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Introduction The Future of Public Health set forth a vision for the public's health and the specific role for the governmental public health agency in that vision, including the mission and substance of public health and an organizational framework. In this perspective, the public's health is a societal priority and goal, to be achieved by governmental public health agencies and other public and private entities in the community. Public health is also a perspective and a profession, both of which focus on improving the health of the public. Specifically, The Future of Public Health stated that the mission of public health agencies is "fulfilling society's interest in assuring conditions in which people can be healthy. Its aim is to generate organized community effort to address the public interest in health by applying scientific and technical knowledge to prevent disease and promote health. The mission of public health is addressed by private organizations and individuals as well as by public agencies. But the governmental public health agency has a unique function: to see to it that vital elements are in place and that the mission is adequately addressed." The Future of Public Health, expressed the basic governmental responsibility for the people's health as assuring a substantive core of activities, assuring adequacy of means and methods, establishing objectives, and providing guarantees in an ideal health system, the substance of basic services will entail adequate personal health care for all members of the community, education of the community-at-large, the control of communicable disease, and the control of environmental hazards biological, chemical, social, and physical (IOM, 19881. 7

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8 HEALTHY COMMUNITIES The report defined the three core functions of public health as: 1. Assessment "Every public health agency [should] regularly and systematically collect, assemble, analyze, and make available information on the health of the community, including statistics on health status, community health needs, and epidemiologic and other studies of health problems. Not every agency is large enough to conduct these activities directly; intergovernmental and interagency cooperation is essential. Nevertheless each agency bears the responsibility for seeing that the assessment function is fulfilled. This basic function of public health cannot be delegated." 2. Policy development "Every public health agency [should] exercise its responsibility 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. Agencies must take a strategic approach, developed on the basis of a positive appreciation for the democratic political process." 3. Assuranc~"Public health agencies [should] assure their constituents that services necessary to achieve agreed upon goals are provided, by either encouraging actions by other entities (private or public sector), by requiring such action through regulation, or by providing services directly.... Public health agencties should] involve key policymakers and the general public in determining a set of high-priority personal and communi~wide health services that governments will guarantee to every member of the community. This guarantee should include subsidization or direct provision of high-priority personal health services for those unable to afford them" (IOM, 1988~. In We eight years since this report was released, there has been a significant strengthening of practice in governmental public health agencies and other settings. Substantial social, demographic, and technological changes in recent years (Brownson and Kreuter, In press), however, have made it necessary to reexamine governmental public health agencies' efforts to improve the public's health. Building upon the concepts of assessment, assurance, and policy development contained In The Future of Public Health, a group of leading public heal organizations (Public Heals Functions Steering Committee, 1994~) adopted a ' Members of the Public Health Functions Steering Committee include: American Public Health Association; Association of State and Territorial Health Officials; National Association of County and City Health Officials; Institute of Medicine, National Academy of Sciences; Association of Schools of Public Health; Public Health Foundation; National Association of State Alcohol and Drug Abuse Directors; and the

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INTRODUCTION 9 vision of public health as "healthy people in healthy communities," six public health goals, and ten essential public health services. The six public health goals are to: (1) prevent epidemics and the spread of disease, (2) protect against environmental hazards, (3) prevent injuries, (4) promote and encourage healthy behaviors, (5) respond to disasters and assist communities In recovery, and (6) assure the quality and accessibility of health services. The ten essential public health services are to: 1. monitor health status to identify community health problems; 2. diagnose and investigate health problems and health hazards in the community; 3. inform, educate, and empower people about health issues; 4. mobilize community partnerships to identify and solve health problems; 5. develop policies and plans that support individual and community health efforts; 6. enforce laws and regulations that protect health and ensure safety; 7. link people to needed personal health services and ensure the provision of health care when it is otherwise unavailable; 8. ensure He availability of a competent public heal and personal health care workforce; 9. evaluate effectiveness, accessibility, and quality of personal and population-based heal services; and 10. research new insights and innovative solutions to heal problems. These essential public heal services were used to describe public heal more readily to external audiences and constituencies and played art important role In defining public heal during He 1993-1994 health care reform debate (Turnock end Handier, 1995~. FACTORS AFFECTING PUBLIC HEALTH We live In a complexly, interconnected global society In which Here are many Greats to, and opportunities to improve, He public's heals. In recent years, we have witnessed He emergence or reemergence of infectious diseases such as hanta virus, cryptosporidiosis, Escherichia cold 0157, and Ebola virus (Gordon et U.S. Public Health Service (Centers for Disease Control and Prevention, Health Resources and Services Administration, Office of the Assistant Secretary for Health, Substance Abuse and Mental Health Services Administration, Agency for Health Care Policy and Research, Indian Health Services, and Food and Drug Administration).

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10 HEALTHY COMMUNITIES al., 1996~. In the late 1980s and early 1990s, tuberculosis made a comeback in cities across the United States, with many drug-resistant cases arising (OTA, 1993, Gittler, 1994), and outbreaks of childhood diseases such as measles and mumps appeared among poor inner city children (Atkinson et al., 1992; Kelley et al., 1993; Vivier et al., 19943. The number of human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS) cases has surpassed 500,000 in the United States, and among persons aged 25~4 years, HIV infection is the leading cause of dead in men and the third-leading cause in women (CDC, 1995a). Despite these outbreaks, which remain important, the 20th century has seen a shift in the major causes of death from infectious to chronic diseases, and behavioral risk factors have increased in importance. Behavior-related factors such as use of tobacco, alcohol, illicit drugs, firearms, and motor vehicles, as well as diet, activity patterns, and sexual behavior, are responsible for nearly half of the deaths in the United States and substantial amounts of disability (McGinnis and Foege, 1993~. Reflecting these realities, behavior and lifestyle interventions are highlighted, for instance, in Healthy People 2000: National Health Promotion and Disease Prevention Objectives (DEWS, 1991), with attention paid not only to the behaviors themselves but also to lifestyle more generally and to the context and social circumstances that influence individual behavior. Consistent with the development of these trends, public health professionals have come to realize that health is a dynamic state that is influenced by many internal and external process, and that embraces well-being-physical, mental, and emotional health. For both individuals and populations, health improvement depends not only on medical care but also on other factors including individual behavior, genetic makeup, and social and economic conditions for individuals and communities. The Field Model, as described by Evans and Stoddart (1994), presents these multiple determinants of health in a dynamic relationship. A wide range of actors, many of whose roles are not within the traditional domain of health activities, have an effect on and a stake in a community's health (Patrick and Wickizer, 1995~. The Field Model suggests a variety of public and private entities in the community that, through their actions, could influence the community's health. As communities try to address their health issues in a comprehensive manner, everyone involved will need to sort out their roles and responsibilities. They also should participate in the process of "community-wide social change" that is needed to improve health (Green and Kreuter, 1990~. As the public health community was coming to appreciate these ideas about the root determinants of health, other concerns about the high and rising costs of health care, the lack of geographical and economic access to health services for many, and questions about the quality and timeliness of the care provided led to many governmental and private attempts to alter the organization, delivery, and

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INTRODUCTION 11 funding of health care. Foremost among these attempts in the past decade has been the growth in organized health care delivery systems, including managed care, and the size of the organizations that deliver it (Gabel et al., 1994; Robinson, 1996~. However, the implications of these changes in the mode of service delivery and funding for public health agencies are uncertain. Has access for disadvantaged populations improved or worsened? Can public health agencies delegate or contract their clinical health promotion and disease prevention and control programs to emerging health care organizations? If they can, can the quality and effectiveness of such programs be assured? Is ensuring adequate clinical health care for all an important public health priority? As the health system has changed, so too has the political landscape. Although Americans have been skeptical of government since the founding of this country, in recent years there has been a growing mistrust of government, government institutions, and politics (Dionne, 1991; La Porte and Metlay, 1996; Washington Post, 1996~. Although distrust of government has received considerable attention, trust in other institutions such as the press, religious institutions, barking, and business has also been challenged. Related to this lack of confidence in government, or perhaps in response to it, is a decided shift in responsibility from the federal government to state and local levels. Furthermore, there has been a growing movement to "reinvent government," including making it more decentralized, responsive to clients or "customers," community-oriented, and entrepreneurial by employing performance monitoring and outcomes standards (Osborne and Gaebler, 1992~. In many communities, public health functions previously performed directly by government employees are being carried out by employees of private organizations. As a result, the opportunities for public- private partnerships are greater than ever before. SUMMARY AND ORGANIZATION OF THIS REPORT In summary, the discussions initiated by the Committee on Public Heal have suggested that three key forces shaping public health are (1) the rise of organized health care delivery systems, including managed care; (2) the changing role and public expectations of government; and (3) the increasing involvement and mobilization of communities in matters pertaining to their own health. Drawing on the committee's activities and discussions, this report addresses two critical public health issues in the United States as it enters a new century the relationship between public health and managed care, and the role of the public health agency in the community and their implications for the broader infrastructure and capacity issues raised in The Future of Public Health.

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12 HEALTHY COMMUNITIES The committee's analysis, presented in this report, reaffirmed the understanding of public health professionals and health scientists that the public's health depends on the interaction of many factors; thus, the health of a community is a shared responsibility of many entities, organizations, and interests in the community, including health service delivery organizations, public health agencies, other public and private entities, and the people of a community. Within this context of shared responsibility, specific entities should identify, and be held accountable for, the actions they can take to contribute toward the community's health. As a result of this understanding, the committee focused its report on how governmental public health agencies, especially at the state and local levels, can develop partnerships with managed care organizations to deliver personal and population-based health services and with public and private community organizations to deal with broader concerns to advance the health of the community. Developing these partnerships, the committee believes, will be critical for advancing the health of the public and of communities in the future.