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Public Health Administration

Public Health Administration
Your first case study is taken from a new set of teaching cases titled “Real Stories” made available by the California Wellness Foundation. The author, Bob Prentice, Ph.D. is a Senior Associate for Public Health Policy and Practice at the Public Health Institute. He previously worked for over seventeen years at the San Francisco Department of Public Health, five years as the Director of the Public Health Division.
Case Directions:
Each group is to develop a response to the case questions. (Make sure you answer all of them!) You should work through each section before proceeding on to the next part. You may experience different viewpoints as you work through this assignment. Give your team enough time to reach a consensus. Please include any relevant references.
Public Health Administration
Bob Prentice
Because “public health” often deals with conditions that maintain the good health of citizens in general, it plays a crucial government role, if sometimes an under-appreciated one. As the following module points out, officials are rarely praised when a diphtheria epidemic does not break out. Organizing a health department so that it can operate efficiently and with the widest impact is an important task that asks you to consider and evaluate the basic structure of public health services.
Particularly since the publication of the influential Institute of Medicine report on The Future of Public Health (1988), there has been a re-thinking of the core functions and organization of public health. Much of what we see in local health departments today is a reflection of developments that had their origins a century ago. These include the emphasis on sanitation (environmental health), the identification of pathogens (public health laboratories), the control of outbreaks and epidemics of communicable diseases (communicable disease control), the focus on the health of infants and children (maternal/child health) and the emphasis on general prevention strategies (health promotion). By mid-century, local health departments had also assumed an increasing role as the health care provider of last resort for those who were poor and uninsured.
Largely through the success of many of those public health activities, people now live on average 30 years longer than they did at the turn of the last century. As people live longer, however, they are more likely to live with, and ultimately die from, chronic diseases (e.g., heart disease or cancer). There is evidence that some of those chronic diseases are linked to the physical environment. The social environment exposes people to the consequences of violence, substance abuse and emotional stress, and the prospects that people will live long and healthy lives is very much influenced by income, ethnicity, gender and other social factors. Much of what defines our health and well-being goes beyond the limits of treating individual illnesses to the conditions that arise from our collective life. If public health, as the Institute of Medicine report suggests, “ . . . fulfill(s) society’s interest in assuring the conditions in which people can be healthy,” then public health must be prepared, both in its mission and its organization, to better understand those broad conditions and to engage in effective action to address them.
PART 1: The Foundation of Public Health
Case Narrative
You are a senior public health administrator who has been asked to participate in the leadership of a strategic planning process to reorganize the health department in a large, urban county. Like other such departments, this one encompasses a broad range of functions, including environmental health, disease control, maternal/child health, health promotion and the provision of medical, mental health and substance abuse treatment services to the poor and uninsured. Services are organized into several separate divisions, each with its own programmatic focus. The decision to reorganize the health department was driven primarily by the need for the hospitals and clinics to engage in managed care competition. However, it is also an opportunity to organize public health in a way that is more appropriate for the conditions that define the health and well-being of people living in the county today.
A basic decision about the reorganization has already been made. There will be two divisions within the health department. One of them will be the health care delivery system (hospitals and clinics) that provides clinical treatment services to individuals; the other will be a public health division that includes the activities designed to prevent illness and premature death among the population as a whole. As a senior public health administrator, you have been asked to convene a process that will result in the reorganization
of public health within the health department.
You are immediately confronted with two major decisions about how to proceed: 1) Who should be involved in the process of formulating a plan to reorganize public health? 2) On what basis should such a reorganization plan be put forward?
Part 1 Questions:
(1) Who should be involved in the process of formulating a plan to reorganize public health?
(2) What is your philosophical basis for your approach to this organization? For example, the clinical division may have chosen “customer service” as their primary focus. What is appropriate for the public health side?
Case Narrative, continued
The reorganization of public health must be based on an understanding of what defines the health and well-being of residents of the county. The epidemiology staff of the health department, for example, recently issued an analysis of premature deaths among county residents using a formula that compares a normal life expectancy with the ages at which people have actually died from specific causes. The report indicates that the ten leading causes of premature—i.e., preventable—deaths were, in order:
1. Heart disease
2. Lung cancer
4. Stroke
5. Drug poisoning
6. Suicide
7. Homicide
8. Pneumonia
9. Chronic liver disease
10. Motor vehicle accidents
The report further detailed the risk factors known to be associated with those causes of death. The risk factors included:
1. Tobacco
2. Alcohol
3. Illicit drugs
4. Diet & exercise
5. Exposure to infectious agents
6. Firearms
7. Motor vehicles
As the report pointed out, however, a singular focus on risk factors, when considered in isolation, tends to individualize prevention strategies (e.g., smoking cessation) when a more effective strategy also includes confronting the broader context (e.g., the tobacco industry, legislation, litigation, cultural supports for smoking).
Part 2 Questions:
1. What services or programs would you need to include within public health to best address the population health issues raised in the analysis of premature mortality?
2. How would you address the identified risk factors of health?
Case Narrative, continued
After deciding who should be involved in the reorganization process and after reviewing with them the available information on the health of the population, you have agreed on the broad features of public health that you would like to have. Now you have to confront two practical issues:
• Is your current staff appropriately trained and is the work environment conducive to carrying out your concept of public health?
• Does your current funding allow you to organize programs and services in a manner that best supports your concept of public health?
You have conducted a review of your current staffing. You discovered that the public health work force consists of physicians trained in preventive medicine, epidemiologists, microbiologists who work in the public health laboratory, public health nurses who work primarily in maternal/child health, health educators, disease control investigators and people working in various administrative and clerical roles.
In addition, the work force is part of civil service and is represented by several different labor unions that negotiate collective bargaining agreements that determine levels of compensation, job responsibilities and hours of work for their membership. With very few exceptions, the staff works Monday through Friday from 8 a.m. to 5 p.m. at health department facilities.
Part 3 Questions:
1. What changes will you need to make to align your present staff with your mission?
Case Narrative, continued
You have concluded that you need flexible financing to reorganize your programs and services in a manner most consistent with your concept of public health. However, as you review your budget, it is clear that most of your federal and state government grants funds are allocated for specific diseases (HIV/AIDS, tuberculosis, sexually transmitted diseases, etc.) or specific populations (maternal/child health, homeless people, etc.). Your most flexible funding is from local government, but you know that it is subject to a highly politicized process and that funding for public health is often secondary to support for clinical treatment services.
Part 4 Questions:
1. Are there any other sources of funds that might support your budget objectives?
PART 5: The Local Public Health System
Case Narrative, continued
In your review of the health profile of the population and of the current organizational capacity in your health department, you concluded that even if public health encompassed more of the services and programs in the health department, it would still not measure up to the scale of factors that affect the health and well-being of people living in your county today. You have reached a conclusion similar to that of many of your colleagues around the nation. For example, the National Association of County and City Health Officials, with funding from the federal Centers for Disease Control, has recently developed a strategic planning process for public health, called Mobilizing for Action through Partnerships and Planning (MAPP), in which they explicitly call for a definition of “the local public health system.” They understand that public health is more than a local (or state) health department, but rather an alliance of institutions and agencies that in combination reflect the range of factors that most influence health and well-being.
Part 5 Questions:
1. Identify public and private organizations that might be instrumental in working collaboratively.
PART 6: Public Health and Medicine
Case Narrative, continued
As you have experienced during your tenure as a senior public health administrator, the health care delivery system tends to get policy and budget priority over public health. People instinctively understand the value of treatment when they are ill, but public health is most effective when nothing (bad) happens. (There are often demonstrations and active lobbying when hospital or clinic services are curtailed, but as Bernard Turnock says in his book, Public Health: What It Is and How It Works, there are no candlelight vigils for people who did not get diphtheria.)
Hospitals employ a disproportionately large share of the health department work force, which makes them a priority for lobbying from labor unions trying to protect their membership. Hospitals are scrutinized by national accrediting bodies and are cited for deficiencies, which generally receive budget priority as a requirement to keep them licensed and operating. Hospital and clinic financial deficits pose immediate problems that must be fixed, so investment in the long-term benefits of public health is often regarded as a luxury. Even the decision to reorganize the health department was driven by the need for the hospitals and clinics to prepare for managed care competition, not because of the need to strengthen public health.
Nevertheless, you are constantly mindful that the greatest achievements in improved health status over the last century have come from public health rather than medical care. You realize that the prevention orientation of public health is a long-term solution to many of the financial crises in health care treatment services, not to mention a better way to address health problems. While your views are shared by many of your public health colleagues, you are not content to repeat it constantly as a lament but would rather have the commitment to public health and its relationship to the health care treatment system properly understood and supported. You see the reorganization of the health department as an opportunity to advance that understanding and support for public health.
Part 6: Questions
1. How would you align your public health division with the general health care treatment system?

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