The public health system rests at a critical juncture. The simultaneous decline of the public health infrastructure and the failure of the private sector to embrace public health responsibilities have created a dangerous void in the availability of public health services. If this trend is not addressed or reversed in the near future, it will become difficult to reconstruct important aspects of public health assessments, public health policy development, and assurances of services. Few qualified professionals will be willing to commit their careers to a system in decline.
If this admittedly melodramatic depiction is reasonably accurate, it leaves public health professionals and advocates in a quandary. Ideally, I suspect, most would like to retain and strengthen the current government based system. But pragmatically, that may not be a strong option right now. Torn between an unrealistic ideal and a set of uncertain or unattractive alternatives, how should we proceed?
The three articles in this section accurately reflect the current thinking about how to organize and deliver public health services. Taken together, the articles represent an important view of the current status of public health administration and practice in the United States. In these articles and the Turning Point Initiative, the goal is to strengthen public health agencies by developing alternative structures with collaborative links to strong private sector and community entities. But if not defending a complete shift of public health services to the private sector, the articles certainly leave little room for a resurrected public approach.
At present, I disagree with this strategy, though it is certainly a defensible approach that deserves to be heard and debated. To a pragmatist, these demonstrate a desirable and creative response to a dire situation. At the same time, it is a distressing confirmation of the decline of the traditional public health infrastructure. For example, the Virginia random survey showing how little the public knows about the public health system is quite disturbing.
Yet I wonder whether the focus on developing alternative structures is the right question. To be sure, these alternatives may be somewhat independent of the political process, as suggested in each article, and also may be more efficient than traditional governmental agencies (though they have not been evaluated to date). Let's assume for now that both are true. What difference will that make for public health? In short, one can support the need for alternative approaches while remaining skeptical that the new structures will address public health's underlying ailments.
The rush to accept public-private partnerships as the best alternative assumes that a new public health structure, regardless of functional needs, will achieve better public health outcomes. Perhaps so, though the failure to ask and resolve certain basic functional questions before deciding on structural change leaves me somewhat uneasy. Form follows function is a standard mantra in architectural design. It makes sense to think first about what a building is attempting to achieve functionally in order to make the design meet the functional needs. In public health, however, the current mantra seems to be function follows form.
To put the matter more bluntly, even the most effective alternative structures only can address the margins of the core public health problems. Before deciding how the system should be structured, we need to resolve some basic functional questions. What, for example, are the core public health services that only can be provided through the government? How can the public sector most efficiently be organized to provide those services? If the public sector no longer can supply the public health services previously provided, what is the range of alternatives that should be considered? What functions can be turned over safely to the private sector? What role will public health professionals play in a public-private partnership? How will public health services delegated to the private sector be monitored and evaluated?
The articles in this section were not designed to address these questions. My concern is that we have accepted an alternative with unknown consequences for public health management and practice before we have considered other options adequately. For instance, if public health services are to become a private sector responsibility, we need to determine whether to encourage the formation of not-for-profit entities or to encourage a competitive for-profit enterprise.
Partnership is indeed one viable alternative, but what constitutes a partnership? Will public-private partnerships be essentially one-time collaborations over specific issues (such as contracting for Medicaid managed care) or will they emerge as permanent community-wide entities? The Public Health Institute (PHI) concept described in the Louisiana article (and operational in other states) is one such entity.
At this point, however, it is not clear what these institutes are designed to achieve and whether they will divert needed resources from actual service delivery and simply emerge as facilitators without political influence or power. Is there a danger that PHIs (as a general model) will end up serving their own ends (i.e., more research funding, larger budgets) at the expense of diverting public health resources to other uses? In any event, it is quite likely that they will be in no better position to advocate for public health than any traditional public health department.
Indeed, it is not altogether clear what the private sector's incentives are for participating in these partnerships. Will they co-opt public resources without providing adequate services, leaving a void? Or will they simply overwhelm the public sector, only to abandon the field when it becomes inopportune? After the public sector is dismantled, it will be very difficult to put back together. It is hard to imagine sustaining a committed public health professional workforce under these conditions.
Citrin 1 warned about the dangers of public-private partnerships because public health will then be seen as just another commodity to be provided by the private sector. Burris 2 warned against excessive devotion to pragmatism among public health advocates because that does little to change social attitudes that currently tend to marginalize public health. Both argue that public health resides in the notions of community and should aspire to achieve social justice and reaffirm its social mission as a manifestation of community.
Despite these legitimate concerns, public health advocates may have no choice but to accept the reality of public-private partnerships. In a world where investment in public health is eroding slowly and where private sector solutions are favored by policymakers and the public, reversing the trend toward more private sector involvement will be challenging, to say the least.
As a practical matter, therefore, public-private partnerships will be an integral feature of public health practice and management for the foreseeable future. How should public health advocates respond? Diverse strategies must be pursued simultaneously.
First, it is necessary to mount a comprehensive media campaign to remind citizens of the fundamental importance of public health to the community. To their credit, several national public health organizations have embarked on such a campaign. Public health professionals and advocates need to support and participate in this effort.
Second, as Jeffrey Wasserman and I recently suggested in the Journal of Public Health Management and Practice, the public health voice has been ineffectual in legislative policy debates. 3 As a complement to the American Public Health Association's (APHA's) media campaign, it is important for public health professionals and advocates to strengthen public health advocacy efforts, particularly at the state level.
Third, it is incumbent on public health professionals and advocates to insist that the public-private partnerships actually provide the promised public health services rather than becoming a device to submerge these services. To do so, public health agencies must monitor how the partnerships work and evaluate the results. Independent evaluations will be critical to determining whether the partnerships have achieved their goals or are undermining public health surreptitiously.
Fourth, public health advocates must participate in the governance structure of the public-private partnerships. It is not sufficient for advocates just to be consulted or be members of advisory committees. Actual participation may be a countervailing force against private sector dominance over the partnerships.
Fifth, public health advocates and professionals must explore a range of alternatives to secure public health and to address the questions posed above. We need to define clearly those services that must be provided by government and develop effective strategies for reinvigorating the entirety of public health.
Sixth, foundations and the government (especially the Centers for Disease Control and Prevention) should fund research and thinking to develop alternative structures for public health. If the model that we've had for the past century is no longer viable, what should replace it? A wide-ranging debate over these alternatives is overdue.
At its core, public health remains a collective enterprise based on an understanding of community, while private health care remains an individual enterprise dependent on a different disease model. Combining the two in some creative way to integrate both an individual and a community perspective remains an ambitious goal, though one that is certainly worth striving toward and one that the partnerships might help shape. In the meantime, it is important not to abandon the ideal of public health without some assurance that what replaces it will not be subsumed by a model based on the antithesis of the community.
The proponents of public-private partnerships have not made, in my view, a compelling case for this as the dominant public health model. But public health advocates and professionals also must recognize that the current strategy is not working to restore public health to its proper place in American policy. New strategies and approaches therefore are needed urgently.
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