PUBLIC HEALTH SYSTEM STRUCTURES AND APPROACHES

Perhaps the programs that impact chronic disease that are least well understood lie within the constellation of agencies that serve the public’s health, working primarily across populations. Governmental public health agencies (GPHAs) are the primary providers of these programs. In many cases, community-based organizations (CBOs) also provide care. Governmental public health agencies have been and likely will be important in helping people live well with chronic disabling conditions and other chronic illnesses particularly in their shared role with clinical services to education and support the transition of care. Over the past 25 years, these agencies have moved from a focus on clinical care for the underserved to improving population health, and they have changed their role from doing to leading.

The Institute of Medicine (IOM) helped to encourage this redirection of focus through two reports on the future of public health. The first report (IOM, 1988) focused almost exclusively on GPHAs. It documented their disarray and attributed it to their being torn between trying to improve population health and serving as care providers, of last resort, of clinical care to the underserved, including the uninsured, all with inadequate resources. The report emphasized both population health and leadership as it described three roles for GPHAs: (1) assessment—to “systematically collect, assemble, analyze, and make available information on the health of the community”; (2) policy development—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”; and (3) assurance—to “assure their constituents that services necessary to achieve agreed upon goals are provided, either by encouraging actions by other entities (private or public sector), by requiring such action through regulation, or by providing services directly” (IOM, 1988).

The second report (IOM, 2002) was much less focused on government and placed the role of GPHAs in a broader context as one of many public health partners with an important role in improving population health. These partners include communities, the health care delivery system, employers and businesses, the media, and the academic community. Specific recommendations to GPHAs again emphasized leadership and included “1) adopting a population health approach that considers the multiple determinants of health; 2) strengthening the governmental public health infrastructure, which forms the backbone of the public health system; 3) building a new generation of intersectoral partnerships that also draw on the perspectives and resources of diverse communities and actively engaging them in health action; 4) developing systems of accountability to assure the quality and availability of public health services; 5) making evidence the



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