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State Public Health Departments

Reflections on the Last 25 Years and Future Challenges

Halverson, Paul K., DrPH, FACHE

Journal of Public Health Management and Practice: January/February 2019 - Volume 25 - Issue 1 - p 7–11
doi: 10.1097/PHH.0000000000000923
25 Years of Publication: Twelve Major Themes: Commentary

Indiana University Richard M. Fairbanks School of Public Health at IUPUI, Indianapolis, Indiana.

Correspondence: Paul K. Halverson, DrPH, FACHE, Indiana University Richard M. Fairbanks School of Public Health at IUPUI, 1050 Wishard Blvd, Indianapolis, IN 46202 (pkhalver@iu.edu).

The author declares no conflicts of interest.

In honor of the 25th anniversary issue of the Journal of Public Health Management and Practice (JPHMP), it is appropriate for us to reflect on one of the most prescient documents in our field, the 1988 Institute of Medicine report on the Future of Public Health.

This nation has lost sight of its public health goals and has allowed the system of public health activities to fall into disarray.1

Thirty years ago, many people in public health took offense that public health was “in disarray.”

Citing the many pressures facing the health of the nation, the now famous Committee for the Study of the Future of Public Health concluded that several aspects of our public health system were broken and needed significant change. Despite the calls of many established public health officials for “staying the course” and “holding on to our traditions,” many public health leaders and policy makers took the advice of the committee seriously and progress has been made on a number of fronts. While any list would be incomplete because of the many perspectives of the field, my notable system milestones include the following:

  • Understanding the importance of public health implementation, the Centers for Disease Control (CDC) and Prevention established the Public Health Practice Program Office (PHPPO) in 1988. While later iterations have seen PHPPO morph into the Center for State, Tribal, Local and Territorial Support, recognition of the CDC as the primary federal agency focused on public health practice is a critical accomplishment.2
  • The development of training programs in leadership and management, for example, the National Public Health Leadership Institute sponsored by the CDC and the State Health Leadership Institute sponsored by the Robert Wood Johnson Foundation.3
  • The evolution of a public health system that acknowledges the critical importance of both governmental agencies and nongovernmental organizations and partnerships.4
  • The creation of Health Alert Network and the development and widespread utilization of public health informatics.5
  • An increased focus on public health preparedness fosters an “all hazards approach” to readiness.6
  • Terrorism and national health security bring a new focus on the importance of public health infrastructure.7
  • Improvements in systematic surveillance systems grow in concurrence with the proliferation of molecular epidemiology.8
  • A greater understanding of chronic disease risk factors, such as tobacco and obesity, brings about a systematic approach to risk reduction.9
  • To advance quality improvement, public health professionals have created system assessment tools such as the National Public Health Performance Standards Program and the Public Health Accreditation Board.10
  • The creation of new frameworks for public health engagement including the Robert Wood Johnson Foundation's “Culture of Health,” Public Health 3.0, including the Foundational Public Health Services, and other emerging scholarship focused on public health delivery systems.11
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State Public Health Structure and Organization

The committee believes that states are and must be the central force in public health. They bear primary public sector responsibility for health.1

While federal funding and coordination are essential to the advancement of public health, the reality is that public health implementation is fundamentally a legal responsibility of states. Aside from national security concerns, the federal government plays a supporting role in the enhancement and delivery of public health. States possess the sovereign constitutional authority to configure local public health delivery systems as it best fits their population and state-specific dynamics. They have the ability to organize and administer in a manner that they choose, including to decide whether a centralized or decentralized local health department structure best meets their needs.

Currently, 27 states have a decentralized or largely decentralized system, 14 states have a centralized or largely centralized system, 5 states employ a mixed governance structure, and 4 states have a shared governance system.12 The resulting configuration of state and local health departments represents wide variation in both capacity and services.13

In light of the fact that states are structured in a number of ways, it is important that every state endeavor to adopt evidence-based organizational practices in order to ensure the delivery of essential public health services. One year following Public Health Accreditation Board accreditation, local and state health departments reported that respondents perceived increased quality and performance improvement opportunities, improved identification of strengths and weaknesses within the department, and greater accountability and transparency.14

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State Public Health Leadership

The committee recommends that the director of the department of health be a cabinet (or equivalent-level) officer. Ideally, the director should have doctoral-level education as a physician or in another health profession, as well as education in public health itself and extensive public sector administrative experience. Provisions for tenure in office, such as a specific term of appointment, should promote needed continuity of professional leadership.1

State health officials (SHOs), who serve as the leaders of state public health departments or agencies, are appointed by and report directly to governors, state secretaries of health, or boards of health. This poses numerous implications as to how SHOs are selected and how much autonomy they have in carrying out their duties. It is also particularly important, given that SHOs are currently experiencing the shortest tenures of the last 5 decades.15 As of 2016, 33 of the 50 SHOs were appointed by the governors of each state, 7 were appointed by the secretary of health, and 5 were appointed by a health board or commission. Twenty-four states have structures where SHOs report directly to governors, 16 states have SHOs who report directly to the state health secretary, and in the other 10 states, SHOs report directly to a board of health.12 Interestingly, SHOs appointed by a board of health averaged more than 8 years in office compared with an average of just less than 4 years for those appointed by governors or secretaries of state agencies.16 This difference is most likely attributed to the fact that SHOs appointed by a board of health are more insulated against politically induced turnover.

Given the variation in the configuration of state health departments, each state has determined its own minimum qualifications for the appointment of SHOs. Based on current research from the State Health Officials Career Achievement and Sustainability Evaluation (SHO-CASE) study, 11 states require that SHOs be a physician; 12 states require a medical degree with public health, health administration, or management experience; 2 states require a medical degree and a graduate degree in public health or health administration; and surprisingly, 9 states had no educational requirements for SHOs.17 This research, supported by the deBeaumont Foundation, reveals some incredible insights into the educational attainment and professional experience trends of SHOs. Of those who participated in the (SHO-CASE) study, 65% have a medical degree, 48% have a formal public health degree, 70% have previous governmental public health experience, and 57% worked in governmental public health immediately before becoming an SHO.18 More findings from this crucial study of SHOs are forthcoming in the JPHMP along with tools and infographics for those who appoint and support new SHOs (Figure).

FIGURE

FIGURE

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Ensuring a Qualified Public Health Workforce

Schools of public health should establish firm practice links with state and/or local public health agencies so that significantly more faculty members may undertake professional responsibilities in these agencies, conduct research there, and train students in such practice situations. Recruitment of faculty and admission of students should give appropriate weight to prior public health experience as well as to academic qualifications.1

In 1988, there were only 23 accredited schools of public health. Fifteen years ago, this had increased to only 32 accredited schools of public health.19 Today, there are 64 accredited schools of public health and 121 accredited programs.20 Accreditation standards require connections with public health agencies and students are required to be engaged in internship opportunities as a part of most degree programs. There are requirements for an applied practice experience (internship) and integrated learning experience (capstone) in MPH and DrPH programs. The Council on Education of Public Health also requires cumulative and experiential activities in BSPH programs.21 It is not essential that these experiences be completed in public health agencies, but they can be, if desired.

While our schools of public health and the number of trained graduates have increased greatly in number, the percentage of students declaring their interest in working with governmental public health agencies is decreasing. While governmental public health is primarily made up of employees with no formal public health training, it is significant to note that despite record numbers of accredited schools and programs, we have not made progress in significantly increasing the number of people working in public health with a public health degree. About 17% of the public health workforce holds a degree in public health at any level.22 The situation is exacerbated by the reality that 42% of individuals in governmental public health anticipate retiring or leaving public health by 2020.23

Given the substantial new capacity of schools and programs granting public health degrees, we must look for systemwide solutions to solve the mismatch between governmental public health positions and new public health graduates.24 From my time as an SHO to my current role as a dean of a school of public health, I see the challenges from both sides of what should be an ever-strengthening partnership.

From a practice perspective, public health jobs are not properly configured to require educational qualifications and are therefore not rated at a competitive enough pay scale to attract most public health graduates. In addition, many of our civil service experience requirements for supervision and management do not provide for educational credit even when it might be logical to satisfy the job responsibilities.

From an academic perspective, a common refrain that we hear is that many of our recent graduates lack the “job-ready” skills necessary to effectively work in the “real world” of public health because their degree is theoretically focused. The claims suggest that these graduates require extensive on-the-job training to bring them up to an acceptable level of productivity. However, our new accreditation criteria and the clear mandate for experiential learning are closing the gap between academia and practice.

Professional credentialing, such as the certified in public health credential, can elevate the profession while simultaneously allowing young professionals to signal to potential employers that they have the capacity necessary for governmental public health positions. In addition, the Public Health Accreditation Board requires that agencies develop partnerships with academia. This has the benefit of increasing the practical realities in schools and the value of lifelong learning in agencies.

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Summary

This anniversary edition of the JPHMP is a celebration of yet additional new knowledge displayed through more than 1100 original research articles and commentaries. This journal plays a key role in advancing knowledge of our public health system.

As former CDC director Dr Thomas Frieden said, “public health is a best buy.” We have the opportunity to demonstrate that additional investment in public health, particularly state public health, will bring substantial health benefits for improved quality of life, reduction of medical care costs, and improvement in life expectancy. A 10% increase in local public health spending per capita is associated with 0.8% reduction in adjusted Medicare expenditures per person after 1 year and a 1.1% reduction after 5 years.25 Moreover, mortality rates decreased between 1.1% and 6.9% for each 10% increase in local public health spending.

Through the work of both scholars and public health practitioners who frequent the pages of this journal, we shine a light on what is working and point out opportunities for improvement. Congratulations to Dr Novick for his exemplary leadership in public health research and to the JPHMP for helping to achieve our cause of advancing the scholarship of practice.

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References

1. Institute of Medicine; Committee for the Study of the Future of Public Health. The Future of Public Health. Washington, DC: The National Academies Press; 1988.
2. Centers for Disease Control and Prevention; Office for State, Tribal, Local and Territorial Support. Technical Assistance and Service Improvement Initiative: Project Officer Survey. https://www.cdc.gov/stltpublichealth/docs/tasii-executive-summary.pdf. Published 2013. Accessed November 8, 2018.
3. Grimm BL, Tibbits MK, Soliman GA, Siahpush M. A retrospective evaluation to determine the effectiveness of public health leadership institutes. J Leadersh Stud. 2017;11(1):6–19.
4. Reich MR. Public-private partnerships for public health. Nat Med. 2000;6(6):617–620.
5. Baker EL, Porter J. The health alert network: partnerships, politics, and preparedness. J Public Health Manag Pract. 2005;11(6):574–576.
6. Moore S, Mawji A, Shiell A, Noseworthy T. Public health preparedness: a systems-level approach. J Epidemiol Community Health. 2007;61(4):282–286.
7. Baker EL Jr, Potter MA, Jones DL, et al The public health infrastructure and our nation's health. Annu Rev Public Health. 2005;26:303–318.
8. Groseclose SL, Buckeridge DL. Public health surveillance systems: recent advances in their use and evaluation. Annu Rev Public Health. 2017;38:57–79.
9. Ezzati M, Vander Hoorn S, Rodgers A, et al Estimates of global and regional potential health gains from reducing multiple major risk factors. Lancet. 2003;362(9380):271–280.
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11. DeSalvo KB, O'Carroll PW, Koo D, Auerbach JM, Monroe JA. Public health 3.0: time for an upgrade. Am J Public Health. 2016;106(4):621.
12. Association of State and Territorial Health Officials. ASTHO profile of health—volume 4. http://www.astho.org/Profile/. Published 2017. Accessed October 5, 2018.
13. Mays GP, McHugh MC, Shim K, et al Institutional and economic determinants of public health system performance. Am J Public Health. 2006;96(3):523–531.
14. Kronstadt J, Meit M, Siegfried A, Nicolaus T, Bender K, Corso L. Evaluating the impact of National Public Health Department Accreditation—United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65(31):803–806.
15. Menachemi N, Danielson EC, Tilson H, et al Tenure & turnover among state health officers: correlates & consequences of changing leadership. 2018. Manuscript submitted for publication.
16. Halverson PK, Lumpkin JR, Yeager VA, Castrucci BC, Moffatt S, Tilson H. Research full report: high turnover among state health officials/public health directors: implications for the public's health. J Public Health Manag Pract. 2017;23(5):537.
17. Halverson PK, Yeager VA, Menachemi N, et al State health official career advancement and sustainability evaluation—the SHO-CASE study. 2018. In press.
18. Yeager VA, Menachemi N, Jacinto CM, et al State health officials: backgrounds and qualifications (1973-2017). 2018. In press.
19. Hernandez LM, Rosenstock L, Gebbie K, eds. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press; 2003.
20. CEPH 2018 Accreditation Statistics. https://ceph.org/constituents/schools/faqs/general/accreditation-statistics/. Accessed October 5, 2018.
21. CEPH Schools of Public Health and Public Health Programs Accreditation Standards. https://storage.googleapis.com/media.ceph.org/wp_assets/2016.Criteria.pdf. Published 2016. Accessed October 5, 2018.
22. Leider JP, Harper E, Bharthapudi K, Castrucci BC. Educational attainment of the public health workforce and its implications for workforce development. J Public Health Manag Pract. 2015;21(suppl 6):S56.
23. Sellers K, Leider JP, Harper E, et al The Public Health Workforce Interests and Needs Survey: the first national survey of state health agency employees. J Public Health Manag Pract. 2015;21(suppl 6):S13.
24. Yeager VA, Beitsch LM, Hasbrouck L. A mismatch between the educational pipeline and public health workforce: can it be reconciled?. Public Health Rep. 2016;131(3):507–509.
25. Mays GP, Mamaril CB. Public health spending and Medicare resource use: a longitudinal analysis of us communities. Health Serv Res. 2017;52:2357–2377.
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