California Public Health Preparedness:
Lessons from Seven Jurisdictions
R. Burciaga Valdez, PhD
June 8, 2004
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Major Findings and Conclusions
• Public health preparedness is improved, but more
work is needed
– Considerable variations across health jurisdictions
• The public health system is structured inefficiently
• Strong State leadership would improve efficiency and
effectiveness
• Focus on preparedness poses risk of serious
unintended consequences
– Attention diverted from other public health threats
– Local cutbacks in contributions to public health
depts.
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History
• Little Hoover Commission requests “gap analysis” of California’s
public health infrastructure
• California Endowment funds initial phase
• First phase addresses “public health preparedness” for
infectious disease outbreak and chronic disease pilot
– Emphasis on local level
– Potential to expand to beyond preparedness
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Approach
• Apply Ten Essential Public Health Services as project
framework
• Review relevant instruments
• Conduct site visits in seven jurisdictions
– 39 percent of State’s population
• Use table-top exercises to measure performance
– Smallpox scenario
– Pilot test diabetes scenario
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Key Findings (1)
Widespread Preparedness Variations
• Each jurisdiction studied has undertaken significant
preparedness activities.
• Widespread variations in ability to respond to
infectious disease outbreaks and other public health
threats.
– Substantial variations in approach to hypothetical
smallpox outbreak despite a year of planning
– Similar variations in approach to chronic disease.
– Californians do not enjoy an even level of
protection against public health threats.
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Key Findings (2)
Uncertainty About Who, What, How
• Ambiguity surrounding appropriate role(s) for a health
jurisdiction vis-à-vis other local agencies and the
State DHS.
– Little agreement about what jurisdictions should do
when faced with a public health emergency and
how they should do it.
– Perceived overlap in some functions between the
DHS, the Governor’s Office of Emergency Services,
and the Emergency Medical Services Authority.
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Key Findings (3)
Preparedness Gaps
• Similar preparedness gaps across many jurisdictions.
– Examples: training of public health staff to assume
“back-up” roles in an outbreak; strategic planning;
community health assessment; workforce needs
(epidemiologic and laboratory capacity); and
access to legal consultation on public health law.
– All jurisdictions need a robust information system.
– Large numbers of uninsured Californians creates
challenges in planning for and managing public
health issues during an outbreak.
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Key Findings (4)
Insufficient Community Involvement
• Community groups, particularly those that serve
underrepresented minority groups, are not
involved in public health preparedness in most
jurisdictions.
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Key Findings (5)
No Central Leadership
• Strong, central leadership and coordination of
public health appears to be lacking.
– Health departments felt they could not rely on
the DHS to address common needs or facilitate
coordination or sharing of resources.
– The State’s public health laboratory may be an
exception.
• The organization of preparedness activities leads
to redundancies and inefficiencies.
• Border and jurisdictional issues need attention.
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Key Findings (6)
Hidden Costs
• Public health preparedness may have a hidden
cost.
– Substantial evidence that staff reassignments
to accomplish preparedness functions and
cuts to public health budgets at a county level
from the current fiscal crisis are compromising
other public health functions
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Key Findings (7)
Cost to Fill Preparedness Gaps
• Estimated additional annual costs statewide of filling the
“preparedness gap” range from $72 to $96 million.
– Does not consider economies of scale that could be
achieved through reorganization and greater sharing of
resources.
• Investments in public health infrastructure for
preparedness build a stronger public health system at the
local and state levels.
– However, countervailing pressures, which stem largely
from California’s fiscal crisis, place the likelihood of
capitalizing on this opportunity at risk.
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Recommendations (1)
• Examine the organization of public health in California, and
develop a shared understanding of what public health is
and does
– Applies to preparedness for an infectious disease
outbreak and other public health functions (e.g.
growing epidemic of chronic disease)
– Role of strong, central leadership focused on public
health at a state level should be a key component of
such a reexamination
– Centralization/regionalization of some functions, and
sharing of resources among others, will likely lead to
greater effectiveness and efficiency
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Recommendations (2)
• Objective performance measures for preparedness
should be developed, implemented, and refined as
needed. Performance should be regularly assessed
through exercises
• Improve the statewide epidemiologic information
system
– A robust information system is the backbone upon
which coordinated public health activities should
be built
• Generate increased community involvement in
preparedness activities
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Recommendations (3)
• Maintain a highly skilled public health workforce
– Invest in training for public health staff at all levels
– Improve training efficiency through better planning
and resource sharing
• Workforce planning must occur at both a local and
statewide level
– In virtually all jurisdictions, key members of the
workforce are aging into retirement and there is
little evidence of succession planning
– Reassignment of key staff to preparedness
functions has created shortages in other areas
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Recommendations (4)
• Strengthen links between public health
departments and the health care delivery system
– Providers and the institutions which deliver
care have critical public health responsibilities
• Evaluate public health preparedness and gaps at
the state level to fully understand critical
preparedness issues
– Such an analysis is essential before
contemplating a reorganization of public health
in California
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Recommendations (5)
• Studies are needed to fill the knowledge gaps
regarding the public health infrastructure
• Additional resources are necessary to improve public
health preparedness and local public health systems
– Our estimates cover additional resources needed
to improve local preparedness to protect against
infectious disease outbreaks
– We found evidence that resources are needed to
assure that essential public health services are
available in all locales to cover wide range of health
threats the people of California face on a daily
basis
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Higher states of preparedness
• Experience with other public health emergencies
•* Strong leadership
•* Successful collaborations
•* Adequate funding
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