Concerns about the nation's health and health systems have returned to the forefront of public debate in the United States. Rising health care costs and persistent gaps in the quality, safety, and accessibility of health services raise troubling questions about the future. 1-3 Despite spending more on health services than any other nation, Americans continue to experience higher rates of premature death and preventable diseases and disabilities, and lower life expectancies than their counterparts in many other industrialized countries. 4,5 At the same time, the threat of terrorism and emerging infectious diseases, such as SARS, have brought increasing public attention to gaps and inadequacies in the basic infrastructure that protects health at the population level. Moreover, the rapidly growing obesity epidemic has highlighted the difficulties faced by the health system in addressing the myriad social, behavioral, physical, and environmental conditions that precipitate disease and injury.

Addressing these problems will require targeted efforts to strengthen the nation's public health infrastructure and to ensure that governmental public health agencies can engage effectively with other components of the health system to mount effective, population-based prevention and health protection activities. 6 Historically, such efforts have been hindered by an under-resourced and deteriorating public health infrastructure 7,8; by institutional, professional, and cultural differences between medical and public health settings 9,10; and by gaps in the evidence base concerning what constitutes effective public health practice. 6,11 Over the past two years, the federal government has allocated more than $2 billion in new funding to improve public health system preparedness for bioterrorism and other emerging health threats. Along with these new resources, the public health community urgently needs a strong evidence base on how best to allocate and apply these funds. The nation's experience with health care financing clearly indicates that increased spending alone will not guarantee improved health.

The Role of Research in Public Health Improvement

Strengthening the nation's public health systems requires better information on how to organize, finance, and deliver public health services to achieve improvements in population health. As demand for this information has grown among public health policy makers and administrators, the academic and research community has responded by applying the concepts and methods of health services research to study public health settings. In doing so, the field of public health systems research has emerged as a specialized branch of health services research that focuses on the structure, operation, and outcomes of public health systems-defined as the collection of organizations, individuals, and communities that contribute to activities that promote health and prevent disease and injury at the population level. 12 This field of research endeavors to produce evidence that can inform policy, administrative, and clinical decision making in public health.

The Institute of Medicine 6 recognized the critical importance of public health systems research in its most recent study of the nation's public health system, finding that this emerging field of research needs to expand considerably to address the current and future need for evidence in public health practice:

Research is needed to guide policy decisions that shape public health practice. The committee had hoped to provide specific guidance elaborating on the types and levels of workforce, infrastructure, related resources, and financial investments necessary to ensure the availability of essential public health services to all of the nation's communities. However, such evidence is limited, and there is no agenda or support for this type of research, despite the critical need for such data to promote and protect the nation's health. CDC, in collaboration with the Council on Linkages Between Academia and Public Health Practice and other public health system partners, should develop a research agenda and estimate the funding needed to build the evidence base that will guide policy making for public health practice.^(p.8-9)

Although studies of this nature do exist and are currently underway, the field of health systems research remains small, and the volume and strength of evidence produced by it are necessarily limited.

Realizing the promise of public health systems research in informing public health practice will likely require developments along several fronts. As the Institute of Medicine stresses, adequate research funding and a well-reasoned research agenda are basic and essential ingredients. Other key elements include:

* Research-quality data resources to support system-level research. A persistent barrier to conducting research on public health systems is the lack of current and longitudinal data on basic characteristics of the nation's public health infrastructure, including information on the public health workforce, public health spending, and state and local public health agencies. Rather than depending on the current mix of episodic and ad hoc data sources, public health researchers and practitioners could benefit greatly from a standardized set of data on public health infrastructure collected at regular intervals.

* Research-practice partnerships. Public health systems research is a practice-based field of inquiry that requires strong partnerships between researchers and public health practitioners to be successful. Practitioners must be engaged throughout the research process to ensure that the studies ask the right questions, collect the right data, interpret the results correctly, and translate the findings appropriately, so that the resulting evidence is useful in the real world of public health practice.

* Methodological advancements. The methodological challenges of defining public health systems and measuring what they do are daunting, given the enormous diversity that exists in the organization and delivery of public health services at state and community levels. Nevertheless, the long-term success of the field of public health systems research will depend on our ability to make progress on this front, building on current efforts such as the National Public Health Performance Standards Program. Although public health systems research exists as an applied field of inquiry, considerable attention must be given to the development of analytical methods and tools in public health measurement before these tools can be applied to answer questions of policy and practice.

* The pipeline of public health systems researchers. Expanding the evidence base for public health practice requires researchers who have the requisite skills, experience, and motivation to pursue research opportunities in public health. In building this research capacity, training opportunities are needed to attract new researchers into the field and to encourage established researchers to apply their skills to public health problems. Such opportunities will require strong partnerships between the academic and practice communities.

In This Issue: Public Health Systems Research II

This issue of the Journal of Public Health Management and Practice (JPHMP 10:3) includes articles adapted from the 2003 meeting of the Public Health Systems Research Affiliate of AcademyHealth, the professional association for health services research and health policy. This affiliate provides a forum for dialogue and interaction among researchers, policy makers, and practitioners interested in the public health delivery system. The initial issue of Public Health Systems Research (JPHMP 9:3) contained articles from the first AcademyHealth meeting, held in June 2002. The June 2003 meeting was held in Nashville, Tennessee, in conjunction with AcademyHealth's annual research meeting. Sponsored by the Centers for Disease Control and Prevention (CDC), this second annual edition of the affiliate meeting included the presentation of four invited policy papers, five research papers selected competitively from a blinded call for abstracts, and an additional 12 research papers presented during a poster session. Building on the success of this meeting, the third annual affiliate meeting will be held in San Diego, California, in June 2004, one day prior to the AcademyHealth's annual research meeting. 13

Collectively, the articles in this issue explore the roles that sound research and analysis can play in illuminating important public health issues and identifying promising pathways to improved system performance. Pursuant to the recent Institute of Medicine recommendations, Cioffi et al. describe the results of a CDC-sponsored initiative to develop a research agenda for public health workforce development-an effort that provides direction and motivation for the next wave of workforce research in public health. Three other articles in this issue use data and experiences from the National Public Health Performance Standards Program to examine critical issues in the organization and delivery of essential public health services. Mays and colleagues use these data to identify underlying dimensions of performance in local public health systems and explore sources of variation in performance across states and communities. Scutchfield and colleagues use similar data to explore relationships between local public health agency capacity and systemwide performance-an analysis that received the award for best paper at the affiliate meeting. A third article by Knight and colleagues evaluates the implementation of the Performance Standards Program and a related readiness process in several Kentucky public health jurisdictions. Collectively, these articles shed important light on the difficult issues of measuring public health system performance and identifying its key determinants.

Another set of articles in this issue of JPHMP examines public health preparedness issues. Costich and Scutchfield assess the validity of a tool developed to inventory local public health preparedness and response capacities, whereas Foldy and colleagues evaluate the performance of an innovative bioterrorism preparedness surveillance model implemented in Milwaukee. Boscarino and Adams examine public perceptions about quality of care and health information resources in New York, and explore the implications for public health information dissemination and risk communication. Two other articles in this issue explore the role of partnerships in public health systems. Padgett and colleagues present an analysis of state-level partnerships in the Turning Point initiative, while Zahner and Corrado examine the role of faith-based organizations in local partnerships with public health agencies in Wisconsin. Finally, Swain and colleagues evaluate the implementation of a performance feedback initiative in a local health department.

The articles in this issue provide compelling examples of how research applied within public health settings can generate useful insight for policy and administration. The articles also raise nearly as many questions as they answer, underscoring the need for expanded research opportunities that focus on public health systems.

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