Public Health System: Structure and Function

25 Public Health System


Structure and Function



Chapter Outline



I. ADMINISTRATION OF U.S. PUBLIC HEALTH 


A. Responsibilities of the Federal Government 

1. Regulation of Commerce 

2. Taxation for the General Welfare 

3. Provision of Care for Special Groups 

4. Funding Federal Legislation 

5. Coordination of Federal Agencies 

B. Responsibilities of States 

C. Responsibilities of Municipalities and Counties 

D. Responsibilities of Local Public Health Departments 

1. “Basic Six” to 10 Essential Services 

2. Health Director’s Duties 

3. Environmental Protection 

II. BROADER DEFINITIONS OF PUBLIC HEALTH POLICY 


III. INTERSECTORAL APPROACH TO PUBLIC HEALTH 


IV. ORGANIZATIONS IN PREVENTIVE MEDICINE 


V. ASSESSMENT AND FUTURE TRENDS 


VI. SUMMARY 


REVIEW QUESTIONS, ANSWERS, AND EXPLANATIONS image


The U.S. Institute of Medicine (IOM) describes the challenges inherent in organizing the public health system for the 21st century as follows1:



The systems and entities that protect and promote the public’s health, already challenged by problems like obesity, toxic environments, a large uninsured population, and health disparities, must also confront emerging threats, such as antimicrobial resistance and bioterrorism. The social, cultural, and global contexts of the nation’s health are also undergoing rapid and dramatic change. Scientific and technological advances, such as genomics and informatics, extend the limits of knowledge and human potential more rapidly than their implications can be absorbed and acted upon. At the same time, people, products, and germs migrate and the nation’s demographics are shifting in ways that challenge public and private resources.


The U.S. public health system was designed at a time when most threats to health were infectious, before computer information systems, and when local autonomy prevailed. This chapter describes the structure of the U.S. health system and discusses how it must respond to contemporary challenges. Public health systems in other countries are likely structured very differently but still need to adapt to the same challenges.



I Administration of U.s. Public Health



A Responsibilities of the Federal Government


The public health responsibility of the U.S. Federal Government is based on two clauses from Article 1, Section 8, of the U.S. Constitution. First, the Interstate Commerce Clause gives the federal government the right “to regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes.” Second, the General Welfare Clause states that “the Congress shall have Power to lay and collect Taxes. .. for the common Defense and general Welfare of the United States.” Federal responsibility also is inferred from statements that Congress has the authority to create and support a military and the authority to negotiate with Indian tribes and other special groups.



1 Regulation of Commerce


The regulation of commerce involves controlling the entry of people and products into the United States and regulating commercial relationships among the states. People may be excluded from entry to the United States if they have infectious health problems, such as active tuberculosis. Products may also be excluded from entry, such as fruits and vegetables if infested with certain organisms (e.g., Mediterranean fruit fly) or treated with prohibited insecticides or fungicides. In the past, similar prohibitions have been extended to the importation of animal products from cattle that might contain the prions of bovine spongiform encephalopathy and, as recently in 2011, produce that might be contaminated with Escherichia coli.


The regulation of commercial relationships between states has increased over time. Contaminated food products that cross state lines are considered to be “interstate commerce”; what crosses state lines are harmful microorganisms. The federal government takes the responsibility for inspecting all milk, meat, and other food products at their site of production and processing. (In contrast, the state or local government is responsible for inspecting restaurants and food stores.) Likewise, polluted air and water flowing from state to state are deemed to be “interstate commerce” in pollution and come under federal regulation.



2 Taxation for the General Welfare


The power to “tax for the general welfare” is the constitutional basis for the federal government’s development of most of its public health programs and agencies, including the Centers for Disease Control and Prevention (part of the Department of Health and Human Services) and the Occupational Safety and Health Administration (OSHA, part of the Department of Labor); for research programs, such as those of the National Institutes of Health (NIH); and for the payment for medical care, such as Medicare and Medicaid (see Chapter 29).



3 Provision of Care for Special Groups


The federal government has taken special responsibility for providing health services to active military personnel, through military hospitals; families of military personnel, through military hospitals or the Civilian Health and Medical Program of the Uniformed Services; veterans, through the Veterans Administration hospital system; and Native Americans and Alaska Natives, through the Indian Health Service of the U.S. Public Health Service.



4 Funding Federal Legislation


Funding of federal legislation requires a two-step process. The initial bill provides an authorization of funds. An authorization bill only sets an upper limit to the amount of funds that can be spent. No monies can be spent, however, until they have been specifically appropriated for that bill’s purposes in a subsequent appropriations bill. The authorization is a political fiction for which members of Congress can claim political gain. In practice, the amount appropriated tends to be about half the amounts authorized in the bills, and the amounts are usually appropriated for only one fiscal year at a time. It is in the funding bills that fiscal (and political) reality must be faced. Because a funding bill covers many items, the voters usually are unaware that the amount actually appropriated is much smaller than the amount promised in the authorization bill.



5 Coordination of Federal Agencies


In the United States the federal department most concerned with health is the Department of Health and Human Services (DHHS), which has four major operating units, described next2 (Fig. 25-1).


image

Figure 25-1 U.S. Department of Health and Human Services (DHHS) organizational chart.


(From http://www.hhs.gov/about/orgchart.)



Administration on Aging


The Administration on Aging provides advice to the Secretary of the DHHS on issues and policies regarding elderly persons. It also administers certain grant programs for the benefit of the aging population.



Administration for Children and Families


The Administration for Children and Families is responsible for administering child welfare programs through the states, Head Start programs, child abuse prevention and treatment programs, foster care, adoption assistance, developmental disabilities programs, and child support enforcement.



Centers for Medicare and Medicaid Services


The Centers for Medicare and Medicaid Services (CMS) is responsible for administering two major programs of the Social Security Act. Medicare is covered under Title 18 of the Social Security Act and pays for medical care for the elderly population. Medicaid is covered under Title 19 and pays for medical and nursing home care in cooperation with the states (see Chapter 29). CMS duties include setting standards for programs and institutions that provide medical care, developing payment policies, contracting for third-party payers to cover the bills, and monitoring the quality of care provided. CMS also supports graduate medical education, residency, and fellowship programs that provide care for individuals covered by Medicare or Medicaid.



Public Health Service


The U.S. Public Health Service (PHS) comprises the following eight constituent agencies:



1. The Agency for Healthcare Research and Quality (AHRQ) is the main federal agency for research and policy development in the areas of medical care organization, financing, and quality assessment. Since 2000, the agency has placed increasing emphasis on medical care quality.


2. The Agency for Toxic Substances and Disease Registry (ATSDR) provides leadership and direction to programs designed to protect workers and the public from exposure to and adverse health effects of hazardous substances that are kept in storage sites or are released by fire, explosion, or accident.


3. The Centers for Disease Control and Prevention (CDC) has the responsibility for “protecting the public health of the [United States] by providing leadership and direction in the prevention and control of diseases and other preventable conditions and responding to public health emergencies.” The CDC directs and enforces federal quarantine activities; works with states on disease surveillance and control activities; develops programs for prevention and immunization; is involved in research and training; makes recommendations on how to promote occupational health and safety through the National Institute on Occupational Safety and Health (NIOSH); provides consultation to other nations in the control of preventable diseases; and participates with international agencies in the eradication and control of diseases around the world. The CDC has a complex organizational structure (Fig. 25-2).


4. The Food and Drug Administration (FDA) is the primary agency for regulating the safety and effectiveness of drugs for use in humans and animals; vaccines and other biologic products; diagnostic tests; and medical devices, including ionizing and nonionizing radiation–emitting electronic products. The FDA is also responsible for the safety, quality, and labeling of cosmetics, foods, and food additives and colorings.


5. The Health Resources and Services Administration (HRSA) is responsible for developing human resources and methods to improve health care access, equity, and quality, with an emphasis on promoting primary care. HRSA also supports training grants and training programs in preventive medicine and public health.


6. The Indian Health Service promotes the health of and provides medical care for Native Americans and Alaska Natives.


7. The National Institutes of Health (NIH) consists of 27 institutes, which perform intramural (in-house) research on their particular diseases, organ systems, or topics (e.g., National Cancer Institute; National Heart, Lung, and Blood Institute; National Human Genome Research Institute; National Center for Advancing Translational Science). The institutes also review and sponsor extramural research at universities and research organizations through competitive grant programs. Some of the institutes also undertake disease control programs and public and professional education in their area (e.g., National Library of Medicine, National Institute for Neurological Disorders and Stroke).


8. The Substance Abuse and Mental Health Services Administration (SAMHSA) provides national leadership in preventing and treating addiction and other mental disorders, based on up-to-date science and practices, and has four major operating divisions: Center for Mental Health Services, Center for Substance Abuse Prevention, Center for Substance Abuse Treatment, and Center for Behavioral Health Statistics and Quality.


image

Figure 25-2 U.S. Centers for Disease Control and Prevention (CDC) organizational chart.
STD, Sexually transmitted disease; TB, tuberculosis.


(From http://www.cdc.gov/maso/pdf/CDC_Official.pdf.)


The PHS is not the only important agency in public health. The other major federal organization is the Office of Public Health and Science (OPHS), which leads the Healthy People initiative through its Office of Disease Prevention and Promotion (see Chapter 26) and oversees the U.S. Surgeon General’s office, President’s Council on Bioethics, U.S. Public Health Service Commissioned Corps, and Office of Minority Health (Fig. 25-3).


image

Figure 25-3 U.S. Office of Public Health and Science (OPHS) organizational structure.
HIV/AIDS, Human immunodeficiency virus and acquired immunodeficiency syndrome.


(From http://www.hhs.gov/about/orgchart/ophs.html.)



B Responsibilities of States


In the United States the fundamental responsibility for the health of the public lies with the states. This authority derives from the 10th Amendment to the Constitution: “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”


In 1988 the IOM stated that “the mission of public health is to ensure conditions in which people can be healthy”, and that the three “core functions of public health agencies at all levels of government are assessment, policy development, and assurance.”3



1. The assessment role requires that “every public health agency regularly and systematically collect, assemble, analyze, and make available information on the health of the community, including statistics on health status, community health needs, and epidemiologic and other studies of health problems.”3


2. The policy development role requires that “every public health agency exercise its responsibility to serve the public interest in the development of comprehensive public health policies by promoting the use of the scientific knowledge base in decision-making about public health,. .. by leading in developing public health policy, and by taking a strategic approach, developed on the basis of a positive appreciation for the democratic political process.”3


3. The assurance role requires that “public health agencies assure their constituents that services necessary to achieve agreed upon goals are provided, either by encouraging action by other entities (private or public sector), by requiring such action through regulation, or by providing services directly.”3

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Aug 27, 2016 | Posted by in PUBLIC HEALTH AND EPIDEMIOLOGY | Comments Off on Public Health System: Structure and Function

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