TURNOCK READING ROOM

Public health expenditures: good news and bad news for public health

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

Jour Public Health Management & Practice 1997;3(3):x-xi

One sign of the treacherous times facing public health in the 1990s is that it is becoming increasingly difficult to tell the good news from the bad.

There is an often told story of a man who received a frantic phone call from his physician. "I am so glad I finally located you," said the physician. "But I must warn you, I have both good news and bad news to tell you. Which would you like to hear first?" The man hesitated for a minute, but then bravely said, "Tell me the good news first." "All right," said his physician, Your tests have come back and they indicate that you have only 48 hours to live." After finally composing himself, the man retorted," I thought you were going to tell me the good news first." "That was the good news," said the physician, "the bad news is that it’s taken me two days to find you."

This edition of the Journal carries news to the public health community that is important for understanding and quantifying the extent of our current investment in public health strategies. Expenditures by local health departments and several key state agencies (i.e., those with public health, environmental health, and behavioral health responsibilities) were identified for ten essential services related to public health’s core functions in ten states.¹ Importantly, direct services of a personal health care nature were delineated from population-based services. As in the story of the man with only 48 hours to live, the findings of this ground breaking effort reflect a mixture of both good and bad news.

First, the good news!

We are now able to quantify the financial resources devoted to public health’s work. This is possible as a result of the professional consensus that has developed for a public health system whose core functions are assessment, policy development and assurance.² As noble as these three functions may be, they must be further operationalized in a manner that is both meaningful and understandable. The framework of ten essential public health services developed through a process coordinated by the U.S. Public Health Service³ has proven useful in translating the core functions into understandable and measurable processes so that the resources necessary for their performance can be identified and quantified, as illustrated by the methodology and findings in the article by Eilbert and colleagues.¹ The essential services framework also allows for population-based activities that assess and address health problems and the factors which contribute to them to be differentiated from personal health services that are provided through the public sector as part of assessing, addressing and assuring the health of the public. The net result of these developments is that we can link financial resources to performance of various aspects of public health’s three core functions and to the population-based and personal health service intervention strategies that result from their performance.

In examining expenditures for public health purposes in this manner, this study confirms what public health leaders have decried for decades: the lack of financial resources necessary to adequately promote and protect the health of the public despite national health expenditure levels more than twice as high as other developed nations. Past arguments, however, were limited by a lack of empirical information as to the actual level of spending for pubic health purposes and whether these resources were keeping pace with changes in need, priorities and a rapidly growing illness care system in the United States. With little consensus as to what pubic health is and what it does, it was not possible to partition health expenditures into categories that represent various forms of pubic health effort.

The findings of this study are consistent with several recent, although limited, efforts to quantify the extent of spending for public health purposes.^4-6 From these various sources, it appears that only about 1 percent of our trillion dollar enterprise---or about 12 cents per day per person---goes for population-based public health purposes. But public health activities embrace interventions beyond population-based strategies; outreach, linkage and direct services also have become essential public health services. These studies indicate that personal health services provided by these public agencies comprise another 2-3 percent of total national health expenditures or about 26 cents per person per day. Altogether, for less than the cost of a daily cup of coffee or pack of chewing gum, Americans are served by their public health system. Bargain shoppers everywhere would find this to be good news!

Now for the bad news!

If the good news is that we now know how much is being invested in the various forms of public health, the bad news is that we now know how much is being invested in public health. In public health we tend to look at financial resources as one of those essential ingredients or basic inputs for our public health system.⁷ There is little debate on this point; financial resources are an important element of the public health infrastructure. But these resources are more than mere inputs into the system; they are also a measure of the value of public health in modern America. Bad news, indeed!

Quantifying phenomena in economic terms may not be uniquely American, but it has become so common in our society that it must reflect some basic value or belief. This is apparent in the vast health sector of American society where more than $1 trillion is expended each year, reflecting the value we place on specific products in the form of policy, program and service interventions that affect our health. With only 1 percent devoted to population-based public heath purposes, it is hard to argue that these activities are highly valued in modern America. This low valuation of public health activities may be a result of not reaching the American public with products that are valued or of providing valued products in ways in which their source is unclear. In either event, this is bad news for the public health community!

Another bit of bad news is the somewhat subtler message of this article---tracking expenditures for public health purposes will require major changes in the way government agencies think and operate. Decades of categorical program incentives have created agencies that resemble aggregates of programs and services rather than guardians of the public health. The common processes that should make these agencies think and act more in tune with pubic health’s core functions have been largely jettisoned and replaced by priorities and programs that are dictated by external sources. The result is that, when judged by what is done (programs and services) they look more different than alike! Agencies tend to measure what they believe they are going to be held accountable for. Unfortunately, there is little movement toward holding public agencies accountable for performing public health functions.⁸ To expect that these public agencies can embrace a framework for quantifying expenditures without embracing a clearer focus on the core functions themselves may be unrealistic.

Conclusion

Whether viewed as good news or as bad news, an opportunity or a challenge, the difficulty in quantifying and measuring key aspects of public health practice has been a chronic affliction of the public health system in the United States. It stems in part from the lack of consensus as to the content of public health practice and is exacerbated by our penchant for defining public health practice in terms of programs and services rather than basic public health functions. Nowhere is this clearer than in our inability to differentiate population-based public health services from personal health services while still appreciating their many interconnections. Hopefully, the public health community will come to grips with this grim reality, and confront and cure this affliction, before we receive a frantic call that our system has only 48 hours to live!

References

1. Eilbert, K.W., et al. "Public Health Expenditures: Developing Estimates for Improved Policy Making." Journal of Public Health Management and Practice 3(1997):xx-xx.
2. Institute of Medicine. The Future of Public Health. Washington, D.C.; National Academy Press, 1988.
3. Baker, E.L., et al. "Health Reform and the Health of the Public: Forging Community Health Partnerships." Journal of the American Medical Association 272(1994):1276-82.
4. Brown, R.E., et al. National Expenditures for Health Promotion and Disease Prevention Activities in the United States. Washington, D.C.; Medical Technology Assessment and Policy Research Center, 1991.
5. Public Health Foundation. Measuring State Expenditures for Core Public Health Functions. Washington, D.C.; Public Health Foundation, 1994.
6. Core Functions Project, U.S. Public Health Service, Office of Disease Prevention and Health Promotion. Health Care Reform and Public Health: A Paper Based on Population-Based Core Functions. Washington, D.C.; U.S. Public Health Service, 1993.
7. Roper, W.L., et al. "Strengthening the Public Health System." Public Health Reports 107(1992):609-15.
8. Turnock, B.J. and Handler, A.S. "Is Public Health Ready for Reform? The Case for Accrediting Local Health Departments." Journal of Public Health Management and Practice 2 no. 3(1996):41-45.