ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM

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Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM

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The Future of the Public's Health in the 21st Century.
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Special Need for Communication Skills

The role of communication in public health practice cannot be underestimated.

It is crucial for the successful performance of public health's core functions and essential services.

Governmental public health agencies must communicate effectively internally as well as externally with other governmental agencies and nongovernmental stakeholders and partners.

Informing and advising the public about health promotion and disease prevention are standard duties of both state and local public health agencies, and listening to community voices is also critical for programs to be effective.

In emergency situations, public health professionals must have the ability to communicate clearly and effectively — being aggressive and credible enough to command attention — with both the public and other officials about the nature of the health hazards and the steps necessary to minimize health risks.


The response to the discovery of anthrax exposures in the fall of 2001 brought into sharp focus the importance of effective communication in the face of serious health risks.

According to New York Times medical reporter Dr. Lawrence Altman, lapses and delays in communication with the public and with public health and health care professionals could have made the situation worse had the anthrax exposures been more widespread (Altman, 2001).

Altman found that the delay was attributed in part to Federal Emergency Response Act restrictions about disclosing information and to the Federal Bureau of Investigation's (FBI's) criminal investigation.

Altman suggested, however, that CDC could have issued information as a part of the parallel public health investigation that was already under way.

The initial paucity of information on anthrax and the investigations in the Morbidity and Mortality Weekly Report (MMWR), one of CDC's most valuable means of quickly informing public health and health care professionals about communicable diseases, was also noted (Altman, 2001).

MMWR's editor reported being “out of the [information] loop” for some time (Altman, 2001).

It should be noted that CDC used the Health Alert Network many times after September 11, 2001, to alert public health officials and to disseminate information.


The federal government's handling of the anthrax attacks also prompted criticism of DHHS for uncoordinated communication as well as a convoluted and inadequate public communication strategy (Connolly, 2001).

For example, as reported by the press, the department's initial decisions to direct all media requests through the Secretary's press office effectively silenced CDC, FDA, and NIH, the agencies with the most relevant expertise (Connolly, 2001).

The lack of information from DHHS was also frustrating to other federal, state, and local leaders and governmental public health officials, some of whom learned about new cases and contamination in their states though network and cable television newscasts (Connolly, 2001).

The lesson from these and other communication breakdowns is evident: clear and effective communication, both internal and external, is a critical service of the governmental public health infrastructure.


Under more normal circumstances, public health communication is important for gathering information from the community about their health concerns as well as delivering and even “marketing” health information to the public.

Because the responsibilities of public health agencies cover all aspects of health, public health officials are in a unique position to provide timely, accurate health-related information to the public on a wide variety of topics, ranging from depression and other mental health issues to obesity and physical activity, environmental health and safety, emergency preparedness, and policies that affect health or health outcomes.

However, few public health agencies have staff members who are trained to interact effectively with the public and to work effectively with the news media.

In fact, the most recent examination of the public health workforce indicated that 575 individuals in the public health workforce have the expertise to be classified in the category of “Public Relations/ Media Specialist” (HRSA, 2000).

Of these 575 people, most are working in DHHS and other federal health agencies.

Of the others, 115 are working in state and territorial public health agencies and 12 are working in voluntary agencies (HRSA, 2000).

Given the tremendous potential of the mass media and evolving information technologies, such as the Internet, to influence the knowledge, normative beliefs, and behavior patterns of individuals and groups, governmental public health agencies must be prepared to use these communication tools.

The public health workforce must have sufficient expertise in communications to be able to engage diverse audiences with public health information and messages and to work with the media to ensure the accuracy of the health-related information they convey to the public.


For example, public health officials can develop relationships with journalists and assist them in accurately representing health risks and interpreting the significance of new research findings so that reporting on public health issues is accurate and members of the public can make informed decisions about protecting their health.

For these reasons, the committee finds that communication skills and competencies are crucial to the effective performance of the 10 essential public health services and the practice of public health at the federal, state, and local levels.

Therefore, the committee recommends that all partners within the public health system place special emphasis on communication as a critical core competency of public health practice.

Governmental public health agencies at all levels should use existing and emerging tools (including information technologies) for effective management of public health information and for internal and external communication.

To be effective, such communication must be culturally appropriate and suitable to the literacy levels of the individuals in the communities they serve.

To build this capacity in the public health workforce, communications skills and competencies should be included in the curricula of all workforce development programs.

Communication competencies should include training in risk communication, interpersonal and group methods for gathering and transmitting information, and interfacing with the public about public health information and issues, as well as the interpretation of health-related news.

This is addressed in greater detail in a companion report, Who Will Keep the Public Healthy: Educating Public Health Professionals for the 21st Century (IOM, 2003).

Information Networks

Information and the systems through which it is produced are critical tools that enable public health agencies to meet their responsibilities for monitoring health status and for identifying health hazards and risks to the populations they serve.

Public health agencies also rely on information and information systems to assess communities' resources and their capacity to respond to health needs and problems.

Such assessments inform the interventions and policies designed to address the community's health needs (Keppel and Freedman, 1995).

It is essential that the governmental public health infrastructure have a system that is capable of supporting the collection, analysis, and application of myriad forms of health-related data and information.

Without adequate surveillance, local, state, and federal officials cannot know the true scope of existing health problems and may not recognize new diseases until many people have been affected.

The committee uses the term “information” in its most general form, referring to three distinct terms in information science: data, information, and knowledge.

Data are the essential elements of information; that is, data are the measurements and facts about an individual, an environment, or a community. Information is what is generated when data are placed in context via the tool of analysis.

When rules are applied to the information, knowledge is generated (Lumpkin, 2001).

All of these elements — data, information, and knowledge — are critical products of public health information networks.

Of particular concern for the public health infrastructure are interrelated weaknesses in the nation's disease surveillance systems and inadequate access to information systems and communication tools.


The committee emphasizes the need for an integrated information infrastructure to overcome many of these problems.

Surveillance Efforts and Reporting Systems

For communicable diseases, effective epidemiological surveillance can make the difference between the rapid identification and treatment of a few cases of disease and an outbreak that debilitates an entire community.

Responsibility for surveillance, one of the most important functions of the public health infrastructure, is shared among federal, state, and local public health agencies.


States and localities collect and report data; and federal agencies, especially CDC, in the case of infectious and chronic diseases, provide valuable technical support, training, and grant funding (GAO, 1999a).

The rapid development of new information technology offers the potential for a greatly improved surveillance capacity.

For example, it is now possible to engage in real-time data collection via the Internet and through linkages to electronic patient records.

New technologies also offer the potential for automated data analyses, such as pattern recognition software that would be able to detect unusual disease patterns.

Moreover, new technologies offer new options for disseminating the information produced by surveillance efforts (Baxter et al., 2000).

However, the nation's surveillance capacity is weakened by fragmentation and gaps.

TO BE CONTINUED ...
thelivyjr
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Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM

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NCBI

The Future of the Public's Health in the 21st Century.
, continued ...

Fragmentation of Surveillance Systems

Fragmentation has developed in surveillance systems in part because legal authority for surveillance rests with states and localities and they have not developed uniform standards for data elements, collection procedures, storage, and transmission.

The lack of uniformity has made it difficult for states and localities to work collaboratively among themselves or with the private sector to develop more effective surveillance systems.

Although The Future of Public Health recommended the development of a uniform national health data set (IOM, 1988), progress has been limited.

Requirements under the Health Insurance Portability and Accountability Act (HIPAA; P.L. 104–191) for the development and use of comprehensive new standards for the electronic transmission of health information may result in greater consistency of certain types of data.

However, there is uncertainty about the scope of the rules under HIPAA, and state and local health departments must determine what portion of their electronic health information might be subject to the requirements established by HIPAA (ASTHO, 2001a, 2001b).

Another key factor shaping the development of surveillance systems is that, historically, investment in these systems has been largely categorical, resulting in fragmentation of surveillance efforts across the spectrum of infectious disease threats and other programs for other specific diseases and populations.

An inventory of public health data projects and systems identified more than 200 separate DHHS data systems in seven broad programmatic areas (Boufford and Lee, 2001).

The multiplicity of surveillance systems for food-borne illnesses illustrates the problem (see Box 3–3).

A lack of integration in federal data systems helps drive fragmentation at the state and local levels.

Data collected in accordance with the specifications of separate federal programs often cannot be accessed at the local level because of differences in formats, definitions, classification systems, personal identifiers, or sampling strategies (Lumpkin et al., 1995).

The fragmentation means that state and local public health agencies inevitably must spend time on duplicative data-reporting activities that drain already scarce staff resources (GAO, 1999a).

The current combination of system incompatibility and lack of integration hinders the ability of program managers to know what information exists and how to access that information and hinders the ability of local health agencies to provide integrated care to their communities (Lumpkin et al., 1995).

CDC's National Electronic Disease Surveillance System (NEDSS) is working to electronically integrate a number of surveillance activities; details can be found in the discussion of information systems later in this chapter.

Gaps in Surveillance

Existing surveillance activities contain notable gaps.

In particular, little information is routinely collected on chronic diseases and conditions, such as asthma and diabetes, even though chronic diseases account for four of every five deaths in the United States and annually cost the nation approximately $325 billion in health care and lost worker productivity (Pew Environmental Health Commission, 2000).

Similarly, environmental pollutants and toxins are monitored primarily for the purposes of environmental protection and regulation, but no surveillance and tracking system monitors the health outcomes, such as birth defects and developmental disorders, that are potentially linked to toxic exposures.


With an improved awareness of these health risks and a more comprehensive understanding of the health status of the population, public health agencies from the federal to the local level would be able to design better interventions and prevention efforts.

The Pew Environmental Health Commission (1999, 2000) has called for the development of a national health-tracking network to monitor the prevalence of chronic conditions such as asthma and for the development of national birth defects registries.

Ideally, these comprehensive disease registries and surveillance networks would be accessible to and used by state and local public health agencies to better understand and monitor the health status of the communities they serve.

Additionally, these registries would have the potential to be linked with registries from private health care delivery organizations (such as hospitals and managed care organizations) so that more comprehensive disease prevalence estimates could be easily and readily obtained.

The Pew Environmental Health Commission reports and recommendations have been endorsed by major public health organizations, including APHA, ASTHO, the Association of Public Health Laboratories, the Council of State and Territorial Epidemiologists (CSTE), NACCHO, and the Public Health Foundation (PHF).

The committee strongly supports this recommendation and applauds the U.S. Congress for providing $17.5 million for the development and implementation of a nationwide environmental health-tracking network and capacity development in environmental health in state and local health departments (Conference Report Accompanying H.R. 3061, 2002).

Another gap in the current disease surveillance system is syndrome surveillance, which captures data on the basis of clinical signs and symptoms of illness (e.g., a fever or rash), not just formal diagnoses of specific diseases.

Related indicators for such surveillance might be sales of prescription and nonprescription medications.

Interest in syndrome surveillance has grown because of its potential value for early detection of disease outbreaks, including those that might result from a bioterrorist act.

Such a system depends on the rapid aggregation and assessment of data to permit detection of clinical and geographic patterns.

Although no national syndrome surveillance network is in operation, some state and local public health agencies are beginning to test and implement such systems.

For example, New York City has had an active syndrome surveillance system since the 1990s (LLGIS, 2001), and systems are also operating in the Seattle–King County Department of Public Health (Duchin, 2002) and the Idaho Department of Health and Welfare (1999).

Syndrome surveillance systems played an important role during the anthrax outbreaks in New York City and in the Washington, D.C., area.

These systems generally require partnerships with practicing physicians, hospital emergency rooms and outpatient departments, community-based clinics, and sometimes neighboring state and county health departments.

A system conceived at Sandia National Laboratories (2002), 9 the Rapid Syndrome Validation Project (RSVP), is being developed and tested in a collaborative effort with the New Mexico Health Department, Los Alamos National Laboratory, and the University of New Mexico Health Sciences Center, Department of Emergency Medicine.

RSVP incorporates a realtime medical database and allows electronic data linkages with all local health departments throughout the state, the four district offices and their satellites, and the state offices.

At the federal level, CDC's Enhanced Surveillance Project (ESP) is working with state and local health departments and information systems contractors to develop real-time syndrome surveillance and analytical methods (CDC, 2001d).

During special events, ESP sites monitor data on emergency department visits at sentinel hospitals.

These data are analyzed at CDC and reported back to the health departments for confirmation and appropriate follow-up.

ESP has been tested at events such as the Republican and Democratic National Conventions in 2000 and the 2002 Olympic Games in Utah (CDC, 2001d).

DOD (2002), through its Global Emerging Infections Surveillance and Response System, is evaluating a system for the rapid identification of disease-related syndromes in patients at military health care facilities in the Washington, D.C., area.

The committee notes that although these syndrome surveillance programs show promise, their widespread effectiveness is still being evaluated and no syndrome surveillance system has identified a potential biological emergency.

A forthcoming report (2003) by the IOM Committee on Emerging Microbial Threats to Health in the 21st Century addresses syndrome surveillance in more detail.

TO BE CONTINUED ...
thelivyjr
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Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM

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NCBI

The Future of the Public's Health in the 21st Century.
, continued ...

Information Systems and Communications Tools

New Systems and Technologies


Several initiatives have emerged to try to resolve the problems of fragmentation and incompatibility in the nation's disease surveillance systems and to gain the benefits of integrated health data networks and communications systems.

A key 1995 report, Integrating Public Health Information and Surveillance Systems, documented the problems and recommended a framework for leadership on the issue as well as specific steps for achieving the long-term vision of integration of public health information and surveillance systems (CDC, 1995).

After publication of that report, CDC established the Integrated Health Information and Surveillance Systems Board to formulate and enact policy for integrating public health information and surveillance systems, yet it is not clear that it has played this role.

If adequately supported, the board could provide an ongoing coordinating mechanism for CDC and ATSDR to lead the integration of public health information systems.

In 1992, CDC developed the Information Network for Public Health Officials (INPHO) in collaboration with state health departments.

INPHO was established to foster communication between public and private partners, to make information more accessible, and to allow the rapid and secure exchange of data (GAO, 1999a).

By 1997, 14 states had begun INPHO projects, some combining their INPHO resources with other CDC grant funds to build statewide networks linking state and local public health departments.

Some states' networks include links to private laboratories.

The system has produced measurable benefits in some states.

For example, in Washington State, electronic information-sharing systems reduced the passive reporting time from 35 days to 1 day and gave both local authorities and the School of Public Health at the University of Washington access to health data for analysis (Davies and Jernigan, 1998; P. Wahl, personal communication, February 2, 2002).

The recommendations of the 1995 report have also led CDC to develop NEDSS (CDC, 2000b).

Although the system is now in the early stages of development, one of its objectives is to electronically integrate a variety of surveillance activities, including the National Electronic Telecommunications System for Surveillance and the reporting systems for HIV/AIDS, tuberculosis, vaccine-preventable diseases, and infectious diseases.

It is also intended to facilitate more accurate and timely disease reporting to CDC and state and local public health departments.

NEDSS will incorporate data standards, an Internet-based communication infrastructure that is designed according to industry and public policy standards on data access and sharing, confidentiality protection, and burden reduction (CDC, 2000b).

CDC has also developed the Epidemic Information Exchange (Epi-X).

This system, which became operational in November 2000, enables secure, web-based communication among federal, state, and local epidemiologists, laboratories, and other members of the public health community and allows them to instantly notify others about urgent public health events and search the Epi-X database for information on outbreaks and unusual health events.


Another initiative, the Health Alert Network, emphasizes the communication capabilities that are necessary for more integrated information systems.

It was designed as a system for electronic communication between health departments and CDC, with the Internet used as its backbone (CDC, 2000c).

It also supports distance-learning activities and provides health departments at all levels with the capacity to broadcast and receive health alerts (CDC, 2000c).

Although parts of this system are still in development, CDC used the Health Alert Network at noon on September 11, 2001, to advise public health officials to begin heightened disease surveillance (NACCHO, 2001b).

In support of these various activities, CDC is adopting information technology standards and procedures to establish a secure data network (SDN).

Network development focuses on the technical requirements for maintaining the confidentiality of data and providing a secure method for encrypting and transferring files from state health departments to a CDC program application via the Internet.

The SDN not only gives CDC several ways of obtaining data from states, but it also provides a consistent method for authenticating the transmission source and ensuring data integrity (CDC, 2000c).

A public health information network is under consideration at CDC to serve as a vehicle, with an effective governance mechanism, to ensure the integration of existing public health information systems within CDC and coordinated development of future ones with state and local public health agencies.

Although the committee applauds the development of these important systems and coordination efforts, it is concerned about the apparent lack of an effective mechanism to ensure their integration or their coordination with future efforts to create a fully developed national health information infrastructure, which we strongly support.

Continuing Problems

Despite these efforts, the public health information infrastructure is not yet fully capable of handling situations for which rapid, clear communication and information transfer are essential.

Because the integration of public health data and information networks has not yet been accomplished, state and local public health agencies are still obliged to operate the more than 100 disparate data systems whose lack of integration slows the flow of information in times of crisis.

Data and information network integration must also take into account the new data and information systems under development.

Many of these new systems have not been fully implemented across the nation or, in the case of Epi-X, have been implemented only at the state level, leaving localities with read-only terminals and other tools that prevent interactive access to information or, even worse, leaving them out of the information loop entirely (Brewin, 2001).

Furthermore, many local public health agencies, especially those in small and remote communities, do not have the resources or technical capacity to handle the implementation of new information technology, which requires expensive and complicated hardware and software.

These disparities result in some states and localities having easy access to updated or urgent information, whereas others must continue to rely on the now-antiquated methods of paper-based reports, telephone connections, and the U.S. Postal Service as their primary means of retrieving and reporting information.

Early detection and response is critical, and it all hinges on communications and information technology.

These weaknesses were demonstrated clearly during the bioterrorism events of October 2001.

Despite the years of warning about the potential for such attacks, only half of the nation's state, local, and territorial public health departments had full-time Internet connectivity when the first anthrax case was reported on October 4.

Another 20 percent of state, local, and territorial health agencies lacked e-mail and, therefore, were unable to receive electronic updates regarding the anthrax events (Brewin, 2001).

Given that robust and smoothly functioning information and communications networks are the key to defending against a bioterrorist attack, many of the nation's public health agencies were left unprepared.

Since September 11, 2001, public health agencies and officials have repeatedly urged the U.S. Congress to increase the levels of funding devoted to improving the nation's public health information infrastructure.

The recommendations in CDC's review of this infrastructure specifically emphasized the need to ensure that health departments at all levels have access to modern means of rapid electronic data exchange and communication (CDC, 2001c).

Although the current bioterrorism preparedness appropriations ($40 million) are directed toward the Health Alert Network and Epi-X (CSTE, 2001), these are just two of the systems necessary for enhanced, comprehensive disease surveillance (NACCHO, 2001e).

It is possible that additional appropriations for bioterrorism or emergency preparedness may be able to provide more resources for the improvement of the other components of the nation's surveillance and information networks.

TO BE CONTINUED ...
thelivyjr
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Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM

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NCBI

The Future of the Public's Health in the 21st Century.
, continued ...

Moving Toward a National Health Information Infrastructure

Through the Telecommunications Act of 1993, the nation embarked on an effort to develop a National Information Infrastructure (NII), sometimes called the Information Super Highway (Boufford and Lee, 2001).

The National Health Information Infrastructure (NHII) is the health component of this effort.

Whereas some parts of the federal government, such as the Department of Commerce and the National Aeronautics and Space Administration, have moved ahead quickly on their NII agendas, the areas of public health, human services related to health, and community health are the least developed aspects of NII.

The National Committee on Vital and Health Statistics (NCVHS), the key external advisory body on data activities to the Secretary of DHHS, has outlined a vision and a process for building NHII.

The report Information for Health: A Strategy for Building the National Health Information Infrastructure (NCVHS, 2002) presents the core of the vision as the pulling together of many separate initiatives and systems into an integrated data system that will give health officials and others optimal access to the information and knowledge they need to make the best possible health decisions for communities.

The report's recommendations are comprehensive, stressing the importance of information flow to the public and across sectors of the public health system and attaching equal importance to consumer, clinical, and population health dimensions (NCVHS, 2002).

To ensure that NHII supports all facets of individual health, health care, and community health, it must be developed in a manner that takes into account human factors (e.g., values and relationships), institutional requirements (e.g., practices, laws, and standards), and technological components (e.g., systems and applications).

NHII, when implemented, could have a profound impact on the effectiveness, efficiency, and overall quality of health and health care in the United States.

It would allow the public health system and others to address concerns such as public health emergencies, medical errors, and health disparities in a more timely and comprehensive fashion (NCVHS, 2002).

The links to data from the health care delivery system are critical to state public health agency efforts to monitor the quality of health care.

The community aspects of population health are ripe for development as part of NHII because of the emerging scientific insight into the nature of health and its determinants (see Chapter 2).


Better access to information on communities and their subpopulations will help health professionals and others identify various health threats, problems related to social or environmental conditions, and the unique needs of vulnerable populations.

More powerful information tools will help identify patterns and trends from isolated events, and the rapid communication afforded by the network will aid in informing and educating individuals and the community at large about critical health issues.

The committee agrees with NCVHS that the nation's public health interest is served by the development of a standardized approach to an information infrastructure and that the development of a comprehensive, integrated system is a federal responsibility.

Therefore, the committee recommends that the Secretary of DHHS provide leadership to facilitate the development and implementation of the National Health Information In frastructure (NHII).


Implementation of NHII should take into account, where possible, the findings and recommendations of the National Committee on Vital and Health Statistics (NCVHS) working group on NHII.

Congress should consider options for funding the development and deployment of NHII (e.g., in support of clinical care, health information for the public, and public health practice and research) through payment changes, tax credits, subsidized loans, or grants.

In carrying out this responsibility, CDC should ensure that this system is easily accessible and can be used and maintained by public health agencies at the federal, state, and local levels.

This system should include the establishment of standards for consistent data collection and transmission practices, the assurance of privacy protections, the capacity for transmission of urgent health alerts across all levels of the public health system, and the implementation of data systems that facilitate reporting, analysis, and dissemination.

CDC should work with its public health partners to ensure adequate and ongoing training in the effective use of the techniques that comprise this system.

Although this system is critical for the fulfillment of the essential services of public health, it should also be both respectful of the need for privacy protections and mindful of the need for efficient data exchange.

The exact cost of a comprehensive NHII needs to be determined.

Estimates by Lee and colleagues (2001) indicate a total need of about $14 billion over 10 years.

This would be a combination of federal, state, local, and private-sector funds ramping up to a peak investment of $1.7 billion per year in 2007 and flattening out for the remaining years; the amounts needed to sustain the system after that period were not estimated.

TO BE CONTINUED ...
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Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM

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NCBI

The Future of the Public's Health in the 21st Century.
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Public Health Laboratories

Public health laboratories are a critical component of the disease surveillance resources of the public health infrastructure, providing essential capacity to detect, identify, and monitor the presence of infectious or toxic agents in populations and the environments in which those populations live.

Investigations in these laboratories resulted in the identification of the organisms that cause diphtheria, cholera, tuberculosis, Hansen's disease (leprosy), and typhoid fever, paving the way for the development of vaccines and treatments to prevent and control those diseases (Valdiserri, 1993).

Public health laboratories are also described as the safety net between the local water plant and the kitchen tap in many communities (APHL, 2000); they provide laboratory support for epidemiological studies and perform diagnostic tests (such as cytology testing and neonatal screening) that may influence the treatment of individual patients.

Moreover, public health laboratories provide leadership to set laboratory regulations and serve as the standard of excellence for local and private laboratory performance (APHL, 2002a).

In 1999, the General Accounting Office (GAO) (1999a) reported that the nation had 158,000 clinical laboratories, of which 90,000 were in physicians' offices.

About 10,000 laboratories were in hospitals or were privately operated.

Every state public health department operates at least one laboratory, and some local health departments have laboratory facilities.

Federal laboratories, such as those operated by CDC, provide testing services and consultation not available at the state level and training in testing methods (GAO, 1999b).

CDC's Division of Laboratory Systems supports extramural and intramural research and oversees a laboratory standards program that describes laboratory practices and services and that assesses parameters for measuring and testing quality (CDC, 2001c).

Highest priority is given to research on testing of diseases that are of the greatest public health importance (e.g., HIV and tuberculosis) and research to enhance the standards under the Clinical Laboratory Improvement Amendments (CLIA) (e.g., genetic testing and cervical cytology). 10

GAO (1999a) also recommended that the CDC director lead an effort by federal, state, and local public health officials to establish a consensus on the core laboratory capacities needed at each level of government.

This information will aid policy makers in assessing whether existing resources are adequate and evaluating where investments are most needed.

With regard to the financing of state public health laboratories, unpublished survey data from the Association of Public Health Laboratories (APHL) show that in FY 2001, public health laboratories received a median of 50 percent of their funding from states, with a median of 33 percent from fee-for-service funding and about 15 percent from the federal government (S. Becker, Executive Director of APHL, personal communication, June 13, 2002).

Although these percentages reflect the funding data obtained by APHL for both FY 1999 and FY 2001, the trend is that state funding for public health laboratories has been decreasing and fee-for-service funding has been increasing, potentially encouraging laboratories to increase their levels of fee-for-service activities.

Although federal funding has remained relatively constant, the recent increases in federal funding for bioterrorism and emergency preparedness and response are likely to increase the federal contribution to public health laboratories.

GAO (2001b) reported that the nation's laboratories and other parts of the infectious disease surveillance system were not well prepared to detect or respond to a bioterrorist attack because of reductions in laboratory staffing and training that have affected the ability of state and local authorities to identify biological agents.

The limitations of existing laboratory capacity were clearly demonstrated by the 1999 outbreak of West Nile virus in New York State.

Even with a relatively small outbreak in an area served by one of the nation's largest local public health agencies, the investigations taxed federal, state, and local laboratory resources (GAO, 2001b).


Both New York State and CDC laboratories were inundated with requests for testing, and CDC had to process the bulk of the testing because of the limited capacity of the New York State laboratories.

Federal officials indicated that if another outbreak had occurred simultaneously, CDC would not have been able to respond (GAO, 2001b).

Many public health laboratories are unable to keep pace with the monitoring and tracking of infectious agents that are already known in communities.

Some states do not routinely test for important infectious diseases.

For example, although most states conducted surveillance for tuberculosis, Escherichia coli O157:H7, pertussis, and cryptosporidiosis, fewer than half of state laboratories tested for penicillin-resistant Streptococcus pneumoniae and hepatitis C (GAO, 1999a).

Nearly half of the state public health laboratories lacked access to advanced molecular detection systems and other technologies for identifying specific strains of pathogens, information that is valuable to epidemiological investigations to trace the sources of disease outbreaks.

Many state public health directors and epidemiologists report that inadequate staffing and information-sharing problems hinder their ability to generate and use laboratory data for surveillance (GAO, 1999a).

A recent study conducted by APHL (2002b) raised concerns about the public health laboratory workforce.

The study found that the country is facing an imminent shortage of qualified public health laboratory directors.

APHL anticipates 13 vacancies over the next 5 years in state public health laboratory directorships, with a replacement pool that current laboratory directors describe as either inadequate or marginally adequate in size to meet future demands (APHL, 2002b).

Moreover, inadequate laboratory staffing is a problem.

Although there is great variability in laboratory staffing among the states, states devoted a median of 8 staff per 1 million population to laboratory testing of infectious diseases 11 (GAO, 1999b).

Additionally, according to the American Society for Clinical Pathology, the United States faces a serious shortage of medical laboratory personnel (ASCP, 2000).

In state or local laboratories that have few personnel trained to handle the complexity and volume of work associated with bioterrorism scares (e.g., anthrax), there is little capacity to sustain states of “alert” for days or weeks (APHL, 2002b).

Efforts are under way to modernize the manner in which laboratory information is recorded and communicated; these efforts emphasize the use of automated, electronic systems (CDC, 1999).

A 1997 meeting of CDC, CSTE, and APHL to design strategies for implementing effective electronic laboratory-based reporting produced a recommendation to base such strategies on the use of Health Level 7 (HL–7), a national standard for communicating clinical health information (CDC, 1997).

Other issues discussed at a 1999 meeting included modes of data transmission, data privacy, software development, data quality, data flow, and recommendations concerning leadership and coordination, software tools and technical support, policy development, training and education, and public–private collaborations (CDC, 1999).

In 2001, the Center for Infectious Disease Research and Policy (CIDRAP) and the Working Group on Bioterrorism Preparedness 12 estimated that approximately $200 million was needed as an initial investment to improve state and local preparedness with regard to laboratory capacity. This funding would support

• Further development and implementation of the Laboratory Response Network, which is a multilevel laboratory network composed of federal, state, county, and city public health laboratories designed to receive and analyze specimens from a range of sources;

• Full implementation of the National Laboratory System, which is a communications system designed to rapidly share laboratory information among public health, hospital, and commercial laboratories;

• Integration of chemical terrorism preparedness into laboratory improvements; and

• Improved diagnostic testing and identification of potential agents of bioterrorism by animal and wildlife laboratories and improved communications among human, animal, and wildlife laboratories.

CDC has initiated a program to develop a cohesive national laboratory system to ensure disease surveillance and the capacity for effective response (CDC, 2001c).

Under this initiative, the proposed National System for Laboratory Testing for Public Health seeks to ensure the availability of a consistent public health laboratory capacity (CDC, 2001c).

A report on the FY 2002 bioterrorism-related appropriations provided for infrastructure improvements.

In FY 2000, CDC awarded approximately $11 million to 48 states and four major urban health departments to improve and upgrade their surveillance and epidemiological capabilities (GAO, 2001b).

More recently (2002), bioterrorism-related federal funds ($1 billion) designated to help prepare state infrastructures for bioterrorism and other emergencies have begun to flow to states (http://www.hhs.gov/news/press/2002pres/20020131b.html).

The bulk of funds designated for laboratory capacity building (about $40 million) will go to enhance CDC's intramural laboratory capacity.

State public health laboratories, assisted by CDC, are working to deploy more sophisticated laboratory equipment that can help identify suspected bioterrorism attacks quickly and precisely.

In addition, CDC is working to validate the use of molecular DNA and antibody tests in potential cases of bioterrorism; setting uniform guidelines for the use of faster, more sensitive instruments; and planning to supply state public health laboratories with identical kits of biological reagents necessary to identify bioterrorism agents.

The efforts aim to improve confidence in test results and guarantee that the results can be verified quickly at other laboratories (Hamilton, 2001).

Given the important role of public health laboratories in assuring the health of the population and in protecting the nation's security, the committee believes that federal, state, and local public health agencies should have access to a strong, state-of-the-art public health laboratory system.

Furthermore, the committee believes that these public health laboratories are an essential part of a robust and stable surveillance capability necessary to identify emerging threats, natural or intentional, to the health of the public and to track the effectiveness of interventions at multiple levels.


In addition to the overall assessment of the public health system, the committee recommends that DHHS evaluate the status of the nation's public health laboratory system, including an assessment of the impact of recent increased funding.

The evaluation should identify remaining gaps, and funding should be allocated to close them.

Working with the states, DHHS should agree on a base funding level that will maintain the enhanced laboratory system and allow the rapid deployment of newly developed technologies.

TO BE CONTINUED ...
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Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM

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The Future of the Public's Health in the 21st Century.
, continued ...

Special Role of the Governmental Public Health Infrastructure in Emergency Preparedness and Response

In the wake of the events of September 11, 2001, federal, state, and local public health agencies — and indeed, the nation as a whole — have been grappling with the crucial question of whether the public health system is prepared to cope with future terrorist attacks.

Even before the events of 2001, the threat of chemical terrorism had grown more real in the United States because of developments in the mid-1990s such as the discovery of the Iraqi biological weapons program and the release of sarin nerve gas in the Tokyo subway by the Aum Shinrikyo cult (Henderson, 1998).

Resources put into the improvement of the public health system's ability to respond to bioterrorism will yield benefits that go far beyond that specific concern, but only if adequate funds are made available to strengthen the public health infrastructure's ability to detect and combat natural disease outbreaks, such as E. coli and other food-borne pathogens, and to work with other vital partners in the public health system to provide the protection necessary for the assurance of public health.

With our public health infrastructure in its current shape, trying to detect and respond to a bioterrorism attack is comparable to running O'Hare Airport's air traffic control system with tin cans and string.


Readiness of Local Public Health Agencies

Until recently, the degree to which public health departments were actually prepared for bioterrorist attacks or other emergencies was unknown.

Determining the level of state and local health departments' emergency preparedness and response capacities is crucial because public health officials are among those, along with firefighters, emergency medical personnel, and local law enforcement personnel, who serve on “rapid response” teams when large-scale emergency situations arise.

These health department officials must work closely with federal public health agencies such as CDC and, occasionally, law enforcement agencies (e.g., the FBI and the Department of Justice) to investigate and resolve the various threats to the community's health, regardless of whether the threat is natural in origin (e.g., floods, tornadoes, and earthquakes) or intentional (e.g., bioterrorist attacks).


Two weeks following the attacks on September 11, 2001, NACCHO (2001a) conducted a brief survey to understand the impacts of the events on local health departments and to assess how well those health departments would be able to respond in the event of this and other types of emergencies such as biological or chemical threats.

Of the 999 NACCHO members contacted, 530 responded within a week.

Survey results indicated that local public health officials played a variety of roles in response to the September 11 terrorist events, including communicating with various community-level partners; working with response partners to develop, update, and review emergency response protocols and plans; and providing information to the media and the concerned public.

Of the inquiries received by local health officials, most concerned vaccination and the availability of medicines.

Other inquiries focused on the degree to which the local community was prepared and what the local public health agency was doing to prepare the community.

The public health system is the vital link in our ability to preserve and protect human life when disaster strikes.

An alarming finding was the extent to which the local public health agencies themselves were unprepared for bioterrorist attacks.

Of those who responded, only 20 percent indicated that their agency had a comprehensive response plan.

Most of the respondents, 56 percent, indicated that their agency's response plan was still under development, and 24 percent indicated that their agency had no plan at all (NACCHO, 2001a).

Health officials themselves were also unprepared.

When asked how prepared they felt to respond to concerned citizens' inquiries, only 38 percent of health officials stated that they were “pretty well prepared” to respond, whereas another 50 percent of respondents indicated that they were only “somewhat prepared.”

The remaining respondents (12 percent) felt that they were “not prepared at all” (NACCHO, 2001a).


Survey respondents also reported on the frustrations that they encountered during that time of crisis.

For example, the main frustration voiced was the lack or malfunctioning of resources and equipment, including necessary communications tools such as pagers, cell phones, e-mail, and faxes.

The second most common frustration was the partial or total lack of communication from federal and state agencies, which was often interpreted as a sign of poor leadership.

In fact, some health officials indicated that they had to rely on the news media rather than on local disaster response agencies, state public health departments, or federal agencies to be alerted to and receive updates about the September 11 crisis (NACCHO, 2001a).


Other state and local public health officials noted that during the subsequent anthrax outbreaks, staff attention to other public health activities was diverted to responding to the public's concerns and questions, not to mention the investigation of false anthrax reports (California Bay Area Health Officials, personal communication, 2001).

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Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM

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The Future of the Public's Health in the 21st Century.
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Improving Preparedness

The data from the NACCHO survey paint a disquieting picture of the preparedness of the nation's local health departments and thus the heightened vulnerability of communities.

This is hardly surprising news, however, given that state and local public health agencies have been underfunded and understaffed for decades and have less “surge capacity or potential” (i.e., the ability to respond to a sudden influx of demand) than hospitals (Center for Civilian Biodefense Studies, 2001).


Several efforts to improve readiness are under way.

In 1999, DHHS created the Bioterrorism Preparedness and Response Initiative, which is aimed at upgrading the nation's public health capacity to respond to bioterrorism and to establish a formal Bioterrorism Preparedness and Response Program. 13

So far the accomplishments that have been under this initiative include creation of a National Pharmaceutical Stockpile Program and operationalization of the Rapid Response and Advanced Technology Laboratory, which is able to identify rapidly biological and chemical agents rarely seen in the United States (CDC, 2001a).

The development of a nationwide, integrated information, communication, and training network (of which the Health Alert Network, NEDSS, and Epi-X should be a part), as recommended by the National Committee on Vital and Health Statistics, will also help strengthen the ability of federal, state, and local public health agencies to share information (CDC, 2001a).

External communications systems also must be strengthened to ensure the rapid and effective transfer of information and communication between public health agencies and other frontline emergency responders, including health care providers, law enforcement and emergency response personnel, and government officials (CDC, 2000a).

The importance of effective communication in times of crisis cannot be overstated (ASTHO, 2001c).

The Columbia University School of Nursing Center for Health Policy is a CDC-supported project that has specified the competencies in emergency response needed by all public health workers (Columbia Center for Health Policy, 2001).

These individual competencies are complementary to the organizational capacities for bioterrorism response developed by CDC (2001b), the standards for state and local public health performance (CDC, 2001b), and procedures for state and local public health department leaders to notify CDC in the event of a bioterrorist attack (CDC, 2001a).

It is also vital that health care providers and facilities acknowledge their important role as part of the larger system that assures population health, both in general and in times of crisis.

Because frontline health care providers (i.e., those in urgent care and emergency room facilities) are often the first to see unusual illnesses or injuries, they must constantly be vigilant to notice trends that seem out of the ordinary and must report these trends to local public health departments (ASTHO, 1999; CDC, 2000a).

Once such observations are reported, public health investigators can provide appropriate follow-up through epidemiological investigations.


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Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM

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Investing in Infrastructure Improvements

If the United States is going to be appropriately prepared for a terrorist attack (biological, chemical, or otherwise), one of the top priorities must be to strengthen the public health infrastructure at all levels so that it is strong enough, flexible enough, and capable enough to respond to emergency situations of this nature (CDC, 2000a).

An estimated initial investment of approximately $400 million is needed to improve state and local preparedness with regard to personnel, training, epidemiology, and surveillance capacity (Center for Infectious Disease Research and Policy and Workgroup on Bioterrorism Preparedness, 2001).

This level of investment would cover the integration of bioterrorism preparedness activities into existing communicable disease prevention and control programs such as CDC's emerging infections program, the training of public health practitioners, and the hiring of designated public health veterinarians for states that do not have one.

An estimated additional $200 million was also recommended to begin to improve state and local preparedness with regard to information and communication systems (e.g., Health Alert Network, NEDSS, Epi-X, and rapid communication systems).

It was also noted that additional funds would be needed to sustain these systems effectively over time.

Progress toward these estimated needs has been addressed by some of the new resources for infrastructure improvement made available through bioterrorism-related appropriations.

A report on the FY 2002 appropriations makes reference to infrastructure improvements such as those authorized by the Public Health Improvement Act of 2000 (P.L. 106–505).

Furthermore, in 2002, Congress authorized a variety of bioterrorism-related activities in the Public Health Security and Bioterrorism Preparedness and Response Act of 2002 (OMB, 2002).

Following the passage of the Public Health Threats and Emergency Act of 2000, there were plans to develop two separate grant programs — one for basic public health infrastructure and the other for bioterrorism preparedness.

These were subsequently combined with a stronger emphasis on specific preparation for bioterrorism and other such emergencies.

CDC staff (Office of Terrorism Preparedness and Emergency Response) provided information on funding for the state and local public health infrastructure from FY 1999 to FY 2002 as a subset of total appropriations for bioterrorism.

Of total appropriations of $124 million (FY 1999), $156 million (FY 2000), and $182 million (FY 2001), $55 million, $57.6 million, and $67.8 million, respectively, were allocated to state and local capacity building prior to the FY 2002 DHHS bioterrorism funding.

The bulk of the funding was for the Health Alert Network; and smaller amounts were allocated for public health laboratory infrastructure and other needs, such as staff development and epidemiology and detection systems.

For FY 2002, and prior to September 11, 2001, states were to receive $75 million; however, this amount was supplemented with $915 million.

The following seven “capacity areas” (along with the estimated funding levels), deemed necessary for bioterrorism preparedness, were identified for allocation of these funds:

1. Preparedness planning and readiness assessment ($183 million, including $65 million for the pharmaceutical stockpile)

2. Surveillance and epidemiology capacity ($183 million)

3. Laboratory capacity, biological agents ($118.9 million)

4. Laboratory capacity, chemical agents ($0)

5. Health Alert Network/communication and information technology ($109.8 million)

6. Communicating health risks and health information dissemination ($46.7 million)

7. Education and training ($91.5 million)

The total represents about 42 percent of CDC's total appropriations for bioterrorism and emergency preparedness.

Although the overall resources for the improvement of state and local public health department capacities have increased substantially because of these allocations, it should be noted that the local public health infrastructure provides other important functions that are not covered by the improvements made as a result of these appropriations (e.g., conducting active syndrome surveillance, performing on-the-spot epidemiological investigation, developing local-level bioterrorism preparedness plans, and administering mass vaccinations) (NACCHO, 2001c).

For these reasons, it is important to ensure that the improvements that will be made to state and local infrastructures are based on comprehensive data about what is needed to ensure the delivery of the 10 essential public health services at the community level.


Furthermore, it is important to ensure that funding levels are sustained over time to maintain these improvements.

Most importantly, however, the improvement of public health preparedness capabilities will require the sustained involvement and commitment of policy makers at all levels of government, with ample attention being given to ensuring appropriate accountability (Salinsky, 2002).

Doing so is crucial in assuring the safety and preparedness of all of the nation's communities.


Can an appropriate balance be struck between responding to the threat of bioterrorism and ensuring an effective public health response to the health problems facing the nation on a daily basis, such as HIV/AIDS and heart disease?

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Re: ON AMERICA'S THIRD-WORLD FOURTH-RATE PUBLIC HEALTH SYSTEM

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The Future of the Public's Health in the 21st Century.
, continued ...

FINANCING THE PUBLIC HEALTH INFRASTRUCTURE

State and local governments traditionally have had financial responsibility for basic governmental public health services, such as workforce training, the development of information systems and the organizational capacity to conduct disease surveillance and prevention programs, the management of public health laboratories, the implementation of population-based prevention and health education programs, and other protections such as water and air quality management, waste disposal, and pest control.

Yet the federal government also has a financial responsibility for assuring the capacity of the public health infrastructure at the state and local levels.

Unlike the areas of medical care and biomedical research, however, the federal government has never made a similar level of investment in the public health infrastructure, such as the clinical laboratories, surveillance systems, or environmental monitoring systems needed to monitor health and health threats at the state and community levels.


In the past, in response to perceptions of great national need, substantial federal investments played a crucial role in the development of the hospital industry and of the biomedical research capacity as well as the expansions of medical schools.

What a national government pays for is a critical statement about priorities.

Assessing Infrastructure Costs and the Need for Federal Investment

As the committee has noted, there are vast differences across the country in the scope of activities, the resources available, and the organization of the governmental public health infrastructure at the state and local levels and in the sizes of the populations served.

This complicates the task of assessing the cost of public health services and the appropriate investment in the governmental infrastructure that delivers these services or ensures that they are provided.

In 1997, the DHHS Office of the Assistant Secretary for Planning and Evaluation commissioned the Lewin Group14 to develop a comprehensive data strategy to characterize the state of the nation's public health infrastructure.

The report urged a collective effort with ASTHO, NACCHO, and PHF to study the status of the public health infrastructure and respond with a sustained investment plan to address the needs identified (The Lewin Group, 1997).

Assessing the funds and expenditures for the public health infrastructure at the local level is complex.

Data from NACCHO (2001d) illustrate some of this complexity.

The average annual expenditure of the 630 local public health agencies reporting was $4.5 million (1999 dollars), but 50 percent of these agencies had expenditures of $621,000 or less.

By contrast, 25 percent of the agencies serving large populations of 500,000 or more had annual expenditures of more than $46 million.

On average, local public health agencies reported receiving 44 percent of their funding from local government, 30 percent from state government (including funds passed through federal programs), 19 percent from reimbursements for services, 3 percent from the federal government, and 4 percent from other sources.

ASTHO, NACCHO, the National Association of Local Boards of Health (NALBOH), and PHF, in various collaborative efforts supported by DHHS, have been exploring ways to measure actual expenditures at the state and local levels for each of the 10 essential public health services (Barry et al., 1998; Public Health Foundation, 2000).

Feasibility studies show promise, but no systematic accounting of this sort is being done on a regular basis.

Almost no data are available on how much would be needed to adequately build and sustain the necessary public health infrastructure to support the nationwide provision of the essential public health services at the local level.

One jurisdiction — Bergen County, New Jersey — conducted a detailed analysis of the funding needed for the public health infrastructure to be able to meet new state public health practice standards.

Its estimate of $5.1 million per year translates into about $6.61 per capita and represents the county's best current judgment of the total, ongoing investment in infrastructure required to support the provision of the 10 essential public health services throughout the county (National Partnership for Social Enterprise, 2002).

Various IOM reports (IOM, 1988, 1992, 1997a, 1997b, 2000a) have made a case for sustained action, both domestically and internationally, to strengthen the public health infrastructure.

A detailed examination of infrastructure needs specifically in support of the nation's immunization system produced a recommendation for annual federal funding of $200 million for the next 5 years, along with an overall increase in funding from state governments of $100 million (IOM, 2000b).

That report also emphasized the importance of stability in infrastructure funding, documenting the adverse impact at the state and local levels of rapid increases followed by rapid decreases in federal funding during the 1990s.

As policy makers and the public health community contemplate substantial increases in funding to improve the ability of the public health system to respond to threats of bioterrorism, the committee urges them to consider the lessons that the experience of the immunization program offers.

Congress responded to the national measles outbreak in 1989–1991, in part, by increasing funding for state immunization infrastructure grants from $37 million in 1990 to $261 million in 1995, but the appropriations were reduced by about $80 million in 1996 and had fallen to $111 million by 1999.


A variety of barriers (e.g., the requirements of state budget cycles and the administrative constraints of a 1-year grant period) had made it difficult for states to absorb the initial influx of grant funds, but funding was cut just as states had begun to build program capacity (IOM, 2000b).

Moreover, the influx of federal funding had led state legislatures to cut state funding for infrastructure activities (Freed et al., 2000).

Both stable and sustained funding is needed for the effective performance of the public health infrastructure.

On the basis of available data, the committee was unable to conclude what level of federal funding may be warranted as an ongoing, governmental investment in the development and maintenance of the public health infrastructure to ensure that it can provide the essential public health services to all Americans.

It is expected that funding for the Public Health Improvement Act of 2000 will enhance the public health infrastructure, but it is unclear to what extent these additional investments would further improve the ability of the public health infrastructure to meet its broad day-to-day responsibilities for protecting and improving the health of the population.

A commitment for sustained public health infrastructure financing (unrelated to bioterrorism-related activities) is clearly needed.

Prior efforts at systematic nationwide studies of financing for public health have failed because of their exclusive focus on the budgets of state and local governmental public health agencies rather than the funding of the public health system, thus preventing appropriate benchmarking for communities that have various approaches to the allocation of roles and responsibilities within the system.

For example, in the late 1960s, Congress became increasingly aware of the need for accountability pertaining to state expenditures and performance as the amount of funding allocated to state health departments was increasing under Section 314(d) of the Public Health Service Act.

As a result, the PHS agencies allocated funds to create the National Public Health Program Reporting System (NPHPRS).

Started in 1970 and operated by the Public Health Foundation, all states routinely participated in this voluntary reporting system.

Data were collected and verified for items such as federal and nonfederal expenditures by program areas, the organizational structures of health departments, and revenue amounts and sources.

This was the only data source of this type in the nation.

While discussions were occurring around health care reform in the early 1990s, PHF worked with state and local public health agencies to improve NPHPRS, using the Healthy People 2000 objectives as the basis for performance measures and the 10 essential services as the framework for collecting expenditure data.

In 1995, PHS discontinued funding because NPHPRS could not provide program management data for federal agencies.

Nearly a decade later, no reporting system exists and no data on state public health expenditures and programs are available.

Although different methods of categorizing and cataloging expenditures have been studied, the research indicates that use of the 10 essential public health services for collection of expenditure data is feasible, reliable, and beneficial to the public health community.

In addition, the National Public Health Performance Standards Program's Local Public Health System Performance Assessment Instrument appears to be effective in assessing the capabilities of local public health agencies to provide essential public health services.

There is still a great need for an expenditure reporting system for public health agencies based on the framework of the essential public health services and consistent with the newly implemented National Public Health Performance Standards Program to produce a needs assessment and expenditures data as a basis for estimating the investments needed.

To begin this process, the committee recommends that DHHS be accountable for assessing the state of the nation's governmental public health infrastructure and its capacity to provide the essential public health services to every community and for reporting that assessment annually to Congress and the nation.

The assessment should include a thorough evaluation of federal, state, and local funding for the nation's governmental public health infrastructure and should be conducted in collaboration with state and local officials.


The assessment should identify strengths and gaps and serve as the basis for plans to develop a funding and technical assistance plan to assure sustainability.

The public availability of these reports will enable state and local public health agencies to use them for continual self-assessment and evaluation.

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Organizational Impact of Federal Grant Funding

The ways in which funds are transmitted have an impact on program effectiveness.

At present, most discretionary funding distributed by DHHS to states and some local entities is allocated through block grants, formula grants, and categorical programs.

According to the White House's Blueprint for New Beginnings accompanying the FY 2002 budget, DHHS manages hundreds of discrete public health activities.

For these activities, states receive about $4 billion in formula grants and about $3 billion through block grants.

The Blueprint for New Beginnings (White House, 2001) notes that potential reform of formula and block grant programs is a priority of the administration.


The administration is considering increasing state flexibility to address public health needs through expanded transfer authorities and other mechanisms to remove barriers to effective targeting of public health resources at the state and local levels.

The Blueprint does not address the need to increase the flexibility of categorical grants.

Formula grants are characterized by the allocation of funds to states in accordance with a distribution formula prescribed by law or administrative regulation.

Two examples of formula grants can be found under Title I and Title II of the Ryan White CARE Act.

Formula-driven grants have been difficult to modify on the basis of new variables influencing a particular issue or changes in the demographics of affected populations.

The political process often prevents formula revisions that would negatively affect significant numbers of states, even if the expressed purposes of funding would be better realized by shifts to more needy populations or to other geographic areas.

Block grant programs are a subset of formula allocation programs in which the recipient has broad discretion in the application of funds received in support of broad program areas (e.g., Prevention and Treatment of Substance Abuse and Preventive Health and Health Services Block Grants).

Block grant programs have various reporting requirements.

One of the questions that has been long asked is about the effectiveness of the block grant mechanism in targeting funding to a particular purpose or need.

Michael Rich (1993) conducted highly regarded studies of this issue, in the area of funding for the poor.

After significant empirical analysis of the distribution of Community Development Block Grants, he drew several broad conclusions about this funding vehicle:

• State and local officials play an important role in determining the degree to which federal grants are used to balance income and resources in resource-poor areas.

• The capacity and will of governments to target federal grant funds to the poor vary widely.

Government officials tend to spread benefits widely as opposed to concentrating them where the need is the greatest.

• Strong coalitions are more effective in influencing federal program decisions, including targeting areas of greatest need.

However, local coalitions need a strong federal partner to make explicit targeting more acceptable locally.

A literature review of different models for federal funding conducted by the DHHS Office of the Inspector General in 1994 noted that states report that block grants increased administrative efficiency and integration and did not replace state funds.

Categorical grants provide states and other recipients with funding for specific programs.

CDC provides a significant amount of funding to state government departments of health through categorical grants (e.g., for HIV/ AIDS prevention, sexually transmitted disease control, tuberculosis control, and chronic disease).

They are highly restrictive in terms of how the recipients may use the funding, may add administrative costs and complexities, and may worsen fragmented program management and service delivery, as federal prohibitions against mixing funds create programmatic “stove-pipes.”

The result can be separation and gaps in services, because even related program areas become insulated and isolated from each other and lack the flexibility to respond to changes at the recipient level.

Furthermore, measuring their real effectiveness has been difficult at times because of the large number of individual grants and the lack of resources for effective performance monitoring (Boufford and Lee, 2001).

The DHHS Performance Partnership initiative and the Oregon Option are examples of efforts to use a more performance-oriented approach to categorical funding by integrating multiple categorical programs under larger umbrella categories.

Under the Performance Partnership initiative, DHHS and its partners worked together to reach consensus on the results to be achieved by the program and develop performance measures to monitor progress toward the stated results.

The Oregon Option tested the proposition that multiple levels of government can align their efforts to achieve results that matter to people.

Both initiatives involved signing memoranda of understanding (MOU) that committed them to work cooperatively to both determine the results to be achieved and to get the job done.

The question of creating linkages of funding to benefit coalitions demands another role for governments in partnering with key local stakeholders.

This situation should be remedied.

Expanded transfer authorities and other mechanisms to remove barriers and facilitate, rather than hinder, the alignment of resources and policy for the actualization of national health objectives should be considered.

Thus, the committee recommends that the federal government and states renew efforts to experiment with clustering or consolidation of categorical grants for the purpose of increasing local flexibility to address priority health concerns and enhance the efficient use of limited resources.

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