In This Article Expand or collapse the "in this article" section Public Health Systems in the United States

  • Introduction
  • Introductory Works
  • Reference Works
  • Anthologies
  • Bibliographies
  • History
  • Relationship between State and Local Agencies: Centralization
  • Organization and Functions of State and Local Agencies
  • Financing
  • Governance
  • National Performance Standards for State and Local Agencies
  • Quality Improvement
  • Accreditation of State and Local Agencies
  • Public Health Services from the Private Sector
  • Public Health Systems and Services Research

Public Health Public Health Systems in the United States
Margaret A. Potter
  • LAST REVIEWED: 26 August 2013
  • LAST MODIFIED: 26 August 2013
  • DOI: 10.1093/obo/9780199756797-0079


Public health systems in the United States are networks of public, private, and voluntary entities. They have responsibility for population-wide health programs, policies, and services. In other countries, programs of support for population-wide health are relatively well integrated with personal health-care services: the same health agencies and ministries that serve individuals also monitor health trends, conduct surveillance for health threats, and introduce health-enhancing interventions to community environments. In the United States, however, individual and population-wide health services tend to be separately organized, financed, and operated. The US population receives health care primarily from private-sector entities with responsibility for individual beneficiaries; for limited durations as defined by employment benefits, income status, or disability status; and for episodes of illness or need. Here public health systems address the health needs of entire communities, of individuals throughout the lifespan, and for social and environmental conditions affecting health. The concept of a “system” for public health arose during the 1990s in the then-developing framework for public health performance standards. Such a network might include health-care providers including hospitals, physicians, and managed care organizations. Other governmental agencies such as environmental regulators and human services might be organizationally integrated with or separate from health departments. Various health-related activities might be supported or carried out by community-based organizations, schools, faith-based institutions, and many others. This article uses the term “system” to mean such a location-specific network and the term “health agency” or “health department” to mean a governmental entity responsible for public health activities within a given state or local jurisdiction. This article provides an overview of publications and other resources that describe public health systems in the United States. It does not address programs, policies, or services for any particular disease or health threat. Rather, it takes a cross-cutting perspective and focuses on what is common to prevention of all diseases and injuries and to promotion of good health. It begins with literature of general coverage including introductory works, reference works, textbooks, anthologies, bibliographies, journals, and histories. The remainder of the article addresses particular aspects of public health systems: structure and organization of state and local health agencies; financing, governance, workforce, performance standards, and accreditation; the role of private-sector entities in public health systems; and the emerging field of public health systems research.

Introductory Works

As a field of practice, public health has a history in the United States of at least two centuries, but only since the late 1980s has the concept of public health systems developed. Beginning with Institute of Medicine 1988, the concept evolved through the 1990s with work by the US Public Health Service agencies. The Public Health Functions Project, initiated during the Clinton Administration, defined terms, stated a mission and goals, introduced an “infrastructure” chapter to the Healthy People Objectives and issued an agenda for workforce development. Workforce enumeration was the subject of a report (Gebbie, et al. 2003) which remains a reference to the present. Institute of Medicine 2002 updated Institute of Medicine 1988, documenting progress and refocusing objectives. A review article (Baker, et al. 2005) summarized the 1990s work of the CDC in conceptualizing public health systems. In 2009, the Robert Wood Johnson Foundation requested that the Institute of Medicine once again consider how the health system, broadly defined, impacts population health. The Institute produced a series of three reports, one each on measurement in action and accountability (Institute of Medicine 2011a), law and policy (Institute of Medicine 2011b), and financing (Institute of Medicine 2012).

  • Baker, Edward L., Jr., Margaret A. Potter, Deborah L. Jones, et al. 2005. The public health infrastructure and our nation’s health. Annual Review of Public Health 26:303–318.

    DOI: 10.1146/annurev.publhealth.26.021304.144647

    The point of departure for this review was the collective work of the CDC’s Public Health Practice Program Office from the 1990s, which defined the public health “infrastructure” and assessed the status of financing, legal authorities, workforce, informational technology, and organizational capacities. The article presents a thorough overview with a copious and still-useful reference list.

  • Gebbie, Kristine, Linda Rosenstock, and Lila M. Hernandez, eds. 2003. Who will keep the public healthy? Educating public health professionals for the 21st century. Washington, DC: National Academies Press.

    This report defined “public health professional,” recommended standards for education and training, and—in addition to the five recognized public health disciplines (behavioral science, biostatistics, epidemiology, policy and management, and environmental-occupational health), cited eight new “critical areas”: informatics, genomics, communication, cultural competence, community-based participatory research, global health, policy and law, and public health ethics.

  • Institute of Medicine. 1988. The future of public health. Washington, DC: National Academies Press.

    This report grew out of concern over that the nation’s public health goals and activities had fallen “into disarray (p. 19).” Its findings outlined core functions for public health, and its recommendations assigned responsibilities among governments at the federal, state, and local levels and to educators. It guided a revitalization of public health in government and academia over the subsequent two decades.

  • Institute of Medicine. 2002. The future of the public’s health in the 21st century. Washington, DC: National Academies Press.

    Fourteen years after the landmark 1988 report, this IOM report and its companion (Gebbie, et al. 2003) described a vision for public health in the new century and documented progress in reforming the nation’s public health systems in government and in academia. It emphasized multisector partnerships to achieve health objectives and recognized health determinants that included laws, policies, and environmental and social factors.

  • Institute of Medicine. 2011a. For the public’s health: The role of measurement in action and accountability. Washington, DC: National Academies Press.

    This is the first of the IOM’s three-part series exploring the necessary strategies to improve health in the United States. This report reviews the measures and assessments used for measuring performance and informing advocacy for public health policy and practice.

  • Institute of Medicine. 2011b. For the public’s health: Revitalizing law and policy to meet new challenges. Washington, DC: National Academies Press.

    In this second report of the three-part series, the IOM committee considers the role of law in health outcomes. This report presents an overview of legal authorities, describes previous developments of model public health laws, and highlights the relevant social and policy contexts for law in the future.

  • Institute of Medicine. 2012. For the public’s health: Investing in a healthier future. Washington, DC: National Academies Press.

    The third and final report in the IOM’s series points up the inadequacies in current patterns of funding and offers recommendations for future funding of state and local public health systems.

  • Public Health Functions Project.

    This project is credited with developing the ten essential services of public health, which framed much of the subsequent development of performance standards and eventually accreditation criteria for state and local health departments. The project and its outputs were based on consensus of committee members including professional associations and federal health agencies. The project concluded in 1999.

  • 2020 Topics & Objectives: Public Health Infrastructure.

    Healthy People, a decennial health plan for the nation, lists public health infrastructure objectives for the third iteration. Greatly expanded from the previous two cycles, the 2020 plan sets objectives for public health infrastructure in three categories: workforce (six objectives), data and information systems (four objectives), and public health organizations (seven objectives).

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