The State of Public Health in Kansas for the Governor’s Public Health Improvement Commission and the Kansas Department of Health and Environment, 1999.

Edwin Fonner,
Jr., DrPH

edfonner@gmail.com

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The objective of the state’s public health improvement initiative is to implement a plan that ensures the state’s health departments, hospitals, physicians, and other public health providers will be able to protect and promote Kansans’ health in the 21st century. The Governor’s Public Health Improvement Commission created a plan describing the infrastructure needed to improve population-based health, establishing priorities for implementation, and identifying a strategy for financing proposed changes.

Public health includes the individual competencies (e.g., skills and literacy levels), organizational capacities, and community resources that keep people well and provide for a high quality of life and sustainable natural resources. The mission of public health in Kansas is to fulfill society’s interest in assuring conditions in which Kansans can achieve optimum health. The goal of the Governor’s Commission is to make Kansas an attractive and healthy environment for families, workers, and businesses. Emphasis is placed on disease prevention and addressing the root causes of illness and disability affecting all Kansans.

Government agencies are a major source of funding and serve as a foundation for public health decision-making. Broadly defined, local government public health includes health departments, schools, public works, hospitals (especially those governed by cities, counties and hospital districts), and other related tax-based organizations. Beyond government agencies, a broad array of public and private sector organizations play a major role in maintaining and promoting the health of the public. Medical care and individual health services play an invaluable part in prevention and education.

Evidence Points to Needed Improvements. In Kansas, as in many areas of the United States, there are significant and growing numbers of citizens with chronic diseases, families lacking basic health insurance, an aging population (especially in rural areas), and more severe and frequent health problems among minorities than in the general population. The state’s system for public health and prevention, as presently constructed, is unable to keep up with the population’s burden of disease. Inadequate surveillance, a core function of public health, impedes a more detailed picture of the health of Kansans.

Coordination of services is limited because there are few incentives for independent agencies and organizations to work together. The roles and responsibilities of different agencies are poorly defined. Communications across professional groups is limited. Data on what cooperative efforts are working are scarce. Access to coordinated services by the poor is extremely limited.

Many local health agencies and indigent clinics are experiencing acute financial difficulties due to rising patient loads, poor farm economies, declining fee income, and the effects of the Balanced Budget Act of 1997. State and local funding for public health in Kansas is below the U.S. average and is inflexible and limited in scope. Improvements in public health education are being made and need to be expanded as a means of attracting workers to Kansas health professions. Health information systems are under-funded and population health data are inadequate, and not timely. The 1,080 public health statutes bear careful examination for the purpose of updating our statutory base.

The framework for policy-making and coordination of planning beyond agency and normal organizational boundaries is minimal. Most health departments serve small population bases and operate without a set of standards to evaluate performance. Authority, structure, and linkages between state and local health departments are not clearly spelled out. Leadership continuity has been limited.

Vision of System Improvements. A vision of an improved public health system must reflect local needs and benefit the state’s residents in the following ways:

O Meet national health objectives – Significant progress must be made toward meeting and exceeding health objectives set forward in Healthy People 2000 and expected in the document’s next edition, Healthy People 2010.
O Touch more lives – There must be broad access to appropriate and affordable care for everyone living and working in the state;
O Target resources to greatest need and public benefit – Disparities in health status of minorities must be eliminated or reduced;
O Empower and reward personal responsibility – The public must be informed so they can make better personal health decisions;
O Slow the advance of health problems and flatten demand – The root causes and economic disincentives to illness must be minimized or eliminated;
O Foster civic pride and economic development – Conditions must be in place for a healthy, well-educated workforce and for economic opportunities for those able to make a contribution;
O Ensure trust in leadership – Confidence in the performance and ability of leaders to accomplish community objectives must be restored and enhanced.

The Commission’s vision includes an infrastructure with the following attributes:

A Solid Foundation:
O Adequate Resources – There must be sufficient capacity and flexibility in use of resources for preventing illness and promoting health in the population;
O Efficient & Effective Administration – Organizations must be streamlined, open to process improvements, and oriented to reducing duplication of service and effort;
O Competent Workers – The workforce must adopt a sense of worth, cultural sensitivity, and be prepared for present and future challenges;
O Solid Statutory Basis – Laws and regulations must be up-to-date, relevant to state and local needs, and contain clear authority to perform functions.

Basic Functions and Essential Services:
O Statewide Strategy and Tactics – There must be consensus and a clear sense of direction in the strategic thinking of organizations playing a role in public health;
O Defined Roles and Accountabilities – Responsibilities must be clearly defined and bring about enhanced coordination among providers;
O A Clear Window into Population Health – A policy framework must be fed by comparative data describing health status, burden of illness, and disability;
O Effective Public Communications – The media must be more consistently informed and channels developed for informing the public on health affairs;
O Responsive and Appropriate Services – A range of accessible services must be made available to all Kansans and targeted to segments with specific needs.

Motivated and Consistent Leadership:
O Technical Assistance and Resource Sharing – Special competencies, information, and other assets musts be readily shared among public service providers;
O Information Products and Analysis – Products containing accurate and timely information and in-depth analysis must be available to decision-makers;
O Mentoring and Education – Programs to inspire leadership, transfer solutions, reduce conflict, involve more staff, and leverage expert knowledge must be available to providers and community support group leaders;
O Advocacy and Partnering – Groups of leaders must apply resources collectively to solve community problems, and transmit the enthusiasm and joy of working productively together to meet common aims;
O Innovation for a Healthy Population – Leaders must be willing to allocate resources to demonstrations and pilot projects leading to innovation.

Recommendations and Goals for Kansas Leaders. The following recommendations comprise the change events that the Governor’s Commission believes will lead to an improved public health system in Kansas.

Recommendation One: Leadership and governance: Institute a statewide, continuous public health planning and development process.

The Commission recommends the establishment of a State level board for policy setting and strategic planning to guide change processes. This board, the Public Health Policy and Planning Forum, will facilitate communications, cooperative planning, and coordinated program implementation. It will provide the vision, set policy, allocate resources, and evaluate progress. It will look out 10 to 20 years, take a broad perspective on the determinants of the public’s health, work from a technically sound basis, and serve the Governor and Legislature on policy and planning issues. It will serve as that single voice for public health with a constant agenda to provide strong support for disease prevention and population-based services.

Representation on the Public Health Policy and Planning Forum will be multi-disciplinary and regionally distributed. Mechanisms will be created for broad input from local, regional, and state stakeholders. Goals include:

Goal 1: Adopt and promote a set of principles of health and environment that create a framework for policy, resource allocation, and coordinated implementation of health improvement initiatives.

Goal 2: Convene an-going process to plan and develop initiatives based on a common framework and set of objectives as outlined in Healthy People 2000.

Goal 3: Establish a subcommittee working toward "zero percent disparities" in the health status of minorities compared with the general population.

Goal 4: Clarify roles and responsibilities in the state public health system fostering cooperative work and communications among agency Secretaries, regional and local public health agencies, and health care systems.

Goal 5: Review statutes related to public health on an on-going basis and make recommendations to the Legislature for revisions.

Goal 6: Tie the Health Care Data Governing Board and related data-based organizations to the statewide policy and planning process so community health assessment standards will be set, benchmark data delivered, technical assistance provided to partnerships, technology synchronized, and information exchange promoted.

Goal 7: Track public health systems change in Kansas, evaluate progress, and report results to the Governor, the Legislature, and all Kansans.

Recommendation Two: Stabilize funding and enhance capacity: Improve essential public health services and population health by increasing and stabilizing financial resources and allocating state funds for local community health improvement initiatives.

Goal 8: Fill existing gaps in essential public health services by creating a long term, stable funding stream for local public health initiatives. Evaluate capacity and identify gaps at the state and local levels using the ten essential public health services model.

Goal 9: Increase public health expenditures to approach the U.S. per capita average as an initial benchmark until data are available to better determine actual and projected demands on the state’s health services system. The initial benchmark is $5 per capita compared to the present level of $3. Consideration should be paid to earmarking funds from “sin taxes” for public health and prevention.

Goal 10: Stimulate broad resource reallocation by linking local public health revenues to tobacco settlement funds, Title XIX, Title XXI, and other government sources. Combine funds for similar prevention programs in different agencies to achieve a greater impact. Identified ways to channel money from personal health services to population-based approaches where prevention reduces the demand for these services.

Goal 11: Fund sustainable, innovative pilot programs designed to improve access to preventive services and basic health care for children, elderly, and poorly served populations and to enhance working relationships among local healthcare providers.

Goal 12: Streamline business process to enhance local agency flexibility and pass through more resources to the local level (i.e., administrative simplification). Simplify budgeting and other administratively intensive processes.

Recommendation Three: ffective delivery: Develop and enhance a statewide network for delivering professional education, workforce initiatives, communications, and public health-related services.

The Commission recommends utilizing existing local agencies and providers to establish a more clearly defined statewide public health network. The Commission believes that the key is not if we should, but how we should connect all of the pieces together. The aim is to provide Kansans with (1) an optimal mix of prevention and primary care services, (2) a clearer understanding of how public health works, and (3) a better means of communicating, sharing resources, and coordinating services so that the public knows how to access their resources. Such a system will be established by pursuing these goals:

Goal 13: Establish workforce education programs for basic public health, continuing education, and credentialing to broadly support the entire public health workforce.

Goal 14: Develop and coordinate delivery of public health training programs across educational institutions utilizing distance learning technologies.

Goal 15: Proactively set standards and guidelines for evaluating state and local public health functions, services, and performance.

Goal 16: Design and develop a regional structure for distributing information, providing technical assistance, and accessing coordinated services. Decentralize state agencies where possible to improve responsiveness and local presence. Encourage local cooperative work with shared services agreements. Use existing regional structures to improve service. It may be possible through cooperative agreements to combine or better coordinate public health administrative functions on a regional basis.

Goal 17: Facilitate the development of a more effective forum for communications, decision-making, and more unified delivery of health services, education, and research among state, regional, and local public health providers.

Goal 18: Enhance the public’s knowledge of public health by improving public communications on health initiatives and strengthening ties with mass media.

Benefits. This plan has the potential to produce these benefits:

O Unity of Purpose and On-Going Dialogue – Leaders will have a clear picture of how and where to move forward. Continuity of leadership will be fostered.
O Measurable Objectives – A tie to national health objectives will improve uniformity of health data and comparable community health assessments.
O Serious Gaps in Health Status will be Addressed – The health status of the underserved and minorities will receive dedicated attention.
O Diversity and Partnerships will be Encouraged – An example will be set for how an effective partnership functions on the basis of inclusion, diversity, and inter-disciplinary communications.
O Sound Statutory Basis – Progress will be made on establishing a sound and relevant statutory basis for public health.
O Performance Evaluation – Leaders will be informed about progress made. Change efforts will be better synchronized.
O Focusing on Root Causes to Poor Health – Policies will address the root causes of disease and disparities in the health of the population.
O Stable and Enhanced Funding to Reduce Demand and Preventable Illness – There will be a level of readiness to respond to outbreaks of communicable diseases and threats to the environmental.
O An Explicitly Defined System of Care - State and local agencies’ capacity to deliver appropriate population-based and personal health services to persons in need will be strengthened. The clinical care sector will be more supportive given clearer linkages with population-based agencies.
O Improved Communications and Cooperation - A forum for communications will facilitate unified service delivery, educational programs, and research among the state’s public health organizations. Messages conveyed in an understandable way through the public media are critical to improving our population’s health.
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