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Ten Organizational Practices of Public Health: A Historical Perspective
Ten Organizational Practices of Public Health: A Historical Perspective William W. Dyal, BS
In 1988, the Institute of Medicine took a major step forward when it defined the functions of governmental public health agencies as assessment (monitoring the health of the American people), policy development (promoting the development of scientifically sound public health policy), and assurance (guaranteeing the benefits of public health for all citizens). The effort to further describe and measure the practice of public health began in January 1989 when the Centers for Disease Control and Prevention (CDC) convened a meeting of public health leaders including representatives of the Association of State and Temtorial Health Officials, National Association of County Health Officials, United States Conference of Local Health Officers, Public Health Foundation, American Public Health Association, Association of Schools of Public Health, Health Resources and
Services Administration, and CDC. Consensus was reached that these core functions provided an appropriate framework. A beginning effort was made to identify the specific practices or processes required to carry out the core functions. The result of this two- year effort was the delineation of 10 organizational practices that functionally define the practice of public health, provide a basis for measuring the three core functions of public health, and also describe a continuum of problem-solving activity from problem identification to evaluation in order to redirect resources and interventions. Although extensive external examination and validation of these 10 organizational practices is called for, early application and investigation of this framework seem promising. [Am J Prev Med 1995;11(Suppl2):6-81
Understanding the role of public health agencies in our nation's health care system has increasingly become a priority for health professionals and policy makers. The recent debate on health care reform has highlighted the need for those in public health to functionally define what the public health system is and how it contributes to the overall health of the nation. In 1988, in anticipation of this need, the Centers for Disease Control and Prevention (CDC) created the Public Health Practice Program Office. Two of the major responsibilities assigned to the program office's Division of Public Health Systems (DPHS) were to (1)assess and monitor the capacity of state and local public health agencies to carry out their primary roles of
assessment, policy development, and assurance, and (2) strengthen the capacity of the public health system to carry out its role of assessment, policy development, and assurance. These were intimidating responsibilities in and of themselves. Because no consensus definition existed of the public health system, its functions, or the capacity needed to carry out those functions, these responsibilities seemed even more daunting. As a first step in carrying out these responsibilities, DPHS developed a working definition of the public health system including delineation of its functions and necessary capacity. Thanks to the contributions of many of our peers and predecessors, the basis for that definition was already in place. As early as 1973, John Hanlon argued that "the official health agency might better concentrate upon its important and unique potential as community conscience and leader. Governmental agencies, such as local departments of health, are in the best position to sense the need for and to promote the establishment of social policy."' Hanlon further suggested that the critical functions of a local health agency were planning, data collection and analysis, coalition building, and stimulating interest in and concern with the needs of the broad community.' In 1979, Model Standards for Community Preventive Health Services2first described the concept of "a governmental presence
O 1995 American Journal of Preventive Medicine. Research and Measurement in Public Health Practice is a supplement to American Journal of Preventive Medicine Volume 11, Number 6.
From the Public Health Practice Program Office, Centers for Disease Control and Prevention, and the School of Public Health, University of Texas, Houston, Texas. Address reprint requests to Dr. Dyal, University of Texas-Houston, School of Public Health, P.O. Box 20186, Houston, TX 77225.
6 Research and Measurement in Public Health Practice
1
at the local level" that is responsible for the health of the community.This concept is based on a multi-faceted, multi-level governmental responsibility for ensuring that the public health needs of tbc community are met. It is a responsibility that often involves q p c i e s in addition to the public health agency at any particular kL Regardless of the structure, every community must be suved by a governmental entity charged with that responsibility, a d general-purpose government must assign andcoordinate aaponsibility for providing and assuring public health and
e report The Future of Public
Hidh3reinforced these concepts by stating that the governmen-
d responsibility to protect the public's health is represented by aatc and local health departments and the federal Department
untary organizations. mission of public health,
Lcrltb agencies, as the governmental representative of public bb,provide leadership and focus to the collective efforts rlbessing this mission. The report further defined the role of v e n t to include three core functions: assessment, policy Indopment, and assurance. Assessment is the regular, systemricc~llection,assembly, analysis, and dissemination of informab a n the health of the community. Policy development is the of the responsibility to serve the public interest in the l a d o p m e n t of comprehensive public health policies by promoth t b c use of the scientific knowledge base in decision making. lrrrunce guarantees constituents that services necessary to rLiepr agreed-upon goals are provided by encouraging actions dabets (private or public), requiring action through regulation,
,of Healthy People 2000:
carrying out the core
nd assurance. It further statdd that ed and institutionalized on the and standards of effective perfore public health system to fully realblic health pra~tice."~ gies for monitoring and strengthenperformance of the public health system, it ther define the public health system and its re in terms that were measurable and meaningful.
the agency to achieve its objective^."^ Although this explanation of infrastructure refers to an agency or organization, it does provide insight into further describing the function of the public health system's local governmental agencies. Building on these past efforts, DPHS proposed the following five partitions of the public health system as a conceptual framt work for describing the function and further defining public health infrastructure in measurable, meaningful terms. 1. System participants: the official government public health agencies as well as the private providers and voluntary organizations. 2. System capacity or inputs: the community leadership, human resources, fiscal and physical resources, information resources, and the system organization necessary to carry onttbt core functions of ~ u b l i chealth. 3. System practices or processes: specifically, those organiutional practices or processes necessary and sufficient to assum that the core functions of public health are being carried out effectively. 4. System services or outputs: health and environmental savices intended to prevent death, disease, and disability and to promote improved quality of life. 5. System results or outcomes: indicators of health status, rkL reduction, and quality-of-life enhancement. This framework looks at the public health system in terms d (1)the organizations and institutions that work together as a s p tem to achieve the mission of public health; (2) the cornpotwaits that determine the system's capacitytability to carry out effectively the core functions of public health; (3) the organizational practices or processes that those organizations use to deteamk the appropriate and necessary services to address the priority needs of their community; (4) the actual services that they vide for the community; and (5) the outcomes in terms of improved health, reduced risk, and improved quality of lift associated with those services. The utility of this framework depended on the delineation of organizational practices. In ~ a n u a r1989, j CDC convened a meeting of representatives from the Association of State and Taritorial Health Officials, National Association of County Hakh Officials, United States Conference of Local Health O f h q American Public Health Association, Association of Schools d Public Health, Health Resources and Services Adminispath, and CDC. This group of public health leaders was asked to cap merate the local public health agency activities that would be necessary to assure that the core functions of public h e a h (assessment, p o k y development, and assurance) are being curied out. This first "brain-storming" session resulted in idea&cation of more than 140 essential activities or functions. Several months later, in the spring of 1989, a Steering Comrmirtee to Measure Public Health capacity was formally appointd Using the results from the January "brain-storming" session a d the catalog of organizational indicators presented in Part I of t k Assessment Protocol for Excellence in Public Health (APEXPH): the committee worked with the staff of DPHS to furcha refine this list of essential local health department activities. Over the course of several meetings, these activities were grouped into 10 organizational practices that must be carried out by a component of the public health system in each l o d t y These 10 practices, once operationally defined, provide a bask for measusing the three core functions of public health. They
Ten Organizatioml P Y I I 7~ ~
also describe a continuum of problem-solving activity, cycling from problem identification to evaluation in order to redirect resources and interventions. Each of these practices has been characterized as a process that has behavioral outcomes demonstrable in practice: (1)assessment-assess the health needs of the community, investigate the occurrence of health effects and health hazards in the community; analyze the determinants of identified health needs; (2)policy development-advocate for public health, build constituencies, and identify resources in the community; set priorities among health needs; develop plans and policies to address priority health needs; and (3) assurance-manage resources and develop organizational structure; implement programs; evaluate programs and provide quality assurance; inform and educate the public. Although extensive external examination and validation of these organizational practices are called for, early application and investigation of this framework seem promising.'s8 If the practices described above represent the function and process of the public health system, then the strength of that system is represented by its capacity (leadership, facilities, material resources, human resources) to carry out those practices. Measures of the various components of the system's capacity (inputs) together with indicators of the essential organizational practices (process) may be linked with measures of output (services) and outcome (health status) to form a conceptual framework for assessing, strengthening, and communicating the value and effectiveness of the public health system.
8 Research and Measurement in Public Health Practice
REFERENCES 1. Hanlon JJ. Is there a future for local health departments. Public Health Rep 1973;88:898-901. 2. Model Standards for Community Preventive Health Services. A report to the U.S. Congress from the secretary of Health, Education and Welfare. August 1979. 3. Institute of Medicine. The future of public health. Washington, DC: National Academy Press; 1988.
4. U.S. Department of Health and Human Services, Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: DHHS publication no. (PHs) 91-50212, U.S. Government Printing Office; 1990.
5. Hanlon J, Pickett G. Public health administration and practice. Santa Clara, California: Times MirrorIMosby College Publishing; 1984.
6. National Association of County Health Officials, U.S. Conference of Local Health Officers, Association of State and Territorial Health Officials, American Public Health Association, Association of Schools of Public Health, Centers for Disease Control. Assessment protocol for excellence in public health. Washington, DC: National Association of County Health Officials; 1990. 7. Turnock BJ. Building public health capacity through the implementation and assessment of organizational practices. Public Health Rep [in press]. 8. Miller CA. Longitudinal observations on a selected group of local health departments. J Public Health Policy 1993;14:34-50.
In 1988, the Institute of Medicine took a major step forward when it defined the functions of governmental public health agencies as assessment (monitoring the health of the American people), policy development (promoting the development of scientifically sound public health policy), and assurance (guaranteeing the benefits of public health for all citizens). The effort to further describe and measure the practice of public health began in January 1989 when the Centers for Disease Control and Prevention (CDC) convened a meeting of public health leaders including representatives of the Association of State and Temtorial Health Officials, National Association of County Health Officials, United States Conference of Local Health Officers, Public Health Foundation, American Public Health Association, Association of Schools of Public Health, Health Resources and
Services Administration, and CDC. Consensus was reached that these core functions provided an appropriate framework. A beginning effort was made to identify the specific practices or processes required to carry out the core functions. The result of this two- year effort was the delineation of 10 organizational practices that functionally define the practice of public health, provide a basis for measuring the three core functions of public health, and also describe a continuum of problem-solving activity from problem identification to evaluation in order to redirect resources and interventions. Although extensive external examination and validation of these 10 organizational practices is called for, early application and investigation of this framework seem promising. [Am J Prev Med 1995;11(Suppl2):6-81
Understanding the role of public health agencies in our nation's health care system has increasingly become a priority for health professionals and policy makers. The recent debate on health care reform has highlighted the need for those in public health to functionally define what the public health system is and how it contributes to the overall health of the nation. In 1988, in anticipation of this need, the Centers for Disease Control and Prevention (CDC) created the Public Health Practice Program Office. Two of the major responsibilities assigned to the program office's Division of Public Health Systems (DPHS) were to (1)assess and monitor the capacity of state and local public health agencies to carry out their primary roles of
assessment, policy development, and assurance, and (2) strengthen the capacity of the public health system to carry out its role of assessment, policy development, and assurance. These were intimidating responsibilities in and of themselves. Because no consensus definition existed of the public health system, its functions, or the capacity needed to carry out those functions, these responsibilities seemed even more daunting. As a first step in carrying out these responsibilities, DPHS developed a working definition of the public health system including delineation of its functions and necessary capacity. Thanks to the contributions of many of our peers and predecessors, the basis for that definition was already in place. As early as 1973, John Hanlon argued that "the official health agency might better concentrate upon its important and unique potential as community conscience and leader. Governmental agencies, such as local departments of health, are in the best position to sense the need for and to promote the establishment of social policy."' Hanlon further suggested that the critical functions of a local health agency were planning, data collection and analysis, coalition building, and stimulating interest in and concern with the needs of the broad community.' In 1979, Model Standards for Community Preventive Health Services2first described the concept of "a governmental presence
O 1995 American Journal of Preventive Medicine. Research and Measurement in Public Health Practice is a supplement to American Journal of Preventive Medicine Volume 11, Number 6.
From the Public Health Practice Program Office, Centers for Disease Control and Prevention, and the School of Public Health, University of Texas, Houston, Texas. Address reprint requests to Dr. Dyal, University of Texas-Houston, School of Public Health, P.O. Box 20186, Houston, TX 77225.
6 Research and Measurement in Public Health Practice
1
at the local level" that is responsible for the health of the community.This concept is based on a multi-faceted, multi-level governmental responsibility for ensuring that the public health needs of tbc community are met. It is a responsibility that often involves q p c i e s in addition to the public health agency at any particular kL Regardless of the structure, every community must be suved by a governmental entity charged with that responsibility, a d general-purpose government must assign andcoordinate aaponsibility for providing and assuring public health and
e report The Future of Public
Hidh3reinforced these concepts by stating that the governmen-
d responsibility to protect the public's health is represented by aatc and local health departments and the federal Department
untary organizations. mission of public health,
Lcrltb agencies, as the governmental representative of public bb,provide leadership and focus to the collective efforts rlbessing this mission. The report further defined the role of v e n t to include three core functions: assessment, policy Indopment, and assurance. Assessment is the regular, systemricc~llection,assembly, analysis, and dissemination of informab a n the health of the community. Policy development is the of the responsibility to serve the public interest in the l a d o p m e n t of comprehensive public health policies by promoth t b c use of the scientific knowledge base in decision making. lrrrunce guarantees constituents that services necessary to rLiepr agreed-upon goals are provided by encouraging actions dabets (private or public), requiring action through regulation,
,of Healthy People 2000:
carrying out the core
nd assurance. It further statdd that ed and institutionalized on the and standards of effective perfore public health system to fully realblic health pra~tice."~ gies for monitoring and strengthenperformance of the public health system, it ther define the public health system and its re in terms that were measurable and meaningful.
the agency to achieve its objective^."^ Although this explanation of infrastructure refers to an agency or organization, it does provide insight into further describing the function of the public health system's local governmental agencies. Building on these past efforts, DPHS proposed the following five partitions of the public health system as a conceptual framt work for describing the function and further defining public health infrastructure in measurable, meaningful terms. 1. System participants: the official government public health agencies as well as the private providers and voluntary organizations. 2. System capacity or inputs: the community leadership, human resources, fiscal and physical resources, information resources, and the system organization necessary to carry onttbt core functions of ~ u b l i chealth. 3. System practices or processes: specifically, those organiutional practices or processes necessary and sufficient to assum that the core functions of public health are being carried out effectively. 4. System services or outputs: health and environmental savices intended to prevent death, disease, and disability and to promote improved quality of life. 5. System results or outcomes: indicators of health status, rkL reduction, and quality-of-life enhancement. This framework looks at the public health system in terms d (1)the organizations and institutions that work together as a s p tem to achieve the mission of public health; (2) the cornpotwaits that determine the system's capacitytability to carry out effectively the core functions of public health; (3) the organizational practices or processes that those organizations use to deteamk the appropriate and necessary services to address the priority needs of their community; (4) the actual services that they vide for the community; and (5) the outcomes in terms of improved health, reduced risk, and improved quality of lift associated with those services. The utility of this framework depended on the delineation of organizational practices. In ~ a n u a r1989, j CDC convened a meeting of representatives from the Association of State and Taritorial Health Officials, National Association of County Hakh Officials, United States Conference of Local Health O f h q American Public Health Association, Association of Schools d Public Health, Health Resources and Services Adminispath, and CDC. This group of public health leaders was asked to cap merate the local public health agency activities that would be necessary to assure that the core functions of public h e a h (assessment, p o k y development, and assurance) are being curied out. This first "brain-storming" session resulted in idea&cation of more than 140 essential activities or functions. Several months later, in the spring of 1989, a Steering Comrmirtee to Measure Public Health capacity was formally appointd Using the results from the January "brain-storming" session a d the catalog of organizational indicators presented in Part I of t k Assessment Protocol for Excellence in Public Health (APEXPH): the committee worked with the staff of DPHS to furcha refine this list of essential local health department activities. Over the course of several meetings, these activities were grouped into 10 organizational practices that must be carried out by a component of the public health system in each l o d t y These 10 practices, once operationally defined, provide a bask for measusing the three core functions of public health. They
Ten Organizatioml P Y I I 7~ ~
also describe a continuum of problem-solving activity, cycling from problem identification to evaluation in order to redirect resources and interventions. Each of these practices has been characterized as a process that has behavioral outcomes demonstrable in practice: (1)assessment-assess the health needs of the community, investigate the occurrence of health effects and health hazards in the community; analyze the determinants of identified health needs; (2)policy development-advocate for public health, build constituencies, and identify resources in the community; set priorities among health needs; develop plans and policies to address priority health needs; and (3) assurance-manage resources and develop organizational structure; implement programs; evaluate programs and provide quality assurance; inform and educate the public. Although extensive external examination and validation of these organizational practices are called for, early application and investigation of this framework seem promising.'s8 If the practices described above represent the function and process of the public health system, then the strength of that system is represented by its capacity (leadership, facilities, material resources, human resources) to carry out those practices. Measures of the various components of the system's capacity (inputs) together with indicators of the essential organizational practices (process) may be linked with measures of output (services) and outcome (health status) to form a conceptual framework for assessing, strengthening, and communicating the value and effectiveness of the public health system.
8 Research and Measurement in Public Health Practice
REFERENCES 1. Hanlon JJ. Is there a future for local health departments. Public Health Rep 1973;88:898-901. 2. Model Standards for Community Preventive Health Services. A report to the U.S. Congress from the secretary of Health, Education and Welfare. August 1979. 3. Institute of Medicine. The future of public health. Washington, DC: National Academy Press; 1988.
4. U.S. Department of Health and Human Services, Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: DHHS publication no. (PHs) 91-50212, U.S. Government Printing Office; 1990.
5. Hanlon J, Pickett G. Public health administration and practice. Santa Clara, California: Times MirrorIMosby College Publishing; 1984.
6. National Association of County Health Officials, U.S. Conference of Local Health Officers, Association of State and Territorial Health Officials, American Public Health Association, Association of Schools of Public Health, Centers for Disease Control. Assessment protocol for excellence in public health. Washington, DC: National Association of County Health Officials; 1990. 7. Turnock BJ. Building public health capacity through the implementation and assessment of organizational practices. Public Health Rep [in press]. 8. Miller CA. Longitudinal observations on a selected group of local health departments. J Public Health Policy 1993;14:34-50.