Which federal government entity is responsible for the U.S. public health the health of the U.S. citizen population and has many agencies contained within it?

Public Health Agencies

This section summarizes the organization of health agencies, the range of activities carried out by them, and their use and allocation of resources at the federal, state, and local levels. When possible, the range of activities of health agencies are categorized by the functions of public health as outlined in Chapter 2: assessment, policy development and leadership, and assurance of access to environmental, educational, and personal health services.

Federal

The federal government plays a large role in the public health system in the country. It surveys the population's health status and health needs, sets policies and standards, passes laws and regulations, supports biomedical and health services research, helps finance and sometimes delivers personal health services, provides technical assistance and resources to state and local health systems, provides protection against international health threats, and supports international efforts toward global health. The federal government does all of these mainly through two delegated powers: the power to regulate interstate commerce and the power to tax and spend for the general welfare. The federal government's regulatory activities, such as labeling hazardous substances, are based in the power to regulate interstate commerce. Its service-oriented programs, such as the cleanup of hazardous substances or financing personal health services through Medicaid and Medicare programs, are based in its power to tax and spend for the general welfare. (Grad, 1981)

At present, the main federal unit with responsibility for public health is the United States Public Health Service in the Department of Health and Human Services. The second major unit is the Health Care Financing Administration, also in the Department of Health and Human Services. Other federal departments also have agencies with responsibilities for health, such as the Food and Nutrition Service in the Department of Agriculture, the Office of Special Education and Rehabilitative Services of the Department of Education, and the Environmental Protection Agency. Their participation will be discussed in a later section of this chapter.

Leadership

The Secretary of the Department of Health and Human Services is chosen by the President of the United States and sits in his Cabinet. The head of the Public Health Service, the Assistant Secretary for Health, is also appointed by the President. The Surgeon General, who is also appointed by the President, acts as an adviser to the Secretary and the Assistant Secretary.

Organization

The United States Public Health Service includes the (1) Centers for Disease Control; (2) the National Institutes of Health; (3) the Food and Drug Administration; (4) the Health Resources and Services Administration; (5) the Alcohol, Drug Abuse, and Mental Health Administration; and (6) the Agency for Toxic Substances and Disease Registry (Figure A.1). Additionally, several offices relating directly to the Assistant Secretary for Health deal with public health issues, such as the Office of Health Promotion and Disease Prevention and the Office of Planning and Evaluation. These offices are concerned with management; health policy, research, and statistics; planning and evaluation; intergovernmental affairs; health promotion; and other special concerns. (Hanlon and Pickett, 1984)

FIGURE A.1

Department of Health and Human Services organization chart.

The Centers for Disease Control, the main assessment and epidemiologic unit for the nation, directly serves the population as well as providing technical assistance to states and localities. The National Center for Health Statistics within the Centers for Disease Control is the main authority for collecting, analyzing, and disseminating health data. The Agency for Toxic Substances and Disease Registry, also an assessment unit, focuses on environmentally related diseases. The National Institutes of Health, the primary research arm of the government, both conducts research and supports research projects across the nation. The Food and Drug Administration directly tests and assesses safety of food, drugs, and a wide variety of consumer goods and sets standards for safe use of these items. The Health Resources and Services Administration is primarily concerned with resources development and health manpower. The Alcohol, Drug Abuse, and Mental Health Administration concentrates on developing programs and setting standards in these areas. Both the Health Resources and Services Administration and the Alcohol, Drug Abuse, and Mental Health Administration establish and support health services through grants and contracts to state and local government agencies, private health care institutions, and individuals. They also act as coordinators and technical assistants to recipients of contracts and grants. Sometimes these agencies provide services, such as the Indian Health Service in the Health Resources and Services Administration, through which the government provides health care services to Native Americans and Eskimos. (Hanlon and Pickett, 1984)

The other major division of the Department of Health and Human Services concerned with public health activities is the Health Care Financing Administration, which operates the Medicare and Medicaid programs. The federal government directly finances health services for elderly Americans through the Medicare program and provides grants to the states through the Medicaid program to assist them in financing health services for poor Americans. A large portion of Medicaid money also goes to finance long-term care for the elderly.

Other operating divisions of the Department of Health and Human Services are primarily oriented toward human and social services. These offices, although not designated specifically for health, conduct many health-related activities. For example, the Office of Human Development Services houses the Administration on Aging and the Administration on Developmental Disabilities, both of which are involved in long-term health care issues. (Figure A.1; Hanlon and Pickett, 1984)

The Department of Health and Human Services also operates regional offices in Boston, New York, Philadelphia, Atlanta, Chicago, Dallas, Kansas City, Denver, San Francisco, and Seattle, which are involved in program development and provide technical assistance to states and local areas within their region. They also oversee programs contracted from the federal government to the states.

Activities

The federal government is involved in each of the public health functions outlined in Chapter 2. The examples of each type of activity are numerous and occur throughout the branches of the Public Health Service and the Health Care Financing Administration, as well as in related government agencies. For example, assessment is a major responsibility of the Centers for Disease Control and the National Center for health Statistics, but also takes place in the Health Resources Administration, which collects data on health manpower; the Food and Drug Administration, which inspects foods, drugs, and other products; the Office of Disease Prevention and Health Promotion, which collects statistics on prevention activities and the population's health status; the National Institute of Mental Health, which collects data on inpatient and outpatient mental health services; and the Health Care Financing Administration, which collects information on use of health services. Biological research is mainly the task of the National Institutes of Health, and epidemiologic research is mainly the task of the Centers for Disease Control.

The National Center for Health Services Research, under the Office of the Assistant Secretary for Health, is the main authority for policy and health services research. But policy research and health services research can be sponsored by any of the many offices. The Health Care Financing Administration, for example, has an office of research and development. Policy-setting and providing technical assistance take place in nearly all federally conducted programs.

Financing personal and public health services is mainly the task of the Health Care Financing Administration's Medicare and Medicaid offices, but grants for specific services are administered throughout the Department of Health and Human Services. Personal health services are directly delivered by the federal government under the auspices of the Health Resources and Services Administration in the Indian Health Service, but also by the Veteran's Administration and the Department of Defense in military clinics and hospitals.

Overall, federal activities fall into two major categories: those that are conducted directly by the federal government—assessment, policy-making, resources development, knowledge transfer, financing, and some delivery of personal health care—and those that are contracted by the federal government to states, localities, and private organizations—the majority of direct service programs. (Hanlon and Pickett, 1984)

The major portion of the federal government's health business is conducted through contracts and grants to states, localities, and private providers and organizations. The federal government acts through financing intergovernmental and interorganizational contracts to encourage various public health initiatives, convening participants around an issue, coordinating activities, and developing state and local provider contracts. In return for federal funds, states, localities, and private organizations must follow the federal standards and policies set in the contract. Thus in many programs, the federal government takes an oversight, policy-setting, and technical assistance role, rather than a direct provider role. Federal contracts can take the form of seed money for researching and developing new programs, such as Community Mental Health Centers, or they can be support for ongoing activities, such as the Early Periodic Screening, Detection, and Treatment Program. Contracts can be made with agencies to operate specific public health programs or to support general agency activities. Contracts can also be made with health care providers, such as nursing homes or home health agencies, for directly delivering personal health services. Contracts with local areas and providers may be operated through the states or be made directly with the local areas and private sector.

Most contracts to states and localities were initially offered as ''categorical" grants, focusing on particular health issues or populations, for example, research training grants for education, nutrition information programs, substance abuse and mental health programs, and family planning programs. In the early 1980s, the federal administration grouped numerous categorical grants to states into four major "block" grants: one in preventive health, one in maternal and child health, one in primary care, and one in alcohol, drug abuse, and mental health. However, a number of categorical aid programs remain, both as grants to states and localities and to private providers. (Hanlon and Pickett, 1984)

Resources

In 1986, the budget for the Public Health Service totaled about $10 billion and is projected to exceed $12 billion by 1988. The budget of the Department of Health and Human Services was $353 billion in 1986. (This figure includes the Public Health Service budget.) A large portion of the department's budget, more than $197 billion, was allotted for the Social Security Program. Another large portion, about $95 billion, was allotted to the Health Care Financing Administration for the Medicare and Medicaid programs. (Executive Office of the President, Office of Management and Budget, 1987) In 1984, about $1 billion of the total departmental budget was spent in contracts to state health agencies; another half billion was contracted directly to local areas for health programs. (See Figures A.2 and A.3; Public Health Foundation, 1984)

FIGURE A.2

Expenditures of the Department of Health and Human Services, 1986. SOURCE: Office of Management and Budget, 1987.

FIGURE A.3

Expenditures of U.S. Public Health Service, 1986. SOURCE: Office of Management and Budget, 1987.

To put federal health spending in perspective, the Health Care Financing Administration reports that federal expenditures in health were $112 billion in 1984; public expenditures (all government) in health care were $160 billion; and national health expenditures (including both public expenditures and private funds for health care and medical care) were in the range of $387 billion. (Bureau of Data Management and Strategy, Health Care Financing Administration, 1985) Federal expenditures per person were about $460 (U.S. Department of Commerce, 1986), and national health expenditures per person were $1,580. (Bureau of Data Management and Strategy, Health Care Financing Administration, U.S. Department of Health and Human Services, 1985)

Federal spending in health and national spending on health have been subjects of great controversy in the 1980s. Federal spending on health increased dramatically between the 1960s and 1980s, to the extent of several hundred percent in some programs. (Bureau of Data Management and Strategy, Health Care Financing Administration, U.S. Department of Health and Human Services, 1985) Many new programs were also initiated in the 1960s. Cutbacks in federal health spending have been a major goal of the federal administration in the 1980s. For example, the block grants initiated in 1981 included a 25 percent cut in funding to states for the categorical programs included. (Omenn, 1982) (A portion of price cutbacks have since been restored.) Remaining categorical grants were also cut back.

Although federal spending in health continues to increase, it is doing so at a slower pace (U.S. Department of Commerce, 1986)

In terms of personnel, more than 128,000 people are employed by the Department of Health and Human Services. Numerous others are employed in health-related positions in other agencies such as the Department of the Interior and the Environmental Protection Agency.

State

States are the principal governmental entity responsible for protecting the public's health in the United States. They conduct a wide range of activities in health. State health agencies collect and analyze information; conduct inspections; plan; set policies and standards; carry out national and state mandates; manage and oversee environmental, educational, and personal health services; and assure access to health care for underserved residents; they are involved in resources development; and they respond to health hazards and crises. (Hanlon and Pickett, 1984; Public Health Foundation, 1986b) States carry out most of their responsibilities through their police power, the power "to enact and enforce laws to protect and promote the health, safety, morals, order, peace, comfort, and general welfare of the people." (Grad, 1981) In the tenth amendment of the U.S. Constitution, states and the people are designated as the repository of all government powers not specifically designated to the federal government. States, as sovereign governments, derive plenary and inherent power to govern from their people. As guardians of the public interest, states have inherent power to act to protect citizens of the state for the good of the entire citizenry. Massachusetts, the first state to establish a State Board of Health, did so "in the interests of health and life among the citizens of the Commonwealth." (Hanlon and Pickett, 1984) States also have the power to delegate agencies with authority to carry out activities in their interest. As phrased in a state law of Virginia.

The General Assembly finds that the protection, improvement and preservation of the public health and of the environment are essential to the general welfare of the citizens of the Commonwealth. For this reason, the State Board of Health and the State Health Commissioner, assisted by the State Department of Health, shall administer and provide a comprehensive program of preventive, curative, restorative, and environmental health services, educate the citizenry in health and environmental matters, develop and implement health resource plans, collect and preserve vital records and health statistics, assist in research, and abate hazards and nuisances to the health and to the environment, both emergency and otherwise, thereby improving the quality of life in the Commonwealth. (Department of Health, Commonwealth of Virginia, 1984)

Leadership

There are 55 state health agencies in the country (the 50 states plus the District of Columbia, Guam, Puerto Rico, American Samoa, and the U.S. Virgin Islands). Each state agency is directed by a health commissioner or secretary of health. Each also has a state health officer, who is the top public sector medical authority in the state. In many states, the state health officer is the director of the state health agency. In some states, the state health officer works for the director, who is an administrator of a larger agency or department. State health officers are appointed either by the governor, the State Board of Health, or an agency head. (Council of State Governments, 1985). Most states require the state health officer to have a degree in medicine, and some require a degree in public health or public health experience. (Table A.1; American Medical Association, Department of State Legislation, 1984) The average term of a state health officer is about 2 years. (Gilbert et al., 1982). The annual salary of state health officers varies substantially among states. In 1986, five states paid more than $80,000 per annum and eight states paid less than $50,000. (Table A.2; Council of State Governments, 1987)

TABLE A.2

Annual Salaries: Principal State Health Officials, 1986.

Twenty-four states have boards of health. In general, boards are responsible for policy-making and for spending. The boards' relationships to the health officers vary. In most states, the health officer reports to the board. In some, the health officer is a board member. More than 90 percent of the appointments to boards of health are made by the governor. The remainder are appointed by professional associations or by the state health agency director. About three-quarters of the members of state boards of health are health professionals, and, among these, most are physicians. The average term of a board member is 4 years. (Gilbert et al., 1982)

Organization

State health agencies are organized in one of two models: as a free-standing independent agency responsible directly to the governor or the Board of Health or as a component of a superagency. Of the 55 state agencies, 33 are independent agencies and 22 are divisions of superagencies. (Public Health Foundation, 1986b) In 1980, 34 were independent and 21 were superagencies. (See Table A.3; Association of State and Territorial Health Officials, 1981)

TABLE A.3

State Health Agency Organization, 1980, 1984.

The scope of responsibilities of independent agencies and superagencies varies. Fourteen state health departments are also the main environmental agency in their state; fifteen are the mental health agency; and eleven are also the state Medicaid agency. (Public Health Foundation, 1986b) A few states have changed organizational responsibilities since 1980. (Table A.3; Association of State and Territorial Health Officials, 1981)

Organizational units within agencies also vary. Some states have divisions based on regulatory and nonregulatory activities; some have divisions based on different service populations; some have divisions based on different health problems; some have divisions based on environmental and population services. The organizational structure of each state is different and subject to change. (Organizational Charts of State Departments of Health, 1980–1987)

State health agency operations also differ in their level of centralization at the state level. About one-third are completely centralized, operating whatever local health agency units exist in the state. The remainder share operation of programs with local health agencies. Some local health agencies operate completely independently of the state health agency, but in most states state agencies are semicentralized, operating some programs completely, sharing some with locals, and acting as an adviser on some programs. (Miller and Moos, 1981)

Activities

Despite major differences in organization and responsibilities among the state agencies, there are some consistencies in programs handled by the states. For example, nearly all states have programs for vital statistics and in epidemiology. Most conduct planning, and many have planning units. Most have regulatory responsibilities. Almost all states conduct environmental safety programs in sanitation and in water quality. And almost all states are involved in the personal health services. (Public Health Foundation, 1986b)

However, while most states have these programs, the programs can vary in importance and in content. For example, although almost all states have programs for collecting vital statistics, in some states these units report directly to the health officer, and in some the unit may be three or four levels down. While nearly all states collect health statistics, some conduct disease registries and some do not, and some conduct health surveys and some do not. States conduct many similar programs and in some areas offer the same or similar services, but there is also room for tremendous variation in services offered. And there is room for additional unique programs on problems or issues of interest to a particular state. Some state programs are delegated pursuant to federal funding requirements, creating many of the consistencies, and others are state mandated, allowing variation.

Despite differences in program content, the similarities that do exist allow state activities to be generally categorized into the functions of public health outlined in Chapter 2, if it is kept in mind that the activities within these functions do vary.

The best source of data on state health agency activities is the Public Health Foundation, which collects information from states on an annual basis. In the following section, most of the data are taken from the 1986 report of the Public Health Foundation, which reports data from 1984. The data include 46 of the 55 state health agencies. It should be noted that data are necessarily reported according to Public Health Foundation classifications, which follow specific public health activities, rather than functions.

In assessment activities, nearly all the states collect and analyze vital statistics, conduct epidemiology programs, do laboratory analyses, screen the population for health problems, and engage in research. (See Table A.4; Public Health Foundation, 1986b)

TABLE A.4

Assessment Activities of State Health Agencies, 1984.

Thirty-one states have state centers for health statistics. Twenty-three states report that they have recently completed assessments of their citizens' health as compared to other states. (Office of Disease Prevention and Health Promotion, 1986a) All states screen the population; as a group, they screen for more than 30 types of health problems. All states are involved in communicable disease control, and all but one conduct laboratory analyses. Thirteen states do research and development in their laboratories. (Public Health Foundation, 1986b) Some conduct research on specific health policy issues and health services. For example, many states have established groups to study the problem of providing care to the medically indigent. (Desonia et al., 1985)

Most states reported that they are involved in policy-making and setting standards. Sixteen states have policy analysis and development units. (Organizational Charts of State Health Departments, 1980–1987) Of the 23 states that have conducted health assessments of their populations, 18 are developing goals and objectives based on these assessments. Eight have set up strategic planning and evaluation systems for health assessment. (Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, 1986a) Thirty states reported involvement in health planning, but nearly all states write plans for specific health services. Thirty-seven states set standards for local health departments. (Table A.5; American Public Health Association, Health Administration Section, 1984)

TABLE A.5

Policy Development Activities of State Health Agencies, 1984.

In assuring health services, states reported a variety of activities in inspection, licensing, regulation, health education, environmental health, personal health services, and resources development. (See Table A.6) In delivery of health services, individual states may emphasize one type of health service—education, environmental health, or personal health—over another. However, all of the states report that they conduct some programs in each. Almost all have programs in maternal and child health, communicable disease control, dental health, substance abuse control, public health nursing, nutrition, and services for the mentally retarded.

TABLE A.6

Assurance Activities of State Health Agencies, 1984.

From the tables, it is easily seen that the activities of any one state agency can differ from another. And, as previously stated, these lists do not indicate the extent of a state's involvement in any one activity. Nor do they indicate states' handling of new responsibilities within an activity. For example, many states have had health education programs for many years, but have increased their efforts in health education in recent years (Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, 1986a). And 34 states have recently developed special programs or services to assure access to care for the medically indigent, which are not separately catalogued. (Desonia et al., 1985)

Resources

The manner in which states allocate both finances and staff to different activities varies with the programs operated by the state agency, with the size of the state, with balance of responsibilities between states and localities, and with state traditions and priorities. As a group, the 46 state agencies reporting to the Public Health Foundation spent nearly $6 billion for their public health programs in 1984 (Public Health Foundation, 1986b). (This figure was for operation of public health agency programs only, and excludes Medicaid expenditures of states.) The expenditures per state ranged from $646 million in California to $13 million in Wyoming. (California is the most populous state in the country, and Wyoming is the least, save Alaska.) (U.S. Department of Commerce, 1986) Expenditures vary both with size of population and with the scope of responsibilities carried out by state agencies. Public health agency dollars per citizen range from the low 20s to the high 20s between states. (U.S. Department of Commerce, 1986)

In 1984, about 54 percent of the states' total spending was derived from state funds; 37 percent came from federal contracts and grants; 5 percent were from fees and reimbursements; about 2 percent came from local funds; and 2 percent from other sources. Of the federal contract and grant money for states, 1.5 percent was designated for general administration purposes or ''core" support. The remainder was designated for particular categories of health services or "categorical" programs, such as maternal and child health or migrant health. The percentages from each source vary by state. For example, in 3 states more than half the state's expenditures came from federal funding; in 24 states one-quarter to one-half of the state's expenditures came from federal funding; and in 14 states, less than one-quarter of the state's total expenditures was from federal funding. (Table A.7; Public Health Foundation, 1986a,b)

TABLE A.7

Sources of State Health Agency Funds in Percentages, 1980, 1984.

In 1980, the state health agencies spent less than they did in 1984. The 55 reporting to the Public Health Foundation in that year had expenditures of nearly $5 billion. Their sources of funding were about 45 percent from state revenues, 28 percent from federal grants and contracts (which were still categorical at that time and not yet grouped into block grants), 20 percent from local sources, and 7 percent from fees, reimbursement, and other sources. (Table A.7; Association of State and Territorial Health Officials, National Public Health Program Reporting System, 1981)

The increases in state expenditures from 1980 to 1984 do not reflect an increase in buying power. For example, in 1980 the states reported tremendous increases in health spending since 1976, from about $2.5 billion to $4.5 billion. But when the figures were adjusted for inflation using the consumer price index, the real dollar amount reflected an annual 2 percent decrease rather than the seeming annual 15 percent increase. (Association of State and Territorial Health Officials, National Public Health Program Reporting System, 1981) Although inflation rates from 1980 to 1984 were somewhat less than those in the late 1970s, increases in real spending power during this time was still substantially less than that indicated by dollar increases, averaging at about a 2 percent annual increase. (Public Health Foundation, 1987)

It is also important to note that decreases in federal financing are not apparent when percentages of sources of money are considered. Many state programs are funded through formulas specifying proportions of state and federal funding. During the early 1980s, the federal government cut grants to states through the block granting process, and only a few states reported that they intended to make up for the cuts with state funds. Many states reported that they expected to handle the cuts by reducing expenditures in programs proportionally to the federal cuts. (O'Kane, 1981) Consequently, proportions of federal and state financing have remained relatively steady.

In terms of general program content area, in 1984 states spent about 74 percent of their funds on personal health services (including some programs otherwise categorized above as assessment such as screening, epidemiology, laboratories, and immunizations), 8 percent on environmental services, 8 percent on health resources, 6 percent on general administration, and 3 percent on laboratories (Public Health Foundation, 1984). These percentages are much the same as those for 1980. (See Table A.8; Association of State and Territorial Health Officials, National Public Health Program Reporting System, 1981)

TABLE A.8

State Health Agency Areas of Expenditure in Percentages, 1980, 1984.

Total state expenditures for activities in the functions of public health defined in Chapter 2 are listed in Table A.9. The majority of state expenditures went to assurance activities, and within that category, personal health services. Assessment activities were the second greatest expense. (Public Health Foundation, 1984) Of course, individual state expenditures on any one activity vary. While total state expenditures on health statistics activities amounted to $59 million, New Jersey and California spent more than $3 million each on health statistics activities, and Wyoming and Delaware spent less than 250 thousand each. And Kentucky spent more than $1 million on health planning, while the majority of states spent nothing. (Public Health Foundation, 1984)

TABLE A.9

Totals Amounts of State Health Agency Spending by Function, 1984.

In staffing, 47 states reported employing a total of 108,100 employees in 1982. The number of employees in each state ranged from a high of 15,100 in Puerto Rico, to a low of 143 in Idaho. The ratio of health agency staff to population ranged from 216 employees per 10,000 persons in the Virgin Islands to 0.8 and 0.9 per 10,000 in Illinois, Iowa, and Washington. These wide variations reflect, to a large extent, variations in responsibilities. State health agencies that are also the mental health agencies or the environmental health agencies for their state, or state health agencies that operate institutions, tend to have larger staffs. The mean number of employees for states acting as mental health authorities and/or operating institutions was 3,800, while the mean for agencies not having these responsibilities was 1,100. (Association of State and Territorial Health Officials Foundation, 1985b) (Other states also have employees working in mental health and environmental protection, but they work in other agencies.) About half of the states reported that their staffing figures showed an overall decrease in number of employees during the previous 5 years. Some of the decreases could be attributed to changes in state health agency responsibilities, notably giving up institutions or authority as the mental health agency. Nearly a third of the agencies reported that they had increased staff in the previous 5 years. (Association of State and Territorial Health Officials Foundation, 1985b) Changes since 1982 have not been reported.

States reported that most of their staff were employed in personal health programs, with half employed in institutions and half employed in non-institutional health programs. Professional, technical, and administrative staff composed 59 percent of the total staff; clerical staff, 41 percent. States reported increases in staff involved in personal health services in the 5 years prior to 1982 and slight decreases in all other areas. (See Tables A.10 and A.11) However, a large increase was shown in staff not reported by program area. (Association of State and Territorial Health Officials Foundation, 1985b) Staff composition of individual agencies, and changes in that composition, of course differ.

TABLE A.10

State Agency Staffing by Area of Specialization, 1982.

TABLE A.11

State Agency Staffing by Profession, 1982.

It should be kept in mind that state health agency expenditures and staffing are only a small part of the nation's allocation of resources to health. These figures do not include expenditures and staffing of other agencies for health-related programs, nor those of the private providers and organizations.

Local

Local health departments are the "front line" of public health agencies. They are generally responsible for direct delivery of public health services to the population. They conduct communicable disease control programs; provide screening and immunizations; collect health statistics; provide health education services and chronic disease control programs; conduct sanitation, sanitary engineering, and inspection programs; run school health programs; and deliver maternal and child health services, public health nursing services, mental health services, and other home care and ambulatory care services. (Hanlon and Pickett, 1984; Miller et al., 1977)

Local health departments carry out their activities under authority delegated by their state or by local jurisdictions. State legislatures may delegate power to local agencies to conduct activities in the state interest. In doing so, legislatures may delegate local health departments only to carry out administrative functions of the state, such as enforcing the state public health code, or they may empower city and town governments with regulatory or rule-making powers. "Such a delegation of rule-making powers is, of course, quite common in the public health field, with numerous local legislative bodies—such as city councils and boards of aldermen—and state and local boards of health being authorized to promulgate public health ordinances or health codes, or other species of rules and regulations relating to public health." (Grad, 1981) Local health departments are traditionally viewed as empowered by the state with delegated authority. However, cities and towns may exercise powers autonomously, as chartered by the state, and may empower local health departments. Additionally, under the concept of home rule—the authority of localities to make decisions concerning their own welfare—jurisdictions not incorporated as cities or towns may also assign responsibilities to local health departments. (Grad, 1981) Localities may not, of course, assign responsibilities to local health departments that are in conflict with state laws and regulations. Thirty states allow home rule. (Beyle and Dusenbury, 1982)

Leadership

There are about 3,000 local health departments in the United States. (Miller and Moos, 1981) The number of local health departments in a state ranges from none in Rhode Island, Vermont, Delaware, and the District of Columbia to 159 in Georgia. Each of these departments is either directed by a local health officer or by an administrator, who works in cooperation with the local health officer.

Directors of local health agencies are generally appointed by the leaders of the jurisdiction for which they work, county supervisors, city and town councils, or the mayor. Some local health directors are employees of or appointed by the state health department. In most states, local health department directors are required to have a valid license to practice medicine in the state, but many allow nonphysicians to act as local health directors if they have public health or administrative experience. (See Table A.12) About two-thirds of the local health department directors in the country are physicians, nearly one-third have a master's degree in public health, and about one-tenth have a bachelor's degree or less. (Miller and Moos, 1981; Cameron and Kobylarz, 1980) It can be guessed that about one-third of the local health departments have a local board of health. (Miller et al., 1977)

TABLE A.12

Local Health Officers' Educational and Experience Requirements, 1980.

Organization

Local health departments vary in jurisdiction and authority. Some health departments serve a single county and some serve groups of counties. Some are municipal. And some serve city—county combinations. (See Table A.13) In about a third of the states, local health departments are district offices of state health agencies. In another third, local health agencies are responsible to both local government and the state health agency. In the remaining third, local health departments are autonomous, receiving only consultation and advice from the state. (Miller et al., 1977) Some types of local health jurisdiction and authority are more common in one region of the country than another, but the differences do not necessarily follow state lines. A state can have several types of local health departments within its borders or a single type. In many states, such as California and New Jersey, there are a few large autonomous city health departments and many semiautonomous county health departments.

TABLE A.13

Jurisdictions of Local Health Agencies by Percentage, 1974.

In some areas, there is no local health department. There are about 3,000 county and municipal health departments in the country, but there are 3,040 counties, 39 independent cities, 18,878 municipalities, and 25 city—county consolidations. (Beyle and Dusenbury, 1982) In some areas without local health departments, the population is served directly by the state health department, as it is in most of South Dakota. But in other areas, the population is not served by either a local health department or the state health department, as in the sparsely populated northwest corner of South Dakota. (See Table A.14; Public Health Foundation, 1986b)

TABLE A.14

Population Coverage by Local and State Health Agencies, 1984.

Local health departments also differ in organization, size, and the programs they operate. Many are separate agencies, but some are divisions of health and human services agencies. Many are also the local environmental agency, but others share this responsibility with another local agency. Some are district offices of a larger agency, some operate satellite offices of their own. They may serve only a few hundred people, or hundreds of thousands. They may operate a few services or dozens of programs. And they may have a staff of two people or a staff of hundreds.

It should be noted that data on the activities of local health departments are hard to come by. The most specific data are available from a survey conducted in 1974 by the University of North Carolina. The data gathered by this survey have not been replicated in recent years. Data on local health departments are also available from the Public Health Foundation, but these data are only available as reported by the states to the Public Health Foundation. States report data on local activities differently, and some states do not report these data at all.

Local activities vary most significantly by differing local relationships with their state agency. In each program area, some local health departments conduct the program exclusively, some conduct the program in cooperation with the state agency, and some are not at all involved in the program. For example, although all states are involved in communicable disease control, in 10 percent of the states the local health department is solely responsible for the program, in 76 percent states and locals share responsibility for the program, and in 14 percent it is solely a state responsibility. And these relationships can change from program to program. (Miller et al., 1977)

Activities

Despite tremendous variation in services rendered, there are some similarities in local health department programs. Local health departments can be characterized as mainly involved in providing health education, environmental health services, and personal health services and in conducting inspections. Most are also involved in assessment: collecting data and conducting communicable disease control programs and inspections. Some, but few, local health departments are involved in planning, regulating, setting local policies, and conducting research. (Miller et al., 1977; DeFriese et al., 1981) The most common specific activities of local health departments are shown in Table A.15. Of course, the extent of any one local agency's activity in a particular program varies.

TABLE A.15

Activities of Local Health Agencies, 1974.

Resources

As a group, local health departments spent nearly $2.5 billion in 1984. This figure had increased marginally from $2.4 billion in 1980. (Public Health Foundation, 1986b). In real dollars, this change reflects a reduction in spending power.

Of the $2.5 billion spent in 1984, nearly $1.3 billion was derived from intergovernmental grants from the state, and the remaining came from other sources. Specifically, funds came from state-financed grants and contracts (28 percent); federal grants and contracts, either directly or as passed on by the state (18 percent); local funds (34 percent); fees and reimbursements (11 percent); other sources (2 percent); and unknown sources (6 percent). In 1980, funds were similarly derived. (See Table A.16; Association of State and Territorial Health Officials, National Public Health Program Reporting System, 1981; Public Health Foundation, 1986b) Of course, sources for a particular agency differ from one agency to another. In California, nearly 60 percent of local expenditures are derived from state funds, while in Washington, only about 5 percent of local expenditures are derived from state funds. (Public Health Foundation, 1986b) In about half the states, local health departments collect fees and in half they do not. (Miller et al., 1977) These proportions of funding sources can also vary between local health departments within a state. The amount of money available to individual local health departments also varies tremendously. Some are well-funded, while many are severely financially constrained.

TABLE A.16

Sources of Local Health Agency Funds in Percentages, 1980, 1984.

A portion of federal block grant money is passed on by states to local agencies. In 1984, about 35 percent of all maternal and child health block grant money was spent by local health departments. The amount of maternal and child health block grant money allocated from states to locals ranges from 1 percent in Nevada to 100 percent in California. About 38 percent of all preventive health services block grant money was spent by local health departments. The percentage allocated from states to locals varied from 3 percent in Pennsylvania to 100 percent in California. Eight states did not allocate any block grant money to local departments. (Public Health Foundation, 1986b)

In terms of program area, in 1984, as a group, local health departments spent 58 percent of their funds on personal health services, including maternal and child health, communicable disease control, dental health, chronic disease control, and mental health services, to name a few. They spent 12 percent of their total funds on environmental health services, including sanitation programs, water and air quality, and waste management. No figure is available for spending on health education as a separate program. In assessment and in policy-setting, local health departments spent 9 percent of their total funds on health resources, including statistics, planning, and regulation, and 2 percent of the total on laboratory services. In addition, 6 percent was spent for general administration, and 14 percent was not allocated to program areas. About 2.7 percent of state funds to local health departments supported general administration activities. In 1980, local spending was similar, but somewhat more was spent on personal health and less on health resources. (See Table A.17; Public Health Foundation, 1986b) Again, these proportions vary from state to state, and within states. In 1984, in Mississippi about 90 percent of local expenditures went for personal health services, while in California only about 10 percent of the total was spent on personal health services. (Public Health Foundation, 1986b)

TABLE A.17

Local Health Agency Areas of Expenditure in Percentages, 1980, 1984.

In general, about a third of the staff of local health departments are administrative or support personnel, about a third are registered nurses, and the other third are sanitarians. There is an average of one physician for every 30 local health department employees. The mean number of employees in a local health department is 34. (Miller et al., 1977) However, the number of staff in a local health department can range from more than 1,000 to just a few. A few local health departments in New Jersey employ two people, contract with a neighboring county for a health officer, and serve about 200 people. Some local health departments are larger than other state health departments. The San Diego health department employs more than 500 people and is responsible for an area the size of Connecticut. The number of physicians in a local health department ranges from one part-time health officer to several full-time staff.

In rating the importance of different factors on their ability to operate programs in 1974, local health departments rated constraints in resources—lack of funds and lack of staff—as the most important. (DeFriese et al., 1981) Since then, resource constraints have not improved for most local health departments. Federal cutbacks incorporated into block grants have, in many cases, been passed on to localities by the states. (O'Kane, 1981) And many states have faced their own fiscal crises in the early 1980s.

Other Participants in the Public Health System

As stated earlier in this chapter, the public health system in the United States is not just composed of the federal Department of Health and Human Services, the state health agencies, and the local health departments. The national public health system includes other representatives within government: congressional committees, state legislature committees, governors' task forces, and county and city officials. It also includes a variety of government agencies dedicated to programs that are closely allied to public health: education agencies, environmental protection and natural resource agencies, mental health agencies, agencies on aging, health financing agencies, social service agencies, agricultural agencies, housing authorities, and traffic and highway agencies. And it includes private sector organizations: professional membership associations, universities, the media, consumer organizations, foundations, private health care providers, the insurance industry, and community clinics. All of these groups can have major influence in the national, state, and local public health systems. They can work with the public health agencies to address health problems—conducting assessment activities, helping set policies, and providing access to personal services. The following section briefly describes the range of actors other than the public health agencies that are important contributors to the public health system. A few representatives of health-related government agencies—those dealing with the environment, mental health and substance abuse, social services and human development, and financing health care—and a few examples of private organizations—professional associations, nonprofit organizations, and consumer groups—are highlighted.

National

Governmental

The four congressional committees most involved in health issues include the Senate Labor and Human Resources Committee and the House Interstate and Foreign Commerce Committee, which deal with most health issues, and the Senate Finance Committee and the House Ways and Means Committee, which deal with programs of the Social Security Act. Forty-three other committees and subcommittees work on topics related to health. Examples of the latter include the Senate Committee on Veteran's Affairs and the House Subcommittee on Water Resources of the Committee on Public Works and Transportation. (National Health Council, 1979). Each of these committees and subcommittees develops legislation on different health and health-related issues for the country. Many of the federal policy initiatives carried out by the public health service and others originate with these committees.

In the federal executive branch, numerous agencies other than the Public Health Service conduct health-related activities. These agencies are concerned with the health of special populations or with special problems, including the medical divisions of the army and navy, the Veteran's Administration, the Bureau of Indian Affairs, the Agricultural Extension Service, the Department of Education, the Occupational Health and Safety Administration, the Federal Trade Commission, the Bureau of Labor Standards, the Bureau of Mines, the Maritime Commission, many bureaus within the Department of Agriculture, and the Bureau of Employees' Compensation. Other agencies are concerned with international health interests, including the Agency for International Development and the Department of Defense. (Hanlon and Pickett, 1984)

In the representative areas of environment, mental health, and social services, there are programs both within the Department of Health and Human Services and outside of that department.

Environmental programs are mainly handled by the Environmental Protection Agency and by the Agricultural Department. These agencies conduct assessment activities, develop policies and standards, provide direct services and technical assistance to states and localities, and conduct research. The Environmental Protection Agency has programs in air pollution and water pollution control, hazardous waste cleanup, control of pesticides, radiation protection, and research. (Haskell and Price, 1973) Some of these programs are direct federal activities, and some provide assistance to state environmental departments and state health agencies. The Agricultural Department has services for food safety and inspection, sanitation, and assessment of both plant and animal diseases. These services are predominantly federally run. The federal government spent more than $3.5 billion on environmental programs in 1986. (Executive Office of the President, Office of Management and Budget, 1987)

The majority of federal mental health programs are sponsored by the Public Health Service in the Alcohol, Drug Abuse, and Mental Health Administration. This administration predominantly conducts its programs through grants and contracts to states, localities, and private organizations. Some additional mental health programs are conducted through other departments, for example, Department of Education programs for the handicapped. The federal government is also involved in directly financing mental health care through the Medicare and Medicaid programs and in directly providing mental health care through the operation of a mental health hospital. The federal government spent more than $3 billion on mental health programs and care in 1983 in contracts and grants and in financing care for individuals. (Mazade et al., 1985a)

Programs devoted to social services and the welfare of citizens are within the Department of Health and Human Services in the Office of Human Development Services and the Family Support Service. These programs are involved in assessment of population needs, policy development, providing technical assistance to the states, and in providing direct services to citizens. Agencies include the Administrations on Aging; Native Americans; Children, Youth and Families; Refugees; and the Developmentally Disabled. Examples of programs in personal health services and social services outside of the Department of Health and Human Services are numerous. The Bureau of Nutrition and Home Economics of the Department of Agriculture works with the agricultural extension service to improve the nutrition of rural populations. The Department of Agriculture also runs the food and nutrition service, including both the food stamp program and the supplemental nutrition program for women, infants, and children. The Department of Defense has hospitals and clinics for military and military dependents. The Veteran's Administration runs hospitals and nursing homes. The Bureau of Mines in the Department of the Interior conducts health, sanitation, and safety programs for employees of the mining industry. The Department of Education promotes programs of health education and health safety, engages in screening and medical examinations of students and teachers, and administers a grant program for vocational education in health. (Hanlon and Pickett, 1984) Some of these programs relate to social service agencies in the states, some to educational departments, and some to health departments. Many provide direct services or assistance to consumers.

Federal spending on personal social and health services is difficult to assess. In 1986 the Office of Human Development Services spent about $5 billion. The Family Support Administration spent about $13 billion. Programs outside the Department of Health and Human Services added considerably to the total spent on personal medical and social services, for example the budget for the Veteran's Administration Medical Care Services was $9 billion in 1986. The Occupational Safety and Health Administration had a budget of $200,000. The budget of the Food and Nutrition Service of the Department of Agriculture was more than $18 billion. The cost of the supplemental nutrition service for women, infants, and children was more than $1.6 billion in 1986. In many states, federally funded nutrition services are the largest public health program. In addition, many personal social and health services are financed by the Health Care Financing Administration and the Social Security Administration, and by programs within the other departments and agencies. In 1986 the Health Care Financing Administration spent more than $70 billion in Medicare expenditures and nearly $25 billion in Medicaid expenditures. That same year the Social Security Administration spent about $10 billion on supplemental security income, which can be used to cover long-term health benefits. (Executive Office of the President, Office of Management and Budget, 1987)

Nongovernmental

In the private sector, the national organizations with interests in health are almost too numerous to list. There are professional membership organizations for almost every type of health professional and every type of health care organization. Examples include the American Medical Association, the American Nurse's Association, the National Social Workers Association, the American Public Health Association, the National Association of Community Health Centers, the American Hospital Association, and the Association of State Mental Health Agency Directors. Members in these organizations come from both the private and the public sectors. These groups generally serve for members to exchange knowledge and to promote policies. Sometimes they are involved in lobbying Congress for changes in national health policies and regulations, changes in programs, and support for research. For example, the American Medical Association has been active in supporting research related to the health effects of smoking and in antismoking campaigns. The American Public Health Association has taken political positions on nuclear policy and Central American politics, as well as campaign for legislation and education on many health problems such as smoking, teen pregnancy, and injury.

There are also numerous nonprofit associations on the national level that are organized around particular health problems or issues, rather than around a professional discipline. Examples include the American Heart Association, the American Cancer Society, the Alzheimer's Disease and Related Disorders Association, and the American Diabetes Association. These associations also provide arenas for information exchange and policy development, and they sometimes sponsor research in their area of concern. They are also often involved in lobbying for new policies, activities, and the development of resources. For example, the American Cancer Society has been integral in developing resources for cancer research and for promoting antismoking campaigns.

There are also national organizations of citizens focused around health issues or concerned about health in general. Groups include both professionals and consumers and representatives from public agencies and from private providers. Examples include Dissatisfied Parents Together, Alcoholics Anonymous, National Association of Retarded Citizens, National Consumers League, and Gay Men's Health Crisis. These groups are generally involved in information exchange, coalition building, and lobbying. They can be the main force in starting new programs. For example, the Gay Men's Health Crisis has played a central role in starting up community health services for AIDS victims in New York City. The National Association of Retarded Citizens played a central role in securing resources for community care and health care for mentally retarded citizens across the country.

Finally, at the national level, there are foundations that support health research projects and demonstrations of new health services, including The Robert Wood Johnson Foundation, Pew Memorial Trust, Rockefeller Foundation, Kellogg Foundation, Commonwealth Fund, and The Rosenwald Foundation. They can act much like the federal government in providing grants to local areas for health programs and in supporting research. These foundations can play a strong role in assisting information and policy development, and in providing services in a local area. In 1984, about $10.4 billion were given to health and hospitals in private philanthropy, and about $8 billion were given to social welfare projects. (U.S. Department of Commerce, 1986) A few examples of programs supported by foundations include health care for homeless citizens in 16 cities supported by Pew Memorial Trust, the promulgation of community services for AIDS victims supported by Robert Wood Johnson, and research on access to health care, also by Robert Wood Johnson.

All of these types of private groups can be vital influences in the development of public health policy on the national level and in the carrying out of public health programs, both in national and local settings.

It should be kept in mind that national resources expended on health include the activities of all of these associations and organizations. The nation spent in the range of $387 billion on health and medical care in 1984. (Bureau of Data Management and Strategy, Health Care Financing Administration, U.S. Department of Health and Human Services, 1985) This figure does not, however, include private grants for health services, membership dues, expenditures of agencies other than health agencies, and tremendous amounts of volunteer time. Public health manpower is also present in all of these arenas. There are approximately 62,000 graduates of public health schools and public health programs in this country (Moore and Kennedy, 1987). And there are about 5.6 million health professionals in the country, including about 1.8 million nurses and some 500,000 physicians. (U.S. Department of Commerce, 1986). Some portion of these individuals work in public agencies, many work in medical care, and some work in nonprofit associations. Taken together, they represent the national public health system's workforce.

State

Governmental

On the state level, government, public agencies, and private groups are also active in the public health system. Many state legislatures have committees with interests in health issues. And several states have governor-appointed task forces on particular health issues. For example, 22 state legislatures introduced bills concerning access to health care for the medically indigent population in 1984; 20 states organized legislative or gubernatorial study commissions on the issue in 1984. (Desonia and King, 1985) These groups can be the principal public health policymakers in a state. The designation, involvement, and activity of these committees and task forces vary from state to state.

States can have several agencies engaged in activities related to public health, including environmental agencies; social service and welfare agencies; agencies for human development, for aging, and for the developmentally disabled; mental health agencies; Medicaid agencies; education departments; housing authorities; and traffic and highway departments. The exact array of agencies in a given state varies, as does the involvement of the agencies in health issues. In the examples of the environment, social services, and mental health, states have an array of agencies that vary as much as their health agencies. In some states, environmental, social service, and mental health agencies are combined with the state health department, and in some states they are separate agencies. In all states, there are programs in these areas that overlap with those of the health department, regardless of whether the agencies are combined.

A majority of the states have independent environmental agencies. These agencies conduct assessment and address environmental hazards. They can be devoted to single environmental issues—water safety, hazardous waste control, fish and wildlife, air pollution control—or they can be environmental superagencies. Nearly all of the states also have units within their health departments devoted to environmental health concerns, such as sanitation, inspection, water supply, pollution control, and sometimes occupational safety and hazardous materials control; and most state health agencies take the lead responsibility in a state for one or more environmental health services. In some states, these functions are combined. In 11 states, the state health agency is the principal ''lead" environmental agency. In 28, another agency fills that function. (In 5 states there is no officially designated lead environmental agency.) In a few of the states in which the health agency is the lead environmental agency, there are additional environmental agencies that coordinate with the health agency. For example, the health department might deal with water supply safety, and a separate agency might deal with toxics and hazardous materials, environmental factors that would affect the water supply. Some states interpret environmental issues as intrinsically related to health, as the cleanliness of the environment directly affects health. Some states interpret environmental activities as conservation of resources. Many states interpret environmental issues as both and separate them between agencies.

In any situation, the activities of environmental agencies and health agencies often overlap. Forty-four state health agencies have lead responsibility for some environmental health programs, even though only 11 are the lead environmental agency. Thirty-two state agencies share responsibility for some environmental programs with another agency, and 26 play a supporting role to another agency that has the lead responsibility for programs. (Public Health Foundation, 1986b; Haskell and Price, 1973)

In 15 states, the state health agency is also the lead mental health agency for the state. (Public Health Foundation, 1986b) In 14 states, the mental health agency is housed within the health and human services superagency; in 5, it is in an independent health agency; in 18, the mental health agency is independent; and in 14, the mental health agency is part of the welfare or social services agency. (National Association of State Mental Health Agencies, 1987). Many states also have separate agencies for developmental disabilities, mental retardation, and substance abuse control.

There can be a good deal of overlap between state health agency concerns and mental health agency concerns. State mental health agencies handle programs of both a public health nature, such as prevention of mental illness, alcoholism and drug abuse prevention, research, and manpower training, as well as personal health services such as treatment of mental illness, rehabilitation for substance abusers, and services for the mentally retarded and developmentally disabled. In 44 states, public health agencies report that they operate programs for the mentally retarded and developmentally disabled; 37 operate mental health programs; 33 have alcohol abuse programs; and 29 have drug abuse programs. (Public Health Foundation, 1986b) All states either operate services for or finance inpatient mental health care. In a few, inpatient mental health, mental disability, and substance abuse services are operated or financed by the state health agency. (Mazade et al., 1985b; Public Health Foundation, 1986b) In each state there is some overlap between public health and public mental health.

In nearly half of the states, the health agency and the social services agency are combined to form superagencies for human services, much like the federal Department of Health and Human Services. These agencies handle social services for the aged; for children, youth, and families; for adolescents; for the developmentally disabled; and sometimes for particular social problems, such as alcoholism and drug abuse—as well as health services for these groups. The remainder of the states have independent social services or welfare agencies. In many states, social services and health services can overlap in areas such as alcohol and drug abuse rehabilitation and mental health or family services and maternal and child health care. Some programs are essentially both social services and personal health services.

Nowhere is the overlap between health and social services more apparent than in the Medicaid program. Many states view Medicaid as a social services program, providing services for disadvantaged citizens. But a few states view Medicaid as a health program, financing health care services. In 14 of the states, the state Medicaid agency is housed within the health and human services superagency. In 27, the Medicaid agency is in an independent welfare or social service agency or in a state welfare agency separate from the health and human services superagency. In 5 states, Medicaid is handled by the independent state health agency, and in 3, Medicaid is a separate agency. (Office of Research and Demonstrations, Health Care Financing Administration, U.S. Department of Health and Human Services, 1983) In any of these cases, there is considerable influence in both directions between public health policy and Medicaid policy. The operation of health programs and the financing of health services are connected, particularly in states in which the state health agency concentrates its efforts on personal health services. In most states, the state Medicaid budget is equal to or far exceeds the public health budget. States spent between $9 million and $370 million on their public health programs in 1980, and between $14 million and $2.7 billion for Medicaid in 1980. (Association of State and Territorial Health Officials, National Public Health Reporting System, 1981; Office of Research and Demonstrations, Health Care Financing Administration, U.S. Department of Health and Human Services, 1983)

Nongovernmental

In the private sector, there are many state-level professional associations, nonprofit associations, and consumer organizations that parallel the national organizations described above. Many are state factions of the national organizations and serve to exchange information, promote policies, and lobby on the state level. There are state medical associations, state nurse's associations, social worker's associations, and public health associations, to name a few.

In addition to state members of national organizations, there are private organizations involved in the public health system that are more visible on the state level. Some states have business coalitions that are involved in health promotion programs at the worksite. The Washington Business Group on Health in Washington, D.C., is an example of this type of organization. Other states have a single major employer that is involved in health promotion. Johnson and Johnson runs a popular "fit for life" program for its employees. Some states have medical schools, public health schools, and nursing schools—Johns Hopkins, Harvard, the University of Washington, the University of California—that are important influences in the public health system in directing policy, providing services, and conducting research. Private health care providers, such as major hospital systems, can also be visible influences in the public health system at the state level. And finally, the media can play a large role in focusing issues and providing information on health at the state level. Many papers, such as The Washington Post, have special health sections written for consumers.

Local

Governmental

On the local level, government, local agencies, and private organizations can also be central to the public health system. County supervisors, aldermen (freeholders, selectmen), and mayors can direct the public health system in the same manner that the legislature and the governor direct public health issues and policies on the state level. Local government can also convene task forces and meetings around particular issues.

Local areas can also have other public agencies active in the public health system. All local areas have boards of education, which may be involved in school health and child and adolescent health issues. And they have police and fire departments, which may be active in emergency care.

Local areas may also have agencies involved in environmental protection, social services, and mental health. These agencies vary as significantly from area to area as local health agencies. They can be divisions of the state agencies, or independent. Or they can be district offices. In addition, these agencies can be combined with the health department or separate from the health department, as on the state level. And their organization may parallel state organization, or it may not. Regardless of local organization, environmental, social service, and mental health public agencies have concerns and conduct activities which overlap with those of the local health agency in the same manner that concerns of state agencies overlap. The local health department may monitor an individual's water supply, while a local environmental agency monitors industrial or agricultural water supplies. The local health department may have a substance abuse prevention program, while inpatient mental health services are provided by another agency. And the local health department may provide maternal and child health services to families that go to the welfare agency to apply for Medicaid.

Nongovernmental

Private organizations can also have a powerful influence on a local public health system. In the local arena, the private health care provider becomes particularly visible. In many areas, the physicians working at the local health department, or even the local health officer, may be a private practitioner. Or a private clinic or hospital may be the principal provider of services for a particular area. As on the state and national levels, the media, consumer groups, and professional organizations can also have a major influence on the public health system in a local area. The media, consumers, and professionals can draw attention to issues; they can lobby local government for changes in policy; and they can be sources for information.

Conclusion

It should be noted that the public health system, as divided above by national, state, and local settings, is not necessarily that static. There are many channels for information and coordinated activity between national, state, and local levels in both the public and private sectors, just as there is exchange of information and coordination of activity between the health agencies, other agencies, and private actors. The system is both intergovernmental and interorganizational. The amount of interchange and cooperation between government levels and the public and private spheres, however, differs between settings and across issues.

References

• American Medical Association, Department of State Legislation, Division of Legislative Activities. 1984. State Health Departments. American Medical Association, Chicago, Ill.

• American Public Health Association, Association of State and Territorial Health Officials, National Association of County Health Officials, U.S. Conference of Local Health Officials, U.S. Department of Health and Human Services, Public Health Service. 1985. Model Standards: A Guide for Community Preventive Health Services. American Public Health Association, Washington, D.C.

• American Public Health Association, Health Administration Section. 1984. State Systems of Local Health Department Standards, 1983. American Public Health Association, Washington, D.C.

• Association of State and Territorial Health Officials Foundation. 1984. Public Health Agencies 1982, vols. 1, 2, and 4. Association of State and Territorial Health Officials Foundation, Washington, D.C.

• Association of State and Territorial Health Officials, National Public Health Program Reporting System. 1981. Public Health Agencies 1980: A Report on the Expenditures and Activities. Association of State and Territorial Health Officials, National Public Health Reporting System, Washington, D.C.

• Association of State and Territorial Health Officials Foundation. 1985. a. Special Report: Profile of 1983 State Health Agency Data Relevant to the 1990 Objectives for the Nation. Association of State and Territorial Health Officials Foundation, Washington, D.C.

• Association of State and Territorial Health Officials Foundation. 1985. b. Staffs of State Health Agencies. Association of State and Territorial Health Officials Foundation, Washington, D.C.

• Beyle, T., and P. Dusenbury. 1982. "Health and Human Services Block Grants: The State and Local Dimension." State Government 55(1):2–13. [PubMed: 10254997]

• Bureau of Data Management and Strategy, Health Care Financing Administration, U.S. Department of Health and Human Services. 1985. HCFA Statistics. U.S. Department of Health and Human Services, Washington, D.C.

• Cameron, C. M., and A. Kobylarz. 1980. "Nonphysician Directors of Local Health Departments: Results of a National Survey." Public Health Reports 95(4):386–397. [PMC free article: PMC1422532] [PubMed: 7422806]

• Council of State Governments. 1985. The Book of the States, 1984–5. Council of State Governments, Lexington, Ky.

• Council of State Governments. 1987. The Book of the States, 1986–87, vol. 26. Council of State Governments, Lexington, Ky.

• DeFriese, G. H., J. S. Hetherington, E. F. Brooks, C. A. Miller, S. C. Jain, F. Kavaler, and J. S. Stein. 1981. "The Program Implications of Administrative Relationships Between Local Health Departments and State and Local Government." American Journal of Public Health 71(10):1109–1115. [PMC free article: PMC1619889] [PubMed: 7270759]

• Department of Health, Commonwealth of Virginia. 1984. The Health Laws of Virginia. The Mitchie Co., Charlottesville, Va.

• Desonia, R., and K. King. 1985. State Programs of Assistance for the Medically Indigent. Intergovernmental Health Policy Project, Washington, D.C.

• Desonia, R., J. Luehrs, and G. Brown. 1985. Addressing Health Care for the Indigent: State Initiatives, 1985. The Intergovernmental Health Policy Project, the National Governor's Association, Washington, D.C.

• Executive Office of the President, Office of Management and Budget. 1987. Budget of the United States Government, Fiscal Year 1988. Government Printing Office, Washington, D.C.

• Gilbert, Benjamin, Merry-K. Moos, and C. Arden Miller. 1982. "State Level Decision Making for Public Health: The Status of Boards of Health." Journal of Public Health Policy, March, pp.51–61. [PubMed: 7085870]

• Gossert, Daniel J., and C. Arden Miller. 1973. "State Boards of Health, Their Members and Commitments." American Journal of Public Health, June, 63(6):486–493. [PMC free article: PMC1775209] [PubMed: 4707551]

• Grad, Frank P. 1981. Public Health Law Manual: A Handbook on the Legal Aspects of Public Health Administration and Enforcement. American Public Health Association, Washington, D.C.

• Hanlon, G., and J. Pickett. 1984. Public Health Administration and Practice. Times Mirror/Mosby.

• Haskell, E., and V. Price. 1973. State Environmental Management: Case Studies of Nine States. Praeger Publishers, New York.

• Mazade, N., T. Lutterman, and R. Glover. 1985. a. Funding Sources and Expenditures of State Mental Health Agencies: Revenue/Expenditure Study Results Fiscal Year 1983. National Association of State Mental Health Program Directors, Washington, D.C.

• Mazade, N., T. Lutterman, and R. Glover. 1985. b. Selected State and Federal Government Agency Mental Health Expenditures Incurred on Behalf of Mentally III Persons. National Association of State Mental Health Program Directors, Washington, D.C.

• Miller, C. A., E. F. Brooks, G. H. DeFriese, B. Gilbert, S. C. Jain, and F. Kavaler. 1977. "A Survey of Local Public Health Departments and Their Directors." American Journal of Public Health 67(10):931–939. [PMC free article: PMC1653734] [PubMed: 911004]

• Miller, C. A., B. Gilbert, D. G. Warren, E. F. Brooks, G. H. DeFriese, S. C. Jain, and F. Kavaler. 1977. "Statutory Authorizations for the Work of Local Health Departments." American Journal of Public Health 67(10):940–945. [PMC free article: PMC1653736] [PubMed: 911005]

• Miller, C. Arden, and Merry-K. Moos. 1981. Local Health Departments: Fifteen Case Studies. American Public Health Association, Washington, D.C.

• Moore, F., and V. Kennedy. 1987. "Analysis of Public Health Workforce." Center for Health and Manpower Policy Studies, University of Texas Health Science Center at Houston, unpublished data prepared for IOM Conference on Education, Training, and the Future of Public Health.

• National Association of State Mental Health Agencies, Membership List, 1987.

• National Health Council. 1979. Congress and Health: An Introduction to the Legislative Process and Its Key Participants. National Health Council, Washington, D.C.

• Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services. 1986. a. A Review of State Activities Related to the Public Health Service's Health Promotion and Disease Prevention Objectives for the Nation. U.S. Department of Health and Human Services, Washington, D.C.

• Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services. 1986. b. The 1990 Health Objectives for the Nation: A Midcourse Review. U.S. Department of Health and Human Services, Washington, D.C.

• Office of Research and Demonstrations, Health Care Financing Administration, U.S. Department of Health and Human Services. 1983. The Medicare and Medicaid Data Book, 1983. U.S. Department of Health and Human Services, Washington, D.C.

• O'Kane, Peggy. 1981. Survey of Health Block Grant Implementation. The Intergovernmental Health Policy Project, Washington, D.C.

• Omenn, G. S. 1982. "What's Behind Those Block Grants in Health?" New England Journal of Medicine 306(17):1057–1060. [PubMed: 7038505]

• Organizational Charts of State Departments of Health. 1980–1987. Unpublished information collected by the Public Health Foundation for the IOM Committee to Study the Future of Public Health.

• Public Health Foundation. 1981. Public Health Agencies, 1980. Public Health Foundation, Washington, D.C.

• Public Health Foundation. 1986. a. 1984 Public Health Chartbook. The Public Health Foundation, Washington, D.C.

• Public Health Foundation. 1986. b. Public Health Agencies 1984, vols. 1, 2, and 4. The Public Health Foundation, Washington, D.C.

• Public Health Foundation. 1987. Public Health Agencies 1987. The Public Health Foundation, Washington, D.C.

• Public Health Service, U.S. Department of Health and Human Services. 1980. Promoting Health/Preventing Disease: Objectives for the Nation. U.S. Department of Health and Human Services, Washington, D.C.

• Rabe, Barry G. 1986. Fragmentation and Integration in State Environmental Management. The Conservation Foundation, Washington, D.C.

• U.S. Department of Commerce. 1986. National Data Book and Guide to Sources: Statistical Abstract of the United States, 106th ed. Government Printing Office, Washington, D.C.

• U.S. Department of Health and Human Services. 1986. Organizational Chart of the Department of Health and Human Services. U.S. Department of Health and Human Services, Washington, D.C.

Which federal government entity is responsible for the U.S. public health?

Who is responsible for the U.S. healthcare system?

What agency is responsible to maintain the public health?

What is the federal government's role in the U.S. healthcare system?