1. Module 4 Law, Government, and Public Health

2. Module 4 Will Help You To:
identify strategies used by governments to influence the health status of their citizens
describe how various forms of law contribute to government's ability to influence health
describe the basic administrative law processes carried out by public health agencies
identify the various federal health agencies and describing their general purpose and major activities
identify different approaches to organizing health responsibilities within state government
describe common features of local health departments in the United States
discuss implications of different approaches among states to carrying out public health's roles

3. American Government and Public Health
“All politics is local” but is all public health local as well?
Federalism and Public Health
“Health” hard to find in US Constitution
Relative roles of national, state and local governments in health matters shift over time
Social values shift over time as well

4. Public Health Law Different forms for law
Constitutionally based law
Legislatively based law
Administrative law
Judicially based law
Purposes for public health laws
Protect and promote health (police and general welfare powers)
Ensure rights of individuals

5. Administrative Law
Separation of powers (legislative, executive, judicial) not apparent in administrative law
Reliance on experts and professionals
Extensive impact on daily life

6. Governmental Public Health
Major levels
National: federal health agencies such as DHHS and its components
Tribal: Indian Health Service and others
State: state health agencies such as health departments and human service agencies
Local: local public health agencies, often called local health departments

7. Federal Health Agencies

8. Fiscal Year 2007 U. S. Public Health Service Agency Budget Authority
Fiscal Year 2007 U.S. Public Health Service Agency Budget Authority. Source: Fiscal Year 2007 Budget, USDHHS, 2006.

9. State Health Agencies
Health roles and duties often scattered among dozens of agencies
Many different configurations for state health agency (free-standing, unit or larger health and human services agency, etc.)
Various duties depending on above.

10. States with Responsibilities in Emerging Areas of Public Health Practice: United States, Source: Beitsch et al. AJPH 2006;96:

11. Selected Organizational Responsibilities of State Health Agencies, Source: ASTHO 2002 Salary Survey of State and Territorial Health Officials.

12. Local Public Health Organizations
Where the rubber meets the road
Often relate to 10 or more state and federal agencies for funding and direction
2 basic arrangements
Decentralized: relate primarily to local government although may also report to state health agency
Centralized: a unit of the state health agency

13. Small, Medium and Large Local Public Health Agencies (LPHAs): Percentage of All LPHAs and Percentage of Population Served, United States, Source: NACCHO, 2006.

14. Median FTEs in Selected Occupational Categories Employed by LHDs
Median FTEs in Selected Occupational Categories Employed by LHDs. Source: NACCHO, 2006
Population Served
<25k
25-50k
50-100k k
500k+
All LHD Staff 6 16 33 88
325
Manager 1 5 15
Nurse 2 10 20 69
Physician 3
Env Health Specialist 9 24
Other Env Health Scientist
Epidemiologist
Health Educator
Nutritionist 8
Info Sys Spec
Pub Info Spec
Emergency Prep Coord
Clerical 4 23 72

15. Intergovernmental Relationships
Prior to 1915, federal government had minimal health role and little financial power; states had authority but local governments were where the action was
After 1915, federal tax resources and social shifts pushed federal government to become more active; states retained primary authority and local governments were unable to keep up with local needs and expectations

16. Federal public health spending as percent of adjusted total public health spending US, 1960-2000

17. Adjusted total public health spending (in millions) from federal and state/local sources US,

18. Implications at Century’s End
Expectations rising
Federal role diminished
Health policy investment opportunities
Tobacco settlement
BT preparedness
Emergency public health preparedness now both a national security as well as personal safety priority
Governmental public health efforts have evolved over time due, in part, to changing relationships among the various levels of government and also due to the nature and perceived importance of threats to the population’s health and safety and public expectations for governmental preparedness and response to those threats. Although far less dramatic than the shift in societal expectations during the 1930s, the transformation of public health practice in the 1990s has served to raise public expectations that are generally directed to more proximal levels of government. As a result, within our system of federalism, state and local governments are assuming greater public health burdens without the authorities, mandates, and capacities including funding, constituencies and leverage to succeed. 21 Heightened public expectations after the terrorist attacks of late 2001, including the anthrax events, represent the most recent chapter in the story of changing threats and expectations for the governmental public health enterprise.
Key aspects of the federal role in public health had diminished by the time new public health threats and expectations appeared after September With consensus on the basis for analyzing public health capacity, it may be possible to establish a coordinated intergovernmental public health response to address these new threats and expectations. Needed are greater incentives to restructure the public health system around the core function and essential public health services frameworks and to create a common taxonomy for practice that will inform public health leaders at whichever level of the federal system within which they operate.
The opportunities afforded by public interest in and increased expectations for public health have not yet resulted in linking congressional support for public health with systematic reform. Even with the enactment of the Frist-Kennedy legislation and substantial funding for bioterrorism preparedness, there has been little link with systematic reforms such as through the use of national public health performance standards, links with Healthy People 2010 priorities, or any nationally consistent approaches to workforce, information, and organizational resources. The federal agencies with responsibilities for public health must devise a structure that communicates a clear public health chain of command and responsibility for public health systems and capacity building. The operational aspects of this structural reform should be based on more flexible resource sharing strategies to states meeting appropriate standards and through these states to local health units meeting specific standards based on public health’s core functions and essential services.
The first test of public health’s new millennium will be whether the substantial levels of funding for bioterrorism preparedness will be effectively deployed to diagnose and treat the problems facing the governmental public health enterprise, especially those exacerbated by more than two centuries of evolving intergovernmental relationships. The “all hazards” view that public health emergency preparedness and response is a vital capacity for all levels of government and all possible threats and hazards must predominate over categorical approaches to addressing the threat of bioterrorism.
The need for a more effective and efficient public health system persists; however this aspiration will not be realized without major advances in the organization, financing, and delivery of governmental public health services. This can still occur but will require re-working of the operational aspects of the federal-state-local system of public health responsibilities and taking maximum advantage of bioterrorism and tobacco settlement resources. This is necessary in order to bring the ability of the federal government into better alignment with the opportunities afforded by an emerging form of local public health practice that is more heavily engaged in identifying and addressing community needs and in exposing itself to the gaps between what is doable and what is now expected.

19. Discussion
All learners should be making arrangements to attend a meeting of an official board of health (these meetings are open to the public). This may require some advanced planning since many boards of health meet only once a month. If you are unsure of what a board of health is, visit the National Association of Local Boards of Health (NALBOH) web site, especially the article "About Local Boards of Health." Another useful resource is the Illinois Department of Public Health site on local health departments in Illinois (or similar information for your state).

20. Discussion
Select a local public health agency from a state other than Illinois (also, it must not relate to the Board of Health whose meeting you will be attending!) and identify the jurisdiction it serves and whether or not it relates to a local board of health. Also include information as to how this local public health agency was established (resolution or referendum), who it reports to, and how it relates to the state health agency (for example: Is it a unit of the state agency or an independent entity?  Is it certified or accredited by the state?).