Organization of Public Health
Services
TH Tulchinsky MD MPH
Braun School of Public Health
Hadassah-Hebrew University
18 October 2010
What is an Organization?
• Bureaucratic Structure
– Max Weber – sociology of bureaucratic organizations
– Military, civil, service, business
• Network organization
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Business management by objectives
Task and goal oriented
Individual and team responsibility
People produce or serve better if they feel part of
“management” and goals of the organization
• Read: NPH Chapter 12
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Bureaucratic and Network Organizations
• Bureaucratic
• Hierarchical
• Process oriented
Interactive team, equal
Task oriented
CEO
Middle Management
Service or Production
Workers
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Who Provides Public Health Services??
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Government – local, state, national
Other government departments, agencies
Health system providers – doctors, hospitals
Voluntary organizations and donors
Religious organizations e.g. Catholic hospitals
Fraternal organizations e.g. Rotary Club
Advocacy groups e.g. Groups against smoking
NGOs e.g. March of Dimes
Research centers e.g.
Private sector
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Structure of Government
• US Federal system - Executive, legislative, judicial
branches – ”checks and balances”
• Parliamentary system, legislative-executive branches
unified e.g. UK, Canada etc
• Command economies – “president-for-life”
• Federal-state powers defined in constitution
– Defense and foreign affairs
– General welfare “for the common good”
– Powers to tax, spend, legislate, regulate, punish
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Federal vs. Unitary Type Government
• Unitary
– National e.g..
– County, municipal/city,
– United Kingdom,
– France, Spanish countries – Napoleonic code
• Federal e.g. US, Canada, Russia (?), Nigeria
– Federal
– State
– Local
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Federal Governments
• Three levels of elected government, federal, state,
local (municipal, county etc)
• Each has taxing and enforcement powers
• Division of powers in constitution and legal precedent
• USA, Canada, Australia, Russia (?), Nigeria, Argentina
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Unitary Governments
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Two levels
National and local
May have regional delegation of national powers
United Kingdom, France, Spain,
Process of change toward federal systems in some
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A Unitary State
• Form of gov’t with a central national and local elected
levels of government; no intermediary legislating level.
• UK and governments based on the French Napoleonic
Code, Spanish-speaking countries.
• Central government overall responsibility for health
• Local government is major factor in sanitation,
business licensing, food control etc
• Regional and local authorities powers derived from the
national structure - decentralization
• Health services may be nationally or locally managed
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Advantages to a Federal Structure
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Examples – Canada, US, Germany, Argentina, Nigeria
Division of responsibilities for health
Federal gov’t - policy, financing and regulatory roles
State level closer to the community and represents
regional issues
• Local health government is closest to the community
• Combination of local gov’t, can promote community
health interests within state and federal guidelines,
funding and accountability.
• Promotes inequality between regions of the country
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Advantages of Unitary Government
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Example – UK, most EU countries
Napoleonic system
More centralized decision making
Taxation sources clearer
Increasing tendency to greater regional autonomy
Devolution
Increasing regionalization, regional autonomy
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Government Sources of Funds
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Income tax
Resource taxes
Excise taxes
Value added tax
“Sin tax” – alcohol, tobacco products
Inheritance taxes
Dedicated tax e.g. gasoline tax for roads
Property tax – local
Business and licensing taxes
Social security
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Inter-Governmental Transfer of Funds
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Tax sharing e.g. resource taxes
Tax transfer e.g. share of income taxes
Cost-sharing e.g. health insurance (Canada, US)
Categorical grants-in-aid
– Per capita grants e.g. health and welfare
– Block grants e.g. public health
– Targeted grant programs e.g.Hill-Burton Act
• Transfer of responsibility
– Veteran’s care in Canada
– Federal initiatives and administration, Medicare in US
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US Dep’t Health and Human Services
DHHS
EPA
NCHS
Surgeon
General
FDA
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FDA
NIH
CDC
HCFA
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Federal System: Federal, State and Local
Authorities
Federal
State
Province
Oblast
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$
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Municipality
$
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County
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Rayon
$
City
$
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Public Health Responsibilities or Mission
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Prevent epidemics and spread of disease
Protect against environmental hazards
Prevent injuries
Promote and encourage healthy behaviors
Respond to disasters and assist communities in
recovery
6. Assure quality and accessibility of health services
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Source: American Public Health Association, 2000
www.apha.org
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Federal - United States
• Constitution 1776
• Executive, legislative and judicial branches
• National defense and international relations
• Interstate commerce, economic regulation
• Food and Drug Act (1906)
• Social Security Act (1935)
• Limited health responsibilities at federal level
• Incremental steps of intervention
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Federal PH Responsibilities
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Overall responsibility for health of population
Varies – federal vs. unitary state
National policy and planning
Financing
Assure regional equity
Special services (labs, technical services)
Research
Bureau (Child Health, CDC, FDA, etc)
Native peoples, armed forces
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US “Hill-Burton Act”
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Federal-state-local partnership in 1950s-1960s
Set national standards and financing to local hospitals
Raised standards of medical care in underserved areas
Renovated obsolescent facilities
Promoted desegregation (southern US)
Limited hospital beds to 4-4.5 acute care beds/1,000
Favored middle-class communities (local $ contributions)
Channeled federal monies to poor communities
Required hospitals to provide free or reduced cost care to
the poor and emergency treatment to uninsured
• Act later expanded to promote primary care facilities
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National Institutes of Health
• Nat Cancer Institute (NCI)National
Eye Institute (NEI)
• Nat Heart, Lung and Blood
Institute (NHLBI)
• Nat Human Genome Research
Institute (NHGRI)
• Nat Institute on Aging
• Nat Institute of Alcohol Abuse and
Alcoholism
• Nat Institute Allergy and
Infectious Diseases
• Nat Inst Arthritis, Musculoskeletal
and Skin Diseases
• Nat Institute of Child Health,
Human Development
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• Nat Institute of Deafness,
Communication Disorders Nat
Institute of Dental Research (NIDR)
• Nat Institute of Diabetes,
Digestive, Kidney Diseases
• Nat Institute of Drug Abuse (NIDA)
• Nat Institute of Environmental
Health Sciences
• Nat Institute of General Medical
Sciences
• Nat Institute of Mental Health
• Nat Institute of Neurological
Disorders and Stroke National
Institute of Nursing Research
(NINR)
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Essential Public Health Services
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Monitor health status to identify community health problems
Diagnose, investigate health problems and hazards in community
Inform, educate and empower people about health issues
Mobilize community partnerships, action to solve health problems
Policies, plans that support individual, community health efforts
Enforce laws, regulations that protect health and ensure safety
Link people to needed personal health services and assure
provision of health care when otherwise unavailable
8. Assure an expert public health work force
9. Evaluate effectiveness, accessibility and quality of health services
10. Research for new insights and innovative solutions to problems.
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Source: MMWR, 1997;46:150-152;
www.apha.org and www.hhs.gov/
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Responsibilities of Local Government:
Local Health Authority
• Ancient city states responsible for quarantine,
sanitation, medical care of the poor
• Elizabethan Poor Law 1601- responsible for welfare
• Limited tax base – property taxes
• Financial grants/tax transfers from higher gov’t
• Sanitation – water, sewage, garbage, streets, labs
• Business licensing and regulation
• Licensing and supervision of food and services
• Zoning, urban planning, housing, building codes
• Recreation
• Welfare
• Emergency services
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APHA Basic Six Local Health Authority
(LHA) PH Services, 1940
1. Vital statistics (births, deaths, marriage, divorce)
2. Control of communicable diseases (VPDs, TB, STDs)
3. Environmental sanitation (water, sewage, business
licensing, food control, garbage, workplace
hygiene)
4. Laboratory services
5. Maternal, child and school health
6. Health education
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“Haven Emerson Six”
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Local Health Authorities
1.
2.
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Sanitation – water, sewage, garbage
Business licensing - food, services
Zoning, building code, recreation
Vital records – births, deaths, marriage, divorce
Welfare services and assistance
Direct health services
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APHA Additions, 1950
1. Chronic disease control
2. Housing and urban planning
3. Accident prevention
4. Coordination with other agencies
5. Surveillance of health status
6. Education of public and professionals
7. Supervision and regulatory activities
8. Personal health services
9. Planning of health needs
10. Special services (TB, STDs, cancer, child
development, dental care)
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State (Province, Oblast) PH Responsibilities
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Coordinate with other departments
Develop fund and supervise standards of LHAs
Legislate, regulate “the health and welfare”
Planning and priorities
Vital statistics
Direct services to LHAs (laboratories)
Direct services (Dx and Rx) e.g. STDs, TB
License and supervise health professions, institutions
Control communicable diseases
Relationships with social and welfare services
Finance health and welfare services e.g. NGOs,
Finance medical care
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US Federal Initiatives to 1950
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Marine Hospital Service 1792
Dep’t Agriculture Extension Services 19thC
Child health bureau 1906
Food and Drug Act 1906
Sheppard-Towner Act 1921
Social Security Act 1935
Food fortification 1941
Emergency Medical Insurance Coverage (EMIC)
1943 for millions of servicemen and families
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US Federal Initiatives 1946-2000
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Failure of National health insurance 1946 (1996)
Hill Burton Act 1946
National Institutes of Health, 1946
Centers for disease control and prevention, 1946
Medicare (elderly), Medicaid (poor), 1965
Voluntary health insurance via unions
Diagnosis Related Groups (DRGs) 1970s
Health Maintenance Organizations, 1970s
Health insurance voluntary, federal, state, none
Failure of NHI in 1995
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Reform Issues
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Universal coverage
Health rights
Central vs. decentralized management
Devolution to specialized agencies
Inequities
Comprehensiveness
Cost sharing
Financing
Balance of services
Targets
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Health System Reform Issues
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Occurring in many countries
Prepayment - taxes or at work
Supply of services - hospital beds/1,000, medical
manpower and distribution
Methods of payment - shift to prospective
payment systems from norms, fee for service,
block payments
Linkages between service sectors i.e. integration
Epidemiologic monitoring
Economic evaluation
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Vertical Integration:
Funding and Services
Health
promotion
Hospital
Clinic
Patient Centered
Home
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PH
Nursing
Long Term
Care
Home
Care
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A Comprehensive Health Services
Continuum
Promotion
Healthy Public
Policy
Prevention
Promotion
Protection
Community
Oriented
Services
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Palliation
Hospitals
Support
Services
To
Seniors
Community
Health
Centres
Home Care
Outpatient
Rural
Urban
Ambulatory
Community Community
Care
Extended
Treatment &
Long Term Care
Tertiary
Palliation
Rehabilitation
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American Public
Health Association
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33
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Fielding et al. Public
Health Rev. 2010:32:
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American Public
Health Association
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Conclusion
• Gov’t, and NGOs are essential for public health
• Different levels of gov’tal responsibilities
• All gov’ts levels play important roles
– Direct - provide a service, finance, plan, monitor
– Indirect - legislation, regulation
– Policy, legislation, funding, regulation, health
promotion
• Koop – US Surgeon general - ”People need medical
care some of the time; everyone needs public health
all of the time”
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Readings
• NPH Chapter 10
• Fielding et al. Public Health Reviews.
2010;32:
• Shortell et al. Public Health Reviews.
2010;32:
• Available at www.publichealthreviews.eu
•
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