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 Service
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
Current Resource Allocation
Ideal Resource Allocation
Low
Low
Moderate
High
Moderate
High
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
Conceptual Flow of Funding
State of
Georgia
Federal
Funds
Other
Funds/TSF
Ryan
White
Division of
Public Health
Hospital ICTF
Foundations
County Funds
Administrative
Program
GIA
Regular
GIA
County
Fees
District Office
Lead County
County Health
Dept.
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.