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Indiana Public Health
System Review
December 2020
IU RICHARD M. FAIRBANKS SCHOOL OF PUBLIC HEALTH
2IU Richard M. Fairbanks School of Public Health
Project Leads
Paul K. Halverson, DrPH, FACHE, MSHA, is the Founding Dean and Professor of the IU Richard M. Fairbanks School Public
Health. He holds additional appointments at the IU School of Medicine and the Regenstrief Institute. Halverson previously
served as the State Health Ocer in Arkansas and as a Division Director at the US Centers for Disease Control and Prevention.
Valerie A. Yeager, DrPH, MPhil, is an Associate Professor in the Department of Health Management and Policy. Previously,
Yeager was a Lister Hill Policy Fellow in the Division of Global Migration and Quarantine at the Centers for Disease Control
and Prevention. Her research focuses on public health systems and services across local, state, and federal levels.
External Consultants and Reviewers
Glen P. Mays, PhD, MPH, Professor and Chair, Department of Health Systems, Management and Policy, Colorado School
of Public Health, Anschutz Medical Campus; Former Coordinating Center Director, Public Health Systems and Services
Research, Robert Wood Johnson Foundation.
Hugh Tilson, MD, DrPH, Senior Advisor to the Dean of the Richard M. Fairbanks School of Public Health; Adjunct Professor,
UNC Gillings School of Global Public Health, Co-Chair of the Institute of Medicine’s 1988 Future of Public Health Report;
former North Carolina State Health Ocer and former Local Public Health Director in Oregon and Maine.
With contributions from
Amber Blackmon, MPH
Amanda Briggs, MS
Jyotsna Gutta, MPH
Harold Kooreman, MA, MSW
Nir Menachemi, PhD, MPH
Nadia Unruh Needleman, MS
Joshua R. Vest, PhD, MPH
The authors wish to express sincere gratitude to all participants who shared their experiences and insights via participation in
a qualitative interview.
This report is made possible by funding from the Richard M. Fairbanks Foundation.
CREDITS
3
IU Richard M. Fairbanks School of Public Health
TABLE OF CONTENTS
Executive Summary ........................................................ 4
Section 1: Introduction to Public Health Systems .............................. 8
Section 2: The Public Health System in Indiana
and Comparison States .................................................... 14
Section 3: Evidence Synthesis .............................................. 36
Section 4: Qualitative Insights from Key Stakeholders in Indiana ................ 55
Section 5: Recommendations for Public Health System Change ................. 64
Section 6: Conclusions .....................................................71
References ............................................................... 74
Appendices ............................................................... 82
4IU Richard M. Fairbanks School of Public Health
EXECUTIVE SUMMARY
Regardless of where you live, all people in Indiana deserve
a strong public health system, one that protects and
improves the health of your community and is based
on science and data. However, today, the extent and
quality of public health services that are available in your
community is entirely dependent on what county you live
in. Because most individuals are often not aware of what
“good public health” looks like, or when they might need it,
they generally do not choose to live in a county based on
the public health services available. Fortunately, the work
of dening what “good public health” looks like and how to
measure it is well established and guidance from that work
can be used to inform improvements to Indiana’s public
health system. This study examines the current state of
Indiana’s public health system.1-5 In particular, this report
focuses on the centerpiece of the public health system -
the network of local and state governmental public health
agencies - their structure, human and nancial resources,
authorities, and activities.
EXECUTIVE SUMMARY
Public health is “the science and art of preventing
disease, prolonging life and promoting health through
the organized eorts and informed choices of society,
organizations, public and private communities, and
individuals”.6 In the period of the 20th century, the US
has gained an additional 30 years in life expectancy,
and 25 of those 30 years are attributed to public health
eorts. As a eld, public health includes expertise in
biostatistics and informatics, epidemiology, health
policy and management, social and behavioral health,
and environmental health. In practice, this expertise
includes activities that inuence the social and physical
environments in which we live, policies and interventions
that inuence behaviors, and assuring access to
essential and high quality health care. More specically,
public health activities include a wide range of activities
such as identifying and tracking food-borne pathogens,
intervening in an outbreak, educating communities,
inspecting restaurants, training restaurant workers in
Build and maintain a
strong organizational
infrastructure for
public health
Improve and innovate
through evaluation,
research, and quality
improvement
Build a diverse and
skilled workforce
Enable equitable
access
Utilize legal
and regulatory
actions
Create, champion,
and implement policies,
plans, and laws
Strengthen, support, and
mobilize communities
and partnerships
Investigate,
diagnose, and
address health
hazards and
root causes
Assess and
monitor
population
health
THE 10 ESSENTIAL
PUBLIC HEALTH
SERVICES
To protect and promote the health of all
people in all communities
The 10 Essential Public Health Services
provide a framework for public health
to protect and promote the health of all
people in all communities. To achieve
optimal health for all, the Essential Public
Health Services actively promote policies,
systems, and services that enable good
health and seek to remove obstacles and
systemic and structural barriers, such as
poverty, racism, gender discrimination,
and other forms of oppression, that have
resulted in health inequities. Everyone
should have a fair and just opportunity to
achieve good health and well-being.
Source: http://phnci.org/national-frameworks/10-ephs
5
IU Richard M. Fairbanks School of Public Health
EXECUTIVE SUMMARY
food-borne illness prevention, and developing policies
to make food processing safer. It also includes assuring
that children are immunized, tracing infectious diseases
and contacting individuals who may have been exposed,
and leading communities in public health emergencies
and disasters such as an event that compromises our
water systems, or in outbreaks such as the COVID-19
pandemic.
Clarifying what public health is and what services it
should provide is an essential goal of this report. In fact,
one of the most important ndings of this study is that
many key state stakeholders are unable to dierentiate
between public health and healthcare. While both work to
improve the health of Hoosiers, public health is focused
on preventing illness and protecting the population
from injury, communicable diseases, and premature
death whereas, the vast majority of the time, healthcare
primarily serves to treat disease and injury and is focused
on making people well again. Unfortunately, when we are
unable to dierentiate between these two roles, making
a case for investing more in the public health system is
challenging, especially given the existing high costs of
health care in our state.
Evidence shows that when communities invest more in
public health, they actually spend less on health care
and live longer. However, ndings presented in this
report show that Indiana communities are less likely to
be implementing nationally recommended public health
activities compared to other states. Further, Indiana’s
communities receive less public health funding compared
to neighboring states, companion states, or exemplar
states. Funding for local public health departments
(LHDs), where many of the essential, community-facing
public health activities are conducted, is typically shared
across federal, state, and local sources with the average
US LHD receiving a quarter of its funding from local
funds. However, Indiana’s LHDs rely on local sources
for the majority of their budgets, unlike most other
US communities that rely equally on state and federal
(passthrough) funding in addition to local funding.
This ensures that less resourced communities that likely
have a greater need for the protection and preventive
services public health provides also have less funding and
less capacity to ensure that they receive them. Although
there is value in having direct local connections in every
county, the current structure ensures that many of the 94
LHDs are able to provide only a fraction of the necessary
public health services and expertise that should be
available to all communities. Epidemiologic expertise,
data analytics to inform education and services relevant
to the needs of communities, emergency preparedness
capabilities, and an information technology infrastructure
that allows for an ecient and eective system are skills
and tools that are not present in many of Indiana’s local
settings. This missing expertise and resources translates
to paper-based reporting systems and delays in routine
outbreak identication for diseases like syphilis and HIV
– triggers that should alert ocials about acute crises
earlier rather than later. It also means that public health is
often not factored into local policymaking or community
decisions. While it may be dicult to imagine, during the
early response to the COVID-19 pandemic, there were
LHDs in Indiana that literally closed their doors and were
not participating in the response or available to their
communities. It cannot be more obvious that the public
health system is not functioning as a system when LHDs
are not seamlessly plugged into a statewide response to
a pandemic.
These issues are not for lack of dedication of the public
health workers at the local or the state levels. These are
issues of a system that has been chronically underfunded
and undervalued. In fact, one thing that is consistent is that
public health investments in Indiana are routinely below
US averages and frequently among the lowest across
neighboring, companion, and exemplar states. America’s
Health Rankings rank Indiana 48th for public health funding.
Funding at the local level is particularly low compared to
Health is a dynamic state of complete physical,
mental, spiritual, and social well-being and not
merely the absence of disease or infirmity.
World Health Organization, 1998
Public health is “what we as a society do
collectively to assure the conditions in which
people can be healthy.”
Institute of Medicine, 1988
6IU Richard M. Fairbanks School of Public Health
other states. The national median funding among LHDs is
$41 per capita and the 25th percentile is $23 per capita,
but the majority of LHDs in Indiana have per capita budgets
far below these levels. In fact, at least 37 of the 94 LHDs in
Indiana have per capita budgets of less than $10 per capita.
Understanding how Indiana’s public health system is
structured and nanced is important in the context
of benchmarking health outcomes across states.
For example, Indiana ranks 41st among all states on
public health and is at least 10% below the US average
rate for preventable mortality such as infant deaths,
accident deaths, and alcohol, drug, and suicide deaths.
In terms of prevention, Indiana has particularly low
rates of vaccinations for inuenza, childhood vaccines,
and adult and elderly vaccines, and the state scores in
the bottom tier nationally with respect to public health
preparedness. Indiana also has one of the highest rates
of adult smokers in the nation (21.8% compared to the
national average of 17.1%), contributing to higher rates of
preventable chronic diseases and cancers.
Based on feedback from stakeholders, Indiana’s
communities are ready for change and willing to work
together to make improvements to the public health
system. A total of 49 stakeholders participated in an
interview for this report and contributed feedback and/
or ideas for improvements to the public health system in
Indiana. The review of the scientic evidence for public
health systems change presented in Section 3 and the
insights provided by Indiana stakeholders in Section 4
informed the recommendations in this report.
In general, the recommendations are focused on
achieving better health for Hoosiers through a more
robust public health system and one that ensures that
the Foundational Public Health Services are provided
to all communities. A stronger, appropriately-funded
public health system means better capacity at the local
and state levels and improved eectiveness of public
health eorts. These improvements will allow Indiana’s
public health agencies to work with public health
partners and to have a bigger collective impact and
begin to address the upstream social determinants of
health. Indiana’s public health system needs substantial
funding increases at both the state and local levels. Four
overarching recommendations are presented in Section
5. These include:
1. Create a uniform approach to deliver the
Foundational Public Health Services (FPHS)
across the state
EXECUTIVE SUMMARY
7
IU Richard M. Fairbanks School of Public Health
2. Create a district-level mechanism to enable
resource sharing among LHDs
3. Strengthen the State Health Department’s
oversight and enabling capacity to support the
local public health delivery system
4. Under the auspices of the state board of
health, create a multi-disciplinary state-wide
implementation committee tasked with executing
the recommended implementation steps outlined
in Section 5
In addition to the 4 recommendations, 15 implementation
steps necessary to improve the capacity and eectiveness
of Indiana’s public health system are provided. In brief,
these steps include the establishment of district level
capacity that will provide resource-sharing of expertise
and services in support of existing LHDs. District oces
should be led by a full-time District Health Ocer
with formal public health training. The District Health
Ocer should be supported by a district leadership
network comprised of health ocials/administrators
from each LHD within the district. Such a structure will
provide district-level strategies that are both resourced
and informed by expertise, local-level data, and local
perspectives. Existing LHDs and district oces will
work together to provide a core package of public health
services that is aligned with the Foundational Public
Health Services for local public health and supports the
state public health system in assuring the 10 essential
services across Indiana.
Specic state-level improvements recommended in
this report include: structures to ensure expertise and
essential skills across the state and local workforce;
information systems that employ a common data
platform and ensure real-time reporting at all levels of the
public health system; state-wide standards that assure
continuous quality and performance improvement; and
improved collaboration between the state and local levels
and with partners external to public so that the state can
work more eectively to improve the health of Hoosiers.
The implementation of the recommendations in this
report will need a clear path to implementation with
funding but with incremental rollout and should be
informed by an empowered state-wide committee made
up of state and local public health representatives as well
as state, county, and city leaders, health care leaders, and
other key stakeholders. While priority should be given
to the establishment of the district health oces and
the provision of core public health services, each of the
implementation steps will need to be strategically phased
into the plan to improve Indiana’s public health system.
Lastly, although all of the costs needed to make
improvements to the public health system are not
estimated in this report, estimates for the priority
actions (district health oces supported by a state-
level expertise and the provision of core public health
services) have been provided along with potential
funding mechanisms for consideration. Of particular
importance is the potential of an increase in tax on the
sale of tobacco products, the most eective mechanism
to reduce tobacco use. Revenue from an increased
tobacco tax should be dedicated to the public health
system and should fund the establishment of an Indiana
Public Health Trust Fund. The Trust Fund would allow for
the new revenue to generate interest and to support the
phased implementation of public health improvements.
The Trust Fund should be explicitly limited to ensuring
the provision of Foundational Public Health Services
and related infrastructure for the public health system.
As a matter of priority, an initial $50 million should be
dedicated in year one of this work with increases annually
over 5 years so that the system has consistent, annual
funding of at least $338 million from the Public Health
Trust Fund. This consistent funding will allow public health
agencies to plan strategically for a future where Indiana
is among the top states in health outcomes rather than
the bottom. There is a bi-directional connection between
health and wealth, not just for individuals but for their
communities and their economies.
As the report indicates, substantial changes are needed
to improve the Indiana public health system, and it is clear
that stakeholders are ready and willing to get started.
Specic thanks and appreciation are due to the hundreds
of public health workers at the state and local levels that
toil every day on behalf of the people of the state and who
do so without the resources they need to do the best job
they can. This report was written to support their work
and give them the tools they need to improve the public
health system for Hoosiers. COVID-19 sounded the alarm
and the status quo is no longer sucient.
EXECUTIVE SUMMARY
8IU Richard M. Fairbanks School of Public Health
SECTION 1: INTRODUCTION TO PUBLIC HEALTH SYSTEMS AND BACKGROUND
The US public health system includes local, state, and
federal governmental public health agencies as well
as numerous multisectoral partners including health
care organizations, community-based organizations,
schools, industry, and other governmental agencies. With
leadership from state and local public health departments,
the public health system protects and promotes the
health of all members of our communities. Through the
provision of the Essential Public Health Services, state and
local agencies ensure policies, systems, and services that
enable good health and work to remove barriers to health
equity, ensuring that all individuals have the opportunity
to achieve good health and well-being (see Figure 1).5
Public health is “the science and art of preventing disease,
prolonging life and promoting health through the organized
eorts and informed choices of society, organizations,
public and private communities, and individuals”.6 While
public health and medicine work together, the focus
of public health is on prevention rather than curative
aspects of health. Additionally, public health is focused
on the population as a whole rather than one individual
or one individual health issue. As a eld, public health
includes expertise in biostatistics, epidemiology, health
policy and management, social and behavioral health, and
environmental health. In practice, this expertise includes
activities that inuence the social and physical environments
in which we live, policies and interventions that inuence
behaviors, and assuring access to essential and high quality
health care. More specically, public health activities include
a wide range of activities such as identifying and tracking
food-borne pathogens, intervening in an outbreak, educating
SECTION 1: INTRODUCTION TO PUBLIC HEALTH
SYSTEMS AND BACKGROUND
Build and maintain a
strong organizational
infrastructure for
public health
Improve and innovate
through evaluation,
research, and quality
improvement
Build a diverse and
skilled workforce
Enable equitable
access
Utilize legal
and regulatory
actions
Create, champion,
and implement policies,
plans, and laws
Strengthen, support, and
mobilize communities
and partnerships
Investigate,
diagnose, and
address health
hazards and
root causes
Assess and
monitor
population
health
THE 10 ESSENTIAL
PUBLIC HEALTH
SERVICES
To protect and promote the health of all
people in all communities
The 10 Essential Public Health Services
provide a framework for public health
to protect and promote the health of all
people in all communities. To achieve
optimal health for all, the Essential Public
Health Services actively promote policies,
systems, and services that enable good
health and seek to remove obstacles and
systemic and structural barriers, such as
poverty, racism, gender discrimination,
and other forms of oppression, that have
resulted in health inequities. Everyone
should have a fair and just opportunity to
achieve good health and well-being.
Source: http://phnci.org/national-frameworks/10-ephs
Figure 1.
9
IU Richard M. Fairbanks School of Public Health
SECTION 1: INTRODUCTION TO PUBLIC HEALTH SYSTEMS AND BACKGROUND
communities, inspecting restaurants, training restaurant
workers in food-borne illness prevention, and developing
policies to make food processing safer. It also includes assuring
that children are immunized, tracing infectious diseases
and contacting individuals who may have been exposed,
and leading communities in public health emergencies and
disasters such as an event that compromises our water
systems or in outbreaks such as the COVID-19 pandemic.
In the period of the 20th century, the US has gained an
additional 30 years in life expectancy. Twenty-ve of
those 30 years are attributed to public health eorts,
including the 10 great public health achievements (see
Figure 2).7,8 These achievements include the provision of
immunizations, family planning, and support for healthy
mothers and babies. Deaths from heart disease and stroke
were prevented by public health activities and policies
that decreased tobacco use, improved what people eat,
and reduced children’s exposure to lead. Tooth decay, the
most common disease of childhood, declined with the
equitable provision of uoridation in community drinking
water systems. Prior to the introduction of workplace
safety policies, injuries were one of the most common
reasons for preventable deaths in the early 20th century.
Each of these public health achievements has played a
role in improving the health of the population.
In general, at the federal level, governmental public health
is responsible for the documentation of the health status
of our population including providing data systems and
analysis. Federal level public health also sponsors relevant
research, programs, and activities and formulates national
objectives and policy related to public health. Such
policies may include setting standards for performance
and protection of the public’s health. Agencies at the
federal level include the Health Resources and Services
Administration (HRSA) and the Centers for Disease
Control and Prevention (CDC).
At the state level, public health agencies exist within
super agencies or as free-standing agencies like the
Indiana Department of Health (IDOH). State public health
agencies are responsible for collecting and analyzing
state health statistics and reporting these to the federal
public health agencies. They maintain state laboratories,
Figure 2.
10 GREAT PUBLIC HEALTH ACHIEVEMENTS
Control of
Infectious Diseases
Family
Planning
Healthier Mothers
and Babies
Motor Vehicle
Safety
Tobacco as a
Health Hazard
Declines in deaths from
heart disease and stroke
Fluoridation of
Drinking Water
Immunizations Safer and
Healthier Foods
Workplace
Safety
Health is a dynamic state of complete physical,
mental, spiritual, and social well-being and not
merely the absence of disease or infirmity.
World Health Organization, 1998
Public health is “what we as a society do
collectively to assure the conditions in which
people can be healthy.”
Institute of Medicine, 1988
10 IU Richard M. Fairbanks School of Public Health
SECTION 1: INTRODUCTION TO PUBLIC HEALTH SYSTEMS AND BACKGROUND
establish and police public health standards for the
state, grant licensure to health care professionals and
institutions, lead public health education eorts in the
state, and establish policies on how local public health
units function and their responsibilities, and determine
funding for local health agencies by disseminating federal
public health resources. State public health agencies also
work with state leaders to declare a state of emergency,
activate state response plans, and request federal
assistance during emergencies.
Local public health departments (LHDs) and their
workforces are the frontlines of public health eorts and
they operate under the authority of the state. They are
responsible for conducting environmental inspections
related to water, sanitation, restaurant safety, and
daycares. LHDs provide communicable disease control,
childhood immunizations, health screenings, and in some
locations, direct clinical care including sexually transmitted
disease clinics. They also maintain vital records such as
birth and death records for their communities. LHDs have
substantial variation in human and nancial resources
as well as community needs and public health priorities.
State and local public health structure, function, funding,
and workforce requirements vary across the nation and
Section 2 of this report characterizes Indiana’s public
health system as it relates to those of other states.
An important component of understanding the role
of public health in state and local communities is
understanding what makes us healthy. While access to
health care is a crucial part of health, it actually makes
up the smallest proportion of what makes us healthy
(about 10%) (see Figure 3). Instead, the vast majority
of what determines our health is the environment we live
in (20%) and our behaviors (50%). Public Health eorts
specically focus on both of these determinants of health,
yet the majority of the dollars spent toward health are
Figure 3.
Source: https://bipartisanpolicy.org/report/what-makes-us-healthy-vs-what-we-
spend-on-being-healthy/
While access to health care is a crucial
part of health, it actually makes
up the smallest proportion of what
makes us healthy (about 10%) (see
Figure 3). Instead, the vast majority
of what determines our health is the
environment we live in (20%) and
our behaviors (50%). Public Health
efforts specifically focus on both of
these determinants of health, yet the
majority of the dollars spent toward
health are spent on medical services.
Not only are these resources directed
at the determinant which has the
smallest impact on overall health,
the resources are often spent when
an individual is already sick. If those
health dollars are instead invested
earlier, in the form of public health
protections and prevention of illness,
they would extend further.
11
IU Richard M. Fairbanks School of Public Health
SECTION 1: INTRODUCTION TO PUBLIC HEALTH SYSTEMS AND BACKGROUND
spent on medical services. Not only are these resources
directed at the determinant which has the smallest impact
on overall health, the resources are often spent when an
individual is already sick. If those health dollars are instead
invested earlier, in the form of public health protections
and prevention of illness, they would extend further. For
example, annual governmental public health spending
is approximately 3% of the national health expenditures
despite that more than 75% of the overall health care
costs are attributable to preventable health conditions.9
Until recently, much of the discourse about improving
health in the US overlooked the role of public health.
The COVID-19 pandemic has reminded everyone of the
important role public health systems have in protecting and
ensuring the public’s health. Unfortunately, this reminder
simultaneously highlighted the limitations of the existing
system including the limited funding for public health.
The US public health system was established in alignment
with the perspective of federalism whereby each state
determines the structure, governance, and activities of
their governmental public health system. In 1988, the
Institute of Medicine (now the National Academy of
Medicine) reported that the public health system was in a
state of disarray and that there was a lack of consistency
in what activities and assurances public health was
providing populations across states.10 Over the three
decades since the pivotal 1988 Future of Public Health
Report, several attempts have been made to establish
national and state-based standards for public health
agencies; however, because state public health has so
much exibility, there remains a lot of variation. First, the
Essential Services were outlined as a guiding framework
by the 1988 IOM Committee, establishing assessment,
policy development, and assurance as the three core
functions of public health. Within these three functions,
ten essential services were outlined.
In 2003 the IOM again convened a committee to review the
Figure 4.
12 IU Richard M. Fairbanks School of Public Health
SECTION 1: INTRODUCTION TO PUBLIC HEALTH SYSTEMS AND BACKGROUND
state of public health in the US and issued a report entitled:
“The Future of the Public’s Health in the 21st Century,”
which recommended the development of national public
health accreditation.11 Building a program for public health
accreditation took the better part of a decade, but national
voluntary accreditation for public health agencies launched
in the fall of 2011 with the rst health departments receiving
accreditation in 2013. Public Health accreditation provides
a standard framework for health departments to prioritize
services, initiatives, and eorts to best promote and
protect the health of their jurisdictions (see Appendix A
for a summary of the national accreditation standards and
measures).3 Uptake has been progressing, but adoption of
accreditation varies across the nation. As of September
2020, the Public Health Accreditation Board (PHAB)
reported that 82% of the US population is covered by an
accredited health department. This includes a total of
36 state, 263 local, 4 Tribal, 1 statewide integrated local
public health department system, and 2 Army Installation
Departments of Public Health.12
The Public Health 3.0 framework is another national
eort to guide and inform the work of governmental
public health agencies. It outlines a strategy for public
health agencies to serve as the chief health strategist in
their communities and to play a key role in leading public
health system partners in addressing social determinants
of health.13 Figure 4 is a diagram of a functioning public
health system. Public health agencies connect and lead
other community partners in the eort to promote and
protect public health and specically address social
determinants of health.
The Foundational Public Health Services (FPHS) is a
recently developed framework for guiding public health
practitioners and ensuring sucient infrastructure for
eective public health systems.14 It outlines foundational
capabilities and public health programs that should
be provided to communities. The FPHS framework is
particularly useful in guiding local public health agencies
and is used for assessing the capacity of the public health
system (see Figure 5).
A particular initiative focused on implementing the
FPHS is called the 21st Century Learning Community, a
program funded by the Robert Wood Johnson Foundation
and supported by the Public Health National Center for
Innovation.15 More specically, the purpose is to support
states in the process of rethinking and strategically
transforming their public health systems. The rst
three states to participate included Ohio, Oregon, and
Washington. Case summaries that explain the eorts in
each of these three states are included in Section 4 of
this report. A total of 10 states are now working toward
modernization of their public health systems as a part of
the 21st Century Learning Community.
Purpose
The response to the COVID-19 pandemic has highlighted
the crucial role the public health system plays in protecting
populations and ensuring the health of our communities.
It has also drawn attention to ways that the system is
strained and limited. The purpose of this report is to
summarize the current state, including the challenges and
strengths, of Indiana’s public health system and to make
recommendations for improvements to the system. To do
so, the current report includes four main components.
• In Section 2, we present a wide range of data to
characterize the context of Indiana’s public health system.
We compare Indiana to neighboring states, states similar
in political culture, policy, and structure (cohort states), as
well as states where innovative public health approaches
have been employed (exemplar states). We specically
examine funding as well as health outcomes impacted by
public health systems such as preventable conditions and
deaths. We also summarize the workforce and structure
of public health within Indiana.
• For Section 3, we have conducted a rapid assessment
of the evidence focused on public health systems
strengthening initiatives. These include structural
changes to state public health systems, resource
sharing within state public health systems, and
strategies such as accreditation of public health
agencies and partnering with organizations outside of
governmental public health. We also examine the role
of public health funding as it relates to health and the
eectiveness of public health systems.
• In Section 4, a list of stakeholders who have contributed
their experiences and insights is provided. A summary
of key insights, challenges, and ideas for resolving these
challenges is provided along with quotes that provide
context for the main themes identied.
• In Section 5, in the context of the insights provided by
13
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SECTION 1: INTRODUCTION TO PUBLIC HEALTH SYSTEMS AND BACKGROUND
the review and stakeholders, we prioritize 4 overarching
recommendations for making improvements to Indiana’s
public health system. Consideration was given to
feasibility and acceptability of these recommendations
given insights from key stakeholders within the public
health system. It should be noted that while 15 specic
implementation steps are provided, these changes will
require stakeholder input and need to be approached
incrementally. Some of the recommendations will be
easier than others to implement and some will take
time. In sum, the recommendations oer a path toward
an eective public health system for the improved
health of Hoosiers.
Limitations
Our process and methodology have several limitations to
note. First, this study was conducted during the ongoing
COVID-19 pandemic, which may have inuenced the
perspectives of stakeholders who contributed insights
through their participation in a qualitative interview.
However, the COVID-19 epidemic provided an important
opportunity to highlight the challenges of Indiana’s public
health system under extreme pressure. Second, we
recognize that there may be additional variables that could
provide insight about Indiana’s public health system or any
of the comparison states’ systems. Further examination of
any of the specic areas of focus may provide additional
and valuable insight moving forward. We presented the
most up-to-date data whenever possible; however, in some
cases the most recent data may be several years old. With
respect to the rapid synthesis of the evidence, while we
have followed standard search protocols, we acknowledge
that there may be additional studies or grey literature that
could have been missed. We believe we have identied
the most relevant studies and cases in the evidence
synthesis. In regard to the recommendations, while
these are framed with the ndings of the current review
in mind, we recognize that there will be implementation
details and decisions that are beyond the scope of the
recommendations made in this report. We welcome the
establishment of a state strategic planning committee of
key public health stakeholders focused on implementing
change and improving Indiana’s public health system.
Figure 5.
14 IU Richard M. Fairbanks School of Public Health
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
This chapter examines characteristics of Indiana’s public
health system, structure, governance, and activities, its
workforce, its nancing, and related health outcomes.
Further, to position where Indiana is in relation to other
states, we examined three collective groups (see Figure
6): neighboring states that experience similar regional
SECTION 2: THE PUBLIC HEALTH SYSTEM IN
INDIANA AND COMPARISON STATES
and cultural norms; companion states that were selected
based on similarities in political leadership and historic
voting patterns or being home rule states; and exemplar
states that have implemented innovative public health
system changes in recent years. A list of states included in
each of these groupings is summarized below.
NEIGHBORING STATES COMPANION STATES EXEMPLAR STATES
Illinois Alabama Washington
Kentucky Arizona Minnesota
Ohio Arkansas North Carolina
Michigan Georgia Oregon
Missouri
Nebraska
South Carolina
Tenessee
Figure 6.
15
IU Richard M. Fairbanks School of Public Health
Figure 7.
Public Health System Structure,
Governance, and Activities
State Public Health in Indiana
Indiana’s public health system consists of the state health
department (the Indiana Department of Health/IDOH)
and 94 local health departments (LHDs).
The Indiana Department of Health (IDOH) is an executive
branch agency of state government. IDOH has four major
operating units called “commissions.” These include:
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
Consumer Services & Health Care Regulation Commission;
Health and Human Services Commission; Laboratory
Services Commission, and the Public Health Protection
Commission. The Department is led by the State Health
Commissioner, Kristina Box, MD, FACOG, who was appointed
in 2016 by Governor Eric Holcomb in his rst term. Figure 7
shows the current organizational chart of the IDOH.
The budget for the State Health Department is contained
within the Health and Human Services function of the
state government, which is the second largest expenditure
16 IU Richard M. Fairbanks School of Public Health
function (24% in 2020) after education (62%).
Within the Health and Human Services function, the
Medicaid budget is the largest share of the 2020 budget
at 63.6%, whereas IDOH is the 10th largest budget line at
$29.6 million. The responsibilities and general roles of the
SHD and LHDs are presented in Figure 8.
Local Public Health in Indiana
Among the 94 LHDs, 91 are county-based health
departments (Fountain County and Warren County
share a LHD) and 3 are city health departments (East
Chicago, Gary, and Fishers).16 Since 1980, Indiana
is a “Home Rule” state. This policy means that a
municipality or county government has autonomy
from the state government in local affairs including
land use, public safety, and public health unless
specifically prohibited by State statute. In the context
of public health, Home Rule translates to wide variation
in the structure, financing, size, and activities of LHDs.
However, Indiana Code does provide rules on local
Boards of Health, the appointment of local health
officials, and the requirement that local health officials
be a medical doctor, but there is no requirement for a
minimum level of public health training or experience.17,18
While substantial variation in LHDs exists, the majority
are small agencies by any measure.
The majority of LHDs in Indiana serve smaller populations.
Indiana’s LHDs range in size from serving populations of
less than 10,000 to serving populations of communities
nearly 1 million residents. However, nearly one-third of
LHDs serve areas with fewer than 25,000 residents and
more than two-thirds of all LHDs serve areas with less
than 50,000 residents (see Figure 9). Measuring LHDs
by number of employees demonstrates a similar variance
and a predominance of small agencies. LHDs range in
employee size from a sta of as few as 3 individuals to as
many as 812 (see Figure 10). The majority of LHDs in the
state (69%; n=65/94) have less than 10 employees (full-
and part-time combined).
Another indicator of size is the employment status of the
local health ocial. Based on 2016 data provided by LHDs
(n=68) to IDOH in their annual survey on structure and
nancing, the majority of LHDs (62%) have a health ocial
in a part-time capacity and 38% have full-time health
ocials (see Appendix B). The average size of a LHD with
a part-time health ocial is 10 employees (ranging from 3
to 28 employees). Excluding Marion County, the average
size of LHD with a full-time health ocial is 21 employees
(ranging from 6 to 92 employees). When Marion County,
the largest LHD in the state, is included in the calculation,
the average number of employees in LHDs with a full-time
health ocial increased to 52 employees (ranging from
6 to 801 employees). Note that the total number of LHD
employees used in these calculations include both full-
and part-time employees.
Those activities that are specically mandated by law
to be provided at the LHD level are detailed in Figure
11. In sum, many of the community-facing services are
provided at the local level by LHDs. For this reason,
prior to COVID-19, relatively few members of the general
community interacted with the SHD or had a clear sense
of what services public health provides at either the state
or the local level.
Numerous national studies describe the strength and
eectiveness of the public health system based on the
activities provided by public health agencies directly
and indirectly through their network of multi-sectorial
partners.19,20 In general, these eorts categorize the
scope of public health activities or the proportion of 20
recommended public health activities implemented in
each county (see Appendix C). In addition to examining
these 20 activities, network density or the network of
community organizations that work together with public
health to implement these recommended activities
is measured.21 Last, a composite measure of public
health system capability combines scope of public
health activities and network density into a categorical
measure of the system with three levels including: 1) a
comprehensive system that is implementing the broadest
scope of activities and engaging the most dense network
of partners toward those activity goals; 2) a conventional
system where there are moderate to high levels of scope
of activity and an intermediate network density; an 3) a
limited system which has relatively low levels of scope
of activity as well as low network density. Across the 10
public health districts in Indiana, an average of 50% of
the 20 activities are being implemented by LHDs ranging
from 40% in District 3 to 67% in District 10 (see Figures
12 & 13).
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
17
IU Richard M. Fairbanks School of Public Health
Figure 8. State/Local Responsibilities
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
18 IU Richard M. Fairbanks School of Public Health
Figure 10. Average Number of Full and Part Time Employees by Size of Jurisdiction Served
160
140
200
180
120
100
80
60
40
20
0
Full-time employees Part-time employees
Very Small
(<25K)
Small
(25K to 50K)
Medium
(50K to 100K)
Large
(100K to 250K)
Very Large
(>250K)
3.2 2.4 6.2 2.6
14.9
6.0
29.9
6.8
194.8
17.0
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
Figure 9. Number of LHDs per Size of Population Served
30
35
12 12
5
40
35
30
25
20
15
10
5
0Very Small
(<25K)
Small
(25K to 50K)
Medium
(50K to 100K)
Large
(100K to 250K)
Very Large
(>250K)
19
IU Richard M. Fairbanks School of Public Health
Provide vital records services and access to public records, birth and death services
e.g., Birth/Death records, name changes, etc.
Associated Legislation: IC 5-14-3; IC 16-20-1-17; IC 16-21-11-6; IC 16-34-3-4; IC 16-35-7; IC 16-37; IC 16-37-1-9; IC 16-38-2-7; IC 16-
38-4; IC 16-38-6-7; IC 16-41-6-9; IC 23-14-31; IC 23-14-57; IC 31-19-5; IC 31-19-13; IC 34-28-2; IC 36-2-14; IC 10-13-5-11; 410 IAC 18
Ensure safe and sanitary food and lodgings
e.g., food inspections, regulations of food/drugs/cosmetics, certifications for food handlers, and establishment of sanitary
requirements for establishments which provide food and/or lodging
Associated Legislation: IC 16-18-2-137; IC 16-20-8; IC 16-41-31; IC 16-42; IC 16-42-5; 410 IAC 7-15.5; 410 IAC 7-22; 410 IAC 7-23;
410 IAC 7-24; IC 16-41-30
Ensure a healthy, clean environment by monitoring and regulating waste and sewage disposal
e.g., set standards for residential sewage disposal and commercial wastewater disposal)
Associated Legislation: 410 IAC 6-8.3; 410 IAC 6-10.1; 410 IAC 6-12; IC 16-41-25; IC 13-26-5-2.5
Perform disease control measures and infectious disease surveillance
e.g., reporting communicable diseases, ensuring confidentiality of individuals is not compromised in reporting, implementing
public health measures to control communicable diseases and epidemics, providing vaccination for indigent individuals
Associated Legislation: IC 16-20-1-21; IC 16-20-1-24; IC 16-41; 410 IAC 1-2.2-5; 410 IAC 1-2.3; 410 IAC 1-2.5-48; 410 IAC 29; IC
16-41-19; 410 IAC 6-9-5(b); IC 16-20-1-25; IC 16-41-8
Control pests and vectors
e.g., provisions for eradication of rats
Associated Legislation: IC 16-41-33; IC 16-41-34
Minimize childhood lead poisoning through reporting, monitoring, management of cases, and implementing preventive
measures
Associated Legislation: 410 IAC 29; IC 16-41-39.4
Provide immunization services
e.g., all child immunizations and basic adult immunizations (including influenza), provide vaccinations/antitoxins to persons
unable to purchase (for diphtheria, scarlet fever, tetanus, and rabies)
Associated Legislation: IC 16-41-19-2
Inspect and license railroad camp cars
Associated Legislation: IC 8-9-10; 410 IAC 6-14
Ensure that dwellings are safe for human habitation
Associated Legislation: IC 16-41-20
Authorize mass gatherings through licensing
Associated Legislation: IC 16-41-22-12; IC 16-41-22
Establish child fatality review teams
Associated Legislation: IC 16-49-2 & 3
Assume jurisdiction over temporary campgrounds (campgrounds operated not more than 10 consecutive days per event,
and not more than 30 days per calendar year)
Associated Legislation: 410 IAC 6-7.1-16 and 7.1-33
Reporting of spills and overows from underground sewage tanks
Associated Legislation: IC 13-23-16
Inspection and cleanup of property/vehicles contaminated by methamphetamine production
Associated Legislation: 318 IAC 1; IC 24-5-13, sections 4.1, 16.1, 16.2, and 24
Notify the public (at least 48 hours beforehand) of board and agency meetings
Associated Legislation: IC 5-14-1.5
Assume responsibility for health-related areas during emergencies/disasters
Associated Legislation: IC 10-14-3
Ensure public and semi-public pool/spa compliance with established standards
Associated Legislation: 15 U.S.C. 8001-8008
Figure 11. Indiana Mandated Local Health Department Activities
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
20 IU Richard M. Fairbanks School of Public Health
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
Figure 12. Map of Average Proportion of Activities Completed by LHDs at District Level (weighted by
population)
The shade of red color
reects the average
proportion of activities
in a district. Lighter
colors indicate a higher
proportion of activities
among LHDs in that
district, whereas a
darker red indicates a
lower proportion.
21
IU Richard M. Fairbanks School of Public Health
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
There is some variation in public health system capabilities
across the 10 districts in Indiana (see Figure 14). However,
at least half of the LHDs in every district have ‘limited’
capabilities and the majority of LHDs in 6 of the 10
districts have ‘limited’ capabilities. Nine of the 10 districts
do have LHDs with a small proportion of comprehensive
capabilities. Note that in 4 of the 10 districts there were no
LHDs with comprehensive capabilities.
Size of jurisdiction has implications for public health
system capabilities (see Figure 15). In particular, when
LHDs are grouped by size of jurisdiction served, 3 of the
5 groups of LHDs contained some agencies that had
comprehensive capabilities. These included the small,
medium, and large LHDs, but not very small or very large
LHDs. Among those groups, the highest proportion of
LHDs that had comprehensive capabilities was 30%. The
majority of all but the large LHDs had limited capabilities,
which speaks to the overall limited capabilities of the public
health system in the state. Note that none of the very large
or very small LHDs had comprehensive capabilities.
The Public Health Workforce
Currently, a total of 814 employees plus another 336
contractors work for the IDOH. The 2014 and 2017
Public Health Workforce Interests and Needs Survey,22 a
national survey of governmental public health workers,
examined topics such as demographics and education,
job satisfaction, intentions to leave the workforce, as
well as skill gaps and training needs. In general, Indiana’s
state public health workforce is similar to the national
public health workforce in age (average age in Indiana is
46.1 years compared to 47.5 nationally) and gender (74%
female in Indiana compared to 77% nationally).
A higher proportion of Indiana’s state workforce has
shorter tenure (new recruits with 0-5 years of experience)
compared to the national averages (61% versus 43%
respectively in 2017). In fact, Indiana’s state public health
Figure 13. Average Proportion of Recommended Activities Completed by LHDs at District Level (weighted
by population)
80%
70%
100%
90%
60%
50%
40%
30%
20%
10%
0% 1 2 3
Public Health Preparedness District Number
4 5 6 7 8 9 10
22 IU Richard M. Fairbanks School of Public Health
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
Figure 15. Count of Local Health Departments by Public Health Capability by Size of Population Served
80%
70%
100%
90%
60%
50%
40%
30%
20%
10%
0%
Comprehensive
Percentage of health departments
Conventional Limited
Very Small
(<25K)
Small
(25K to 50K)
Medium
(50K to 100K)
Large
(100K to 250K)
Very Large
(>250K)
Figure 14. Count of Local Health Departments by Public Health Capability by District
80%
70%
100%
90%
60%
50%
40%
30%
20%
10%
0% 1 2 3
Public Health Preparedness Districts
Comprehensive
4 5 6 7 8 9 10
Percentage of health departments
Conventional Limited
23
IU Richard M. Fairbanks School of Public Health
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
workforce with 0 to 5 years of experience grew from
50% in 2014 to 61% in 2017, indicating that public health
agencies are recruiting new individuals to their agencies.
Compared to national responses in 2017, Indiana’s public
health workforce has slightly higher levels of education
with 42% having Bachelors degrees and 29% having
Masters degrees, compared to an average of 35% and
26% nationally. These statistics may be tied to the
increases in new sta and the introduction of two schools
and multiple programs of public health to Indiana’s higher
education environment in the last decade.
Indiana’s public health state workforce reported higher
levels of satisfaction with their jobs and their organizations
in 2017 compared to 2014. In particular, among Indiana’s
2017 PH WINS respondents, 86% reported being
somewhat or very satised with their jobs; however, 29%
reported planning to leave governmental public health
in 2018. Additionally, only 3% of these individuals plan
to do so as a result of retirement. The top 5 reasons for
planned voluntary turnover among respondents include
pay (58%), lack of opportunities for advancement (42%),
other opportunities outside the agency (24%), weakening
of benets (23%), and other reason (23%).
The 2017 PH WINS identied a number of self-reported
“skill gaps” among Indiana’s state health department
workforce by level of supervisory status (see Figure 16).
Public Health Financing
Public health funding is a mix of dollars from federal
sources, state sources, and local sources making
public health financing particularly complex. One
thing that is consistent is that public health
investments in Indiana are consistently below US
averages and frequently among the lowest across
neighboring, companion, and exemplar states as
shown in the three diagrams below (see Figure
17). This includes federal funds from the Centers for
Disease Control and Prevention (CDC) and the Health
Resources Services Administration (HRSA), as well
as overall state and local investments in public health.
IDOH’s total 2019 budget from all sources was $343.6
million with the largest portion ($232.1 million; 67.5%)
sourced by federal funding followed by dedicated state
funds ($79.8 million; 23.2%), and state general funds
Top Skill Gaps and
Training Opportunities
Non-supervisors
Systems and Strategic Thinking
Budget and Financial Management
Develop a Vision for a Healthy Community
Supervisors and Managers
Budget and Financial Management
Systems and Strategic Thinking
Cultural Competency/Competence
Executives
Budget and Financial Management
Change Management
Develop a Vision for a Healthy Community
Figure 16. Indiana’s State Public Health
Workforce Gaps and Training Opportunities
24 IU Richard M. Fairbanks School of Public Health
Figure 17. Public Health Investment
Public Health Investment Across Neighboring States
Public Health Investment Across Comparison States
Gray bands represent
range of comparison
states as percent change
from the US rate (dotted
line). A red dot indicates
Indiana is at least 10%
worse than the US rate,
an orange dot indicates
5% worse, and a green
dot indicates 10% better
than the rate of the
US overall. A grey dot
indicates that Indiana is
not signicantly dierent
from the US rate.
SOURCE
• Trust for America’s
Health, Investing in
America’s Health,
201623
• Trust for America’s
Health, A Funding
Crisis for Public Health
and Safety, 201724
• Center for Disease
Control and Prevention,
Map of Funding –
Appropriations/Grants
Total Per Capita25
• Trust for America’s
Health, Ready of Not:
Protecting the Public’s
Health from Diseases,
Disasters and
Bioterrorism, 201926
• Trust for America’s
Health, Promoting
Health and Cost
Control in States,
201927
• WalletHub, States that
Vaccinate the Most,
201928
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
25
IU Richard M. Fairbanks School of Public Health
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
Public Health Investment Across Exemplar States
Gray bands represent
range of comparison
states as percent change
from the US rate (dotted
line). A red dot indicates
Indiana is at least 10%
worse than the US rate,
an orange dot indicates
5% worse, and a green
dot indicates 10% better
than the rate of the
US overall. A grey dot
indicates that Indiana is
not signicantly dierent
from the US rate.
($31.8 million; 9.2%). State dedicated funds include
those funding sources that are earmarked for specific
public health programs such as the Tobacco Master
Settlement Agreement, the administration of the
Youth Risk Behavior Survey (YRBS), or the Safety Pin
(Protecting Indiana’s Newborns) Program targeting
infant mortality prevention.
Approximately, 8.4% ($28.9 million) of IDOH’s annual
budget is allocated to the 94 local health departments
(LHDs) and the services they provide their communities.
In other words, including both the state general fund and
state dedicated funds, the SHD provides approximately
1.3 cents per capita to the local provision of public health
programs and services.
When considering the entire budget of LHDs as a whole
(state, federal, and local funds), LHD expenditures per
capita vary greatly by state. For example, in 17 states
including Indiana, LHD expenditures were less than $30
per capita on average whereas 15 states spend between
$30-50 per capita, 4 spend between $50-70 per capita,
and another 8 states spend more than $70 per capita.29
Indiana’s average per capita revenues across LHDs in the
state are low compared to national NACCHO reported
distributions (see Figures 18 & 20).29 Note that the
national median among LHDs is $41 per capita and the
25th percentile is $23. The vast majority of Indiana’s LHD
budgets are far below both of these levels. At least 37 of the
92 counties have a local public health per capita spending
of less than $10. Local per capita revenues across 2016
to 2018 range from a low of $1.25 per person in Shelby
County to a high of $82.71 per person in Marion County.
When these data were examined by location (e.g., rural/
urban/mixed) there was no pattern; per capita spending
was not associated with location.
The majority of LHD budgets comes from local funding
provided by the county general fund or a county tax
earmarked for public health (see Figure 19). The second
largest portion of LHD budgets is state base funding, which
includes the Indiana Local Health Maintenance Fund,30 the
Indiana Local Health Department Trust Account (funded
by the tobacco master settlement)31, and public health
preparedness funds. The third and smallest portion of
LHD budgets is made of clinical care revenues generated
by charges for clinical health services. and other fees
collected for services provided to the public.
26 IU Richard M. Fairbanks School of Public Health
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
Figure 18. Average Per Capita Local Health Department Revenue (ination adjusted to 2020 dollars)
Figure 19. Indiana LHD Average Source of Funding Per Capita (2020 Dollars)
$40.00
$30.00
$20.00
$70.00
$80.00
$60.00
$50.00
$10.00
$0
Marion
Brown
Union
Vigo
Ohio
Jeerson
Harrison
Rush
Crawford
Dubois
Vanderburgh
Spencer
Bartholomew
Elkhart
Kosciusko
Blackford
Scott
Jay
Pike
Howard
Switzerland
Dearborn
Washington
Fountain Warren
Steuben
Parke
Boone
Allen
Jackson
Floyd
Hendricks
St. Joseph
Ripley
Clinton
Clay
Knox
Morgan
Whitley
Wells
Jasper
Warrick
Vermillion
LaGrange
Franklin
Monroe
Montgomery
Adams
Carroll
Clark
Madison
Lawrence
Putnam
Hamilton
Daviess
Sullivan
Noble
Delaware
Wabash
Huntington
Greene
Gibson
Martin
Hancock
White
Orange
Johnson
Grant
Owen
Randolph
DeKalb
Jennings
Shelby
National Median $41
National 25th Percentile $23
74.0%
21.2%
4.8%
73.9%
19.5%
6.6%
80%
70%
60%
50%
40%
30%
20%
10%
0% Small
(25K to 50K)
Very Large
(>250K)
Local State Clinical/other service fees
Figures 18 & 19 are based o of 2016-2018
data provided by LHD self-report in an
annual survey administered by IDOH. Data
in Figure 19 do not provide information
about federal funding and are not available
for all LHDs. Data for 7 counties are not
included due to missing data or the data
are not distinguished by source.
27
IU Richard M. Fairbanks School of Public Health
Figure 20. Map of Average Per Capita Revenue by County
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
28 IU Richard M. Fairbanks School of Public Health
Health Outcomes
Across the 6 health outcomes examined, neighboring
states are less healthy overall with the majority of
neighboring states below or just at the US overall rate
for these health outcomes (see Figure 21). However,
Indiana is at least 10% worse than the US rates on
adult smoking, adults with diabetes, and adults with
cardiovascular diseases. The percentage of adults
with poor mental health is also high; Indiana is at
least 5% worse than the US rate. Among companion
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
Figure 21. Health Conditions
Health Conditions Across Neighboring States
Health Conditions across Companion States
Health Conditions across Exemplar States
SOURCE
• Center for Disease
Control and Prevention,
Behavioral Risk Factor
Surveillance System,
BRFSS; Kaiser Family
Foundation, 201832
• Center for Disease
Control and Prevention,
Behavioral Risk Factor
Surveillance System,
BRFSS; Kaiser Family
Foundation, 201933
• March of Dimes Report
201934
Gray bands represent
range of comparison
states as percent change
from the US rate (dotted
line). A red dot indicates
Indiana is at least 10%
worse than the US rate,
an orange dot indicates
5% worse, and a green
dot indicates 10% better
than the rate of the US
overall.
29
IU Richard M. Fairbanks School of Public Health
states examined, a number of states are at or
above the US rate for these 6 health conditions and
the range above the US rate is even higher among
exemplar states.
Indiana ranks 41st in state public health rankings
overall, which means that Indiana is in the bottom 10
states on public health. Among neighboring states,
Michigan and Illinois are ranked higher. Among
companion states, Arizona and Nebraska are ranked
30th and 15th respectively, and two of the exemplar
states have rankings among the top 10 states
(Minnesota is the 7th and Washington is the 9th).
Public Health Rankings
Historically, Indiana has ranked in the bottom half of
states or among the bottom 10 states for the last 30
years. Figure 22 shows Indiana’s ranking over this
period of time.
The consistent underfunding of public health
presented above relates to why Indiana ranks 41st
among all states on public health and is at least 10%
below the US average rate for preventable mortality
such as infant deaths, accident deaths, and alcohol,
drug, and suicide deaths. Additionally, the state’s high
rates of smoking contribute to these health outcomes.
Indiana receives approximately $137 million in Master
Settlement Agreement funds annually as a portion of
the state dedicated funds; however, 21.8% of adult
Hoosiers smoke tobacco compared to the national
average of 17.1%.35
Figure 22. Indiana Historical Public Health Rankings, 1990-2018
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
1
10
20
30
40
50
90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18
41
30
30 IU Richard M. Fairbanks School of Public Health
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
Public Health Rankings across Neighboring States
Measure Indiana Illinois Kentucky Michigan Ohio
State Health Rankings (overall) 2018 41 26 45 34 40
Mental Health Ranking 2016 38 7 48 40 35
Infant Mortality Rate 2016 42 31 37 34 43
Mortality Rate 2017 41 23 48 36 42
Obesity Rate 2017 39 23 43 31 40
Smoking Rate 2017 44 15 49 38 43
Suicide Rate 2017 25 7 28 15 18
Public Health Rankings across Companion States
Measure Indiana Alabama Arizona Arkansas Georgia Missouri Nebraska South
Carolina Tennessee
State Health Rankings (overall) 2018 41 48 30 46 39 38 15 43 42
Mental Health Ranking 2016 38 47 25 49 31 39 543 42
Infant Mortality Rate 2016 42 50 14 48 45 36 26 38 41
Mortality Rate 2017 41 47 10 45 38 39 24 40 44
Obesity Rate 2017 39 46 20 44 26 33 34 41 35
Smoking Rate 2017 44 41 16 46 30 40 14 36 47
Suicide Rate 2017 25 27 33 42 12 32 14 26 29
Public Health Rankings across Exemplar States
Measure Indiana Minnesota North Carolina Oregon Washington
State Health Rankings (overall) 2018 41 7 33 21 9
Mental Health Ranking 2016 38 4 29 36 21
Infant Mortality Rate 2016 42 12 40 8 6
Mortality Rate 2017 41 537 18 11
Obesity Rate 2017 39 16 30 19 12
Smoking Rate 2017 44 11 27 21 5
Suicide Rate 2017 25 13 16 37 30
SOURCES
• United Health Foundation – America’s Health Rankings, 201836
Public Health Rankings
The following tables present comparisons between Indiana
and neighboring, companion, and exemplar states on public
health rankings overall as well as specific indicators of public
health such as mental health ranking, infant mortality rate,
obesity rate, smoking rate, and suicide rate.
Indiana’s overall public health ranking (41st) is lower than all
neighboring states except Kentucky (45th). Across the public
health indicators, Indiana is typically ranked lower or worse
than Illinois and Michigan and higher or better than Kentucky.
Of particular note, however, Indiana has the lowest ranking in
the 2017 smoking rate measure across neighboring states,
ranking 44th nationwide.
Among companion states, Indiana is neither the best nor
the worst. Indiana consistently performs better on public
health measures than states such as Alabama and Arkansas;
however, Indiana performs worse on most measures compared
to Arizona and Nebraska.
As expected, when compared to exemplar states, Indiana
is worse on most, if not all, public health measures. Though
states that rank highly overall may not be ranked highly in
every measure (e.g., Washington is ranked 9th overall, but
is 30th in the nation in suicide rates), states that are ranked
strongly overall tend to perform well on the other measures.
• US News and World Reports, Public Health Rankings, 201737
31
IU Richard M. Fairbanks School of Public Health
The red indicates at least 10% worse than the US rate, the orange indicates 5% worse, and the green indicates 10% better than the US overall.
Market Characteristics for Neighboring States
Measure U.S. Indiana Illinois Kentucky Michigan Ohio
Hospital Characteristics
Percent Non-Prot Hospitals, 2018* 56.40% 55.30% 78.10% 68.60% 78.50% 71.60%
Percent For-Prot Hospitals, 2018* 24.90% 25.80% 9.60% 21.00% 17.40% 19.60%
Percent Public Hospitals, 2018* 18.60% 18.90% 12.30% 10.50% 4.20% 8.80%
Percent of Rural Hospital at Risk of Closure,
2018
21.00% 23.10% 17.30% 24.60% 25.40% 10.80%
Physician Supply
Active Patient Care Physicians per 100K pop.,
2019
242.1 212 240.5 214.6 249.7 248.6
Active Patient Care PCPs per 100K pop., 2019 83.2 74.4 8 7. 2 72.9 8 7. 6 83.7
Active Patient Care Gen. Surgeons per 100K
pop., 2019
6.6 6.1 5.8 7.6 6.7 7. 1
Health Insurance
Avg. Annual Premium- SINGLE coverage, 2018 $6,715 $6,778 $7,123 $6,690 $6,322 $6,804
Employee contribution for SINGLE coverage,
2018
21.30% 21.30% 20.40% 24.40% 22.70% 24.00%
Avg. Annual Premium- FAMILY coverage, 2018 $19,565 $19,551 $20,407 $19,277 $18,242 $19,640
Employee contribution for FAMILY coverage,
2018
27.80% 23.30% 26.40% 27.90% 23.50% 25.50%
% of Employees Enrolled in HDHPs, 2018 49.10% 51.90% 48.10% 53.20% 44.40% 54.00%
Percent of Income Devoted to Health Care
(before full coverage kicks in) 2017
11.70% 11.50% 9.50% 12.90% 8.50% 10.60%
Spending
Per Capita Personal Healthcare Spending, 2014 $8,045 $8,300 $8,262 $8,004 $8,055 $8,712
Per Capita State Government Healthcare
Spending, 2015
$1,880 $1,491 $1,482 $2,618 $1,743 $1,820
Market Characteristics
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
Healthcare market characteristics are presented below and
compared across neighboring, comparison, and exemplar states
in the following tables. Healthcare market characteristics are of
particular importance as these resources provide context for the
health-related environment in the state and the stakeholders
and partners who may partner with public health agencies in
responding to outbreaks, preventing chronic conditions and
treating them, as well as addressing social determinants of health.
In terms of market characteristics across neighboring
states, Indiana fares at least 10% worse than the US rate on
4 measures that relate to access to health care – percent of
rural hospitals at risk of closure, active patient care physicians
per 100,000 population, active patient care primary care
providers (PCPs) per 100,000 population, and per capita
state government healthcare spending. The closure of rural
hospitals, has implications for public health’s reach as it would
reduce the availability of important stakeholders and potential
partners in addressing health needs in rural communities.
Aside from Georgia, Missouri, and South Carolina, almost all of
the companion states have a 10% higher risk of rural hospital
closure than average states. Most of the companion states
are worse than the average US state on physician supply.
However, Missouri, Nebraska, and South Carolina have better
health insurance coverage than other states in the group.
As one may expect, Indiana can generally be considered ‘worse’
than the exemplar states. Most of the exemplar states have
better health insurance coverage and healthcare access. In
general, these characteristics translate to a decreased likelihood
that their residents will experience severe nancial distress as
a result of healthcare needs or have unmet healthcare needs.
32 IU Richard M. Fairbanks School of Public Health
Market Characteristics for Companion States
Measure U.S. Indiana Alabama Arizona Arkansas Georgia Missouri Nebraska South
Carolina Tennessee
Hospital Characteristics
Percent Non-Prot Hospitals, 2018* 56.40% 55.30% 29.70% 51.80% 58.00% 55.20% 54.10% 53.80% 43.50% 43.50%
Percent For-Prot Hospitals, 2018* 24.90% 25.80% 33.70% 43.40% 31.80% 18.60% 20.50% 7.50% 36.20% 39.10%
Percent Public Hospitals, 2018* 18.60% 18.90% 36.60% 4.80% 10.20% 26.20% 25.40% 38.70% 20.30% 17.40%
Percent of Rural Hospital at Risk of Closure,
2018
21.00% 23.10% 50.00% 25.00% 36.70% 41.30% 23.00% 11.40% 26.70% 18.90%
Physician Supply
Active Patient Care Physicians per 100K pop.,
2019
242.1 212 196.7 224 188.2 202.9 236.3 214.5 205 225.8
Active Patient Care PCPs per 100K pop., 2019 83.2 74.4 71.2 73.2 75 71.9 79 80.3 72.3 7 7. 8
Active Patient Care Gen. Surgeons per 100K
pop., 2019
6.6 6.1 6.9 6.1 6.5 6.1 6.3 6.2 6.2 7.4
Health Insurance
Avg. Annual Premium- SINGLE coverage, 2018 $6,715 $6,778 $6,089 $6,229 $5,974 $6,799 $6,664 $6,851 $6,708 $5,971
Employee contribution for SINGLE coverage,
2018
21.30% 21.30% 23.90% 25.00% 23.00% 21.70% 21.10% 20.30% 21.30% 23.60%
Avg. Annual Premium- FAMILY coverage, 2018 $19,565 $19,551 $18,001 $18,875 $17,995 $18,575 $19,249 $19,015 $19,284 $17,663
Employee contribution for FAMILY coverage,
2018
27.80% 23.30% 29.30% 30.70% 31.80% 31.50% 26.00% 28.50% 27.50% 31.20%
% of Employees Enrolled in HDHPs, 2018 49.10% 51.90% 38.10% 59.30% 42.60% 55.30% 51.90% 47.40% 49.70% 56.80%
Percent of Income Devoted to Health Care
(before full coverage kicks in) 2017
11.70% 11.50% 10.40% 14.30% 12.80% 13.80% 11.50% 11.30% 12.80% 13.90%
Spending
Per Capita Personal Healthcare Spending, 2014 $8,045 $8,300 $7,281 $6,452 $7,408 $6,587 $8,107 $8,412 $7,311 $7,372
Per Capita State Government Healthcare
Spending, 2015
$1,880 $1,491 $1,679 $1,598 $2,441 $1,242 $1,837 $1,186 $1,879 $1,498
Market Characteristics, continued
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
The red indicates at least 10% worse than the US rate, the orange indicates 5% worse, and the green indicates 10% better than the US overall.
33
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Market Characteristics, continued
Market Characteristics for Exemplar States
Measure U.S. Indiana Minnesota North
Carolina Ohio Oregon Washington
Hospital Characteristics
Percent Non-Prot Hospitals, 2018* 56.40% 55.30% 77.20% 60.70% 71.60% 77.00% 47.80%
Percent For-Prot Hospitals, 2018* 24.90% 25.80% 0.00% 13.40% 19.60% 4.90% 8.70%
Percent Public Hospitals, 2018* 18.60% 18.90% 22.80% 25.90% 8.80% 18.00% 43.50%
Percent of Rural Hospital at Risk of Closure,
2018
21.00% 23.10% 21.30% 12.80% 10.80% 3.60% 15.00%
Physician Supply
Active Patient Care Physicians per 100K pop.,
2019
242.1 212 265 223.5 248.6 271.5 246.3
Active Patient Care PCPs per 100K pop., 2019 83.2 74.4 96 781 83.7 101 91.7
Active Patient Care Gen. Surgeons per 100K
pop., 2019
6.6 6.1 6.6 6.2 7. 1 8.3 6.1
Health Insurance
Avg. Annual Premium- SINGLE coverage, 2018 $6,715 $6,778 $6,781 $6,339 $6,322 $6,441 $6,646
Employee contribution for SINGLE coverage,
2018
21.30% 21.30% 23.20% 20.40% 22.70% 16.50% 14.40%
Avg. Annual Premium- FAMILY coverage, 2018 $19,565 $19,551 $18,211 $18,211 $18,242 $18,977 $18,783
Employee contribution for FAMILY coverage,
2018
27.80% 23.30% 32.70% 32.70% 23.50% 31.20% 20.60%
% of Employees Enrolled in HDHPs, 2018 49.10% 51.90% 62.30% 55.30% 44.40% 49.60% 50.50%
Percent of Income Devoted to Health Care
(before full coverage kicks in) 2017
11.70% 11.50% 9.70% 13.80% 8.50% 11.30% 8.70%
Spending
Per Capita Personal Healthcare Spending, 2014 $8,045 $8,300 $8,871 $7,264 $8,712 $8,044 $7,913
Per Capita State Government Healthcare
Spending, 2015
$1,880 $1,491 $2,032 $1,393 $1,820 $2,538 $1,963
SOURCES
• Kaiser Family Foundation, American Hospital Association Annual Survey, 201738
• Navigant, Rural Hospital Sustainability, 201939
• Association of American Medical Colleges, State Physician Workforce Data
Report, 201940
• Center for Disease Control and Prevention, National Health Interview Survey
Early Release Program, 201841
• Employee Benet Research Institute, Self-Insured Health Plans: Recent
Trends by Firm Size, 1996-201842
• State Health Access Data Assistance Center: Employer Sponsored Insurance
Premiums, 201843
• Business Insider, Commonwealth Fund Analysis, 201744
• Health Aairs, Health Spending By State 1991-2014: Measuring Per Capita
Spending By Payers and Programs, 201745
• USA Today, What State Spends the Most on its Residents’ Health Care? 201846
• American Medical Association, Competition in Health Insurance, A
Comprehensive study of U.S. Markets, 201947
• Health Care Cost Institute, Healthy Marketplace Index, 201948
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
34 IU Richard M. Fairbanks School of Public Health
SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
Public Health Organizational Characteristics
Public Health Organizational Characteristics
Public Health Organizational Characteristics for Neighboring States
Public Health Organizational
Characteristics US Indiana Illinois Kentucky Michigan Ohio
Agency Structure [free-standing
(independent)/under a larger agency]
. Freestanding Freestanding Under a larger
agency
Under a larger
agency
Freestanding
Agency Governance (decentralized/
centralized/shared)
. Decentralized Decentralized Shared Decentralized Decentralized
Accreditation Status (State agency) 39 Not Accredited Accredited Not Accredited Not Accredited Accredited
Number of Local Agencies that are
accredited
. 3 12 16 841
Percent of Local Agencies that are
accredited
. 3% 12% 26% 18% 36%
State-run local health agencies 612 0 0 0 0 0
Independent Local Health Agencies 2197 94 96 61 45 113
State-run regional or district oces 326 0 7 0 0 2
Independent regional or district oces 99 0 0 0 0 0
Full Time Equivalents State Agency .814 1169 440 515 1049
Temporary and Contract Workers State
Agency
. 336 30 114 374 82
SOURCES
• ASTHO Individual Agency Proles, 201949
• Public Health Accreditation Board, 2020t
Indiana and the majority of the neighboring states have
decentralized governance structures, with the exception of
Kentucky. Like Indiana, Illinois and Ohio are freestanding,
while Kentucky and Michigan are under a larger, state agency.
Of this group of states, only Ohio and Illinois are accredited
at the state agency level. Indiana had the fewest number of
accredited health agencies (n=3 or 3%; Montgomery, Rush,
and Vanderburgh Counties).
The majority of companion states, like Indiana, are
freestanding, with the exception of Nebraska. Most state
health agencies are accredited (n=6), with the exception of
Missouri and Nebraska. Generally, these states also had a low
percentage of accredited local health agencies, with Arizona
(33%) and Nebraska (29%) as exceptions.
All exemplar states, like Indiana, are decentralized. The only
not accredited state agency is North Carolina. North Carolina
also had a low percentage of local health departments that
were accredited through national public health accreditation,
although North Carolina has a state-based accreditation
process which many of the LHDs have completed. Of the
exemplar states, Oregon had the highest percentage of
accredited local agencies (43%).
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SECTION 2: THE PUBLIC HEALTH SYSTEM IN INDIANA AND COMPARISON STATES
Public Health Organizational Characteristics
Public Health Organizational Characteristics for Companion States
Public Health Organizational
Characteristics US Indiana Alabama Arizona Arkansas Georgia Missouri Nebraska South
Carolina Tennessee
Agency Structure [free-standing
(independent)/under a larger agency]
.Freestanding Freestanding Freestanding Freestanding Freestanding Freestanding Under
a larger
agency
Freestanding Freestanding
Agency Governance (decentralized/
centralized/shared)
.De-
centralized
Centralized De-
centralized
Centralized Shared De-
centralized
De-
centralized
Centralized Mixed
Accreditation Status (State agency) . Not
Accredited
Accredited Accredited Accredited Accredited Accredited Accredited Not
Accredited
Not
Accredited
Number of Local Agencies that are
accredited
. 3 1 5 0 5 7 6 0 1
Percent of Local Agencies that are
accredited
. 3% 1% 33% 0% 3% 6% 29% 0% 1%
State-run local health agencies 612 0 65 075 000089
Independent Local Health Agencies 2197 94 2 15 0159 114 2 0 0
State-run regional or district oces 326 0 6 0 5 18 9 0 4 7
Independent regional or district oces 99 0 0 0 0 0 0 19 0 6
Full Time Equivalents State Agency .. 814 2677 1369 1948 1012 1697 428 3176 2918
Temporary and Contract Workers State
Agency
. 336 23 125 52 104 118 34 476 83
Public Health Organizational Characteristics for Exemplar States
Public Health Organizational
Characteristics US Indiana Minnesota North Carolina Oregon Washington
Agency Structure [free-standing
(independent)/under a larger agency]
. Freestanding Freestanding Under a larger
agency
Under a larger
agency
Freestanding
Agency Governance (decentralized/
centralized/shared)
. Decentralized Decentralized Decentralized Decentralized Decentralized
Accreditation Status (State agency) 39 Not Accredited Accredited Not accredited Accredited Accredited
Number of Local Agencies that are
accredited
. 3 10 315 6
Percent of Local Agencies that are
accredited
. 3% 17% 3% 43% 15%
State-run local health agencies 612 0 0 0 1 0
Independent Local Health Agencies 2197 94 51 84 33 35
State-run regional or district oces 326 0 8 0 0 4
Independent regional or district oces 99 0 0 6 1 0
Full Time Equivalents State Agency .814 1504 1664 588 1886
Temporary and Contract Workers State
Agency
. 336 6 286 11 96
36 IU Richard M. Fairbanks School of Public Health
SECTION 3: EVIDENCE SYNTHESIS
EVIDENCE SYNTHESIS INTRODUCTION
STRUCTURE AND GOVERNANCE
Overview
This section describes the literature that focuses upon
public health agency structure and governance models.
These concepts are distinct from a related term, the
‘public health infrastructure,’ which describes the
workforce, information and knowledge systems, as well
organizational capacity.50
Public health services are delivered through a mix of
local and state governmental and nongovernmental
agencies. Such agencies can be organized in centralized,
decentralized, or “mixed” structures depending on
where the authority for decision making resides.
Generally, centralized refers to state-level decision
making authority, whereas decentralized refers to
decision-making authority residing at the local county
or city level. Mixed (sometimes referred to as “shared”)
decision authority describes instances where the state
and local health agencies have joint responsibility and
authority for decisions.
In addition to these structures, public health agencies
also have varying governance models at the state or
local levels. Approximately 60% of state public health
agencies are governed by a board or council of health
typically made up of governor-appointed public health
professionals, citizens, business professionals, and
educators.51 Nationally, 80% of local public health
agencies are governed by a board of health similarly
comprised of representatives from the local community.
Local boards of health are significantly less common in
centralized state structures (87.1% vs. 22.2%).52
Boards or councils of health at the state and local
The following section includes reviews of the relevant
literature related to public health systems change. It
also includes case summaries of each of the exemplar
states, which explain their ongoing work toward public
health system improvements. Reviews focus on the
state of evidence as it relates to 5 general topic areas of
public health systems and public health performance.
level could have varying responsibilities including
promulgating rules, advising elected officials (in 7%
of states, Boards are made up of elected officials)51,
developing public health policies and/or legislative
agendas, and other responsibilities. Local health
departments that serve a population of less than
50,000 people make up almost two-thirds (64%)
of all such agencies but serve only 12% of the US
population.51 As seen in the “Public Health Organizational
Characteristics” tables above, Indiana’s public health
departments are freestanding, with a decentralized
governance structure.
Associations Between Structure
or Governance and Public Health
Outcomes
Several studies examined how either structural and/or
governance models are associated with public health
performance. In these studies, performance includes
(1) the extent to which the 10 Essential Public Health
Services are oered, (2) the community health outcomes
of a given locale, and (3) the use of administrative
evidence-based practices by health departments.
The findings across studies that examined how
structural attributes are associated with the provision
of essential public health services are not consistent.
Whereas some researchers reported that centralized
structures were associated with a greater number
of Essential Services provided,53,54 other researchers
reported that mixed or shared authority structures
had higher public health performance.55,56 Yet other
studies observed no performance difference.51 One
study reported that centralized state structures were
These include: 1) the structure and governance of public
health, 2) regionalization within public health systems,
3) accreditation of public health, 4) public health
partnerships, and 5) public health expenditures. Reviews
include a conclusions section and summary of key
takeaways as they relate to the context in Indiana and the
recommendations provided in Section 5 of this report.
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SECTION 3: EVIDENCE SYNTHESIS
associated with a greater occurrence of administrative
best practices (Brownson et al, 2014).57
The association between overall system structure and
performance may be contingent on the presence of a
local board of health. Researchers examining how the
structure and governance of public health agencies are
associated with community health outcomes utilized
a composite measure of ‘proximal health outcomes’
to measure performance. Their findings suggest that
whereas centralized (e.g., state-run) systems achieve
the lowest mean performance scores; agencies with
local boards of health performed best. Specifically,
health departments with the best performance were
those with local boards comprised of both local health
professionals and political officeholders, but where
neither group has a majority.58 Relatedly, researchers
analyzing data from local health departments in
Massachusetts found that one of the strongest
predictors of overall performance and capacity to
deliver Essential Services was an understanding of
health issues among elected officials that serve on
the local board of health.51 This finding, the authors
suggested, represents an opportunity to improve public
health capacity by educating elected municipal leaders
about the responsibilities of local health officials.
With respect to governance models, several researchers
have reported that having a local board of health, with
policy-making authority, is positively associated with
performance on some Essential Services offered;55, 59, 60
but this relationship was not observed in local health
agencies who served a smaller population of under
100,000 residents.60 This latter caveat raises the
potential for benefits associated with regionalization as
described below.
Conclusions/Takeaways
As evidenced by some of the conflicting findings, the
relationship between structure and/or governance
and performance is complex and nuanced. However,
an important insight from this body of research is that
educating local leaders about the responsibilities of
public health agencies and public health officials is an
opportunity that should not be overlooked.
Studies that examined differences in public health
performance by structure or governance have typically
relied on two common data sources: (1) the NACCHO
National Profile of Local Health Department series, or
(2) the ASTHO Profile of State Public Health Surveys,
both of which are conducted every 3 years on average.
One or both of these data sources are typically
combined with other datasets to examine various
public health performance measures. The limited data
on performance that are available for such studies is
recognized by many contributing authors as a limiting
factor. Furthermore, the variability in how structure
and governance attributes have proliferated across
jurisdictions makes precise measurement challenging.
In an effort to manage this variability, one group of
researchers created a typology of observed structures
and identified seven groups that explained a high
proportion of structure and governance configurations
among public health agencies.61 Still, the lack of
longitudinal studies that can better elucidate how
changes to structure or governance attributes affect
outcomes is a recognized limitation among researchers.
More research is needed to better understand how
governing structures, and what specific board powers
and authorities, are most critical in positively influencing
public health performance.
38 IU Richard M. Fairbanks School of Public Health
SECTION 3: EVIDENCE SYNTHESIS
REGIONALIZATION
Overview
Many scholars have highlighted the challenges that health
departments serving smaller populations face, including
resource constraints, that result in insucient service
oerings and a dearth of on-sta expertise.51 Researchers
have long observed that the size of the population served
by a public health agency was consistently the strongest
predictor of public health performance as measured
by the capacity to provide a greater number of the 10
Essential Services.51,55 Given that public health agencies
that serve smaller populations have challenges in oering
a complete complement of Essential Services, there have
been calls to consider pooling resources across a given
region to better enable the performance of local public
health. This concept, known as either “regionalization”
or “cross-jurisdictional resource sharing” is modeled
after the experiences of police, re, and waste water
treatment departments who have implemented similar
strategies over the past decades.62 The call for public
health regionalization became more prominent in the
early 2000’s following the events of 9/11 that raised
concerns about the vulnerability of the US public health
infrastructure to a potential bioterrorism attack.
Evidence of Regionalization from
Other Government Agencies
Some of the benefits of regionalization observed in
other governmental services (e.g., police, fire) include a
more efficient use of resources (28% reduction in costs
without a reduction in services in one study), economies
of scale to procure specialized expertise or equipment,
better-trained staff members, lower turnover rates, and
higher levels of 24-hour coverage.63 Researchers also
noted that police departments that ignored coordination
of services with neighboring jurisdictions exacerbated
problems regionally.63 Nevertheless, scholars have
noted that potential drawbacks to regionalization could
include resistance to ceding local autonomy because
of perceptions that regionalization can lead to a loss
of focus on specific local needs; and the potentially
challenging legal and fiscal issues that can assure a fair
allocation of funding if variability exists in the resource
inputs available among counties or cities that began to
cooperate.
Regionalization and Public Health
Koh et al. described multiple degrees of regionalization
activities each of which is progressively more involved
including: (1) Networking, (2) Coordinating, (3)
Standardizing, and (4) Centralizing.63 Networking
represents the loosest form of cross-jurisdictional sharing
and merely involves interactive sharing of plans and
information among dierent local health departments.
Coordinating occurs when otherwise independent
health departments plan, train, or engage in exercises
together. Standardization describes the process of
creating uniformity across regional health departments
through the mutual adoption of functions, tools, press
releases, and response activities. Finally, centralization
involves the creation of a consolidated entity to support
or potentially replace the previously autonomous health
departments for the purposes of all public health services,
programs, and activities. Importantly, each of these levels
of regionalization requires varying legal, governance, and
management structures; and it is unclear what level of
regionalization is required among public health agencies
for benets to accrue.
Since the early 2000’s, several states have implemented
some aspect of intra-state cross-jurisdictional resource
sharing. Researchers have determined that 54% of local
health departments engage in some regular level of
resource sharing. Those with a more formally educated
director and/or those with a board of health were more
likely to resource-share with other health agencies.64
Most of the remaining literature on regionalization uses
qualitative methods to better understand experiences with
regionalization in public health. For example, researchers
interviewed local health directors in Connecticut
and Massachusetts to elucidate the advantages and
disadvantages of regionalization from the perspective of
leaders who implement such approaches.65 Advantages
included being able to provide more community health
programs and services. A reported disadvantage of
regional resource sharing was the perception that the
governing body had less local knowledge about issues
that dierentially aect the adjacent jurisdictions that
shared resources.
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SECTION 3: EVIDENCE SYNTHESIS
A similar study in Kansas reported that public health
workers believed that regionalization positively inuenced
trust, mutual respect among local agencies, and improved
public health service oerings.66 Moreover, Kansas public
health workers reported that regionalization helped
increase operational eciency and resulted in additional
resources including personnel, knowledge, technology,
and technical expertise. However there remained
dissatisfaction after regionalization due to insucient
funding, a lack of documented benets, and insucient
engagement from local elected ocials in the regional
process and activities.66
Researchers found that Ohio local health departments
that consolidated experienced a 16% reduction in total
expenditures; and qualitative findings suggest that
county health officials believed their consolidations
yielded financial and public health benefits.67 However, in
a synthesis of several early case studies that examined
the impact of public health regionalization, Stoto and
Morse noted that the mere need to provide services
is not typically sufficient to entice regionalization.68
Instead, the perceived need for a regional response—
for example in response to bioterrorism or an infectious
disease, can help motivate action. Stoto and Morse,
summarizing the findings of the case studies, concluded
that a consistent reported benefit of regionalizing was
the enhancement of social capital.68 Social capital in
this context includes connections and relationships
that may prove beneficial between otherwise disparate
public health agencies and partner stakeholder groups.
These connections, whether catalyzed by the threat
of bioterrorism or some other reason, stand to benefit
other public health activities as well.
Researchers in Montana, a rural frontier state with a
decentralized structure, surveyed local elected ocials
and public health sta to determine attitudes and
potential barriers to regionalization. They reported that
public health ocials and elected county commissioners
have similar viewpoints with respect to the benets
of regionalization but dierent viewpoints regarding
barriers to local resource-sharing.69 Specically, elected
ocials perceived regionalization as a greater threat
to their autonomy and ability to respond to local
needs. In a separate study, interviews of Nebraska
health departments that underwent regionalization
suggested that decisions about resource allocations in
regionalized health departments were prioritized based
upon community needs and the size of the vulnerable
population served—but were contingent upon the amount
of funds received from the state.70 Thus, Chen et al.,
asserted that regionalization without commensurate
resource allocation from the state may undermine some
of the gains expected from local resource sharing.70
Conclusions/Takeaways
Regionalization can be used to overcome resource
constraints faced by local public health agencies that
serve a relatively small population. To date, most of the
literature has been limited to qualitative case studies
designed to understand perceptions of regionalization
by local health department leaders who implemented
this strategy. Lacking are quantitative analyses,
including longitudinal ones, that can more objectively
determine the impact of regionalization on public
health outcomes. However, benefits of regionalization
include being able to provide more services and
programs, financial efficiencies, and improved social
capital within a region. Based on the current evidence,
two key takeaways should be considered. The potential
of improved capacity, expertise, an stability will likely
be realized if there is sufficient and sustained resource
allocation from the state. In planning for a regional
structures, legal and governance issues need to be
considered so that there is responsiveness to local
needs. This may mean establishing governing bodies
that include representation of existing counties or local
health departments.
In regard to the current pandemic (see Section 4
for specific insights), informal regional responses
were attempted but were perceived to be relatively
inefficient as they were reactionary rather than
strategic and intentional. In an emergency, it is nearly
impossible to generate expertise or effectively stand-
up essential infrastructure.
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ACCREDITATION
Overview
As of September 1st, 2020, the Public Health Accreditation
Board (PHAB) reported that 82% of the US population was
covered by an accredited public health department. This
includes a total of 36 state, 263 local, 4 Tribal, 1 statewide
integrated local public health department system, and
2 Army Installation Departments of Public Health.12
Specically, within Indiana, the Indiana Department of
Health is in the process of their state agency accreditation
review. Additionally, 3 of 94 LHDs are accredited including:
Montgomery County Health Department, Rush County
Health Department, and Vanderburgh County Health
Department.
Public health department accreditation began in
September 2011, in response to the “fragmentation
in governmental public health department services”3
described in a 2003 Institute of Medicine Report.11 The
purpose of accreditation is to “improve and protect the
health of the public by advancing and transforming the
quality and performance of governmental public health
agencies in the U.S. and abroad”.3 PHAB accreditation
provides a standard framework for health departments
to prioritize services, initiatives, and eorts to best
promote and protect the health of their jurisdictions.3
The accreditation standards and measures are designed
to assess population health services3 and align with
the CDC’s 1993 “10 Essential Public Health Services”
framework (as shown above in Figure 1 of the report).71
PHAB’s accreditation standards are grouped into 12
domains.72 See Appendix A for a complete list of PHAB’s
12 domains and the related standards and measures.
Initial PHAB accreditation indicates a health department
has the capacity to carry out the 10 essential services,
administer/manage their health department, and
eectively engage with its governing entity.3 PHAB
accreditation is organized in a manner which allows
health departments to foster a culture of health73 and
incorporates the components of Public Health 3.0, where
public health agencies serve as the chief health strategists
in communities. 13, 74 The Association of State and Territorial
Health Ocials (ASTHO)’s Accreditation Leadership Guide
describes accreditation as a tool for new health ocials to
ensure their health department meets national standards,
and are able to proactively identify issues thus ensuring
optimal public health performance.75 An independent
research rm has evaluated how accreditation and
outcomes are related at multiple points before and after
receiving accreditation. Specically, researchers have
examined how accreditation is associated with quality
improvement (QI), performance management (PM),
partnerships, accountability, workforce development,
resources, community health and equity, and emergency
preparedness.
Quality Improvement and
Performance Management
Researchers have found that QI is consistently one of
the top motivations for pursuing accreditation and is
also one of the most commonly cited benets.3, 76, 77 The
majority (80%) of local health departments accredited
by June 2017 implemented a formal QI program, a
larger percentage than reported in earlier years, and
larger than among non-accredited health departments.3
Several researchers have reported improvements in
process, program, or service eciency as a result of
engagement in QI,3, 78-81 underscoring the justication for
why QI is prominent in the accreditation process. Some
observed improvements in either QI and/or PM occurred
immediately after undergoing accreditation,82 or soon
after completion of the accreditation process.83 The
specic QI benets associated with accreditation include
decreased time or cost of providing services, improved
process quality, and improved public health outcomes.82
One study found that among 35 public health projects that
measured the economic impact of quality improvement,
there was a mean return on investment of $8.56 per dollar
spent.84
Partnerships
Public health departments often collaborate with partners
from a multitude of sectors, including but not limited to
academic partners, hospitals or hospital systems, other
clinical organizations, nonprots, businesses, and faith
organizations. When compared with non-accredited
health departments, accredited departments oer more
public health services, and have more partners who assist
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in delivery of those services.85 Following accreditation, a
majority of health departments (70%) report strengthened
relationships with external partners,3 and greater intra-
and inter-organizational communication with partner
organizations.86 Researchers report that collaborations
between public health departments and health care
delivery organizations are enhanced through public health
accreditation processes,87, 8 8 including as a result of pursuing
community health assessments in conjunction with
nonprot hospitals.89,90 Researchers report that successful
collaborations can improve outcomes such as reduced
mortality rates due to preventable conditions,19, 91 reduced
disparities in life expectancy,91 better alignment of policy
goals, increased policy expertise, and joint governance
leading to collaborative action.92
Accountability
PHAB believes that accreditation leads to greater
transparency, a more accountable public health
infrastructure, and serves as a “seal of approval” that
signals that an agency exceeds an industry threshold
of competence and capabilities to the outside world.
Accreditation assures that a health department has the
ability to deliver essential services through a competent
workforce able to deliver evidence-based solutions.93
After one year of accreditation, the majority of surveyed
health departments (n=214) reported that accreditation
led to greater accountability and transparency, both
within the health department (90% of respondents),
and to external partners.3, 77 The majority also stated
that the accreditation process improved their credibility
within their community and/or within their state
(79% of respondents) and enhanced their visibility
and reputation with external stakeholders (74% of
respondents).3, 77 Researchers have reported that health
departments which seek and achieve accreditation are
more engaged with their governing boards of health,94, 95
and have leaders that are more engaged with legislative
partners.96
Workforce
Given that a skilled workforce is essential to an eective
public health department, accreditation is designed to
address gaps in workforce competencies.97-99 A year after
accreditation, the majority of accredited public health
departments report increased ability to identify and
address gaps in workforce training and development
(89% of respondents), and the majority (69% of
respondents) report competencies improving as a result
of accreditation.77 This is important because employee
development in public health agencies is associated
with increased levels of job satisfaction and intention
to remain in their position.100-101 Case studies conducted
by researchers indicate that accreditation boosts
employee pride102 and increases intra-organizational
collaboration.103 Analysis of PH WINS data indicates that
there were no signicant dierences in reported burnout
or intention to leave when controlling for individual and
agency characteristics, indicating that accreditation is
not considered to be a burden.74 Overall, employees in
accredited departments reported higher job satisfaction104
and because accreditation includes a strong focus on
continuous quality improvement, this may be appealing
to many public health workers.105
Resources
In addition to the benets described above, accreditation
has also been associated with a nancial return on
investment. The majority of health departments that have
been accredited report more eective use of resources
within the department.3 The potential benet may be
achieved through multiple mechanisms. For example,
accreditation activities may allow health departments
to increase their funding opportunities. Moreover, the
required process of developing community health
assessments (CHAs) and community health improvement
plans (CHIPs) has been linked to being more competitive
for funding opportunities,106 and seeking new funds.107
Researchers who conducted case studies reported that
accreditation status is a factor in distributing state funding
to local health departments.3 Likewise, opportunities for,
and usage of, federal funding may be enhanced through
accreditation. For example, the CDC is a co-funder of PHAB
and the CDC provides support for projects that could be
used to meet accreditation standards.108 Additionally, as a
potential harbinger of future requirements directly tying
accreditation to funding opportunities, the CDC’s Notice
of Funding Opportunities requires applicants to report
their accreditation status as demonstration of their
organization’s capacity.3
Community Health and Equity
PHAB does not claim a direct link between accreditation
status and health outcomes, but instead argues multiple
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SECTION 3: EVIDENCE SYNTHESIS
intervening steps exist between accreditation and any
improvements in health status.3 However, their logic model
indicates that improved health outcomes are a long-term
outcome from accreditation eorts.109 Therefore, PHAB
has added a requirement for monitoring and reporting of
outcomes during the reaccreditation process.3 An analysis
of CHIPs by accredited health departments indicate the
health departments perceive accreditation as associated
with positive impact in their community’s health, lending
credence to the acceptance that accreditation can be
linked with improved population outcomes. Many of the
activities designed to improve community health come
from implementation of evidence-based practices, a key
component of accreditation.3, 110 A recent ASTHO report
indicates that health departments have used accreditation
processes as an opportunity to emphasize health equity.111
Emergency Preparedness
Improved eciencies and eectiveness, both
overarching goals of accreditation, may support public
health departments in preparing for and responding
to public health emergencies.3 Case studies reported
that the accreditation process better prepared health
departments to address the recent Zika outbreak.94, 112
Because accreditation eorts have led to improvements
in QI, which in many cases proved benecial in terms of
enhanced laboratory and epidemiological performance,
it is believed that accreditation improves communicable
disease investigations.3, 113 Lastly, researchers noted that
while all departments’ preparedness capabilities declined
when funding decreased, those that were accredited
experienced fewer degradations in their preparedness
capacity.114
Accreditation Challenges
Several challenges exist for LHDs that impede the
decision to engage in the accreditation process or the
process itself. The most commonly cited barriers or
challenges include stang concerns (limited time and
turnover), competing priorities, and nancial costs
associated with accreditation. Although these barriers
are faced by LHDs of all sizes, they are particularly
challenging for LHDs with fewer employees/serving
smaller jurisdictions.115-120
Conclusions/Takeaway
Quality improvement (QI) is one of the most cited benets
of public health accreditation leading to improvements
in process, program, and service eciency. Accredited
health departments oer more public health services,
have more partners and stronger relationships with those
partners, greater job satisfaction among their employees,
and improved accountability and transparency. In the
context of an extended pandemic, it is important to note
that these benets along with associated improvements
in laboratory and epidemiological performance have
the potential to make a dierence in the response and
ultimately in health outcomes.
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SECTION 3: EVIDENCE SYNTHESIS
PARTNERSHIPS
Overview
This section describes the literature focusing on
partnerships between public health departments
and their multi-sectoral partners. Public health
partners can include academic institutions, hospitals
and health systems, other clinical organizations,
nonprofits, businesses, and faith-based organizations.
Partnerships are a viable strategy for addressing
problems that may be difficult to solve alone due to
limited resources, expertise, or time.
Public health organizations have historically expanded
and adapted the scope of their activities in order to
better serve the health needs of their communities
and to address health disparities.121 One method of
doing so is to seek collaborations with external entities,
thus increasing available expertise and capacity.
Collaboration allows organizations to combine
resources and expertise, and has historically been a
cornerstone of public health practice.122,123 Successful
collaboration hinges upon all partners sharing, or
having compatible organizational objectives and
incentives.124, 125 Partnerships require strong coordination
mechanisms, or they risk perpetuating and potentially
increasing existing inefficacies.127, 128
Despite the historic tendency of public health agencies
to pursue partnerships, experts have noted that
overt incentives for organizations to collaborate with
public health agencies have been minimal or non-
existent.129 Given historic reimbursement models,
clinical organizations, as noted by experts, may have
had a perverse incentive to partner with public health
because successful collaborations may result in lost
revenue due to the prevention of disease and/or slowing
of disease progression thus reducing demand for
health care services.130 Nevertheless, clinical providers
could potentially benefit from partnerships to address
the needs of uninsured members of the population
who would otherwise require uncompensated medical
care.128 Further, given federal policies that require not-
for-profit hospitals to document community benefit
contributions and to conduct periodic community
health needs assessments, partnerships between
hospitals and public health agencies are of growing
importance.126, 127
Who does Public Health partner
with? And what is known about these
partnerships?
Hospitals and health systems.
Hospitals and health systems often partner with
public health departments, especially for community
health needs assessments (CHNAs) that are required
of nonprofit hospitals.89, 90, 133-136 An analysis of cross-
sector networks indicated that organizations such as
hospitals, community health centers, and public health
agencies were considered to be the most trusted and
valued by other members of the partnerships (e.g.,
nonprofit organizations, private firms, government
agencies, employer/business groups, or academic
institutions).137 Collaboration between public health
departments and providers of medical care is accepted
as an effective strategy for improving population health,
due to the combination of health-related and clinical
skills, as well as the complementary resources of each
organization.138-140
Researchers examining the impact of public health
partnerships with hospitals and/or health systems
have reported reductions in infant mortality rates141 and
Partnerships between public health agencies
and hospitals/health systems oer the following
opportunities:
• Incorporation of community voices into CHNAs
• Pathways for increasing individuals’ access to
community resources
• Identication of relevant priorities for communities
served
• Support for partnerships to last beyond initial
assessment eorts
• Enhanced understanding of collected data and what
initiatives can be launched based on those data
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SECTION 3: EVIDENCE SYNTHESIS
increased patient satisfaction with expanded services
and provision of holistic services.142
Community partners.
Relationships between social service organizations and
local health departments (LHDs) are important and
widespread, and assist communities with addressing
the eects of social determinants of health. The federal
government has encouraged cross-sector partnerships
with community stakeholders and encourages public
health agencies to assume the role of “chief health
strategist” in order to guide community organizations
in a concerted eort toward improved population
health.98 Public health agencies most frequently partner
with social service organizations to address issues
pertaining to housing and food assistance.143 An analysis
by Hogg and Varda found that collaborations between
nonprot organizations and public health departments
are prevalent, potentially due to shared goals and
objectives.137 Recent multi-sector collaborative networks,
including community-based organizations, have been
designed to improve access to community resources.144, 145
Partnerships between public health agencies and
community-based organizations have been associated
with a reduction in single-occupant vehicle crashes (as
a long-term outcome associated with substance use
disorder),146, 147 childhood obesity,148 increases in social
support and self-rated health, as well as decreases in
depressive symptoms among minority communities.149
Such partnerships have also been associated with a
50% reduction in African American infant mortality
rates within 2 years following the partnership
inception.150 Lastly, public health and social services
organizations have successfully partnered to decrease
adolescent pregnancy and birth rates among 14 to 17
year olds in three Kansas counties.151
Academic partners.
Academic health departments (AHDs) refer to
partnerships between governmental public health
agencies and academic institutions such as colleges
and universities. AHDs are typically established to
increase the use of research and evaluation in support
of public health, create opportunities for access to
continued education among the existing workforce
and applied training for students, and provide service
exchange opportunities for public health experts and
academics.152
Academic and public health practice partnerships are
not new. In 1984, Congress enacted the Prevention
Research Center (PRC) program which, administered
by the Centers for Disease Control and Prevention
(CDC), established centers for applied public health
research within academic institutions. As the PRCs
were in a limited number of states, in their 1988 report,
the Institute of Medicine (IOM) further recognized
the need for continued and expanded collaboration
between public health practice and academia and
made recommendations to facilitate relationships.10
In 2003, the IOM again recommended that academic
partnerships be implemented to help carry out the
three core functions of public health: assessment;
policy development; and assurance.11
The structure of AHDs can vary. An AHD typically joins
(formally or informally) a health professions school
(a school with programs in public health, medicine,
nursing, dentistry, environmental health, health
education, or other health field) with a state or local
health department. AHDs can be similar to teaching
hospitals, where public health staff and university
faculty have joint appointments within each other’s
organizations.152 Students are able to get “real-world”,
Community partners or social service organizations
are those that strive to improve health by
delivering services directly to an individual or
their family. These can include (but are not limited
to) organizations which provide assistance or
resources in the following areas:
• Food
• Housing/shelter
• Transportation
• Cash assistance (for low income individuals or
families)
• Employment assistance including job training
• Support for special populations (veterans,
children/families, those with special needs,
older adults)
• Legal assistance
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AHDs may include some or all of the following:
• Involvement of at least one health professions school
and at least one public health practice organization
• Formal partnership agreements between
involved institutions
• Shared (jointly appointed and funded) faculty
and/or sta
• Organizational structure which allows for
resource sharing
• Exchange of resources or other compensatory
methods between institutions in exchange for
provided services
• Collaborative eorts to provide education
and training for public health students and
professionals, grounded in theory and practice
• Joint proposal, then implementation of projects
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practical experience through internships at public
health agencies.153
Studies of academic practice partnerships and
AHDs154-156 have determined that formal agreements
between LHD staff and university faculty increase
collaborative benefits. Erwin et al., analyzed local
health department relationships with academic
institutions and determined that local health
departments with a formal academic partnership had
higher organizational support for evidence-based
programming and decision-making when compared
to their counterparts with less formal relationships
with academia.157 However, a study focused specifically
on PRCs determined that AHDs do not need a formal
agreement to provide benefits to public health practice,
noting that most do not have formal agreements
between public health departments and the academic
institution.153 The researchers determined that the
PRCs and health departments built on each other’s
strengths to augment core public health functions
where health departments provided the “boots on
the ground” practical expertise, while PRCs enhanced
data quality and scientific rigor and filled knowledge
gaps. Further, the presence of academic partnerships
with LHDs was also associated with providing at least
one chronic disease evidence-based intervention.157
Academic partnerships have been found to be mutually
beneficial for the local health department and the
academic institution, resulting in impactful research,
innovative programming, and public health policies.153
Other key benefits include:152, 158
• Maximization of scarce resources
• Expansion of academic research beyond academic
settings and more application of research within
practice settings
• Involvement of academic institutions in community
health
• The potential for an increased number of people
working in public health through the addition of
academic faculty, staff, and students
• Additional expertise available to support local
public health agencies
• Use of tuition reimbursements for employees
resulting in higher numbers of individuals working
in public health with advanced degrees
• Additional, more qualified public health
professionals
• Enhanced career opportunities for public health
graduates
• Increased capacity for performing essential public
health functions
• More opportunities for grant funding which can
support public health and local organizations and
improve the health of the population
Multisectoral and Other partners.
There is limited evidence in the literature regarding
the specific impacts of public health partnerships with
nontraditional partners (e.g., employers, business
groups, and academic partners), but these partners
have reported contributing high levels of resources (i.e.,
community connections, information, health expertise,
advocacy, etc.) to multisectoral partnerships.137
Studies that examined multisectoral partnerships in
pursuit of public health goals have reported promising
impacts. For example, multisectoral partnerships
have been associated with declines in death due
to largely preventable chronic diseases, such as
cardiovascular disease, diabetes, and influenza.19
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Moreover, multisectoral partnerships could reduce
income-related disparities in life expectancy.91
Multisectoral partnerships attempt to address
population health issues, by sharing resources and
knowledge.128, 140, 147, 159-161 These outcomes appear to
depend on the availability of organizations and their
willingness to work towards prioritized public health
goals.162, 163 Factors which may encourage organizations
to collaborate include economic incentives (e.g.,
revenue gains, cost reduction, marketing advantages,
achievement of economies of scale, reduction in
duplicative efforts), non-economic advantages (i.e.,
organizational missions to improve health and welfare,
reaching new populations, expanding or improving
services), or regulatory mandates.128, 164-170
Conclusion/Takeaways
Researchers have noted that partnerships promote
better alignment of policy goals, increased policy
expertise, and joint governance leading to collaborative
action.92 Partnerships between external stakeholders
and public health agencies also contribute to
organizational policy changes147 and to increased
organizational capacity.171
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IU Richard M. Fairbanks School of Public Health
Overview
State and local governmental public health agencies
are funded by a combination of federal, state, and local
sources resulting in wide variability in community-
specific public health expenditures across jurisdictions.
Public health decision-makers are often faced with
questions about how to align funds to maximize the
effectiveness of public health at the local, state, and
federal levels. Concurrently, public health agencies are
being asked to take on additional responsibilities at a
time when fiscal constraints and budget reductions
continue to occur.172 Researchers determined that
in order for all Americans to receive adequate public
health services, an annual expenditure of $32 per
person is needed; yet current average expenditures are
only approximately $19 per person.173
In the US, 75% of health care costs are allocated to
treating preventable health conditions.174 However,
governmental public health expenditures which focus
on preventing and/or controlling these conditions
constitute less than 3% of national health spending.175
As a result, the varying levels of public health
funds available across communities are frequently
insufficient given the high need to focus on key services
and population-based programs. For example, public
health expenditures in the top 20% of US localities
are 13 times greater than similar expenditures in the
bottom 20% of US localities.176
Often, local health departments heavily depend on
local governments and local tax revenues. Nationally,
local government agencies received on average 25%
of their funding from local government appropriations,
21% from state government, 27% from Federal direct
or pass-through, and 21% from services and fees
provided to their communities.29 As described below,
these expenditures are linked to a wide range of
population health outcomes.
Associations between Funding and
Performance/Health Outcomes
Given the wide variability in available funding and local
public health expenditures, researchers have examined
how such investments are associated with health
outcomes. In a study of Missouri local public health
departments, researchers reported that local agencies
that receive more from federal and state sources also
raise more funds at the local level and perform better.
For example, the local agencies who receive more
funding perform a broader range of the 10 essential
public health services (e.g. inspections, education,
and monitoring).177 Moreover, in a national study, local
health departments across the US, with greater per
capita expenditures perform more core public health
activities.178 Experts suggest that in order for substantial
improvements in performance, additional funds are
necessary to support local health departments.55
One study using national data found that a $10 per
capita increase in local health department expenditures
was associated with significant reductions in infectious
disease incidence and in years of potential life lost.179
Another study concluded that a 10% increase in local
public health spending was associated with a reduction
in infant mortality and deaths from cardiovascular
disease, diabetes, and cancer.180 The researchers
further noted that for the average metropolitan area,
a 10% increase in local public health expenditures
translated into approximately $312,000 and resulted
in the same mortality reduction as would be expected
by the introduction of 27 new primary care doctors in
the same community.
Researchers using California data from 2001 to 2009
found that an additional investment of $10 per capita
in local health department expenditures reduced 9.1
deaths for every 100,000 people. The study also found
that the additional public health investments improved
PUBLIC HEALTH EXPENDITURES
Governmental public health investments have
been associated with a wide range of outcomes
including a reduction in the incidence of diseases,
a reduction in overall and disease-specific
mortality, and improvements in health status.
SECTION 3: EVIDENCE SYNTHESIS
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SECTION 3: EVIDENCE SYNTHESIS
the self-reported health status of approximately
24,000 people who improved from a “poor” or “fair”
rating to a health status in the “good, very good, or
excellent” health category.181
In a national study using more than 20 years of data
ending in 2013, researchers found that a 10% increase
in local public health spending per capita (the equivalent
of $594,000 for the average sized community) reduced
Medicare expenditures in the county by 0.8% per person
after 1 year, and by 1.1% after 5 years.174 These Medicare
savings represented $515,000 after 1 year and $656,500
after ve years. Thus, Medicare alone could recover $1.10
for every $1 invested in public health over a ve-year period
and the overall societal returns (including to Medicaid and
other payers) would be even greater.
The Bipartisan Policy Center recently completed a review
of the research on public health spending and costs in
order to develop evidence-based recommendations
about needed levels of investment. This review
focused specically on the resources required to
support cross-cutting public health infrastructure --
including surveillance, assessment, analysis, planning,
communication and coordination functions -- which are
collectively designated as “foundational public health
capabilities” by the Institute of Medicine and other national
public health advisory bodies. The review found that state
and local public health agencies collectively achieved
only about 60% of the recommended capability levels.
To achieve full capability levels, the review concluded that
the average U.S. community requires an additional annual
investment of $32 per capita, or $4.5 billion nationally, to
support foundational capabilities.173
Limitations
There are several limitations of existing studies on the
relationship between public health funding and public
health performance and outcomes. First, most studies
are limited to select data sources, notably a periodic
survey of local health departments and/or census data,
to estimate public health expenditures. Ideally, additional
data sources would allow for replication of results and
could further enrich current conclusions. Second, we
found few studies that examined how increased public
health expenditures aect health disparities—including
in rural, minority, or other under-represented groups.
Conclusions/Takeaways
Evidence indicates that there is a strong relationship
between public health funding and health outcomes of
communities. In particular, more investment in public
health translates to LHDs performing a broader range
of the 10 essential public health services and more
core public health activities. Higher investment in
public health also relates to reductions in the incidence
of chronic diseases and infant mortality and deaths
from cardiovascular disease, diabetes, and cancer. In
addition, higher per capita funding for public health is
associated with improvements in self-reported health
status, increased life expectancy, and reductions in
Medicare expenditures. Public health investments result
in improved health across the population and reduced
healthcare expenditures.
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CASE SUMMARIES OF EXEMPLAR STATES
North Carolina
North Carolina’s public health system includes the North Carolina Department of Health and Human Services (DHHS)
and within this super-agency, the Division of Public Health. DHHS and the Division of Public Health are accountable for
overseeing local public health programs and services and distributing federal and state funds to local public health agencies.
In 2017-2018, North Carolina’s public health budget was $157,214,360 (or approximately $14.99 per capita) and they were
ranked 33 in the 2018 America’s Health Rankings for public health.9 As a decentralized public health system, county
governments have legal authority and responsibility for public health. North Carolina’s fundamental accomplishments
toward a modern and sustainable public health system can be attributed to their early work in establishing a state system
for accreditation paired with accreditation requirements and their flexibility in local public health agency organizational
structures.
As of 2014, North Carolina requires all local public health agencies to be accredited and maintain accreditation through a
state accreditation board – the North Carolina Local Health Department Accreditation (NCLHDA) Board. To receive state
funding or federal pass-through funding from the state, LHDs must be accredited and re-accredited every four years.182 The
accreditation process is comprised of LHD self-assessments, site visits by the NCLHDA, and review of board decisions. To
meet accreditation standards, LHDs must reasonably perform approximately 90% of 148 specific activities, as well as be
able to provide the ten essential public health services.183 Although all 85 of North Carolina’s LHDs have been accredited
through the NCLHDA, only three have received national accreditation through the Public Health Accreditation Board
(PHAB).12, 184
Although North Carolina does not have a formal regional structure of public health services, the state is divided into four
regions for public health preparedness and response. Each region has a field office with staff, consultants, and other
support specialists who are employed by the state and work with and in support of local public health departments. In
2012, new legislation was introduced that offered flexibility for local public health agency structure.184 The new laws made
it possible for counties serving populations of 425,000 people or less to be able to create a consolidated human service
agency, as well as the option for county commissioners to assume the duties of a local board of health. Only three counties
previously were large enough to meet the population threshold, but as of 2014, at least eighteen counties had reorganized,
changed their local board of health, or both.182 The state currently has a total of 85 local health agencies, serving 100
counties with jurisdiction sizes ranging from 6,000 to over 900,000 people.184
In sum, local public health departments in North Carolina can provide public health services in various ways: establishing a
county health department; forming a multi-county district health department; forming or joining a public health authority;
establishing a consolidated human services agency; or contracting with the state to provide public health services. These
various agencies are all considered local health departments, must have a ‘governing board,’ and are obligated to provide
local public health services.182
50 IU Richard M. Fairbanks School of Public Health
CASE SUMMARIES OF EXEMPLAR STATES
Ohio
Ohio’s state health department, the Ohio Department of Health (ODH) is supported by 114 local health departments (LHDs)
including general health districts, city health districts and combined health districts. In 2017-2018, Ohio’s public health
budget was $153,239,809 (or approximately $13.11 per capita) and they were ranked 40 in the 2018 America’s Health
Rankings for public health.9 In 2013, Ohio was the first state to mandate public health accreditation by law. It is also one
of the three initial 21st Century Learning Community states working to modernize their public health systems.15 Ohio local
public health departments have been working to incorporate the foundational public health services (FPHS) framework to
guide improvements to public health practice, service delivery, and health outcomes.
To support planning for public health modernization efforts, in 2016, Ohio conducted LHD surveys to assess FPHSs and
the extent of shared services across LHDs. Findings indicated that, although LHDs were already engaging in some sharing
of services, additional sharing arrangements and service contracts were needed to facilitate increased cross-jurisdictional
sharing.185 Following this work, a costing tool was employed that factored in FPHS capabilities, identified FPHS gaps, and
then estimated the cost of closing those gaps. While these costs estimates were being generated, the 2017-2019 proposed
state budget consisted of $1 million to assist LHDs in transitioning from a five-year Community Health Assessment (CHA)
to a three-year cycle that aligned with hospital Community Health Needs Assessments and includes common metrics that
can be used by both partners.186 The 2017-2019 budget also included an additional $12,500 incentive for each LHD to aid
in addressing two of three specific population health areas including: mental health/addiction, maternal/child health,
and chronic diseases. Another $3.5 million of the 2017-2019 budget was allocated to support infrastructure costs and
accreditation efforts for merging LHDs.186 The ODH continues to strategically work to communicate the importance of the
FPHS and public health accreditation for improving health outcomes in the state. In sum, substantial state increases for
Ohio’s public health budget and state mandated accreditation were crucial to Ohio’s public health modernization efforts.
The additional funding allowed Ohio to develop a costing tool to close FPHS gaps; supported the LHDs in transitioning to
a three-year funding cycle; funded specific population health areas; and supporting LHD accreditation for the state.
51
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CASE SUMMARIES OF EXEMPLAR STATES
Oregon
Oregon’s state health department, the Oregon Health Authority, is supported by 33 county-based local health departments
(LHDs) and 1 public health district serving 3 counties. In 2017-2018, Oregon’s state public health budget was $116,277,440
(or approximately $27.57 per capita) and they were ranked 21 in the 2018 America’s Health Rankings for public health.9
Starting in 2013, the Oregon Health Authority, the Oregon Coalition of Local Health Ocials, and the Oregon Public Health
Advisory Board led the state in a process they refer to as public health modernization. In 2015, the state legislature established
the foundational public health services (FPHS) model in state law and mandated a public modernization plan, requiring local
public health modernization plans to be submitted by 2023.187 Oregon has used the foundational FPHS framework to dene
its health activities and to inform reorganization of their public health system.
As a first step toward the state’s public health modernization plan an evaluation was conducted that examined capacity
for the FPHS and estimated the cost of fully implementing the FPHS at the state and local levels.188 Findings from this
work were used to develop a statewide public health modernization plan and communication tools to help with technical
assistance. Additionally, Oregon emphasized relationships among LHDs, legislators, and key stakeholders in order to build
awareness and a shared understanding of FPHS in the state. Oregon established various resources to guide the state’s
implementation of FPHS, including the online Public Health Modernization Roadmap for moving to FPHS implementation.
The Roadmap provides strategies and tools such as decision aids and model agreements for cross-jurisdictional sharing.188
The Oregon Coalition of Local Health Officials held several regional meetings to prepare LHDs to apply for a local public
health modernization grant.187 In 2017, a total of $5 million was awarded in public health modernization grants within
the state. A total of $3.9 million was awarded to 32 out of the 34 LHDS and $1.1 million was awarded to the state health
authority.188 In 2018, the state published its baseline Public Health Accountability Metrics Report to identify shared goals
and track progress toward population health priorities.189 Following the RWJF grant work, Oregon is currently working
towards continuing to identify public modernization tools and resources for the roadmap, as well as implementing other
service delivery models for cross-jurisdictional sharing and regionalization.15
In sum, Oregon is an exemplar state because they are committed to improving the public health system. Their legal mandate
that all LHDs submit modernization plans to establish the FPHS model in the state is one example of this commitment.
Another example is that the State incentivized it by using state funds for modernization grants for LHDs.
52 IU Richard M. Fairbanks School of Public Health
CASE SUMMARIES OF EXEMPLAR STATES
Washington
Washington’s state health department, the Washington Department of Health (DOH), is supported by 35 local health
departments (LHDs). Other public health authorities include the Washington State Association of Local Public Health
Officials and the State Board of Health. In 2017-2018, Washington’s state public health budget was $341,908,500 (or
approximately $44.69 per capita) and they were ranked 9 in the 2018 America’s Health Rankings for public health.9 In an
effort to advance its increasing demand for public health services and a historic lack of public health funding, the state
implemented the foundational public health services (FPHS) framework in 2018.190 The Robert Wood Johnson Foundation
provided grant funding for Washington to build on longstanding working relationships between state and local public health
leaders. Washington has focused its efforts on defining the governmental public health system and creating a modern and
sustainably-funded governmental public health system.191 Washington was the first state to implement the Uniform Chart
of Accounts (UCOA), a system to standardize the tracking of public health financial data. Over a period of multiple years,
the State built a crosswalk so that LHDs could report their financial data (where funds come from, which services are
covered by specific funds, etc.) into a uniform and standard system across the state. The ultimate purpose of the UCOA is
to improve transparency and accountability for public health funding and to be able to examine the use of funds in terms
of effectiveness and efficiencies. Additionally, the state agency and the local public health delivery system each established
defined services and funding roles. Strategically allocating funds toward this work, the state awarded an initial investment
of $10 million to LHDs and $2 million to the DOH for statewide efforts toward implementing statewide strategies to control
the spread of communicable disease and other strategies. The LHDs and the Washington State Association of Local Public
Health Officials apportioned $1 million out of its $10 million funding to support shared service delivery demonstration
projects.192 Local public health leaders are optimistic that these demonstration projects will provide opportunities to test
new service delivery models and expand access to learned expertise and increase awareness.
The state of Washington is an exemplar state because they have a longstanding and shared commitment to improving the public
health system. Through the investments made in implementing the Uniform Chart of Accounts as well as the the commitment
of a statewide team that systematically assessed how to structure the delivery of the FPHS, the State has developed a strategy
to create sustainable change. Through these eorts they have also estimated the costs to implement these structural changes
and to perform the FPHS. They have used this work to inform a formal budget request of their legislature.
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CASE SUMMARIES OF EXEMPLAR STATES
Comparisons Across Exemplar States
Indiana North Carolina Ohio Oregon Minnesota Washington
State Public
Health Budgeta
$92,570,257 $157,214,360 $153,239,809 $116,277,440 $244,955,000 $341,908,500
Per Capita
Spending
$13.75 $14.99 $13.11 $27.57 $43.43 $44.69
Public Health
Rankingb
41 33 40 21 7 9
State Public
Health
Emergency
Preparedness
Scorec
Bottom Tier Top Tier Bottom Tier Middle Tier Middle Tier Top Tier
State Agency
Structure
Freestanding Under a super
agency
Freestanding Under a super
agency
Freestanding Freestanding
Governance of
State and Local
Public Health
Decentralized Decentralized Decentralized Decentralized Decentralized Decentralized
Number of
Local Health
Departments
94 84 113 33 51 35
Regional/
District Health
Oces
No Ye s No Ye s No No
aTrust for America’s Health, The Impact of the Chronic Underfunding on America’s Public Health System: Trends, Risks, and
Recommendations, 20199
bUnited Health Foundation – America’s Health Rankings, 201836
cTrust for America’s Health, Ready or Not: Protecting the Public’s Health from Diseases, Disasters and Bioterrorism, 201926
54 IU Richard M. Fairbanks School of Public Health
Fishers Health Department
In the early weeks of the COVID-19 pandemic, Mayor Scott Fadness of
the City of Fishers, Indiana, found himself reading national public health
recommendations and the state and local policies governing public health.
At the time, he was focused on nding ways to ensure resiliency. This
required a focus on essential public safety and public health infrastructure
so that his city could weather the anticipated impacts of COVID-19. He
learned that the law allowed him to stand up a health department in his city and it aligned with his vision of making sure that the
health of his community is considered in all governmental decisions. In the eld of public health systems, this concept is referred
to as a “health in all policies” approach and in practice it means consulting with or having public health experts at the table when
policy decisions are being made regarding transportation, parks and recreation, public safety, etc.
Mayor Fadness, with a background in mental health services, was of the mind that the health of the members of a community
is directly tied to the economic success of those individuals and the economic success of the businesses operating in that
community. However, as a Mayor and leader of a city, it was his experience that he was “completely divorced” from decisions
inuencing the welfare and health of the population by both structure and culture. He said, “I saw a future where public health
had to be seamlessly integrated into the urban setting and in the structures that exist in government at the local level.” So, on
April 24, 2020, the City Council of Fishers approved the establishment of the Fishers Health Department, established a board
of health, and appointed Dr. Indy Lane as the Health Ocer. At the same time, the City Council approved the reallocation of
$2 million in city resources in addition to reallocated resources from Hamilton County to fund the public health department.
As discussed in Section 1 of this report, the Public Health 3.0 approach emphasizes the concept of health in all policies. It also
emphasizes the idea that public health agencies should be the chief health strategist for their communities. More specically, as a chief
health strategist, public health agencies convene government as well as non-governmental for-prot and not-for-prot organizations
to use their diverse resources to collectively work to improve public health. Using public health expertise and tools, the collective of
stakeholders has the potential to make a bigger impact on the public’s health. These two concepts, the health in all policies approach
and public health as the chief health strategist have similar goals – working with stakeholders to improve public health from a systems
perspective. According to Mayor Fadness, in the years prior to the COVID-19 pandemic, he rarely experienced interactions with the
county health department in his jurisdiction and did not see the connections between public health and other community stakeholders,
which was part of his worry as he was considering ways to prepare his community for the pandemic. He said, “when a crisis does occur
and those [connections to public health] aren’t there, you’re at a decit before you even get started. So what we’re trying to create here
is those relationships, that web has to be nurtured and developed and become muscle memory for the future.”
In alignment with the goal of public health integration within a system, Mayor Fadness and Fishers Health Department Director,
Monica Heltz, have worked to cross-train other governmental employees with relevant expertise and responsibilities. For
example, the City of Fishers requires that all re department employees are trained paramedics. Since you have to have re
departments, even when there are rarely res, there is a value proposition for the community for re ghters to support public
health, especially in health-related response roles. In fact, the more than 15,000 COVID-19 tests that have been administered to
Fishers residents have been conducted by re ghters. While this approach is working for Fishers, Mayor Fadness cautioned that
this process is not simple and that this model would not work everywhere; however, for a relatively large city in a large county
primarily made up of rural settings, he believes this was the best solution to ensuring the health and wellbeing of his community.
CASE SUMMARY
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IU Richard M. Fairbanks School of Public Health
QUALITATIVE INSIGHTS
Interviews were conducted with public health and health
care experts as well as business and policy leaders across
the state of Indiana. A total of 49 individuals contributed
insights about their experiences with the public health
system, their vision for improving the public health system,
and considerations for creating a path to change. The
authors would like to acknowledge and thank the following
list of stakeholders who participated in an interview.
Public Health Experts and
Practitioners
• Dr. David Allison, Dean and Distinguished Professor at
Indiana University School of Public Health-Bloomington
• Dr. Jeremey Adler, Tippecanoe County Health Ocer
and President, Indiana State Association of County
and City Health Ocials (INSACCHO)
• Dr. Kris Box, Indiana State Health Commissioner, Indiana
• Dr. Virginia Caine, Marion County Public Health
Department Director
• Dr. Robert Einterz, St. Joseph County Health Ocer
• Dr. Richard Feldman, former Indiana State Health
Commissioner
• Dr. Mark Fox, St. Joseph County Deputy Health Ocer
• Monica Heltz, Fishers Health Department Public
Health Director
• Dr. Merle Holsopple, Former President, Indiana
State Association of County and City Health Ocials
(INSACCHO)
• Kim Irwin, Health by Design Executive Director and
Administrator, Indiana Public Health Association
• Dr. Greg Larkin, former Indiana State Health
Commissioner
• Dr. Judy Monroe, former Indiana State Health
Commissioner
• Betsy Prentice, Indiana Public Health Association
Administrator
• Dr. Jennifer Sullivan, Secretary, Indiana Family Social
Services Administration
• Dr. Matt Sutter, Allen County Health Ocer
• Dr. Chandana Vavilala, Lake County Health Ocer
• Mindy Waldron, Allen County Health Administrator
• Dr. David Welsh, Ripley County Health Ocer
• Dr. Eric Yazel, Clark County Ocer
Health Care Experts
• Dr. Joseph Bonanno, Dean and Professor, Indiana
University School of Optometry
• Dr. David Daleke, Vice Provost for Graduate Education
and Health Sciences and Associate Dean, Indiana
University Graduate School
• Dr. Sarah Giaquinta, Vice President of Community
Health, Parkview Health
• Dr. Lisa Harris, Chief Executive Ocer, Eskenazi Health
• Dr. Dawn Haut, Chief Executive Ocer, Eskenazi
Health Centers
• Dr. Jay Hess, Dean, Indiana University School of
Medicine and Executive Vice President for University
Critical Aairs
• Dr. Indy Lane, Fishers Health Department Chief
Medical Director
• Dr. David Lee, Vice President, Provider Engagement
and Contracting, Anthem
• Dr. Patrick McGill, Chief Analytics Ocer, Community
Health Network
• Bryan Mills, President/Chief Executive Ocer,
Community Health Network
• Dr. Mike Mirro, Chief Academic and Research Ocer,
Parkview Health
• Dennis Murphy, President/Chief Executive Officer,
IU Health
• Jonathan Nalli, Chief Executive Ocer, St. Vincent/
Ascension Health Care
• Dr. Robin Newhouse, Dean and Distinguished
Professor, Indiana University School of Nursing
• Mike Packnett, President/Chief Executive Ocer,
Parkview Health
• Julie Reed, Executive Vice President, Indiana State
Medical Association
• Dr. Paul Wallach, Executive Associate Dean of
Educational Aairs and Institutional Improvement,
Indiana University School of Medicine
• Dr. Ram Yeleti, Chief Physician Executive, Community
Health Network
Business and Policy Leaders
• Senator Jean Breaux, Indiana Legislature
• Kevin Brinegar, President and Chief Executive Ocer,
Indiana Chamber of Commerce
SECTION 4: QUALITATIVE INSIGHTS FROM KEY STAKEHOLDERS IN INDIANA
56 IU Richard M. Fairbanks School of Public Health
SECTION 4: QUALITATIVE INSIGHTS FROM KEY STAKEHOLDERS IN INDIANA
• Senator Ed Charbonneau, Indiana Legislature
• Scott Fadness, Mayor, City of Fishers
• Mark Fisher, Chief Policy Ocer, Indy Chamber of
Commerce
• Angel Franklin, Vice President of Compensation and
Benets, Cummins
• Michael Huber, President/CEO, Indy Chamber of
Commerce
• David Johnson, President/CEO, Central Indiana
Corporate Partnership
• Representative Cindy Kirchhofer, Indiana Legislature
• David A. Ricks, Chairman and Chief Executive Ocer, Eli Lilly
• Dr. Michael McRobbie, President, Indiana University
• Representative Robin Shackleford, Indiana Legislature
Qualitative Insights About Public
Health in Indiana
Overview
Participants were asked to provide their perspectives on
the current state of the public health system. They were
also asked if they have specific insight about issues with
the public health system either during the COVID-19
pandemic specifically or prior to the pandemic.
Participants identified a total of 6 overarching issues
with the public health system. These include:
1. Public health is not well understood and is undervalued
2. Public health does not have sucient funding
3. There is a lack of specic types of public health expertise
at the local level
4. There is a lack of connectedness and communication
between the state health department (SHD) and local
health departments (LHDs)
5. There is insucient technology and essential
infrastructure coupled with inconsistent data for
evidence-based decision making
6. The local public health system is not providing the
essential public health services consistently across
communities.
The next section describes these issues in detail and
provides the context for each issue as well as key
quotes from participants. Participants were also asked
for recommendations about strengthening the public
health system in Indiana. As available, participant
suggestions for improvements are explained within
each of the related themes.
Participant Identied Public Health System Issues
and Suggestions for Improvement
Issue 1: Public health is not well understood and is
undervalued
Across the three types of participants, it was reported that
there is a general lack of understanding of the value of public
health and its role in protecting and ensuring the health of
the population. For example, participants felt that state
lawmakers and other key stakeholders do not recognize that
public health and healthcare delivery are dierent entities or
that they have different roles. A policy expert said,
“The biggest challenge, number one is, is that the
average [member of the] public does not realize the
value and importance of what public health does.
When public health is effective and efficient, they
don’t hear anything about it.”
In a related comment, a health care expert noted, for
example, “[Indiana] is woefully inadequate on vaccine
education in the state.” While the general public may
not understand the role of public health, participants
perceived dierent implications when lawmakers and local
leaders do not understand public health. In particular, a
policy expert reported that elected ocials are not aware
of the impact of behavior change on health and believes
that this disconnect limits state funding for public health.
Another important consideration that was raised by a
health care expert is that investing in public health is
about investing in the path toward health goals and having
realistic expectations for the time it takes to see returns
on those investments. The health care expert stated:
“There’s this sense ‘I want to invest in something
today, and I want to see material payback in twelve
months.’ I don’t think that’s realistic…It feels like
public health is more like our bridge and road
infrastructure improvements – nobody’s looking for
an immediate return on investment for all the money
we’re putting in roads. But there’s an inherent belief
that that makes us a better statewide economy,
if we have better roads and bridges. I don’t know
how you get people to that same understanding on
public health -that this is a long-term investment
for major returns as opposed to this ‘I need to see
improvements in twelve months.’”
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IU Richard M. Fairbanks School of Public Health
Participant Suggestions for Improvement
A public health expert suggested that: “Public health
has to do more community outreach and education
about all the things that public health is responsible
for and all the things that it does.” Additionally, it was
suggested that providing local leaders with more
information about the value of public health, may be
benecial. Specically, one public health expert said:
“I think one of the things that would really help
a great deal to our commissioners and to other
elected ocials is on demonstrating to them, with
some concrete data from either within the state of
Indiana or from other states, about the economic
benets of a strong public health system. That’s the
one thing that they seem to really latch on to - the
things that benet the economy. And if they could
see how spending that money on public health
creates a large return on investment, that I think it’d
be a lot easier for them to wrap their heads around
the idea of spending more money on public health.”
Other participants supported this idea, reporting
perceptions that the lack of clarity about the value of public
health impedes funding at both the local and state level as well
as support from state and county leadership. Respondents
also suggested that state leaders, local government, and
private organizations may be more supportive of public
health if they had a better understanding of its value and
role and how to partner in support of public health. A policy
expert stated, “Your biggest gap in the legislature is people
not knowing what public health means.”
Issue 2: Public health does not have sucient funding
Participant insight about the issues of public health in
Indiana focused on funding as the root cause of many of
the other more specific issues detailed in this section of
the report. A policy expert said, “Public health in Indiana
is not a high priority. When we start to prioritize where
our limited dollars go, it does not appear to me that public
health receives a sufficient amount of those dollars to
be able to really have a meaningful impact on health
overall in the state of Indiana.” Additionally, participants
explained that understanding the value of public health
and the potential of providing sufficient funding for
public health are directly connected. One policy expert
said: “…our legislative body feels that changing behavior
is not motivated by necessarily allocating more money
towards public health initiatives. It’s just not convinced
that behavior is changed in the public health space by
allocating more money.” Another policy expert said,
“I think Indiana is a sicker state, and when you’re
sicker it costs more money. But we don’t want to
contribute the money, and so I think that there is
a real disconnect between understanding the role
that a healthy community and a health society can
play versus the financial commitment it takes to
achieve that.”
Health care experts summarized the problem of funding
by explaining their perspective that Indiana pays for health,
but it does so in the most costly way – by paying for it
through a sicker population and the costs of their medical
care. A policy expert stated “We pay for poor health, but we
do so ineectively.” A health care expert explained:
“We have very low-income state taxes for
corporations and individuals. We have very high
healthcare taxes…[Employers are] basically tax[ed]
to do business [in Indiana]. So if you’re a pro-growth
Republican, you should really care about healthcare
costs. Those are things that won’t change overnight
with public health, but over time really can change
quite a bit.”
There is also the issue of LHDs receiving little funding from
the state, causing them to be dependent on local leaders/
county commissions who may not understand the value
of public health. One public health expert said: “I know
some of the counties around us have the same attitude I
think the state does – where public health funding is kind of
an afterthought. When things get tight around the belt, it’s
one of the rst things they want to cut.” The dependency
on local funding and county leadership also leads to
problems with funds being supplanted. More specically,
if a LHD is seeking ways to generate more review with the
intention of expanding services or meeting community
public health needs; if they are successful, the county
commissioners/councils might take that same amount of
money back from the LHD budget. This, in eect, creates
a zero sum game whereby LHDs are discouraged from
SECTION 4: QUALITATIVE INSIGHTS FROM KEY STAKEHOLDERS IN INDIANA
58 IU Richard M. Fairbanks School of Public Health
Participant Suggestions for Improvement
Participant suggestions often echoed the same
sentiment – that public health funding from the
state needs to be increased to support the delivery
of the essential services of public health at both
the state and the local level. One public health
expert said:
“It makes no sense to me to fund public health
out of local dollars – what you’re assuring
then is that the most impoverished areas are
going to have the worst health department and
they’re the ones who need it the most. So it’s
got to come from a shared pool and if that’s not
federal dollars then it needs to be state dollars.”
Another participant offered more specifics about
the potential of increased state funding for public
health. More specifically, the public health expert
suggested that more state funds are necessary to
allow for “prioritization of public health work through
a realignment of funding [such as] having funding in
some sort of statute or regulatory framework that
it isn’t so tied up in local politics…to allow public
health to do what it’s supposed to do, which is to
prepare, respond and grow.”
One public health expert spoke to changing what
the state funds. Instead of funding sickness care,
the state can accomplish more by funding the
prevention of sickness. The participant said:
“[Public Health] is a great investment. You
put in pennies and you get back dollars. From
a fiscal standpoint, it seems like a no-brainer.
The problem is the pots of where the money
comes out of and where the benefit goes into
aren’t the same. It’s not like a business where
you invest ten cents and you get a dollar back;
you have to come up with ten cents and then
somebody else gets your dollar. The incentives
do not align. But if we stop smoking, if we
reduce obesity, if we cut Medicaid for the state
then there’s all these downstream effects, plus
healthier better lives and more jobs.”
spending time trying to increase their budgets through
external grants or improved billing of services. A public
health expert explains:
“We had an opportunity to get paid for immunizations
for people with [insurance] coverage. So we went
through the whole process of being a provider for
Medicaid and Medicare and Blue Cross and so forth,
even had [staff] lined up to do the billing. We did
everything correctly, and [local leaders] wanted to
do the same things. ‘Oh, great, you got these funds
from doing the immunizations? So let’s subtract
that from over here.’”
Another problem that was explained by participants was
a lack of consistent funding to be able to recruit a trained
workforce and to retain them. One public health expert said:
“Public health has an aging workforce and salaries
that are not competitive with other businesses.
So how does public health continue to recruit a
younger population and recruit them into local
health departments, especially when we continue to
see decreases in funding every year?”
Another public health expert explained, “If I have
somebody with really good credentials, it’s going to be
hard to keep them in my county because I’m not going
to be able to pay them enough.” Other participants
said that not having consistent funding means that
people trained specifically in public health often have
to be hired as contractors either because salaries are
not sufficient or there are not permanent positions for
them in the agency. The public health expert said:
“The fact that many of our team in public health are
hired based on time limited grants [means] we don’t
have longevity or long standing expertise in those
programs. Because we don’t just say we’re going
to pay for these people to work here…it gets in the
way of us hiring and retaining and growing powerful
expert teams within the public health workforce. I
think that that fundamental change of investment
is building out teams that we’re going to support
for the long haul…We’re not just giving more money,
we’re doing it to do something.”
SECTION 4: QUALITATIVE INSIGHTS FROM KEY STAKEHOLDERS IN INDIANA
59
IU Richard M. Fairbanks School of Public Health
Issue 3: There is a lack of specic types of public
health expertise at the local level
Public health experts consistently noted that LHD
employees would benet from improved training
opportunities. In particular, local health ocials report that
when they start working for the LHD they receive no on-
the-job training in public health or what is expected of their
specic role as a health ocial. One public health expert
said: “There’s just really no system of having standardized
ways of doing what we do [in LHDs] and there’s no training.
The training that’s there is very pocketed.” Another public
health expert explained: “I’ve been a health ocer for
[many years]. And it’s been kind of on-the-job training.” In
addition to the lack of public health training among local
health ocials, respondents reported that LHDs are not
resourced with enough appropriate expertise overall. In
particular, respondents reported that local public health
does not have resources for public health preparedness,
Medicaid billing, epidemiology and informatics, and
surveillance and disease intervention – some of which
was perceived to have impeded local response eorts for
COVID-19. One public health expert said: “whatever we
think we don’t have in training and expertise at the state
level, we have even less of it at the local level.”
Issue 4: There is a lack of connectedness and
communication between the SHD and LHDs and
among LHDs
LHDs report that there is a lack consistent communication
between the SHD and LHDs. One public health expert
directly stated: “The state health department does not
have enough contact with local health departments or Local
Health Ocers.” A specic example from the COVID-19
pandemic referenced situations in which LHDs learned
of SHD response initiatives and decisions through the
media. Participants reported being caught o guard and
unprepared to respond to their community’s questions
about state announcements. Further, participants believed
that this lack of communication created ineciencies
at a time when resources were crucial. Participants also
suggested that the lack of consistent communication
between the SHD and LHDs contributes to a lack of
alignment and lack of strategic eorts across LHDs and
the state. One local public health expert said “when there
is a major [state public health] announcement coming out,
just a little bit of forewarning would be awesome…You may
not be calling the shots about what the state’s doing but
you’re frequently asked details and it certainly impacts you,
so having that information ahead of time would be helpful.”
In another example, a participant said their LHD dedicated
a week preparing for a COVID-19-related decision and the
public announcement of it, only to see their work become
irrelevant by a change made by the SHD. A public health
expert explained:
“I continue to think that Home Rule is a awed system. It’s
very unclear what the state and local health departments
have responsibilities for and what they have shared
responsibilities for and who gets to make the rules. It’s
been incredibly frustrating throughout [the pandemic]
that the state [health department] will make an edict and
say ‘call your local health department because they’ll take
care of it.’ So then local health departments are tasked
with enforcing something that we had no role in creating
and no voice in discussing the implications of and we
Participant Suggestions for Improvement
Local health ocials suggest that ongoing
training covering new public health initiatives and
innovations would benecial. Two public health
experts oered their perspectives:
“Some kind of ongoing educational process is
needed. ‘What’s the latest thing on vaccinations?
What’s the latest thing on water safety? What’s
the latest thing on farming issues? If you have
a highway going through your county, what are
some of the transportation issues you need to
be aware of about hazmat coming through your
county?”’
“Some sort of health ocers training would be
great…I think you still get a decent amount of
[local] health ocers who think, ‘I can just walk
through [the health department] for 30 minutes
on Friday and pick up my check,’ and [they have]
no interest in the actual process themselves. I
think [mandatory trainings] would help weed
out the ones that are truly wanting to [be health
ocers] for the right reasons.”
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60 IU Richard M. Fairbanks School of Public Health
found out ten minutes before the public found out. That
fractures the relationship [between the state and the
locals]. In other states that are state-run, at least you’re
clear who has the authority and what the relationship is.
So this shared relationship where we both, both the state
and the county, have responsibility but it’s not really clear
who ultimately has responsibility and who gets to make
decisions, is a set-up for poor management. At the end of
the day, you’ve got to know who’s making the shots and
who’s responsible for enforcing them. Right now we don’t
know. A lot of times, it’s whoever speaks the loudest.”
A health care expert explained an example that alludes
to the lack of connectedness within the public health
system. The example provided relates to the COVID-19
pandemic response and highlights a need for public
health coordination to work with health care systems at
a district level. The health care expert said:
“Two things that have been very challenging. One
is getting increased capacity for hospital beds. So
we have a district where we’re going to run out of
beds much quicker than we thought we would.
What are we going to do to set up a field hospital?
Unfortunately, there’s no one person that we can go
to, to rally by district. And the second thing is [the
State Health Department] is sending out vaccines to
different hospitals, but again this is uncoordinated. I
think that having a district approach makes sense.”
Participant Suggestions for Improvement
Most LHD respondents suggested that they would
benet from a structure that oers improved
connections between the SHD and LHDs. A suggestion
from one public health expert was: “There needs
to be a team of people [at the state] that their
assignment is the local health departments and the
communication with, the interaction with, and kind of
holding accountable the local health departments for
metrics.” A public health expert also suggested that
the large number of LHDs makes communication
dicult and recommended a regional support
structure to facilitate better connectedness.
“I don’t think you can put [new funds] out to
92 local health departments and make it work.
I think you got to have at least some level of
regionalization at least for oversight. And I
think there’s some advantages to that – having
a regional contact as opposed to just a state
contact. I just think the regions are different
enough that I think you’ve got to have some
middle layer there.”
Another reason provided for sharing-resources at a
district level was that it would improve surge capacity
at the local level. A public health expert said: “having
the ability to move resources around from county to
county I think would be very helpful because in the
non-COVID world, most of the time my workow is
ne. But then all of a sudden something will happen
and I could use all hands on deck, and we’re absolutely
overextending all our local people.” Specic ideas
generated included one from a public health expert:
“You could hire one full time health ocer that
could oversee ve or six counties, one large
administrator that oversees ve or six local health
oces, and you get economies of scale from that
standpoint, but also better trained, maybe better
educated, MPH-type candidates along with the
local health ocer. [The state] could have more
interaction with them, provide more training for
them, and be more supportive of them.”
Another public health expert explained that the
current funding structure of dependency on local
county governments and local taxes makes it
dicult to work together on regional public health
issues and initiatives. Given this context, it was
recommended that efficiencies could be gained by
supporting LHDs to work together. The expert said:
“I understand we are all constrained within our
own county budgets and nobody wants to spend
public health dollars from county [A] in county
[B], but a little more cooperation would be huge
on the local level. Because, again, an opioid
epidemic doesn’t stop as soon as you leave
county [A]. So a lot of these programs would be
much more ecient if we worked together.”
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Issue 5: There is insucient technology and
essential infrastructure coupled with inconsistent
data for evidence-based decision making
Participants report inefficiencies and delays in
essential service provision by LHDs because public
health functions remain paper-based. One participant
reported that many of the services that LHDs provide
do not have community access to web-based forms or
technology that would streamline processes. A public
health expert explained:
“I’d say the biggest gap is information…[LHDs are] stuck
in 1970 because that’s where we’re at in terms of the
information systems. We’re just woefully impoverished
from a resource perspective as relates to information
systems…We do not have online permitting; no web-
based permitting. We’re still using paper.”
Another public health expert provided an example
about improving the efficiency of infectious disease
reporting (e.g., new HIV infections are still received
as paper-based reports) and the implications for the
timeliness of identifying or responding to an outbreak.
The participant said that at one time:
“[the State Health Department had a] goal to become
80% paperless and got a long way down that path…but
those things always take a backseat because there’s
always a ‘re’ to put out and, when you have such a
small workforce, all of that growth gets constantly
interrupted because you end up with all hands on
deck for a response. Then your baseline teams that
are supposed to be making you good at what you do
get pulled to do other stu.”
Regarding laboratory capabilities, one participant
reported that as of mid-March, at the start of the
COVID-19 pandemic, the state public health laboratory
was capable of processing 40 COVID-19 tests per day,
which was insufficient and was resulting in long turn-
around times. To support the state public health system,
private industry stood up the capacity to process more
tests. More specifically, Eli Lilly developed that capacity
for Indiana. One health care expert said, “within a month
Lilly built the capacity for 2,600 tests and can now
[process] 40,000.” It was recommended that laboratory
capabilities and “diagnosis capabilities for public health
emergencies need to be permanent going forward.” A
public health expert echoed this sentiment about the
need for consistent and sufficient infrastructure:
“I feel like even more now than previously, our State
Department of Health in particular and our local
health departments have to scrap to get stuff done
and they have to rebuild things every single time
there’s a problem. And that doesn’t have to be that
way… existing infrastructure is really key.”
LHDs also shared that they often have to report data
manually to the SHD, but that when they ask the SHD
for analytics about their own LHD data, they are told
the SHD cannot share it back to them. This mattered
to participants because they suggest that time is being
wasted in reporting data to the SHD and that LHDs
are hindered by not being able to use data analytics
in decision-making. One public health expert said, “I
feel like I’m going to seven different systems to get very
little meaningful information.”
Participant Suggestions for Improvement
A public health expert made the following
recommendation: “As a state, the best thing would
be if we came up with one IT system that connected
everything together, and we made sure every local health
or every county had a connection.” Another public health
expert echoed this call: “being able to have a common
platform would be critical to be sure, and I think there
However, one public health expert also said: “I think
you’d almost have to have both [LHDs and a district
office] because I think some of the relationships
that are cultivated at the local level would be really
hard to do at the regional level.” Another important
consideration offered by a public health expert
is that “one of the potential barriers from the
standpoint of a larger health department is that
many of them may fear that they’re going to be
given extra [district level] responsibilities, but then
not be given extra staff or extra funding to take care
of those other counties.”
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62 IU Richard M. Fairbanks School of Public Health
Issue 6: The local public health system is not
providing the essential public health services
consistently across populations
Participants reported that there are variations in what
public health provides at the local level. According to
one public health expert:
“LHDs say, ‘We can’t aord to have a food safety
person along with the person who does the septic
system stu along with preparedness.’ So [LHDs]
hire one person and they do all three. And so then
you’ve got basically someone who likes preparedness
better. So they spend all their time on that. And one
person actually said ‘well, I just don’t do food safety.
I don’t really understand it.’ So that’s where you need
to have counties joined together and hire a food
safety person that the State Department of Health
can train well and interact with and they know that
they go out and do these X number of counties. And
the same with the septic person. And, and the same
with a preparedness person.”
Another public health expert said: “I do think that
there should be some incentive, whether for good or
for bad to actually achieve essential public health work.
The fact that locals get to pick and choose what they
do, and what they don’t do is pretty alarming.” It was
suggested that the challenge is the differences in sizes
of jurisdictions. According to a public health expert:
“We have such disparate county sizes, which is a bit of
a problem when it comes to what we do as local public
health. For example, [our county is large enough to deal
with] TB (Tuberculosis) and STDs (sexually transmitted
diseases) all the time. So we’re good at it and we have
routines. Whereas smaller counties will call us and say,
‘hey, we’ve got our rst case of TB in three years. What
do we do again?’ There’s no state system that supports
locals. The locals rely on the locals.”
In a similar sentiment, another public health expert
said:
“Getting people together and having the
combined resources of multiple counties
working to fund public health initiatives in a
particular area would be very beneficial and
probably would benefit a lot of the rural counties
to a great extent, because many of those health
departments are very small. And I’m sure they
have some challenges meeting some of the basic
public health needs of their area.”
Even more specifically, another public health expert
explained:
“The local health departments are almost
completely autonomous from the state health
department. There is some funding that flows down
to the local health departments, but not much. The
vast majority of funding in Indiana for local health
departments comes from the local community…If
we think about public health as having responsibility
of protecting and improving the health of the public,
how well are [LHDs] doing with that? And what are
things that could be done better or suggestions that
[the state] might have about how to move farther
faster?... So if there was some sort of template that,
‘Hey, county, this is the stuff you need to have in
place for a good, functioning health department.
Here’s the way you need to act. Here’s the funding
level for basics and if you don’t do your job, county
government, then there’s a mechanism for the state
to step in to protect the population.’”
It was stated that LHD activities are limited to just those
required of them (as shown in Figure 11). One public
health expert said:
“What we focus on, at least in this county, are the
statutory obligations and really if [a LHD] goes
beyond that, it’s unusual. And unfortunately the
statutory obligation seems to be stuck in 100 years
ago and there’s no real emphasis or expectation on
the part of the health department to really engage
in identifying or grappling with and taking action
items against the real health problems of this
would be cost savings in this infrastructure.” Relatedly,
a public health expert suggested: “What we need to do
is invest in and continue to push metric-based, evidence-
based programming that is getting results, even if it
doesn’t get results as fast as people want.”
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county and of this state. For example, a simple one
would be adverse childhood experiences - clearly
a major problem for children and the outcomes
of those in adulthood are profound. And yet what
health department within the state of Indiana is
really grappling with these?”
Participant Suggestions for Improvement
One public health expert suggested that the
accreditation process could oer systematic
process improvement across a variety of related
areas. More specically, the participant stated: “…
accreditation does kind of raise all levels, really does
improve services that public health provides, and
the way public health provides them and documents
them.” Similarly, another public health expert
said: “I think there is value to doing the work that’s
required for accreditation…and so I suggested we
look at the framework of what’s required and holding
ourselves to try to account for all that.” Along that
same line, a number of participants indirectly asked
for local public health in Indiana to have standards
for services such as that which is provided by the
Foundational Public Health Services framework. A
public health expert said:
“If it were a little bit more prescriptive in terms
of the development of standards that each of the
local health departments had to meet, whether
it’s services or scope of the overall mission,
having that as a touchpoint may be helpful to
working with county commissioners and others
to identify those things that you had to do.”
A related recommendation came from a health care
expert:
“I think there is a foundational set of capabilities
that every department needs to have. Today, I think
it’s highly variable and it’s not prescribed. And I
see that more in a regulatory framework than a
legislative framework. Lay out requirements, but
leave them to the experts to lay out.”
Health care experts recognize the limitations the
existing public health system have on their efforts
to address health inequity. More specifically, one
health care expert said:
“[Indiana] really needs a unified message and
a unified coordinated plan. Because of the lack
of coordination in the counties and the state,
[healthcare system efforts] have become
ineffective, even when resources are put in. It’s
not just the money, but the connectivity – there
are different initiatives that are not connected.
And so we were struggling right now with ‘how
do we [as healthcare systems] reach out to the
locals or the state to help us address some of
these health inequities based on race? And
there is no one go-to place, one go-to person,
one situation where we can tap into resources
to help them do the best we can. It’s even more
than an uphill battle.”
Participants directly expressed the need for a
comprehensive strategic plan for public health
and that this lack of guidance trickles down to the
decisions at the local level as well. A public health
expert said: “[LHDs] don’t really get into a lot of
the chronic issues like obesity and things like that,
unless there’s a small little pocket of grant money,
so we don’t have that full [public health] system.”
One policy expert noted that state strategic plans
exist in most other areas, but not one for public
health and wellness.
“We don’t have a comprehensive state health
and wellness plan…You have a comprehensive
plan for everything else but you don’t have
one for wellness…Where [we] need to start is
drafting a comprehensive health and wellness
plan for the state.”
A health care expert made a similar call for planning:
“There needs to be a post-pandemic reckoning
process…[we need to know] what we need to do to
be better-prepared.”
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64 IU Richard M. Fairbanks School of Public Health
SECTION 5: RECOMMENDATIONS FOR PUBLIC HEALTH SYSTEM CHANGE
RECOMMENDATIONS
The recommendations and implementation steps
contained in this section are based on the comprehensive
review of Indiana’s state and local public health system
as well as the relevant evidence and experiences of
public health systems experts. As noted in Section
2, Indiana’s current public health system is not able
to provide the full range of capabilities necessary to
protect health and safety for all Hoosiers. Current
capabilities vary widely across the state, fall significantly
short of national recommendations and guidelines,
lag behind the capabilities maintained in neighboring
states, and are most severely constrained in Indiana’s
small and rural communities. These problems derive
from multiple contributing factors, but root causes
lie in its fragmented delivery system structure and its
inadequate financial and human resources.
Indiana’s under-resourced public health system
contributes to higher levels of preventable disease
and injury burden along with higher medical care
costs, compared to many other states. These health
and economic burdens are not distributed evenly
across the state, but rather they are concentrated
in rural communities, low and moderate income
households, and racial and ethnic minority groups. As a
consequence, strategic investments in Indiana’s public
health system can produce sizable improvements
in health status for state residents while helping to
constrain growth in medical spending and creating
more equitable opportunities for health in low-resource
and under-served communities. Over the longer
term, these investments can also boost economic
development and growth across the state as children
face fewer health-related interruptions in learning and
educational attainment, and as workers face fewer
health-related interruptions in productivity, earnings,
and career advancement.
Based on feedback from stakeholders, Indiana’s
communities are ready for change and willing to work
together to make improvements to the public health
system. A total of 49 stakeholders participated in an
interview and contributed feedback and/or ideas for
improvements to the public health system in Indiana.
The review of the scientific evidence for public health
systems change presented in Section 3 and the
insights provided by Indiana stakeholders in Section
4 informed the following recommendations. Broadly,
the recommendations include considerations for
changes to the public health system with notable
structural and financing changes. A general estimate
of costs needed to make improvements to the public
health system is provided along with potential funding
mechanisms for consideration.
Indiana’s public health system needs substantial
funding increases at both the state and local levels.
Four overarching recommendations are made. The two
tables below present implementation steps necessary
to improve the capacity and effectiveness of Indiana’s
public health system. Cost estimates for two of the
recommendations are provided below the table.
Overarching Recommendations
1. Create a uniform approach to deliver the
Foundational Public Health Services (FPHS)
across the state (see steps 12 and 15 below)
2. Create a district-level mechanism to enable
resource sharing among LHDs (see steps 12-14
below)
3. Strengthen the State Health Department’s
oversight and enabling capacity to support the
local public health delivery system (see steps 1-11
below)
4. Under the auspices of the state board of
health, create a multi-disciplinary state-wide
implementation committee tasked with executing
the implementation steps below (see step 1 below)
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SECTION 5: RECOMMENDATIONS FOR PUBLIC HEALTH SYSTEM CHANGE
State Level Implementation Steps to Improve Public Health Capacity and
Eectiveness
Step Description Evidence and Considerations
1. Convene a public
health strategic
planning committee
to begin implementing
the recommendations
and steps.
The committee should include stakeholders from state and local
agencies as well as public health systems experts, representatives
from state, city, and county leadership, local healthcare delivery
systems, and other key partners. This committee should focus on
implementing the recommendations and steps in this report.
The committee should propose to the State Health Commissioner and
Governor a comprehensive state strategic plan for public health every
three years. The strategic plan should have specic and measurable
objectives. The State Health Commissioner should report progress toward
the strategic plan to the legislature each year.
Stakeholder calls for a state-wide
strategic plan were consistent.
Given the extent of public health
system improvements necessary,
a planning committee needs to be
convened along with implementation
teams and funding to move the
recommendations and steps forward.
2. Enhance formal
training of public
health sta across
state and local
public health
agencies through the
establishment of a
tuition reimbursement
program.
Support/tuition reimbursement for employee enrollment in professional
degree programs and certicates should be made available and should
have specied employment commitment requirements after funding is
complete. Such programs should support current employees and can
aid in the recruitment of new employees.
With few exceptions, executive management (commissioner, deputy
commissioners, commission/office heads) should have doctoral
level training with a minimum of 5 years of experience leading large
and complex organizations. While helpful, a doctoral degree in
medicine or law alone is insufficient without substantial experience
or formal training in public health. In addition, program heads
should also have a minimum of a master’s degree in public health
with strong preference for a doctoral degree in public health with a
minimum of 5 years of experience in governmental public health.
Similarly, experienced and trained experts should be available in a SHD
oce dedicated to supporting program implementation at the local
level as noted in step #7.
Currently, less than a quarter of the
executive staff and division leaders at
the SHD have doctoral-level degrees
and 20% have formal public health
training.
While it is preferable that leadership
at the SHD have significant technical
expertise in public health, it is also
recognized that for various reasons
related to transition and feasibility
that this will take several years to
achieve. Nevertheless, a commitment
should be made to only replace
current positions with the appropriate
credentials moving forward.
3. Revise the title
and requirements for
the Commissioner
of Health through a
revised public health
law.
The title of the Commissioner of Health should be changed to Secretary
of Health and State Health Ocer and should be a Cabinet-level
position, recognizing the importance of public health to the state’s
wellbeing. Further, the state department of health should be maintained
as a stand-alone agency. Additional language should specify and require
that the Secretary of Health have a minimum of a master’s degree in
public health with experience in governmental public health. These
requirements compliment the requirement noted in step #2 that the
Secretary of Health have formal public health training and a minimum of
5 years of experience leading large and complex organizations.
This recommendation for state
public health to be a stand-alone
agency is consistent with national
recommendations contained in the
numerous iterations of the Institute
of Medicine (IOM) Reports on Public
Health.1, 11, 139
4. Develop and adopt
a uniform data set and
provide and require the
use of a common data
platform for integrated
real-time reporting at
all levels of the public
health system.
A uniform data set should include defined and comparable health,
workforce, and financial metrics. A uniform data set and common
data platform would create efficiencies in reporting and ensure
consistent and reliable data across all levels and locations of the
public health system. It would also ensure that data collected at the
local level will be readily available for evidence-informed decision-
making at the local, district, and state and agency levels.
This recommendation is in alignment with
national recommendations to improve
public health infrastructure. It will be
essential to reporting on performance and
providing accountability for new funds.
Stakeholders report frustration with a dearth
of reliable data and inefficiencies in reporting.
66 IU Richard M. Fairbanks School of Public Health
5. Adopt the Public Health
Accreditation Board
(PHAB) standards and
verication process,
requiring accreditation of
all LHDs/district health
oces within 5 years.
Applying the PHAB standards will assure that public health agencies
in Indiana are routinely implementing quality and performance
improvement. Continuously meeting accreditation standards
will ensure that there are public accountability measures for the
investment of taxpayer funds. A summary of the PHAB standards
and measures is provided in Appendix A.
Accreditation has been shown to
improve LHD capacity and more
robust partnerships. LHDs also report
better eciencies and eectiveness.
Evidence indicates that state-initiated
collaboration and support structures
help LHDs navigate the process.
6. Establish performance-
based contracts with
periodic review for each
major public health
program and each large
LHD/district.
Grants and aid to LHDs should be both performance-based and
needs/per-capita-based. Annual state and local public health
system performance and capability reports should be provided to
the legislature.
Performance-based contracting
and accountability are supported by
stakeholders with the caveat that step
#4, the uniform data and a common
data platform, is essential.
7. Establish an Oce
of Local Support and
Technical Assistance
within the SHD.
Although not an exhaustive list, this oce should provide technical
assistance for program implementation, nancing issues, legal
resources and interpretation, program assessment and evaluation, grant
writing, as well as education and training to the local level. It will oer
formal mechanisms for consultation/advice and service coordination
between the SHD and district oces/LHDs. This oce should be led by
an experienced public health administrator with a minimum of 5 years of
LHD administrative expertise.
The oce should have assigned a representative of each major
program oce and commission on a full-time basis who can act as
a liaison and technical advisor for implementation questions and
requests for program improvement. This oce should act as a clearing
house for requests of all sorts arriving from the local level. Where
feasible, this oce should also integrate directly with agency wide
quality improvement eorts and work closely with oces that support
communication, legislative liaison and the oce of legal aairs.
Stakeholder insights indicate that
many LHDs lack important expertise
and there is an overall sense of
disconnection with the SHD.
As it relates to legal aairs, state law
or regulations should be changed
to explicitly state that health law
information may be provided by the SHD
legal department to LHDs/district oces
without qualication. This extension of
services would not extend representation
responsibilities for legal action. It would
specically recognize the specialized
knowledge and expertise contained at
the SHD is generally not available at the
local public health level. State public
health attorneys should also be available
to act as a resource for local county
attorneys on questions related to public
health regulations and policy.
8. Assure that state
universities with
accredited schools
of public health are
formally collaborating
with and supporting
all levels of the public
health system.
Formal collaboration should ensure that workforce training programs
provide training that is appropriate and accessible to public health
professionals, internship and practicum opportunities are available
for students and aid health departments in recruitment, and practice-
based research and evaluation is conducted where appropriate and
advantageous to public health.
Academic partnerships have been found
to be mutually benecial for the local
health department and the academic
institution, resulting in impactful research,
innovative programming, and public
health policies. Additionally, there is
overall stakeholder support for improved
collaboration with academic institutions.
9. Expand social
marketing and
tailored public health
communication.
Communication that targets specific demographic segments with
health prevention messaging is needed. Communication should
be developed by health communication specialists at the SHD
and tailored (as appropriate) and implemented at the local level.
Federal grant proposals should routinely request funding to support
marketing and communication.
Among the lessons from the
COVID-19 pandemic is that public
health is not well understood
among policymakers or the public.
Improvements to public health
communication are needed and have
been requested by stakeholders.
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10. Ensure that local
public health funding
is not supplanted
when additional
funding is awarded/
received.
Local public health funding should not be supplanted (reduced
commensurate with new funds) when locals are successful
in achieving additional grant funds for specific innovations or
programs or when they generate revenue through reimbursement of
clinical services. Provisions preventing supplanting of funds should
be included in all state to local funding agreements.
Currently, 8.4% of the SHD budget is allocated
to programs and services at the local level.
LHDs in IN have a higher reliance on local taxes
for the delivery of many of the foundational
public health services compared to
averages among LHDs nationally.
Public health funding has been shown
to lead to improved capacity and health
outcomes.
Stakeholder insights indicate widespread
support for increased local public health
funding, in particular as it relates to reduced
health care expenditures, reduced employer
costs, and population health improvements.
11. Train new and
current Local Health
Ocials.
Local Health Officials are required by law to be physicians, but
do not have requirements for either formal public health training
or public health experience. An orientation program and ongoing
training for local health officials should be developed.
Local health officials acknowledge
a need for onboarding and ongoing
training. Most would welcome an
orientation program and periodic
updates delivered in a manner that is
accessible and useful to their work.
District Level Implementation Steps to Improve Public Health Capacity and
Eectiveness
Step Description Evidence and Considerations
12. Add district level
oces to the existing
public health system
structure.
Services and skillsets that are essential to local public health
practice, but are often unavailable outside of the SHD or very large
LHDs, include: epidemiology, public health preparedness and
response, disease intervention specialists, chronic disease program
specialists, public health laboratory services, public health risk
communication and media relations, public health education and
marketing, public health implementation science, evaluation and
assessment services. District health offices should provide these
services and expertise as shared-resources for the counties within
each of the 10 public health preparedness districts. See current
district map provided in Appendix D.
The advantage of this model is that district health office staff could
be primarily focused on regional public health issues with local buy-
in and acceptance and have the ability to marshal SHD resources.
Resource-sharing models such as the
recommended district health oce
model are being implemented in all
exemplar states.
Stakeholders unanimously support this
model. One reservation was consistent
across stakeholders: funding for
district models needs to be sustainable.
Additionally, the location and governance
model for district health oces should
be the subject of additional deliberation
between the SHD and LHDs within each of
the 10 public health preparedness districts.
A trained epidemiologist is essential
for acute outbreak investigation and
surveillance of infectious and chronic
diseases. An improved network of
accessible public health laboratory services
will ensure capacity for water, food, and
infectious diseases testing. Chronic disease
program specialists can work to address
diabetes, cancer, and heart disease within
districts and specic communities.
SECTION 5: RECOMMENDATIONS FOR PUBLIC HEALTH SYSTEM CHANGE
68 IU Richard M. Fairbanks School of Public Health
13. Establish
leadership and
capacity for regional
resource sharing and
expertise sharing.
An important aspect of regional sharing is the leadership network
necessary for the deployment of expertise and resources and
improved communication and coordination.
Two elements are recommended for this leadership network. 1) It
is recommended that each district employ a District Health Officer.
Another title for this role may be Deputy Health Commissioner. The
District Health Officer should have doctoral level training (e.g. a
MD, PhD, DrPH, etc.) and particular training in public health (e.g., a
MPH, MSPH, etc.). 2) To ensure representation across each county
within a district, a Regional Health Board should be established
and be composed of Local Health Officials/ Administrators. The
District Health Officer would have a dual reporting relationship to
both the Regional Health Board and a direct reporting relationship
to the State Health Commissioner. The District Health Officer would
provide each county and district a direct link to the resources and
expertise at the SHD.
District health oces may be stand-
alone state oces or co-located at
an existing LHD. However, large LHDs
should play a prominent role in district
leadership and resource sharing. Large
LHDs with a population of 250,000 or
larger should have the ability to remain
independent of a district arrangement.
It is recommended that large LHDs
should be allowed to compete to lead as
a “regional referral center” that would
serve as the district oce. Given the
population-level needs of large LHDs,
the extent of “in-house” expertise is
often greater than most smaller LHDs.
A resource adjustment for population
should be considered for equity after
system conguration for district
arrangements. Overall, large LHDs
should not have an incentive to spend
less per capita than current allocations.
14. District health
oce employees
may be either SHD
employees or district/
local employees.
Employment level will be of particular importance as it will
determine responsibility for the costs associated with salaries and
influence the physical location of employees responsible for district
services and skills.
If district health office employees, including the District Health
Officer, are SHD staff they would be included under the SHD budget
and existing reporting structure. In such a model, district health
office employees may operate out of a stand-alone office or be
incorporated into/work from offices housed within existing LHDs.
Such a structure would lend itself to consistent communication
between the SHD and district health offices and across the
network of district health offices. It may also facilitate the strategic
implementation of state-wide initiatives. This structure may also
allow for district employees to be located across the LHDs within a
district, rather than centralized in one location.
A “regional referral center” model could also be employed where, a
LHD would continue to serve their county and local community while
also providing the skills and expertise to the region as required of
a district health office. In this model, the district health office staff
would be local employees.
Should the responsibility for district
health employees and services be
assigned to a LHD that serves as a
“regional referral center”, it would be
recommended that funding for such
arrangements be provided to the LHD
by the SHD and be guaranteed for a
pre-determined, set period of time
for consistency of operations.
Inconsistency in funding for these
responsibilities would erode the
sustainability of the district health
office model and would interfere
with the provision of essential
expertise and skills in the district. As
an example of consistent funding,
the SHD could establish a 5-year
district health office fund/grant paid
to the “regional referral center” that
will house district staff and take
responsibility for the provision of
regional expertise. In such a model,
the existing LHD Health Officer would
serve as the District Health Officer
with continued local and expanded
district responsibility.
SECTION 5: RECOMMENDATIONS FOR PUBLIC HEALTH SYSTEM CHANGE
69
IU Richard M. Fairbanks School of Public Health
Local Level Implementation Steps to Improve Public Health Capacity and
Eectiveness
Step Description Evidence and Considerations
15. Dene and ensure
the provision of a core
package of services
that must be provided
by each LHD.
Each county should be served by a LHD that provides core public
health services specifically designated and funded jointly by the
county and/or municipality and the SHD. Regardless of county size,
each LHD should be served by a core staff which should be outlined
in the state strategic plan (e.g., an administrator, public health
nurse, vital records clerk, and environmental health specialist) and
provide core public health services (to be defined in alignment with
the 10 Essential Public Health Services and the Foundational Public
Health Services).5, 14 Additional staff and services may be required
based on population size, complexity and need.
LHDs in Indiana are currently providing
a comprehensive level of services in
11% of LHDs. With adequate funding
and systems changes, improving the
capacity and eectiveness of the local
public health services is feasible. National
recommendations support foundational
public health services and capabilities.
Existing statutes of what services must be
provided at the local and state level and
revisions to these should be considered
as they relate to the provision of the
Foundational Public Health Services.
SECTION 5: RECOMMENDATIONS FOR PUBLIC HEALTH SYSTEM CHANGE
Estimates of Cost and Benets of
Public Health System Improvements
Two components of the recommendations are needed
to support the public health system transformation.
Cost estimates for these combined components are
provided. The first estimate broadly summarizes
the employee salary costs that can be expected if
recommendation #2 is implemented. The second cost
estimate is the cost of improving the capacity of the
LHD public health system to deliver the core package
of essential services discussed in recommendation #3.
Costs Associated with Implementation Step 12 -
New Expertise and Skills at the District Level
In particular, the addition of district health offices across
the 10 public health preparedness districts would be
associated with an additional $10.4 million in employee
salaries and facilities and administrative costs or a
minimum of $1,036,750 needed to fund district-level
health offices in each district. When this is examined on
a per capita basis, this translates to an average of $2.27
per capita in additional funds (per capita costs range
from $0.57 to $3.73 per district).
Costs Associated with Implementation Step 15 –
Delivering the Core Package of Essential Services at
the LHD level
The cost of assuring services, improving capacity of
the local public health system is estimated for 1.) an
average availability of comprehensive services and
capacity in LHDs and 2.) for state-wide availability of
comprehensive services and capacity.193
1. An additional $14 in per capita spending would
bring Indiana’s Foundational Public Health Service
capabilities to the national average of capacity.
This $14 increase in per capita spending translates
to an additional $81 million in annual public health
spending, but is estimated to provide $168 million
in reduced medical costs annually by the tenth year
of this investment. Models developed for Indiana in
conjunction with this report indicate that increasing
per capita public health spending by $14 would
result in the prevention of an additional 890 deaths
per year and extend life expectancy by nearly 1 year
for low and moderate income households in Indiana,
2. To achieve a comprehensive level of public health
system capabilities across all levels of public health
in Indiana, an additional $55 in per capita public
health spending would be required. This translates
to $328 million in additional public health spending
annually. These investments are expected to reduce
medical costs by $350 million by the tenth year of
implementation. It is crucial to note, however, that
models indicate this would prevent 3,600 deaths
annually and add an additional 4.1 years of life for
lower-income populations within the state.
70 IU Richard M. Fairbanks School of Public Health
SECTION 5: RECOMMENDATIONS FOR PUBLIC HEALTH SYSTEM CHANGE
Funding Opportunities
State Tax Increase on the Sale of Tobacco Products and
Establishment of the Indiana Public Health Trust Fund
Polling data supports the notion that voters are generally
favorable of an increase in tax on the sale of tobacco
products when the increased tax revenue is used to
support health needs within the state.194 There are several
different mechanisms for tax distribution that should
be explored including establishing support for new staff
within the Office of the Commissioner of Health at IDOH
and the establishment of core roles within regional units.
To allow for the new tax revenue to generate interest
and to support the phased implementation of public
health improvements, an Indiana Public Health Trust
Fund should be established. The Trust Fund should be
explicitly limited to Foundational Public Health Services
and related infrastructure.
Increased Portion of State General Funds Dedicated
to Public Health
Depending on the percentage of the tobacco tax that
is dedicated to public health funding requirements,
additional funding from the general fund should be
allocated to support core staffing of the Office of the
Commissioner of Health at IDOH and the establishment
of core roles within regional units.
State Health Care Savings Oset Payment
Another potential mechanism to support public health
activities is through a savings oset payment. Such a
payment has been shown to raise a sucient amount
of funds to support population health in general.1
Minnesota and Vermont are two states that have they
have used this type of nancing mechanism to generate
funds for health-related needs including the expansion
of medical care.195-196 Applying this model to Indiana, a
0.2% percent assessment applied to all health care
transactions in the state is estimated to yield $149
million in revenue in scal year 2020. Note that Indiana’s
estimated healthcare transaction base in calendar year
2020 is calculated using the most recently available
U.S. National Health Expenditure Accounts estimate of
$55.4 billion in personal healthcare expenditures among
Indiana medical providers in 2014 and applying observed
annual growth rates in personal healthcare spending for
the U.S. between 2014-2020.
71
IU Richard M. Fairbanks School of Public Health
This review of Indiana’s public health system was
undertaken with the purpose of making recommendations
for system improvements. It will be up to stakeholders to
determine the exact path forward and to prioritize actions
based on funding provided toward these recommendations.
Improving the health of Hoosiers is feasible through
increased public health funding, transformation of the
public health system from the current structure (see
Figure 8 in section 2) to the new structure illustrated in
Figure 23 below, and enhanced collaboration within public
health and with partners external to health departments.
Recommendations in this report should be tailored to
state and local preferences and needs. As the report
indicates, substantial changes are needed to improve
the Indiana public health system, and it is clear that
stakeholders are ready and willing to get started. Specic
thanks and appreciation are due to the hundreds of
CONCLUSIONS
public health workers at the state and local levels that toil
every day on behalf of the people of the state and who do
so without the resources they really need to do the best
job they can. This report was written to support their
work and give them the tools they need to improve the
public health system for Hoosiers. COVID-19 sounded
the alarm that the status quo is not sucient.
As a next step, a statewide taskforce should be
established to develop a strategic plan alongside
implementation teams charged with moving new
initiatives forward. Even with sufficient resources
this will be a difficult job and may take years to
implement some of the recommendations over phases.
Stakeholders around the state, in particular, the Indiana
University Richard M. Fairbanks School of Public Health,
stand ready and willing to support the state in moving
the agenda for public health improvement forward.
Figure 23: Possible Future Responsibilities of a Public Health System with State, District, and Local Levels
SECTION 6: CONCLUSIONS
LHD Responsibilities
Recommended Districts Health Responsibilities
• Deliver or assure the foundational public health services (FPHS).
• Vital records and health permits
• Core environmental services
• Infectious disease surveillance/contact tracing
• Immunizations
• Liaison with local hospitals and health professionals
• Develop and maintain emergency preparedness plans
• Execute emergency and recovery responses
• Establish and promote community readiness
• Provide public health education and marketing
• Develop and implement a health education/prevention
strategies and programs
• Ensure access to timely laboratory services
• Risk communication and local media relations
• Evaluation and assessment of program of services
• Identication of district/local health priorities
• Create local partnerships and convene local stakeholders for
collective action
• Collect and employ local public health data evidence-based
strategies and programs
State Responsibilities
• Provide grants/funding to local boards of health
• Use data-driven policy for evidence-based activities
• Evaluate public health activities
• Bring essential partners together
• Engage partners in policy making and programming
• Integrate public health and health care activities
• Promote health care quality
• License health care facilities, agencies, clinics, centers, and
providers
• Ensure accurate state vital records/statistics
72 IU Richard M. Fairbanks School of Public Health
THE FENCE OR THE AMBULANCE
The Fence or the Ambulance
‘Twas a dangerous cli, as they freely confessed,
Though to walk near its crest was so pleasant;
But over its terrible edge there had slipped
A duke, and full many a peasant;
So the people said something would have to be done,
But their projects did not all tally.
Some said, “Put a fence around the edge of the cli;”
Some, “An ambulance down in the valley.”
But the cry for the ambulance carried the day,
For it spread through the neighboring city,
A fence may be useful or not, it is true,
But each heart became brimful of pity
For those who slipped over that dangerous cli;
And the dwellers in highway and alley
Gave pounds or gave pence, not to put up a fence,
But an ambulance down in the valley.
Then an old sage remarked, “It’s a marvel to me
That people give far more attention
To repairing the results than to stopping the cause,
When they’d much better aim at prevention.
Let us stop at its source all this mischief,” cried he.
“Come, neighbors and friends let us rally:
If the cli we will fence we might almost dispense
With the ambulance down in the valley.”
Better guide well the young than reclaim them when old,
For the voice of true wisdom is calling:
“To rescue the fallen is good, but ‘tis best
To prevent other people from falling.”
Better close up the source of temptation and crime
Than to deliver from dungeon or galley;
Better put a strong fence ‘round the top of the cli,
Than an ambulance down in then valley!
73
IU Richard M. Fairbanks School of Public Health
THE FENCE OR THE AMBULANCE
The Fence or the Ambulance
This poem, attributed to John N. Hurty, M.D., was published in the American Journal of Public Health and the Nation’s
Health in August 1933.197 Dr. Hurty was the head of the Indiana State Board of Health for more than 25 years, serving as the
Secretary from 1896 to 1922. Under his tenure, a number of public health achievements were made, from ensuring water
quality to collection of vital statistics.198
The poem itself can be seen as an early commentary on the role of public health versus the role of healthcare. In this poem, the
author explains that a great many people have slipped o the edge of a cli. Although everyone agrees that this is a dangerous
situation, the answer many provide is to devote resources to placing an ambulance at the bottom of the cli to rescue people
after they have fallen. When an “old sage” points out that that it may be better to address preventing the problem before it
occurs, and that it would be more practical to do so, he is met with resistance. However, there are a “practical few” who agree
with him, emphasizing the idea that prevention is better than cure. The author nishes the poem by encouraging the reader
to be one of these practical people, and advocate for preventive measures, rather than devoting resources to xing a problem
after it occurs.
This poem has had multiple attributions, including to Joseph Malin, an English temperance activist. Sources estimate he
may have written it in 1895 and published it in the Iowa Health Bulletin in 1912. In the illustration above, the individuals
slipping o the cli are representative of public health concerns of the time, including (but not limited to) infectious diseases
such as smallpox, typhoid fever, scarlet fever, diphtheria, cholera, or venereal diseases. The two ambulances (one is the City
Ambulance, the other is the State Ambulance), are seen to be loading patients to take them to the hospitals, located next
to graveyards. This illustration again underscores the role of public health- a simple ‘fence’, or preventive measures, could
protect people against adverse events such as hospitalization and/or death.
74 IU Richard M. Fairbanks School of Public Health
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preventive care save money? Health economics and the
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P.K., Moonesinghe, R., & Honoré, P. (2004). Getting what
you pay for: Public health spending and the performance
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179. Erwin, P.C., Mays, G.P., & Riley, W.J. (2012). Resources
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82 IU Richard M. Fairbanks School of Public Health
The Public Health Accreditation Board (PHAB) was
formed in 2007 as a national consensus-based entity
to implement and oversee national public health
department accreditation. The purpose of public health
department accreditation is to promote high performance
and continuous quality improvement; recognize high
performers that meet nationally accepted standards of
quality and improvement; illustrate health department
accountability to the public and policymakers; increase
the visibility and public awareness of governmental public
health, leading to greater public trust and increased
health department credibility, and ultimately a stronger
constituency for public health funding and infrastructure;
and clarify the public’s expectations of health departments.
Through input from various think tanks, workgroups, expert
panels, and committees, PHAB established standards and
measures which a health department (tribal, local, and
state) must meet to be accredited. Initially launched in
September 2011, the standards and measures were most
recently updated to Version 1.5 in December 2013.
The standards are grouped into 12 domains. Domains
1 through 10 address the 10 Essential Public Health
Services. Domain 11 addresses management and
administration, and Domain 12 is about governance. A
standard is the level of achievement that must be met
by a health department. Each standard contains at
least one measure, to evaluate if the standard was met
(validated by required documentation).
Below is a summary of the 12 domains and their
respective standards and measures. Full documentation
is available for download as a pdf.72
Domain 1 includes 4 standards:
Standard 1.1: Participate in or lead a collaborative
process resulting in a comprehensive community
health assessment
• Measure 1.1.1 S: A state partnership that develops a
comprehensive state community health assessment of
the population of the state
• Measure 1.1.1 T/L: Tribal/local partnership that develops
a comprehensive community health assessment of the
population served by the health department
• Measure 1.1.2 S: A state level community health
assessment
• Measure 1.1.2 T/L: A Tribal/local community health
assessment
• Measure 1.1.3 A: Accessibility of community health
assessment to agencies, organizations, and the general public
Standard 1.2: Collect and maintain reliable,
comparable, and valid data that provide information
on conditions of public health importance and on
the health status of the population
• Measure 1.2.1 A: 24/7 surveillance system or set of
program surveillance systems
• Measure 1.2.2 A: Communication with surveillance
sites
• Measure 1.2.3 A: Primary data
APPENDIX A: PUBLIC HEALTH ACCREDITATION BOARD (PHAB) STANDARDS AND MEASURES
APPENDIX A
Domain 1: Conduct and disseminate
assessments focused on population
health status and public health
issues facing the community
Domain 1 focuses on the ongoing assessment of
the health of the population served by the health
department. This corresponds with the essential
public health service, “Assess and monitor population
health status, factors that inuence health, and
community needs and assets”.
Features of Domain 1 can include:
• systematic monitoring of health status
• collection, analysis, and dissemination of data
• use of data to inform public health policies,
processes, and intervention
• participation in a collaborative process for the
development of a shared, comprehensive health
assessment of the community, its health challenges,
and its resources.
APPENDIX B: NATIONAL
LONGITUDINAL
SURVEY OF PUBLIC
HEALTH SYSTEMS
CAPACITY ASSESSMENT
QUESTIONS
83
IU Richard M. Fairbanks School of Public Health
• Measure 1.2.4 S: Data provided to Tribal and local
health departments located in the state
• Measure 1.2.4 L: Data provided to the state health
department and Tribal health departments in the jurisdiction
the local health department is authorized to serve
• Measure 1.2.4 T: Data provided to the state health
department and to local health departments
Standard 1.3: Analyze public health data to identify
trends in health problems, environmental public
health hazards, and social and economic factors
that aect the public’s health
• Measure 1.3.1 A: Data analyzed and public health
conclusions drawn
• Measure 1.3.2 S: Statewide public health data and their
analysis provided to various audiences on a variety of
public health issues
• Measure 1.3.2 L: Public health data provided to
various audiences on a variety of public health issues
• Measure 1.3.2 T: Public health data provided to the
Tribal community on a variety of public health issues
Standard 1.4: Provide and use the results of
health data analysis to develop recommendations
regarding public health policy, processes, programs,
or interventions
• Measure 1.4.1 A: Data used to recommend and inform
public health policy, processes, programs, and/or
interventions
• Measure 1.4.2 S: Statewide summaries or fact sheets of
data to support health improvement planning processes
at the state level
• Measure 1.4.2 T/L: Tribal/community summaries or
fact sheets of data to support public health improvement
planning processes at the Tribal or local level
• Measure 1.4.3 S: Support provided to Tribal and
local health departments in the state concerning the
development and use of summaries of community data
Domain 2 includes 4 standards:
Standard 2.1: Conduct timely investigations of
health problems and environmental public health
hazards
• Measure 2.1.1 A: Protocols for investigation process
• Measure 2.1.2 S: Capacity to conduct and/or support
investigations of infectious diseases simultaneously
• Measure 2.1.2 T/L: Capacity to conduct an investigation
of an infectious disease
• Measure 2.1.3 A: Capacity to conduct investigations of
non-infectious health problems, environmental, and/or
occupational public health hazards
• Measure 2.1.4 A: Collaborative work through established
governmental and community partnerships on
investigations of reportable diseases, disease outbreaks,
and environmental public health issues
• Measure 2.1.5 A: Monitored timely reporting of
notiable/reportable diseases, lab test results, and
investigation results
• Measure 2.1.6 S: Consultation, technical assistance, and/or
information provided to Tribal and local health departments
in the state regarding the management of disease outbreaks
and environmental public health hazards
Standard 2.2: Contain/mitigate health problems
and environmental public health hazards
• Measure 2.2.1 A: Protocols for containment/
mitigation of public health problems and
APPENDIX A: PUBLIC HEALTH ACCREDITATION BOARD (PHAB) STANDARDS AND MEASURES
Domain 2: Investigate health
problems and environmental
public health hazards to protect the
community
Domain 2 focuses on the investigation of suspected
and identied health problems and environmental
public health hazards. This corresponds with
the essential public health service, “Investigate,
diagnose, and address health problems and hazards
aecting the population”.
Features of Domain 2 can include:
• Epidemiologic identication of emerging health
problems
• monitoring of disease
• availability of public health laboratories
• containment and mitigation of outbreaks
• coordinated response to emergency situations
• communication
APPENDIX B: NATIONAL
LONGITUDINAL
SURVEY OF PUBLIC
HEALTH SYSTEMS
CAPACITY ASSESSMENT
QUESTIONS
84 IU Richard M. Fairbanks School of Public Health
environmental public health hazards
• Measure 2.2.2 A: A process for determining when the
All Hazards Emergency Operations Plan (EOP) will be
implemented
• Measure 2.2.3 A: Complete After Action Reports (AAR)
Standard 2.3: Ensure access to laboratory and
epidemiologic/environmental public health expertise
and capacity to investigate and contain/mitigate public
health problems and environmental public health
hazards
• Measure 2.3.1 A: Provisions for the health department’s
24/7 emergency access to epidemiological and
environmental public health resources capable
of providing rapid detection, investigation, and
containment/mitigation of public health problems and
environmental public health hazards
• Measure 2.3.2 A: 24/7 access to laboratory resources
capable of providing rapid detection, investigation and
containment of health problems and environmental
public health hazards
• Measure 2.3.3 A: Access to laboratory and other
support personnel and infrastructure capable of
providing surge capacity
• Measure 2.3.4 A: Collaboration among Tribal, state,
and local health departments to build capacity and
share resources to address Tribal, state, and local
eorts to provide for rapid detection, investigation, and
containment/ mitigation of public health problems and
environmental public health hazards
Standard 2.4: Maintain a plan with policies
and procedures for urgent and non-urgent
communications
• Measure 2.4.1 A: Written protocols for urgent 24/7
communications
• Measure 2.4.2 A: A system to receive and provide
urgent and non-urgent health alerts and to coordinate an
appropriate public health response
• Measure 2.4.3 A: Timely communication provided to
the general public during public health emergencies
• Measure 2.4.4 S: Consultation and technical assistance
provided to Tribal and local health departments on
the accuracy and clarity of public health information
associated with a public health emergency
Domain 3 includes 2 standards:
Standard 3.1: Provide health education and health
promotion policies, programs, processes, and
interventions to support prevention and wellness
• Measure 3.1.1 A: Information provided to the public on
protecting their health
• Measure 3.1.2 A: Health promotion strategies to mitigate
preventable health conditions
• Measure 3.1.3 A: Eorts to specically address factors
that contribute to specic populations’ higher health
risks and poorer health outcomes
Standard 3.2: Provide information on public health
issues and public health functions through multiple
methods to a variety of audiences
• Measure 3.2.1 A: Information on public health mission,
roles, processes, programs, and interventions to improve
the public’s health provided to the public
• Measure 3.2.2 A: Organizational branding strategy
• Measure 3.2.3 A: Communication procedures to provide
information outside the health department
• Measure 3.2.4 A: Risk communication plan
• Measure 3.2.5 A: Information available to the public
Domain 3: Inform and educate
about public health issues and
functions
Domain 3 focuses on informing and educating
the public about the role of public health. This
corresponds with the essential public health
service, “Communicate effectively to inform and
educate people about health, factors that influence
it, and how to improve it”.
Features of Domain 3 can include:
• Processes for continuing two-way communication
with the public as standard operating procedure
• Actionable messaging that is culturally
appropriated and trusted, with accessible and
easily understood language
• Building and maintaining a positive, trustworthy
reputation with diverse communities
APPENDIX A: PUBLIC HEALTH ACCREDITATION BOARD (PHAB) STANDARDS AND MEASURES
85
IU Richard M. Fairbanks School of Public Health
through a variety of methods
• Measure 3.2.6 A: Accessible, accurate, actionable, and
current information provided in culturally sensitive and
linguistically appropriate formats for target populations
served by the health department
Domain 4 includes 2 standards:
Standard 4.1: Engage with the public health system
and the community in identifying and addressing
health problems through collaborative processes
• Measure 4.1.1 A: Establishment and/or engagement
and active participation in a comprehensive
community health partnership and/or coalition;
or active participation in several partnerships or
coalitions to address specific public health issues or
populations
• Measure 4.1.2 S: Technical assistance provided to
Tribal and local health departments and/or public health
system partners regarding methods for engaging with
the community
• Measure 4.1.2 T/L: Stakeholders and partners linked to
technical assistance regarding methods of engaging with
the community
Standard 4.2: Promote the community’s
understanding of and support for policies and
strategies that will improve the public’s health
• Measure 4.2.1 A: Engagement with the community
about policies and/or strategies that will promote the
public’s health
• Measure 4.2.2 A: Engagement with governing entities,
advisory boards, and elected ocials about policies and/
or strategies that will promote the public’s health
Domain 5 includes 4 standards:
Standard 5.1: Serve as a primary and expert
resource for establishing and maintaining public
health policies, practices, and capacity
• Measure 5.1.1 A: The monitoring and tracking of public
Domain 4: Engage with the
community to identify and address
health problems
Domain 4 focuses on the health department’s
community engagement. This corresponds with the
essential public health service, “Strengthen, support,
and mobilize communities and partnerships to
improve health”.
Features of Domain 4 can include:
• Aligning and coordinating eorts towards health
promotion, disease prevention, and health equity
across a wide range of partners
• Actionable messaging that is culturally appropriated
and trusted, with accessible and easily understood
language
• Building and maintaining a positive, trustworthy
reputation with diverse communities
• Establishing and maintaining community
partnerships and collaborations to facilitate
public health goals being accomplished, promote
community resilience, and advance the improvement
of the public’s health
Domain 5: Develop Public Health
Policies and Plans
Domain 5 focuses on developing public health policies
and plans, which can serve to guide the work done
by the health department while bringing structure
and organization to the health department. This
corresponds with the essential public health service,
“Create, champion, and implement policies, plans,
and laws that impact health”.
Features of Domain 5 can include developing
policies and plans, used for the following:
• Bringing structure and organization to the
department
• Serving as a resource to health department sta and
the public
• Orienting and training sta
• Informing the public and partners
• Developing consistency in operations
• Noting key areas for improvement
APPENDIX A: PUBLIC HEALTH ACCREDITATION BOARD (PHAB) STANDARDS AND MEASURES
86 IU Richard M. Fairbanks School of Public Health
health issues that are being discussed by individuals and
entities that set policies and practices that impact on
public health
• Measure 5.1.2 A: Engagement in activities that
contribute to the development and/or modication of
policy that impacts public health
• Measure 5.1.3 A: Informed governing entities, elected
ocials, and/or the public of potential intended or
unintended public health impacts from current and/or
proposed policies
Standard 5.2: Conduct a comprehensive planning
process resulting in a tribal/state/community
health improvement plan
• Measure 5.2.1 S: A process to develop a state health
improvement plan
• Measure 5.2.1 L: A process to develop a community
health improvement plan
• Measure 5.2.1 T: A process to develop a Tribal community
health improvement plan
• Measure 5.2.2 S: State health improvement plan
adopted as a result of the health improvement planning
process
• Measure 5.2.2 L: Community health improvement
plan adopted as a result of the community health
improvement planning process
• Measure 5.2.2 T: Tribal community health improvement
plan adopted as a result of the health improvement
planning process
• Measure 5.2.3 A: Elements and strategies of the health
improvement plan implemented in partnership with others
• Measure 5.2.4 A: Monitor and revise as needed, the
strategies in the community health improvement plan in
collaboration with broad participation from stakeholders
and partners
Standard 5.3: Develop and implement a health
department organizational strategic plan
• Measure 5.3.1 A: Department strategic planning process
• Measure 5.3.2 A: Adopted department strategic plan
• Measure 5.3.3 A: Implemented department strategic
plan
Standard 5.4: Maintain an all hazards emergency
operations plan
• Measure 5.4.1 A: Process for the development and
maintenance of an All Hazards Emergency Operations
Plan (EOP)
• Measure 5.4.2 A: Public health emergency operations
plan (EOP)
• Measure 5.4.3 S: Consultation and/or technical
assistance provided to Tribal and local health departments
in the state regarding evidence-based and/or promising
practices/templates in EOP development and testing
Domain 6 includes 3 standards:
Standard 6.1: Review existing laws and work with
governing entities and elected/appointed ocials
to update as needed
• Measure 6.1.1 A: Laws reviewed in order to determine
the need for revisions
• Measure 6.1.2 A: Information provided to the governing
entity and/or elected/appointed ocials concerning
needed updates/amendments to current laws and/or
proposed new laws
Standard 6.2: Educate individuals and organizations
Domain 6: Enforce Public Health
Laws
Domain 6 focuses on the role of public health
departments in enforcement of public health related
regulations, executive orders, statues, and other
public health laws. These laws are important tools
for health departments in their work of protecting
and promoting public health. This corresponds with
the essential public health service, “Utilize legal and
regulatory actions designed to improve and protect
the public’s health.”
Features of Domain 6 can include:
• Enforcing public health regulations, executive
orders, statutes, etc.
• Promoting new laws and revisiting existing laws
• Educating regulated entities about the meaning,
purpose, compliance requirements, and benets of
public health laws
• Educating the public about the benets of public
health laws, and the importance of compliance
APPENDIX A: PUBLIC HEALTH ACCREDITATION BOARD (PHAB) STANDARDS AND MEASURES
87
IU Richard M. Fairbanks School of Public Health
on the meaning, purpose, and benet of public
health laws and how to comply
• Measure 6.2.1 A: Department knowledge maintained
and public health laws applied in a consistent manner
• Measure 6.2.2 A: Laws and permit/license application
requirements are accessible to the public
• Measure 6.2.3 A: Information or education provided
to regulated entities regarding their responsibilities and
methods to achieve full compliance with public health
related laws
Standard 6.3: Conduct and monitor public health
enforcement activities and coordinate notication
of violations among appropriate agencies
• Measure 6.3.1 A: Written procedures and protocols for
conducting enforcement actions
• Measure 6.3.2 A: Inspection activities of regulated
entities conducted and monitored according to
mandated frequency and/or a risk analysis method that
guides the frequency and scheduling of inspections of
regulated entities
• Measure 6.3.3 A: Procedures and protocols followed
for both routine and emergency situations requiring
enforcement activities and complaint follow-up
• Measure 6.3.4 A: Patterns or trends identied in
compliance from enforcement activities and complaints
• Measure 6.3.5 A: Coordinated notication of violations
to the public, when required, and coordinated sharing of
information among appropriate agencies about enforcement
activities, follow-up activities, and trends or patterns
Domain 7 includes 2 standards:
Standard 7.1: Assess health care service capacity
and access to health care services
• Measure 7.1.1 A: Process to assess the availability of
health care services
• Measure 7.1.2 A: Identication of populations who
experience barriers to health care services identied
• Measure 7.1.3 A: Identication of gaps in access to
health care services and barriers to the receipt of health
care services identied
Standard 7.2: Identify and implement strategies to
improve access to health care services
• Measure 7.2.1 A: Process to develop strategies to
improve access to health care services
• Measure 7.2.2 A: Implemented strategies to increase
access to health care services
• Measure 7.2.3 A: Implemented culturally competent
initiatives to increase access to health care services
for those who may experience barriers to care due to
cultural, language, or literacy dierences
Domain 7: Promote Strategies to
Improve Access to Health Care
Domain 7 focuses on the public’s access to needed
health services. This corresponds with the essential
public health service, “Assure an effective system
that enables equitable access to the individual
services and care needed to be healthy”.
Features of Domain 7 can include:
• Assessment of the population’s access to health
services
• Promoting new laws and revisiting existing laws
Domain 8: Maintain a Competent
Public Health Workforce
Domain 8 focuses on the need for a health
department to strategically develop a competent
public health workforce. This corresponds with the
essential public health service, “Build and support
a diverse and skilled public health workforce”.
Features of Domain 8 can include:
• Creating a multidisciplinary workforce, matched to
the needs of the population being served
• Aligning workforce development with the health
department’s mission and goals
• Developing strategies to acquire, develop, and retain sta
• Educating regulated entities about the meaning,
purpose, compliance requirements, and benets of
public health laws
• Educating the public about the benets of public
health laws, and the importance of compliance
APPENDIX A: PUBLIC HEALTH ACCREDITATION BOARD (PHAB) STANDARDS AND MEASURES
88 IU Richard M. Fairbanks School of Public Health
Domain 8 includes 2 standards:
Standard 8.1: Encourage the development of a
sucient number of qualied public health workers
• Measure 8.1.1 S: Relationship and collaboration with
educational programs that promote the development
of future public health workers
• Measure 8.1.1 T/L: Relationships and/or collaborations
that promote the development of future public health
workers
Standard 8.2: Ensure a competent workforce
through assessment of sta competencies, the
provision of individual training and professional
development, and the provision of a supportive
work environment
• Measure 8.2.1 A: Workforce development strategies
• Measure 8.2.2 A: A competent health department
workforce
• Measure 8.2.3 A: Professional and career development
for all sta
• Measure 8.2.4 A: Work environment that is supportive
to the workforce
• Measure 8.2.5 S: Consultation and/or technical
assistance provided to Tribal and local health departments
regarding evidence-based and/or promising practices
in the development of workforce capacity, training, and
continuing education
Domain 9 includes 2 standards:
Standard 9.1: Use a performance management
system to monitor achievement of organizational
objectives
• Measure 9.1.1 A: Sta at all organizational levels
engaged in establishing and/or updating a performance
management system
• Measure 9.1.2 A: Performance management policy/
system
• Measure 9.1.3 A: Implemented performance
management system
• Measure 9.1.4 A: Implemented systematic process for assessing
customer satisfaction with health department services
• Measure 9.1.5 A: Opportunities provided to sta
for involvement in the department’s performance
management
• Measure 9.1.6 S: Technical assistance and/or training
provided on performance management to Tribal and
local health departments
Standard 9.2: Develop and implement quality
improvement processes integrated into
organizational practice, programs, processes, and
interventions
• Measure 9.2.1 A: Established quality improvement
program based on organizational policies and direction
• Measure 9.2.2 A: Implemented quality improvement
activities
Domain 9: Evaluate and
Continuously Improve Processes,
Programs, and Interventions
Domain 9 focuses on using and integrating
performance management and quality
improvement practices or processes to improve
health department practices, programs, and
interventions. This corresponds with the essential
public health service, “Improve and innovate public
health functions through ongoing evaluation,
research, and continuous quality improvement”.
Features of Domain 9 can include:
• Performance management identifying results
against the intended results
• Performance management systems ensure
progress is being made towards goals, using
collected data to track results, identify
opportunities, and target improvements
• Ongoing quality improvement activities to
achieve equity and improve the health of the
community
APPENDIX A: PUBLIC HEALTH ACCREDITATION BOARD (PHAB) STANDARDS AND MEASURES
Domain 10: Contribute to and
Apply the Evidence Base of Public
Health
Domain 10 focuses on the role of health
departments in building upon and advancing the
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IU Richard M. Fairbanks School of Public Health
Domain 10 includes 2 standards:
Standard 10.1: Identify and use the best available
evidence for making informed public health
practice decisions
• Measure 10.1.1 A: Applicable evidence-based and/
or promising practices identified and used when
implementing new or revised processes, programs,
and/or interventions
• Measure 10.1.2 T/S: Fostered innovation in practice
and research
Standard 10.2: Promote understanding and use of
the current body of research results, evaluations,
and evidence-based practices with appropriate
audiences
• Measure 10.2.1 A: Protection of human subjects
when the health department is involved in or supports
research activities
• Measure 10.2.2 A: Access to expertise to analyze
current research and its public health implications
• Measure 10.2.3 A: Communicated research findings,
including public health implications
• Measure 10.2.4 S: Consultation or technical
assistance provided to Tribal and local health
departments and other public health system partners
in applying relevant research results, evidence-based
and/or promising practices
• Measure 10.2.4 T: Technical assistance provided
to the state health department, local health
departments, and other public health system
partners in applying relevant research results,
evidence-based and/or promising practices
Domain 11 includes 2 standards:
Standard 11.1: Develop and maintain an operational
infrastructure to support the performance of public
health functions
• Measure 11.1.1 A: Policies and procedures regarding
health department operations, reviewed regularly, and
accessible to sta
• Measure 11.1.2 A: Ethical issues identied and ethical
decisions made
• Measure 11.1.3 A: Policies regarding condentiality,
including applicable HIPAA requirements
• Measure 11.1.4 A: Policies, processes, programs, and
interventions provided that are socially, culturally, and
linguistically appropriate to specic populations with
higher health risks and poorer health outcomes.
• Measure 11.1.5 A: A human resources function
• Measure 11.1.6 A: Information management function that
supports the health department’s mission and workforce
by providing infrastructure for data storage, protection,
and management; and data analysis and reporting
• Measure 11.1.7 A: Facilities that are clean, safe,
accessible, and secure
Standard 11.2: Establish eective nancial
Domain 11: Maintain Administrative
and Management Capacity
Domain 11 focuses on management of health
departments and the capacity of administration.
Features of Domain 11 can include:
• A well-managed human resources system
• Competency in general nancial management
• Capacity and capability for data management
• Knowledge of public health authorities and
mandates
• Leaders and sta who are knowledgeable about
structure, organization, and nance of their public
health department, as well as other organization
and agencies which provide services
APPENDIX A: PUBLIC HEALTH ACCREDITATION BOARD (PHAB) STANDARDS AND MEASURES
science of public health, by adding to the body of
evidence for promising practices. This corresponds
with the essential public health service, “Build and
maintain a strong organizational infrastructure for
public health”.
Features of Domain 10 can include:
• Employing evidence-based practices for their
eectives and credibility
• Assisting in the development new evidence
• Applying innovation and creativity while providing
appropriate public health services
90 IU Richard M. Fairbanks School of Public Health
management systems
• Measure 11.2.1 A: Financial and programmatic oversight
of grants and contracts
• Measure 11.2.2 A: Written agreements with entities from
which the health department purchases, or to which
the health department delegates, services, processes,
programs, and/or interventions
• Measure 11.2.3 A: Financial management systems
• Measure 11.2.4 A: Resources sought to support
agency infrastructure and processes, programs, and
interventions
Domain 12 includes 3 standards:
Standard 12.1: Maintain current operational
definitions and statements of the public health
roles, responsibilities, and authorities
• Measure 12.1.1 A: Mandated public health
operations, programs, and services provided
• Measure 12.1.2 A: Operational definitions and/or
statements of the public health governing entity’s
roles and responsibilities
Standard 12.2: Provide information to the
governing entity regarding public health and the
official responsibilities of the health department
and of the governing entity
• Measure 12.2.1 A: Communication with the
governing entity regarding the responsibilities of the
public health department and of the responsibilities
of the governing entity
Standard 12.3: Encourage the governing entity’s
engagement in the public health department’s
APPENDIX A: PUBLIC HEALTH ACCREDITATION BOARD (PHAB) STANDARDS AND MEASURES
overall obligations and responsibilities
• Measure 12.3.1 A: Information provided to the
governing entity about important public health
issues facing the community, the health department,
and/or the recent actions of the health department
• Measure 12.3.2 A: Actions taken by the governing
entity tracked and reviewed
• Measure 12.3.3 A: Communication with the
governing entity about health department
performance assessment and improvement
Domain 12: Maintain Capacity to
Engage the Public Health Governing
Entity
Domain 12 focuses on the health department’s
support and engagement of its governing entity,
in respect to maintaining and strengthening public
health infrastructure. There is a significant amount
of variation in structure, definition, roles, and
responsibilities of governing entities.
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IU Richard M. Fairbanks School of Public Health
APPENDIX B: NATIONAL LONGITUDINAL SURVEY OF PUBLIC HEALTH SYSTEMS
CAPACITY ASSESSMENT QUESTIONS
APPENDIX B
1. In the past three years in your jurisdiction, has a community needs assessment process been conducted that
systematically describes the prevailing status in the community?
2. In the past three years in your jurisdiction, has a survey of the population for behavioral risk factors been
conducted?
3. In the past three years in your jurisdiction, are timely investigations of adverse health events conducted on an
ongoing basis, including communicable disease outbreaks and environment health hazards?
4. Are the necessary laboratory services available to support investigations of adverse health events and meet
routine diagnostic and surveillance needs for your jurisdiction?
5. In the past three years in your jurisdiction, has an analysis been completed of the determinants of and contributing
factors to prioritize health needs, the adequacy of existing health resources, and the population groups most eected?
6. In the past three years in your jurisdiction, has an analysis been completed of age-specific participation in
preventive and screening services?
7. In your jurisdiction, is there a network of support and communication relationships that includes health-related
organizations, the media, and the general public?
8. In the past year in your jurisdiction, have there been formal efforts to inform public officials about the potential
public health impact of decisions under their consideration?
9. In the past three years in your jurisdiction, has there been a prioritization of the community health needs that
have been identified from a community needs assessment?
10. In the past three years in your jurisdiction, have community health initiatives been implemented that are consistent
with priorities established from a community health needs assessment?
11. In the past three years in your jurisdiction, has a community health action plan been developed with community
participation to address community health needs?
12. In the past three years in your jurisdiction, have plans been developed to allocate resources in a manner consistent
with community health action plans?
13. In the past three years in your jurisdiction, have resources been deployed as necessary to address priority health
needs identified in the community health needs assessment?
14. In the past three years in your jurisdiction, has an organizational assessment of the local public health agency
been conducted?
15. In the past three years in your jurisdiction, have age-specific priority health needs been addressed effectively
through the provision of or linkage to appropriate services?
92 IU Richard M. Fairbanks School of Public Health
APPENDIX B: NATIONAL LONGITUDINAL SURVEY OF PUBLIC HEALTH SYSTEMS
CAPACITY ASSESSMENT QUESTIONS
16. In the past three years in your jurisdiction, have there been regular evaluations of the effects of public health
services on community health status?
17. In the past three years in your jurisdiction, have professionally recognized process and outcome measures been
used to monitor public health programs and to redirect resources as appropriate?
18. In the past three years in your jurisdiction, has the public regularly received information about current health
status, health care needs, health behaviors, and health care policy issues?
19. Within the past year in your jurisdiction, has the media received reports on a regular basis about health issues
affecting the community?
20. In the past three years in your jurisdiction, has there been an instance in which a mandated public health program
or service failed to be implemented as required by state or local law, ordinance, or regulation?
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IU Richard M. Fairbanks School of Public Health
APPENDIX C: INDIANA LOCAL PUBLIC HEALTH DEPARTMENT REFERENCE TABLE
Health Department
Population
served
Count of
Health
Department
Employees
Ratio of
Population
per
employee Recent Budget Health Ocial
Health
Ocial
Part/
full-time
Department
Administrator
Adams County Health
Department
35,636 93,943 $397,250.11 Michael Ainsworth, M.D. Part-time Jessica Bergdall
Bartholomew County
Health Department
82,753 26 3,155 $1,694,684.00 Brian Niedbalski, MD Full-time Link Fulp
Benton County Health
Department
8,653 61,436 $127,907.66 Joseph Moody, MD Full-time Kathy Sarault
Blackford County
Health Department
11,930 61,996 $212,049.73 Lori Skidmore, MD Part-time None
Crawford County
Health Department
10,558 33,522 $222,346.17 Devi Pierce, MD Part-time
Decatur County Health
Department
26,79 4 46,684 $437,568.28 Arthur Alunday, MD Full-time Carol Beck
Elkhart County Health
Department
205,560 97 2,114 $5,731,510.34 Lydia Mertz, MD Full-time
Fayette County Health
Department
23,047 73,316 $318,380.11 Wayne White, MD Full-time Matthew Sherck
Fishers City Health
Department
93,362 615,560 Indy Lane, M.D., FACOG Part-time Monica Heltz
Fountain-Warren
County Health
Department
24,614 64,102 $400,958.46 Sean Sharma, MD Full-time None
Gary City Health
Department
74,879 15 4,992 $423,079.44 Roland Walker, MD Veronica Collins
Gibson County Health
Department
33,452 65,596 $508,044.12 Bruce Brink Jr, DO Part-time Diane Hornby
Hancock County
Health Department
76,351 89,373 $557,441.91 Sandra L. Aspy, MD Part-time Crystal Baker
Henry County Health
Department
48,271 10 4,848 $545,880.29 John Miller, MD Part-time Angela Cox
Huntington County
Health Department
36,240 66,056 $290,880.23 Thomas Ringenberg, DO Full-time Tami Hurlburt
Jackson County Health
Department
44,111 10 4,388 $664,154.96 Christopher Bunce, MD Part-time Karla Hubbard
Jay County Health
Center
20,764 82,618 $394,408.28 Jerry Whetzel, MD Part-time Heath Butz
Jennings County
Health Department
27,611 73,947 $313,328.06 Gregory Heumann, MD Part-time Peggy Roe
Johnson County Health
Department
156,225 20 7,6 9 5 $1,444,207.12 Craig Moorman, MD Full-time Elizabeth
Swearingen
Lake County Health
Department
381,715 35 10,906 $2,658,852.89 Chandana Vavilala, MD Full-time Nick Doffin
Lawrence County
Health Department
45,668 12 3,806 $532,974.35 Alan F. Smith, M.D. Full-time None
Marion County Health
Department
954,670 801 1,192 $74,039,579 Virginia A. Caine, M.D. Full-time Karen Holly
APPENDIX C
94 IU Richard M. Fairbanks School of Public Health
APPENDIX C: INDIANA LOCAL PUBLIC HEALTH DEPARTMENT REFERENCE TABLE
Health Department
Population
served
Count of
Health
Department
Employees
Ratio of
Population
per
employee Recent Budget Health Ocial
Health
Ocial
Part/
full-time
Department
Administrator
Marshall County Health
Department
46,248 85,812 $752,171.85 Byron Holm, MD and Joel
Schumacher, MD
Full-time Ashley Garcia
Martin County Health
Department
10,217 42,554 $108,998.00 Larry Sutton, DO Part-time David Miller
Miami County Health
Department
35,567 57,1 6 9 $279,761.35 Christi Redmon, MD Part-time None
Morgan County Health
Department
70,116 15 4,64 8 $661,509.12 Paul Broderick, DO Full-time Jeanne LaFary
Newton County Health
Department
14,011 43,533 $263,308.77 Gonzolo Florido, MD Full-time None
Noble County Health
Department
47,532 76,779 $526,642.47 Terry Gaff, MD Part-time Cheryl Munson
Parke County Health
Department
16,927 44,232 $144,943.71 Franklin Swaim, MD Part-time None
Perry County Health
Department
19,102 53,816 $363,162.26 William Marcrum, MD Part-time Sarah Gehlhausen
Pike County Health
Department
12,410 62,061 $284,035.31 Nathanial Grow, MD Part-time Amy Gladish
Porter County Health
Department
169,594 33 5,103 $2,142,360.34 Maria L. Stamp, M.D. Full-time Letty Zepeda
Posey County Health
Department
25,540 83,199 $521,811.01 Kyle Rapp, MD Part-time Denny Schaffer
Pulaski County Health
Department
12,469 34,156 $205,859.69 Rex Allman, MD Part-time Teresa Hansen
Putnam County Health
Department
3 7,7 7 9 75,386 $444,953.58 Robert Heavin, MD Full-time Joni Young
Randolph County
Health Department
24,851 54,984 $257,062.54 Kenneth Sowinski, MD Part-time Debbie Weimer
Starke County Health
Department
22,935 45,723 $292,994.23 Thomas Browne, MD Part-time Frank Lynch
Sullivan County Health
Department
20,690 45,187 $327,223.87 Michael Gamble, MD, MBA Full-time Ryan Irish
Tipton County Health
Department
15,128 53,026 $201,968.76 Mary Compton, MD Part-time Lindsey Ogden
Union County Health
Department
7,0 3 7 61,200 $216,466.04 Susan Bantz, MD Part-time
Vigo County Health
Department
107,386 31 3,468 $1,700,729.64 Darren Brucken, MD Full-time Joni Wise
Washington County
Health Department
27,943 83,478 $340,214.87 Jeffery Morgan, MD Full-time Susan Green
Wayne County Health
Department
65,936 45 1,471 $5,246,496.20 David Jetmore, M.D. Full-time Christine Stinson
White County Health
Department
24,133 54,836 $298,133.07 Charles R. Tribbett, M.D Part-time Mary Grace Winkle
Note: Budget data are from the most recent year available on Indiana Gateway Annual Financial Reports, Disbursements by Fund Report. Health department
related funds were summed to estimate a recent budget.
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IU Richard M. Fairbanks School of Public Health
Figure 24. Indiana Public Health Preparedness District Map
APPENDIX D: INDIANA PUBLIC HEALTH PREPAREDNESS DISTRICT MAP
APPENDIX D
INDIANA UNIVERSITY
RICHARD M. FAIRBANKS SCHOOL OF PUBLIC HEALTH
1050 Wishard Blvd. | Indianapolis, IN 46202
(317) 274-2000 | fsph.iupui.edu
