Association of State and Territorial Health Officials, Arlington, Virginia.
Correspondence: Karl Ensign, MPP, Association of State and Territorial Health Officials, 2231 Crystal Dr #450, Arlington, VA 22202 (KEnsign@astho.org).
The author declares no conflicts of interest.
Among public health practitioners, policy makers, and researchers, it is generally agreed that public health services and activities are highly valuable to the individuals and communities that receive them but all too often their value is immeasurable. How does one value the public health threat or outbreak that is quickly mitigated or avoided altogether? And with mortality rates increasing, the prevention and treatment of avoidable diseases are more necessary than ever.1 Yet, the mitigation of adverse health outcomes is difficult to attribute to specific public health interventions that focus on environmental factors or were delivered years earlier. As a result, studies often suffer from a “lack of rigor and standards.” Moreover, efforts to calculate the value of public health have been hampered by the absence of agreed-upon definitions of public health services and measures of these activities.2,3
It has been 4 years since the Institute of Medicine (IOM) recommended that a “robust research infrastructure for establishing the effectiveness and value of public health and prevention strategies”4(p7) be undertaken. Responding to this call to action, a number of recent studies have undertaken sophisticated analyses of changes in expenditure data to estimate the value of public health. Additional work has been undertaken to develop taxonomies describing and defining a core set of public health services. Other work is developing standard charts of accounts, common frameworks for classifying agency expenditures. The coming challenge, and opportunity, is to bring these pieces of the puzzle together. The uniform chart of accounts can be used to more accurately cost out the Foundational Public Health Services. Analysis of expenditure data can then be applied to determine the optimal levels and configurations of public health services.
But what do we know now about the value of public health? Recently, a small number of sophisticated studies have been able to tease out the health impact of investing in public health services. A 2011 study authored by Glen Mays and Sharia Smith5 analyzed changes in public health spending and mortality rates nationally over a 13-year period in nearly 3000 public health agencies. The authors found that for each 10% increase in local public health spending, decreases occurred for the following avoidable and much more costly mortality rates:
* Infant mortality decreased 6.9%;
* Cardiovascular disease decreased 3.2%;
* Diabetes decreased 1.4%; and
* Cancer decreased 1.1%.5
Communities with the largest increases in public health spending experienced significantly larger reductions in preventable causes of death. The analysis controlled for a host of potentially explanatory factors including medical resources and demographic and socioeconomic characteristics.5
In 2014, Timothy Brown6 used county public health expenditure data from 56 of California's counties to conduct similar analysis. Increasing public health expenditures by just $10 per capita was found to reduce mortality by 9.1 deaths per 100 000, saving just under 27 000 lives each year in the state. A second study of 40 counties' data found that a $10 increase in per capita health expenditures increased the percentage of the state population reporting good or excellent health; 24 000 individuals moved from “poor or fair health” to “good, very good, or excellent health.”7
These results are particularly impressive, given that less than 5% of health spending in the United States is devoted to public health activities.5 Therefore, it is not surprising that an analysis published in 2010 reported that projects best poised to have the largest and most direct effects on population health are those undertaken by partnerships in which “public health agencies serve as focal points, ... rely[ing] heavily on the ability to inform and influence the work of others.”8(p1) The success of these partnerships rests on information exchange and policy development and planning.8
The importance of partnerships is validated by a new study published by Glen Mays et al.9 Their analysis sought to discern whether communities that have a broad array of sectors engaged in population health–focused activities experience better health outcomes over time. The authors first analyzed the ways in which public health was organized and delivered, finding that from 1998 to 2014, the proportion of communities that had both a broad scope of population health activities and a dense network of participating organizations increased from 24% to 40%.9 Those communities that expanded multisectoral networks supporting public health activities experienced the largest declines in deaths due to influenza, heart disease, and diabetes.9
So it is clear that well-funded public health systems engaging in multisectoral partnerships add value to individuals and communities. But how should public health be optimally organized and funded to maximize benefits? As a first step, efforts to address this need to use a common taxonomy for describing public health services programs, activities, and capabilities. Fortunately, this framework has been developed.
As background, a year after the 2012 IOM report was published, the Robert Wood Johnson Foundation funded RESOLVE to convene and facilitate the Public Health Leadership Forum to define a minimum package of public health services. As shown in the Figure, the project resulted in defining:
* Foundational capabilities: Cross-cutting, essential skills and capacities supporting all activities in state and local public health.
* Foundational areas: Substantive expertise or program-specific activities.
* Foundational Public Health Services: The foundational capabilities and areas essential for delivering public health services.10
But what are the costs of these services? A first cut of this was undertaken by Glen Mays et al.11 They found that agencies spent an estimated $15.4 billion (or $48.14 per capita) in 2015-2016 on services and activities that could be categorized as Foundational Public Health Services. They estimated that this level of funding was sufficient to support more than 60% of the full complement of recommended skills and capabilities shown in the Figure. The authors also estimated the total cost for Foundational Public Health Services if they were fully implemented by state and local agencies nationwide. Full implementation of the Foundational Public Health Services would require an additional $10.94 billion (or an additional $34.29 per capita) per year. The authors note that “generating these additional resources from state and local government sources would require an increase in spending of 16.1% over the levels estimated in the National Health Expenditure Accounts for 2014. Alternatively, the estimated resource gap could be filled by nearly doubling federal government spending on public health activities from the $11.0 billion level estimated in 2014.”11(p2)
More precise cost estimates of the Foundational Public Health Services can be assisted by projects such as the uniform chart of accounts and the Public Health Uniform Data System. A uniform chart of accounts is defined as a broadly agreed-upon “classification structure for an accounting system that systematically organizes the agency's financial data.”12 This approach enables comparisons over time and between agencies, identifies drivers in cost variation, and explains how targeted investments affect service costs. Led by Betty Bekemeier at the University of Washington School of Nursing, a Robert Wood Johnson Foundation–funded project is working with 4 state public health agencies (Minnesota, Missouri, New York, and West Virginia) and 4 local public health departments within each of these 4 states to (1) develop a blueprint for a uniform chart of accounts; (2) develop and test crosswalks to reorganize existing financial data into the uniform chart of accounts; and (3) evaluate the validity of the crosswalk.13
It will be exciting to watch these pieces of the puzzle come together. The uniform chart of accounts has the potential to add a higher degree of rigor to estimating the cost of the Foundational Public Health Services. With this completed, expenditure and comparative analyses can be undertaken to arrive at optimal levels and configurations of public health investments in states and communities.
1. Stobble M. US life expectancy falls, as many kinds of death increase. Washington Post. Web site. https://http://www.washingtonpost.com
/national/health-science/us-life-expectancy-falls-as-many-kinds-of-death-increase/2016/12/07/3bd8320e-bccf-11e6-ae79-bec72d34f8c9_story.html?utm_term=.a6d2af76a5d9. Accessed December 13, 2016.
2. Jacobson PD. Measuring the Value of Governmental Public Health Systems Final Report. Boston, MA: Tufts-New England Medical Center; 2007.
3. Neumann PJ, Jacobson PD, Palmer J. Measuring the value of public health systems: the disconnect between health economists and public health practitioners. Am J Public Health. 2008;98(12):2173–2180.
4. Institute of Medicine. For the Public's Health: Investing in a Healthier Future. Washington, DC. Institute of Medicine; 2012.
5. Mays G, Smith SA. Evidence links increase in public health spending to declines in preventable deaths. Health Aff. 2011;30(8):1585–1593.
6. Brown TT. How effective are public health departments at preventing mortality? Econ Hum Biol. 2014;13:34–45.
7. Brown TT, Martinez-Gutierrez MS, Navab B. The Impact of changes in county public health expenditures on general health in the population. Health Econ Policy Law. 2014;9(3):251–269.
8. Mays GP, Scutchfield FD. Improving public health systems performance through multiorganizational partnerships. Prev Chronic Dis. 2010;7(6):A116.
9. Mays GP, Mamaril CB, Timsina LR. Preventable death rates fell where communities expanded population health activities through multisector networks. Health Aff. 2016;35(11):2005–2013.
10. Beitsch LM, Castrucci BC, Dilley A, et al From patchwork to package: implementing foundational capabilities for state and local health departments. Am J Public Health. 2014;105(2):e7–e10.
11. Mays GP, Mamaril CB. Estimating the Costs of Foundational Capabilities for the Nation's Public Health System. Lexington, KY: Department of Health Management and Policy, University of Kentucky; 2016.
12. Bekemeier E, Singh S. Establishing a uniform chart of accounts for public health agencies. Paper presented at: ASTHO CFO Peer Network In-Person Meeting; December 2016; Arlington, VA.
13. Developing and evaluating strategies for a nationwide uniform chart of accounts to measure public health investment and spending. Robert Wood Johnson Foundation Web site. http://http://www.rwjf.org
/en/library/grants/2015/12/developing-and-evaluating-strategies-for-a-nationwide-uniform-ch.html. Accessed December 13, 2016.