Between 2011 and 2013, all BCHC members reported having been actively involved in policy or advocacy activities related to tobacco, alcohol, or other drugs, as well as obesity/chronic disease. More than two-thirds of BCHC members worked on smoke-free indoor air policy, smoke-free outdoor air policy, and reducing the sale of cigarettes to minors. About 30% worked on raising the cigarette tax and 47% on reducing advertising. No members reported working to alter alcohol taxes in their jurisdiction. In the area of obesity and chronic disease, more than three-quarters of BCHC members reported actively engaging in urban design policy, school physical activity policy, reducing unhealthy eating at schools, expanding recreational facilities, and increasing fruit/vegetable options in retail locations. Only 2 BCHC LHDs said that they worked on limiting access to fast food.
Ninety percent of BCHC members reported that a public health ordinance or regulation had been adopted in their jurisdiction in the past 2 years. Several jurisdictions passed multiple ordinances or regulations. Thirteen BCHC jurisdictions passed tobacco, alcohol, or other drug ordinances; 6 passed environmental health ordinances; 2 passed health care access-related ordinances; 3 passed occupational health-related ordinances; 6 passed obesity/chronic disease–related ordinances, 2 passed injury prevention ordinances, and 8 passed “other” ordinances. Sixty percent of other large LHDs, 44% of medium-sized LHDs, and 29% of smaller LHDs adopted a public health ordinance or regulation in the past 2 years.
Leadership perspectives from interview data
The 45 interview participants from the BCHC departments included 23 women and 22 men (Table 1). Thirty listed professional or doctoral degrees as their highest level of education. Participants indicated that they had worked in their current position 3.4 years on average (median 3 years), in management for 14.8 years on average, and had worked in public health for 18 years on average. Seven BCHC directors were appointed by a mayor, 1 by a board of health, 3 by a county executive, and 6 by some other arrangement (typically some combination of various state and local agencies).
Perceived needs and barriers in BCHC LHDs
We asked BCHC leaders about perceived needs of large, urban health departments. The majority thought that the biggest barrier faced by health departments was the lack of funding for public health activities, especially those considered to be core public health and infrastructure. Information management needs were also commonly mentioned. Overall, BCHC leaders identified 3 key policy areas as priorities over the coming years: core funding for public health activities, “health in all policies” (where the effects of, for example, transportation, housing, or education policies on health are taken into account and public health is at the table), and LHDs participation in the implementation of the Affordable Care Act (ACA). Participants commonly cited political barriers, including ideological stances on where to assign blame for poor health outcomes, as well as outdated laws (Table 2). As one participant noted:
Among the decision-makers and also to a large extent among the electorate, the attitude is that there is not a role for government to undertake steps that are communal in nature to benefit all. There is an underlying culture that people should be responsible for themselves and that if you made a bad health decision in some way, that's your own fault.... As opposed to recognizing that it's not about blame; it's about where do we know that we can make interventions that will lead to fewer people making bad choices.
Similarly, participants explained that it was sometimes difficult to convince decision makers of how to proceed with public health policy and programming because of their lack of understanding of public health or of how to interpret data. Local bureaucracy was considered to be a major barrier by several participants, who explained that the governmental systems in place in their particular jurisdictions made it nearly impossible to hire appropriate staff, execute purchase orders, or accept grants in a timely fashion. Some interviewees noted the difficulty in engaging diverse community stakeholders to formulate comprehensive and unified strategies, indicating that a lack of resources and many different community agendas made it difficult to facilitate collaboration.
Participants uniformly reported that workforce needs are substantial in BCHC LHDs. These needs relate to workforce development in terms of continuing education and the acquisition of new skills, as well as the ability to hire the right people for the job. Participants reported that their departments lacked employees with the skills required to carry out the full range of activities critical to public health services, especially advocating for policy change and engaging the community. From their perspectives, these problems are exacerbated by complex and restrictive hiring practices as well as low employee mobility.
The BCHC leaders were asked specifically about the most important types of skills their staff needed to be effective (Figure 3). The most commonly-cited skills needed by staff were “big picture” or “public health 101” training. Systems thinking constituted abilities were needed to interconnect departmental programs, as well as to understand how the health department fits within the broader city environment. Skills in quantitative analysis were also mentioned as being necessary. Finally, many said that it was difficult to hire staff in a timely way. One participant illustrated her point with the following response when talking about running into challenges while trying to hire for policy-oriented positions:
There just isn't a policy position [in the HR system]. And we do have things like a Research Assistant III or an Epidemiologist II but we don't have this kind of position carved out and recognized. So for example I had a really hard time hiring a health economist. We had to go through a third party contractor to hire them because we had no items that he could fit on. There's no such thing as a health economist before. And yet we're trying to do more of this kind of work, like health impact assessments. So that is a really big challenge.
Programmatic Budget Cuts
The majority of BCHC departments had approximately the same budget in 2013 as 2012 in nominal dollars; 4 had budget cuts greater than 10%. Although many BCHC LHDs had relatively small changes to total expenditures between fiscal year 2012 and fiscal year 2013, programmatic budget changes did occur. The BCHC policy chiefs (1 per LHD) were asked to quantify any changes in programmatic areas over the previous fiscal year. Most participants reported some fluctuation in their programmatic budgets, with more cuts reported than growth. Those with budget growth had it in areas such as immunization (1 LHD), communicable disease control (1 LHD), chronic disease (3 LHDs), maternal and child health (2 LHDs), other personal health services (2 LHDs), population-based primary prevention (2 LHDs), and in other environmental health programs (1 LHD). More commonly, BCHC LHDs reported cuts, especially in immunizations, epidemiology, and population-based prevention services (Figure 4).
Discretion to Reallocate Dollars
One policy chief per department was asked to indicate the level of control associated with various revenue streams, including local revenue, state direct, federal pass-through dollars, federal direct sources, Medicare and Medicaid, other clinical revenue, and all other sources. With the exception of local sources, the majority of participants indicated that they had no or only a small amount of control. Six of 13 policy chiefs said that they felt that they had a great deal of control for local sources of revenue, while 3 others felt that they had moderate control. Nine participants indicated that they felt that they had no discretion to reallocate dollars from federal direct or pass-through funds. Three said that they felt that they had no control over state sources; 6 said that they felt that they had a small amount of control over state sources.
Public health policy has the potential to impact large portions of a population and contribute to an environment in which the healthy option is the default option. This is especially the case in metropolitan areas, which are now home to almost 83% of Americans.22 With the United States facing important health challenges in the 21st century—from obesity rates to opioid abuse—large urban jurisdictions and their public health systems are serving as key hubs for the greatest returns on health investments.
Increasingly, over the past decade, big city and large metro governments have become incubators of policy innovation and strong executive leadership.23 In the field of public health, local leadership is critical, particularly during a time of federal paralysis. Cities are better positioned to respond quickly to emerging threats than the slow-moving federal bureaucracy and are able to take strong stances on governance and local issues when partisan gridlock stalls federal efforts. Mayors across the country have taken risky stands on health issues from tobacco control to childhood obesity.24–27
The BCHC member LHDs have been the most active in policymaking among all LHDs nationally. All but 1 BCHC jurisdiction passed at least 1 public health ordinance in the past between 2011 and 2013, with all working on policy on 2 key fronts: tobacco, alcohol, and other drugs; and obesity and other chronic diseases. National leadership on new strategies and health challenges has arisen from urban jurisdictions. For example, Los Angeles County Department of Public Health drove the development of public letter grading for restaurants, which resulted in improved hygiene, reduced restaurant inspection violations, and a lower incidence of foodborne illness.28 In addition, Seattle-King County was one of the first to regulate electronic cigarettes as tobacco products with the aim to decrease adolescent nicotine addiction.29 Finally, New York City instituted a wide scope of new policies, such as restaurant calorie postings, school and vending machine food standards, and bonus food stamp coupons for fruits and vegetables.30 , 31
Thomas Frieden, former commissioner of the New York City Department of Health and Mental Hygiene and current director of the Centers for Disease Control and Prevention, noted a decade ago that many public health agencies had failed to implement effective policies and programs to prevent current health problems, in part due to structural inadequacies and insufficient funding.30 While large metropolitan health departments have advanced important policy initiatives in the past decade, the results of the current study confirm the challenges remaining that prevent LHDs from achieving optimal impact on improving the population's health.
Insufficient funding is the most frequently identified barrier to LHD impact improving the population's health. Big city spending per capita varies tremendously, which is partially attributable to local support but largely due to variable levels of federal funds reaching urban centers, because state health agencies are allocating those federal dollars differently. Greater transparency is needed to track this variable distribution and its impacts on effective investments in public health. The barriers are not merely having too little money, but that the fiscal environment hampers departments' potential impact in policymaking process because of restricted fiscal flexibility and discretion, inadequate workforce skills, and limited policymaker knowledge.
Data from the 2013 NACCHO Profile identified opportunities for greater involvement for LHDs in the policymaking process. Policy development should be a priority among LHDs individually and in NACCHO collectively.32 , 33 A key message of the Institute of Medicine's recent report is for government agencies to familiarize themselves with the toolbox of public health legal and policy interventions at their disposal.1 (p27)
The BCHC member LHDs were active at the local, state, and federal levels for all policy activities queried, but this was not the case for other large LHDs or LHDs with small or medium-sized jurisdictions. It may be that federal-level policy involvement from all LHDs is an unrealistic expectation except for the largest LHDs. However, some policy activity at the local level, regardless of jurisdictional size, should be universal. Policy development is a core function of public health practice and has been instantiated as such in the Ten Essential Services34 and, more recently, both as part of the Foundational Public Health Services model35 and the health department accreditation process by the Public Health Accreditation Board.36
Gaps in funding, lack of political support, and needs for strengthening professional staff are not new challenges in the management of public health departments. For the past 20 years, there has been a steady drumbeat of calls for sustained and strategic funding streams that would allow governmental public health to respond to emerging health threats, build capacity to address and prevent chronic conditions, and institute policies to improve conditions for healthy living. These needs persist. With their dense populations, strong leadership, and demonstrated commitment to engage in public health policy innovations, large metropolitan centers must become a greater priority at the federal and state levels for achieving improved returns on health investments.
This study had several limitations. It is a cross-sectional study and focuses primarily on the members of the BCHC. Data from the 2013 NACCHO Profile are widely used but do have limitations. These include potential issues due to nonresponse bias, though a 78% response rate is relatively robust for surveys of this type.1 (p27) In addition, the data are self-reported. Qualitative results should be interpreted within the context of the large, urban health departments that constitute the BCHC.
The need and opportunity exist to increase all LHDs' policy activities. The BCHC members have become incubators of policy innovation and strong executive leadership. However, even those departments in the BCHC have been hindered from making further gains in prevention and public health by continued inadequate funding and constraints in targeting resources to address local priorities. Leaders from BCHC member LHDs need to engage leaders in other large LHDs and medium-sized LHDs to increase their policy involvement at the local and state levels to create stronger support for public health investments. Public health leaders need greater political and financial support to make concrete progress on the most winnable health battles.
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* At the time of the interview portion of this study, 18 LHDs constituted the BCHC. Two additional LHDs have since joined: those serving San Antonio, Texas, and San Diego, California.
Keywords:Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Big Cities Health Coalition (BCHC); local health departments (LHDs); public health practice