Eliminating health disparities is one of the two goals of Healthy People 2010.1 With less than 2 years remaining to achieve this goal, disparities in health have not significantly improved despite improvements in overall US population health. Midcourse review of the Healthy People 2010 tracked indicators show that more than 80 percent of the disparities by race/ethnicity, gender, and education remained unchanged, whereas virtually no indicators improved for income and geographically based measures of disparity.2 Minorities continue to bear a disproportionate burden of morbidity and mortality, men have shorter life expectancies, low-income populations have riskier health behaviors, and rural populations are more likely to report poor health status.
As the nation prepares to establish new goals for Healthy People 2020, it is important to look back and examine the missed opportunities for progress and look forward to new opportunities to maximize success in reducing health disparities. We believe that two of those opportunities are voluntary accreditation of public health agencies and public health services and systems research (PHSSR). Although these emerging vehicles will likely lead to changes across the entire public health system, especially noteworthy is their potential for disparity reduction. In this commentary, we tie these new movements in public health to the persistent problem of health disparities.
What began in 2004 as a small convening of public health stakeholders to explore the feasibility of national public health accreditation has turned into the recent creation of the Public Health Accreditation Board. The Public Health Accreditation Board will launch a national public health agency voluntary accreditation program in 2011. The view of public health agency accreditation is that it is a means for increasing the quality and performance of public health agencies and establishing a set of criteria that the public and policy makers could use to hold health agencies accountable for investments in public health. The logic driving accreditation is that increasing the quality and accountability of health agencies will ultimately translate into improved population health. Although some states already have accreditation processes in place, national accreditation is a way to drive nationwide improvement in the performance of health agencies.3
As the field prepares for the launch of public health agency accreditation, it is important to emphasize the role that accreditation could play in addressing health disparities. Although health departments serve the population, regardless of income, race/ethnicity, gender, etc, disadvantaged populations of all backgrounds stand to benefit the most from the protections that health agencies provide. Disadvantaged populations often have greater exposures to health risks, limited availability of, and greater barriers to, making healthful choices and limited access to preventive clinical interventions. Consequently, improvement in the efficiency and effectiveness of health agencies to deliver population-based health services could result in a disproportionate improvement in health for those populations and reduce the disparity gaps.
We are optimistic that accreditation will improve agency performance and are hopeful that this will also improve the population's health and diminish disparities. Making these explicit goals of agency performance can focus an emerging field of science to address questions related to public health service delivery and systems performance on related outcomes. This emerging science, PHSSR, focuses on the structure, operation, and outcomes of public health systems—defined as the collection of organizations, individuals, and communities that contribute to activities that promote health and prevent disease and injury at the population level.4 Although research that can be classified as PHSSR has been going on for well over a decade, the recognition of this work as a new discipline provides an opportunity to centralize, define, and grow the work, increasing its visibility within the broader field and, ultimately, its impact.
PHSSR has already begun to provide information on how best to provide core public health services and the impact of various organizational, administrative, and financial systems on the provision of public health services. For example, recent research has shown that one can classify health departments as one of seven types on the basis of the scope of services provided, the number of public health partners, and the proportion of public health services provided by the health department. An analysis of these types and their performance has provided a guide for organizing and how best to administer community-based public health services.5
The 2002 Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, provided an exhaustive summary of research in healthcare that clearly delineated disparities in access, provision, and quality of medical care.6 Unlike healthcare, however, the degree to which access, provision, and quality of public health services vary and whether these differences relate to health disparities has not been well examined. A couple of PHSSR studies provide some promise to understanding the relationship between public health services and systems and health disparities.7,8 Given the breadth of issues that the public health system is expected to address, it will also be important to understand the extent to which the structure, organization, and financing of the system are related to health disparities and what changes to its structures and processes strengthen its ability to eliminate disparities.
Although public health is behind healthcare in understanding health disparities within the context of a system, we can translate lessons learned into practices that will maximize our ability to address disparities, placing us at a marked advantage. First, when engaging in systems improvement, we know we must place health disparities at the forefront to avoid the unintended consequence of exacerbating the gaps. Second, if we want to infuse the field with perspectives and insight that only individuals with shared experiences from communities adversely impacted by disparities can provide, we must increase the diversity of PHSSR researchers. Doing so will improve the science and our ability to formulate solutions to address disparities.
Many of the current efforts to address the issue of health disparities have not been successful in altering the nation's health status indicators, suggesting that we need a different approach. PHSSR tools and datasets might provide a more effective evidence base to identify the best organizational practices that will have an impact on those disparities and a means for understanding the relationship between health disparities and various public health system characteristics. In addition, the practice focus of PHSSR is advantageous because practitioners across the country are identifying many of the early research questions in the field, easing the translation of the science to practice. Similarly, accreditation could become a means by which disadvantaged population groups could benefit from systemwide improvements because disparity becomes a focus for the performance measures.
As we move forward, we must be more vocal about the role that public health plays in population health if we hope to secure the vital resources we need to not only expand and improve the public health system but also conduct research that examines and informs the improvement of the system. The United States spends roughly $2 trillion on healthcare despite the fact that the overwhelming majority of diseases driving the costs are entirely preventable.9,10 Unless we can make this clear and compelling to policy makers, the current Presidential candidates, and Americans as a whole, it is unlikely that the nation will realize the potential that accreditation and PHSSR can have for eliminating disparities.
1. US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health
. 2 vols. 2nd ed. Washington, DC: US Dept of Health and Human Services; 2000.
2. US Department of Health and Human Services. Healthy People 2010 Midcourse Review
. Washington, DC: Government Printing Office; 2006.
4. Mays GP, Halverson P, Scutchfield D. Behind the curve? What we know and need to learn from public health systems research. J Public Health Manag Pract.
5. Mays GP, Smith S, Scutchfield D, Bhandari M. The dynamics of public health infrastructure: using a delivery system typology to assess structural change and outcomes. Paper presented at: 25th Academy Health Annual Research Meeting; June 8, 2008; Washington, DC.
6. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care
. Washington, DC: Institute of Medicine; 2002.
7. Morita JY, Ramirez E, Trick WE. Effect of a school-entry vaccination requirement on racial and ethnic disparities in hepatitis B immunization coverage levels among public school students. Pediatrics
8. Grembowski D, Conrad D, Bekemeier B, Kreuter W. Are local health department expenditures related to racial disparities in mortality? Paper present at: 25th Academy Health Annual Research Meeting; June 8, 2008; Washington, DC.
9. Catlin A, Cowan C, Heffler S, et al. National health spending in 2005: the slowdown continues. Health Aff
. 2007; 26(1):142–153.