Strengthening New York's Public Health System for the 21st Century



A. General

Moving from this larger context to the particular one of New York State, the Work Group found that certain realities cut across the state public health system and are judged as central to its effectiveness. The Work Group identified five key findings:

1. An adequate investment in the public health infrastructure is an essential responsibility of federal, state and local governments.34 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.

2. 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 bodies, for instance. In response, leadership development and capacity strengthening should be a priority at every level of the NYS public health.

3. Regional, multi-county approaches have proven 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;

4. Work Force recruitment challenges in NYS include budgetary constraints, aging of the work force and a scarcity of qualified public health professionals including 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;

5. 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 and performance monitoring.

B. Workforce

6. The NYS Work Force enumeration reveals that the level of specialization and differentiation of personnel is greater in the more urban settings than in the rural settings. Epidemiologists, disease control specialists, health scientific investigators and health educators represent a higher proportion of the total full time equivalent (FTE) staff in city or urban local health departments than they do in rural county departments where public health nursing staff number among the largest single job category represented.

7. Improvement in Work Force training is a need throughout the New York State public health system. At the local health departments, in particular, training access, relevance, its relation to core competencies, and limited funding are concerns.

8. Work Force recruitment challenges at the county level in NYS derive from budgetary constraints as well as from lengthy hiring procedures, non-competitive salaries and labor market shortages.

9. Work Force retention has not been a problem however the aging of the work force is becoming an issue due to the anticipated retirement of many professionals with long years of service. As vacancies result, there is concern about how labor market shortages or a less than competitive recruitment environment may impact new hiring.

C. Organizational Systems and Relationships

10. Leadership and effective communication are critical elements to a well functioning public health system infrastructure. Leadership is key to public health's success by assuring maximum participation of appropriate system partners and by securing optimal outcomes for the public. County governments, legislatures and boards of health can facilitate or impede LHD efforts with support for or resistance to new policy and program initiatives.

11. Regional networks formed from multi-county alliances as well as partnerships with local academic institutions are critical to organizing the necessary resources to meet existing public health challenges. Inter-county LHD collaborations providing epidemiology services within a region funded by the recent CDC bioterrorism grant are potentially a model of such an alliance. Other examples also pertain to emergency preparedness. Local law enforcement, fire, emergency medical personnel, hospital emergency room staff, physicians and county health departments are forming new coalitions prepared to bring their respective expertise and assets to a planned response in the event of an emergency. This inclusive approach to plan and execute public health initiatives is an emerging model to be used more broadly by public health to secure community wide commitment;

12. Expertise in epidemiological analysis, surveillance monitoring, data analysis, leadership, communication skills, and evaluation methods were identified as critical needs for improving public health performance throughout the NYS DOH system.

13. Without regard to the size, character or financial resources of local health departments, there is ample evidence of the need for, and desire to, have public health programs and services be "data driven" and "evidence based."

14. There is an expressed tension between a totally data driven approach to setting policy and program direction versus one that recognizes resource, administrative and public perception issues. Finding the balance between these two considerations was an acknowledged challenge.

15. Federal, state and local governments must cooperate and offer standardized outcome indicators for public health programs. Local health departments are finding ways to quantify certain program benefits through the use of partnerships with schools of public health, medical schools and neighboring counties. More effort to measure outcomes must occur, however.

D. Data and Information Systems

16. The results of the National Public Health Performance Standards Program/New York revealed that local health departments experience more difficulty carrying out surveillance and disease monitoring than diagnosing and investigating health problems and hazards. Part of this can be attributed to the limits of local health departments to access sophisticated epidemiological analysis associated with surveillance. Part of this is also a function of competing priorities and limited resources, particularly in the small counties.

17. The present communication networks such as the Health Alert Network (HAN), the Health Provider Network (HPN) and the Health Information Network (HIN) were felt to be both very helpful and very under utilized. Additional training and education to community health partners, including hospitals, about the benefits of using these systems is needed.

18. Information Technology (IT) varies across all counties with respect to its organization; so too does its support of the LHD. Similarly, some local health departments and their IT staff have very fine rapport with the NYS DOH IT staff and some seem less informed about how to leverage its resources. Better communication and outreach should occur between state and local health agencies.

19. There are too many data collection systems, too many databases, too many data collection points, and too little standardization across all IT systems. As a consequence, linkage between various computer systems is made more difficult. Common definitions, terms and conventions would improve system integration.

34 The Future of the Public's Health in the 21st Century, Institute of Medicine, National Academy Press, 2002, p. 148.