deaths. Other agencies followed: the National Society to Pre- vent Blindness was formed in 1908, the Mental Health Asso- ciation in 1909, the American Cancer Society in 1913, the National Easter Seal Society for Crippled Children and Adults in 1921, and the Planned Parenthood Federation of America, also in 1921. In the late 1800s, organized charities such as the Red Cross, previously denounced for promoting dependent poverty, began to be recognized for their contributions to health and welfare. Philanthropy, too, became prominent with the establishment of the Rockefeller Foundation in 1913, fol- lowed by the Carnegie-Mellon, Kellogg, and Robert Wood Johnson Foundations (Public Health Encyclopedia, 2007).
Health-related Professional Associations Many health-related professional associations have influenced the quality and type of community health services delivery.
Among these, the National Organization for Public Health Nursing, from 1912 to 1952, significantly influenced early preparation for and the quality of public health nursing serv- ices (Abrams, 2004). The American Public Health Association (APHA), founded in 1872, maintains a prominent role in the dissemination of public health information, influence on health policy, and advocacy for the nation’s health. Other nursing and community health organizations that have promoted quality efforts in community health include the Association of State and Territorial Directors of Nursing (ASTDN), the Association of State and Territorial Health Officers (ASTHO), the National League for Nursing (NLN), the American Nurses Association (ANA), and the Association for Community Health Nursing Educators (ACHNE).
HEALTH ORGANIZATIONS
State government health agencies function fairly autonomously while working within federal guidelines.
They assess, develop, and monitor statewide health needs and services. Historically, they have been responsible for communicable disease control, vital statistics, laboratory services, environmental sanitation and hygiene, health education and maternal–child health, with the addition of categorical programs (e.g., heart disease, migrant health) in the 1950s (Scutchfield & Keck, 2003). In the 1980s, block grants were instituted to give more flexibility to states in how funds are targeted.
At the local level, one may find a city government health agency, a county agency, or a combination of both to assess, plan, and serve the health needs of that locality. Most local health departments are under county jurisdiction, with only a small percentage of cities (usually large cities) having local health departments. Some are city–county agencies or special districts, and most local health departments report to either local government councils or boards of health (Scutchfield & Keck, 2003). In some states, local health departments also report to state public health agencies. In about 30% of the states, local health departments are oper- ated by the state health agency, which provides services locally, without city or county oversight (Turnock, 2004).
Unlike private organizations that tend to have a specific focus, government health agencies exist to accomplish a broad goal of protecting and promoting the health of the total popula- tion under their jurisdiction. Such a task requires a wide range of services and the combined talents of many types of profes- sional disciplines. Among them are nurses, physicians, health educators, sanitarians, epidemiologists, statisticians, engineers, administrators, accountants, computer programmers, planners, sociologists, nutritionists, laboratory technicians, chemists, physicists, veterinarians, dentists, pharmacists, demographers,
and meteorologists. Furthermore, public health agencies must function not only on an interdisciplinary basis but also on an interorganizational basis. Other government services (e.g., edu- cation) can meet their goals fairly autonomously, but public health cannot accomplish its important objectives without the collaboration of many agencies and organizations, both public and private (Barton, 2003; Williams & Torrens, 2002). To man- age the AIDS epidemic, for example, public health agencies, educational institutions, welfare agencies, mental health pro- grams, home care services, Medicaid, and private groups, among others, may be called upon to collaborate.
Many different government agencies contribute to the health of a community. Most obvious are the local and state health departments, which provide a variety of direct and indirect health services, including community health nurs- ing. Other tax-supported agencies that sponsor health care or health-related services include welfare departments, departments of public works, public schools and hospitals, police departments, county agricultural services, and local housing authorities.
Local Public Health Agencies
At the grassroots level, government health agencies vary con- siderably in structure and function from one locality to the next. This partly results from variations in local needs and the size and resources of the community. For example, a rural community served by a county or state health department may have needs and services that differ widely from those of a densely populated urban community (see Chapter 29). Differ- ing health care standards and regulations, as well as the type and stipulations of funding sources, also contribute to varia- tions in the structure and function of health agencies. Nonethe- less, each local governmental health agency shares some com- monly held responsibilities, functions, and structural features.
The primary responsibilities of the local health depart- ment are to assess the population’s health status and needs, determine how well those needs are being met, and take action toward satisfying unmet needs (Scutchfield & Keck, 2003). Specifically, local government health agencies should fulfill these core functions as follows:
◆ Monitor local health needs and the resources for addressing them.
◆ Develop policy and provide leadership in advocating equitable distribution of resources and services, both public and private.
◆ Evaluate availability, accessibility, and quality of health services for all members of the community.
◆ Keep the community informed about how to access public health services.
The local health agency represents a critical level of health services’ provision because of its closeness to the ulti- mate recipients—health care consumers. The most recent survey of local health departments revealed the top three expenditure categories as enforcing laws and regulations;
informing, educating, and empowering people; and ensuring the provision of care (Barry et al., 1998).
The structure of the local health department varies in complexity with the setting. Rural and small urban agencies need only a simple organization, whereas large metropolitan agencies require more complex organizational structures to support the greater diversity and quantity of work.
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UNIT 2 Public Health Essentials for Community Health NursingTABLE 6.3
Core Public Health Functions Applied to Populations and People at Risk
Population-Wide Services Assessment
• Health status monitoring and disease surveillance Public Policy
• Leadership, policy, planning, and administration Assurance
• Investigation and control of diseases and injuries
• Protection of environment, workplaces, housing, food, and water
• Laboratory services to support disease control and environmental protection
• Health education and information
• Community mobilization for health-related issues
• Targeted outreach and linkage to personal services
• Health services quality assurance and accountability
• Training and education of public health professionals Personal Services and Home Visits for People at Risk
• Primary care for unserved and underserved people
• Treatment services for targeted conditions
• Clinical preventive services
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Where a board of health exists, it holds the legal respon- sibility for the health of its citizens. About 80% of local pub- lic health departments work with a board of health, and they are more commonly found with smaller populations (Turnock, 2004). Health board members may be appointed by the mayor if the board of health serves a city, by a board of supervisors if the board of health serves a county, or by vot- ers if they are publicly elected. In turn, the board of health usually appoints a health officer (about 80%)—often a physi- cian (about 50%) with public health training (about 15%)—
who directs the remaining staff of the health department, including public health nurses, environmental health workers, health educators, and office personnel (Turnock, 2004). Oth- ers, such as nutritionists, statisticians, epidemiologists, social workers, physical therapists, veterinarians, or public health dentists, may be added as needs and as resources dictate. The number of staff at local health departments can range from five to over 100, depending upon the size of the agency and population served (Scutchfield & Keck, 2003).
Revenues to support local health departments come from various sources. Local and county general appropriations
make up the largest share of the local health department’s budget—around 44%. State revenues account for about 30%
of the total local budget—with additional funds provided through special levies and programs such as school health, Head Start, air pollution, toxic substance control, primary care, immunizations, fees, and private foundation grants.
Federal funds provide another source of revenue (about 3%) targeted at specific efforts, such as AIDS research and serv- ices, family planning, child health, environmental protec- tion, and hypertension and nutrition programs. According to Turnock (2004), fees, reimbursements, and additional mis- cellaneous sources, such as state laboratory revenues and food supply supplements, make up the remaining portion of the budget (about 23%). A good number of health depart- ments bill Medicaid for personal health services rendered (e.g., prenatal care, TB treatment, well-baby care), but an increasing number of states are offering Medicaid managed care, and moving personal health care out of local health departments (Scutchfield & Keck, 2003). Figure 6.1 depicts the organization of one local health department serving a population of approximately 300,000.
CHAPTER 6 Structure and Economics of Community Health Services
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129City Council and Board of Health
Health Planning and Administration
Commissioner of Health
Medical Consultation Public Health
Advisory Committee
Health Statistics and Management Information Health Planning and Evaluation/
Contract Monitoring Finance and Administrative Services
Environmental Health Services
Animal Control Environmental Control: Housing Hygiene/Pest Control Food Protection and Sanitation/
Institutional Health
Public Health Nursing Services
Illness Care and Rehabilitation (HVNA)
Health Promotion (HHD)
Personal Health Services
Nutrition Services WIC
Health Education
Public Health Laboratory Services Dental Program Maternal and Child Health Services
F I G U R E 6.1 Organizational chart of a city public health department.
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State Public Health Agencies
State-level government health agencies also vary in struc- ture and in how they carry out the core functions. Each state, as a sovereign government, establishes its own health department, which in turn determines its goals, actions, and administrative structure. The state health department is responsible for providing leadership in and monitoring of comprehensive public health needs and services in the state.
It establishes statewide health policy standards, assists local communities, allocates funds, promotes state-level health planning, conducts and evaluates state-level health pro- grams, promotes cooperation with voluntary (private) health agencies or NGOs, and collaborates with the federal gov- ernment for health planning and policy development (Scutchfield & Keck, 2003). Of the various levels of gov- ernment health agencies, the states recently have played the most pivotal role in health policy formation.
General functions of state health departments include (Scutchfield & Keck, 2003):
◆ Statewide health planning
◆ Intergovernmental and other agency relations
◆ Intrastate agency relations
◆ Certain statewide policy determinations
◆ Standards setting
◆ Health regulatory functions
Specifically, the Institute of Medicine (1988) described the role of state government related to health. Summarized, it includes:
◆ A statewide method of collecting and analyzing data to assess health needs
◆ Adequate statutory base for state health activities
◆ Statewide health objectives (holding localities accountable where power for implementation has been delegated)
◆ Statewide development and maintenance of essen- tial personal, educational, and environmental health services
◆ Identification of problems that threaten the health of the state
◆ Support for local health services (when needed to achieve adequate service levels) through subsidies, technical and administrative assistance, or direct action
State public health agencies face a challenge in address- ing the health-related issues confronting them. Health insur- ance, long-term care, organ transplants and donations, AIDS, care of the medically indigent (those who are unable to pay for and totally lack medical services), malpractice, and cer- tificates of need for new health services are among the prob- lems faced by most states. Clearly, state health departments must collaborate closely with other agencies, such as social services, education, public works, the legislature, and the housing bureau, to effectively solve such problems. Thus, the solution of state health problems and delivery of health serv- ices requires the functioning of an interdependent network of organizations, many of which are not health agencies per se.
Budgetary sources for a state health department include state-generated funds, federal grants and contracts, and fees and reimbursements. A large source of federal
monies to the states comes through the Department of Agri- culture, which supports the Women, Infants, and Children (WIC) Program, a supplemental nutrition program. State health agencies often provide grant opportunities for local health departments (often through federal grant monies awarded to states). Fragmentation of public health roles and functions among different state agencies poses problems for coordinating the core public health functions at this level (Turnock, 2004). Funding for state public health agencies comes largely from state coffers, with less than 40% coming from federal contracts and grants, and a smaller percentage generated from fees and third-party reimbursements, local taxes and funds, as well as other sources (Scutchfield &
Keck, 2003). The Department of Agriculture, the Centers for Disease Control and Prevention, and Health Resources and Services Administration (HRSA) all provide substantial funding at the state level. Less than 6% of all state health care expenditures go toward population health (e.g., health promotion, chronic disease control), even with the addition of new federal bioterrorism monies (Milbank Memorial Fund et al., 2003). In many states, these new funds have been accompanied by state and local funding cuts that actually leave agencies in worse financial shape (Elliott, 2002).
State-level population health expenditures in 2001 accounted for 6.3% of all health care expenditures. Most expenditures were for promotion of chronic disease control and healthy behaviors, along with environmental hazards control programs (Milbank Memorial Fund et al., 2003).
Prevention of epidemics and communicable disease control, injury prevention, disaster preparation and response, and health infrastructure were also included under this spending category.
Each of the 50 state health departments in the United States has developed its own unique structure. Some are strongly centralized organizations, whereas others are decentralized. In most states, the appointed director or exec- utive of the agency reports to a state board of health or directly to the governor. Some states have advisory boards that make health policy recommendations and review depart- mental activities. Significant variation occurs in the types of programs managed by state health agencies—in 2002, about 90% reported administrative responsibility for the WIC pro- gram, public health laboratories, vital statistics, and tobacco programs, but only 25% served as the state’s environmental regulatory agency (Turnock, 2004). Over 70% regulate health care facilities and deal with food safety and environ- mental health issues, while over 30% regulate licensing of health professionals. Organizational structures vary from state to state, but there are usually several divisions or bureaus under the director. Those most commonly found in state health department organizational structures are disease prevention and control, community health services, mater- nal and child health, health systems and technical services, laboratory services, environmental health, and a state center for health statistics. Figure 6.2 shows the organizational chart of a state health department.
National Public Health Agencies
The national level of public health organization consists of many government agencies. They can be clustered into four groups. First and most directly focused on health is the 130
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Public Health Service(PHS). It is concerned with the broad health interests of the country and is a functional (not organi- zational) unit of DHHS (see Chapter 30 for more on the PHS Commissioned Corps).
The Secretary of Health and Human Services (a cabinet- level position) has ultimate responsibility for the PHS. The PHS consists of the Office of Public Health and Science (headed by the Assistant Secretary for Health), and comprises the Commissioned Core (over 6,000 uniformed health profes- sionals), the Office of the Surgeon General, and 12 public health offices (e.g., Office of Women’s Health, National Vac- cine Program Office, Office of HIV/AIDS Policy, Office of
Minority Health). The PHS is made up of eight functional branches: the CDC, the FDA, the NIH, the Substance Abuse and Mental Health Services Administration (SAMHSA), the HRSA, the Agency for Healthcare Research & Quality (AHRQ), the Indian Health Service, and the Agency for Toxic Substances and Disease Registry (ATSDR). One of its major functions through these eight branches is the administration of grants and contracts with other government agencies, pri- vate organizations, and individuals. In some instances, the PHS provides hospital, clinical, and other types of health services, for example, for Native Americans and Eskimos through the Indian Health Service. Through the CDC and the CHAPTER 6 Structure and Economics of Community Health Services
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131Accounts and Finance
Personnel and Training
Administrative Services
Vital Records
Center for Health Statistics
Health Education
District Services
Mortuary Science
Hotels, Resorts and Restaurants
Occupational Health
Water Supply and General Engineering
Radiation
Health Risk Assessment
Analytic Services
Field Services
Microbiology
Immunology
Special Lab Studies
Clinical Laboratory Improvement
Laboratory Services
Hereditary/
Metabolic and Viral Diseases
Data and Specimen
Handling
Acute Disease Programs
Chronic Disease Control & Health
Promotion
Chronic Disease Epidemiology
Epidemiologic Field Services
Dental Public Health
Nutrition
Public Health Nursing
MCH Technical Services
Services for Children with
Handicaps
Women, Infants and Children Food Supplements
Technical Consulting and
Training Environmental
Health Division Director
Engineering Services
Survey and Compliance
Quality Assurance and Review
Planning and Resource Control
Emergency Medical Services
Health Economics
Health Manpower
Analysis Health Maintenance Organizations Community Health
Services Advisory Committee
Maternal and Child Health Advisory
Task Force
Bureau of Health Services Assistant Commissioner Health Facility Complex
Assistant to Commissioner
Health Law Controller
Deputy Commissioner Commissioner of Health
GOVERNOR
Bureau of Community Services Assistant Commissioner Office of Community Development
Acute Disease Epidemiology Medical Labs
Division Director
Disease Prevention
& Control Division Director
Maternal & Child Health Division
Director
Health Systems Division Director Bureau of Administration
Assistant Commissioner
F I G U R E 6.2 Organizational chart of a state public health department.
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NIH, it provides epidemiologic surveillance and numerous research programs. The FDA of the PHS monitors the safety and usefulness of various food and drug products, as well as cosmetics, toys, and flammable fabrics (Office of the Public Health Service Historian, 2004; USDHHS, 2006, 2007).
Through its staff offices, the PHS offers other services.
It has responsibility for the formation, planning, and evalu- ation of health policy; health promotion; health services management; health research and statistics; intergovernmen- tal affairs; legislation; population affairs; and international health. It provides financial assistance to the states through grants-in-aid—monies raised by Congress through taxes for specific purposes. It also offers consultation through national advisory health councils and special advisory com- mittees made up of lay experts. The PHS maintains 10 regional offices to make its services more readily available to the states. These offices are located in New York City, Boston, Philadelphia, Atlanta, Chicago, Kansas City, Dallas, Denver, Seattle, and San Francisco.
At the federal level, the primary agencies concerned with health are organized under the DHHS. Assistant secre- taries manage offices for Health, Administration and Man- agement, Resources and Technology, Planning and Evalua- tion, Public Health Emergency Preparedness, Legislation, and Public Affairs. Within the DHHS, clusters of federal agencies deal with the needs of special population groups, such as the elderly (Administration on Aging), children (Administration for Children and Families), and Native Americans (Bureau of Indian Affairs), and government health insurance programs (Centers for Medicare and Med- icaid Services) (USDHHS, 2006). Figure 6.3 is the organi- zational chart for USDHHS.
Another cluster of service departments addresses spe- cial programs or problems. Examples are the Department of Labor, the Department of Education, the Department of the Interior, the Department of Agriculture, and the Department of Transportation. A final cluster of federal agencies focuses on international health concerns of interest to the nation.
Two important ones are the U.S. Agency for International Development (USAID), an independent agency, and the Office of International Health Affairs, under the Department of State (Turnock, 2004).
Budgets and Funding for Public Health
Annually, only 8% of health spending goes toward health promotion and improvement, while 92% is spent for medical care (Trust for America’s Health, 2005). Actual government spending for public health is estimated at only 3% of total U.S. health spending (Sensenig, 2007). In 2000, the state and local levels contributed about 70% of spending for public health service. Federal funds for public health are more often directed toward research, health status monitoring, program evaluation, and workforce training (Turnock, 2004). In 2004, the CDC spent just under $15 per capita, with individual state spending ranging between just above
$9 to almost $46 per person (Trust for America’s Health, 2005). The sum is paltry considering that total current per capita annual health expenditure well exceeds $6,100 (Col- liver, 2007). This disproportionate funding for health con- tinues despite estimations that more “robust” public health funding would provide the following benefits:
◆ Prevent 43,000 amputations, 165,000 kidney failures, and over 10,000 cases of eye disease among diabetics every year
◆ Reduce annual traffic deaths by 9,000
◆ Reduce, by 50%, new cases of HIV (40,000 annually)
◆ Reduce the number of alcohol-exposed fetuses by two-thirds
◆ Eliminate childhood lead poisoning by the year 2010 (Trust for America’s Health, 2005, p. 7) Most of the Healthy People 2010 goals remain unmet, and strategies for wide scale change and capturing of suffi- cient funding have not materialized. The Public Health Foundation (n.d., ¶1) estimates that “2 million deaths may occur this decade . . . as a result of not meeting only nine of the Healthy People 2010” objectives. But, in addition to health promotion, public health services must be ready for disasters, bioterrorism, and pandemics, and evidence is mounting that the system is structurally weak and suffers from poor access and inconsistent preparation (CDC, 2002, 2008; Institute of Medicine, 2002). To meet the necessary standards and immediate needs, an estimated $10 billion plus in new funding is required (Public Health Foundation, 2007).
Private Sector Health Services
The nongovernmental and voluntary arm of the health care delivery system includes many types of services. Privately owned, nonprofit health agencies (most hospitals and welfare agencies) make up one large group. Privately owned (pro- prietary), for-profit agencies are another. Private profes- sional health care practice, composed largely of physicians in solo or group practice, forms a third group. These make up the non–tax-supported, nongovernmental dimension of community health care.
Private health services are complementary and supple- mentary to government health agencies. They often meet the needs of special groups, such as those with cancer or heart disease; they offer an avenue for private enterprise or phi- lanthropy; they are less constrained than government agencies in developing innovations in health care; and they have been spurred to development, in part, by impatience or dissatis- faction with government programs. Their financial support comes from voluntary contributions, bequests, or fees (Scutchfield & Keck, 2003).
For-Profit and Not-for-Profit Health Agencies Proprietary health servicesare privately owned and man- aged. They may be nonprofit or for-profit. Many hospitals and nursing homes offer nonprofit services, but must gener- ate sufficient revenues to keep ahead of operating costs.
Often, one or more special services offered by a hospital generate enough income to cover the drain from more expensive programs or uncompensated care. As more hospi- tals have merged or been integrated into larger health con- glomerates, the practice in many cases has been to establish a separate, for-profit corporation that generates revenues so that the basic organization can retain its nonprofit, tax-exempt status.
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