1. Public Health Services and Systems
Kristine M. Gebbie, DrPH, RN
Columbia University School of Nursing
Center for Health Policy
630 West 168th Street, Mail Box 6
New York, NY
(212)
Kristine Gebbie joined the faculty of Columbia University School of Nursing in 1995, and is the Director of the Center for Health Policy. Her teaching and research are in health policy and health systems, with particular attention to population-focused prevention and public health systems. She currently has research funding from both the Health Resources and Services Administration and the Centers for Disease Control and Prevention.
Prior to coming to New York, Dr. Gebbie served as the nation’s first National AIDS Policy Coordinator, a White House position created by President Clinton to coordinate national efforts in HIV/AIDS prevention, treatment and research. Prior to that she was Secretary of Health for Washington State and head of public health in Oregon. Dr. Gebbie’s earlier career was in academic health centers, as faculty member at UCLA School of Nursing and as faculty member and hospital administrator at St. Louis University School of Nursing and St. Louis University Hospitals. She has served on national committees advisory to the Secretary of the US Department of Energy as well as the Director of the Centers for Disease Control and Prevention.
Dr. Gebbie is an elected member of the Institute of Medicine, the American Academy of Nursing,and the New York Academy of Medicine. She is also an active participant in a wide variety of national and international professional organizations.
Dr. Gebbie’s extensive list of publications includes topics such as community mental health, mental health consultation, public health nursing, public health infrastructure, health policy and HIV/AIDS. In addition to many peer-reviewed journal publications, she has authored or co-authored several texts and book chapters and editorials. She writes a regular health policy column for the journal AIDS Reader, and serves on the editorial boards of the American Journal of Nursing, Journal of Public Health Policy and Journal of Public Health Management and Practice.

2. Developed as part of an Enhanced AHEC Community Partnership for Health Professions Workforce and Educational Reform project funded by the Health Resource and Service Administration (HRSA)

3. OBJECTIVES Identify essential services Describe core functions
Describe future trends
Objectives
The objectives are stated in abbreviated form on this slide; the specifics are that at the end of this module students will be able to:
- Identify at least 5 of the essential services of public health.
-Describe the core functions of public health in America.
-Describe the major trends affecting public health practice in the new century.

4. Report on the Future of Public Health
Institute of Medicine, 1988
Impact on public health practice and practitioners included
stimulus for public health system research
stimulus to strengthen the system
new vocabulary for describing the system
The Institute of Medicine is a Congressionally chartered organization that is designed to provide Congress, the Administration and the nation with analysis of scientific information on topics related to health. It is just over 25 years old, and is a component of the National Academy of Science. Members are elected based on contributions and potential contributions, and reports of the Institute generally have a significant impact on the field.
The Institute's 1988 Report on the Future of Public Health can be found at:
There have been recent IOM reports on immunizations, tuberculosis and sexually transmitted diseases, to name a few. If there are recent reports on topics of particular importance to the interests of your students, this would be a good place to mention them.

5. IOM 1988 Report, Continued Mission of Public Health
Assuring healthy conditions
Focus on community-wide concerns
Organize efforts to address health concerns
The Institute’s report defined the mission of public health as:
“fulfilling society’s interest in assuring conditions in which people can be healthy. Public Health is distinguished from health care by its focus on community-wide concerns -- the public interest -- rather than the health interests of particular individuals or groups. It’s aim is to generate organized community effort to address public concerns about health by applying scientific and technical knowledge.” (IOM, 1988, p. 140)

6. IOM 1988 Report, Continued Core Functions of Public Health Assessment
Policy development
Assurance
The report also identified the core functions of public health:
Assessment: Regularly and systematically collecting, analyzing and disseminating information on the health of a community, including statistics on health status, epidemiological and other health studies, community health needs, and community assets and resources.
Policy development: Serving the public interest in the development of comprehensive public health policies (laws, regulations, funding) that use the scientific knowledge base in decision making and involving those affected by the policy in the process.
Assurance: Seeing that services necessary to achieve agreed-upon goals (policies) are provided by encouraging actions on the part of others, by requiring action through regulation, or by providing services directly.
Note: Core functions will be discussed in more detail in subsequent slides. The highly abstract level of conceptualization reflected in these terms, while useful in a classroom discussion or as a theoretical organizing principle, has made them of less value in communicating with the general public.

7. Public Health in America
The IOM core functions paradigm is helpful but does not communicate well outside the public health world
Public health and interest in the health of populations were almost lost during the health reform debates
Public Health in America was written to provide a statement for general use
The statement Public Health in America was written by the Public Health Functions Steering Committee, a national collaboration of the public health agencies of the Department of Health and Human Services and the major national public health associations
American Public Health Association
Association of State and Territorial Health Agencies
Association of Schools of Public Health
National Association of County and City Health Officials
National Association of State Alcohol and Drug Abuse Directors
National Association of State Mental Health Directors
Partnership for Prevention (a business-based advocacy group)
Public Health Foundation (research arm of ASHTO & NACCHO)
The Public Health Functions Project web site may be found at:

8. Public Health in America
The Vision
Healthy People in Healthy Communities
The Mission
Prevent disease and injury
Promote physical and mental health
While these statements are definitely consistent with the IOM report of 1988, they care the concepts through to greater specificity.
The vision of healthy people in healthy communities provides an excellent illustration of the intersection of personal and population-focused health efforts. There are many things that can be done to promote individual health, working serially with individuals, and healthy individuals can work together to promote a healthy community. Likewise, if the community itself is healthy, which requires working with people in their social or group interactions, it will be far easier to promote or protect the health of individuals.
The mission stated here is that of the whole public health system or network. No one agency or individual is responsible for this mission, although there is a chief official health agency in each state and in most local jurisdictions. These public health organizations must work with the full range of health professionals and health-related organizations in the community to see that this mission is realized.
This is a vision and mission that is nation-wide, and not attached to any one level of government or organizational entity. Accomplishing it will take the combined efforts of all components of the system.

9. Responsibilities of Public Health
Prevent epidemics and the spread of disease
Protect against environmental hazards
Prevent injury
Promote and encourage healthy behavior
Respond to disasters and assist in recovery
Assure quality and accessibility of health services
Responsibilities of Public Health
Prevent epidemics and the spread of disease: This is the classic role of public health, although each time it is invoked there is a need to re-negotiate the balance between community protection, social justice and individual autonomy.
Protect against environmental hazards: The limitation of hazardous exposure in the first place is one of the basic approaches of public health.
Prevent injury: The application of Epidemiology to understanding risk factors and the causes of intended and unintended injuries has allowed organized programs to reduce traffic death and injury, occupational injury, food-borne epidemics and other injuries.
Promote healthy behavior: Respecting the autonomy of individuals, it is appropriate to provide education, support and encouragement for for adoption of healthier decisions, actions and lifestyles.
Respond to disasters and assist in recovery: Any disaster markedly increases public health risk by disrupting food, water, medical services and other support systems.
Assure access to health services: This responsibility has become ever more important as the cost of personal care has risen and the numbers of uninsured and underinsured has increased.
Every community should expect that these responsibilities are being fulfilled on a regular, reliable basis, by some combination of entities.

10. Public health is a continuous process that is supported by
management &
developed by
research
Public Health in America goes into greater detail regarding the services that are needed to assure that the core functions of public health identified by the Institute of Medicine are carried out. The change in terminology from core functions to essential services has been confusing to some, however. This ‘wheel’ was developed to illustrate 3 things:
-the core functions and the essential services that make them up are a continuous, rather than a linear process
-the essential service of research does not stand alone, but informs all of the other services
-the entire system must be managed, though this is not itself an essential public health service to the community
Students familiar with other analytic processes (e.g., problem-solving, diagnosis and treatment, the nursing process) should quickly see the parallels to this depiction of public health’s work.

11. Essential Services of Public Health
Monitor health status
Investigate outbreaks
Inform the public
Support coalitions
Develop policy
Enforce regulations
Monitor health status: This includes monitoring not only specific diseases (TB, plague, HIV, cancer), but also health status (vital records, health surveys), threats to health (risk factor surveys, environmental monitoring), and the health resources of the community. It cannot be carried out effectively without the collaboration of providers of personal care (disease reports), laboratories (test reports) and care systems (discharge records).
Investigate outbreaks: Investigations begin either because a health professional notices a change from background or ‘steady state’ in a key monitoring element or the community (an unusual case of disease, for example); or asks a question about an observation (a suspected cancer cluster, an observed dumping of chemicals near an industry).
Inform the public: Accessible information about both routine monitoring and specific investigations must be made available to the concerned public, health professionals and policy makers.
Support coalitions: As later modules will discuss, a mobilized community is one of the best ways to achieve any health improvement goals
Develop policy: Actions should be planned and desired outcomes identified in advance, as a foundation for the specific activities that will follow.
Enforce regulations: Public health must use enforcement power (licensing of restaurants, permitting of industrial sites, certification of care providers, school immunization laws) when voluntary efforts fail in important areas.

12. Essential Services of Public Health
Link people to care or provide care
Prepare the workforce
Assure quality, accessible, effective services
Research for new solutions
Link people to care or provide care: Some care is critical to public health, such as treatment for active tuberculosis, and so is often publicly provided. Other care services may be in the public sector by plan or default. Current trends are moving away from direct provision and emphasize developing access and assuring quality.
Prepare the workforce: The public health system should be in a position to assure the public that all health workers (those giving personal care and population-focused services) are prepared for their responsibilities.
Assure quality, accessible, effective services: This essential service is just beginning to get the attention it deserves from all components of the system
Research for new solutions: While biomedical and clinical research are well supported and funded, studies of both personal health services and the public health system are sorely needed to assure that improvements are appropriately made over time.

13. Core Functions and Essential Services
Assessment
Monitor health
Diagnose problems
This slide should stimulate exploration of how these activities may be carried out, e.g., regular reporting of vital statistics, or investigation of an outbreak such as the West Nile viral encephalitis in the greater New York City area, or a citizen-requested investigation of a perceived cluster of cancer cases around a school.
Assessment includes three aspects of health and health problems:
-the health status of the population (disease rates, birth and death information)
-threats to health (environmental risk factors of all kinds)
-health resources (the type and distribution of services or professionals that can be a part of health improvement)

14. Did you know that . . .
To diagnose diseases, the SC public health laboratory was established in 1909?
South Carolina got its first epidemiologist, Dr GE McDaniel, in 1935?
Factlets about assessment in South Carolina’s history

15. Core Functions and Essential Services
Policy Development
Inform and educate the public
Mobilize community partnerships
Develop policies and plans
Once information about health status is known, an informed public may mobilize to reduce threats or assure appropriate response. Rather than the historical, parental approach today’s practitioners expect to rely on partnerships and community action in achieving any public health policy development. The official agency, however, retains the authority and responsibility to act immediately if the threat to health is immediate.

16. Did you know that . . .
1950’s pollution control policies were developed in partnership with the Development Board and the Textile Manufacturers Association?
Public health boards designing public health budgets and programs are carrying out a process similar to an individual giving informed consent for a medical procedure?
More factlets related to assessment and policy development

17. Core Functions and Essential Services
Assurance
Enforce laws and regulations
Link people to needed care and assure care when otherwise unavailable
Evaluate effectiveness, accessibility and quality of health services
The process of assuring that policy is carried out is in some ways the most complex of the core functions, because it is the phase at which the complexity of the partnerships that make up public health become most evident. This is also the point at which our national debate about whether there is a communal responsibility to assure access to care or whether people are really on their own once it has been determined that they are not actively transmitting diseases to others. In addition, all of the issues of business regulation and the role of government will come into play in the enforcement of health codes. Finally, we have only begun to develop the tools we need to evaluate the effectiveness and quality of services. CDC in partnership with the American Public Health Association and state and local health departments is developing, for the first time, performance standards for local public health systems. More about this effort can be learned through the CDC web site:

18. Did you know that . . .
To assure services, the first public health nurse was hired in 1903?
To limit health hazards in the 1940’s, privies were built for $18.20?
The WIC program brought 16 nutritionists to the state in 1973?
Factlets about assurance

19. Discussion Time
How can practicing health professionals participate in assessment, policy development or assurance at the local level?
This discussion should be particularized to the professions represented in the class, but might include issues of responsibility for disease reporting, participation on boards and committees, contributions of services to voluntary organizations or role modeling healthy behavior.

20. Core Functions and Essential Services
Research is an essential service that supports all of the core functions
Leadership and management of the system transcend the functions and services
One of the features of public health that may interest students is its interdisciplinary nature. Much public health research involves teams that cross disciplinary lines, and today’s public health leaders come from almost any profession that can be named.

21. Did you know that . . .
Healthy People is our national visionary planning process for improving the nation’s health?
The goals of HP2010 are to increase years of healthy life and eliminate disparities in health?
Turning Point is SC’s state-wide, interactive process for transforming public health in the new century?
This slide is included to identify for students that we do have a national process for applying the basic principles of the public health core functions. The process of working with a community to improve health will be presented in detail in Module 4, so no extensive discussion is expected at this point.
The Healthy People Web site can be used as an assignment at this point as an introduction to the process. The Healthy People 2010 Objectives draft may be found at:

22. Forces Shaping Public Health
Public attitude toward government
Federalism and devolution of responsibility
The economy
Environmental policy
Changes in personal care and financing systems
Public attitude toward government: If government is seen as a burden, or as a negative force, people are less inclined to use structural approaches to improve the public’s health, and more inclined to believe that private and voluntary efforts will suffice. The problem is that private and voluntary efforts are neither obliged to include all members of the community, nor to include them on an equitable basis.
Federalism: The country regularly cycles through phases of centralization and decentralization mirroring the conflict among the founding fathers about government (the Federalist Papers). We have been devolving responsibility for program design and implementation to more local levels in recent years.
The Economy: During recessions and tight economic times, available tax revenues are decreased, and public health must compete for resources with all other governmental services. Likewise, private dollars for charitable purposes decrease.
Environmental attitudes: When we exploit the environment for economic or pleasure reasons, we seem less inclined to take the necessary steps to protect individuals from health threats that may arise. When there is an interest in environmental conservation and protection, it may be easier to include attention to limiting or controlling those threats.
Changes in personal care system: Changes in the personal care and health care finance systems produce changes in the need for emergency health support, and billable services may supplement other public health funding. Managed care is one such impact.

23. Discussion Time
How can a public health perspective strengthen the perspectives dominant in your profession?
There are no “right” answers to this question, but students should be expected to identify possibilities such as an awareness of potential partners to achieve health goals, the relationship of even the most technical professions to the overall health system, and the like.

24. Summary
The vision of public health is healthy people in healthy communities.
The mission of public health is to prevent disease and injury and promote physical and mental health.
The core functions of public health are assessment, policy development and assurance.

25. Module Author Kristine M. Gebbie, DrPH, RN Elizabeth Standish Gill
Associate Professor in Nursing
Columbia University School of Nursing
Director
Center for Health Policy
Kristine M. Gebbie, DrPH, RN
Columbia University School of Nursing Center for Health Policy
630 West 168th Street, Mail Box 6
New York, NY
(212) or at
Kristine Gebbie joined the faculty of Columbia University School of Nursing in 1995, and is the Director of the Center for Health Policy. Her teaching and research are in health policy and health systems, with particular attention to population-focused prevention and public health systems. She currently has research funding from both the Health Resources and Services Administration and the Centers for Disease Control and Prevention.
Prior to coming to New York, Dr. Gebbie served as the nation’s first National AIDS Policy Coordinator, a White House position created by President Clinton to coordinate national efforts in HIV/AIDS prevention, treatment and research. Prior to that she was Secretary of Health for Washington State and head of public health in Oregon. Dr. Gebbie’s earlier career was in academic health centers, as faculty member at UCLA School of Nursing and as faculty member and hospital administrator at St. Louis University School of Nursing and St. Louis University Hospitals. She has served on national committees advisory to the Secretary of the US Department of Energy as well as the Director of the Centers for Disease Control and Prevention.
Dr. Gebbie is an elected member of the Institute of Medicine, the American Academy of Nursing,and the New York Academy of Medicine. She is also an active participant in a wide variety of national and international professional organizations.
Dr. Gebbie’s extensive list of publications includes topics such as community mental health, mental health consultation, public health nursing, public health infrastructure, health policy and HIV/AIDS. In addition to many peer-reviewed journal publications, she has authored or co-authored several texts and book chapters and editorials. She writes a regular health policy column for the journal AIDS Reader, and serves on the editorial boards of the American Journal of Nursing, Journal of Public Health Policy and Journal of Public Health Management and Practice.