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The 2018 Forces of Change in America’s Local Public Health System

Tuesday, December 18, 2018  
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New Data Show Local Health Departments Faced Challenges Associated with Emerging Public Health Threats including Opioid Misuse, Increased Severity of Influenza, and Impacts of Climate Change —

Washington, DC, December 18, 2018 — The National Association of County and City Health Officials (NACCHO) has released its 2018 Forces of Change report containing new findings on the forces that are affecting the nation’s local health departments. Local health departments face both challenges and opportunities as the public health environment evolves, and the Forces of Change survey helps to identify infrastructure gaps, as well as strategies for strengthening public health capacity.  

KEY FINDINGS:

  • WORKFORCE ISSUES:  Although the overall proportion of local health departments reporting budget cuts and job losses has remained steady in recent years, local health departments have eliminated 56,630 jobs over the past decade.
  • OPIOID CRISIS:  Overall, approximately two-thirds of LHDs reported conducting activities to address the opioid crisis in 2017, but lack necessary funding to provide these services.
  • POPULATION HEALTH: Local health departments are increasing their work in population health—which includes addressing community infrastructure; community violence; family and social supports; food insecurity, hunger, and nutrition; and housing instability and homelessness.
  • INFECTIOUS DISEASE/INFLUENZA:  The 2017-2018 influenza season was particularly bad, with one of the dominant strains, H3N2, being associated with complications in people with certain conditions. Local health departments played important roles as communicators and conveners in their community immunization response.
  • TECHNOLOGY: Informatics and health information technology (HIT) enable communication between providers to streamline healthcare systems, improve healthcare delivery, and ensure continuity in care across the lifespan. Most departments are using electronic surveillance systems to identify possible food-borne and influenza-like illnesses.
  • CLIMATE CHANGE:  Environmental health work at the local level protects the public’s health against a wide range of threats that can be worsened by the impacts of climate change; however, fewer departments reported addressing climate change-related issues than five years ago.

For additional information on the key findings, please see the Highlights section below.

            “The 2018 Forces of Change survey results illustrates that while local health department economics are improving, challenges remain, especially related to the need for sustained investment at the local level where services are provided ,” said Adriane Casalotti, MPH, MSW, NACCHO’s Chief of Government and Public Affairs. “For example, the survey showed that nearly two-thirds of local health departments reported no or insufficient dedicated funding to combat the opioid epidemic. Without funding support, local health departments in states like West Virginia, New Hampshire, and Ohio--which have the highest rate of opioid fatalities--may be forced to divert resources slated for other community services.  Local health departments should not be forced to support one sector of their community at the expense of others.”

Since 2008, NACCHO has periodically surveyed local health departments to assess the impact of the economic recession. NACCHO has recently expanded the survey to address more generally the forces that affect change in local health departments, including the emergence of new infectious diseases and a growing need for collaboration across sectors. Topics included in the 2018 Forces of Change focused on changes in local health department budget and workforce capacity, response to opioid use and abuse, population health activities, influenza preparedness and response, informatics capacity, and environmental health activities.

Visit www.nacchoprofilestudy.org/forces-of-change to learn how economic and political forces are changing local public health.

HIGHLIGHTS

Although the overall proportion of local health departments reporting budget cuts and job losses has remained steady in recent years, local health departments have eliminated 56,630 jobs over the past decade. In 2017, local health departments reported an estimated 800 jobs lost; of those, 500 were due to layoffs and another 300 were due to attrition. However, this is the lowest reported estimate since 2008. In addition, 2017 saw a positive net change in the number of job positions within local health departments—with 170 more jobs added than were eliminated. This evidence indicates that local health department staffing levels are starting to rebound from the Great Recession.

Overall, approximately two-thirds of local health departments reported conducting activities to address the opioid crisis in 2017. To do so, local health departments often partnered with local/state government agencies and healthcare organizations. Regardless of population size served, the major barrier to conducting opioid-related activities was a lack of dedicated funding. For small departments, lack of staff expertise or training was also a barrier. Combating the opioid epidemic and ensuring resilient communities requires a broad and integrated effort across the local public health system.

As the health of a community is impacted by people's access to resources and supports, local health departments are increasing their work in population health—which includes addressing community infrastructure; community violence; family and social supports; food insecurity, hunger, and nutrition; and housing instability and homelessness. In 2017, nearly 75% of local health departments conducted activities to address food insecurity. Regardless of topic area, most local health departments reported partnering with local/state government agencies and non-profits to conduct population health activities. Although other entities provide these services in some communities, local health departments must be a partner and leader in population health work as they are uniquely positioned as the face of public health.

The 2017-2018 influenza season was particularly bad, with one of the dominant strains, H3N2, being associated with complications in people with certain conditions. To address this risk, the majority of local health departments participated in immunization-focused partnerships or coalitions in some capacity. In addition, the most common activities for local health departments during the most recent flu season were focused on disseminating information through outreach and education within the community and public communications platforms.

Informatics and health information technology (HIT) enable communication between providers to streamline healthcare systems, improve healthcare delivery, and ensure continuity in care across the lifespan. More than half of local health departments had access to data from an electronic syndromic surveillance system that uses hospital emergency department data. In addition, local health departments use these syndromic surveillance systems to detect influenza-like and food-borne illnesses. As local health departments continue to strengthen their informatics capacity, they will need to develop their staff HIT capabilities.

Environmental health work at the local level protects the public’s health against a wide range of threats that can be worsened by the impacts of climate change. Although environmental health service provision experienced stabilization for many local health departments, the most commonly reported service reduction was in emergency preparedness. Furthermore, for almost all issues impacted by climate change, fewer local health departments reported addressing them in 2017 than in 2012—particularly in water-, food-, and vector-borne diseases; storms, hurricanes, and floods; and unsafe or ineffective sewage and septic system operation. Bolstering local health department capacity to address environmental health threats is an urgent need for the local public health system, especially as the effects of climate change become more pronounced.

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About NACCHO

The National Association of County and City Health Officials (NACCHO) represents the nation's nearly 3,000 local health departments. These city, county, metropolitan, district, and tribal departments work every day to protect and promote health and well-being for all people in their communities. For more information about NACCHO, please visit www.naccho.org



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