does not allow the committee to determine
with any precision what proportion of the nation’s health spending is needed
to support population-based public health efforts. Improvements in the
11This research model should reflect a desire for real progress by using traditional and
nontraditional methods.
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tracking of revenues and expenditures in public health and the enhance-
ments in research and evaluation described in this chapter would no doubt
inform the determination of public health funding needs, but a national ef-
fort is needed to begin to ascertain this and to make recommendations for
an optimal balance. As the minimum package of public health services is
established and the resources required to deliver them are ascertained, the
public health field will gain a deeper understanding of the relative values of
public health and clinical services. That understanding will inform invest-
ment in the public health system and the appropriate allocation between
clinical care and population health.
Defining the minimum package of public health services will require the
attention of a dedicated group that is knowledgeable about public health
and population-based prevention, the economic impact of public health
activities, and the value that could be realized by investment in clinical,
nonclinical, and population-based efforts.
Recommendation 7: Expert panels should be convened by the Na-
tional Prevention, Health Promotion, and Public Health Council
to determine
• The components and cost of the minimum package of public
health services at local and state and the cost of main federal
functions.
• The proportions of federal health spending that need to be in-
vested in the medical care and public health systems.
The information developed by the panels should be included in the
council’s annual report to Congress.
Public health is dynamic, and there are always new challenges and the need
to maintain progress in meeting old challenges. The recommended expert
panels would anticipate future needs and capacities and adapt to changing
circumstances.
CONCLUDING OBSERVATIONS
This chapter has described two kinds of efforts needed to revitalize the
public health infrastructure by clarifying how public health funding is used:
standardizing financial information, which will require the development
and adoption of a uniform chart of accounts, and expanding public health
research to improve public health effectiveness and make the best use of
resources. Earlier in this report, the committee described categories of public
health knowledge that are adequate to inform action. Research and tools
for disciplined management (given performance objectives and real world
resource constraints) are needed to help public health professionals to do
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their work better and more efficiently and to identify effective strategies and
appropriate interventions. At the national level, expert guidance will fulfill
two purposes: describing the governmental public health services that every
community needs and determining the magnitude of funding necessary to
accomplish them.
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