Before discussing the specific activities of PHLs, it is first important to characterize the larger public health infrastructure in which PHLs reside. In a 1988 report entitled The Future of Public Health by the Institute of Medicine (IOM), the report attributed many of the major improvements in the health of the American people to the success of public health measures.2
The services and functions provided by national, state, and local public health agencies cover a broad range of population-based activities and direct personal services. The value of a strong public health infrastructure has been realized in the decline of communicable diseases such as syphilis, improvements in the nation's drinking water, and increased awareness of the importance of environmental health issues.
The public health infrastructure is comprised of an extensive network of federal, state, and local health agencies. On the national level, the agencies of the Public Health Service (e.g., CDC, Health Resources and Services Administration, Indian Health Service), provide federal leadership through policy development and funding. At the next level of government, state health agencies (SHAs) serve as the major link between federal health priorities, funding, and the local delivery of personal and population-based health services. Regardless of their organizational structure, SHAs have a responsibility for ensuring core public health services either directly or in coordination with local health departments. Local health departments and agencies provide the most direct level of public health service through the provision of direct health care services and the support of population-based public health activities.
The public health community has identified three core functions of public health agencies: assessment, policy development, and assurance. The IOM report on the future of public health recommended that public health agencies should be responsible for conducting the following three core functions:
- Assessment: Each public health agency should regularly and systematically collect, assemble, analyze, and make available information on the health of the community, including statistics on health status, community health needs, and epidemiologic and other studies of health problems.
- Policy Development: Each public health agency should exercise its responsibility to serve the public interest in the development of comprehensive public health policies by: (a) promoting use of the scientific knowledge base in decision-making about public health, and (b) leading development of public health policy. Agencies must take a strategic approach that is developed on the basis of a positive appreciation for the democratic political process.
- Assurance: Each public health agency should assure its constituents that services necessary to achieve agreed upon health goals are provided, either by encouraging actions by other entities (private or public sector), by requiring such action through regulation, or by providing services directly. Also, public health agencies should involve key policymakers and the general public in determining a set of high-priority personal and community-wide health services that governments will guarantee to every member of the community. This guarantee should include subsidization or direct provision of high-priority personal health services for those individuals who cannot afford them.
The structures and functions of state and local public health agencies vary greatly. The organizational relationships between local health departments and state health agencies range from independent local health departments that have contractual and financial relationships with an SHA, to local health departments that function as sub-units of an SHA. Although most public health agencies perform some personal and population-based health services, the extent to which public health agencies perform these two types of services differs among states and, in some cases, localities. For example, some states, such as Minnesota, have focused their public health activities on population-based health services (i.e., disease surveillance, health education, and community action planning). Other states, such as Tennessee, have a broader focus on direct health services, investing their resources and personnel into the provision of personal health care.