What is the benefit of having local public health departments?
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Local public health agencies located throughout Missouri work to improve the health of thousands of Missourians every year. These agencies address a wide range of public health issues, from assessing the health risks of environmental problems to providing emergency services during natural
disasters. Local public health agencies protect food safety by inspecting restaurants and grocery stores. And they work to control communicable diseases such as flu and tuberculosis and to alleviate chronic conditions, including heart disease, diabetes, and stroke. Most local public health agencies were formed under Chapter 205, Revised Statutes of Missouri, which allows counties to enact a property tax to support local public health services. Each of these public health agencies has an
elected board of trustees that sets policy for the agency. Other local public health agencies are governed by locally elected bodies such as county commissions and city and county councils. Local funding for those agencies comes from city and county general revenue. Missouri’s 114 local public health agencies operate independently of each other and are independent of state and federal public health agencies. The local agencies work directly with the Missouri Department of Health and
Senior Services through contracts to deliver public health services to the communities they serve. Funding for many of the contracts comes from the Centers for Disease Control and Prevention, other federal agencies, state general revenue and other sources. The state health department also provides technical support, laboratory services, a communication network and other services to support local public health efforts. Local public health agencies also work with numerous partners, including
private health care professionals and health advocacy organizations, to improve the health of Missourians. Local public health agencies are responsible for protecting, maintaining, and improving the health of everyone in their jurisdictions. That responsibility is more than simply preventing and treating disease. In accord with the Ottawa charter, it is to create the conditions where people can be healthy and to enable them to achieve their full potential. Yet, most public health departments fall short of being able to shoulder the breadth of this responsibility because they are small, poorly funded, understaffed, and subject to the frequently changing priorities of local politicians. The essential functions of public health illustrate the range of capacities that need to be available. In an effort to assure that those services are available to every resident, an accreditation process has been developed with the intent to raise the capacity and performance of all departments to at least a minimum level. Most public health agencies are largely externally funded with resources funneled from the federal and state governments supplemented variably by local tax support and by grants from other entities. These grants generally have well-defined requirements limiting the flexibility of local agencies to use them. Public health departments remain remarkably diverse in terms of their organizational structure, capacity of staff, scientific sophistication, funding, and the scope of services. And, of course, they serve remarkably different communities in size, sociodemographics, and political leadership. It is perhaps not surprising that economists exist in only a tiny handful of local health departments (LHDs), though economic analyses could play a greater role as policy analysis, program evaluation, and development of incentives for health relevant policies and programs become more central to the public health mission. There is growing recognition that the ability to improve population health and reduce disparities is determined primarily by social and environmental conditions as well as the health behaviors they influence. Thus, future improvements in health will primarily come from interventions (programs, policies, and systems change) in those areas rather than from changes in the delivery of clinically related services. To improve housing, active transportation, educational attainment, or incomes requires the collective action of local public health with other stakeholders, including other governmental departments at multiple levels, businesses, schools, community groups, and many others. One of the primary tools of public health is the ability to assess the value of interventions in terms of their effectiveness and economic consequences, and then to communicate that information to decision makers. This paper reviews some of the ways economics has contributed to LHDs and suggests needs and future opportunities. Establishing Program ValueWhen many people think of public health economics, cost effectiveness is the first thing that comes to mind. Economic evaluations (cost-effectiveness analyses [CEAs] and cost–benefit analyses) can answer the basic question: What is the value of this intervention and how does it compare to alternative uses of resources? In the context of public health, these compare invested monetary resources to health outcomes of interest. They often provide justification for departmental activities. For the most part, LHDs use or adapt published CEAs rather than developing them de novo. Although some LHDs, such as the Los Angeles County Department of Public Health, have conducted independent studies to facilitate decisions, such as how to formulate and select the highest-value tuberculosis screening policy for school entry and the specific tests to be used. Similarly, work to demonstrate the value of maternal and child health programs supports continued state and national funding of those activities. CEAs can also show who bears the costs and who receives the benefits. Getting support is more difficult when different agencies invest than those to whom the benefits will accrue. In order to put those costs and benefits into perspective, CEAs should be done from a societal perspective so all the costs and benefits are accounted for, in addition to any other important perspectives. Priority SettingWith limited funding for core functions and programmatic needs, difficult choices must be made. There are many criteria for priority setting: effectiveness, urgency, level of risk, feasibility, political considerations, and, of course, budget impact and health value. Economic analyses should provide information for the deliberative processes needed to make good choices. Despite their obvious benefit, these analyses are often lacking because either they have not been made applicable to a specific jurisdiction or there is a lack of individuals with the skills to use the information wisely, such as understanding the difference between average and incremental cost effectiveness. Work currently under way at the University of California, Los Angeles Fielding School of Public Health’s Center for Health Advancement is examining the financial and health impact of interventions in other sectors. Although economic evaluations can inform decision processes, they are only one input into what is invariably a more complex decision-making calculus. RegulationMost public health regulatory policy is made at the state or national level, although some decisions can be made by local legislative bodies. Most LHDs are involved with enforcing policies, and have differing degrees of discretion in how to enforce them. Examples include environmental regulation (water standards, food inspection), clinical care standards (healthcare facilities inspections), and reporting (surveillance). Though scarce, economic assessments could greatly help decision makers understand the potential and actual impacts of regulations and enforcement. PolicyPolicy is arguably the most powerful lever available to LHDs. For example, the 50% reduction in the percentage of tobacco smokers can in large part be attributed to enactment and enforcement of local tobacco policies. Economic consequences of policies, particularly concerns about costs to business of policies such as clean air laws, created a demand for economic projections and evaluations that were adaptable to local areas. 4 CDC. Smoking-attributable mortality, morbidity, and economic costs (SAMMEC): adult SAMMEC and maternal and child health (MCH) SAMMEC software. 2007.
Economic evaluations to inform policies to reduce obesity, sedentary lifestyle, and substance use are often central to securing popular and political support. As LHDs work to address social, economic, and environmental determinants of health, economic analyses that demonstrate costs and benefits to different stakeholders will become increasingly important and can be used to suggest mechanisms to align more effectively the cost of interventions to stakeholders most likely to benefit. Financial and Behavioral IncentivesEconomic analysis of alternative financial incentives and other behavior change (behavioral economics) strategies can facilitate access to clinical, social, and environmental services as well as improve adherence to clinical regimens and accelerate health-improving behavioral change. For example, immunization rates improve markedly when services are available in non-traditional settings, at more convenient hours, and with zero copays. Obtaining an influenza vaccine at a local pharmacy while one is already there for other reasons is more convenient, saves time, increases access, and costs less than a physician visit. Similarly, diets can be improved by altering cost structures of different foods and making healthier choices the easy choices. Both traditional financial incentives and innovative behavioral incentives can inform programmatic and policy choices as well as how they are implemented. Understanding behavioral economics can facilitate evaluating interventions as well as help optimize interventions. Management and Financial SystemsManagement systems that link resources, expenditures, outputs, and outcomes would enable LHD leaders to understand how well resources are being deployed and help them manage those resources more effectively. Most governmental financial systems are currently designed to manage budgets and grants rather than manage resources. Grant requirements often lead to duplicative systems, thereby increasing inefficiency. Management information systems offer a large opportunity to improve the effectiveness of LHDs. 6 IOM
ChallengesIn addition to traditional prevention activities, more LHDs are engaging with other sectors, such as education, housing, transportation, law enforcement, and criminal justice, to improve the social and environmental determinants that are central to improving health and equity over the longer term. Recognizing reciprocal benefits with other sectors, such as income and education, strong collaborations are becoming increasingly common in the most progressive LHDs. As health is incorporated more systematically into policy and programmatic decisions, demonstrating potential short- and long-term financial and economic impacts can be instrumental in influencing those decisions. Although the need for such information is high, the ability to produce and use it is modest at best. Ideally, economic expertise would be readily available to LHDs; at a minimum, staff need access to economic models and information and the ability to use and communicate that information effectively. Capacity building, including training, will be required. Because many LHDs are small and under-resourced, it makes sense to consider regional or state economic analytic resources being made available to them rather than expecting each LHD to have this internal capacity. A series of ideologic disagreements have constrained public health action. Less government means fewer resources as well as restrictions on protective actions LHDs can take. A stern belief that behaviors are solely an individual responsibility rather than shaped in large part by the social and physical environments limits the opportunity for progress in social environmental conditions that can improve health over the long term. There remains a deficit in the number of public health professionals. Estimates run as high as 250,000. The continued underinvestment in public health is really a tragedy of the commons, a fundamental economic concept that we systematically underinvest in essential areas that benefit us all in favor of investments that favor us individually. Economists can help demonstrate the value of public health action and enable LHDs to better serve their communities. AcknowledgementsPublication of this article was supported by the Centers for Disease Control and Prevention. No financial disclosures were reported by the authors of this paper. References
Article InfoFootnotesThis article is part of the supplement issue titled The Use of Economics in Informing U.S. Public Health Policy. IdentificationDOI: https://doi.org/10.1016/j.amepre.2015.10.011 Copyright© 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. User LicenseCreative Commons Attribution – NonCommercial – NoDerivs (CC BY-NC-ND 4.0) |How you can reuse PermittedFor non-commercial purposes:
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