September 11, 2001, brought renewed resolve to the effort to improve public health surveillance and infrastructure (Madamala et al., 2011). The anthrax attack that same year solidified interest in improving public health population-based functions. Federal funding past 9/11 increased in the area of disease surveillance and emergency preparedness. However, in subsequent years between 2002 to 2006 federal monies were reduced (Landers, 2007). Starting in 2007 federal funding improved again. For example, in 2007 state health departments received approximately $896.7 million in federal funds to prepare for and respond to terrorism, infectious disease outbreaks, and other public health threats and emergencies (U.S. Department of Health and Human Services [USDHHS], 2007). Funding levels remained stable for 2008 to 2009 at $861 million and at $842 million for 2010 with the focus moving toward law enforcement (U.S. Department of Homeland Security [USDHS], 2008, 2009, 2010).

All 50 SHAs indicate persistent problems with resource allocation, staffing, and surveillance (National Governors Association [NGA], 2004, 2007). The federal government has added responsibilities for emergency preparedness to SHAs without consistently funding these responsibilities. The CDC (2011b) has issued a national strategic plan for preparedness that has added additional preparedness responsibilities to state and local health departments. As a result, SHAs have had to reassign resources and personnel from other program areas, thus reducing services in those areas (Bashir et al., 2007; Morbidity and Mortality Weekly Report, 2009). This has exacerbated problems inherent in public health services and programs. The Institute of Medicine (IOM, 2003) issued a second study titled The Future of the Public’s Health in the 21st Century, which provides additional recommendations for strengthening the public health system in the United States. The CDC (2000) status report to the U.S. Senate indicated the following three critical areas for improvement necessary to strengthen the public health infrastructure:

Most funding for SHAs comes from public tax dollars provided by the state and federal government. States vary in the degree to which they fund public health and population-focused activities. Public health expenditures are a small percentage of state spending. In 2009 public health expenditures for all activities including SHAs were $65 billion. Public health expenditures represented only 4.3% of the $1.5 trillion spent by all states in 2009 (CMS, 2011a; National Association of State Budget Officers [NASBO], 2010).

State budgets for health and welfare programs have been squeezed by several factors. In the past 3 decades, federal funding to SHAs has been reduced and concentrated in block grants. This action by the federal government was intended to give states more control over their programs as well as put limits on federal spending for health and welfare programs. In actuality, states have experienced a reduction in the proportion of federal funding provided for state health and welfare programs and additional constraints on how federal funds are spent (Fee & Brown, 2002; Chapter 4). Turnock (2009) reports that block grants resulted in a 25% reduction in federal funds to state and local health agencies. Funds for public health activities were included in the reductions in federal support. At the same time, state sources of money (the state tax base) were strained. State income sources have not kept up with state responsibilities, because of a downturn in the economy and as a result of tax reform efforts and pressures to improve disaster preparedness and response (ASTHO, 2010; Madamala et al., 2011; NACCHO, 2007). Consequently, SHAs have experienced budget cuts and staffing reductions, and have had to reduce services to individuals and communities.

An LHD has been defined by the National Association of County and City Health Officials (NACCHO, 2009, p. 3) as “an administrative or service unit of local or state government concerned with health and carrying some responsibility for the health of a jurisdiction smaller than the state.” There are five major types of LHD: county, city, city-county, township, or multi-county/region. County LHDs are the most common type. City health departments are the least common. Multicounty health departments span large geographical areas and are more common in the western United States. For example, the Northeast Colorado Health Department serves six counties in Colorado. Website Resource 29A

provides several examples of the organizational charts for different types of local public health agencies (LPHAs).

NACCHO reports the following information concerning LHDs:

The funding source for LHDs is a combination of local, state, and federal funds (Figure 29-4). In addition, LHDs may collect fees from clients who receive direct personal health care services and from regulatory or licensing fees. For example, a health department responsible for inspecting restaurants to ensure food safety may collect fees as part of the food permit process.

Budgets for LHDs range from less than $25,000 to more than $5 million (NACCHO, 2011a). LHD budgets represent less than 1% of the total national health care budget (see Chapter 3). Local public health costs are estimated at approximately $36 to $48 per community resident (NACCHO, 2011a). For the most part, LHDs that serve larger populations have bigger budgets and are more reliant on state and local funding and less on Medicare and Medicaid (Figure 29-5). Thirty-one percent of all LHDs have budgets of $1 million or less per year (NACCHO, 2011a).

Local health department costs—salaries, supplies, equipment, and benefits—increase annually. However, the amount of appropriations often remains the same over time or is reduced. Thus, the degree to which this money actually supports local services is decreased (NACCHO, 2010a). In the difficult economy of the late 1990s through the early 2010s, the demand for public health nursing services has increased. Local health departments are continually challenged to be innovative, creative, flexible, and available.

At one time, LHDs tried to avoid having nursing and/or other staff on time-limited, or “soft,” money, but currently, staff may be paid by two or three funding sources. This is where the full-time-equivalent factor enters the equation. Community health nursing administrators address difficult questions as they modify budgets. What components of a perinatal or child health program can be financed by other money when a funding source ends or decreases? When child health funds do not keep pace with costs, how can sufficient child health services be incorporated into the Women, Infants, and Children (WIC) program? Similar questions arise for all public health nursing services. With flexible hours and flexible staffing, two part-time employees can fill a full-time position. If possible, other types of employees, such as nursing assistants, may be hired to perform nonnursing tasks and allow more efficient use of nursing time.

Both federal and state legislatures and agencies are skilled at passing health-related bills or issuing health-related directives without appropriate funds to implement the program. One example involves the use of the WIC program to monitor childhood immunizations. Studies indicate that linking WIC and children’s immunization services is an effective strategy (Briss et al., 2000; Hutchins et al., 1999). Children seen for WIC services were reviewed to determine immunization status. Those found deficient were either immunized at the WIC center or referred to other sources for immunization. The costs of providing these services at each WIC site ranged from $19,500 to $60,300, depending on staff requirements. The preliminary studies were done with grant money. In 2000 a presidential directive required the WIC program to implement immunization screening and referral at all WIC sites (Shefer et al., 2002). In 2010 the U.S. Department of Health and Human Services directed states to provide Medicaid coverage for tobacco-cessation counseling and drug therapy for pregnant women (NACCHO, 2010b). No additional money was allocated for the additional staffing and administrative requirements for either directive.

Public health employees are becoming more effective working with legislators. Public health nurses, environmentalists, administrators, and other staff working with programs such as substance and alcohol abuse, human immunodeficiency virus (HIV) testing, and acquired immunodeficiency syndrome (AIDS) case coordination organize networks to initiate, support, or oppose legislation that will adversely affect LHDs and communities. For example, in a number of states, public health professionals have been highly effective in guiding and supporting specific HIV testing and AIDS legislation. The bills afford protection for health care workers by the availability of HIV tests and employment security if that test is positive. Public health advocates have been equally effective in opposing broad AIDS legislation that would compromise an individual’s privacy, employment, and/or health insurance coverage (Roseau & Reomer, 2008).

Medical personnel and health services are often concentrated in urban areas and in group medical practices in the United States. Group practices afford individuals access to the care they may need, be it family medicine, internal medicine, or another specialty represented in a group practice. This sounds beneficial to the client. This geographical maldistribution of physicians has led to inner-city and rural areas being medically underserved, although there has been a slight improvement in physician supply in rural areas (Smart, 2006). These areas may attract only the single-specialty physician, who may practice alone in communities with great needs. Some communities with populations of 15,000 to 30,000 have only one physician. Even the state health department may not have clinics in inner-city areas or some rural communities. Transportation problems and appointment times that conflict with employment can be added barriers (see Chapter 32).

Public health nurses in rural communities and city health departments provide wide-ranging wellness care and health screening to detect potential problems. An important component is education regarding health-promotion and lifestyle adaptations that reduce risks to good health. Nurse practitioners monitor and/or treat illnesses and chronic diseases depending on the support of the department’s medical director and on community needs. Because most public health nurses are long-term residents of their community, they know their community.

Some state health departments, through maternal and child health programs, may provide itinerant multidisciplinary teams of specialists for diagnosis and treatment of infants and children with disabilities. The local public health nursing staff provides follow-up, case management, advocacy, and continuing family and client support and guidance.

Since 9/11 emergency preparedness is a critical focus of all levels of government including SHAs and LHDs (see Chapter 22). In response to the CDC (2011b) and the USDHS, LHDs have implemented or improved in three areas: emergency preparedness, emergency exercises, and workforce development.

In 2008, 82% of LHDs had emergency response plans in place as compared to 20% in 2001. In addition many have advanced plans for rare but potentially lethal attacks such as smallpox, anthrax, and pandemic influenza (NACCHO, 2008). Most LHDs (86%) have conducted drills/exercises to test out personnel, equipment, and communications systems (CDC, 2008a). Workforce development has been slower and needs significant improvement. Only 36% of LHDs have completed a needs assessment for personnel and 60% report they do not have enough personnel dedicated to preparedness efforts (NACCHO, 2008). The funding problems discussed earlier at both the state and local levels have slowed progress in all three areas listed above.

In the early 1980s, as a response to increases in the number of medically uninsured and underinsured people, more health departments became directly involved in providing primary care services. Starting in the early 1990s, LHDs began to reassess and redefine their role in health care delivery in line with the IOM recommendations. A renewed focus on population-based health services has resulted in a reduction in direct personal health care by LHDs. Today, LHDs still provide direct care, although many are attempting to redirect these types of services to other organizations such as managed care (Gollust & Jacobson, 2006). For example, the state of Maryland redirected its well-child and sick-child care to specially contracted managed care organizations. The managed care organizations are paid to provide specific screening and immunization services for well-children. They also provide specific illness and rehabilitative services up to a certain dollar amount for children with health problems. Some of the state and local public health nurses act as case managers to oversee and coordinate additional services for children with special needs.

Redirecting or eliminating direct personal health care services is influenced by the geographical area and availability of other health care resources. Nonmetropolitan areas are more likely to have problems finding alternative sources for direct care. In 2010, 25% of LHDs provided home health care services to community members, a 30% decline since 1993 (NACCHO, 2001, 2011a). However, twice as many nonmetropolitan LHDs still provide home health care as do metropolitan LHDs.

Figure 29-6 illustrates the types of direct care provided by various LHDs. Aside from screening services, the bar graph shows that personal services are provided by fewer LHDs today than in 1993. For example, HIV/AIDS treatment was provided by 32% of LHDs in 1993, and only 21% still provide direct care in 2010. Family planning services were provided by 68% of LHDs in 1993 and 55% in 2010 (NACCHO, 1995, 2011a).