Strengthening New York's Public Health System for the 21st Century
REPORT OF THE PUBLIC HEALTH INFRASTRUCTURE WORK GROUP TO THE PUBLIC HEALTH COUNCIL
I. EXECUTIVE SUMMARY Background
The New York State Public Health Council has had a long-standing interest in the effectiveness of the public health system in New York State. In 1996, the Council appointed a committee to identify public health priorities for New York State. The report issued by the committee, Communities Working Together for a Healthier New York (CWT), noted that a strong public health infrastructure is essential in helping New York achieve its public health objectives. In early 2001, the Public Health Council asked for an update on the CWT project to assess progress in achieving the 12 priorities that had been targeted. During this update, the Council learned that while many objectives had been achieved or surpassed since 1996 (see Appendix E), other challenges still remained. As a natural follow-up to the CWT findings, the Council expressed an interest to study how the public health system infrastructure supported communities in their efforts to achieve these health priorities. In particular they directed that a review of the public health infrastructure in New York State be undertaken.
In late 2001, in the face of increasing demands on the public health system, the Public Health Council appointed a Public Health Infrastructure Work Group to assess the public health system throughout the state. The Council requested that this body provide recommendations on how to strengthen the system. The Work Group's members included individuals in positions of public health leadership and expertise, in academia, medicine, public policy, government, private foundations, business, and the voluntary sector.
The Work Group's goals were to understand the current organizations and systems that comprise New York State's public health infrastructure and evaluate its strengths and weaknesses; to identify strategies to strengthen the capabilities of the public health system; and to make appropriate recommendations for improvement to the Public Health Council. The Work Group endorsed a vision for a public health system that incorporates the core public health functions of assessment, policy development and assurance together with the ten essential public health services. These services are delivered from an infrastructure platform made up of three components: the public health workforce, public health organizational systems and relationships, and public health data and information systems.
The group further emphasized a vision of public health that encompasses the efforts of private and voluntary partners in communities in addition to the traditional public health agencies. Importantly, the vision assumes an enterprise funded to achieve its goals and mandates, informed by the best science and technology, efficiently and effectively coordinated and poised to meet society's needs into the 21st century.
Work Group Assessment Methods
The Work Group began its task in February 2002 with a broad orientation to the New York State public health system. Members considered the organization of state and local government in New York State (NYS) with its particular reliance on a local, county-based system for delivery of public health services. The Work Group reviewed the findings of numerous studies, publications and background reports. In particular, the Work Group benefited from the work of two IOM committees that were examining specific aspects of the national public health infrastructure at the time the Work Group was conducting its assessment. The Work Group established subcommittees to address each of the three infrastructure areas in greater depth. Local health departments (LHDs) were invited to provide their insights into New York State's public health infrastructure: its capacity, capabilities, competencies and needs. The LHD representatives came from a cross section of urban, suburban and rural counties and participated in one of three infrastructure component assessments including a survey questionnaire, telephone interview and focus group.
Emerging trends currently impact the nation's health. Many of these trends intersect and interrelate:
- Globalization has created more movement between and among individuals and nations;
- New infectious diseases and the reoccurrence of old pathogens have emerged; sometimes with antibiotic resistance;
- Changing demographics have increased numbers of immigrant and elderly persons;
- The character of many diseases has shifted from acute to chronic; and
- Technological and scientific advances have occurred in communication and biomedicine, both curative and preventive.
These developments are social, geopolitical and economic as well as medical. While some hold great promise for the future, they also pose significant current challenges for America's and New York's health. All carry a cost and the potential for unintended consequences.
In addition, there are other broad principles that provide a context for a contemporary understanding of public health today. To the degree that they also inform and influence New York State's public health system, they provide a foundation for an assessment of public health infrastructure needs. Their impact came into particular focus and offered important background for the Work Group as it reviewed data and held many discussions with its public health colleagues at the state and county level.
- Public Health focuses on Prevention
- Public Health is both Local and Global
- Public Health is an Essential Investment for Society
- Public Health Must Engage the Public as a Partner
Moving from this larger context to the particular one of New York State, the Work Group found that certain realities cut across New York State's public health system and are central to its effectiveness. The Work Group identified five key findings:
- An adequate investment in the public health infrastructure is an essential responsibility of federal, state and local governments.1 Investments in NYS must meet increasing demands on governmental public health agencies. Moreover, in an environment of emerging needs from emergency readiness to programs such as chronic disease control, resources must be sufficient to ensure that essential services are not neglected or, worse still, abandoned. The federal government, New York State and local governments must assure that localities have the assets and resources necessary to carry out both the traditional essential public health services as well as the new emergency preparedness and other programs designed to address emerging needs.
Substantial investments have been made in New York's state and local public health agencies through a complex array of funds including federal and state grants, state aid reimbursement for general public health work activities, third party reimbursement, local aid and fees. NYS has benefited greatly from the most recent influx of federal dollars for emergency preparedness. However, it is unclear whether these funds will be sustained or remain sufficient into the future. Ongoing analysis of financing for local health departments is essential to assure that there is a proper balance between federal, state and local investments and that incentives are in place to encourage effective public health service delivery. Local health departments must effectively manage the provision of essential and mandated public health services, set priorities, maximize revenue and be responsive to local needs.
- Public health leaders face challenges related to increasing demands on public health, engaging the public in public health activities and programs, and assuring a balance between policy driven decisions and certain political realities such as financial and legal constraints or the priorities of elected officials, for instance. In response, leadership development and capacity strengthening should be a priority at every level of the NYS public health system.
- Regional, multi-county approaches have proven to represent innovative models in NYS for strengthening local health departments' capacities to assure community access to the essential public health services as well as for securing specialized expertise when necessary.
- Work force recruitment challenges in NYS include budgetary constraints, aging of the work force and a scarcity of qualified public health professionals such as public health nurses, sanitarians and health educators. Improvement in work force training is essential to ensure that there is a pool of trained professionals entering the work force and that continuing education is accessible, relevant and linked to core competencies.
- Public health data in NYS at the county level in particular, if it is to be useful, must be timely, integrated, and meaningful; expertise in data analysis and data interpretation is essential to good outcome measurement, performance monitoring, and program management.
1 The Future of the Public's Health in the 21st Century, Institute of Medicine, National Academy Press, 2002, p. 148.
These recommendations are directed at all components of the public health system from every level of government including town boards of health or legislatures, county officials, state legislatures, and the federal government. They are also directed to key health care contributors such as physicians, hospitals, social service agencies, insurers, voluntary groups, employers and businesses. These recommendations are advanced in the certain knowledge that public health today is a system of alliances, partnerships and coalitions all of whose goal is to protect the health of the whole community in order to assure the well being of each of its members. In addition to these priority recommendations, a list of long-term recommendations can be found at the end of the full report.
The Work Group recommends that:
1. The Public Health Council appoint a standing Public Health Committee to oversee implementation of this report and to report on progress in achieving the actions recommended. In particular, this Committee should focus on implementing recommendations 2, 3 and 5 below.
2. The Public Health Council invite representatives of the NYS Department of Health and other members of the NYS public health system to update the Council at each meeting about the current challenges and issues facing public health at all levels of government and throughout the broader system of private and voluntary agencies.
3. The Federal Government, New York State and localities support a sustainable and flexible funding stream that assures that the State and localities can support the essential public health services and also emerging issues. Traditional essential programs should not have their resources depleted with the advent of new priorities.
The Work Group also recommends that the Public Health Council work with the NYS DOH to examine all funding sources that support local health departments and make recommendations for financing mechanisms that ensure effective public health service delivery. Improved mechanisms for management reporting and performance accountability linked to funding should be proposed.
4. A statewide public health training task force be convened including the schools of public health in New York State, representatives from the State and local health departments and other academic partners. This Task Force will consider issues of access, competency based training, leadership subjects and public health career curricula at schools and colleges.
5. The Public Health Council review the NYS Sanitary Code to ensure that job titles and minimum qualifications are appropriate to today's public health needs and examine how the sanitary code qualifications and training requirements can be revised to support career ladders.
Organizational Systems and Relationships
6. The New York State Department of Health (NYS DOH) and local health departments examine regional, multi-county models for providing essential public health services in which specialty knowledge, expertise or other resources might be shared across regions. Such models represent one way to address the uneven distribution of work force specialists that currently exists in many areas of the state. This examination will need to address the legal barriers existing now that may constrain such a solution or make regional approaches more difficult to put in place.
7. The New York State Department of Health and its academic partners creatively use and make available to counties expert resources organized by and available in the disciplines of disease surveillance, epidemiological analysis, behavioral science, environmental health, social marketing, community organizing, and public health administration. This need is particularly acute for counties that lack the resources to purchase or leverage such services independently.
8. The state and local health departments together with academic institutions and others develop strong leadership training opportunities for public health professionals. The curriculum content should focus on team building, creating and sustaining coalitions, forging strong partnerships, communicating with diverse publics, inspiring a steady community engagement, fiscal and program management and overcoming competing agendas and conflicts.
9. The state and local health departments work with the media to consider a campaign to improve public understanding about the public health system and its benefits. To begin, findings from research about what the public knows and understands should be used to support a campaign to educate the public about the benefits of the public health system and increase the public's involvement in this partnership.
Data and Information Systems
10. With assistance from the NYS Office for Technology (OFT), the NYS DOH, NYSACHO, and the New York State Association of Information Technology Directors develop a Comprehensive New York State Data and Information System Plan. The objective of this assessment and plan would be a comprehensive design and execution strategy for a system architecture capable of meeting today's public health infrastructure requirements for the State of New York.
11. The federal, state and local governments standardize public health program indicators so that effectiveness can be measured, benefits communicated, and shifts in policy direction or service delivery appropriately made.
12. The NYS DOH and its academic partners collaborate to develop methods to teach public health evaluation methodologies to strengthen and increase the capacity at the State and LHDs to undertake evaluations. Such evaluations are critical to understanding a program's effectiveness, to improving accountability and to communicating the value of public health to the public.
Continuous quality improvement requires periodic assessment of public health in order to identify gaps and provide appropriate solutions. With demands on public health changing and accelerating, this infrastructure assessment is regarded as all the more timely. The broad public health system must be responsive to new thinking, new initiatives and emerging issues. Leaders must continuously appraise the opportunities and threats to the population's health and assure that public health is positioned with its community partners to meet these adequately. All the assets of the infrastructure must demonstrate proficiency, accountability, competence and readiness if public health is to function well in ordinary and extraordinary times.
The public health system must be strengthened to meet emerging threats while still maintaining the traditional core services at the community and state level. Funding when weighed against documented needs and new priorities must be studied, quantified and changed to sustain investments in public health.
Failure to renew the public health infrastructure to more effectively meet tomorrow's priorities will put communities at greater risk in a world where risks to good health have already risen to new levels.