The delivery of health care services to urban populations in the United States is a system of rapidly increasing complexity. Technological progress, improved resources, and medical advances are countered by an ever-growing disparity between suburban communities and their concentrated urban counterparts.
The historical model of urban health care delivery is largely one of individual interventions of private and community providers, hospitals, churches, nonprofit organizations, and schools. Collaborations have been common, but often limited in their focus, resources, management abilities, and efficacy. The information age, generated by the development of the Internet, has led to the demand for evidence-based practices that are becoming more relevant in medical care. Evidence-based tools must now be applied to the intervention strategies for urban health. There is a growing need to link the resources from academic institutions with expertise in data analysis and integration to those who work in service organizations, such as our public policy makers and health care providers.
In order to adequately explore the challenges to providing health care to urban populations, we must evaluate not only those in need, but also the administrative and service delivery challenges of our health care system. Figure 1 illustrates the triangle of integration among the administration, provision, and utilization (APU) of services.
This model is intuitive and provides a systematic approach for analyzing a complex problem such as the delivery of medical services. By controlling for variables influencing each of the three elements in the APU triangle and analyzing the datasets two at a time, seemingly complex issues may be simplified for meaningful analysis. For instance, in order to define hurdles to providing health care, it is feasible to compare variable fields that are defined by administration as red-flag indicators for a public health care problem against variable fields derived from population survey data for utilization. The significant variables from that analysis can then be matched against the variables for resources and hurdles in provision of health care, resulting in measurable, meaningful recommendations for intervention. The APU triangle model revolutionizes recommendations for intervention by providing an evidence-based rather than an intuitive approach.
In this article, we will discuss the roles and challenges of the three entities of the APU triangle in the delivery of urban public health care. The challenges and roles of administration, provision, and utilization are generalizable to many populations, making this model a useful tool with national and international implications. Furthermore, our APU triangle is a powerful tool applicable to virtually any service-delivery system. Following the Kellogg Logic model,1 once the hurdles to the provision of health care are defined, then resources, influential factors, strategies, and outcomes may be better developed to target specific populations. Using our APU triangle model, each of these steps to service delivery (in this specific case, urban public health) may be taken from the perspective of the administrator, the provider, and the user, resulting in the most comprehensive perspective for intervention.
Entities Involved in Urban Public Health
Administration of Health Care Services
Public health agencies and government officials are among those who administer health care by developing and implementing public policy and services. These agencies and officials are charged with overseeing the holistic health of a community, which includes economic, social, political, educational, and health factors. Their specific duties encompass policy development, coordination of providers and service delivery, preparedness, management, education, public health data acquisition, and record keeping, as well as funding of urban public health.
Provision of Health Care Services
The community assets available to provide for urban health care include institutions, health care providers of all types, funding agencies, and educational organizations. Providers make up the most diverse, independent and heterogeneous portion of the health care delivery system. Therefore, they are probably the most difficult group of the APU triangle to identify and direct, although they obviously play a vital role in healthy populations. The media, public schools, universities, medical societies, private philanthropies, and religious organizations, as well as the public health department, may provide different aspects of patient care. Some of them provide the actual medical care, some provide funding for others to access medical care, and yet others may provide psychosocial or educational support—all of which play important roles in the overall health status of a community. Recently, there has been widespread effort within the United States to increase collaboration among our many autonomous and sometimes competitive providers in order to overcome hurdles to the delivery of care.
Utilization of Health Care Services
Individuals who use health care services are the most important group of the APU triangle. In order to most effectively and efficiently provide services to a population, the obstacles that they face on a personal and community level must be considered. Advocacy groups also fall into the “utilization” category because they play an important role in identifying and implementing changes necessary in a population. Only recently have significant research dollars and hard analytical techniques begun to be applied to understanding the stresses and needs of the users (or should we say, underusers) of health care services.2,3
Hurdles to the Delivery of Urban Public Health Care
Universal hurdles to public health care exist, regardless of the environment (see List 1). We recognize that there is an ethical dimension that must be understood in the context of the hurdles in each part of the APU triangle. For instance, confidentiality, privacy, and patient rights are intertwined throughout health care delivery. Likewise, cultural or religious values are likely to influence the ultimate interventions determined to best overcome a hurdle. We do not address these specific ethical concerns in this article, but rather we encourage individuals to consider their own, unique ethical imperatives as overriding matters in the application of the elements of the triangle.
The Impact of the Urban Environment on Public Health
Environment influences all three corners of the triangle model. The urban environment offers its own set of unique challenges to care for the public’s health and public health.4 Because we have identified universal hurdles affecting the delivery of public health common to any environment, we can now discuss the unique impact of the urban environment using our triangle model.
Urban Environment and Public Health Administration
Many hurdles to the administration of public health are specific to the urban environment and cross geopolitical borders. For instance, the significant numbers of service users, providers, and administrators pose both unique opportunities and challenges to urban areas. Larger bureaucracy or administrative staff is necessary, as are more costly techniques for advertising, marketing, and coordinating health care efforts. Additionally, political ideology and pressures, and financial considerations may collectively be considerably greater in large urban populations that tend to be culturally, socially, and economically diverse, although these pressures exist in other environments as well. Whereas a rural environment may have relatively few authorities for the administration of public health, urban areas often have multiple layers of responsibility placed on few individuals and agencies that form alliances and competitive plans for health care management. The greatest hurdle for the administrator in an urban health environment is to minimize the duplication of services by separate agencies, and to decrease the fragmentation of services brought about by the environment itself. For instance, uninsured patients may use different sources for accessing and paying for clinical care, hospitalizations, and laboratory or pharmaceutical needs.
Because of these increased demands, urban public health administration is evolving. There is increasing awareness of the need to revolutionize the infrastructure and financial management of these vital organizations that are entrusted with significant resources and responsibility. It is a challenge to recruit and educate individuals knowledgeable about large corporate business techniques and organization. The most effective leaders are those with a deep personal knowledge and experience of medical practice, with management and research skills. The advantage of gaining these individuals for public health administrative positions can be seen by looking once again at our APU triangle. A physician who has been in practice knows firsthand, and in depth, about the challenges facing providers. This vantage point is invaluable when making administrative decisions. We must work to overcome the lack of well-defined educational pathways at this time to bridge the gap in the transition from physicians in practice to the public health administration.4
By applying models typically used by large corporations, we change our mindset from that of a public institution funded mostly by tax dollars to one with stewardship and revenue-generating responsibility. There are more challenges here, both in changing the mindset of our culture and how our culture views public health, as well as convincing our public officials to consider funding of public health as a reinvestment process rather than a general fund expense. Our public health system should now be viewed not only as one that gives direct return on investment, but also as an immeasurable socioeconomic benefit.
Data management, tracking, follow-up, and notification are all significant challenges faced by urban public health facilities. At no other time in the history of civilization have we had the information system capabilities that we have now. The Internet and the computer make information-sharing easier, but they also create increased expectation and demand on our urban health care providers. Whereas rural health care systems may be responsible for hundreds of thousands of data points, urban communities must develop the infrastructure and ability to manage billions of data points—in some cases, the volume equivalence of a small country. The saying, “To whom much is given, much is expected,” is abundantly appropriate here. As our statistical and analytical capabilities improve, it is an ongoing challenge to master and incorporate these systems into our public health administration, for the health of our populations. Systems such as geographic information systems5,6 afford us increasing opportunities for rapid evaluation and adjustment of our public health delivery systems. These powerful tools, however, are not among the typical urban public health administrator's immediate resources, so collaborative efforts must be forged.
Urban Environment and Public Health Provision
Public health provision in the urban environment also faces unique challenges not seen in rural environments. Traditional needs-based models of community development are increasingly being replaced with innovations such as the asset-based community development model.7 Because of the complexity of the urban environment, it may be helpful to consider it in terms of two frames—urbanization and inner-city environment—as described by Leviton et al.8 Urban health care challenges may be a result of urbanization itself, or may be an issue involving only the inner-city environment.
For instance, the anonymity of the individual in the concentration of large populations serves as a barrier to providing consistent and continuous health care. This problem is one of urbanization, and applies to most people in an urban population, regardless of income level. Anonymity is further exacerbated by immigration and increased mobility of families and individuals. Tracking systems used to remind patients of needed appointments are often confounded by this mobility, losing patients who need care in a sea of anonymity. The urban environment and urban sprawl contribute to pollution, emergence of resistant organisms, concentrated epidemics, and outbreaks of disease brought from abroad, all of which challenge the provider system in affluent and poorer communities. On the other hand, when evaluating community-based assets, it is frequently only the inner-city pocket that has a health care hurdle to overcome, and this disparity is a result of multiple factors specific to that population, and not to the generalized urbanization.
Additionally, urban providers may be from very different backgrounds and provide very different levels of service. Providers may be part of public institutions or private groups, physicians or physician extenders, specialists or primary care providers, or academically affiliated. All of these providers must be rapidly educated on the importance of public health regulations, new standards of care, product availability, outbreaks, and emergency procedures.
Urban Environment and Public Health Utilization
The urban environment significantly affects the utilization of health care and results in pockets of poverty that often form a community of crime, and have poor housing conditions, disconnected social support structures, lack of education, and a poor job market. These communities suffer from disparities in health, economics, education, and many other quality-of-life factors. Additionally, urban poverty may foster concentrations of cultural barriers to the utilization of health care, such as religious and cultural beliefs and language differences. The distance to health care facilities may be greater in an urban environment, because the economics of providing care to a large population often favor far flung facilities that provide specialized services, rather than the needed concentration of “medical homes” where patients maintain a relationship with a health provider team who provide an array of basic primary care services with referral streams to specialists. Of course, economics plays a large role in the utilization of services. Patients who lack health care insurance or knowledge of the public funding available to them may often avoid using the medical system for fear of financial or social repercussions.
Last, but not least, often the individual's needs are lost in the urban environment. Factors that affect the individual's use of services may often have more to do with convenience, such as the time of day, length of appointment, distance to the facility, cost of transportation, and the availability of child care, than with the individual's desire for medical care.
We must continue to overcome the hurdles to health care use brought about by the explosion of technology and specialists. Throughout our urban centers, we must encourage our populations to incorporate the concept of a “medical home” and preventive medicine into their concept of health care. This is a universal concept and not just for the inner-city population. In order to ensure the healthiest urban populations, primary care givers and general treatment facilities must be actively supported, despite the temptation to fragment our funding and health care services by seeking services only on a critical basis or from superspecialists.
Overcoming the hurdles to the delivery of urban health care extends beyond the health care industry itself. The health of a community depends on functional city services, neighborhoods, businesses, the creative strength of the community, religious organizations, nonprofit groups, and individuals, in addition to health care providers and users. Partnering with academic centers, social and behavioral scientists, educational facilities, businesses, and other groups not typically considered part of the public health system is an excellent first step toward analyzing and breaking down these hurdles.
In addition, we must explore those new emerging relationships with individuals and agencies that are becoming increasingly important within the public health and medical care system, such as Homeland Security, that will ensure the appropriate response to real or perceived threats. By collaborating and guiding these efforts in urban centers, the safety of the entire community is enhanced. Who better to serve as the voice for the entire community than the local public health department?
The authors wish to thank Mical J. Kupke, MD, MPH, and Mark D. Summers, MD, MPH, for their enthusiastic review and editing assistance.