Who in public health doesn't think about money at least some of the time? Budgets are always tight, there's always a request for lobbying Congress or the state legislature for support, there's always more to be done than there is money to pay for it!! But think as we might, we have not yet been able to devise a system for regularly reviewing the national investment in public health or studying the various ways in which that investment does (or does not) contribute to measurable improvements in health status at the community or population level. And we have further challenged ourselves by including in Healthy People 2010, the nation's objectives for achieving a higher level of health, Goal 23-16: Increase the proportion of federal, tribal, state, and local public health agencies that gather accurate data on public health expenditures, categorized by essential public health service.1 Should we really spend so much time thinking about money?
As anyone who pays the least bit of attention to health policy news knows, we can track the proportion of our national resources that go to health and illness care on a year-by-year basis, can compare ourselves to other economically developed nations, and consider the differential impact of hospital, pharmacy, long-term care or other cost shifts on this ever-larger number. Analyses of potential policy changes include, as a matter of course, the economic impact. And a major change, such as the addition of a pharmacy benefit to the Medicare program, can keep health economists busy for months as they outline the various potential costs and benefits, not only taken as a whole but as they affect groups of Medicare recipients at different income levels and with differing prescription use patterns.
But when it comes to public health, suddenly the discussion changes. It is possible to discuss specific appropriations such as Title X of the Public Health Service Act: how much was appropriated in a given year, how much was allocated to the states or to other nonfederal partners, and what was spent by the federal agency administering the program. The Womens, Infants, and Children (WIC) food program is another for which details on food purchases and administration can be tracked in detail. And every state health official can describe the official agency's budget, as can a local health director for the locality. Unfortunately, none of these answers is complete or informative, and most state health officials cannot readily state the total expenditure on public health for the state for a given year.
Public health is not only interdisciplinary, but it is practiced or delivered by an amazing network of inter-related local, state, federal, and private organizations. Some activities that are important contributors to the health of the community are also deeply imbedded in the system of personal care and are accounted for there. For example, many adult and childhood immunizations are given by primary care providers in the private care system. Even though the vaccines may be publicly purchased, the full cost of this service that is both personal and public health is not captured as a public health expense. Likewise, the epidemiology done by hospital-based infection control programs is "booked" as part of the overhead of hospital costs, not extracted as a public health investment. If one wanted to reach even further, there are the occupational and environmental health staffs working for large corporations and unions: these are graduates of public health training programs and are contributors to the public's health, but the cost of their work is not typically included when discussing public health economics.
The most commonly quoted public health expenditures figure is 1%-2% of the total national health expenditure.2 That amount comes from estimates done a decade ago, when it appeared to some that public health was being lost in the debate about comprehensive health insurance coverage. There had been earlier, regular reports on state public health expenditures built around information needed to account for federal block grant expenditures.3 But these reports were not comprehensive of all public health spending within a state and were generally criticized as inaccurate and incomplete. Small scale studies were also done at that time in a few states4,5 and localities,6 trying to find a way to transcend the confusions of differing tables of accounts, fiscal years, and definitions of terms and provide an intelligible picture of how public health agencies spend money. More recently, the Milbank Memorial Fund has made an effort from a different direction, working with state budget directors to identify public health expenditures at the state level as a part of a larger report on state health expenditures.7
As an example of the challenge each of these efforts has encountered, in some accounting systems, fee revenue is treated as a part of the general fund that must be specifically appropriated before it can be spent; while in others, it is kept in separate accounts, can be carried forward year to year, and is managed by the agency. In some systems, federal dollars coming to the state and later distributed to local public health agencies can be clearly followed; in others, those federal funds are allocated to local government jointly with other state revenues and are difficult to track. The easiest systems to consider are those of states in which local health departments are simply branches of a single state-wide system, but even there, the expenditures and contributions of the voluntary health organizations are not included.
None of that gets at the further difficulty of knowing what it is that is purchased. Salaries? What about contracts with nongovernmental agencies that then hire staff? Do those salaries get counted as well? At what level of detail should a program be described? Parent and child health? Or each of its components, such as vaccines, school health, family planning, well-child services, day care licensing, WIC? Any program area for which there has been a special federal or state appropriation (HIV/AIDS or the new bioterrorism resources come to mind) has usually ended up with a special accounting, in order to assure the funder that the dollars went in the desired direction. Yet, the separate accounting for one stream of funds in a program area may mask the multitude of related or supporting expenditures from other sources.
One of the conceptual tasks taken on by public health over this past decade has been an attempt to describe and discuss public health as a generic service to the community that transcends any one condition or area of immediate concern. This has led to the emergence of two key sets of terms: those describing public health infrastructure and those describing the essential services of public health. Both of these constructs have been used to assist both students and policy makers to understand that public health agencies and services are a generic part of a well-functioning community, regardless of the "disease d'jour" getting the press attention. These constructs have been used in developing performance standards for public health systems and governing bodies and in considering what a model public health law should include. They also were the structural basis of the experimental public health expenditure reporting systems mentioned above and were used by Milbank in the state budget reporting.
What is it that people want to know? If what was wanted was only a total of governmental expenditures, with no internal clarification, that would be achievable with a little collaboration across the several associations representing state and local public health, plus key federal agencies. The trick would be to keep funds passed from one level of government to another from being counted twice. But that is not what policy makers want to know. The interest is in what was spent for what was gained, and here, the long-term cycle of public health adds further to the challenge. What do you "buy" with a tobacco-free kids campaign? The real payoff will be in 20 years when these young folks do not have heart and lung disease. Even programs related to maternal and infant health are a challenge, with a 9-month gestation period to delay the outcome of improved maternity services.
A comprehensive picture of public health expenditures would be complicated. It would be multidimensional. Income would have to include general revenue tax funds, special tax funds, fees, grants from other governmental agencies, and grants from private sources. And expenditures could be displayed several ways: traditional tables of accounts such as salaries and other personnel expenses, rent or building costs, computers, travel, office supplies, grants and contracts to other agencies; major program areas such as epidemiology, vital records, restaurant safety, drinking water safety, day care licensing, family planning and so on; generic essential services, including monitoring health status, investigation of problems, law enforcement; spending agency, including local, state or federal government, voluntary health organizations, nongovernmental service organizations, and businesses. And those are just a few of the possibilities.
Public health professionals claim to be systems-thinkers, working with long-term goals in mind. If that is so, then those systems-oriented approaches should be brought to bear on the long-term goal of finding an approach to tracking the money of public health in ways that are illuminating to the public and useful to policy makers. For example, we public health experts may know that every dollar spent on epidemiology is of value in tracking baseline health status and responding to potential outbreaks or shifts. But the limited number of epidemiology positions suggests that this information has yet to be presented in ways that are understood and accepted as worth the dollars. The current flurry of interest in emergency preparedness and potential bioterrorism has led many in public health to think that they might be better off adopting the language of the emergency preparedness community and talk about their work in front-line surveillance for disaster. While that may be somewhat helpful for a small part of what public health is about, emergency preparedness will never explain child health programs or the behavioral risk factor surveys.
We not only need to think about money, we need to begin documenting it, comprehensively and comprehensibly, across the nation, now.
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