Rural Public Health:
 

Issues and Considerations
 

A Report to the Secretary 

U.S. Dept. of Health and Human Services 

The National Advisory 

Committee on Rural Health 

February, 2000 

The National Advisory Committee on Rural Health, February 2000 i 
 

Project Consultant and Primary Author 

Rhonda Johnson
 

Research Associate
 

North Carolina Rural Health Research and Policy Analysis Program
 

The Cecil G. Sheps Center for Health Services Research
 

The University of North Carolina at Chapel Hill
 

Contributing Editor 

Thomas F. Morris
 

Policy Coordinator
 

Federal Office of Rural Health Policy
 

Health Resources and Services Administration
 

U.S. Department of Health & Human Services
 

Rockville, MD 20857 

The National Advisory Committee on Rural Health, February 2000 ii 
The National Advisory Committee on Rural Health 

Chartered in 1987, this fourteen-member citizen’s panel of nationally recognized rural health 

experts advises the Secretary of Health and Human Services on ways to address health care 

problems in rural America. Chaired by former Iowa Governor Robert D. Ray, the 

committee’s private and public-sector members reflect wide-ranging, first-hand experience 

with rural issues - in medicine, nursing, administration, finance, law, research, business, and 

public health. 

The National Advisory Committee on Rural Health, February 2000 iii 
The National Advisory Committee on Rural Health
 

Outgoing Chair

Robert D. Ray 

Incoming Chair

Nancy Kassebaum Baker 

Former Iowa Governor Former U.S. Senator 

Des Moines, IA Burdick, KS 

Members 

* Member of the Public Health Task Force 

** Chair of the Public Health Task Force 

J. Graham Atkinson, D.Phil. 

Health Care Financial Consultant 

Washington, DC 

H.D. Cannington 

Chief Financial Officer 

Emanuel Medical Center 

Swainsboro, GA 

William H. Coleman, M.D., Ph.D. 

Practicing Physician 

Scottsboro, AL 

Shelly L. Crow * 

Clinic Administrator 

Eufaula Indian Clinic 

Eufaula, OK 

Barbara Jean Doty, M.D. * 

Associate Director 

Alaska Family Practice Residency 

Wasilla, AK 

Jennifer Frary, P.A.-C. 

Occupational Health Management 

Wyoming Medical Center 

Casper, WY 

Faye Gary, R.N., Ed.D. * 

Professor 

University of Florida 

College of Nursing, JHMHC 

Gainesville, FL 

Alison M. Hughes * ** 

Associate Director, Rural Health Office 

University of Arizona College of 

Medicine 

Tucson, AZ 

Louis P. Lerma 

Chief Executive Officer 

Clinicas de Salud del Pueblo, Inc. 

Brawley, CA 

Thomas Scott Nesbitt, M.D., M.P.H. * 

Acting Assistant Dean for 

TeleHealthOutreach and Special 

Projects Telemedicine, Rural Health and 

Hospital Affiliations 

U.C. Davis Medical Center 

Sacramento, CA 

The National Advisory Committee on Rural Health, February 2000 iv 
 

Frank Scott Newman, Ph.D. Montana State Office of Rural Health 

Professor Emeritus Ekalaka, MT 

Veterinary Virulogy and Medical Science 

Montana State University 

Retired Director 

E. Jay Wheeler, M.D., Ph.D.
 

Professor and Chairman
 

Department of Health Organization
 

Management, Texas Tech University
 

Health Sciences Center, School of Medicine
 

Lubbock, TX
 

Executive Secretary to the Committee

Wayne W. Myers, M.D.
 

Director
 

Federal Office of Rural Health Policy
 

Health Resources and Services Administration
 

U.S. Department of Health & Human Services
 

Rockville, MD 20857 

The National Advisory Committee on Rural Health, February 2000 1 
Preface
 

As the American health care system continues through dramatic change, there has been a 

renewed focus on how to ensure the continued viability of the public health system. In 

particular, the concern has been centered on what might best be defined as the public health 

infrastructure. This catch-all term, for the purpose of this report, refers to a wide range of 

connected issues related to public health from the training and education needs to the funding 

streams that sustain it. These concerns are being felt across the public health spectrum but are 

particularly pronounced in rural areas, where the local health departments are often isolated 

and understaffed. In September of 1998, the National Advisory Committee on Rural Health 

decided to examine the impact of these changes on the rural public health infrastructure. This 

report, which is the product of that effort, is intended to bring a rural focus to a larger 

national issue and frame some of the crucial issues that specifically affect the viability of the 

rural public health infrastructure. Further, it serves as a resource for the Committee should it 

choose to make any recommendations to the Secretary on ways to improve the rural public 

health infrastructure. 

The National Advisory Committee on Rural Health, February 2000 2 
 

 

Public Health Overview: A Time of Transition 

Public health is often referred to as 

the foundation of the health care 

system, but many signs point to 

emerging structural problems. Recent 

reports document the steady 

deterioration of the national public 

health system. Health departments are 

closing. Technology and information 

systems are outmoded. Emerging and 

drug-resistant diseases threaten to 

overwhelm resources and serious 

training inadequacies threaten the 

capacity of the public health 

workforce to address new threats and 

adapt to changes in the health care 

market. (Medicine and Health 

Perspectives, 1998). 

Despite these concerns, there is little 

consistent public outcry from the 

public to fix a system that often isn’t 

missed until it’s gone. The 

consequences of a continued 

weakening of the public health 

system, however, aren’t as easy to 

explain away. Public health 

professionals say they could lead to 

more widespread outbreaks of 

infectious diseases and slower 

response times by health care 

professionals to emerging threats. 

The perceived instability of the public 

health infrastructure is part of the 

larger debate and persistent ambiguity 

about the appropriate roles and 

Core Public Health Functions 

ASSESSMENT: The regular systematic 

collection, assembly, analysis and dissemination 

of information on the health of the community. 

Assessment practices are specifically to: 

° ASSESS the health needs of the
 

community,
 

° INVESTIGATE the occurrence of health
 

effects and health hazards in the
 

Community, and
 

° ANALYZE the determinants of identified
 

health needs.
 

POLICY DEVELOPMENT: The development of 

comprehensive public health policies by 

promoting the use of scientific knowledge base in 

decision-making. Policy development practices 

are specifically to: 

° ADVOCATE FOR PUBLIC HEALTH, build 

constituencies and identify resources in the 

community, 

° SET PRIORITIES among health needs, and 

° DEVELOP PLANS and policies to address 

priority health needs. 

ASSURANCE: Assure constituents that services 

necessary to achieve agreed-upon goals are 

provided by encouraging actions of others (private 

or public), requiring action through regulation, or 

providing services directly. Assurance practices 

are specifically to: 

° MANAGE RESOURCES and develop
 

organizational structure,
 

° IMPLEMENT programs, 

° EVALUATE programs and provide quality 

assurance, and 

° INFORM AND EDUCATE the public. 

(Dyal, 1991; Turnock and Handler, 1992 ) 

responsibilities of ‘public health.’ More than ten years ago, the Institute of Medicine released 

a paper on The Future of Public Health that identified the mission of public health as 

‘assuring conditions in which people can be healthy,’ and conceptualized three core public 

health functions: assessment, assurance and policy development. (IOM, 1988). 

The move toward local implementation of these public health functions, as well as the rapid 

expansion of managed care have forced a change in the traditional roles of local health 

The National Advisory Committee on Rural Health, February 2000 3 
 

 

departments in rural areas (Moscovice, et al, 1998). Yet the challenges faced by such 

departments are just part of the larger picture of public health infrastructure instability. 

Diminished funding, and fragmentation 

of public health responsibilities have all 

contributed to this instability. Between 

1990 and 1993, the percentage of the 

nation’s health care dollars spent on 

public health declined from 2.7% to 

1%. With expansion of managed care, 

devolution of governmental 

responsibilities, and restructuring of 

state agencies, public health agencies 

have had to rethink many of their 

traditional roles and responsibilities. 

Health departments have long played a 

key role in shoring up the health care 

safety net, that group of private and 

public providers that disproportionately 

care for the poor and uninsured. Now, 

these health departments are also being 

asked to refocus on the traditional core 

public health activities. 

This is problematic because health departments have become more involved in direct clinical 

care during the past 20 years, particularly for Medicaid beneficiaries. These clinical 

reimbursement dollars became very important to the overall support of the agencies. This 

strategy was particularly attractive to state and local funding entities because Medicaid 

payments include large proportions of federal funds, which lessened state funding pressure. 

In those areas were Medicaid paid on an actual cost-basis, the health departments were able 

to include many of their administrative costs in their clinical care budgets. 

These dollars helped subsidize core public health activities and, in some cases eventually 

largely supplanted existing funding sources for core public health functions. States only 

began to worry when they started seeing growing Medicaid expenditures. Many moved their 

Medicaid populations into managed care plans, which did not contract with health 

departments to continue providing those services. That meant the loss of Medicaid revenues 

for the health departments and fewer dollars to cover traditional public health duties. 

Funding shortfalls are only part of the problem for the deteriorating public health 

infrastructure, though. The Public Health Foundation reports that only 15 percent of the 

nation’s public health workforce has received academic education in public health. That 

creates a significant workforce challenge for local health departments given the call for a 

return to core public health activities called for by the IOM. Recruitment and retention of 

qualified public health workers continues to be a problem, particularly in rural areas. And 

Ten Essential Public Health Services 

1. Monitor health status to identify community 

health problems 

1. Diagnose and investigate health problems 

and health hazards in community 

1. Inform, educate, and empower people about 

health issues 

1. Mobilize community partnerships to identify 

and solve health problems 

1. Develop policies and plans that support 

individual and community health efforts 

1. Enforce laws and regulations that protect 

health and ensure safety 

1. Link people to needed personal health 

services and assure the provision of health 

care when otherwise unavailable 

1. Assure a competent public health and 

personal health workforce 

1.	 Evaluate effectiveness, accessibility, and 

quality of personal and population-based 

health services 

1.	 Research for new insights and innovative 

solutions to health problems 

(Public Health in America, PHFSC) 

The National Advisory Committee on Rural Health, February 2000 4 
while technology and distance learning offer great potential possibilities, the rural areas in 

most need of these services are the least equipped to take advantage of them. 

All of these influences have created an increasingly fragile infrastructure during a time of 

great change. Both the states and the Federal governments find themselves dealing with 

budget surpluses for first time in many years, but few extra dollars are being committed to 

public health concerns. A recent survey of state health agencies demonstrated limited 

progress and much room for continued effort and improvement in implementation of IOM 

recommendations (Scutchfield, Beversdof, Hiltabiddle, and Violante, 1997). One core 

function, policy development, had actually declined in some agencies since 1989. 

As expected, professional associations are expressing concern about basic infrastructure 

issues. In 1994, the American Public Health Association (APHA) picked the enhancement of 

the federal, state, and local public health infrastructure as one of its two priorities for 

legislative action, and also lobbied for expansion of both medical care services and public 

health programs to improve the nation’s overall health status (Trevino and Jacobs, 1994). 

Chapter 7 and 14 of the draft Healthy 

People 2010 report is exclusively 

devoted to supporting a strong and 

responsive public health system as a 

critical foundation for all other 

objectives. In fact, the infrastructure 

goals and objectives described in the 

report drive the ability to support the 

other 25 priority areas. Yet calls to 

support the infrastructure often fall on 

deaf ears. At the same time, there is no 

corresponding cry for help from the 

general public, which has trouble 

relating to a service that is largely 

invisible to the masses. 

Any attempt to address these core 

infrastructure issues is made even more 

difficult by the fragmented nature of our 

current public health system. At least six 

different federal agencies (The U.S. 

Department of Agriculture, the Centers 

for Disease Control, the National 

Institutes of Health, the Administration 

for Children and Families, and the 

Health Resources and Services 

Administration, and the Environmental 

Did You Know... 

° About 3000 local public health agencies, 

boards and departments make up the heart 

of the public health system; 2/3 of these are 

in small towns with populations of less than 

50,000. (National Association of County and 

City Health Officials) 

° In 1996, a survey by the National Governor’s 

Association (NGA) found that 27 out of 49 

states planned to redirect resources from 

direct provision of services (medical) to 

performance of core public health functions. 

Michigan and Oregon no longer provide any 

direct services. 

° In 1995, the Committee for the Improvement 

of Public Health in Montana conducted a 

survey of local public health agencies, and 

found that most agencies had the ability to 

perform fewer than half of six core public 

health functions and services. (Frontier 

Education Center, 1999). 

° Less than half of the public health workforce 

have had training in public health. Less than 

half of the nation’s local public health 

agencies have the capacity to provide the 

essential public health services. (U.S. 

Department of Health and Human Services, 

Draft Document, 1998) 

Protection Agency) all have major funding responsibility for various public health activities. 

Each of the 50 states also devote significant financial resources to public health as do 

The National Advisory Committee on Rural Health, February 2000 5 
individual counties. These myriad funding sources create a confusing minefield of different 

priorities and guidelines that must be navigated by local health departments. 

Rural public health departments feel the same strains as their urban counterparts. In many 

ways, however, these issues are even more challenging in rural areas. This is because rural 

public health departments face the added challenge of having even fewer resources coupled 

with geographic isolation and a lack of educational and training support. While there has 

been a fair amount of research and discussion about general public health infrastructure 

issues, there has been little attention given to the rural dimensions of this topic. 

This paper will attempt to bring a rural focus to some of these key public health infrastructure 

issues and to provide the background material to the Committee should it decide to make any 

recommendations to the Secretary. Specifically, the report will focus on the rural aspects of 

the following issues: 

° Leadership: 

° Workforce Preparedness 

° The Safety Net: 

° Impact of Managed Care: 

° Telecommunications: 

° Funding: 

The National Advisory Committee on Rural Health, February 2000 6 
Leadership 

A void in public health leadership

on rural issues may be

exacerbating current problems. 

There are few real rural voices taking part 

in the policy discussions and decisionmaking processes that shape the public 

health infrastructure. This is often true at 

both the state and Federal level and there 

are several factors at work that are 

responsible for this situation. One is the 

changing demographics of our 

communities. As rural areas continue to 

lose population relative to the urban and 

suburban areas, there is also a 

corresponding loss of political power in 

state legislatures. Many state governing 

bodies used to be dominated by their rural 

members. These rural voting blocks held 

great sway in many states and ensured that 

rural communities had a place at the 

decision-making table. As the voting 

power has shifted toward urban and 

suburban-areas, rural communities have 

lost political power. 

At the same time, there has been no effective lobbying organization devoted solely to rural 

public health. Larger national organizations such as the American Public Health Association 

(APHA), the Association of State and Territorial Health Officers (ASTHO) and the National 

Association of City and County Health Officials (NACCHO) must appeal to a much broader 

public health constituency. This is not to suggest that these organizations are insensitive to 

rural concerns, but only that they must be balanced with the overall concerns of the larger 

public health community. The National Rural Health Association has been successful at 

pushing selected rural public health issues but also has had to balance these concerns with the 

other general health care concerns of its constituency, which is made up of health care 

providers, administrators, educators, policy experts, and consumers. 

The ongoing perception that public health is largely a service for poor people is another 

factor, albeit on a more general level. This misunderstanding of the importance and purpose 

of public health makes it hard to win the support of the middle and upper class. As a result, 

the general public is rarely engaged in the discussion of issues regarding the public health 

infrastructure. 

Public Health Resources 

° Turning Point, a program of the WK Kellogg 

Foundation and the Robert Wood Johnson 

Foundation is designed to transform and 

strengthen the public health infrastructure in 

the US. Concurrently, up to 60 local public 

health partnerships in those states receive 

funding for capacity-building, planning, and 

leadership activities for up to three years. 

Contact information: Bobbie Berkowitz, 

National Program Director. Tel: 206-543-

8410 Fax: 206-616-8466 

gomenn@u.washington.edu. 

° Institute of Medicine, (1996). Healthy 

Communities: New Partnerships for the 

Future of Public Health. Washington, DC. 

National Academy Press. This follow up 

report to the Future of Public Health 

addresses two additional critical public 

issues: 1) the relationship between public 

health agencies and managed care 

organizations, and 2) the role of the public 

health agency in the community. (IOM, 

1988) 

The National Advisory Committee on Rural Health, February 2000 7 
A greater awareness of rural concerns at the Federal and state levels would help to empower 

rural public health departments and there are some tools available to make this happen. Since 

1991, there has been a state office of rural health within each of the 50 states. These offices 

are uniquely positioned to link rural communities to state and federal resources. Funded 

through a matching grant program from the Federal Office of Rural Health Policy, most of 

these offices are located in the state health departments, but nine are university based. They 

are quite variable in scope, staffing and access to resources. One-person offices are not 

uncommon. A recent survey of the state offices by ASTHO confirmed that variability. The 

survey found that while 41 of the responding states said their state holds a periodic meeting 

or conference on public health issues, only 33 said the event included any formal discussion 

of rural-specific issues. 

Additional Resources 

Similarly, attention to rural public 

health issues at the Federal level is also ° The National Rural Health Association 

variable. While the Federal Office of (NRHA) with funding through a three-year 

grant from the WK Kellogg Foundation, Rural Health Policy is positioned to be recently launched Rural Community the voice of rural health within the Leadership Development Initiative. This larger U.S. Department of Health and initiative aims to create a cadre of rural 

Human Services, it would be hard leaders to provide key input regarding their 

pressed to become the focal point for communities real needs. Contact: Robert 

Quick, NRHA special assistant to the rural public health issues on anything executive vice president. Tel: 816-756-3140. more than a general basis. Currently, Quick@nrharural.org. the office has responsibility for 

reviewing all Medicare and Medicaid ° The Public Health Practice Program Office 

regulations that affect rural health care (PHPPO) of the Centers for Disease Control 

and Prevention (CDC) recently prepared a delivery while also administering five free booklet called Principles of national grant programs. The Community Engagement to improve fragmentation of public health communication, promote common 

programs across different agencies also understanding and strengthen community 

makes coordination of efforts and partnerships to fulfill shared public health 

goals. Contact: Michael T. Hatcher (Chair), attention to specific issues such as rural through http://www.phppo.cdc.gov/ health a difficult task. 

Ultimately, solutions to the leadership void for rural public health will have to come from a 

number of sources. One potential model for improving leadership at the state and local level 

is the new Management Academy for Public Health, jointly funded by CDC, HRSA and the 

WK Kellogg and the Robert Wood Johnson Foundations. The Academya joint effort of the 

University of North Carolina School of Public Health and the Kenan-Flagler Business 

Schoolwill strengthen the management skills of 600 senior-and mid-level managers in 

local and state health departments across Georgia, North Carolina, South Carolina and 

Virginia. Participants will come in teams to Chapel Hill, NC for Phase I of the academy, a 

one-week intensive management training program covering financial management, civic 

entrepreneurship, human resources and strategic management. Managers then graduate to 

Phase II, returning home for the next nine months with continuing course study over the 

internet, and during two regional seminars. Finally, Academy participants return to Chapel 

Hill for Phase III, a wrap-up session. According to program organizers, Academy teams will 

The National Advisory Committee on Rural Health, February 2000 8 
 

 

 

 

produce integrated business plans at the end of their 10-month training to be implemented in 

their home agencies to improve service delivery and effective collaboration with others. 

Rural communities must be pro-active in seeking participation in such innovative strategies 

to link expertise with need, and federal programs should support such rural participation. 

Other solutions, undoubtedly, will have to come from rural communities through new and 

innovative partnerships. Some communities have already taken the lead. County extension 

agents in Georgia are helping communities to empower themselves and strengthen 

community infrastructure (Jenkins, 1991). Over the last few years, several rural communities 

have shored up their local health systems and staved off potential hospital closures by taking 

part in a planning called Community-Initiated Decision Making. This decision-making 

method gets local citizens engaged in learning about the importance of the local health care 

system on both an economic and a clinical basis, identifying problems and working together 

to come up with solutions. The CDC pushes a similar process called the Apex Model, which 

is a tool used by the local health department that includes local citizen participation as a key 

part of the process. As communities work their way through this process, some rural 

advocates are urging communities to consider placing their health departments inside the 

local hospital to take advantage of critical Empowering Local Communities mass and become more of a one-stop shop 

for clients. Rural public health The Community Based-Public Health Initiative 

departments could benefit from (CBPH), funded by the WK Kellogg Foundation in 

developing partnerships with their local 1991, was one of the earliest efforts to encourage 

collaboration between communities, local health hospitals and taking part in these departments and academia to improve public community-oriented planning processes. health. Its specific objectives included building 

the capacity of communities to become equal 

Some native American tribes have also partners in efforts to improve the community’s 

taken control of their own public health health, enabling teaching, research and service to 

be more reflective of diversity and pluralism, and decision making, thanks to the Indian increasing multicultural competency among Self-Determination Act. This law allows students, faculty, agency personnel and tribes to contract for their health care community members. 

services through entities other than the 

Indian Health Service. In Alaska, for 

example, nearly all the health care programs traditionally administered by the Indian Health 

Service have been steadily transferred to 13 Alaska Native regional corporations over the 

past two decades. Local tribal agencies and officials are becoming increasingly important 

decision-makers in the provision of public health services in many rural communities. 

Ultimately, the issue of increasing the leadership on rural public health issues has two 

distinct challenges. One lies in bringing more awareness of critical rural concerns within the 

context of the larger public health debate. The other lies in encouraging the development of 

local leaders at the community level who can develop and implement the innovative ideas 

needed to ensure the continued viability of the rural public health infrastructure. 

The National Advisory Committee on Rural Health, February 2000 9 
 

Workforce Preparedness 

Rural health departments face a

continuing problem attracting

and retaining the proper mix of

public health professionals.

Further, there is a growing need

to improve continuing education

opportunities to deal with new

and emerging threats. 

Recruitment, training, placement and 

retention of some health professionals 

are familiar headaches to rural health 

advocates and policy makers. These 

difficulties occur within the public 

health arena as well, and in fact may 

be exacerbated by the greater demand 

for, and even more limited pool of 

appropriately-trained public health 

practitioners. More than four out of 

every five public health employees 

nationwide – more than 400,000 

people – have no degree, certificate or 

formal education in public health. The 

one exception to this rule may be 

nursing. Nurses traditionally receive a 

block of instruction in public health in nursing school, but they are only one facet of full 

complement of public health employees. That means other members of the local health 

department team must learn essential skills on the job. This disparity points out a dramatic 

weakness in our public health infrastructure. 

It is exacerbated in rural areas that may not be located near the educational institutions that 

can help workers get the training they need. Filling other needs in the areas of soil and water 

assessment, epidemiology, and food inspection also can be more difficult in some rural areas. 

This is in part because of difficulty in paying the salary of these professionals in more remote 

areas and also because the volume of work for these professionals may not be enough to 

warrant a full-time presence at the local level. 

Maintaining the needed diverse skill mix of public health professionals, however, presents 

further challenges. As mentioned earlier, local health departments used to be able to depend 

on Medicaid dollars raised from providing personal health services to fund some populationbased services, such as assuring clean water supplies and safe-food preparation at restaurants. 

As local health departments shift from an emphasis on personal services to more communityfocused efforts, there may be a corresponding loss of Medicaid dollars available to cover 

those costs. Because these ‘public health’ services have long been invisible to the general 

Training Resources 

° The National Laboratory Training Network 

has reached over 8,000 individuals through 

its seven regional training centers, providing 

state of the art public health laboratory 

methods. For more info: 

http://www.phppo.cdc.gov/about/ 

° Burke, T, Tran, N, and Shalauta, N. (1995). 

Identification of state environmental 

services: a profile of the state infrastructure 

for environmental health and protection: a 

final report. Rockville, MD: Contract No. 

240-92-0046. 

° The Pew Health Professions Commission, in 

its 1995 report entitled Critical Challenges: 

Revitalizing the Health Professions for the 

Twenty First Century, concluded that the 

demand-driven system in health care and 

health professions practice will result in 

surplus of 100-150,000 physicians in the 

next century. However, the same study 

concluded that the demand for public 

health professionals will increase 

substantially. 

The National Advisory Committee on Rural Health, February 2000 10 
public, their gradual erosion and eventual disappearance in some sites has not yet engendered 

public outcry. 

The loss of community disease surveillance capacity, lack of oversight over local sanitation, 

and inadequate assurance of safe food and water supplies are behind many of the recent, 

nationally publicized outbreaks of preventable disease, such as Hepatitis A and E coliinduced food poisoning and new outbreaks of tuberculosis. The growing prevalence of 

hepatitis C has put a further burden on public health agencies as the number of people 

affected continue to multiply and practitioners struggle with both diagnosing and treating the 

disease. Since 1987, the National Academy of Science’s Institute of Medicine (IOM) has 

published three reports that identified erosion of the public health infrastructure among the 

factors contributing to new and reemerging infectious diseases (Satcher, 1995). 

In recognition of these issues, the Centers for Disease Control and Prevention’s (CDC) calls 

for increased laboratory-based surveillance, better communication networks and 

improvements in the public health infrastructure as cornerstones to combat emerging 

microbial threats to health. Attempts to deal with new and emerging threats such as this point 

to another critical problem facing rural public health providers: continuing education. The 

existing base of rural public health workers will need ongoing training to respond to the new 

and emerging public health crises identified by the CDC. 

Many rural public health departments may need to recruit new personnel to fill these roles 

and to plug gaps in their personnel so they can more adequately address emerging public 

health needs. Experts agree that community health needs are too complex to be managed 

solely by our individualistic medical care delivery system. Yet incentives to attract a diverse 

team to rural areas are even more inadequate than the few incentives available to attract 

general clinicians to rural areas. Adapting existing recruitment and retention strategies to 

include public health personnel is a potential, relatively painless strategy. One model that 

might be particularly appropriate for rural public health providers is the Triple R Network (or 

the Rural Recruitment and Retention Network). This recruitment service, which is operated 

by the Wisconsin Office of Rural Health, seeks to match physicians interested in rural 

practice with rural communities in need of a clinician. The network is made up of 46 statebased organizations such as State Offices of Rural Health, Area Health Education Centers, 

(AHECs) and State Primary Care Associations who work together to share and coordinate 

information between those seeking physicians and those providers looking for places to 

practice. 

What is needed right away, though, is a broad-based strategy for improving the skills of the 

current public health workforce. Training programs that take advantage of 

telecommunication strategies such as internet-based instruction and interactive distance 

learning programs are a viable alternative and are discussed in a subsequent section in this 

report. Rural communities would also benefit from innovative partnerships with local 

community colleges, schools of medicine, nursing and public health. Most land-grant 

colleges and universities and other state educational institutions have a service responsibility 

to their communities. Rural public health departments would benefit from these resources as 

well as any available Federal, state or foundation money that supplements training efforts. 

The National Advisory Committee on Rural Health, February 2000 11 
 Safety-Net Provider Support 
 

Rural Public Health Providers 

have long been a critical part of

the safety net but changes in the

health care market may be

undermining that role. 

Public health is one of the key elements 

of the safety net that provides care for 

the most vulnerable members of the 

community. The rural safety net 

includes both public and private 

professionals and institutions that 

provide a disproportionate share of care 

to the poor and the uninsured. It also 

includes the federal government 

through multiple, and longstanding 

Safety Net Vs. Population Services 

“The vitality of the public health system has been 

undermined in the last two decades by escalating 

pressures on state and local governments to 

provide medical care for the poor and uninsured.“ 

1994 statement in JAMA by a group led by officials 

from the Centers for Disease Control and 

Prevention. 

“However necessary, “support for indigent medical 

care has exacted a huge toll in lost opportunities 

for preventing morbidity and mortality in vulnerable 

populations and for promoting optimal health 

conditions for the entire community.”

 (Medicine and Health Perspectives, Nov. 23, 

1998). 

treaty obligations to tribal governments and their communities. 

This traditional role, however, has been under increasing pressure as the public health 

community struggles to survive and define itself in an era where cost-effectiveness and the 

bottom line in health care delivery are priorities. As a result, the importance of public health 

efforts may be minimized and that contributes to the destabilization of the rural public health 

infrastructure. The frequently conflicting demands placed upon rural public health 

providersto shift from personal to population-based services while simultaneously assuring 

the continuity and stability of the safety net—are increasing in a time of scarce resources. 

This coincides with the continued ambivalence regarding the appropriate roles and 

responsibilities of public health regarding focusing on population-based services or 

individual health services. 

There appears to be a philosophical 

divide within the public health 

community. There are those who favor 

continuing the role of providing personal 

health services for both the indigent and 

those enrolled in Medicaid. Others, 

though, believe that approach is 

inconsistent with recent developments in 

the health care system and believe public 

health agencies should focus on the 

population-based services that serve the 

entire community. This conflict has yet 

to be addressed effectively at the federal, 

state or local level. Different funding 

strategies provide competing incentives 

Rural Health Care Safety Net is... 

“a complex web of organizations, individuals, and 

obligations that depend on the explicit support of 

public funds as well as the tacit crosssubsidization of services’...and unlike urban 

systems, cannot depend on teaching hospitals 

and professional educational programs which 

deliver care almost as a byproduct of their training 

programs. Rural systems rarely have access to 

such resources, and depend more heavily on 

publicly subsidized community health centers or 

clinics, supplemented by private practitioners, 

some of whom receive bonus payments and other 

federally-supported incentives to provide unreimbursed care to the poor.” 

Ricketts, Slifkin and Silberman, 1998

The National Advisory Committee on Rural Health, February 2000 12 
 

 

for both roles. What is also clear is that an inadequately prepared and financed public health 

infrastructure is increasingly accountable for both types of services, particularly in rural 

areas, where private resources that might supplement this mission may be even more scarce 

than in urban areas. 

Recent transformations in our public health systems with particular implications for the 

survival of the safety net are detailed in a recent article in Health Affairs (Hall, 1998). 

According to this review, personal health services still consume the largest share of the 

average local health department’s staffing and funds, but in most places, that is rapidly 

changing. Some health services provided to individuals, such as immunizations, sexually 

transmitted disease identification and control, and tuberculosis services, have obvious 

positive implications for the community at large because they are targeted at communicable 

diseases. 

Other personal health services, such as For More Information On The Rural family planning, mental health services, Safety Net: and chronic disease monitoring, have 

less obvious impact on the community’s Ricketts, T, Slifkin, R, and Silberman, P. (1998) overall health and are likely to be The Changing Market, Managed Care and the eliminated first. Comprehensive primary Future Viability of Safety Net Providers-Special 

care services are not commonly Issues for Rural Providers. Background Paper for 

delivered by most health departments, the Institute of Medicine. November 11, 1998. 

but in truly remote areas, and historically 

in the South, such services have been considered central to the health department mission 

because of the shortage of private providers. In such areas, the shift from personal to 

population-based services may actually eliminate the safety net for the most vulnerable 

members of the community. 

The problem facing rural communities is the creation of a possible void in the safety net as 

rural public health departments move to population-based services and decrease their 

provision of personal health services to the poor. The rural safety net is stretched thinner than 

in urban areas, where there are a higher number of large public hospitals, academic medical 

centers and Federally qualified health centers that provide outlets for caring for the 

uninsured. In rural areas, the safety net is smaller and more intertwined among the few health 

care entities that exist, whether it’s a small rural hospital, a private practitioner, a rural health 

clinic or the local health department. The loss of safety net services at the health department 

will only shift the burden over to the other community providers, which may or may not have 

the capacity to handle this new responsibility. Given this transition, there would seem to be a 

need for Federal and state support for maintaining the viability of the safety net in these 

communities. Direct subsidies to community and migrant health clinics, and indirect 

subsidies (via Medicare) to both the private and non-profit sectors to encourage continued 

care to the poor will become increasingly essential, as will assuring continued adequate and 

appropriate funding for provision of public health services to Native American communities. 

The National Advisory Committee on Rural Health, February 2000 13 
 

Impact of Managed Care 

While managed care penetration

in rural areas remains variable, 

the overall impact of managed

care has the potential for

undermining rural public health

systems by altering existing

funding mechanisms. 

Managed care is no longer a small 

player in either rural communities or 

public health discussions. As of May 

1997, 57% of rural counties 

participated in some form of Medicaid 

managed care programs (Slifkin, et al, 

1998). The impact of managed care on 

the rural public health infrastructure is 

closely related to the earlier discussion 

of the fragility of the rural safety net. 

Insofar as the infrastructure has 

responsibility as a provider of last 

resort for vulnerable members of the 

community, changes in the financing 

and delivery of traditional health care 

services are important to public health 

activities. 

Inclusion of all public health agencies 

and private providers in managed care 

organizational networks is far from 

guaranteed, so the potential 

development of a fragmented and two-tiered health delivery system must be considered. In 

fact, some public health departments and other rural safety net providers may not be able to 

enter easily into contracts with managed care organizations due to different cultures and 

misunderstandings about their respective roles. If they are unable to reach contract 

agreements, public health agencies may find themselves cut out of the funding stream as the 

dollars that used to pay for personal health services are now going to the managed care. This 

is particularly troubling when the client base and the uninsured continue to seek personal care 

services through the public health agency rather than the managed care organization. 

The recent ascendance of payers willing only to cover costs associated with insured 

individuals within specific plans threatens the cost-shifting that allowed both the provision of 

population-based services and the absorption by both private and public safety net providers 

Additional Resources on Managed

Care and Public Health
 

° Local Public Health Agencies and Managed 

Care Organizations in Rural Areas: 

Opportunities and Challenges. (1998) By Ira 

Moscovice, Rural Health Research Center, 

Institute for Health Services Research, 

School of Medicine, University of Minnesota. 

Supported by Robert Wood Johnson 

Foundation. For more info: Tel: 612-627-

4411. Fax: 612-627-4415. 

° Rural Impact of Changes in Public Health, 

(1999), report in progress by Rebecca Slifkin 

and Pam Silberman, University of North 

Carolina, Chapel Hill, funded by Federal 

Office of Rural Health Policy. Anticipated 

completion Oct 1999. The study will use 

several state case studies to answer the 

questions: 1) to what extent are rural public 

health departments increasing or decreasing 

their direct patient services? What factors 

are associated with this change?, 2) Have 

recent changes in the health care system 

affected the ability of local health 

departments to fulfill their traditional pubic 

health functions?, and 3) In rural areas 

where public health departments no longer 

offer direct patient care services, has this 

function been assumed by private providers, 

or has access to services for rural 

populations diminished? 

The National Advisory Committee on Rural Health, February 2000 14 
of uncompensated costs of care to the poor and uninsured. Rural advocates are concerned 

about where the funding and coverage decisions of the managed care organizations take 

place. While Medicaid managed care has moved into rural areas, the companies providing 

these services are often located in urban areas and may have little understanding of the 

fragility of the rural safety net and the local health department’s role in that arrangement. 

The decisions made about managed care are also part of a larger public debate about the 

appropriate role of private sector policies applied to the public provision of health services 

(Rice, 1998). The interplay of managed care and public health has been the focus of a 

significant amount of recent attention. 

A 1999 report from the U.S. Department of Health and Human Services Office of the 

Inspector General also focuses on the interplay and dynamics the managed care-public health 

relationship. The report indicates that while there is a conceptual alignment between 

managed care and public health concepts of prevention-oriented health services, managed 

care goals do not translate easily into public health goals. Further, the report points out that 

managed care operational decisions and activities are affected by multiple stakeholders, such 

as medical providers and private health purchasers, but these groups are often absent in 

planning and implementing the collaborations. The issue should garner additional attention 

with the Fall, 1999 release of a similar report from the Institute of Medicine. This study 

examines the impact of managed care on the safety net. Both of these studies, as well as other 

papers and studies point to potential conflicts between maintaining the strength of the public 

health in a health care sector that continues to be dominated by managed care. 

These studies show that effective collaboration between public health agencies and managed 

care organizations in rural areas is likely to require a high degree of negotiation and 

communication between parties. Whether that happens remains to be seen. Historically, the 

health care system has tended to focus on one-size-fits-all approaches that are usually very 

problematic for rural areas. While managed care penetration is increasing in all areas of the 

country, delivery systems that are appropriate in urban areas may be inappropriate and 

particularly difficult to implement in rural areas (Slifkin, et al, 1998). The 1997 Balanced 

Budget Act, which required states to make supplemental payments to FQHCs and RHCs 

during a five-year transition period, is another important but temporary form of support. 

Clearly, it may be too early to see the full effect of managed care on the public health sector. 

What is known at this point is that the move to managed care will bring some dramatic 

changes and it is creating some anxiety among public health advocates, state health 

departments and other interested parties. A recent qualitative survey of State Office of Rural 

Health Directors specifically investigated the public health capacity and infrastructure in 

rural areas and confirmed that many policy makers are concerned that managed care may 

have a negative impact on rural access to public health services (ASTHO, 1999). Most states 

had not yet established any provisions (either legislative or regulatory) to require Medicaid 

managed care organizations to contract with local health departments for public health 

services. The vast majority of states also do not provide direct funding to local health 

departments in rural areas to compensate for the loss of funding through Medicaid managed 

care for core public health functions (ASTHO, 1999). Much as federal direction and 

The National Advisory Committee on Rural Health, February 2000 15 
subsidies helped shape the current organization of existing delivery systems, it may fall to 

Federal policy makers to determine the structure and capacity of future public health systems. 

The National Advisory Committee on Rural Health, February 2000 16 
 

 

 

 

Telecommunications 

Many rural communities that are

most in need of recent advances 

in the field of 

telecommunications technology

may be least equipped to take

advantage of it. 

The telecommunications revolution has 

had significant implications for health 

care providers as a way to bridge the 

gap of time, distance, and isolation. 

Much of the attention to date has 

focused on the clinical applications 

under the catch-all term, 

“Telemedicine,” with an emphasis on 

the remote delivery of clinical care. For 

many public health care providers, 

however, the term telehealth more 

effectively encompasses the full range 

of health care uses for this technology. 

Many public health advocates are 

already taking advantage of 

videoconferencing and regional 

“continuing Education” activities that 

support professional development for 

isolated staff. This technology has the potential for effectively supporting recruitment and inhouse retention of competent personnel in local health departments. 

Telehealth can also bring the expertise of essential public health professionals to rural areas 

on an “as needed basis,” making the use of such specialized knowledge economically 

feasible for communities whose need for such services may be both sporadic and immediate. 

Dealing with the outbreak of the Hanta virus and crafting an effective local emergency 

response to the derailments of trains carrying toxic wastes are just two examples of situations 

where telehealth can help make a modest infrastructure sufficient. In fact, in the wake of 

recent concerns regarding the public health implications for biological terrorism, telehealth 

becomes an essential component of local “first response” capabilities. The ever increasing 

base of medical knowledge coincident with the increasing global mobility of our population 

makes the rapid deployment of new clinical guidelines and standards of practice critical both 

to maintaining the competence of isolated professionals and the safety of the public. Of 

particular note is CDC’s new bioterrorism budget initiative, which received approximately 

$121 million in fiscal year 1999 and has a strong telecommunications component. Some of 

the grant funds will be used to create Health Alert Networks (HANs) to work towards 

creating a nationwide system to provide information, electronic linkages, and resources for 

improving organizational competence and capacity when responding to bioterrorist acts. 

Creating an Public Health Information

Infrastructure on the Utah Frontier 

Until recently, the rural and frontier county health 

departments of Southern Utah were isolated by 

more than just distance. With few computers or 

telecommunications resources, county health 

officials had no way to take advantage of new 

communication technologies that would link them 

to the State health department in Salt Lake City. 

Now, the Utah State Department of Health is 

using telecommunications to reach out to its most 

remote offices in the southern part of the state to 

create the Utah Public Health Information 

Network. 

The network has put e-mail, document transfer, 

and Internet access within reach of its most 

isolated branches. Now, these offices can share 

and access information such as state 

immunization records or information on Medicaid 

eligibility rules and other regulations pending at 

both the state and federal level. The project also 

provided training for state health workers so they 

could take advantage of the new technology. 

Some offices are also working on developing 

electronic surveillance tracking. 

The National Advisory Committee on Rural Health, February 2000 17 
Rural health departments may have to deal for the first time with malaria and/or resistant TB 

in recent immigrants while also being prepared for routine immunizations. The ability to 

share new knowledge and quickly train workers through distance learning may be a critical 

need for local health departments. Telehealth technology may provide a useful tool for 

accomplishing this goal by linking local public health workers with the expertise of 

universities, schools of public health, the state health department and the CDC a smoother 

diffusion of innovations in practice. For example, telecommunications allowed the fairly 

easy recent distribution of new federal guidelines on management of Hepatitis C to public 

health agencies with the capability to participate in such networks of knowledge exchange. 

The emerging field of public health informatics is yet another use of this versatile tool. Data 

transfer is particularly important when trying to understand and manage the health of 

populations rather than individuals. Telehealth also has the potential for stretching scarce 

resources. Small rural public health departments that may not have enough resources to hire a 

full-time epidemiologist can use a telecommunications link to the state health department to 

get these services on an as-needed basis. 

While the potential of telehealth is readily apparent, the reality of applying this technology is 

still developing. The development of clinical telemedicine systems has been driven by 

regional medical centers in search of referrals. No such interest has yet materialized to 

support development of public health networks. In fact, the isolated rural areas that may 

benefit the most from this technology often lack the infrastructure needed to take advantage 

of it. Consider these numbers: 

° Less than half of the state and local public health agencies have adequate
 

communications and information systems.
 

° One recent Hawaiian study indicated that although 85% of rural health workers had 

access to computers, only a small minority (30%) had modems, and even fewer used 

online resources, or could access the free electronic databases at public and university 

libraries (Lundeen, Tenopir and A Resource for Public Health Wermager, 1994) 

The Public Health Training Network (PHTN) is a The unreliability or absence of even distance learning system that takes training to the the most basic communication learner. PHTN uses a variety of instructional 

systems in many remote areas of the media ranging from print-based to videotape and 

country reinforces the notion that multimedia to meet the training needs of the 

public health workforce. Since 1993, PHTN has stabilizing the public health successfully trained over 300,000 public health infrastructure with professionals. Key to its effectiveness is the telecommunications must start at a pivotal role played by 50 State Distance Learning 

very basic level. Even seemingly Coordinators who ensure state and local health 

simple tools such as personal workers are able to access PHTN programs. For 

more info: http://www.cdc.gov/phtn/. computers and modems can 

dramatically improve public health 

capabilities at the local level. 

The National Advisory Committee on Rural Health, February 2000 18 
Public health advocates and 

policymakers alike see Improving the Practice of Public

telecommunications as one of the key Health 

tools for reinforcing the public health 

infrastructure. They point to the need to The Information Network for Public Health 

link local public health agencies with Officials (INPHO) was initiated by CDC in 1992 

as part of its strategy to improve information state health departments for data exchange and thus strengthen the public health collection and evaluation and to provide infrastructure. Twenty one states currently 

core public health training to areas. Such participate in this effort to make public health 

links are not without problems, though. practice more effective. For more info: 

There are concerns about costs of this http://www.phppo.cdc.gov/inpho/ 

technology. The rapid expansion of 

technology makes equipment purchasing difficult since much of the off-the-shelf computer 

equipment for this technology quickly becomes obsolete. Further, the high 

telecommunication costs of linking rural health departments to urban partners can also be 

prohibitively expensive. Consequently, some public health departments have relied on state 

and Federal support to offset some of the fixed costs. Across the country, states have built 

telecommunication networks that can help support these activities. Federal agencies such as 

the Health Resources and Services Administration (HRSA), the Centers for Disease Control 

(CDC), the National Library of Medicine (NLM), the Department of Commerce and the 

Department of Agriculture have provided millions of dollars in grant funds for telehealth 

projects that included public health functions. 

The Office for the Advancement of Telehealth (OAT) in HRSA, which has funded telehealth 

network projects since 1994, has found that its most successful projects are those that 

incorporate a range of uses on their Improving Communication network system. This often results in 

systems that serve a variety of functions In September, 1997, the American Public Health from specific clinical applications such as Association (APHA) held a workshop on 

specialty consultations to more public “Effective Communication of Public Health Data 

health oriented activities such as distance and Information: Skills for a Changing Public 

education and health information sharing. Health Environment.” The workshop was a 

collaborative effort among APHA, the University 

of Pittsburgh Graduate School of Public Health, While the early results are promising, the Association of Schools of Public Health and 

telehealth technology will not be a the Pennsylvania Public Health Association, and 

panacea for the rural public health was supported by APHA’s Public Health 

infrastructure. Rather, most advocates Innovations Project, a cooperative agreement 

funded by CDC. point to it as another tool that can be used 

to target specific education and 

information-sharing needs. 

The National Advisory Committee on Rural Health, February 2000 19 
 

Funding Issues 

The fragmented layers of

Federal, state and local funding

of public health activities creates

a confusing financial patchwork.

These funding lines often have

conflicting guidelines and lack

the flexibility to respond to

community public health needs 

One of the underlying reasons for the 

current instability across the public 

health landscape lies with the complex 

and ever-shifting funding sources for 

these services. Part of this equation, the 

impact of managed care, has already 

been discussed. The other public health 

funding streams, however, are just as 

variable since most public health 

agencies are funded by a patchwork of 

Federal, state and local sources. Much 

of the money starts at the Federal level 

before being sent to the states in the 

form of large block grants. The 

Women, Infants and Children (WIC) 

nutrition program and other USDA 

nutrition funds account for the largest 

share of state health departments’ 

budgets while the Maternal and Child 

Health block grant (Title V) is a distant 

second. Other federal public health 

grants include family planning (Title X) and the preventive services block grant (Wall, 

1998). 

How those dollars break down often depends on how public health is defined and the extent 

to which it varies state to state. For example, according to Public Health Foundation 

estimates, in FY 1995, expenditures by state health agencies totaled $13.2 billion. Of that 

amount, approximately 66.8% funded direct delivery of medical and related services (e.g. 

primary care and health promotion). The remaining 33.2% was used as follows: 

° 15.8% for environmental health, health resources and regulation, technical and support 

services, vital records and health statistics (e.g., licensing, inspection, quality assurance, 

public health engineering, EMS development). 

° 12.2% for the operation and regulation of state hospitals, residential facilities, home
 

health and skilled nursing agencies.
 

Unexpected Cases Cut Deep 

The Pamlico (N.C.) County Health Department 

has treated 28 people for rabies in the past two 

years and it can ill afford any more. 

As state and federal public health block grants 

have been cut in recent years, there's precious 

little money left over to handle unforeseen 

emergencies. But in rural areas like this coastal 

county of North Carolina, rabies outbreaks do 

happen and it's the local public health agency that 

has to handle it. "An average eight-year old child, 

it costs me $800 to treat that child," says Jenny 

Lassiter, the Pamlico County Health Director. "The 

state Medicaid reimburses me $400." 

During the first rabies outbreak in 1998, Lassiter's 

agency spent $7,000 on vaccines and treatment. 

While two of the 11 people treated qualified for a 

state indigent care rabies program, the rest were 

listed as self-pay. So far, the health department 

has collected $1,200 of its fees. The local 

residents in this poor, underserved community 

don't have the money. And there's little flexibility in 

either the Federal or state funding to cover these 

costs. That means Lassiter must pull dollars from 

somewhere else to cover the shortfall. 

"It's coming out of your pocket either way," 

Lassiter said, "and I do not have a good answer 

other than the fact that there has got to be some 

kind of block grant money that has to be 

established to address local issues and 

problems." 

The National Advisory Committee on Rural Health, February 2000 20 
 

 

° 2.7% for operation of public laboratories and services (medical examiner) and
 

regulation of others.
 

° 2.5% for “general support of local health departments.” 

Since federal dollars, usually in the form of block or categorical grants, still make up a 

substantial portion of most states’ public health budgets (50-85%), these programs are key 

determinants of the fiscal capacity of the public health infrastructure. Often, those dollars 

come with strings attached. That means the availability of federal dollars often dictates the 

activities of state public health agencies. For example, Texas and Colorado support few 

public health programs that do not draw federal dollars. Likewise, state support of public 

health dollars differs with each state. 

Local funding for public health 

agencies, particularly rural public 

health agencies, is often dependent on 

local tax revenues 

This confusing patchwork of existing 

financial mechanisms often exacerbates 

the instability and inefficiency of the 

rural public health infrastructure. One 

local health director interviewed by the 

National Advisory Committee on Rural 

Health for this report indicated that he 

routinely managed more than eighty 

distinct funding streams in the course 

of his annual work. The associated red 

tape and complexity of these funding 

streams have prompted some rural 

public health advocates to favor more 

streamlined and flexible funding mechanisms. Yet alternatives provided to date have not 

always exceeded, or even met the achievements of the older, categorical funding streams. 

Both block and categorical funding mechanisms often lack the flexibility needed to respond 

appropriately to local emergencies. Health officials frequently describe the frustration of 

having minimal or no “untargeted” funds to address even well-recognized, or predictable 

local needs, which do not fall into simple budget categories. 

The devolution of responsibility for social and health services from the federal to the state 

governments has dominated almost two decades of public policy. In such traditional public 

health programs as Maternal Child Health, such transfer of power has also been accompanied 

by the significant growth of block grants and a decrease in traditional categorical funding 

streams. The Maternal and Child Health Services Block Grant (MCHSBG), passed in 1981, 

provides direct health services to women, infants, children and youth, and consolidated eight 

categorical programs into a single, reduced federal block grant to the states. 

The Block Grant formula (which considers both number of low income individuals and poor 

health indicators) theoretically targets resources to needy populations in both rural and urban 

The Association of Schools of Public Health 

supports the following FY2000 funding 

recommendations for programs of primary 

concern to the public health community: 

Centers for Disease Control and Prevention 

° Prevention Centers: $30 million 

° Prevention Research: $100 million 

° NIOSH Training: $20 million 

° Environmental Research $8 million 

° Injury Control: $20 million 

° NCHS: $110 million 

Health Resources and Services Administration 

° Public Health, Preventive Medicine, Dental 

Public Health: $ 20 million 

° MCH Training: $ 20 million 

° Health Professions: $316 million 

° MCH Block Grant: $800 million 

° HRSA Program Mgmt $136 million 

The National Advisory Committee on Rural Health, February 2000 21 
areas. But the formulas (last reviewed in 1982) have been outdated for years, and may no 

longer reflect true demographics. 

The devolution of federal power to the states may have had additional negative impacts upon 

the efficacy of this and other block grants. First, power and funds shifted to state legislatures 

that may have little institutional memory, particularly for those funds previously 

administered at the federal level. Second, some state legislatures might be less likely than 

their federal counterparts to contain strong public health or rural advocates. 

Rural populations served by multiple agencies (local, county, state, federal, including tribal 

and military) create an even more complicated funding picture. In the absence of concerted 

coordination efforts, some rural populations may be ‘over-served’ and others virtually 

ignored. Some public health advocates have called on the Federal government to take the 

lead in rewarding inter-agency collaboration in its distribution of federal funds and providing 

technical resources to facilitate such essential coordination. 

The National Advisory Committee on Rural Health, February 2000 22 
Conclusions 

The instability of the rural public health infrastructure presents a daunting challenge for rural 

health advocates, policymakers, elected officials and public health workers. While much 

work remains to be done, it is important to understand that there is also an opportunity for 

positive change. Despite current problems, however, it is worth noting there has been 

dramatic improvement in public health in the past 100 years. In observance of National 

Public Health Week 1999, the Centers for Disease Control and Prevention identified “Ten 

Great Public Health Achievements in the 20th Century,” which are listed below: 

° Vaccination 

° Motor vehicle safety 

° Safer workplaces 

° Control of infectious diseases 

° Decline in deaths from coronary heart disease and stroke 

° Safer and healthier foods 

° Healthier mothers and babies 

° Family planning 

° Fluoridation of drinking water, and 

° Recognition of tobacco use as a health hazard 

None of these achievements would have been possible without a capable public health 

infrastructure and several of them have not yet fully reached rural communities. The next set 

of improvements may prove a more daunting challenge, especially for rural areas. 

This report has briefly identified and reviewed six salient threats to the rural public health 

infrastructure: leadership, workforce preparedness, safety-net provider support, the impact of 

managed care, telecommunications and funding. It has also tried to identify resources and 

emerging “best practices” that may be of benefit to rural communities and to identify federal 

options to help stabilize the rural public health infrastructure. The challenge comes in 

deciding where the most pressing problems are and what are the best ways to bring about 

needed change. 

The National Advisory Committee on Rural Health, February 2000 23 
Recommendations 

At the close of its September 1999 meeting, the Committee sent two public health 

recommendations to Donna Shalala, the Secretary of the U.S. Department of Health and 

Human Services. They are listed on the following pages: 

The National Advisory Committee on Rural Health, February 2000 24 
 

NACRH-10/01/99 

NATIONAL ADVISORY COMMITTEE ON RURAL HEALTH
 

FISCAL YEAR 2000 RECOMMENDATION
 

Recommendation Title: Improved Coordination of Federal Public Health Activities 

Current Law: (Not applicable, falls within the Secretary’s authority) 

Proposal: The National Advisory Committee urges the Secretary to seek an Executive Order 

for the creation of a Federal Interagency Public Health Coordination Committee comprised 

of senior representatives from the various public health agencies and federal departments. 

The committee would produce an annual report (the first of which would be produced within 

12 months of the establishment of the Committee). The Committee would study current 

efforts by each of the Federal Agencies involved in public health activities overall while 

evaluating ways to integrate funding streams to benefit rural communities in the areas of 

leadership development, workforce development, viability of the safety net, impact of 

managed care, and telecommunications. This committee would include appointed 

representatives from the Department of Health and Human Services, the Department of 

Agriculture, the Environmental Protection Agency, the Department of Commerce, the 

Department of Veteran Affairs, the Department of Labor, the Department of Education, the 

Department of Housing and Urban Development, the Department of Transportation, the 

Department of Defense and any other relevant Federal agencies. 

Rationale: Currently, public health funding is spread across several Federal agencies with 

little or no coordination of how these dollars are targeted. The result is a patchwork of 

Federal programs that leads to confusion and conflicting intents at the State and local level. 

Creation of a Federal inter-agency coordinating committee could go a long way toward 

helping improve interaction among these agencies and the subsequent use of these funds at 

the local level. Ensuring coordination at the Federal level will only serve to improve 

implementation of public health efforts at the community level. This initiative would prevent 

parallel and disconnected activities by different agencies and programs while improving 

evaluation of Federal public health efforts. The further attention to rural public health issues 

would recognize the fact that the majority of local health departments are small entities 

located in rural areas. 

This committee would build upon the efforts of the Public Health Function Steering 

Committee within the Department of Health and Human Services. By expanding to all of the 

cabinet-level agencies, this committee would better ensure coordination of federal public 

health efforts, particularly as they relate to rural areas. Furthermore, this coordinating 

committee could serve as a powerful force for change and improvement at crucial time in the 

evolution of the public health system. Recent changes in the health care system, the impact of 

managed care and continued devolution of Federal responsibility to the states have created a 

great deal of uncertainty over the goals and mission of public health activities. This initiative 

could help provide needed guidance to public health activities and create a framework for 

The National Advisory Committee on Rural Health, February 2000 25 
addressing these challenges. Improved coordination of Federal public health activities could 

help avoid programmatic duplication and improve efforts at strategic planning related to 

public health. This, in turn, would provide assistance to agencies as they comply with the 

Government Performance Results Act (GPRA). 

Effect on Population: Better coordination of Federal public health activities would improve 

delivery of public health services nationwide. 

Cost: (in millions) To be determined by the Secretary 

FY 2000 FY 2001 FY 2002 FY 2003 FY 2004 

Effective Date: To Be Determined 

The National Advisory Committee on Rural Health, February 2000 26 
 

NACRH-10/01/99 

NATIONAL ADVISORY COMMITTEE ON RURAL HEALTH
 

FISCAL YEAR 2000 RECOMMENDATION
 

Recommendation Title: Creation of a Dedicated Funding Stream for Public Health Activities 

Current Law: Public Health Service Act (42CFR) 

Proposal: The Committee urges the Secretary to support the development of a dedicated 

funding stream for public health infrastructure activities with assurances that funding is 

equitably distributed among rural and urban health departments at the local level. 

Rationale: One of the underlying reasons for the current instability across the public health 

landscape lies with the complex and ever-shifting funding sources for these services and the 

rigid nature of the funding requirements. Since federal dollars, usually in the form of block or 

categorical grants, still make up a substantial portion of most states’ public health budgets 

(50-85%), these programs are key determinants of the fiscal capacity of the public health 

infrastructure. Often, those dollars come with strings attached. That means the availability of 

federal dollars often dictates the activities of state public health agencies and their local 

health departments. That leaves public health departments with no funding source to help 

them adapt to the myriad changes now taking place. Public health departments face 

immediate challenges in a number of areas. The growing influence of managed care has had 

a significant impact on public health funding and upon the health care safety net. Studies also 

indicate that less than half of the nation’s public health workforce has had training in public 

health. The expansion of telecommunications technologies holds great promise for use in the 

field of public health both in sharing data and information but also for increasing training 

opportunities. Unfortunately, local health departments have been unable to take advantage of 

these new technologies. These issues and others directly affect the continued viability of 

public health. Federal categorical and programmatic funding has not kept pace. Public health 

departments do not have a direct funding line for responding to the changing environment in 

their respective states and communities. Creation of a dedicated and flexible funding stream 

for public health would improve quality, stability, and accessibility of public local health 

resources. Further, ensuring an equitable distribution between rural and urban health 

departments would ensure that the needed funding gets to the local level. 

Effect on Rural Residents: The provision would ensure that a dedicated funding source 

would be available to address key issues related to the support of the rural public health 

infrastructure that is not tied to categorical constraints. 

Cost: (in millions): To be determined by the Secretary 

FY 2000 FY 2001 FY 2002 FY 2003 FY 2004 

Effective Date: Upon implementation 

The National Advisory Committee on Rural Health, February 2000 27 
 

 

 

 

 

References 

ASTHO (1999). State Office of Rural Health: Survey of Public Health Capacity and Infrastructure in
 

Rural Areas, 1998. Sponsored by the Association of State and Territorial Heath Officials (ASTHO),
 

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