ASSIGNMENT:Week 5: Public Health Finance

ASSIGNMENT:Week 5: Public Health Finance

Advertising campaigns that promote healthier lifestyles often cite the costs to society of various health conditions, such as the cost of childhood obesity in later diabetes rates and the costs of not vaccinating young women in later cancer rates. What is not always mentioned are the very real costs of offering public health programs, which are soaring despite a simultaneous trend in cutting budgets amidst economic woes. Public health administrators today are charged with doing more with less. Even funding sources such as the federal Prevention and Public Health Fund created by the 2010 Patient Protection and Affordable Care Act have felt the brunt of severe cuts (Johnson, 2014).

This week, you examine the financing of public health programs and strategies for “doing more with less.” You also identify concepts related to public health financing.

Required Readings

Shi, L., & Johnson, J. A. (2014). Novick and Morrow’s public health administration: Principles for population-based management  (3rd ed.). Sudbury, MA: Jones & Bartlett Learning.

· Chapter 9, “Public Health Finance” (pp. 181–199)

Centers for Disease Control and Prevention (CDC). (2018). Budgets, grants and funding. Retrieved July 13, 2018, from https://www.cdc.gov/stltpublichealth/grantsfunding/index.html

Grants.gov. (n.d.). About Grants.gov. Retrieved October 6, 2014, from http://www.grants.gov/web/grants/home.html

Johnson, T. D. (2014). Prevention and public health fund paying off in communities: Success threatened by cuts to fund. Retrieved from http://thenationshealth.aphapublications.org/content/42/6/1.4.full

Public Health Finance and Management. (n.d.). Retrieved October 6, 2014, from http://www.publichealthfinance.org/

Suarez, V., Lesneski, C., & Denison, D. (2011). Making the case for using financial indicators in local public health agencies. American Journal of Public Health, 101(3), 419–425.

Note: You will access this article from the Walden Library databases.

U.S. Department of Health and Human Services. (2014). Grants/funding. Retrieved from http://www.hhs.gov/grants/

Assignment: Doing More With Less

As explored in Week 4, public health organizations at the local, state or regional, and governmental levels provide services to and/or engage with many community members. This week, you explore how leaders and managers work within public health departments seek to fund all of the many programs and initiatives they provide, from immunizations to surveillance for communicable and infectious diseases to screenings and food safety and inspections. Leading and managing such responsibilities is no small feat, especially in an environment of fiscal scarcity.

Public health services, like most public services, are almost always provided within a financially constrained environment, one that is vulnerable to economic shifts. With limited funds come many choices: Focus on prevention or promotion? If cuts are needed, what should go first? Facilities improvements? Salaries? Personnel? Supplies? Programs themselves?

In the course text, Shi and Johnson (2014) define public health finance as “A field of study that examines the acquisition, utilization, and management of resources for the delivery of public health functions and the impact of these resources on population health and the public health system” (p. 181).

Thus, the skillset involved in obtaining funds (acquisition) is absolutely critical to public health leadership. Obtaining funds without the context around what funds are needed, why, and how funding will address specific community health problems is a hollow task, however. Public health leaders need to be well versed in budgeting, applying strategies for funding, and analyzing variations in public health funding. Fortunately, tools exist that aid in the process of determining funding and devising strategies for funding.

For this week’s Assignment, review the budget worksheet provided in the Weekly Resources. In addition, in the media titled “Public Health Finance”, reflect on the insights a finance director from the Howard County Health Department provides regarding challenges and strategies related to funding programs. ) I will attached this MEDIA down below)

With the budget worksheet in mind, review the Learning Resources. Research other resources providing information on funding public health initiatives. Access the national websites to search for funding for public health and other initiatives: Explore your state, local, and regional health-related funding organizations’ websites. Research these organizations’ targeted grant opportunities.

The Assignment:

As explored in Week 4, public health organizations at the local, state or regional, and governmental levels provide services to and/or engage with many community members. This week, you explore how leaders and managers work within public health departments seek to fund all of the many programs and initiatives they provide, from immunizations to surveillance for communicable and infectious diseases to screenings and food safety and inspections. Leading and managing such responsibilities is no small feat, especially in an environment of fiscal scarcity. Public health services, like most public services, are almost always provided within a financially constrained environment, one that is vulnerable to economic shifts. With limited funds come many choices: Focus on prevention or promotion? If cuts are needed, what should go first? Facilities improvements? Salaries? Personnel? Supplies? Programs themselves?

In the course text, Shi and Johnson (2014) define public health finance as “A field of study that examines the acquisition, utilization, and management of resources for the delivery of public health functions and the impact of these resources on population health and the public health system” (p. 181). Thus, the skillset involved in obtaining funds (acquisition) is absolutely critical to public health leadership. Obtaining funds without the context around what funds are needed, why, and how funding will address specific community health problems is a hollow task, however. Public health leaders need to be well versed in budgeting, applying strategies for funding, and analyzing variations in public health funding. Fortunately, tools exist that aid in the process of determining funding and devising strategies for funding.

For this week’s Assignment, review the budget worksheet provided ( is attached) in the Weekly Resources. In addition, in the media titled “Public Health Finance” ( I attached the TRANSCRIPT, word with word) reflect on the insights a finance director from the Howard County Health Department provides regarding challenges and strategies related to funding programs.

With the budget worksheet in mind, review the Learning Resources. Research other resources providing information on funding public health initiatives. Access the national websites to search for funding for public health and other initiatives: Explore your state, local, and regional health-related funding organizations’ websites. Research these organizations’ targeted grant opportunities.

The Assignment:

By Day 7, submit a 5-6 page paper, plus the budget worksheet appendix, to include the following sections:

· 1) Explain the basic principles and tools of budget and resource management ( you can take this from ch 9 of the book I attached in here, PLEASE PARAPHRASE EVREYTHING, do not copy-paste!!!)

·

2) Describe two specific examples of principles and/or tools that relate to your selected public health project. You must support why you are using these tools and principles and describe how they will be used to address your selected public healthleadership issue

· 3) Explain the funding issues related to your selected public health project, including whether these issues are long- or short-term, how urgent they are, and state which stakeholders might be most affected and why

·

· 4) Based on the Learning Resources and your research, as well as the information included in the budget worksheet, recommend some potential funding sources and explain why you recommend them. In your explanation, include variations in funding and how these variations influenced your decision making

· 5) Complete the provided budget worksheet indicating the funding opportunities and costs related to the chosen project and copy it into an appendix at the end of the paper

Media titled “Public Health Finance VIDEO TRANSCRIPT:

Public Health Finance Program Transcript

VERONICA WORTH: You have to love numbers, you have to love being detail oriented, you have to love solving issues, you have to love supervising people.

[MUSIC PLAYING] NARRATOR: As director of fiscal services at Maryland’s Howard County Health Department, Veronica Worth and her staff manage over 50 budgets totaling $27 million.

VERONICA WORTH: Most of our funding is comprised of funding that we receive from the Department of Health and Mental Hygiene, from the county, and then we receive some private funds. My office does not actually going and seek funds out. That would be done mostly by the people that are actually in the programs. We have to apply for the funding every single year in the form of budgets and program plans. But for most of that funding, it is pretty much guaranteed as long as we provide them with the requirements that they expect of us. The funding and reimbursement issues that we have sort of tend to flowing and go according to how the economy is. When, of course, we’re in a recession, then a lot of our funding gets cut. And so it becomes really challenging to keep our programs going. One of the big changes right now is that, in a lot of the programs, such as addictions, the emphasis is more towards collections. And we’re expected to be more like a private industry in that we’re expected to be much more selfsufficient. And that’s sort of hard to do for some individuals that have been used to public health. But it’s a necessity. And that’s where a lot of our programs are going. I think what we really need to do is become more aware of what insurances are out there. I think there’s been sort of a misconception that giving free services is a good thing. But in actuality, with addictions clients, it’s actually the opposite. If you have some kind of an investment into your well being, you’re going to end up doing a lot better. Now, there are other services that we will continue to provide that are going to be non-chargeable. And of course, public health issues come up. And we’re not going to be able to charge for those. But it is going in that direction. So I think the true, true public health areas, like epidemiology and emergency preparedness or whatever there is out there that is health promotion, a lot of that is going to be continued to be funded through the Health Department.

FEMALE SPEAKER: Was this helpful? Was this helpful to understand how much sugar’s in some things? OK. Very good.

VERONICA WORTH: The problem is that a lot of the funds that we have are categorical, meaning that you have to use them for a very specific purpose. And so you can’t really use funding that’s meant for addictions, you can’t use it for emergency preparedness. You have to use it just for that purpose. So that makes it a little bit more challenging. Yesterday, my husband ran into some person that was having issues. He was struggling with alcoholism. And that has nothing to do with my job as a finance director. But it was really nice, because he asked me, where should he go? And I told him the Health Department. And the fellow ended up coming over here and getting help. Even though that’s not my job, just interacting with all these people that do help others gives me an opportunity to be able to help somebody if they need the Health Department for any reason. And that’s just a really rewarding sideline of my job.

HERE is MY FINAL PROJECT TOPIC and the OUTLINES:

Addressing Infant Mortalities in Minnesota

Introduction

The State of Minnesota is attributed with various accomplishments particularity in the establishment of institutions, more so schools, colleges, and universities. The State of Minnesota is also well placed in the health sector as it is one of the best ranking states in terms of health equity, and the well-being of communities. However, in the recent past, Minnesota State has documented an increase in economic inequalities, and this has also been translated into the health sector (CDC, 2018).

Communities in the state have been distressed by high rates of infant mortality and morbidity rates as documented by mortality and morbidity data under the Minnesota State Health Department website. Numerous efforts have been put in place by various public health agencies to curb this health outcome in the state of Minnesota. Recent data and statistics on infant mortality and morbidity indicate, however, that more concerted efforts are needed to improve health conditions in Minnesota and more in order to achieve the main objectives of Health People 2020 (HealthPeople.gov, 2018).

Public Health Leadership Problem

A comprehensive community health needs assessment conducted by the Lake Troubled Shallows Department in Minnesota documents that monitoring and treatment of maternal, infant and child health is a real challenge for the state residents. A careful analysis of the state of health in the state of Minnesota reveals that there are excellent facilities within the hospitals, however the effectiveness of service is affected by the aging healthcare facilities, and a lack of primary network. Another underlying issue to this problem is that there is a poor workforce management, which is compounded by a shortage of key personnel in the healthcare facilities. The levels of organizational efficiency are greatly hampered by poor workforce management, lack of key personnel, and a lack of defined internal communication structure which ultimately results and translates to the poor birth outcomes in the state (MDH, 2015).

According to (MDH, 2018) approximately 71,000 babies are born every year in Minnesota with the majority of the women giving birth after having normal terms and having health infants. However, there are adverse health outcomes and they include prematurity and low birth weight that heavily contribute to high infant mortality and morbidity rates. Data statistics between the year 2010 and 2015 show that there has been a constant infant mortality rate of 5.5 infant deaths per 1,000 live births (MDH, 2018). The main cause of infant mortality is premature birth and low birth weight, especially for children of Asian, and Hispanics heritage (Olson, 2015).

Other causes include congenital anomalies particularly to children of African American heritage. The leading cause of infant mortality rate for infants of American Indian heritage is documented as Sudden Unexpected Infant Deaths (SUID) and sleep. Another compelling statistics from the data shows that infant mortality rates in Minnesota are higher for African- American women with higher education than for Hispanic and White women with lower education (Peristats , 2016).

Health People 2020 Priority Areas

Data statistics and findings on Maternal, Infant and Child Health Monitoring and Treatment in the state of Minnesota shows that infant mortality and morbidity is a serious health issue plaguing the residents of Minnesota. This necessitates the need for a leadership and strategy plan to address the issue. One of the sub-objectives most relevant and relating to this issue is on reducing the rate of infant mortality among the residents of Lake Troubled Shallows and in Minnesota at large. To achieve health equity, elimination of health disparities and improvement of the health of all groups requires a multi-sectoral and multi-disciplinary approach that encompasses input and commitment from various public health agencies, public health officials, and other various stakeholders (Lassi, Kumar, & Bhutta, 2016).

Under Health People 2020 the priority is to solve the complex issue of infant mortality rates using cost-effective interventions through building effective partnerships and collaborations with select stakeholders who will help in achievement of better birth outcomes, improvement of delivery of services, improvement of quality of healthcare, and ultimately justified investments in maternal, infant, and child health (HealthPeople.gov, 2018).

References Admin Minnesota. (2002). Indicator 13: Infant Mortality. Retrieved from Minnesota Milestone: https://www.leg.state.mn.us/docs/2011/mandated/110254/Milestones_2011/www.demography.state.mn.us/milestones/indicatora6c4.html?Id=1096&G=30 AMCHP. (2013). Minnesota: Maternal and Child Health Block Grant 2013. Retrieved from Association of Maternal and Child Health Programs : http://www.amchp.org/SiteCollectionDocuments/Minnesota.pdf CDC. (2018, January 11). National Center for Health Statistics: Infant Mortality Rates by State. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/nchs/pressroom/sosmap/infant_mortality_rates/infant_mortality.htm HealthPeople.gov. (2018, Decem ber 18). Maternal, Infant, and Child Health. Retrieved from Office of Disease Prevention and Health Promotion : https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives Lassi, Z. S., Kumar, R., & Bhutta, Z. A. (April 11, 2016). Community-Based Care to Improve Maternal, Newborn, and Child Health. 263-284 MDH. (2015, March 16). Infant Mortality Reduction Plan for Minnesota for Minnesota. Retrieved from Minnesota Department of Health : http://krocam.com/files/2015/04/infantmortality.pdf MDH. (2018, September 27). Infant Mortality in Minnesota. Retrieved from Minnesota Department of Health : http://www.health.state.mn.us/divs/chs/pubs/infantmortality/index.html MDH. (2018). Infant mortality: facts & figures. Retrieved from Minnesota Department of Health : https://data.web.health.state.mn.us/infant_mortality Olson, J. (2015, April 29). Minnesota infant deaths show racial gap: Minnesota’s infant mortality disparity linked to poverty, racism, isolation. . Retrieved from StarTribune : http://www.startribune.com/minnesota-s-infant-mortality-gap-blamed-on-poverty-racism-isolation/301782181/ Peristats . (2016). Infant mortality rates by race/ethnicity: Minnesota. Retrieved from March of Dimes: Peristats : https://www.marchofdimes.org/peristats/ViewSubtopic.aspx?reg=27&top=6&stop=92&lev=1&slev=4&obj=1

HERE is the CHAPTER 9 of this MAIN BOOK: Shi, L., & Johnson, J. A. (2014). – use this to address the first pages of Assignment

Chapter Overview

Public health practice consists of organized efforts to improve the health of communities. The field of finance plays a major part in this process. Generally, the role of finance is to plan for, acquire, and use resources to maximize the efficiency and value of the organization.1 More specifically, public health finance is defined as a field of study that examines the acquisition, utilization, and management of resources for the delivery of public health functions and the impact of these resources on population health and the public health system.2 Its primary focus is on the resources needed for the delivery of essential public health services and how those resources are acquired and managed.

Although many significant achievements can be credited to the public health system, public health services, like most public services, are provided within a financially constrained environment. According to a Trust for America’s Health analysis, the U.S. public health system has been chronically underfunded for decades. At the federal level, funding has remained relatively flat and at an insufficient level for years. At the state and local levels, public health budgets have been reduced drastically in recent years as evidenced by the fact that local health departments have lost a total of 34,400 jobs due to budget cuts. Such funding deficiencies have prevented federal, state, and local public health departments from adequately performing many core functions.3 With bleak federal, state, and local government revenue projections, it is unlikely that the chronic underfunding will be reversed in the near future.

As the scarcity of financial resources increases, the role of public health finance increases in importance. Each dollar that is available must be spent wisely and productively to produce the greatest benefit at the least cost. In addition, public health organizations must be proactive in protecting existing funding as well as recognizing and accessing potential new funding sources from the public and private sectors. Public health managers at all levels and from all disciplines, including senior leadership, unit administrators, finance specialists, and program managers, must be engaged in financial activities, so a knowledge of public health finance is critical to system productivity and sustainability.

Sources of Public Health Funds

It is impossible to provide services of any kind without funding. For example, at the federal, state, and local levels, public health organizations need money for facilities, personnel, equipment, supplies, and many other purposes.

Public health programs are financed through a combination of federal, state, and local governmental appropriations and, especially at the local level, from local taxes, fees, and other reimbursements from sources such as Medicaid and Medicare received directly for services provided. In its current configuration, public health is a public good and, as such, relies heavily on government sources for funding. In this financing structure, each level of government has different, but important responsibilities for protecting the public’s health.

Financing public health functions at different levels of government is grounded in the basic theory of fiscal federalism. Historically, the fiscal federalism framework assigns responsibility for specific functions to national, state, and local levels of government and puts in place proper financing mechanisms to fulfill those functions.4 Fiscal federalism lies within the field of public finance and the financing instruments such as federal grants that are used to transfer funds to state and local levels for the delivery of public health services are covered in detail later in this chapter. The transfer of funds for purposes specified at the federal level provides some perspective on the influence that the federal government can exert over establishing public health program priorities at the lower levels. As an example, the federal government provides an incentive for states to establish policies like setting the legal drinking age at 21 as a condition for receiving federal funding.

While public health plays a critical role in population health interventions, far more of the health resources of the United States are allocated to the provision of medical care as opposed to the promotion of health. Nationally, only a small percentage of the total funds spent on health care are allocated to public health. For example, of the roughly $2.6 trillion total health expenditures in 2010, only 3.2% was spent on governmental public health activities.5 Put another way, Americans spent $8,402 per person on medical care but only $267 per person in public health spending.

Federal spending accounts for about 30% of total public health expenditures while state and local spending cover the remaining 70%. Unfortunately, data on public health funding are not completely reliable because of the large number of funding sources, differences in accounting practices, and even problems in separating public health from other healthcare activities.

Understanding the financing of public health services is critical to understanding the public health system. In essence, the “follow the money” rule helps public health managers understand the role that different entities play in providing public health services to the U.S. population. The purpose of this section is to introduce the financing structure of the public health system.6

Federal Funding Mechanisms

Federal funds are distributed through its system of agencies. It is each agency’s responsibility to manage the distribution of funds utilized for public health services, including ensuring that the funds are used for the purposes stated in the enabling legislation and in a prudent manner. The funds are provided to beneficiaries, or recipients, such as states, local health departments, and other health services providers, through hundreds of individual programs, such as the Maternal and Child Health Program. Each program, which is assigned a unique name to distinguish it from other programs, is created for a specific purpose. For administrative purposes, programs are assigned to offices or operating divisions within a federal agency and may include administrative personnel who work directly or indirectly with the program.

Program funds are distributed to recipients through federal grants (awards), which use funds that are allocated from general revenues. Recipients must first apply for the award directly to the federal agency that administers the program. The agency then determines the amount of assistance to be awarded and notifies the recipient of the award. In order for an award to be considered official, a grant agreement (contract) between the agency and the recipient, which delineates the purpose of the award as well as restrictions and limitations, is signed by both parties.

Federal awards typically specify a time period, called the period of availability, during which the recipient may use the funds. Most grants have a term of 1 year (although some may have a longer lifespan), and the recipient must use the grant funds within that timeframe. The expiration of funds is a consequence of the federal budget process, which dictates that any funds not used within the specified time limit revert to other uses. As a condition of receiving federal grants, recipients must agree to comply with the applicable laws and regulations to avoid potential penalties or legal charges.

Types of Federal Grants

The federal government has several different types of grants, each with its own unique way of awarding and/or operating:

•   Categorical grants. These are the main source of federal aid to state and local governments for public health services.

•   Project basis. Such grants are awarded competitively. Project grants are the most common form of grants in terms of numbers (not dollar value), and most grants are found in scientific research, technology development, education, social services, and the arts. Examples of project grants for health services include the Community Health Centers, Head Start, and health disparities in minorities programs.

•   Formula basis. These grants are awarded on the basis of a precise formula often specified in the legislation that creates the program. Formula grants are typically funded on the basis of measurable factors, such as overall population, proportion of population below the poverty level, or infant mortality rate. The specified formula informs potential recipients, typically states, precisely how they can calculate the quantity of aid to which they are entitled, as long as the recipient qualifies for such assistance under the stipulations of the program. Usually, the elements in the formula are chosen to reflect characteristics related to the purpose of the aid. Examples of formula grant programs include the Ryan White HIV/AIDS Program and the Substance Abuse and Mental Health Services.

•   Block grants. 1966 marks the initial year that block grants were introduced as a federal funding mechanism. With the creation of nine new or revised block grants, the Omnibus Budget Reconciliation Act of 1981 renewed the focus on this type of funding. Block grants typically are large amounts of funding awarded to state or local governments with only general provisions for the way the grant is to be spent. This is in contrast to other types of grants, which contain very specific provisions regarding how the funds are to be used. Block grants allow state and local governments to use different approaches to solving problems as well as allow the funds to be used to address needs determined by the recipient to be most worthwhile.

•   Mandatory (earmark) grants. These are explicitly specified in appropriations by the U.S. Congress. They are not competitively awarded and are subject to the vagaries of the political process.

Federal Pass-Through Grants

The federal government permits certain recipients to act as pass-through entities, which allows the initial recipient to provide the funds to another recipient. The pass-through entity is still considered the recipient of the grant, but the assistance provided in the grant may be “passed on” to another recipient, who is called a subrecipient. This process is used when the federal granting agency does not have the organizational capability to provide assistance directly to the final recipient and hence requires administrative support from an intermediate entity.

For example, the Women, Infants, and Children (WIC) program is a federally funded nutrition program that provides nutrition assessments, diet counseling, and food coupons to low-income women. The funds are granted to states (and similar governmental jurisdictions), but then are further allocated through subgrants to counties and municipalities, typically ending up in local health departments. The original recipients, the states, are the pass-through entities and the counties and cities are the subrecipients, all of which share the responsibility of supporting the original purpose of the program. Subrecipients may in turn pass some or all of the funds to another subrecipient if it supports the purpose of the program. Therefore, a recipient may be considered a pass-through entity and a subrecipient at the same time.

Pass-through entities and subrecipients are equally responsible for the management of all federal funds received. The federal government monitors the federal aid provided to any recipient and requires all pass-through entities to monitor the aid they pass on. Noncompliance of a federal regulation on the part of a subrecipient may be attributed to the pass-through entity because it remains responsible for the management of the funds that it passes on.

Federal Funding Amounts

As mentioned earlier, the primary federal agencies involved with funding state and local public health efforts are the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC).

HRSA distributes approximately 90% of its total funding in grants to states and territories, public and private healthcare providers, and health professions training programs. The bulk of HRSA funds are in its two largest programs, the community and migrant health centers and the Ryan White HIV/AIDS Program, which are awarded on a competitive basis and/or based on disease burden. In 2011, HRSA distributed about $7.5 billion to a variety of public health entities, which amounts to $23.75 per person (per capita). However, the amount of funding spent for key health programs varied from state to state, with a per capita low of $12.77 in Nevada to a high of $82.95 in Alaska. The amount of funding also varied regionally, with the Midwest averaging a per capita low of $20.20 and the Northeast averaging the high of $27.31. The West and South fell in the middle at $25.24 and $22.09 respectively.3

Approximately 75% of the CDC’s budget is distributed to states, localities, and other public and private partners to support services and programs. Some of the CDC’s funding is based on the number of people in a state or on a need-based formula. Other funds are based on competitive grants. States can apply to the CDC for grants for a specific program area, but typically there are insufficient monies available to fund all requests. In 2011, the CDC distributed about $6.3 billion to various public health entities, which translates to a per capita amount of less than $20.28. However, as with HRSA funding, CDC funding was highly variable, ranging from a per capita low of $14.20 in Ohio to a high of $51.98 in Alaska. The funding also fluctuated regionally, with the Midwest averaging a per capita low of $17.65 and the West averaging a high of $21.94. The Northeast and South fell into the middle at $20.70 and $19.91 respectively.3

The combined annual federal funding from the CDC and HRSA to state and local public health entities in 2011 was approximately $13.8 billion, or about $45 per person. Although there is some rationality to the differences in per capita amounts distributed to individual states, it is likely that the funding variation does not totally represent disparities in public health needs.

Currently, most of the federal funding from the CDC to states is distributed for specific programs (categories). While each category provides important funding for serious public health concerns, the funding is not allocated based on priority goals for reducing disease and injury rates, such as those outlined in the Healthy People 2020 initiative, or to programs that have demonstrated effectiveness in reducing disease.7 Furthermore, although many federal programs do help alleviate a number of health problems, the funding typically is not well coordinated among federal agencies or with state and local funding programs.

Funding at the State and Local Levels

States and localities have the following public health responsibilities:7

•   Fulfill core public health functions such as diagnosing and investigating health threats, informing and educating the public, mobilizing community partnerships, protecting against natural and manmade disasters, and enforcing state health laws.

•   Provide relevant information on the community’s health and the availability of essential public health services. This information should be integrated with reporting from local hospitals and healthcare providers to show how well public concerns and health threats are being addressed. Furthermore, this information should be publicly available and utilized by public health departments to work collaboratively with hospitals, physicians, and others that have a role in public health to set health goals.

•   Work collaboratively with the multiple stakeholders who influence public health at the community level to design appropriate programs and interventions that address key health problems and improve the health of the region.

•   Deal with complex, poorly understood problems by acting as “policy laboratories” to take advantage of the fact that states and localities are closer to the people and to the problems causing ill health than is the federal government.

There are three types of organizational structures for state public health departments: stand alone, umbrella, and mixed function. Stand-alone public health agencies are independent from other agencies in the state and have a dedicated public health mission. State public health agencies that fall under larger agencies like a state department of health services are called umbrella agencies. Lastly, mixed-function state agencies function independently but perform other functions in addition to public health such as Medicaid and health insurance regulation. Although organizational differences have a significant impact on the administration of the state public health function, organizational structure does not appear to affect the amount of state funding devoted to public health activities.

There are approximately 2,600 local health departments (LHDs) in the United States serving a diverse assortment of populations ranging from less than 1,000 residents in some rural jurisdictions to about 9 million people, the number served by the New York City Department of Health. LHDs are structured differently, depending on state, and may be centralized (controlled at the state level) or decentralized (controlled at the local level). Therefore, the level of responsibility and services provided by LHDs varies among states, and consequently so does the way that funding levels are established and allocated.

State-Level Funding

States and local communities have chosen a variety of ways to fund public health activities and services, hence the amount of funding is highly variable. To illustrate, although the median per capita revenue at the local level in 2010 was $44, funding ranged from less than $10 to more than $100 and the annual budgets of LHDs ranged from less than $10,000 to more than $1 billion. Roughly 25% of LHDs had annual funding of less than $500,000, while 17% had funding of more than $5 million.8

Table 9.1 State Health Department Funding Sources

Source	National Average
Federal	45%
State general funds	23%
Other state funds	16%
Fees and fines	7%
Other sources	5%
Medicare and Medicaid	4%

Source: Data from Association of State and Territorial Health Officials (ASTHO). Profile of state public health. Vol. 2 (2011), Arlington, VA: ASTHO. Available at: []http://www.astho.org/uploadedFiles/_Publications/Files/Survey_Research/ASTHO_State_Profiles_Single[1]%20lo%20res.pdf. Accessed February 17, 2013.

Table 9.1  lists the 2009 national average funding sources of state health departments. The largest funding source was the federal government with 45%, followed closely by state sources that totaled 39%.9 Note that approximately 60% of the federal funding and more than half of the total amount of state-level funding were used to support local health departments and community-based organizations. In general, the amount of funding and distribution of those funds at the state level is controlled by the legislature and governor as part of the state budgetary process.

Local-Level Funding

Table 9.2  lists the 2010 national average revenues (funding) of LHDs by source.8 Note that local and state appropriations provided 48% of the funding, while federal appropriations provided 23% of the funding, for total governmental appropriations funding of 71%. That means that on average, 29%, or almost one-third, of the funding of LHDs came from sources other than appropriations. These sources included Medicaid reimbursements (13%), service fees (7%), and Medicare reimbursements (3%). Other nonappropriation sources consist primarily of private foundation grants.

Table 9.2 Local Health Department Revenue Sources

Source	National Average
Local	27%
State direct	21%
Federal pass-through	17%
Medicaid	13%
Fees	7%
Federal direct	6%
Other	6%
Medicare	3%

Source: Data from National Association of County and City Health Officials (NACCHO). 2010 national profile of local health departments, Washington, DC: NACCHO. Available at: http://www.naccho.org/topics/infrastructure/profile/resources/2010report/upload/2010_Profile_main_report-web.pdf. Accessed February 17, 2013.

The data in Table 9.2 highlight two important points. First, a significant proportion of public health funding at the local level is generated from services provided to the community and foundation grants, which typically can be influenced by local managerial actions more than the amount of government appropriations. Second, national average data are just that: averages. Thus, revenue percentages at the local health department level are highly variable. For example, some LHDs do not provide clinical services to individual clients, and hence their revenues do not include clinical service fees.

It is important to note that public health does not finance local services to a great degree with dedicated property taxes.10 While other public entities such as school districts and police and fire departments historically finance services with dedicated property taxes, only 12 states in the nation have authorized their local governments to levy a dedicated tax for public health purposes. Local governments do use property tax revenues held in their general funds to fund local public health services, but the lack of a tax levy specifically dedicated for public health exposes those agencies to annual appropriation fluctuations that jeopardize the continuation of services.

Geographic Variations in Public Health Funding

State and local public health departments are on the front line of the nation’s “prevention delivery” system and hence are responsible for keeping Americans healthy and safe and preventing disease and injury. But in order for this system to work efficiently, all Americans must have more-or-less equal access to disease-prevention programs, disaster-response plans, food-safety inspections, and other services provided by local public health departments.

Although the median per capita funding of public health services at the local level in 2010 was $44, funding ranged from under $10 to over $100. This variation, and its implications, was highlighted in a 2009 report by the Robert Wood Johnson Foundation.11 The report, which summarized the results of an academic study, confirmed that public health funding varies widely across communities, suggesting that people have greater or lesser access to critical public health services depending on where they live.12Also, communities with high proportions of racial and ethnic minority populations were much more likely to have experienced reductions in public health spending over the past decade than were their counterparts. It is believed that this funding variation is due to the fact that public health funding decisions typically are determined by a complex interaction of economic, political, bureaucratic, and population health–related factors that place some communities at a disadvantage in securing resources.

In addition, communities that spend more on public health services were the same communities that have been shown to have lower levels of medical care spending, which suggests that the availability of public health resources in a community reduces the need for medical care in that community by limiting disease and injury.

Variations also exist in financing public health through the use of dedicated property taxation at the local level. While dedicated property taxation for public service purposes is aggressively used for functions such as public education, fire, and police services, local governments in only 12 states have authority to levy and collect a property tax dedicated for public health services.

Geographic variation in medical care spending has long been a source of policy concern because it implies large inefficiencies and inequities in resource availability. As policymakers struggle with how to reform the healthcare delivery system and how to pay for it, prevention must be front and center. Many of the costly chronic diseases that Americans are suffering from can be prevented. If certain communities spend more on prevention, do they need to spend less on medical care to treat patients? If communities are spending more on medical care, does this mean they are not spending enough to keep people from getting sick in the first place? These are the tough questions policymakers face as they work to make decisions about how to improve the health system and the health of all Americans.

As the nation’s health system reforms and evolves, it is critical that policymakers examine both the delivery and prevention sides of the system. The current close examination of the health system presents an opportunity to make an historic and strategic investment in community-based prevention programs that will help Americans live healthier lifestyles and keep them out of doctors’ offices and hospitals.

However, to accomplish this worthy goal, every dollar allocated to public health must be spent wisely. By measuring spending levels in specific programs, such as tobacco control, obesity prevention, and communicable disease control, policymakers and public health officials will be able to identify exactly how funding is being used and the value of each type of investment. A uniform tracking system also will enable policymakers to correct wasteful and inequitable variations in public health spending.

Uses of Public Health Funds

Building on an understanding of how public health organizations are funded, the next logical step is to examine how those funds are spent.

Spending at the Federal Level

Because much of the public health spending at the federal level involves the transfer of funds to local and state levels, this discussion focuses on how state and local agencies use their funding. However, to get some feel for how one federal agency spends its funds, consider the CDC.  Table 9.3  shows the uses of the CDC’s 2010 funding, with emphasis on the top five uses.13 Because there are 25 listed uses in the 2010 budget, only the top five are presented; they comprise 76% of the agency’s roughly $11 billion budget.

Table 9.3 Uses of CDC Funding

Funding Use	Percentage of Total Budget
Vaccines for children	35%
Bioterrorism preparedness	15%
HIV/AIDS, hepatitis, STD, and TB prevention	10%
Chronic disease prevention	9%
Immunization and respiratory diseases	7%
All other activities	24%

Source: Data from U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC). Justification of estimates for appropriation committees, Washington, DC: CDC. Available at: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2011_CDC_CJ_Final.pdf. Accessed February 17, 2013.

The data in Table 9.3 show that more than one-third of CDC spending is for children’s vaccines, while another quarter is spent on bioterrorism prevention and selected disease prevention. Remember, though, that only about 25% of CDC’s budget is spent in house; the remaining 75% is distributed to state and local public health entities. Although there is no doubt that federal spending on public health services accomplishes a great deal in keeping the population healthy, critics of such government spending claim that much of the money is spent without hard evidence that the benefits match the costs.

Spending at the State Level

Although spending on public health activities at the federal level is crucial to the population’s health, most of the delivery of public health services occurs at the state and local levels. To begin the discussion of public health spending at the state level, consider  Table 9.4 , which lists how states, on average, allocated their 2009 revenue dollars.14

To better understand these data, the categories are defined as follows:

•   Improving consumer health—includes all clinical programs such as those for Alzheimer’s disease, adult day care, medically handicapped children, AIDS treatment, renal disease, breast and cervical cancer treatment, TB treatment, emergency health services, and assistance to LHDs

•   WIC—includes all expenditures related to the Women, Infants, and Children program, including nutrition education and voucher dollars

•   Infectious disease—includes TB prevention, family planning education programs, and AIDS and STD prevention and control; also includes immunization programs (including the cost of vaccine and administration) and infectious disease control

Table 9.4 State Public Health Expenditures by Category

Category	Percentage of Total Budget
Improving consumer health	24%
Women, infants, and children (WIC)	24%
Infectious disease	13%
Chronic disease	8%
Quality of health services	6%
All hazards preparedness and response	5%
Environmental protection	5%
Administration	5%
Injury prevention	2%
Health laboratory	2%
Health data	1%
Vital statistics	1%
Other	4%

Source: Data from Committee on Public Health Strategies to Improve Health, Institute of Medicine. For the public’s health: investing in a healthier future, Washington, DC: Institute of Medicine; 2012. Available at: http://books.nap.edu/catalog.php?record_id=13268#toc. Accessed February 17, 2013.

•   Chronic disease—includes chronic disease prevention such as heart disease and cancer programs as well as substance abuse prevention programs including tobacco programs; also includes programs such as disease investigation, screening, outreach, and health education

•   Quality of health services—includes quality-regulation programs such as health facility licensure and certification, regulation of emergency medical systems, health-related boards or commissions, and licensing boards; also includes the development of health access planning and financing activities

•   All hazards preparedness and response—includes disaster preparedness programs (including bioterrorism), and the costs associated with disaster response such as shelters and emergency healthcare facilities

•   Environmental protection—includes lead poisoning and air quality programs, solid and hazardous waste management, and water quality and pollution control; also includes food service and lodging inspections

•   Administration—includes all costs related to public health department management such as human resources, information technology, supplies, finance, and facilities; also includes expenses related to health reform and policy development not otherwise embedded in program areas

•   Injury prevention—includes programs such as consumer product safety, fire injury prevention, defensive driving, child abuse prevention, occupational health, and boating and recreational safety

•   Health laboratory—includes costs related to state health laboratories such as those for personnel, administration, facilities, and supplies

•   Health data—includes the costs of data collection, data analysis (including vital statistics analysis), report production, monitoring of disease and registries, monitoring of child health accidents and injuries, and death reporting

•   Vital statistics—includes all costs related to vital statistics administration, including records maintenance, reproduction, generation of statistical reports, and customer service at the state level

•   Other—includes forensic examination and infrastructure funds provided to local public health agencies

It is important to recognize that most of the state-level expenditures are not spent at the state level, but rather are sent to local health departments and community-based organizations. To illustrate, in 2008 and 2009 state health departments sent a total of $5.3 billion to fund local health departments and $2.5 billion in grants to communities for nonprofit health organizations. These funds were distributed as follows: 60% to local health departments, 21% to regional/district health department offices, and 19% to nonprofit health organizations.14

Spending at the Local Level

Because most of the public health services are provided at the local level, it is important to understand how local health departments spend their funds.  Table 9.5  lists the 10 activities and services most frequently provided directly by LHDs, and  Table 9.6  lists those activities and services most frequently provided through LHD contracts with other organizations.13

Table 9.5 Ten Most Frequent Activities and Services Provided Directly by LHDs

Activity or Service	Percentage of LHDs
Adult immunization	92%
Communicable/infectious disease surveillance	92%
Child immunization	92%
Tuberculosis screening	85%
Food service inspection	78%
Environmental health surveillance	77%
Food safety education	76%
Tuberculosis treatment	75%
Schools/daycare center inspection	74%
Population-based nutrition services	71%

Source: Data from U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC). Justification of estimates for appropriation committees, Washington, DC: CDC. Available at: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2011_CDC_CJ_Final.pdf. Accessed February 17, 2013.

These tables indicate that most activities and services are provided directly by LHDs. Furthermore, the most common activities are immunization programs and communicable/infectious disease surveillance. Of the activities and services that are contracted to other organizations, the most common are laboratory services and communicable/infectious disease screening and treatment.

Recommendations for Change

In spite of the many successes of the public health system, there is no doubt that funding inadequacies, coupled with an overall lack of coordination and focus of services offered, have kept the system from reaching its full potential. A recent Institute of Medicine (IOM) report assessed the financial challenges facing the public health infrastructure and provided recommendations for stable and sustainable funding as well as its optimal use by public health agencies.14

Table 9.6 Ten Most Frequent Activities and Services Provided by LHDs Through Contracts with Other Organizations

Activity Service	Percentage of LHDs
Laboratory services	21%
HIV/AIDS treatment	12%
Cancer screening	11%
HIV/AIDS screening	11%
STD screening	9%
Tobacco prevention	9%
Oral health	9%
Tuberculosis treatment	9%
STD treatment	9%
Child immunization	9%

Source: Data from U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC). Justification of estimates for appropriation committees, Washington, DC: CDC. Available at: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2011_CDC_CJ_Final.pdf. Accessed February 17, 2013.

The report contained several recommendations regarding reforming public health and its financing, including the following:

•   Public health agencies at all levels of government should endorse the need for a minimum package of public health services.

•   To enable the delivery of the minimum package of public health services, Congress should double the current appropriation for public health and make periodic adjustments to reflect changes in the cost of the minimum package.

•   Public health departments should focus their activities on population health and work with other public and private providers to provide clinical care. (This recommendation assumes that healthcare reform will provide health insurance for almost all citizens.)

•   State and local health departments should have greater flexibility in the use of federal grant funds to achieve state and local population health goals.

If these recommendations are followed, the potential exists for a significant change in both the level of public health system financing and how those funds are spent.

Public Health Financial Management

In the introduction to this chapter public health finance was defined as the field of study that examines the acquisition, utilization, and management of resources for the delivery of public health functions and the impact of these resources on population health and the public health system. As the scarcity of financial resources increases, the role of finance in the management of public health services increases in importance. Each dollar that is available must be spent wisely and productively to produce the greatest public benefit at the least cost.

This section provides an overview of the financial activities conducted by public health managers to help ensure that financial resources are being well utilized. It begins with a discussion of essential public health finance competencies, then provides some insights into selected areas of public health financial management, including accounting for costs, budgeting, financial reporting, and grant management. Of course, this section merely scratches the surface of public health financial management; the purpose here is to provide some of the specific finance competencies that are required of public health managers and the activities needed to achieve those competencies.

Public Health Finance Competencies

It is now widely recognized that public health managers must have some finance skills, but which are most important? This question is best answered by examining public health finance competencies. Contemporary examinations of essential finance competencies for public health managers trace their lineage back to a 1993 report released by the Public Health Faculty/Agency Forum.15 While the finance recommendations of this panel were stated only in general terms, they did serve to lay the foundation for a greater understanding of the field of public health finance.

Following the initial impetus, researchers and practitioners from across the United States collaborated on several studies that drew on secondary analysis of existing public health finance competencies as well as the collection of original data through surveys, focus groups, and expert panels. The goals of these studies were to consolidate the results of previous efforts and to develop a better understanding of the public health finance competencies that are relevant to public health managers. These efforts culminated in the 2009 publication of consensus public health finance competencies.16

The study identified 39 essential competencies. Although the competencies focus on public health finance, they were developed using an organizational systems (holistic) perspective that integrates finance with strategy, operations, human resources, information systems, law, ethics, and cultural competence.

Another feature of the study is that competencies were identified for both public health financial specialists and general managers. The intent was to identify those competencies that are unique to either financial or nonfinancial managers. Interestingly, the set of competencies required of both financial and nonfinancial managers are the same, which implies that generalist managers must have some understanding of the same finance principles and concepts as do specialists.

The study also focused on the amount of knowledge required for each competency. To accomplish this, the competencies were broken down into three knowledge levels: basic, which implies familiarity with the concept; knowledgeable, which requires a working knowledge of the subject; and proficient, which implies expert knowledge of the concept. Not surprisingly, most of the competencies require expert knowledge for financial managers but only basic knowledge for nonfinancial managers.

Table 9.7  lists 10 of the identified public health finance competencies along with the knowledge level suggested for nonfinancial managers. These are the basic finance competencies suggested for generalist public health managers.

Note that 8 of the 10 competencies listed require only basic knowledge by nonfinancial managers. However, the “knowledge and ability to manage monetary (cash) resources” competency requires working knowledge. Furthermore, two competencies require expert knowledge: “assesses the financial status of the organization and develops any necessary corrective measures” and “sets the strategic financial direction of the organization.”

The key point here is that public health finance knowledge is too important to leave to the financial specialists. Any manager in a public health setting, whether a program manager, a local health department director, or a senior executive at state or national levels, must have at least a basic proficiency in public health finance.

It is also important that the appropriate educational, training, and professional development opportunities be available for public health students and professionals. Reviews of finance-related coursework for this audience revealed insufficient content specific to public health. Additionally, while professional associations for healthcare finance and management were established as early as 1926, there is no professional home for this area of public health.

Table 9.7 Selected Public Health Finance Competencies and Knowledge Level

•   Demonstrates knowledge of general accounting principles and other appropriate standards (B)

•   Gathers, interprets, and reports financial data and communicates data and information according to standards (B)

•   Assesses the financial status of the organization and develops any necessary corrective measures (P)

•   Develops budgets and financial data according to prescribed submission formats and specifications (B)

•   Uses cost, managerial accounting, and economic evaluation approaches and applies these skills to the practice of public health (B)

•   Integrates knowledge of the grant-making process with financial management practices (B)

•   Applies knowledge of basic financial and business processes (e.g., procurement, accounts payable, accounts receivable) (B)

•   Applies management, evaluation methods, and performance measurement to monitor program performance and track achievement of program objectives (B)

•   Demonstrates the knowledge and ability to manage monetary resources (K)

•   Sets the strategic financial direction of the organization (P)

Note: (B) = basic knowledge (familiarity); (K) = working knowledge; (P) = expert knowledge

Financial Activities

Public health managers have many financial responsibilities. The more important ones include planning for the future, establishing policies that control the operations of the organization, and overseeing day-to-day financial activities. One of the key steps in the planning process is to estimate the future demand for programs and services and see to it that the organization has the facilities, staff, and supplies necessary to meet the forecasted demand. This task is accomplished primarily with budgets that use forecasted future volume to estimate the resources needed to meet expected community needs.

All of these financial activities require great deal of information. Furthermore, this information has to be presented in a format that facilitates analysis, interpretation, and decision making. Without timely and relevant financial information, public health managers would be making decisions in the dark. Of course, accurate information does not ensure good financial decision making, but without it the chances of making good decisions are almost nil.

The National Association of County and City Health Officials (NACCHO) recently launched the Public Health Uniform National Data System (PHUND$) to improve the availability of valid and reliable public health financial data.17 Designed as a web-based portal for the collection of financial data, PHUND$ provides users with values on financial and operational ratios and trends and also with comparative analysis to peer agencies. In addition to aiding agency decision making for predicting and avoiding declines, the analytical capacities of PHUND$ have also been shown to facilitate agency turnarounds from a deficit to a surplus position.18

Grants Management

Because a significant amount of public health funding comes in the form of grants, grant management is an important part of the overall financial management process. This section covers some basic principles of good grant management.

Suppose your organization just received a grant—that’s the good news. The bad news is that now the grant must be managed. Regardless of whether you’re a seasoned professional at the state level or a new LHD program manager, the job of grant manager at receiving organizations involves a difficult balancing act: ensuring that program staff have the latitude to accomplish the grant’s purpose without violating any of the funding agency’s requirements.

To begin the process, a good grant manager will study the terms and conditions of the award and compare them to the approved grant application. Occasionally, the grantor will make a mistake or include inappropriate terms and conditions in the final grant agreement. If corrections or clarifications are needed, it is important to raise the issue as promptly as possible.

The next step is to hold a project initiation briefing with the project manager and all staff responsible for carrying out the grant activities. This briefing should ensure that everyone involved with the grant understands the essential terms and conditions of the grant as well as their individual responsibilities. At a minimum, the project manager and staff must have a workable plan of action for carrying out each approved activity.

In addition to the program activities, the grant agreement will contain a set of compliance requirements. To ensure that all compliance responsibilities are met, it is prudent to develop a checklist of all the compliance actions required, and then document the actions taken to meet each requirement. Often this can be accomplished by placing the compliance documentation in a dedicated file that can be provided to the grantor if necessary.

Another essential component of good grant management is the establishment and maintenance of a sound financial control system. Good financial control has three major components: 1) an accounting system that meets generally accepted accounting principles for public and nonprofit organizations; 2) a system of controls that ensures proper cost allocation and that complies with cost-management requirements imposed by the grantor; and 3) a reporting system that fairly and accurately documents the expensing of grant funds. The process of allocating, charging, and documenting costs is vitally important to good grant management. Grant managers, project administrators, and organizational financial managers must have a thorough understanding of how costs are defined, composed, allocated, and charged to one or more authorized grants.

In many grants, the largest expense item is personnel. Federal grant assurance requirements dictate that organizations maintain a system of personnel administration that is merit based and nondiscriminatory. In essence, when federal grant funds are used for personnel, the organization must hire on merit and avoid practices that violate state and federal laws concerning discrimination, equal opportunity, and nepotism. Grant-funded personnel must be treated the same as other organizational employees, although they may be considered as conditional employees whose employment is subject to the availability of grant funding.

Regular audits are a sound business practice for any organization. State or local law usually mandates annual audits for municipalities and state-supported institutions, and many foundations are reluctant to award grants to organizations that do not conduct periodic audits. As applied to grant funding, an audit examines whether the financial transactions are properly recorded and documented according to generally accepted accounting principles.

While most grantees have well run grant programs, a few do not. Unfortunately, even within excellent programs there can be individuals who bend the rules or commit outright fraud or larceny. Organizational and personal conflicts of interest are matters that can affect every type of grant-funded program. All organizations must have written policies that prohibit employees from personal gain associated with grant funding. Employees who work on funded programs should be required to disclose any personal or organizational relationship that might compromise the integrity of the program. To help protect the organization from both personal and property liability, grantees should carry liability insurance that includes grant assets and personnel. Furthermore, key managers and employees who handle grant receipts and payments should be bonded.

Finally, grant managers must monitor program performance in its entirety as well as the progress and completion of grant-funded activities. To accomplish this task, managers must create performance metrics that measure program progress and activity completion. This process might indicate that program success will require a reallocation of funds among program activities. Most grantors will permit organizations to make minor budget reallocations, but major budget changes require approval by the grantor.

This section has presented the financial management competencies required of public health managers along with some tools to manage financial resources as efficiently as possible. It is our hope that this overview of public health has stimulated your interest to learn more and, perhaps, to pursue a career as a public health finance specialist.

Future Outlook

Building a vision to set a future course of action for financing and management of resources in public health could benefit from a critical analysis of the past. The current predicament of underfunding, perceived lack of accountability, and absence of financial management educational and professional development opportunities are interrelated. As a general observation, professionals trained in finance-related disciplines have never been heavily recruited and integrated into the leadership of public health. Consequently, these professionals, for the most part, are not attracted to careers in public health. Evidence of this can also be seen in the marginal and, in most cases, absence of invitations to finance professionals to participate in national committees convened to examine public health finance and other topics.19 It is highly plausible that without the infusion of knowledge from these disciplines on how to build economic models for financial strength, public health has succumbed to a position of overreliance on unsustainable financing structures.

An overreliance on traditional public health funding methods, such as those presented in this chapter, is not a sustainable strategy. Projected economic conditions do not favor increases in federal government grant funding and flat revenue collections have a direct impact on state and local allocations to public health budgets. These conditions represent a new normal that requires a shift in how public health leadership should plan for sustainability. It is possible that public health may be better positioned by transitioning from overreliance on government budget allocations to building product lines that generate diversified revenues.

Models for population health consistently show the marginal influence of medical care on improving health status when compared to other determinants. When exploring future directions, public health could use this reality to identify new avenues for revenue generation and diversification. The financial inefficiencies of 85% of national health consumption expenditures on personal health care5 that impact only 20% of population health improvements19 could be used to support the creation of public health innovations that influence improvements in health.

Data collection and analysis are well established public health activities that are perfectly aligned with contemporary investment interest in information diffusion and technology. Public health innovations that turn this established niche into revenue-generating business models are plausible opportunities. Growing calls to strengthen the integration between public health and medical care to produce health improvements provides a potential existing market for such services.

For these innovations to be successful, public health must also ensure that managers with appropriate financial management skills are folded into all levels of the profession. This will happen when demands are placed on academic institutions to offer appropriate levels of education and training and when value is placed on this segment of the public health workforce.

Public health must evolve into a 21st-century enterprise that is capable of long-term sustainability. Being categorized for the most part as a public good does not erase expectations of long-term sustainability supported with nongovernmental revenue sources. Reliance on financing models that originated in the 19th century will not translate into 21st-century sustainability.