California Public Health Preparedness: Lessons from Seven Jurisdictions R. Burciaga Valdez, PhD

1. California Public Health Preparedness: Lessons from Seven JurisdictionsR. Burciaga Valdez, PhD June 8, 2004

2. Major Findings and Conclusions • Public health preparedness is improved, but more work is needed • Considerable variations across health jurisdictions • The public health system is structured inefficiently • Strong State leadership would improve efficiency and effectiveness • Focus on preparedness poses risk of serious unintended consequences • Attention diverted from other public health threats • Local cutbacks in contributions to public health depts.

3. History • Little Hoover Commission requests “gap analysis” of California’s public health infrastructure • California Endowment funds initial phase • First phase addresses “public health preparedness” for infectious disease outbreak and chronic disease pilot • Emphasis on local level • Potential to expand to beyond preparedness

4. Approach • Apply Ten Essential Public Health Services as project framework • Review relevant instruments • Conduct site visits in seven jurisdictions • 39 percent of State’s population • Use table-top exercises to measure performance • Smallpox scenario • Pilot test diabetes scenario

5. Key Findings (1)Widespread Preparedness Variations • Each jurisdiction studied has undertaken significant preparedness activities. • Widespread variations in ability to respond to infectious disease outbreaks and other public health threats. • Substantial variations in approach to hypothetical smallpox outbreak despite a year of planning • Similar variations in approach to chronic disease. • Californians do not enjoy an even level of protection against public health threats.

6. Key Findings (2)Uncertainty About Who, What, How • Ambiguity surrounding appropriate role(s) for a health jurisdiction vis-à-vis other local agencies and the State DHS. • Little agreement about what jurisdictions should do when faced with a public health emergency and how they should do it. • Perceived overlap in some functions between the DHS, the Governor’s Office of Emergency Services, and the Emergency Medical Services Authority.

7. Key Findings (3)Preparedness Gaps • Similar preparedness gaps across many jurisdictions. • Examples: training of public health staff to assume “back-up” roles in an outbreak; strategic planning; community health assessment; workforce needs (epidemiologic and laboratory capacity); and access to legal consultation on public health law. • All jurisdictions need a robust information system. • Large numbers of uninsured Californians creates challenges in planning for and managing public health issues during an outbreak.

8. Key Findings (4)Insufficient Community Involvement • Community groups, particularly those that serve underrepresented minority groups, are not involved in public health preparedness in most jurisdictions.

9. Key Findings (5)No Central Leadership • Strong, central leadership and coordination of public health appears to be lacking. • Health departments felt they could not rely on the DHS to address common needs or facilitate coordination or sharing of resources. • The State’s public health laboratory may be an exception.    • The organization of preparedness activities leads to redundancies and inefficiencies. • Border and jurisdictional issues need attention.

10. Key Findings (6)Hidden Costs • Public health preparedness may have a hidden cost. • Substantial evidence that staff reassignments to accomplish preparedness functions and cuts to public health budgets at a county level from the current fiscal crisis are compromising other public health functions

11. Key Findings (7)Cost to Fill Preparedness Gaps • Estimated additional annual costs statewide of filling the “preparedness gap” range from $72 to $96 million. • Does not consider economies of scale that could be achieved through reorganization and greater sharing of resources. • Investments in public health infrastructure for preparedness build a stronger public health system at the local and state levels. • However, countervailing pressures, which stem largely from California’s fiscal crisis, place the likelihood of capitalizing on this opportunity at risk.

12. Recommendations (1) • Examine the organization of public health in California, and develop a shared understanding of what public health is and does • Applies to preparedness for an infectious disease outbreak and other public health functions (e.g. growing epidemic of chronic disease) • Role of strong, central leadership focused on public health at a state level should be a key component of such a reexamination • Centralization/regionalization of some functions, and sharing of resources among others, will likely lead to greater effectiveness and efficiency

13. Recommendations (2) • Objective performance measures for preparedness should be developed, implemented, and refined as needed. Performance should be regularly assessed through exercises • Improve the statewide epidemiologic information system • A robust information system is the backbone upon which coordinated public health activities should be built • Generate increased community involvement in preparedness activities

14. Recommendations (3) • Maintain a highly skilled public health workforce • Invest in training for public health staff at all levels • Improve training efficiency through better planning and resource sharing   • Workforce planning must occur at both a local and statewide level • In virtually all jurisdictions, key members of the workforce are aging into retirement and there is little evidence of succession planning • Reassignment of key staff to preparedness functions has created shortages in other areas

15. Recommendations (4) • Strengthen links between public health departments and the health care delivery system • Providers and the institutions which deliver care have critical public health responsibilities • Evaluate public health preparedness and gaps at the state level to fully understand critical preparedness issues • Such an analysis is essential before contemplating a reorganization of public health in California

16. Recommendations (5) • Studies are needed to fill the knowledge gaps regarding the public health infrastructure • Additional resources are necessary to improve public health preparedness and local public health systems • Our estimates cover additional resources needed to improve local preparedness to protect against infectious disease outbreaks • We found evidence that resources are needed to assure that essential public health services are available in all locales to cover wide range of health threats the people of California face on a daily basis 

17. Higher states of preparedness • Experience with other public health emergencies • * Strong leadership • * Successful collaborations • * Adequate funding