I. Statement of Problem and Purpose of Position Paper
Discussions of health care reform in the United States largely overlook the importance of public health principles and the roles of public health agencies in maintaining and improving the public's health. This statement is intended to identify these principles and roles and to clarify their relationship to personal health services and other health activities provided by the private sector.
Society must create and maintain the conditions under which members of the community can be healthy. The responsibility for maintaining and improving the public's health lies with all sectors of society.
Society's efforts have been carried out through a combination of the personal health care (sometimes called "medical care") and public health systems. Through the activities of both private and governmental health care providers, organizations, and institutions, the personal health care system provides primarily curative services, such as treating illnesses and injuries, to individuals with relatively little attention to prevention. The financing of these services comes from the out-of-pocket payments of patients, private health insurance, and government.
However, to enhance and maintain the public's health, preventive programs and activities are needed. The public health system focuses on prevention through population-based health promotion-those public services and interventions which protect entire populations from illness, disease, and injury-and protection. The primary providers of these public health services are government public health agencies. Public health agencies in communities throughout the United States are responsible for protecting, assessing, and assuring individual, community, and environmental health. These agencies build partnerships and often provide or coordinate direct services to ensure that there is access to adequate health services in a community. Public health agencies have particularly played this role in efforts to reduce the toll from illness, injury, and environmental and other risks. They have also directly taken on the challenges of addressing the health care service needs of the most vulnerable and at-risk. Public health agencies meet obligations to their communities in many different ways: by fostering a wide range of policy-guided community initiatives to promote health and improve health conditions; through the collection, monitoring, and dissemination of information about health status and disease occurrence; through the direct provision of service in the community and in the home; and through community education. Another role public health agencies play is to regulate sources of risk and promote health and safety practices such as by licensing restaurants and health facilities, and regulating water and air quality.1
Public health tasks are carried out primarily by governmental health and environmental protection agencies at local, state, and national levels. Some non-governmental organizations and private individuals perform public health activities in cooperation with or at the request of government agencies. Frequently, the government agency provides either financial or technical assistance. Because government functions as a representative of the people and needs to be responsive to them, the ultimate responsibility for public health activities must lie with government agencies.
Non-governmental organizations carry out many useful activities. However, only government agencies derive their authority from the entire community, locality, and nation and are therefore accountable to the entire public. Public health agencies, even while being cost conscious, are in principle not constrained by profit motives nor by agendas other than that of the public's health.
Since 1900, American life expectancy at birth has increased from 45 to 75 years. Much of this 30-year increase is the result of actions by the public health system and improvements in living conditions such as better sanitation, the provision of clean drinking water and safe food, and the elimination of occupational and worksite hazards.2 The major health problems we face today-workplace and environmental hazards, tobacco-induced illnesses, drug abuse, HIV (human immunodeficiency virus), poor nutrition, low birthweight infants, sedentary lifestyles, injuries, especially from violence-call for policy-guided population-based public health interventions. Coronary heart disease, stroke, diabetes, and certain cancers are the result of environmental, occupational, or social conditions that have been responsive to public health interventions. Morbidity associated with some of these chronic diseases can be controlled or eliminated by public health activities.3
Public health interventions focus on the health needs of the entire population or population groups. Personal health care providers have little incentive to consider population-based services, although they may provide individual clinical preventive care. Even with increased attention to the provision of clinical preventive services by managed care organizations and others, the clinical preventive services provided will often be those with short-range, immediate payoffs. Moreover, populations most at risk for increased morbidity and mortality may be least likely to receive these clinical preventive services because of financial and non-financial barriers. Public health addresses these issues through outreach, health education, transportation and translation services, and culturally sensitive provision of services. These are provided by the public health system.
Personal health care can help heal injuries, alleviate disorders, and treat many diseases, but it is public health programs that prevent the onset and spread of disease and diminish the likelihood of injury. Yet, the vast bulk of health spending in the United States is in the personal health care system; public health programs are funded by a very small and decreasing portion of health expenditures, with the result that society is not provided with all the public health services necessary to maintain the public's health.3 If the public's health is to be assured, the content of all activities must be altered to focus more on disease and injury reduction and on health protection and promotion-that is, on how the public health system supports the public's health.
The activities within the public health and personal health care systems must be integrated and coordinated. A better job of integration and coordination needs to occur within each of these systems as well as between them. 4
III. Functions of Public Health Agencies
The public health system forges community partnerships and community action, providing leadership for the integration and coordination of the personal health care and public health systems. Health departments and agencies can be objective, are publicly accountable, and have legal responsibility for those in their geographical jurisdictions. Improving and maintaining the public's health also requires a concern for social, economic, and environmental hazards that few individuals can avoid without strong governmental protective action. Prevention of the health consequences of workplace hazards, polluted air and water, and contamination of the food supply requires government action and intervention, as only government has the legal authority to require action. In order to understand the risks and health status of populations, data and surveillance systems must be maintained and improved. The monitoring of health hazards, including newly emerging diseases, and the creation of standards of protection are important functions of public health agencies. Public health laboratories, other facilities, and the tools for carrying out health hazard appraisals are crucial for maintaining the critical surveillance systems. Public health research allows scientific advancement in protecting the public's health. Many local health agencies have experience in working with their communities to develop public policies, plan improvements, implement new interventions, and translate research into community-appropriate programs.
Within the public health system, governmental health agencies have a legal and constitutional responsibility for protecting the health of the public.1 These agencies should be encouraged to extend their present authorities to include a role in the coordination of public and personal health care systems. The participation of these agencies in such activities should result in the health care system placing greater emphasis on disease prevention and health promotion.
Historically, most health agencies have not been able to act consistently upon such a broad interpretation of their role, nor have they been funded to do so.1 Public health functions are usually divided among several government agencies, e.g., those dealing with environmental hazards, those dealing with mental health, those assuring the provision of personal health care for low income persons, and those providing other public health services. This results in fragmentation of services.
To meet their goals, health agencies must first assess the state of health of their communities, identify variations in health status, and analyze the factors responsible for poor health. Interventions then must be designed to address these factors. To do so requires a three-pronged approach: developing appropriate social and public policies; developing community-based prevention activities; and assuring the delivery of comprehensive and high-quality personal preventive services. The social and public policies will need to ensure adequate food and shelter, clean air and water, and protection from workplace hazards. Community-based health promotion programs must be planned with the participation of the community to address its priority areas. Personal preventive services should be part of comprehensive care and meet the standards developed by the U.S. Preventive Services Task Force.
Rapid changes in the organization and delivery of personal health services, specifically the growth of for-profit medical care and managed care organizations, affect access for vulnerable populations, the health outcomes of the general public, and the activities and abilities of local public health agencies to operate. Public health agencies have a critical new role to play in overseeing these changes in the organization and delivery of services, assuring capacity to care for all populations, monitoring, evaluating, and improving quality, and understanding the relationship between changes in health services delivery and the public's health. Finally, the effectiveness of these solutions must be reviewed and modified in the light of what was learned.
Government health agencies will need to develop comprehensive plans working collaboratively with the community, social agencies, and the personal health care system, including both the public and private sector.
Public Health Agency Roles:
Public health functions and agencies exist on the federal, state and local levels. The division of responsibilities and authority varies considerably by state. Nevertheless, at each level of government, the public health agency is responsible for the following essential health services:
- collecting and analyzing health status and utilization information;
- developing policies and policy recommendations to maintain and protect the public's health by building upon the data and its analysis and responding to community values;
- informing the public and policy makers of its analysis and recommendations;
- working to develop consensus on needed action; and
- making sure that necessary public health and personal health services are provided to all.
The agency must have sufficient capacity and financial support to carry out these functions.
The Federal Government's Role is to:
- provide leadership, technical assistance, and funds for the nation;
- create national standards as needed and a national framework for their implementation;
- assure national data, monitoring, and surveillance systems; and
- engage in research and epidemiological studies.
National funding can provide resources necessary for improving the public's health as well as assurance of equity across all the states, so that a person's health doesn't suffer because of his or her place of residence. Past federal funding has concentrated on categorical programs intended to deal with specific problems. Some of these programs have been very important and successful.
However, categorical programs are competitive and not available to all communities. Reliance on such single-focus programs for financing has sometimes left public health agencies with insufficient resources to deal with health threats not included in those categorical programs, and little funding for broad health promotion and prevention efforts. Broader funding, such as a general operations budget, is necessary at all levels to provide the public health system with ongoing capacity to monitor, anticipate, and respond to health problems.
Public health services should be considered part of the social safety net which is the responsibility of government to provide for all people. Stable funding is also necessary. One way of ensuring stable funding is by requiring organizations and institutions paying for personal health services to support public health in proportion to the amount they spend on personal health care.
State governments have carried a major responsibility for governmental health activities. The scope of these activities, and the organizational entity within the state government responsible for them, varies from state to state. Variation among the more than 3,000 local public health agencies is even greater.1 They range from large autonomous comprehensive agencies in some major metropolitan areas to small agencies primarily in rural areas. Several political jurisdictions may be served by a jointly sponsored multi-county or city-county agency. The relationship of these agencies to their state agencies is complementary, and varies widely. The local health agency's scope of programs is generally more limited than the state's and the extent of its autonomy varies, although local health agencies remain the point of service for most public health programs and functions.
IV. Action by the Public Health Community
APHA and the public health community should encourage and assist in:
- Defining the role of the government with respect to health and strengthening the role of federal, state, and local health agencies.
A stronger government health system which ensures the provision of essential public health services and works actively with the personal health system to promote and protect health will result in improved health and cost efficiency across the nation.
The federal government must:
- provide standards and guidelines;
- conduct research and disseminate its findings;
- ensure equity across states; and
- develop priorities for the nation.
Federal, state, and local public health agencies must:
define standards for public health that improve the overall health of the population and provide strategies for achieving greater health system efficiency and effectiveness;
- promote the most efficient methods of public health action based on the political and health traditions of each particular state or locality;
- have a specific role in monitoring health effects and advising policy makers on the effectiveness of programs in meeting health objectives;
- develop innovative and effective public health programs supported by research-driven questions that are directly applicable to meeting public health needs and by evaluation studies which provide support for program planning and quality improvement;
- be funded at the several levels necessary for performance of their responsibilities; and
- provide leadership for the creation of comprehensive health records and mechanisms which assure shared utilization of data by private and public sector providers and by community-based groups so as to facilitate: disease surveillance and assessment of progress toward meeting prevention goals, evaluation of utilization patterns, quality of personal health services practices and health outcomes, and the identification of gaps in health care access.
- Establishing a leadership role for the public health community in decisions that shape the personal health care system and models of health care delivery.
- New ways of making policy and of organizing the purchase and delivery of personal health care are needed, and public health officials should have a major role in developing them to ensure health promotion and prevention. This requires a central role in the allocation of capital resources and in ensuring the adequacy of the primary care infrastructure and the distribution of adequate primary care personnel to currently underserved areas.
- State and regional health planning should draw together the public and private sectors in a collaborative model that is publicly accountable. State and local health agencies should articulate the division of labor between agencies. State and local health agencies should collaborate with purchasers and providers of personal health care and with community-based organizations representing ethnic and other minorities, women, and vulnerable groups to assure that health plans and health delivery are culturally sensitive and are appropriate to meet population needs. Working with the private sector, public health agencies must define standards to ensure high quality services are provided to all populations, and encourage a phased redistribution of resources from illness to preventive care with targets and timelines.
Existing models need to be utilized and new models need to be developed that go beyond the provision of personal health care to enhance the health status of populations. These models require particular emphasis on culturally sensitive personal health delivery systems. One such model is Community-Oriented Primary Care (COPC), which designs and evaluates community health interventions as an integral part of the provision of primary medical care. Many community migrant health centers and other models of integrated practice have developed COPC practices in which personal health services and public health interventions are combined in one organizational model. Such programs have great potential to develop more effective health promotion, social support, and personal health care approaches to all populations.5-9
Even when there are no financial barriers to care, private providers may not meet the needs of all residents or provide the special services and expertise required by high risk populations that are now offered by many public health programs and agencies. Local public health agencies and other community-based organizations may therefore need to continue to serve the needs of these persons, in addition to the agencies' broader role in the health care system as a whole. Particular attention must be paid to assure personal health care for indigent persons not eligible for Medicaid.
V. Methods of Implementation
APHA should play an active role in:
- Educating public health workers, public and private sector policy makers and leaders, health service payers and providers, and the general public about essential public health functions to be performed by federal, state, and local governments and the private sectors, and their implementation and effectiveness around the nation.
- Encouraging the training of public health professionals to participate in influencing public policy.
- Encouraging academic health centers to emphasize the teaching of concepts, skills, and attitudes about prevention and coordination to students of the health professions and research to document the cost effectiveness of prevention.
- Providing technical assistance and encouragement to public health workers to actively participate in national and state health reform efforts, articulating the appropriate role for public health in such efforts.
- Advocating funding for essential public health services.
- Advocating a strong infrastructure that will be capable of implementing the roles and responsibilities described in this position paper.
- Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press, 1988.
- Bunker JP, et al. Improving health: Measuring effects of medical care. Milbank Q. 1994;72:255-258.
- U.S. Public Health Service. For a Healthy Nation: Returns on Investment in Public Health, 1994.
- Freeman P, Robbins A. National health care reform minus public health: A formula for failure. J of Public Health Policy. 1994;15:261-282.
- Institute of Medicine. COPC: A Practical Assessment, Vol. 1 and 2. Washington, DC: National Academy Press. 1994.
- Wright RA. Community-oriented primary care: The cornerstone of health care reform. JAMA 1993;269:2544-2547.
- Kark S, Abramson JH. Community Oriented Primary Care: Meaning and Scope. Community Oriented Primary Care: Conference Proceedings. Washington, DC: National Academy of Sciences, 1982.
- Geiger J. The Meaning of COPC in an American Context. Community Oriented Primary Care: Conference Proceedings. Washington, DC: National Academy of Sciences, 1982.
- Nutting P, ed. Community Oriented Primary Care: From Principles to Practice. (HRSA Publication ITRS-A-PE-86-1).1987.
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