Despite recent emergency infusions of federal funds for disaster preparedness and bioterrorism, and despite the state's efforts to "backfill" a large share of local revenues lost by repeal of the Motor Vehicle Excise Tax, Washington's local public health infrastructure has been eroding for years. The public health functions that have been largely responsible for nearly doubling life expectancy during the last century are now threatened, including the analysis and public reporting of community patterns of illness; the mounting of quick responses to infectious diseases like TB, HIV and influenza; and the assurance of sanitary food, water and air, even in the wake of natural disasters or attacks.

As local revenue has been reduced, some vital services have been privatized. Others have been forced to rely almost exclusively on user fees (e.g., restaurant and sewage treatment system inspection). These strategies have produced better performance and acceptable alternatives to general revenue financing of some core public health services. However, these new methods have generated few funds for proper oversight or quality improvement, and almost none for changes needed to meet emerging health threats at the local level (e.g., indoor air and toxics monitoring).

Recent emergency infusions of funds to respond to potential bioterrorist attacks or other health emergencies have not kept their promise of buttressing core public health infrastructure. Instead, they have diverted the focus from some of these core functions, and eroded management energies needed to keep them performing consistently. Now, even these federal funds may be reduced, leaving in their wake heightened public expectations of a robust public health response to emergencies, without the resources to produce it.

WHF believes that the roots of the problems with our public health infrastructure are unstable, inadequate public financing and inconsistent system performance.

The findings of the 2005 PHIP Standards Assessment of our state’s public health system indicated the following:
…[P]erformance, while connected to budget (>$7.5 million/year) and size (number of employees), also has other drivers. Field observation suggests these may include:

• local leadership and priority setting…
• local funding levels…and pursuit of grant funding for special program initiatives…
• staff skill, training and experience, particularly in program management...
• documentation and data systems…and
• …higher performance… in the Assessment topic area…

These findings suggest that in public health, clear and consistent policies, specific targets, a well-trained and properly compensated workforce and adequate funding combined with strong management leadership are associated with high levels of performance.

Local government plays a key role in administering public health programs in response to community needs. Yet, local governments have widely varied capacity to finance public health functions and most now have fewer means than ever before. WHF believes greater consistency of financial assistance from local government is key to stable public health programs. However, it seems unrealistic to expect that local government will be successful in generating an adequate and consistent financing platform using only locally generated revenue sources. Further, without strong central leadership, it is unrealistic to expect that local program operations will be sufficiently consistent and integrated to protect Washingtonians from public health threats.

If Washington is to become the Healthiest State in the Nation, state government must continue efforts already underway to improve public health infrastructure. Following guidance of the Joint Select Committee on Public Health Financing, the state must increase not only the amount of funding, but also its stability.

In coming years, state government should lead the development of a clear and realistic agreement regarding the roles of local, state, and federal public health financing partners. This should entail significant increases in state funding, tied to specific, measurable performance indicators to ensure a consistent level of core public health protection across Washington.

And state funds should provide a stable and predictable financial base for public health. At the very least, state funds should "fill the gaps" in current funding to assure the state's compelling interest in: 1) health assessments, 2) controlling the spread of disease, and 3) protecting the public from environmental threats to health, including rapid response to emergencies and disasters.

Limiting public health efforts to these areas would protect us from "losing ground" against the disease threats of the twentieth century. But a twenty-first century public health system must address today's leading causes of preventable death. Improving chronic disease prevention and treatment and deploying current public health knowledge toward improving child health are necessary for that. WHF recognizes the importance of public health nurses and supports public health's pioneering roles in chronic disease prevention and treatment, including public health's successful leadership in curbing tobacco use; in leading medical practice changes in treating chronic diseases like diabetes; and in initiating community-wide efforts to increase physical activity, improve nutrition, and address other known risk factors for chronic illness. Similarly, new research in child development and proven public health programs like the Nurse-Family Partnership Program are forging the way for more of Washington’s children to begin life with every opportunity to succeed.