Regionalization in
Local Public Health: Variation in
Rationale, Implementation, and Impact
on Public Health Preparedness
Michael A. Stoto
PHSR CyberSeminar, May 2007
Washington Metropolitan Area
Definitions
• National Capital
Region (NCR)
• Metropolitan
Washington Council
of Governments
(COG)
• Media market
• Healthcare markets
• Federal government
Stoto PHSRCyberSeminar 2 5/07
NCR organization and governance
• Who’s in charge?
– “Let me speak to the health officer for the
National Capital Region”
• MWCOG Health Officers Committee (HOC)
– Forum to communicate on a regular basis,
but no legal authority
• Senior Policy Group (SPG) and COG Chief
Administrative Officers (CAO) committee
– Receive and distribute federal funds
Stoto PHSRCyberSeminar 3 5/07
Regional capacity in the NCR
• ESSENCE II regional surveillance system
• MWCOG
– Conference call facility
– Regional Incident Communication and
Coordination System (RICCS)
• DC Hospital Association emergency radio
network (H-MARS)
• VDH Northern Virginia Regional Team
Stoto PHSRCyberSeminar 4 5/07
NCR conclusions
• Regional capacity created
• Numerous regional entities and relationships
among public health and partners
• Relationships tend to be informal
– More formality may not be possible
– May be optimal: personal relationships
more important than formal arrangements
in an emergency
• “Who’s in charge” will remain an issue
• Biggest challenge is role of the federal
government
Stoto PHSRCyberSeminar 5 5/07
Cross-cutting issues:
Impetus for regionalization
• Efficient use of preparedness funds
– MA, others to lesser degree
• Crisis or perceived need for a coordinated
response
– MA 4b, NCR, others to lesser degree
• Building local public health capacity
– Strengthening existing local public health
structures (No. IL)
– Building local public health itself (NE)
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Formal organizational relationships vs.
informal professional networks
• NACCHO Public Health Ready typology
– Coordination
Standardization
– Centralization
Networking
• Describes collaboration of existing LHDs
– Not as effective for building local public
health capacity (e.g. MA, NE)
• Does organization build social capital?
• Or, are the professional networks built through
regionalization the most important effect?
Stoto PHSRCyberSeminar 7 5/07
Relationship between public health
regions and geopolitical jurisdictions
• Variety of combinations
– Combinations of local LHDs (No. IL, MA)
– Combinations of counties (NE)
– NCR: multiple definitions, cross-state, sub-regions
• Congruence with
– Regional structures for partner agencies (e.g. EMA)
– Hospital markets, HRSA funding regions, etc.
– Need to preserve existing relationships if possible
• Impact on political support and social capital?
– Authority and resources for public health follow
jurisdictional lines, but outbreaks don’t
Stoto PHSRCyberSeminar 8 5/07
Leadership, trust and sustainability
• MA 4b started with a small group formed in
a crisis and grew from 15 to 27 communities
with state funding
– Cambridge (fiscal agent) had to ensure it
was not perceived as “driving”
• Competition for UASI funds in NCR
• Can the perceived need for regional
response overcome home rule barriers?
– Need perception that at the end of the
day it will be worth it
• Do regions build social capital?
– Does this help with sustainability?
Stoto PHSRCyberSeminar 9 5/07
Does regionalization improve preparedness?
• May depend on setting, existing resources, and
variety of regionalization
• Logically, yes
– More efficient use of resources
– Outbreaks don’t respect geopolitical
boundaries, so need coordination
• Demonstrated progress in
– Planning and coordination
– Memoranda of Understanding, etc.
– Development of local and regional capacity,
training, exercises
– Professional network development
• Response to
– Flu vaccine shortage (MA)
– Anthrax and tularemia alarms (NCR)
Stoto PHSRCyberSeminar 10 5/07
Does regionalization improve
public health generally?
• Same efficiency, communication needs
• Regional capacities address other needs
– Regional epidemiology in NCR
• Preparedness concerns are forcing us to
think about public health structures in a way
not done in decades
– Communities think about preparedness in terms
of day-to-day activities
• Network development may be creating
social capital that helps with other concerns
• But, do preparedness demands draw
resources and attention from other areas?
Stoto PHSRCyberSeminar 11 5/07
Acknowledgements
RWJ HCFO Public Health Systems Initiative
MA: Howard Koh, Christine Judge
MA 4b: John Grieb, Mary Clark
No. IL: Patrick Lenihan
NE: Dave Palm, Colleen Svoboda
NCR: Lindsey Morse
Contact Information
stotom@georgetown.edu
(202) 687-3292