Public Health Systems Research: What We Know and Need to Learn Glen P. Mays, PhD, MPH Department of Health Policy & Management UAMS College of Public Health

What is Public Health Systems Research? A field of inquiry examining the organization, financing, and delivery of public health services at local, state and national levels, and the impact of these activities on population health Mays, Halverson, and Scutchfield. JPHMP 2003

What Constitutes a Public Health System? The collection of governmental and private entities that contribute to the delivery of public health services for a defined population.  How to define the population?  Local vs. state systems  Variation in system structure and composition

Why Study Public Health Systems? “Unlike the medical care system, there is little research and relatively few measures for studying how well the public health system operates.” — Center for Studying Health System Change, 1996

Why Study Public Health Systems? “The Committee had hoped to provide specific guidance elaborating on the types and levels of workforce, infrastructure, related resources, and financial investments necessary to ensure the availability of essential public health services to all of the nation’s communities. However, such evidence is limited, and there is no agenda or support for this type of research, despite the critical need for such data to promote and protect the nation’s health.” —Institute of Medicine, 2003

Why Study Public Health Systems? u Concerns about preparedness for emerging threats u Wide variation in public health resources u Persistent disparities in outcomes u Difficulties demonstrating accountability/value for investments in public health u Desire for evidence-based decision-making

Key Questions for Policy and Practice u How best to organize public health services? –Federal vs. state vs. local authority and responsibilities –Regional strategies and cross-border issues u What is the necessary mix of services? u What funding and staffing levels are required to assure availability and adequacy of services? u How to address disparities in resources & services?

Why Study Public Health Systems? Intervention Research u What works – proof of efficacy u Controlled trials u Guide to Community Preventive Services Systems & Services Research u How to implement in real-world settings –Reach –Quality –Efficiency –Sustainability –Disparities u Observational studies, CBPR

Where Are We Now? Descriptive Inferential Interventional Translational How are public health systems organized and financed? What do they do? What factors influence their work? How does their work influence the public’s health? How can we improve performance and population health? Research topics:Type:

Examples: Variation in System Performance Mays et al. AJPH 2004 Local Jurisdictions with at Least 100,000 Population, 1998

Examples: Variation in System Performance Lurie et al. Health Affairs 2005

Examples: Who Contributes to the System? State Agencies Local Agencies Federal Hospitals Physicians CHCs Health Plans Universities Others Mays et al. Public Health Reports 2001

Examples: Does Scale Matter? Monitor Investigate Inform Partnerships Policy/plan Performance Associated with Population Size of Local Jurisdiction Mays et al. AJPH 2006

Example: Do Resources Matter? Percentage point  Changes in Performance Associated with 10% Increase in Spending/Capita Mays et al. JPHMP 2004

Understanding the Links Between Systems and Outcomes System Dynamics Modeling of Diabetes Interventions Jones et al. AJPH 2006

More Questions than Answers? Priorities for Future Research u Adoption & maintenance of evidence-based programs u Better understanding how system structure affects PH interventions and outcomes –Organizational structures –Workforce composition & competency –Financing methods and levels u Cost, economic impact, and return on investment

Developments on the Horizon u National accreditation and performance measurement activities u NACCHO’s Operational Definition initiative u Translational research priorities in biomedical and clinical research u Priority areas for research-practice linkages –Disaster preparedness and response –Obesity and chronic disease burden –Emerging infections –Health information infrastructure