Question

What is a key social determinant of health outside the health sector which affects your community? How might public health professionals work with this sector to improve health outcomes?

Answer 1

1.  Action on the social determinants of health (SDH) is required to reduce inequities in health. ... Political, economic and resource distribution decisions made outside the health sector need to consider health as an outcome across the social distribution as opposed to a focus solely on increasing productivity.There are a growing number of initiatives to address social determinants of health within and outside of the health care system. Outside of the health care system, initiatives seek to shape policies and practices in non-health sectors in ways that promote health and health equity. Within the health care system, there are multi-payer federal and state initiatives as well as Medicaid-specific initiatives focused on addressing social needs. These include models under the Center for Medicare and Medicaid Innovation, Medicaid delivery system and payment reform initiatives, and options under Medicaid. Managed care plans and providers also are engaged in activities to identify and address social needs. For example, 19 states required Medicaid managed care plans to screen for and/or provide referrals for social needs in 2017, and a recent survey of Medicaid managed care plans found that almost all (91%) responding plans reported activities to address social determinants of health.

Social Beterminants of Health Economic Stability Education Food Health Care System Neighborhood and Physical Environment Housing Transportation Community and Social Context Social integration Employment Hunger Health coverage Income Literacy Language Early childhood education Access to healthy options Expenses Support systems Provider availability Safety Parks Debt Medical bills Support Vocational training Community engagement Discrimination Playgrounds Walkability Zip code / geography Provider linguistic and cultural competency Quality of care Higher education Stress

2

Public health functions and agencies exist on the federal, state and local levels. The division of responsibilities and authority varies considerably by state. Nevertheless, at each level of government, the public health agency is responsible for the following essential health services:

• collecting and analyzing health status and utilization information;
• developing policies and policy recommendations to maintain and protect the public's health by building upon the data and its analysis and responding to community values;
• informing the public and policy makers of its analysis and recommendations;
• working to develop consensus on needed action; and
• making sure that necessary public health and personal health services are provided to all.

The agency must have sufficient capacity and financial support to carry out these functions. The Federal Government's Role is to:

• provide leadership, technical assistance, and funds for the nation;
• create national standards as needed and a national framework for their implementation;
• assure national data, monitoring, and surveillance systems; and
• engage in research and epidemiological studies.

National funding can provide resources necessary for improving the public's health as well as assurance of equity across all the states, so that a person's health doesn't suffer because of his or her place of residence. Past federal funding has concentrated on categorical programs intended to deal with specific problems. Some of these programs have been very important and successful.

However, categorical programs are competitive and not available to all communities. Reliance on such single-focus programs for financing has sometimes left public health agencies with insufficient resources to deal with health threats not included in those categorical programs, and little funding for broad health promotion and prevention efforts. Broader funding, such as a general operations budget, is necessary at all levels to provide the public health system with ongoing capacity to monitor, anticipate, and respond to health problems.

Public health services should be considered part of the social safety net which is the responsibility of government to provide for all people. Stable funding is also necessary. One way of ensuring stable funding is by requiring organizations and institutions paying for personal health services to support public health in proportion to the amount they spend on personal health care.

State governments have carried a major responsibility for governmental health activities. The scope of these activities, and the organizational entity within the state government responsible for them, varies from state to state. Variation among the more than 3,000 local public health agencies is even greater.1 They range from large autonomous comprehensive agencies in some major metropolitan areas to small agencies primarily in rural areas. Several political jurisdictions may be served by a jointly sponsored multi-county or city-county agency. The relationship of these agencies to their state agencies is complementary, and varies widely. The local health agency's scope of programs is generally more limited than the state's and the extent of its autonomy varies, although local health agencies remain the point of service for most public health programs and functions.

IV. Action by the Public Health Community
APHA and the public health community should encourage and assist in:

1. Defining the role of the government with respect to health and strengthening the role of federal, state, and local health agencies.

A stronger government health system which ensures the provision of essential public health services and works actively with the personal health system to promote and protect health will result in improved health and cost efficiency across the nation.

The federal government must:

• provide standards and guidelines;
• conduct research and disseminate its findings;
• ensure equity across states; and
• develop priorities for the nation.

Federal, state, and local public health agencies must:
define standards for public health that improve the overall health of the population and provide strategies for achieving greater health system efficiency and effectiveness;

• promote the most efficient methods of public health action based on the political and health traditions of each particular state or locality;
• have a specific role in monitoring health effects and advising policy makers on the effectiveness of programs in meeting health objectives;
• develop innovative and effective public health programs supported by research-driven questions that are directly applicable to meeting public health needs and by evaluation studies which provide support for program planning and quality improvement;
• be funded at the several levels necessary for performance of their responsibilities; and
• provide leadership for the creation of comprehensive health records and mechanisms which assure shared utilization of data by private and public sector providers and by community-based groups so as to facilitate: disease surveillance and assessment of progress toward meeting prevention goals, evaluation of utilization patterns, quality of personal health services practices and health outcomes, and the identification of gaps in health care access.

1. Establishing a leadership role for the public health community in decisions that shape the personal health care system and models of health care delivery.
2. New ways of making policy and of organizing the purchase and delivery of personal health care are needed, and public health officials should have a major role in developing them to ensure health promotion and prevention. This requires a central role in the allocation of capital resources and in ensuring the adequacy of the primary care infrastructure and the distribution of adequate primary care personnel to currently underserved areas.
3. State and regional health planning should draw together the public and private sectors in a collaborative model that is publicly accountable. State and local health agencies should articulate the division of labor between agencies. State and local health agencies should collaborate with purchasers and providers of personal health care and with community-based organizations representing ethnic and other minorities, women, and vulnerable groups to assure that health plans and health delivery are culturally sensitive and are appropriate to meet population needs. Working with the private sector, public health agencies must define standards to ensure high quality services are provided to all populations, and encourage a phased redistribution of resources from illness to preventive care with targets and timelines.

Existing models need to be utilized and new models need to be developed that go beyond the provision of personal health care to enhance the health status of populations. These models require particular emphasis on culturally sensitive personal health delivery systems. One such model is Community-Oriented Primary Care (COPC), which designs and evaluates community health interventions as an integral part of the provision of primary medical care. Many community migrant health centers and other models of integrated practice have developed COPC practices in which personal health services and public health interventions are combined in one organizational model. Such programs have great potential to develop more effective health promotion, social support, and personal health care approaches to all populations.^5-9

Even when there are no financial barriers to care, private providers may not meet the needs of all residents or provide the special services and expertise required by high risk populations that are now offered by many public health programs and agencies. Local public health agencies and other community-based organizations may therefore need to continue to serve the needs of these persons, in addition to the agencies' broader role in the health care system as a whole. Particular attention must be paid to assure personal health care for indigent persons not eligible for Medicaid.

V. Methods of Implementation
APHA should play an active role in:

1. Educating public health workers, public and private sector policy makers and leaders, health service payers and providers, and the general public about essential public health functions to be performed by federal, state, and local governments and the private sectors, and their implementation and effectiveness around the nation.
2. Encouraging the training of public health professionals to participate in influencing public policy.
3. Encouraging academic health centers to emphasize the teaching of concepts, skills, and attitudes about prevention and coordination to students of the health professions and research to document the cost effectiveness of prevention.
4. Providing technical assistance and encouragement to public health workers to actively participate in national and state health reform efforts, articulating the appropriate role for public health in such efforts.
5. Advocating funding for essential public health services.
6. Advocating a strong infrastructure that will be capable of implementing the roles and responsibilities described in this position paper.