November 18, 2022
Washington State Department of Health

Introduction

The first recommendation in the report Public Health Forward: Modernizing the U.S. Public Health System calls for decision-makers to provide flexible funding, avoid issue-specific grants, and maximize existing assets to support public health services and capabilities, including those needed to address health inequities. The report charges departments with building accountability mechanisms to track how current funding is spent and the impact of that spending. Showing accountability helps public health practitioners to build the trust and political will needed to protect public health services.

Context

Washington state has a decentralized governmental public health system comprising 35 autonomous local health jurisdictions under the authority of county government and local boards of health, a state department of health, a state board of health, and 29 federally recognized sovereign tribal nations and Indian health programs. The Foundational Public Health Services Steering Committee is the decision-making body for efforts to support the provision of foundational services across the state. Legislation passed with bipartisan support in 2019 (RCW 43.70.512 and 40.70.515) reflects recommendations from elected officials to mandate the provision of Foundational Public Health Services (FPHS). The accountability process described in this case study is part of Washington’s system-wide effort to secure and maintain adequate and stable funding for FPHS by demonstrating the value and impact of these services across the public health system.

Key Actions

Achieve consensus on what to measure.

In Washington, the accountability process is designed to measure the impact of public health investments system wide as outlined in state legislation. The Steering Committee initially requested the state invest in just one area, communicable disease, which was the focus of the first impact measurements.

Define a measurement framework.

Availability of FPHS. The FPHS were broken down into elements, and elements were further broken down into a total of 350 activities. Elements and activities have “functional definitions,” i.e., highly detailed descriptions of what is being measured.

Indicators of system output were selected from existing statewide data systems. Communicable disease indicators included the total number of syphilis and gonorrhea cases investigated systemwide, the number of hepatitis C cases investigated, and immunization series completion rates for children.

For example:
  1. Foundational public health service:
    Prevention and Control of Communicable Disease and Other Notifiable Conditions.
  2. Element:
    Ensure disease surveillance, investigation, and control for communicable disease and notifiable conditions in accordance with local, state, and federal mandates and guidelines.
  3. Activity:
    Ensure disease surveillance, investigation, and control for communicable disease and notifiable conditions in accordance with local, state, and federal mandates and guidelines.

    • Establish and maintain 24/7 access to receive and respond to case reports in a timely manner according to Washington Administrative Code and Revised Code of Washington timeframes.
    • Each activity is assessed by two factors: capacity (resources/staff) and expertise (knowledge/proficiency).
    • Each factor is rated on a 5-point scale ranging from “not available” to “fully available”
    • The combined ratings = “availability of foundational public health services”

To establish a baseline of the availability of FPHS, each agency in the public health system rated itself for all 350 activities that had been identified. The baseline assessment was conducted by a contractor who handled communication and technical assistance to individual agencies, data collection, data cleaning, follow-up with individual agencies on data irregularities or questions, and data analysis and visualization and report development.

Annual Foundational Public Health Services investment reports measure changes from baseline in the availability of FPHS and system output indicators that received funding during that year. The accountability process will evolve to include indicators for all areas in which FPHS funds are invested, long-term population health outcomes, and equity.

After the first annual report was completed, the last step in the assessment process cycle was to publicly communicate the results of the FPHS funding in a succinct and compelling way to elected officials, partners, and the community. In addition to ensuring transparency, the results are intended to help justify additional investments in the public health system.

Recommendations

Financial

Funding to establish and implement the accountability process.
  • In Washington, funds from the initial legislative investment of $6 million per year for the delivery of communicable disease services also helped establish the system and conduct the baseline assessment ($325,000 for vendors as well as pro-rated funds for all agencies, based on the size of the population served, that could be used to support their time and effort).
  • Ongoing measurement is coordinated and conducted through existing staff and FPHS funds ($55,000 per year for provide limited support from a vendor to prepare the annual assessment data collection tool, analyze data, create data visualizations, and develop the annual investment report).

Using vendors for this work provides an independent analysis that further enhances the credibility of the process.

Policy

Work with legislative champions to develop an accountability process.

The FPHS Steering Committee in Washington discussed ideas for public health system transformation with legislative champions at the beginning of their work and solicited feedback on the proposed plan. One result of this approach can be found in RCW 43.70.515: With any state funding of foundational public health services, the state expects that measurable benefits will be realized to the health of communities in Washington as a result of the improved capacity of the governmental public health system. Close coordination and sharing of services are integral to increasing system capacity. Having this type of legislation in place increases the likelihood that the work will continue – even during public health emergencies.

The entire system must be held accountable, including governmental public health agencies at the state, local, and tribal levels. Each part of the system is necessary and none alone is sufficient, because public health issues such as germs, toxins, and social challenges do not respect geopolitical or agency/institutional boundaries. Protecting and improving the public’s health requires the whole system. According to one member of the Steering Committee, “It really does ‘take a village,’ and in this case, that is the public health system!”

Accountability Process Features

Develop a set of functional definitions for each service that will be measured.

Develop a set of functional definitions for each service that will be measured to ensure that the measurement activities are consistent over time. If the definitions are not clear, agencies may rate themselves inconsistently, making it difficult to generate accurate and meaningful comparisons between public health agencies and over time.

Measurements of system performance will not be exact, but the use of measurement principles and a methodological approach can provide the structure needed for meaningful assessments.

The Steering Committee uses data from the annual assessment process in identifying needed changes to their approach to allocating funds.

Workforce

Engage staff throughout the public health system.
  • Engage staff throughout the public health system.
The Steering Committee designed a process using:
  • Data that already are collected, to the extent possible; and
  • A simplistic annual reporting tool that only assesses areas with new FPHS investments, so it is more streamlined than the baseline assessment.
  • Washington’s detailed baseline assessment required much thought, internal data collection, and coordination among agency staff – especially those within larger agencies with many programs and capacities.
  • The annual assessment is dramatically briefer than the baseline but still requires some focused staff attention.

Allocate time for staff to participate in designing and conducting assessments and plan accordingly to ensure that staff have the bandwidth to complete this work.

Anticipated Impacts For Public Health Departments

Health

The accountability process provides information that reflects incremental steps toward improved system output indicators, helping to make the case for ongoing investments in the public health system.

Since the accountability process compels more funding for the public health system, it is expected that the FPHS will be available in a more equitable way in every community across the state.

Potential Challenges To Implementation

Unique resources, skills, and time.

Unique resources, skills, and time are needed to establish and operate an accountability process for public health system performance, and public health department staff typically do not have the vantage point, knowledge, and experience required for this work. Additionally, it takes a great deal of time to understand, interpret, and use system-level data to demonstrate the impact of public health funding. Moreover, it can be very difficult to translate and visualize these data in a way that clearly connects programmatic, policy, and fiscal analyses. Therefore, it is critical to engage consultants, partner with academia, or otherwise secure the expertise needed to do this work.

Measuring system performance is complex and more involved than measuring individual agency performance, with many confounding factors (e.g., when funds are redirected in response to public health emergencies). The thought of establishing an accountability system can therefore be daunting, but with expert guidance, it is doable. Start small by measuring just a few outputs and/or intermediary outcomes. Learn, adapt, and build a more robust process over time.

For example, positive impacts from new funding could encourage more investment or it could prompt policy makers to decide that no additional funding is necessary. On the other hand, if system performance declines – even for reasons beyond the system’s control – policy makers could decide to decrease the funding, thinking it does not make a difference. The way that results are communicated can influence how they are interpreted, so a strong communications function is key in reporting findings.

Sustainability

Sustaining the accountability system in Washington relies on:
  • Governmental public health system partners’ interest, desire, and engagement in the cycle of estimating funding needs, making a funding request, deciding how to allocate funds appropriated by the legislature, spending the funds, and providing data on the impact of the funding.
  • Partners’ ability to institutionalize their engagement in this work so it will be less vulnerable to changes in leadership.
  • Partners’ commitment to “taking the long view” and adhering to the established framework and accountability system to ensure valid comparisons from year to year.
  • Policymakers’ consideration of the impact of FPHS funding as demonstrated in the annual assessment reports.

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