Tracking Changes in the Public Health System:

Originally published by the Center for Studying Health System Change (HSC). HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

Tracking Changes in the Public Health System: What Researchers Need to Know to Monitor and Evaluate These Changes

Issue Brief No. 02 | September 1996

Just as the medical care system was changing in communities across the country, so too was the public health system. Reduced resources, fragmentation of traditional public health functions, the spread of managed care, and the development of new partnerships were among the most important of these changes. In April 1996, two dozen public health officials and health policy researchers gathered at the Center for Studying Health System Change to discuss changes in the financing and delivery of public health services and the research needed to monitor and evaluate their impact.

The Tradition of Public Health

The federal, state, and local agencies making up the U.S. public health system performed a wide range of functions and provided services affecting the lives of millions of people. Core functions included preventing epidemics, protecting the environment and food and water supplies, promoting healthy behaviors, monitoring the population's health status, mobilizing community action, responding to disasters, ensuring the quality and accessibility of medical care, connecting high-risk and hard-to-reach people with needed services, conducting research for innovative solutions, and leading the development of sound health policy.

The heart of the system consisted of some 3,000 local public health agencies, boards, and departments across the country. While New York City, Detroit, and Los Angeles County represented the popular image of large health departments, big city or county agencies accounted for only 4 percent of the nation's local public health departments. Most were in small cities, towns, and rural areas -- half served fewer than 25,000 people and two-thirds served fewer than 50,000. It was at the local level where decisions by public health departments had the most direct impact on the public's health.

Changes in Public Health Services

The changes taking place in the financing and delivery of medical care were having a substantial and ongoing impact on the public health system. They affected the quality, accessibility, and organization of services traditionally provided by public health departments. The health of the populations these departments served was also changing.

Chief among the pressures on the system were diminished levels of state and local funding and increasing fragmentation of public health responsibilities among nontraditional partners in the community. As a result, the tools and strategies used to address public health in the past might not be adequate or appropriate going forward.

With increased fragmentation, public health departments found it increasingly difficult to coordinate and be held accountable for the services they were responsible for. Primary care facilities and hospitals could treat patients with tuberculosis, but the local health department remained responsible for overseeing contact tracing to find other people in the community with the disease. The proliferation of health and safety programs in non-public health government agencies further complicated coordination. Many states housed environmental health programs under their environmental protection agency, food safety under the agriculture department, drug awareness in education offices, and highway safety in the department of transportation. Each tended to view health problems through its own lens.

Dwindling Resources

Perhaps the most significant change in recent years concerned resources. Between 1981 and 1993, total U.S. health expenditures increased by more than 210 percent, while funding for population-based health strategies, as a proportion of the health care budget, declined by 25 percent. In 1993, just $8.4 billion -- less than 1 percent of the nation's health care dollars -- went to public health, down from 2.7 percent in 1990.

Not only was less money available, but much of it was categorical -- set aside for specific programs or services. This made it difficult to respond to local emergencies or unexpected disease outbreaks, such as food poisoning or cryptosporidiosis from contaminated water. State and local health department administrators wanted more discretionary funding to allow flexibility in redirecting money among public health services as needs arose.

Compounding the problem was a growing number of uninsured people -- including those with complex health problems such as AIDS and drug-resistant tuberculosis -- who relied on public health facilities for their medical care. Local health departments were among the few places in many communities where people without adequate or any insurance could go for health care. At one public health clinic for the indigent in Missouri, half the patients had no health insurance and most of the rest were on Medicaid.

Managed Care and Public Health

Managed care plans represented a large and growing part of the public health system as HMOs took on responsibility for some traditional public health functions for their enrollees, especially Medicaid beneficiaries. Missouri, for example, contracted with 14 HMOs to provide both population-based and personal health services under its Medicaid plan -- work previously done by the public health department. Services included programs for immunizations, sexually transmitted diseases, lead poisoning, tuberculosis, and HIV-AIDS.

Managed care had the potential to take on more population-based services, but it could not be expected to replace all the population-based functions of public health departments. An HMO could identify a child with lead poisoning, but it was not responsible for removing lead paint from a building, monitoring other children in the neighborhood, or enforcing building codes.

The relationship between public health and managed care varied by location. In Los Angeles County, the public health department competed with private providers to deliver managed care under Medicaid. In San Diego County, it only monitored care delivered by the private sector. The loss of revenue from Medicaid patients was significant in some areas, because that income had supported vital public health services and programs that generated little or no money on their own. Medicaid reimbursements constituted 10 percent of the annual budget for some state health departments. Where there were savings from Medicaid managed care, public health departments wanted to ensure those funds went toward population-based work rather than being redirected to other government priorities.

New Partnerships

A positive development in public health was the growing involvement of community partners. New partnerships were forming between public and private health care organizations as well as among public health agencies themselves. Where public health departments had once been the primary providers of services to improve community health, many were now developing partnerships with a broad range of public and private sector institutions.

In Texas, Wendy's restaurants had instituted an MBA program -- Mop, Bucket, and Attitude -- to help protect food safety. A Columbus, Ohio, business coalition developed a strategic plan closely following the public health department's plan, called Community Health 2010, aimed at improving residents' health through education, behavioral changes, and access to preventive health services. In other communities, local health departments were building relationships with private hospitals, managed care organizations, and business groups to strengthen public health services.

On the public sector side, 98 of Missouri's 115 local health agencies had signed contracts with the state health department to assess their communities' health status and needs. The Centers for Disease Control and Prevention was developing sentinel networks across the country to serve as early warning systems for potential public health problems. With a broader number of partners, however, local health departments faced greater challenges in coordinating and maintaining accountability for the services delivered.

Accountability and Measurement

Public health departments were increasingly being asked to demonstrate that the resources given to them were being spent effectively. Both government and the public wanted to know what public health dollars were buying and what impact those expenditures were having. Were there fewer low-birthweight babies? Were childhood disease rates declining because of well-managed immunization programs?

Public health activities were not the only determinants of outcomes, however. Infant mortality rates were affected not only by prenatal services but also by Medicaid eligibility, community employment levels, and whether a pregnant woman was homeless. A public health department could not take sole credit or blame for a community's health statistics.

Health goals were needed to measure outcomes and ensure accountability. In some cities, public health goals included raising awareness of sexually transmitted diseases and improving immunization rates. Public health agencies could develop indicators to track whether goals were being met and how they affected medical outcomes, while remaining aware of which indicators were most likely to change and how those changes would affect service delivery.

Measuring Public Health Functions

To better assess how medical care changes affected the public health system, researchers needed to track those changes and how local agencies responded. Several studies were underway. Since 1989, the National Association of County and City Health Officials (NACCHO) had sponsored the National Profile of Local Health Departments, which examined funding levels, what those dollars covered, and who was providing services. NACCHO's APEX project assessed an agency's organizational capacity and worked with local residents to improve community health -- about 45 percent of local health departments had used it.

Under the Illinois Process for Local Assessment of Needs (IPLAN), every local health department in Illinois had examined community needs and organizational capabilities. North Carolina was tracking changes in public expectations of local public health agencies and their progress toward the Healthy People 2000 goal of having 90 percent of the public served by a local health department.

Traditional tools for tracking public health functions had focused on describing and assessing the local health department's infrastructure, capacity, and organization. But as public health activities moved beyond the walls of the local department, these tools were falling short. New methods needed to be developed that could describe how public health responsibilities were shifting among public and private sector entities, assess the impact of public health activities on community health outcomes, and identify what communities wanted from their public health agencies.

Looking Ahead

Unlike the medical care system, relatively little research and few measures existed for studying how well the public health system operated. Public health and health policy researchers had been challenged to develop new tools. Ideas generated at the Center's meeting included: measuring local health department involvement in community decisions, including their role in forming partnerships and their expenditures on population-based services versus personal care; tracking how much money agencies had to spend over time and how much discretion they had in allocating it; monitoring the number of uninsured patients seeking treatment at public facilities and the types of care they received; and examining how local agencies defined their core functions by looking at what services they offered and who now provided services that once came only from public health departments.

This Issue Brief is based on a discussion held at the Center for Studying Health System Change on April 29, 1996.

Sources and Further Reading

Center for Studying Health System Change, Issue Brief No. 02, September 1996. Public Health Service, U.S. Department of Health and Human Services, "For a Healthy Nation: Returns on Investment in Public Health," 1994.