TURNOCK READING ROOM

Evaluating the performance of local health agencies: the 10 public health practices vs. the 10 public health services---a clarification

Turnock BJ and Handler AS---Division of Community Health Sciences, University of Illinois at Chicago, School of Public Health

Amer Jour Public Health 1995;85:1295-96 (letter; also available in PDF format)

Once again, Arden Miller and his colleagues have advanced our understanding of the important work of local health departments through their development of a tool to measure the performance of public health's core functions at the local level.¹ Their use of 10 public health practices that operationally define the three core functions identified in the Institute of Medicine (IOM) report provides additional evidence that this framework can be successfully applied to both the measurement and improvement of public health practice by focusing on function rather than form. Miller and colleagues' important work, and that undertaken by investigators at the University of Illinois at Chicago, the University of South Florida, and the Centers for Disease Control and Prevention, have established important footholds on this slippery slope.^2-7

Recently, the lack of concurrence among various US Public Health Service agencies as to how the content of public health practice should be characterized. Together with the need for a unitary and understandable approach to public health in the health reform debate, led to the development of a listing of 10 essential public health services.⁸ Although many of the concepts embodied in the essential public health services are recognizable in the 10 public health practices, the two list are dissimilar enough to raise important questions. Should investigators such as Miller et al and ourselves drop the 10-practice construct for the essential services framework? Or alternatively, are these formulations different enough and developed for distinct enough purposes to peacefully coexist?

The 10 practices were developed specifically to operationally define IOM's three core functions at the local level so that local public health practice could be measured in terms consistent with Year 2000 National Health Objective 8.14 (90% of the population to be served by a local health department that is effectively addressing the core functions of public health). They reflect the organizational or collective processes through which public health inputs (work force, information, organizational relationships) are applied to address the broad functions of public health. These processes result in outputs that are recognizable as programs and services intended to improve community health status, the ultimate outcome of the public health enterprise. The use of this framework, therefore, seems logical for activities that focus on local public health performance in comparison to a national target or optimal organizational performance.

The essential public health services were developed for an entirely different application, namely, to describe public health activities more understandably for external audiences and constituencies. This has been widely perceived to be necessary to secure or even maintain public resources for population-based, community-oriented prevention efforts, but especially to serve as a basis for the funding of core public health functions once this opportunity materialized in the national health reform debate. A list of core functions was deemed necessary in view of the conflicting language between health reform's version of core functions and that promoted by the IOM report. As a result, health reform's core functions were recast by the US Public Health Service as essential public health services. They actually represent a mixed bag of inputs, processes, and outputs that serve a useful purpose, but that may not provide the most rational basis for assessing and enhancing local public health practice.

In sum, although these two formulations are generally compatible (embodying basically the same concepts), they were derived for quite different applications and should not be viewed as generic equivalents. In our view, if we are committed to an effective public health presence at the local level, it is essential that we not only clearly describe these activities to our constituencies but reliably measure these efforts as well. In this age of public accountability, building support for public health and building capacity for effective public health practice must go forward hand in hand.

References

1. Miller CA, Moore KS, Moore TB, Monk JD. A proposed method for assessing the performance of local public health functions and practices. Am J Public Health 1994;84:1743-1749.
2. Roper WL, Baker EL, Dyal WW, Nicola RM. Strengthening the public health system. Public Health Rep 1992;107:609-615.
3. Turnock BJ, Handler A, Dyal WW, et al. Implementing and assessing organizational practices in local health departments. Public Health Rep 1994;109:478-484.
4. Studnicki J, Steverson B, Blais HN, et al. An analysis of organizational practices: a methodology to describe the work activities of the local health department. Public Health Rep 1994;109:485-490.
5. Turnock BJ, Handler A, Hall W, et al. Local health department effectiveness in addressing the core functions of public health. Public Health Rep 1994;109:654-658.
6. Miller CA, Moore KS, Richards TB, McKaig C. A screening survey to assess local public health performance. Public Health Rep 1994;109:659-664.
7. Oberle MW, Baker EL, Magenheim MJ. Healthy people 2000 and community health planning. Ann Rev Public Health 1994;15:259-275.
8. Baker EL, Melton RJ, Stange PV, et al. Health reform and the health of the public. JAMA 1994;272:1276-1282.