From Theory to Practice: What drives the core business of public health? AcademyHealth 2005 Annual Research Meeting Tina Anderson Smith, MPH June 27, 2005

Research Questions What is the current core business of Georgia’s governmental public health agency? What is the “ideal” core business of Georgia’s governmental public health agency?

Principal Findings Relevant, but not resonant Practice Paradox –Current core business not aligned with “ideal” core business Driver Dilemma –Current drivers not aligned with “ideal” drivers Strategy Shortage –Call for public health leadership and collaboration

State Context 8.5 million residents + Relatively younger and more diverse 13% below Federal Poverty Level Poor health status, disparities 1 million + Medicaid 1 million + uninsured Rural access issues

Public Health Agency Infrastructure State agency within Department of Human Resources 18 District Offices 159 Local Health Departments 6,000 DPH Staff Approximately $624 million budget in 2004 State public health spending $7 per capita

Methods: Design Case study approach Primary Unit: State public health agency Embedded Units: District and local agencies Resource flow, collaboration, structure, strategy, and staff perceptions Contextual Elements: Political, economic, financing, and regulatory environment, as well as stakeholder perceptions

Methods Data sources –Interviews (n=69) Internal and External Stakeholders –Focus groups (86 participants in 6 groups) –Archival documents Analysis –Emergent, data-based, inductive –Holistic –Triangulation –Participant Validation

Principal Findings Relevant, but not resonant Practice Paradox –Current core business not aligned with “ideal” core business Driver Dilemma –Current drivers not aligned with “ideal” drivers Strategy Shortage –Call for public health leadership and collaboration

Practice Paradox Essential ServiceCurrent Resource AllocationIdeal Resource Allocation LowModerateHighLowModerateHigh Monitor health status Diagnose and investigate Inform, educate and empower Mobilize community partnerships Develop policies and plans Enforce laws and regulations Assure access and Link people to needed personal health services Assure a competent public health work force Evaluate effectiveness, Research

Driver Dilemma Current Drivers –Money –Safety Net –Uninsured –Performance-based budgeting –Regulation –Leaders’ philosophies Ideal Drivers –Need –Evidence-based practices –State strategy informed by local perspective –Local culture

Money State of Georgia Division of Public Health Federal Funds Other Funds/TSF District Office Lead County Program GIA Hospital ICTF Foundations County Funds County Fees Regular GIA Ryan White Administrative County Health Dept. Conceptual Flow of Funding

Summary Practice preferences aligned with the 10 Essential Services Current core business not aligned with theoretical ideal Inherent systemic challenges mediate translation of theory into practice Moving toward “ideal” practice requires addressing larger system drivers

Implications Understanding practice drivers and their impact on performance is essential May be difficult in some states to balance essential services without broader policy change –Performance Standards –Accreditation Emerging role for public health to participate in, even lead, broader policy conversations

Possibilities “Upstream” interventions to address drivers of practice may emerge as important compliment to more proximal strategies – structure and process – to improve public health performance.

Acknowledgements Georgia Division of Public Health Georgia Health Policy Center Team: –Karen Minyard, Ph.D. –Chris Parker, M.D., M.P.H. –Beverly Tyler –Rachel Ferencik, M.P.A.