Organization of Public Health Services

1. Organization of Public Health Services TH Tulchinsky MD MPH Braun School of Public Health Hadassah-Hebrew University 18 October 2010

2. What is an Organization? • Bureaucratic Structure • Max Weber – sociology of bureaucratic organizations • Military, civil, service, business • Network organization • Business management by objectives • Task and goal oriented • Individual and team responsibility • People produce or serve better if they feel part of “management” and goals of the organization • Read: NPH Chapter 12

3. Bureaucratic and Network Organizations • Bureaucratic Interactive team, equal • Hierarchical Task oriented • Process oriented CEO Middle Management Service or Production Workers

4. Who Provides Public Health Services?? • Government – local, state, national • Other government departments, agencies • Health system providers – doctors, hospitals • Voluntary organizations and donors • Religious organizations e.g. Catholic hospitals • Fraternal organizations e.g. Rotary Club • Advocacy groups e.g. Groups against smoking • NGOs e.g. March of Dimes • Research centers e.g. • Private sector

5. Structure of Government • US Federal system - Executive, legislative, judicial branches – ”checks and balances” • Parliamentary system, legislative-executive branches unified e.g. UK, Canada etc • Command economies – “president-for-life” • Federal-state powers defined in constitution • Defense and foreign affairs • General welfare “for the common good” • Powers to tax, spend, legislate, regulate, punish

6. Federal vs. Unitary Type Government • Unitary • National e.g.. • County, municipal/city, • United Kingdom, • France, Spanish countries – Napoleonic code • Federal e.g. US, Canada, Russia (?), Nigeria • Federal • State • Local

7. Federal Governments • Three levels of elected government, federal, state, local (municipal, county etc) • Each has taxing and enforcement powers • Division of powers in constitution and legal precedent • USA, Canada, Australia, Russia (?), Nigeria, Argentina

8. Unitary Governments • Two levels • National and local • May have regional delegation of national powers • United Kingdom, France, Spain, • Process of change toward federal systems in some

9. A Unitary State • Form of gov’t with a central national and local elected levels of government; no intermediary legislating level. • UK and governments based on the French Napoleonic Code, Spanish-speaking countries. • Central government overall responsibility for health • Local government is major factor in sanitation, business licensing, food control etc • Regional and local authorities powers derived from the national structure - decentralization • Health services may be nationally or locally managed

10. Advantages to a Federal Structure • Examples – Canada, US, Germany, Argentina, Nigeria • Division of responsibilities for health • Federal gov’t - policy, financing and regulatory roles • State level closer to the community and represents regional issues • Local health government is closest to the community • Combination of local gov’t, can promote community health interests within state and federal guidelines, funding and accountability. • Promotes inequality between regions of the country

11. Advantages of Unitary Government • Example – UK, most EU countries • Napoleonic system • More centralized decision making • Taxation sources clearer • Increasing tendency to greater regional autonomy • Devolution • Increasing regionalization, regional autonomy

12. Government Sources of Funds • Income tax • Resource taxes • Excise taxes • Value added tax • “Sin tax” – alcohol, tobacco products • Inheritance taxes • Dedicated tax e.g. gasoline tax for roads • Property tax – local • Business and licensing taxes • Social security

13. Inter-Governmental Transfer of Funds • Tax sharing e.g. resource taxes • Tax transfer e.g. share of income taxes • Cost-sharing e.g. health insurance (Canada, US) • Categorical grants-in-aid • Per capita grants e.g. health and welfare • Block grants e.g. public health • Targeted grant programs e.g.Hill-Burton Act • Transfer of responsibility • Veteran’s care in Canada • Federal initiatives and administration, Medicare in US

14. US Dep’t Health and Human Services DHHS EPA FDA NCHS Surgeon General NIH FDA CDC HCFA

15. Federal System: Federal, State and Local Authorities Federal $ State $ Province $ Oblast $ Municipality $ Rayon $ City $ County $

16. Public Health Responsibilities or Mission • Prevent epidemics and spread of disease • Protect against environmental hazards • Prevent injuries • Promote and encourage healthy behaviors • Respond to disasters and assist communities in recovery • Assure quality and accessibility of health services Source:American Public Health Association, 2000 www.apha.org

17. Federal - United States • Constitution 1776 • Executive, legislative and judicial branches • National defense and international relations • Interstate commerce, economic regulation • Food and Drug Act (1906) • Social Security Act (1935) • Limited health responsibilities at federal level • Incremental steps of intervention

18. Federal PH Responsibilities • Overall responsibility for health of population • Varies – federal vs. unitary state • National policy and planning • Financing • Assure regional equity • Special services (labs, technical services) • Research • Bureau (Child Health, CDC, FDA, etc) • Native peoples, armed forces

19. US “Hill-Burton Act” • Federal-state-local partnership in 1950s-1960s • Set national standards and financing to local hospitals • Raised standards of medical care in underserved areas • Renovated obsolescent facilities • Promoted desegregation (southern US) • Limited hospital beds to 4-4.5 acute care beds/1,000 • Favored middle-class communities (local $ contributions) • Channeled federal monies to poor communities • Required hospitals to provide free or reduced cost care to the poor and emergency treatment to uninsured • Act later expanded to promote primarycare facilities

20. Nat Cancer Institute (NCI)National Eye Institute (NEI) Nat Heart, Lung and Blood Institute (NHLBI) Nat Human Genome Research Institute (NHGRI) Nat Institute on Aging Nat Institute of Alcohol Abuse and Alcoholism Nat Institute Allergy and Infectious Diseases Nat Inst Arthritis, Musculoskeletal and Skin Diseases Nat Institute of Child Health, Human Development Nat Institute of Deafness, Communication Disorders Nat Institute of Dental Research (NIDR) Nat Institute of Diabetes, Digestive, Kidney Diseases Nat Institute of Drug Abuse (NIDA) Nat Institute of Environmental Health Sciences Nat Institute of General Medical Sciences Nat Institute of Mental Health Nat Institute of Neurological Disorders and Stroke National Institute of Nursing Research (NINR) National Institutes of Health

21. Essential Public Health Services • Monitor health status to identify community health problems • Diagnose, investigate health problems and hazards in community • Inform, educate and empower people about health issues • Mobilize community partnerships, action to solve health problems • Policies, plans that support individual, community health efforts • Enforce laws, regulations that protect health and ensure safety • Link people to needed personal health services and assure provision of health care when otherwise unavailable • Assure an expert public health work force • Evaluate effectiveness, accessibility and quality of health services • Research for new insights and innovative solutions to problems. Source: MMWR, 1997;46:150-152; www.apha.org and www.hhs.gov/

22. Responsibilities of Local Government:Local Health Authority • Ancient city states responsible for quarantine, sanitation, medical care of the poor • Elizabethan Poor Law 1601- responsible for welfare • Limited tax base – property taxes • Financial grants/tax transfers from higher gov’t • Sanitation – water, sewage, garbage, streets, labs • Business licensing and regulation • Licensing and supervision of food and services • Zoning, urban planning, housing, building codes • Recreation • Welfare • Emergency services

23. APHA Basic Six Local Health Authority (LHA) PH Services, 1940 • Vital statistics (births, deaths, marriage, divorce) • Control of communicable diseases (VPDs, TB, STDs) • Environmental sanitation (water, sewage, business licensing, food control, garbage, workplace hygiene) • Laboratory services • Maternal, child and school health • Health education “Haven Emerson Six”

24. Local Health Authorities • Sanitation – water, sewage, garbage • Business licensing - food, services • Zoning, building code, recreation • Vital records – births, deaths, marriage, divorce • Welfare services and assistance • Direct health services

25. APHA Additions, 1950 • Chronic disease control • Housing and urban planning • Accident prevention • Coordination with other agencies • Surveillance of health status • Education of public and professionals • Supervision and regulatory activities • Personal health services • Planning of health needs • Special services (TB, STDs, cancer, child development, dental care)

26. State (Province, Oblast) PH Responsibilities • Coordinate with other departments • Develop fund and supervise standards of LHAs • Legislate, regulate “the health and welfare” • Planning and priorities • Vital statistics • Direct services to LHAs (laboratories) • Direct services (Dx and Rx) e.g. STDs, TB • License and supervise health professions, institutions • Control communicable diseases • Relationships with social and welfare services • Finance health and welfare services e.g. NGOs, • Finance medical care

27. US Federal Initiatives to 1950 • Marine Hospital Service 1792 • Dep’t Agriculture Extension Services 19thC • Child health bureau 1906 • Food and Drug Act 1906 • Sheppard-Towner Act 1921 • Social Security Act 1935 • Food fortification 1941 • Emergency Medical Insurance Coverage (EMIC) 1943 for millions of servicemen and families

28. US Federal Initiatives 1946-2000 • Failure of National health insurance 1946 (1996) • Hill Burton Act 1946 • National Institutes of Health, 1946 • Centers for disease control and prevention, 1946 • Medicare (elderly), Medicaid (poor), 1965 • Voluntary health insurance via unions • Diagnosis Related Groups (DRGs) 1970s • Health Maintenance Organizations, 1970s • Health insurance voluntary, federal, state, none • Failure of NHI in 1995

29. Reform Issues • Universal coverage • Health rights • Central vs. decentralized management • Devolution to specialized agencies • Inequities • Comprehensiveness • Cost sharing • Financing • Balance of services • Targets

30. Health System Reform Issues • Occurring in many countries • Prepayment - taxes or at work • Supply of services - hospital beds/1,000, medical manpower and distribution • Methods of payment - shift to prospective payment systems from norms, fee for service, block payments • Linkages between service sectors i.e. integration • Epidemiologic monitoring • Economic evaluation

31. Vertical Integration: Funding and Services Hospital Health promotion Long Term Care Clinic PH Nursing Home Care Patient Centered Home

32. A Comprehensive Health Services Continuum Promotion Palliation Hospitals Healthy Public Policy Prevention Promotion Protection Support Services To Seniors Community Health Centres Outpatient Ambulatory Care Rural Community Urban Community Tertiary Palliation Community Oriented Services Home Care Extended Treatment & Long Term Care Rehabilitation

33. American Public Health Association 33

34. Fielding et al. Public Health Rev. 2010:32:

35. American Public Health Association 35

36. Conclusion • Gov’t, and NGOs are essential for public health • Different levels of gov’tal responsibilities • All gov’ts levels play important roles • Direct - provide a service, finance, plan, monitor • Indirect - legislation, regulation • Policy, legislation, funding, regulation, health promotion • Koop – US Surgeon general - ”People need medical care some of the time; everyone needs public health all of the time”

37. Readings • NPH Chapter 10 • Fielding et al. Public Health Reviews. 2010;32: • Shortell et al. Public Health Reviews. 2010;32: • Available at www.publichealthreviews.eu