State Statutes Could Slow Down Public Health Agency Response to New Challenges
Public health statutes can help or hinder health officials in doing their jobs. Because market reforms and the transfer of power from the federal government to the states is changing the way public health is practiced at the state level, prudent policy necessitates a reexamination of the existing statutes of state public health agencies.
This 19961998 project compared the health agency enabling statutes from 50 states and one territory and mission statements from 42 states and one territory with the standard of practice held by professionals in the field. It produced a monograph summarizing the study and a one-day dissemination symposium.
The study found clear agreement across the country about the core activities of public health agencies and their traditional focuses, such as communicable disease and epidemic control.
However, it found limited agreement in the statutes about the area in which public health agencies are now identifying a major role, i.e., mobilizing community partnerships to identify and solve health problems.
The findings suggest that if state public health agencies are to meet the recognized standard of practice, then a large number of states should consider making revisions to their enabling statutes.
The project findings may be useful to individuals and groups interested in strengthening the public health infrastructure in their states.
This study also provides a framework for state public health agencies to consider the statutory basis for operating in a changing environment and has helped focus the discussions of those interested in statutory revision.
In addition, the project provides one of the few sources of data on existing statutes and could be used as the baseline for monitoring changes in statutes over time. The project report along with individual state reports were distributed to all state public health officials.
The Robert Wood Johnson Foundation (RWJF) provided a $45,171 grant to support the project.
As states, local health departments, federal public health agencies, and interested private sector entities attempt to strengthen the nation's public health system, they may be impeded by the incapacity of health agencies to respond to the changing environment.
Because many of the current efforts at improvement are grounded in state health agencies, the scope and authority of these entities are crucial. If the state health agencies do not have a scope of authority consistent with the model being used by those interested in improvements, statutory change will be needed.
Further, discrepancies between an agency's statute and its mission statement could cause difficulties in practice, either because of unmet legislative or gubernatorial expectations or because the agency is moving in directions that are not sanctioned politically. Knowing in advance the degree of consistency between the standards observed by professionals in the field and current statutes and agency mission statements can facilitate identification of needed next action steps.
The overall model of public health held by professionals in the field has not changed dramatically in the last decade. It is elaborated in "Public Health in America" (PHA), a statement produced by the Public Health Functions Project, a collaborative effort of the US Public Health Service and a number of major national public health organizations.
It was adopted in fall 1994. (For the complete statement and the organizations supporting it, see the Appendix.) However, due to the emergence of new health services delivery and finance mechanisms and new public attitudes about the role of government, the environment within which public health workers apply these principles has changed.
In a time of rapid change, it is necessary to analyze the existing legal basis of public health in each state and compare it with current standards of public health practice to assess the relevance of those standards.
The results of this assessment could be valuable to people attempting to strengthen the public health infrastructure particularly state health directors, governors, and state legislatures. It would also assist sites in the Robert Wood Johnson Foundation (RWJF) national program, Turning Point: Collaboration for a New Century of Public Health, an initiative, in collaboration with the W.K. Kellogg Foundation, to help states improve the performance of their public health functions through a state-level strategic assessment of public health's mission, its relationship to the private sector, organizational structure and governance, work force capacity, accountability, and sources of revenue.
The project was funded to assess the enabling statutes for the 50 state health agencies and conduct a content analysis in order to compare each with the health agency's mission statement and current practice. Specifically, the project would:
- Identify the extent to which the statements of purpose or mission for state health agencies contained in state laws are consistent with the public health paradigm as expressed in the PHA statement;
- Identify the extent to which the published mission statements of state health agencies are consistent with either the state's statute or the PHA paradigm;
- Identify which concepts from PHA are the most underrepresented as well as any additional concepts that are included.
The findings were to be summarized in two types of reports a general report and individual state reports. The grant also funded a one-day dissemination symposium for leaders from associations representing state health directors, governors, state legislators, and schools of public health.
In order to accomplish these objectives, investigators collected enabling statutes from 50 state health agencies and one territory, either directly from the office of each chief state health official or through an electronic statutory information resource. The mission statements of 42 states and one territory were also collected from the office of the chief health official. Investigators could not determine whether the remaining eight state agencies lacked a mission statement or simply chose not to share it.
Because the specific listing of duties included in statutes is most similar to the PHA's essential services listing, they were compared to that portion of the statement. Since mission statements are usually phrased in a broader manner than statutes, they were compared only to the "mission" section and the six "public health" statements in the PHA.
- There is clear agreement among the states about the core activities of public health agencies and their traditional focuses, such as communicable disease and epidemic control.
- The enabling statutes are in only limited agreement with allowing public health agencies and health departments to engage in activities they now identify as major, such as mobilizing community partnerships to identify and solve health problems.
Findings from the Statute Analysis
The investigators divided the states into three categories: "highly congruent" states, whose enabling statutes included 7 or more of the 10 essential public health services concepts from the PHA; "congruent" states, whose enabling statutes included between four and six concepts; and "divergent" states, whose statutes included one to three concepts. (One state public health statute had no content that matched with the statement and was not tabulated in the study.)
- No state public health enabling statute included content from all of the essential services of public health as articulated in the PHA.
- All 11 highly congruent states assigned their public health departments responsibilities consistent with three essential services identified in PHA: monitoring health status, diagnosing problems in the community, and informing and educating the community. The lowest areas of match in these states were responsibility for mobilizing the community, evaluating services, and research.
- The clearest agreement among the 23 congruent states was on monitoring health status and enforcing laws. As with the "highly congruent" states, the lowest matches for these states were in mobilizing the community, evaluating services, and research. The greatest difference between them and the "highly congruent" states was the relatively lower attention to developing policies and plans. Along with the weak match in the area of mobilizing the community, this may suggest that the leadership functions involved in initiating community action and developing responses to problems are not well developed in these states' understanding of public health.
- The 16 divergent states did not concur on any one of the 10 areas, although 13 of them have statutes that include enforcing laws and regulations.
- No one component of PHA is found in the content of all state public health enabling statutes, nor is there any one that is completely omitted. Enforcing laws and regulations that protect health and safety are most common, followed by monitoring health status to identify community problems. Least common is research for new insights and innovative solutions.
- Other services often assigned to state health agencies but not included in the PHA included administrative responsibilities and grant fund management.
Findings from the Mission Statement Analysis
The investigators grouped states into three categories: "highly congruent" states, whose missions included six or more PHA concepts; "congruent" states, whose missions included three to five PHA concepts; and "divergent" states, whose missions included one or two concepts from the PHA.
- State health agency mission statements were less consistent with the PHA than were the statutes. Only one state included all components of PHA in its mission statement.
- The 10 highly congruent state agencies concurred in identifying prevention of disease as a component of mission. Responding to disasters was matched only in one statement.
- The 17 congruent state agencies were dominated by the mission of promoting health. No mission statement included preventing epidemics, which may reflect an assumption that this is part of preventing disease.
- Of the 16 divergent state agencies, 14 included the promotion of health generally or the promotion of physical health as the agency's purpose. None of these states included preventing disability, preventing epidemics, responding to disasters, and assisting communities in recovery after disasters in their mission statements.
- Other missions identified by state agencies but not included in PHA were the general advancement of public policy and the promotion of self-reliance.
- Each of the mission concepts from PHA was included in the mission of at least one state health agency. One concept, promoting health or physical health, was dominant. Responding to disasters appeared least in the mission statements.
- The single largest group of states were those for which both the enabling statute and mission statement were consistent with the PHA, but not highly so.
The project was extended to address additional questions identified by participants in the dissemination symposium. Under this extension, it found that:
- There was no apparent relationship between the date of statute adoption and the degree to which the statute contains concepts consistent with the PHA.
- Those states with high congruence to the PSA were more likely to have a lower infant mortality rate, and those with low congruence were more likely to have a higher infant mortality rate. There is no reason to assume that this is a causal relationship; a more plausible hypothesis is that states with a stronger interest in public health goals and using public health approaches to improve the health of residents will adopt statutes with a clearer expression of public health responsibilities and services, and achieve better health outcomes.
The findings suggest that if current demands on states and state public health agencies require them to attend to the full range of issues and programs encompassed in the PHA statement, then a large number of states should consider revisions to the agencies' enabling statutes. Alternatively, the marked lack of state public health agency responsibility for some of the components may be a signal that the PHA was written too broadly and may require review by those who developed it.
This study provides a framework for state public health agencies to consider the statutory basis for operating in a changing environment, and has proven useful in focusing some of the discussions of Turning Point sites. It also offers the framers of Healthy People 2010 a useful perspective for the chapter on public health infrastructure. Because the project provides one of the few sources of baseline data on existing statutes, it could be used as the baseline for monitoring changes in statutes over time.
- With a range of approaches, types of government organization, and specificity in statutes, caution should be exercised in linking an agency's congruence with the PHA to its effectiveness.
- The lack of historical data on changes in state health agencies makes it difficult to conclude that the findings from this study represent movement toward more current thinking or simply the random result of decision-making processes influenced by a wide range of other factors.
The key dissemination activity was the "Conference on State Public Health Statutes," planned as a part of the original project, and held in October1997. It was attended by representatives from 15 states, the Centers for Disease Control and Prevention Public Health Practice Program Office, and national organizations with an interest in public health infrastructure. The project report along with individual state reports was distributed to all state public health officials. It was also presented at various conferences including a program session at the 1997 American Public Health Association Annual Meeting. The principal investigator is working on a journal article based on the project.
AFTER THE GRANT
In addition to completing the article and submitting it to a peer-reviewed health journal, the principal investigator is also discussing with another researcher the possibility of jointly seeking funding to develop model approaches to enabling key components of statutes. Further, if the goal of developing model statutes relating to essential public health services is adopted by Healthy People 2010, the project director will seek active participation in the process and development of data to monitor adoption of the models by states.
The grantee is also interested in developing a model public health law for states. RWJF is making an investment in specific consultation on these issues to the directors of projects in its national program, Turning Point.
GRANT DETAILS & CONTACT INFORMATION
Assessment of State Health Agencies' Authorizing Legislation
Columbia University School of Nursing (New York, NY)
Dates: September 1996 to May 1998
Kristine M. Gebbie, Dr.P.H., R.N.
Public Health in America (PHA)
Vision: Healthy People in Healthy Communities
Mission: Promote Physical and Mental Health and Prevent Disease, Injury, and Disability
- Prevents epidemics and the spread of disease
- Protects against environmental hazards
- Prevents injuries
- Promotes and encourages healthy behaviors
- Responds to disasters and assists communities in recovery
- Assures the quality and accessibility of health services
Essential Public Health Services
- Monitor health status to identify community health problems
- Diagnose and investigate health problems and health hazards in the community
- Inform, educate, and empower people about health issues
- Mobilize community partnerships to identify and solve health problems
- Develop policies and plans that support individual and community health efforts
- Enforce laws and regulations that protect health and ensure safety
- Link people to needed personal health services and assure the provision of health care when otherwise unavailable
- Assure a competent public health and personal health care workforce
- Evaluate effectiveness, accessibility, and quality of personal and population-based health services
- Research for new insights and innovative solutions to health problems
Adopted Fall 1994, Public Health Functions Steering Committee
Public Health Functions Steering Committee Members:
- American Public Health Association
- Association of Schools of Public Health
- Association of State and Territorial Health Officials
- Environmental Council of the States
- National Association of County and City Health Officials
- National Association of State Alcohol and Drug Abuse Directors
- National Association of State Mental Health Program Director
Public Health Foundation, US Public Health Services
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Books and Reports
Gebbie, KM. Identification of Health Paradigms in Use in State Public Health Agencies. New York, N.Y.: Columbia University School of Nursing, Center for Health Policy and Health Services Research, 1997. 300 copies distributed.
"Conference on State Public Health Statutes," October 29, 1997, New York, N.Y. Attended by 28 people from 15 states and eight other organizations including the Centers for Disease Control and Prevention Public Health Practice Program Office and Georgetown University Law Center. Five presentations given:
- "Introduction to Public Health in America," Nicole Cumberland.
- "The Assigned Duties of State Public Health Agencies," Kristine M. Gebbie. "Collaboration to Change Statutes in Public Health Laws," Mimi Fields.
- "State Disease Reporting Statutes," Larry Gostin.
- "Public Health Infrastructure and Healthy People 2010," Pomeroy Sinnock.
Presentations and Testimony
Kristine M. Gebbie, "Paradigms in Current State Public Health Laws," at the American Public Health Association Convention, Indianapolis, Ind., November 11, 1997.
Kristine M. Gebbie, "State Public Health Statutes and Public Health in America," Poster Presentation, Prevention 98, San Francisco, Calif., April 2, 1998.
Report prepared by: Robert Crum
Reviewed by: Susan G. Parker
Reviewed by: Molly McKaughan
Program Officer: Susan B. Hassmiller