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Week 9 - Part 1: Public Health Organizations

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Ashley Conway

on 9 February 2017

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Transcript of Week 9 - Part 1: Public Health Organizations

Week 9 - Part 1:
Public Health Infrastructure & Organizations

Public health infrastucture and organizations:
Describe the characteristics of governmental agencies, quasi-governmental agencies, nongovernmental agencies, voluntary agencies, professional organizations/associations, and others
Describe the responsibilities of federal, state, and local public health agencies and how they relate to each other
Describe the 3 core public health functions and the 10 essential services

Health care delivery in the United States:
Identify major concerns of the health care system
Trace the history of US health care
Explain the spectrum of health care delivery
Discuss the politics of health care delivery
Examining the organizational structure of public health and how health care is delivered in just one week is like "big and little". Tackling
two big topics
in a short time will allow you a
little glimpse
into the vast network of public health organizations and the complex health care delivery system in the United States.

Gaining an understanding of both topics is important to those of you who will have careers in public health or as health care practitioners; but these topics are important to everyone -- as consumers of health care and as individuals who rely on the day-to-day work of the public health system.

Let's take a look at the learning objectives for this week.
Your text book begins the exploration of public health organizations with international organizations. This lecture will start with local health departments (LHD) because of their critical role in public health.

Public health professionals know that when health events occur it is on the local level; whether responding to a disease outbreak or providing health care services to a priority population.

LHDs are governmental health agencies.

LHDs protect and improve community well-being by preventing disease, illness and injury and impacting social, economic and environmental factors fundamental to excellent health. The LHD is the foundation of the local public health system that comprises public- and private-sector health care providers, academia, business, the media, and other local and state governmental entities. Adapting to local circumstances, LHDs vary in the strategies and tactics used to protect and improve community well-being. Every person, regardless of where they live, can reasonably expect the following from their LHD.

• Track and investigate health problems and hazards in the community
LHDs gather and analyze data on the community’s health to determine risks and problems. This information drives specific programs and activities designed to control multiple threats: both communicable and chronic diseases; food, water, insect and other “vector-borne” outbreaks; biological, chemical and radiological hazards; and public health disasters.

• Prepare for and respond to public health emergencies
. As a result of extensive and ongoing preparation, LHDs respond quickly and effectively to disease outbreaks and other public health events—they are intensively trained to respond to increases in the incidence of diseases, natural disasters, and acts of terrorism. They coordinate delivery of drugs, supplies, and provisions to victims and populations at risk. They keep the public informed and serve as the network hub for community hospitals, physicians, and other health care providers.

• Develop, apply and enforce policies, laws and regulations that improve health and ensure safety.
Acting on their knowledge about their community, LHDs create data-driven policies to meet health needs and address emerging issues. They help craft sound health policies by providing expertise to local, state and federal decision makers. LHDs also inform individuals and organizations about public health laws while monitoring and enforcing compliance.

• Lead efforts to mobilize communities around important health issues
. With local and state government agencies, businesses, schools, and the media, LHDs spearhead locally organized health promotion and disease prevention campaigns and projects. They galvanize the community to tackle disease prevention and personal health care needs. LHDs also educate and encourage people to lead healthy lives through community forums; public workshops and presentations; and public service announcements.

• Link people to health services.
LHDs connect people with personal health services, including preventive and health promotion services, either in the community or as close to the community as possible. They also advocate for development of needed programs and services in underserved populations and continuously monitor the quality and accessibility of public health services.

• Achieve excellence in public health practice through a trained workforce, evaluation, and evidence-based programs
. LHDs recruit and develop skilled workers with expertise in core public health competencies. They ensure that public health workers update their knowledge and skills through continuing education, training and leadership development activities. They regularly evaluate the effectiveness of all programs and activities using evidence-based standards and strive to adapt successful interventions from other communities.

The Role of Local Health Departments
Public Health Logo video, NAACHOph (1:53)
State Health Departments
All 50 states have a state health department to promote, protect, and maintain the health and welfare of their citizens*. These purposes are the core functions of public health. Within the three core functions are the 10 essential public health services.
* Citizen in this context means a person who lives in a particular place and belongs to that community. It doesn't refer to an individual's legal status.
- Jones & Bartlett Learning
Core Public Health Functions
& 10 Essential Services
Coordinated school health (CSH) is recommended by CDC as a strategy for improving students' health and learning in our nation’s schools.

Schools are funded by tax dollars and are under the supervision of a school board
Schools have great potential for impacting community health
CSHP essential components:

Next you will read about a CSHP success story in Philadelphia.
Coordinated School Health Programs
Research shows that school health programs pay off in better academic performance and healthier children and communities.

But significant barriers exist for school health programs including inequitable school funding (schools are often funded by property taxes, so the poorer the neighborhood - the less money its schools have); steep funding cuts or the complete elimination of school health programs; and high student to nurse ratios - despite the fact that students' health needs are evermore complex.
Challenges for school health programs
- McKenzie, Pinger & Kotecki
New Jersey's State Board of Health was established in 1877. The New Jersey Department of Health (DoH) was created in 1947 and renamed the New Jersey Department of Health and Senior Services (DHSS) in 1996. Under reorganization by Governor Christy in 2012, Senior Services moved back to the New Jersey Department of Human Services and it became the New Jersey Department of Health once again. The Department of Health is headed by the Commissioner of Health who is appointed by the Governor.

NJ Department of Health: http://www.nj.gov/health/
Meet the Commissioner (2:01)
New Jersey Commissioner of Health
N.J. Department of Health Major Divisions and Programs
Office of the
Office of Policy and
Strategic Planning
Public Health
Health Systems

•Office of the State Epidemiologist/Environmental and Occupational Health Services
◦Communicable Disease Service
◦Consumer, Environmental and Occupational Health Service
◦Cancer Epidemiology Services
•Division of HIV/AIDS, TB and STD Services
•Division of Family Health Services
•Division of Public Health Infrastructure, Laboratories and Emergency Preparedness
◦Public Health and Environmental Laboratories

Commissioners of health (and other top-level positions) in state health departments are appointed by the elected governor. They are responsible for making policy and determining the direction of health for the state. What are ways that political agendas or ideologies could influence the public health of a state?
Who pays for public health?
Well, YOU do. Tax monies from federal, state, and local sources fund LHDs, state health departments, and national health agencies. As you have learned, having a strong public health infrastructure is critical to control disease and as the rates of chronic, non-communicable disease increase to implement prevention measures. However, the investment of sufficient and sustainable funding is a struggle in today's economic environment.
Federal funding for public health has remained at a relatively flat and insufficient level for years. For instance, the budget for CDC has decreased from a high of $7.31 billion in 2005 to $6.13 billion in 2012.

At the state and local levels, public health budgets have been cut at drastic rates in recent years. According to a survey by the Association of State and Territorial Health Officials (ASTHO), 48 state health agencies reported experiencing budget cuts since 2008. State and local health agencies have cut more than 45,700 jobs across the country since 2008. During 2011, 57 percent of all local health departments reduced or eliminated at least one program.
- Investing in America's Health: A State-by-State Look at Public Health Funding and Key Health Facts.
(2013) The Trust for America’s Health (TFAH) and Robert Wood Johnson Foundation (RWJF)
National Health Agencies
Each nation has a department or agency within its government responsible for protection of health and welfare of its citizens

The Department of Health and Human Services (HHS) is the United States government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves. HHS is headed by the Secretary (a Presidential appointment) who is the chief managing officer for its family of agencies, including 11 operating divisions, 10 regional offices, as well as the Office of the Secretary.

Yes, HHS is a bureaucracy - a large institution governed by an administrative system, managed by departments, and staffed by non-elected officials. Governmental bureaucracies are often criticized for being inflexible, overly complicated, and inefficient.

But the negative stereotypes of governmental agencies don't tell the whole story and can be used to undermine services that are critical to the health of the country.

Governmental bureaucracies were intentionally created to be run by rules and standards in order to root out corruption and end a hiring system of patronage (who you know vs. what you know). No organization is perfect; whether public sector (think HHS) or private sector (think Apple Computers) and - like a scientific theory - they can be improved upon!

The problem with stereotypes of bureaucracies is that they focus on the short-comings of an organization such as HHS while overlooking its achievements (remember the 10 Greatest Public Health Achievements studied in Week 2?) and the role they play in promoting the important missions of a modern democratic government.

I have been a public servant for most of my career, and from my perspective, government agencies are overwhelmingly staffed by highly skilled professionals who are dedicated to their organization's mission and to serving the public.

As you listen to the many opinions in the debate over "big government" during the election season try to think like a journalist and decide for yourself how important government services are to you.

Let's take a closer look at one of the 11 Operating Divisions of HHS - the Centers for Disease Control and Prevention. CDC is an organization that interests most students of public health - and for good reason! CDC employs more than 15,000 employees in more than 50 countries and in 168 occupational categories (cdc.gov)

The Centers for Disease Control and Prevention (CDC) serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and health education activities designed to improve the health of the people of the United States (CDC Mission Statement).
CDC approach to public health:

First find out what’s making people sick and killing them and then do the things that work to protect them and make them healthier. With this philosophy in mind, we are at the forefront of public health efforts.. We work with many partners at the local, state, and national levels to improve the public’s health, with a particular focus in the following areas:

Increasing support to local and state health departments
- We are only as strong as our partnerships. We are passionate about offering the best technical, financial, and direct assistance possible for the good of the whole in public health.
•Improving global health
- Provide unwavering leadership in health policy development. We strengthen the ability of governments and organizations across the globe to achieve their health goals and deepen the effectiveness and efficiency of their health systems.
•Decreasing leading causes of death
- We are fiercely devoted to improving the social determinants of health — disparities in the conditions in which people are born, grow, live, work, and age. These imbalances are largely responsible for health
inequities in everything from obesity to heart disease.
•Strengthening surveillance and epidemiology
- Rigorous surveillance and epidemiology are our most powerful tools. They form our ethos and the foundation of our authority.
•Reforming Health Policies
- Prevention is on the map as never before; it is key to the future of health in this country and is a part of the legislation currently under debate. We are closely monitoring the legislation and potential impacts on public health entities and are working closely.

Within the CDC are CIO - Centers, Institutes and Offices. The purpose of the CIO is to "allow the agency to be more responsive and effective when dealing with public health concerns" (CDC website). CIOs and their roles are presented in more depth in the text book.
International health organizations are usually divided into three groups:
multilateral organizations, bilateral organizations, and non-governmental organizations

means that funding comes from multiple governments (as well as from non-governmental sources) and is distributed to many different countries. The major multilateral organizations are all part of the United Nations. The World Health Organization (WHO) is the premier international health organization.

agencies are governmental agencies in a single country which provide aid to developing countries. The largest of these is the United States Agency for International Development (USAID). Most of the industrialized nations have a similar governmental agency.

Non-governmental organizations (NGOs)
, also known as private voluntary organizations, provide approximately 20% of all external health aid to developing countries. An example of a large NGO is Oxfam, but most of these organizations are quite small; many are church-affiliated.

The largest and most influential international organization is the World Health Organization (WHO). You will be reading about WHO in Chapter 2, but first watch this....

International Health Organizations
- International Medical Volunteers Association (IMVA)
Happy New Year from WHO (3:52)
Geography Video. Millennium Development Goals - Dream or Reality? (26:47)
This video critiques the concept of Millennium Development Goals (MDGs) and the progress that has been made - or not made.

Read Chapter 2 in the text - Organizations that Help Shape Public Health.

When you are ready, open Part 2 of the Week 9 lecture (available on the Week 9 page in Canvas).

Understanding how public health and the health care system is organized (its structure) can provide you with a mental map that can be helpful when you navigate the job market!

Ashley Conway
Principles of Public Health
Bloustein School of Planning and Public Policy
Rutgers University
Fall 2016
Most sources are credited in individual frames

Leachman, M. & Mai, C. 2014. Most States Still Funding Schools Less Than Before the Recession.
Center on Budget and Policy Priorities.
Why do I need to know this stuff?
: Proportionality requires that restrictions to individual liberty and measures taken to protect the public form harm should not exceed what is necessary to address the actual level of risk to the community (or the actual needs of the community).

: Individuals have the right to privacy in health care. In a public health crisis it may be necessary to override this right to protect the public from serious harm.

Duty to Provide Care
: Inherent to all codes of ethics for health care professionals is the duty to provide care and to respond to suffering. Health care providers have to weigh demands of their roles against competing obligations to their own health, and to family and friends.

: Requires that society support those who face a disproportionate burden in protecting the public good and take measures to minimize that burden.

: Difficult decisions will need to be made about which health services to maintain and which to curtail.

: Decision makers will be confronted with the challenge of maintaining stakeholder trust implementing various control measures during an evolving health crisis. Trust is enhanced by upholding values such as transparency and honesty.

: A health crisis such as a pandemic can challenge ideas of sovereignty, security or territory. Collaborative approaches that set aside traditional values of self-interest is required among response partners, health care institutions, institutions, cities, counties, states & nations.

: Those entrusted with governance roles should be guided by the concept of stewardship. Inherent in the concept is trust, ethical behavior, and good decision-making.

As you progress through this week's content, think about the ethical underpinnings of public health (Week 5) and how decisions made at all levels of our public health infrastructure have an ethical component.

Applied, professional, and advocacy ethics are inherent in health care delivery issues. This will be part of your discussion in groups this week.
Issues to consider in ethical decision making
- Joint Centre for Bioethics, University of Toronto
NACCHOph. (2015) Public Health Trasnformation. (5:22)
I like the way this video emphasizes the interrelatedness of medical practice and public health. Also, take note of how it mentions the challenge of an aging PH workforce. This is troubling for those of us in PH who look around a conference room and see a sea of grey heads, but an opportunity for those of you just beginning your PH career. As baby-boomers near the end of their careers, the next generation of public health professionals will need to assume important positions in PH organizations to carry on the important work of public health.
The National Association of County & City Health Officials (NACCHO) is comprised of nearly 3,000 Local Health Departments across the United States.

The association considers itself the national voice for Local Health Departments by serving a critical role in Washington. NAACHO advocacy efforts focus on informing policymakers of the critical role that local health departments play in keeping communities healthy and safe.

NACCHO has a great website with lots of free resources available: http://www.naccho.org/
What is NACCHO?
Sounds like a great idea, doesn't it? Unfortunately, States are providing less per-pupil funding for kindergarten through 12th grade than they did seven years ago — often far less. The reduced levels reflect primarily the lingering effects of the 2007-09 recession. This decline in state educational investment is cause for concern.
This model was presented in Week 2. Let's take a look at the 10 essential public health services and some examples of each.
When I made this video, Maureen O'Dowd was the NJ Commissioner of Health. O'Dowd stepped down in 2015 when Cathleen Bennett was named Commissioner. Bennett holds a Master of Government Administration from the University of Pennsylvania, a Juris Doctorate from The Dickinson School of Law, and a Bachelor of Arts from Villanova.

I kept this video in the presentation so you could get an idea of the role of a State Health Department. Also, O'Dowd was only 33 when she was appointed Commissioner and I thought that might interest you.
This is a streamlined org chart of the NJ Dept. of Health. When you are searching for a job or going to an interview, its always a good idea to research the organizational hierarchy so that you will understand how you fit in.
A review of junior high civics class - here is where health fits in the Executive Branch of the federal government.
Full transcript