**Core Public Health Functions**

**A National Council of Nursing Position Paper**

**Approved September 1997**

Issue:

The Indian Health Service (IHS) is a public health agency. Its stated
goal is "To raise the health status of American Indian and Alaska
Natives (AI/ANs) to the highest possible level". For a variety of
reasons, the IHS is currently undergoing major changes in size,
structure, and functions. As the implementation of a redesigned Agency
proceeds, the past stewardship responsibility which IHS has maintained
must be considered, if essential public health services for AI/AN
peoples are to remain guaranteed.

Background:

The public health system has a broad societal charge to promote health,
prevent disease and protect the health of the environment and
population. Indian Health Service has historically provided a true
public health model in services provided to the AI/AN population. The
focus of many efforts through the IHS/Tribal/Urban (I/T/U) programs has
been on the AI/AN population as a whole, rather than just on
individuals.

The mission of public health is to "fulfill society's interest in
assuring conditions in which people can be healthy". The substance of
public health includes organized community efforts aimed at the
prevention of disease and promotion of health. It provides a circle of
services, linking many disciplines from the community to the
institution, ambulatory care, outreach and back into the community. It
offers primary, secondary, and tertiary services enhancing its ability
to serve, and utilizing a broad mix of health, education, and outreach
providers, all resting upon a scientific core of epidemiology.

The organizational framework of public health includes both the
activities undertaken within the formal structure of government and the
associated efforts of other public, private and voluntary sectors
(Future of Public Health, 1988).

The public health model is the cornerstone for health care delivery that
is primarily designed to raise the health level of a group of people to
the highest level possible. It encompasses a more comprehensive form of
health care delivery, including determining the health status, needs,
and desires of the population served; developing plans to best meet the
most pressing of those needs; and finally making sure that identified
services are directly provided or provided by others. It is a model that
is defined by how it is organized and implemented.

The [Assessment]{.underline} function is an essential activity required
to determine causes of health problems, to identify unmet needs, to
evaluate health care delivery, and to learn about community perceptions
regarding health service provides. This information has value locally,
but is also used collectively to describe AI and AN health status and to
advocate for resources at a national level.

The [Policy Development]{.underline} function may take place at any
point along the local or national spectrum. Analysis of public health
needs and evaluation of best methods to meet those needs are required.

The [Assurance]{.underline} function includes the processes that ensure
the availability, accessibility and acceptability of services that
provide an environment in which individuals can be healthy.

**PARTNERSHIP:** The public health core functions of assessment, policy
development and assurance are the responsibility of official public
health agencies at all levels of government, Tribal, local, State, and
Federal. Fulfillment of of these core functions is achieved through
leadership by the I/T/Us in partnership with other public, private and
voluntary sectors. Partnerships can directly benefit Tribal communities
and the nation as a whole, by:

♦providing greater unity of purpose;

♦promoting wholeness and cooperation rather than fragmentation and
competition;

♦strengthening communications and links complex systems;

♦fostering collaboration and interdisciplinary efforts;

♦promoting more efficient and effective use of resources;

> ♦fostering the development of essential, accountable leadership to
> improve public health infrastructure to carry out the public health
> functions.
>
> Since IHS was authorized in 1955, it has worked with Tribal
> governments, Tribal health boards, and urban Indian programs to
> produce major improvements in the health of AI and AN people. The
> greatest improvements have come as a direct result of the preventive
> care and other public health services provided to individuals, to
> their tribes, and the communities in which they live.

Discussion:

Two factors that have impeded the public health performance of US health
care system as a whole are [access problems]{.underline} and the
traditional [lack of reimbursement for preventive services]{.underline}
to individuals and even more so for services to communities.

Even in the newer managed care settings where one might expect some
incentive for prevention, the public health model is not commonly seen.
Frequent enrollee turnover is the norm in these care systems. Therefore,
investments in health outcomes that might come 5-10 years in the future,
rarely yield returns for the managed care organization making the
investment.

In contrast, Indian health systems, with their typically long term
client relationships, can more easily justify these important
investments. This, together with their defined responsibility for an
entire community, tribe, or population gives Indian health programs the
opportunity to improve health status to a much greater extent than most
private systems. To do so, the commitment must be made to employ the
public health model.

The public health model uses the concept that the health care needs of a
population are best addressed through an organized, targeted, and
proactive approach. Employing the public health model, a tribe or
community periodically and systematically collects, analyzes, and
disseminates information on the health status, needs, and desires of a
defined population (assessment); prioritizes those needs, determines the
best method to address them (policy development); and then makes sure
that the plan is implemented with the services provided in an effective
and appropriate manner by I/T/Us, States, or other public or private
entities (assurance).

The major causes of morbidity and mortality facing American Indian and
Alaska Native people, as well as all Americans, have been shifting from
problems that can be directly addressed through relatively straight
forward public health services (better and more widespread
immunizations, more effective antibiotics, clean water, better
sanitation services, etc.) to lifestyle related conditions such as
smoking related illnesses, diabetes, domestic violence, injuries, etc.

Very significant improvements have occurred in the health of American
Indian and Alaska Native people through the use of the public health
model by Indian Health Service and other Indian health systems.

# Since 1973:

♦The infant mortality rate for American Indians/Alaska Natives (AI/AN)
has decreased by 54%.

♦The maternal death rate for AI/AN has decreased by 65%.

♦The TB mortality rate for AI/AN has decreased by 74%.

♦The influenza/pneumonia mortality rate for AI/AN has decreased by 50%.

♦Life expectancy for AI/AN has increased by 12.2 years.

> However, unusually high mortality rates remain in several health
> concern areas, and need increasing attention by a public health
> support infrastructure and local I/T/Us.

# Age Adjusted Mortality Rates:

♦Alcohol related death rates are 440% higher in the AI/AN population
than the general population.

♦Accidental death rates are 165% higher in the AI/AN population than the
general population.

♦DM death rates are 154% higher in the AI/AN population than the general
population.

♦Homicide death rates are 50% higher in the AI/AN population than the
general population.

♦Suicide death rates are 43% higher in the AI/AN population than the
general population.

> In order to maintain the impressive advances already made and to have
> an impact on the new areas of concern, we must continue to provide
> services utilizing the public health model rather than merely
> providing individual medical services.
>
> In the uncertain climate of health care reform, we are concerned that
> the IHS and Tribal programs not lose their focus as a public health
> organization, with responsibilities to assist in carrying out the
> unique and ongoing Federal government obligations to AI/AN people with
> respect to their health.

Recommendations

> 1\. Communicate key messages broadly:
>
> ♦[Public Health is a network of essential services that work together
> to keep us healthy and safe.]{.underline} Public health is more than a
> few specific services that serve some people and not others. It is an
> infrastructure of overlapping services that are essential because they
> work together to protect us from a variety of health hazards. Each
> service is important in its own right, but it is the overlapping of
> such services into a unified system which provides maximal value.
>
> ♦[Public Health has a primary responsibility for your community's
> health.]{.underline} This message reinforces the protective aspect of
> public health. It addresses not only the health of individuals and
> families, but that of entire communities. An important aspect of this
> concept is the role of data in monitoring health status and
> documenting progress in combating diseases, injuries, and
> disabilities.
>
> ♦[Public Health is indispensable.]{.underline} Without public health,
> our quality of life would definitely be diminished. We would lose
> confidence in the safety of our environment. We would be more
> vulnerable to preventable diseases. Some examples of public health
> services include:

-   Immunizations

-   Communicable Disease Control

-   Food Handling Safety

-   Highway Safety and Enforcement

-   Air Quality Safety

-   Fire and Police Protection

-   Building Code Regulation

-   Trash and Refuse Requirements

-   Animal Control

-   Lake, Stream and River Safety Requirements

> We would not know as much about the health status of our communities,
> nor would we have the information and expertise to address health
> problems. Without public health services, the costs of treating
> medical conditions, which already account for most of our health care
> expenditures would increase at an even faster rate.
>
> 2\. Increase awareness of public health as a system.
>
> Methods to consider include:
>
> ♦Show public health's benefits to the broader community
>
> ♦Enhance public health practitioners' skills in media advocacy.
>
> ♦Develop relationships with management and editorial staff in local
> media.
>
> ♦Encourage practitioners to portray public health as a system.
>
> ♦Adopt a National Public Health Week to highlight the significance of
> public health as a cornerstone to our Nation's health, and to provide
> opportunities for local versions that build on national media and
> materials.
>
> 3\. Build an understanding of the essential services.
>
> Methods to consider include:
>
> ♦Use familiar public health services to explain essential services.
>
> ♦Make data more relevant to people's lives by becoming a source of
> credible data and interpretation for constituents and community
> organizations.
>
> ♦Emphasize the role of assessment and monitoring health status and the
> resulting data in identifying and responding to health problems.
>
> ♦Translate data into newsworthy language and timely concepts.
>
> ♦Develop and publicize health status report cards (i.e. progress
> reports re: how we are improving the health of
>
> our communities) for all segments of the population.
>
> ♦Utilize breaking news stories about public health crises at the
> local, state or national level to illustrate the essential services
> provided by public health.
>
> 4\. Develop community partnerships.
>
> Methods to consider include:
>
> ♦I/T/U Public Health practitioners need to increase partnership
> opportunities with in-patient staff, medical staff, health education,
> CHRs, EMTs, Headstarts, Schools, etc.
>
> ♦Train public health practitioners in coalition building and
> management.
>
> ♦Train lay public health leaders.
>
> ♦Lead community sponsored forums.
>
> ♦Provide technical assistance, data, and other forms of support to
> community organizations seeking to address health issues in their
> communities and neighborhoods.
>
> 5\. Increase appreciation of public health by elected officials.
>
> Methods to consider include:
>
> ♦Adopt a legislator (Tribal/State/Federal).
>
> ♦Sponsor legislative conferences on public and community health for
> legislators and practitioners.
>
> ♦Use cost-benefit data responsively.
>
> 6\. Support current and create new Federal/Tribal/State partnerships
> for public health that build on communication and collaboration
> linkages.
>
> ♦Market demonstrated public health successes completed by I/T/U
> programs especially those which showcase multi-disciplines at local
> and state meetings, as well as national and professional seminars and
> conferences.
>
> ♦Share prepared public health demographic and trend presentations
> routinely with local Tribal, StateRegional, and National Indian Health
> Boards.
>
> ♦Provide for increased utilization of holistic approach to healing and
> utilization of Native Healers.
>
> 7\. Clarify Federal and Tribal responsibilities as they pertain to
> population based core public health functions of assessment, policy
> development and assurance. Use the core functions to bridge the public
> health system into all aspects of the public, private and voluntary
> sectors.
>
> ♦Redesign current staffing levels to enhance the public health
> initiatives. Maintain creditability.
>
> ♦Provide financial support to insure the integrity of the public
> health initiatives already place.