Building Accountability for Public Health Investments

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.

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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!”    

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• 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). 

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

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• 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.  

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• 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.

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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. 

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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.  

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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.  

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

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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.  

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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.

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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.

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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.

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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.

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• 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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