Project Background
Introduction
At the Town Hall Meeting of NACCHO Annual 2002, the membership and a distinguished panel of local, state, and federal public health leaders discussed a vision paper entitled “Imagining the Ideal Local Public Health Agency.” Following a rich exchange between panelists and conference participants, a general consensus developed on the importance of engaging the NACCHO membership around a vision of an ideal local health department (LHD) and moving that vision forward. This consensus drove a series of deliberations by NACCHO’s leadership about how best to proceed.
The leadership’s deliberations gradually focused on the need to define what people in any community can reasonably expect their local governmental public health agency to provide. Taking this approach emphasizes the common denominator in all communities: the unique role of the governmental local health department that cannot be delegated to or assumed by others in the community. It also avoids debates about what constitutes ideal size, staffing, structure, and governance of LHDs – characteristics that, by necessity, vary widely among jurisdictions.
As a result of these deliberations, the NACCHO leadership added a new objective to the strategic plan: Develop and promote an operational definition of a local public health agency. The Background section below traces events over the past 15 years that illustrated the need to develop a shared understanding of an operational definition of an LHD. Before engaging in this effort, NACCHO distributed a prospectus based on this paper to NACCHO members, other national public health associations, federal agencies, academics, and other partners. The feedback received indicated a high level of interest, support, and desire to participate.
History
Over the past 15 years, several large-scale efforts have sought to strengthen public health in a variety of ways: by defining public health, measuring the performance of public health entities, setting public health goals, establishing the direction of public health policy, and determining how best to staff and fund public health activities. These external forces have influenced local public health practice, sometimes in a disparate fashion. A pro-actively developed, shared definition of what people in any community can expect from their governmental local health department could serve to inform and lend consistency to ongoing and future efforts to strengthen public health practice. In response, the National Association of County and City Health Officials (NACCHO) developed an operational definition of a local health department, based on the input and acceptance of interested parties including LHDs and representatives of state health departments, federal agencies, local boards of health, and state and local elected officials.
The landmark Institute of Medicine (IOM) report issued in 1988, The Future of Public Health, marked the first significant activity in defining public health. Perhaps most memorable observation was that governmental public health was in “disarray.” The report also went on to identify three core functions of public health and offered a series of recommendations regarding the mission and governmental role (at all three levels of government) of public health. The three core functions quickly became the basis for further definition of public health. Subsequently, the “Ten Essential Services” were developed by a national committee of public health professionals and are recognized today as the foundation for defining public health. The essential services provide an excellent framework for an operational definition of LHDs. Through this operational definition, NACCHO identified the unique role of local governmental public health in providing each essential service.
Efforts have been under way over the past several years by the American Public Health Association (APHA), the Joint Committee on Accreditation of Hospitals (JCAHO), the IOM, and others to develop and implement performance standards and competencies at all levels of government. Most notably, the National Public Health Performance Standards Program (NPHPSP) measures the performance of the public health system at the state level, at the local level, and from the perspective of governing agencies (i.e., boards of health). The NPHPSP uses the "Ten Essential Services" as a framework to measure the public health system. However, it does not offer a means to measure and hold accountable governmental public health agencies for their role within the public health system. NACCHO’s operational definition speaks to the specific role of LHDs in providing each essential service in order for a local public health system to meet the standards put forth in the NPHPSP.
Approaches to certification of local public health agencies in whole or in part are increasingly being recommended and/or pursued at the state level and by others such as APHA and IOM. A range of interested parties--federal agencies, some states, APHA, the Public Health Foundation, schools of public health, and others--are involved in ongoing and increasing efforts regarding credentialing of the public health workforce at the local level. Implementing these activities effectively would determine LHDs’ programs, services, and workforce qualifications. On the other hand, an operational definition of LHDs is intended to drive certification and credentialing efforts, providing the basis of what needs to be measured and promoted in LHDs.
Bioterrorism preparedness has set the stage for unprecedented public expectations and concerns regarding public health preparedness and responsiveness. The increased funding and policy attention directed toward governmental public health is likely to result in increased accountability measures and documentation of readiness and performance. The operational definition provides the basis for accountability measures and clarifies what the public should expect from LHDs in terms of public health preparedness and responsiveness -- for bioterrorism as well as for other public health threats. Furthermore, at some point, funding for bioterrorism preparedness will diminish, and other funding mechanisms will need to be secured. The operational definition provides a much-needed framework to assist in securing funds and establishing methods and measures of accountability.
The final effort of note is the 2002 Institute of Medicine (IOM) report, The Future of the Public’s Health in the 21st Century. This report takes a systems approach to public health, identifying the members of the system and offering a series of recommendations about the role of each. Further, the report describes governmental public health as being the “backbone” of the public health system. Absent, however, is an articulation of how the system actually works -- that is, how members come to understand and embrace their roles, and what it means for governmental public health to serve as the system’s backbone. As the public health community works to implement the recommendations contained in the IOM report, it has become increasingly important to have a shared understanding of the role of governmental public health. NACCHO contends that serving as the “backbone” of the public health system means that, with their governmental authority and accountability to the public, governmental public health agencies are responsible for bringing the system together and moving members’ public health efforts forward. This role is critical to achieving a functional system. Without a clear definition of the role of governmental public health agencies, there is a risk that the IOM’s recommendations will amount to little more than a compiled list of organizational entities, with no activity or collective effort to improve public health.
Opportunities
For these reasons, the release of the IOM report added an additional degree of urgency to the need to develop an operational definition of LHDs. Recent public health threats underscore the urgency as well: The advent of Severe Acute Respiratory Syndrome (SARS) and the continued threat of a bioterrorism event provide timely opportunities to include support for basic public health preparedness in discussions about funding. Missing these opportunities could contribute to the ongoing practice of backing into a definition of public health by citing the most pressing issues and by subsequent resource redirection. On the other hand, the public attention on current and potential public health threats and crises, coupled with the weight of the IOM’s identification of governmental public health as the system’s backbone, provides an exceptional opportunity to create an expectation of governmental public health responsibilities. NACCHO is seizing this opportunity to clearly articulate the governmental responsibilities of LHDs, within the context of the local public health system.
Currently, LHDs’ size, structure, staffing, jurisdiction size and type, programs, and services offered vary widely. Keeping that in mind, the operational definition describes what basic public health protections people in every community can expect from their local public health agency. Through implementation of the operational definition, what LHDs are expected to accomplish, and their ability to direct available resources to this end, will become consistent, though how this is accomplished will vary.
It is also important to note that, in order to be implemented, the operational definition of LHDs needs the support of others in the public health system. State health departments, state and local boards of health and elected officials, federal agencies, and others are key in helping to move NACCHO's development of an operational definition into implementation.
With the Operational Definition developed, and a shared understanding of the role of local public health established, several initiatives are underway. The first is assessing the gap between the operational definition and existing LHD capacities; as mentioned above, current capacities vary widely. Another initiative includes gathering information on the various structures of LHDs that meet this definition. NACCHO is assisting LHDs in acquiring the capacities to meet the operational definition through a variety of mechanisms such as model practices, technical assistance and workshops. It is anticipated that all of these efforts will help achieve the Healthy People 2010 goal to “Ensure that Federal, Tribal, State, and local health departments have the infrastructure to provide essential public health services effectively.”
For more information, please contact Jessica Solomon at jsolomon@naccho.org or (202) 783-5550, Ext. 266.
