Public Health as a Problem-Solving Activity: Barriers to Effective Action

Carrying out the public health mission requires systematic identification of health problems and the development of means to solve those problems. The history of the development of this problem-solving capability and its current status in the United States.  the recent evaluation of progress by the U.S. Public Health Service—The 1990 Health Objectives for the Nation (Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, 1986), the committee has identified some appreciable barriers to effective problem-solving in public health. These barriers include:

• lack of consensus on the content of the public health mission;
• inadequate capacity to carry out the essential public health functions of assessment, policy development, and assurance of services;
• disjointed decision-making without necessary data and knowledge;
• inequities in the distribution of services and the benefits of public health;
• limits on effective leadership, including poor interaction among the technical and political aspects of decisions, rapid turnover of leaders, and inadequate relationships with the medical profession;
• organizational fragmentation or submersion;
• problems in relationships among the several levels of government;
• inadequate development of necessary knowledge across the full array of public health needs;
• poor public image of public health, inhibiting necessary support; and
• special problems that limit unduly the financial resources available to public health.

Unless these barriers are overcome, the committee believes that it will be impossible to develop and sustain the capacity to meet current and future challenges to public health while maintaining the progress already achieved. Deaths and disabilities that could be prevented with current knowledge and technologies will occur. The health problems cited in Chapter 1, and many others, will continue to take an unnecessary toll, and the nation will not be prepared to meet future threats to health.

the Lack of Consensus on Mission and Content of Public Health

Progress on public health problems in a democratic society requires agreement about the mission and content of public health sufficient to serve as the basis for public action. There is no clear agreement among public decision-makers, public health workers, private sector health organizations and personnel, and opinion leaders about the translation of a broad view of mission into specific activities the governmental activities that can be described "public health" vary greatly among jurisdictions. This diversity reflects a wide variety of views about the appropriate scope of public health activities among the many publics that must support public health in the political process and through supportive activities in the private sector. Thus, it is difficult to build effective constituencies that extend beyond a particular issue to the support of broad purposes and the necessary continuing infrastructure of public health.

Public Health Responsibility for Indigent Care

Some public health workers are concerned when their agencies serve as providers of last resort for medical care of the indigent, or administer Medicaid or other financing programs. Those concerned see these functions as detracting from essential public health activities such as disease surveillance and control through prevention. One county health officer told us that "when you put together preventive and curative, the latter gets the money, because no one has the guts to say I'm going to emphasize prevention. Sickness care takes precedence."

Others see the public health role in the care of the indigent as essential—at least until other means are devised by society to take care of these needs. In many of our site visits, we were told of overwhelming unmet needs for medical care of the indigent almost three-quarters of state and local health agency expenditures are for personal health services. Many public health agencies have a long-standing focus on the provision of maternal and child health services to the indigent, emphasizing those services that have substantial long-term benefit through disease prevention and health promotion. This maternal and child health focus has been especially strong in a number of public health agencies in the South.