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Revisiting The Future of Public Health In the course of its discussions about current public health issues, the Committee on Public Health had the opportunity to readdress the findings and conclusions of The Future of Public Health, and to assess the impact that the report has had on the field. If not begun directly in response to The Future of Public Health, then many of the following activities were at least informed and energized by it. BETTER DEFINITIONS OF PUBLIC HEALTH One of the most valuable aspects of The Future of Public Health was the articulation of the mission and functions of governmental public health agencies (see Introduction). Specifying the functions of public health enabled federal, state, and local health departments to begin a dialogue and assessment about what they do and whether it was appropriate and adequate. This clarification of the roles for public heal agencies was part of a larger movement to reinvent and reorganize governmental public health programs to make them more efficient and effective and to build support from public officials and the general public (University of Illinois, 1994~. From the core functions identified in The Future of Public Health, experts developed more specific frameworks of public health processes. Miller and colleagues developed 10 public health practices, each linked to one of the core functions thriller, 1995; see also Box 13~. This framework was then used to assess the performance of local health departments (Miller et al., 1994~. 43

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44 HEALTHY COMMUNITIES BOX 13. Public Health Practices ASSESSMENT PRACTICES (The regular systematic collection, assembly, analysis, and dissemination of information on the health of the community.) 1. Asses the health needs of the community by establishing a systematic needs assessment process that periodically provides information the health status and health needs of the community. 2. Investigate the occurrence of adverse health effects and health hazards in the community by conducting timely investigations that identify the magnitude of health problems including their duration, trends, location, and populations at risk. 3. Analyze the determinants of identified health needs to identify etiologic and contributing factors that place certain segments of the population at risk for adverse health outcomes. POLICY DEVELOPMENT PRACTICES (The exercise of the responsibility to serve the public interest in the development of comprehensive public health policies by promoting the use of the scientific knowledge base in decision making.) 4. Advocate for public health, build constituencies and identify resources in the community by generating supportive and collaborative relationships with public and private agencies and constituent groups for the effective planning, implementation and management of public health activities. 5. Set priorities among health needs based on the size and seriousness of the problems, the acceptability, economic feasibility and effectiveness of interventions. 6. Develop plans and policies to address priority health needs by establishing goals and objectives to be achieved through a systematic course of action that focuses on local community needs and equitable distribution of resources and involves the participation of constituents and other related governmental agencies. ASSURANCE PRACTICES (The assurance to constituents that services necessary to achieve agreed-on goals are provided by encouraging actions of others (private or public), requiring action through regulation, or providing service directly.) 7. Manage resources; develop organizational structure through the acquisition, allocation, and control of human, physical, and fiscal resources; and maximize the operation functions of the local public health system through coordination of community agencies' efforts and avoidance of duplication of services.

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REVISITING THE FUTURE OF PUBLIC HEALTH 45 8. Implement programs and other arrangements ensuring or providing direct services for priority health needs identified in the community by taking actions that translate plans and policies into services. 9. Evaluate programs, provide quality assurance in accordance with applicable professional alla regulatory standards to ensure that programs are consistent with plans and policies, and provide feedback on inadequacies and changes needed to redirect programs and resources. 10. Inform and educate the public on public health issues of concern in the community, promote art awareness about public health services' availability, and health education initiatives that contribute to individual and collective charges in health knowledge, attitudes, and practices achieve a healthier community. | SOURCES: Miller et al., 1994; Turnock and Handler, 1995 l The National Association for County and City Health Officials, working from the goal of healthy people in healthy communities, developed a paradigm for a community's health system. The paradigm incorporates ten elements, each of which must be present for a health system in a community to be considered complete (NACHO and CDC, 1994~. In this framework, the role of the governmental public health agency is to assess whether the elements are present either on its own or in partnership with others; to develop legal or financial incentives for the ten elements; or through its own efforts to provide the ten elements or a subset of the elements, based on local priority setting, if others cannot be found to provide, will not provide, or are unable to provide elements of a high quality to meet community benchmarks. The maternal and child health (MCH) community also expanded upon the list of ten essential services to develop an MCH Functions Framework (Graven and Guyer, 1995~. This framework details MCH program functions and provides examples of local, state, and federal activities for implementing MCH program functions. It has been used as a strategic planning, evaluation, and educational tool by state and local MCH programs and schools. While The Future of Public Health has had an important impact on public health professionals, health officials have not yet found the correct formula for informing the public about the importance of public health. Finding better ways to inform the public and elected officials of the substance and importance of public health clearly deserves more attention.

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46 HEALTHY COMMUNITIES PUBLIC HEALTH CAPACITY By clarifying goals within the profession and supplying tools for advocacy, The Future of Public Health provided a stimulus for activities to strengthen the capacity of public health. Although there is still tremendous variability in capacity among state and local public health agencies, over the past eight years, there have been many targeted areas in which public health capacity has improved. Two important areas have been in response to the resurgence of tuberculosis and the increase in childhood vaccine-preventable disease, both occurring in the late 1980s and early 1990s. A heavy infusion of federal funds and a reorganized operationally focused tuberculosis program enabled New York City to reverse the increase in cases (Frieden et al., 1995~. In response to outbreaks of measles, mumps, and other childhood diseases, the federal government dramatically increased appropriations for immunization, and immunization action planning projects were initiated in cities and states across the country (Woods and Mason, 1992~. Another important area has been in small rural communities. Some local health departments find that The Future of Public Health report is valuable in helping to direct public health activities (Box 14~. At the state level, The Future of Public Health spawned a series of activities intended to clarify and strengthen the core functions of public health. These include the State of Washington's Public Health Improvement Plan (Washington State Department of Health, 1994) and the Illinois public health improvement plan (Illinois Department of Public Health, 1990, 1993, and 1994~. Currently, 69% of the expenditures of state and local health departments are used to provide personal health care services (Eilbert et al., 19961. Funding for these personal services from federal and state sources such as Medicaid help pay for administrative and other functions. Thus, as revenue streams for services to vulnerable populations shift from public health departments to managed care organizations, the financial base for governmental public health agencies could shrink. In light of new roles for public health agencies to work with managed care organizations and the community as outlined above, some states have begun to explore ways to reinvest in local public heals agencies (Re-Invesunent Work Group, 19951. This will require public health officials and their allies to inform state legislatures about what public health agencies do in the state and community and their contributions to the public's health. PRACTICE GUIDELINES FOR PREVENTION It became clear to public health professionals that to improve the public's health further, it was necessary to develop guidelines for practice and prevention.

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REVISITING THE FUTURE OF PUBLIC HEALTH 47 BOX 14. Barron County Health Department, Wisconsin Barron County is a rural community in Wisconsin that is distant from any metropolitan area. Because it is difficult to get current public health information, Barron County has relied on The Fixture of Public Health. The report has provided valuable information that the County Health Department has used in managing the community's public health activities. Some recent activities in Wisconsin and Barron County demonstrate the relevance of The Future of Public Health. The State of Wisconsin has used many of the report's recommendations. It has published its own version of Healthier People in Wisconsin: An Agenda for the Year 2000. It recently revised Wisconsin Public Health Statutes 1993 to define a health planning arid leadership role for local health departments that is fundamental to the protection of the health of the community. The three core functions of a local health department identified in the statutes are assessment, policy development, and assurance. In 1995, these documents provided the Barron County Health Department the impetus to assume the lead in a countywide process to assess the health of Barron County using the National Association for County and City Health Officials' APEXPH (Assessment Protocol for Excellence in Public Health). The goal was to assess the county's health needs, develop policies to meet those needs, and to ensure that quality services (including personal health services) that are necessary for the protection of public health are available and accessible to all persons in Barron County. The APEXPH process has been successful. The community has renewed confidence in the Barron County Board of Health. Since the completion of the Barron County Health Plan 2000 in December 1995, the Board has passed two county ordinances to protect the public's health, and it continues to involve the community by requesting input from other government agencies and community organizations on health concerns, department programs, and fiscal matters. SOURCE: Based on information provided by Kathy Newman, director of the Barron County Health Department, 1996; NACCHO, 1991. The Council on Linkages, with support from the W. K. Kellogg Foundation, sponsored a "Guideline Development Project for Public Health Practice." The goals of this project were to assess the desirability and feasibility of practice guidelines and to test a methodology for evaluating the scientific evidence on which such guidelines could be built. Four public health problems were chosen for study: (1) immunization of children, (2) treatment for tuberculosis, (3) prevention of cardiovascular disease, and (4) prevention of lead poisoning. This project found that the development of public health practice guidelines is feasible and should be pursued (Council on Linkages, 1995), and efforts are underway to develop prototype guidelines.

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48 HEALTHY COMMUNITIES The CDC has also begun to assess the effectiveness of community-based prevention guidelines. They have collected these guidelines into a "Prevention Guidelines Database," available to practitioners though CDC's PC Wonder (Friede et al., 1993), an on-line electronic communication system, and the Internet (Gordon et al., 1996~. The CDC is providing staff support to a newly established U.S. Task Force on Community Preventive Services intended to complement the U.S. Preventive Services Task Force Guide to Clinical Preventive Services (DHHS, 1989, 1996), which is designed for practitioners to use with individual patients. The proposed new guide will focus on community-based prevention and control strategies. TRAINING OF PUBLIC HEALTH PROFESSIONALS the couture of Public Health identified needs and gaps in the training of public health professionals, which were further addressed at an IOM Conference on Education, Training, and the Future of Public Health held in 1987 (IOM, 1991~. The F?vt?are of Public Health called for strengthening the links between schools of public health and public health agencies. In 1988, the Health Resources and Services Administration and the CDC established a "Public Health Faculty/ Agency Forum" to develop universal and discipline-specific competencies and recommendations (Sorensen and Bialek, 1991~. These competencies are now being used by public health schools and programs to guide the development of curriculums and by agencies to assess needs for training. The forum's work led to formation of the "Council on Linkages Between Academia and Public Health Practice." The council is working to improve practice in public health agencies and education by refining and implementing the recommendations of the Public Health Faculty/Agency Forum, establishing links between academia and the agencies of the public health community, and creating a process for continuing public health education throughout one's career (Sorensen end Bialek, 1991~. DEVELOPING STRONGER LEADERS AND PRACTITIONERS The Future of Public Health identified serious gaps in the leadership skills of governmental public health leaders and others interested in improving the public's health, including difficulty with the interaction of technical expertise and political accountability, lack of management skills, a high turnover and lack of continuity of leaders, inadequate national leadership, a lack of supportive relationships with the medical community, and insufficient capability in working with the

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REVISITING THE FUTURE OF PUBLIC HEALTH 49 community (IOM, 1988). Roper (1994) notes that public health leaders must understand and deal with multidimensional problems. The straightforward challenges of the past (e.g., developing a vaccine for an uncomplicated infectious disease) have given way to problems such as teen pregnancy, drug abuse, and STDs that are intertwined with seemingly intractable social and economic problems. Even active and experienced public health professionals, Roper reports, are not prepared for current and future challenges and, worse yet, suffer from problems of morale, skills, and systems. These conditions demand that today's leaders in public health be equipped differently than the leaders of yesterday. Since the IOM's report was released, leadership institutes have been developed at the federal, regional, and state levels. The CDC and the Western Consortium for Public Health established a training institute for state and local public health practitioners at the national level. Regional leadership institutes have been organized at the University of Washington, University of North Carolina, and St. Louis University Schools of Public Health and in the states of Florida, Illinois, Michigan, Missouri, Ohio, and Texas (Gordon et al., 1996~. The CDC has developed an "Information Network for Public Health Officials" (INPHO). This federal-state partnership is designed to connect public health professionals so that they may have access to current data and information to make informed decisions and to provide a vehicle for data exchange. INPHO computer networks and software link organizations eliminate geographic and bureaucratic barriers to communication and information exchange. Georgia was the first state to join the network, and INPHO projects are underway in 13 states. The CDC has also developed a "Public Health Training Network," a distance learning system comprising public, private, and academic partnerships. This network will use computers and satellite systems to train public health professionals and health care providers in the latest issues in public health, such as managed care (Baker et al., 1994; Gordon et al., 1996~. CONCLUSIONS Through its analysis of the interactions between managed care organizations and the role of governmental public health agencies in enhancing the health of the community and through its discussions about the many responses to The Future of Public Health, the committee found that the constructs of He mission and substance of governmental public health agencies envisioned in that report have been extraordinarily useful in revitalizing the infrastructure and rebuilding He federal, state, and local public health system in the United States. These agencies continue to be a fundamental building block in efforts to improve He public's health for the future. However, although clear progress has been made, some of

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50 HEALTHY COMMUNITIES the recommendations of that report have not yet been achieved. In light of this, the committee's analysis shows that the concepts in The Future of Public Health remain vital and essential to current and future efforts to energize and focus the efforts of public health. These concepts need to be advanced, applied, and taught to all health professionals. The committee also found that the concepts of assessment, policy development, and assurance, while useful in the public health community itself, have been difficult to translate into effective messages for key stakeholders, including elected officials and community groups. These concepts need to be translated into a vernacular that these groups understand. In conclusion, the committee found that the public health enterprise in the United States, as embodied in governmental public health agencies, is necessarily diverse in organization and function, but operates within the common framework set out in The Future of Public Health. The committee's discussions, however, revealed continuing evidence of inadequate support for governmental public health in many communities. Now, as nearly a decade before, society must reinvest in governmental public health agencies, with resources, commitments, and contributions from government, private, and nonprofit sectors and substantial legal authorities, if the public's health is to improve. The partnerships that are the focus of this report between governmental public health agencies and managed care organizations, and between public health and the community-can provide both political support and a vehicle for this reinvestment.