Dennis Lenaway

Institutional and Economic Determinants of Public Health System Performance

OBJECTIVES Although a growing body of evidence demonstrates that availability and quality of essential public health services vary widely across communities, relatively little is known about the factors that give rise to these variations. We examined the association of institutional, financial, and community characteristics of local public health delivery systems and the performance of essential services. METHODS Performance measures were collected from local public health systems in 7 states and combined with secondary data sources. Multivariate, linear, and nonlinear regression models were used to estimate associations between system characteristics and the performance of essential services. RESULTS Performance varied significantly with the size, financial resources, and organizational structure of local public health systems, with some public health services appearing more sensitive to these characteristics than others. Staffing levels and community characteristics also appeared to be related to the performance of selected services. CONCLUSIONS Reconfiguring the organization and financing of public health systems in some communities-such as through consolidation and enhanced intergovernmental coordination-may hold promise for improving the performance of essential services.

Public Health Systems Research: Setting a National Agenda

The Institute of Medicine has recommended that policy decisions about improvement of national public health systems be guided by sound scientific evidence. However, to date there is no national research agenda to help guide public health systems. The Centers for Disease Control and Prevention was called upon to lead a collaborative consensus-based process to define key research questions and establish a framework to create opportunities to better coordinate, leverage, and identify public health resources, which are increasingly scarce. The public health systems research agenda that emerged from this process has 14 over-arching priority research themes. This national agenda should stimulate and guide research to meet the urgent need to improve the nations public health systems.

Getting what you pay for: public health spending and the performance of essential public health services.

Governmental spending in public health varies widely across communities, raising questions about how these differences may affect the availability of essential services and infrastructure. This study used data from local public health systems that participated in the National Public Health Performance Standards Program pilot tests between 1999 and 2001 to examine the association between public health spending and the performance of essential public health services. Results indicated that performance varies significantly with both local and federal spending levels, even after controlling for other system and community characteristics. Some public health services appear more sensitive to these expenditures than others, and all services appear more sensitive to local spending than to state or federal spending. These findings can assist public health decision makers in identifying public health financing priorities during periods of change in the resources available to support local public health infrastructure.

The national public health performance standards: driving quality improvement in public health systems.

Since its inception in 1998, the Centers for Disease Control and Preventions National Public Health Performance Standards Program (NPHPSP) has helped lay the groundwork for public health quality improvement (QI) activities at the state and local levels. This article describes how the NPHPSP has promoted QI through its instruments and guidance and how it has continually strengthened the focus on QI over the years. The NPHPSP Version 2 instruments and enhanced guidance have been designed to more strongly reinforce QI and catalyze the transition from assessment to action. Despite positive reports from some state and local users that emphasize the value the NPHPSP holds for those that do successfully move forward with improvement actions, 2005 evaluation results from the Association of State and Territorial Health Officials and the National Association of County and City Health Officials indicated challenges in transitioning the assessments results into performance improvement. More recent data are promising; a 2009 postassessment survey of early Version 2 respondents indicates that the majority (75% of all respondents) report action in one or more performance improvement steps. The NPHPSP has played an important role in fostering QI in many states and local jurisdictions. Furthermore, its experiences and lessons learned in supporting QI have helped to pave the way for other initiatives, such as the emerging national accreditation system for state and local health departments.

Quality improvement and performance: CDC's strategies to strengthen public health.

Within the context of health reform, the Obama administration’s ambitious goal of integrating prevention, public health, and healthcare delivery systems anticipates greatly expanding prevention and wellness activities as the primary means to reduce the burden of disease, injury, and disability in the United States. This prescription for change represents a significant challenge. If public health is to succeed in delivering on the “promise of prevention,” as well as exert our leadership role, then we need to counter with bold initiatives that promote accountability, performance, and improvements in public health. The reason is clear— without a high-performing public health system, we will not be able to attain the goals of the new administration and, most important, the health aspirations of communities across the nation. In addressing this challenge, we believe that the Centers for Disease Control and Prevention (CDC) has an opportunity to expand its programs and activities to help transform our public health system. Quality improvement (QI), the focus of this issue of Journal of Public Health Management and Practice, can be the critical component that combines knowledge and guidance with the tremendous energy and talent of public healthcare practitioners to achieve program, organizational, and system goals. The principles of QI are embedded in several significant and highly visible programs supported by the CDC. The National Public Health Performance Standards Program (NPHPSP), the emerging national program for accreditation, environmen-