- 1 Introduction
- Professor Emeritus, Public Administration and International Affairs
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- Larry D. Schroeder
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Ask a librarian. Part 4. Hobson a Rangarajan and D. Srivastava Fiscal decentralization and the mobilization and use of national resources for development : issues, exp Aboriginal, Torres Strait Islander and other First Nations people are advised that this catalogue contains names, recordings and images of deceased people and other content that may be culturally sensitive. Book , Online - Google Books. Includes bibliographical references. Intergovernmental fiscal relations -- Asia.
Professor Emeritus, Public Administration and International Affairs
It can be used to gain political goals that means when the fiscal decentralization is made correctly or served politically decentralization but in practice or reality due to lack of resource sometimes local governments alive for political reasons. Any type of federal arrangement involves a division of functions between the Central Government and sub national governments expenditure assignment as well as assignments of different sources of revenue to different types of government revenue assignment.
Adopting the principles of expenditure and revenue assignments cannot by itself guarantee a balanced budget at all levels of government. Some degree of mismatch between expenditure needs and revenue means at various levels of government is likely to occur. It is alleged that it is inevitable to have fiscal imbalance for it is necessary to retain some taxing powers at the federal government.
In such circumstances, Eshetu noted, only rarely does one encountered balance between the spending needs and revenue capacity of either the Central Government or the regions, and all too often, either the center or the region is unable to cover its expenditure from its own fiscal resources.
- Association of Southeast Asian Nations;
Vertical fiscal imbalance is the disparity between revenue means and expenditure needs at various levels of government in a federation. It occurs when own revenue and expenditure capacity of varies levels of government within a federation are unequal. It is the result of an allocation of expenditure responsibilities with higher cost than the source of revenue assigned to sub-national governments.
The second reason is that, no matter how carefully the original designers of the federation may attempt to match the revenue sources and the expenditure assignments of each order of government, over time the significance of different taxes change and the costs of expenditures vary in unforeseen ways.
From the outset it can be stated that the most lucrative taxing powers are granted to the federal government. For instance, the customs duties and other taxes on imports and exports constitute more than 30 per cent of the total revenue generated in Ethiopia is given for federal government. This has meant significant more per capita revenue for the producing states, but because they are underdeveloped and poor they have complained that this share is inadequate. They also want a special share of offshore revenues, though the offshore lies outside state boundaries. In addition, the producing states want a greater say in the actual management of the resources, which has often been done in an environmentally damaging fashion and with little regard for the local population.
As far as the regional taxing powers are concerned, even at first sight it is clear that some of them taking into account the current state of Ethiopian society will generate little revenue. In this regard, we can mention the power of the regional states to levy taxes on the income of farmers. The taxes on income from transport services rendered on waters will neither generate substantial income. Ethiopia has many rivers and lakes, but there is little transport on these waters.
Finally, the alarming scale of deforestation will negatively affect royalties for the exploitation of forests. For example: - The impression that the taxing powers of the regions will generate little income is confirmed by the following table. Whereas the contribution of the regions to the total fiscal revenue does not show an increasing trend, in the period the regions had an increasing share of expenditure.
We can observe a marked decrease of the regional share in total expenditure from to , which can be explained by the higher federal expenditure for defense necessitated by the war with Eritrea. Ithaca, , P. Intergovernmental fiscal transfers: Principles and practice. Washington, D. C: The World Bank. Federalism in a changing world — learning from each other. Fiscal federalism and local government finance in Nigeria.
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In den Warenkorb. Concept of Fiscal imbalance Any type of federal arrangement involves a division of functions between the Central Government and sub national governments expenditure assignment as well as assignments of different sources of revenue to different types of government revenue assignment. World Journal of Education, 2 5 , 6 Solomon neguse, fiscal federalism in the Ethiopian ethnic — based federal system , published , p.
Watts p. Comparative Analysis of Intergovernmental Relations in Ethiopia. Assessement of the effect of government expenditure on privat inves Public Economics and Intergovernmental Grants. Effect of the strong economic growth in Ethiopia on its neighborcou Phenotypic Characterization of indigenous Chicken Ecotypes in North The situations of trafficking women from Ethiopia to Sudan.
Furthermore, a similar network of State and Regional Public Health Leadership Institutes has been funded and, over time, has developed the capacity to work collaboratively through a national network, which permits institutes to benchmark and share best practices and continue the process of learning needed to help with state-of-the art curriculum and educational training efforts. Equally notable has been the development of the Management Academy for Public Health, a joint effort of the major public health philanthropies.
Although effort is still at an early stage, this academy has already generated graduates who work hand in glove with senior leadership in public health organizations. Furthermore, the Turning Point Initiative devotes efforts to increasing collaborative leadership across all sectors and at all levels Larson et al.
Another key to leadership is continuity in office long enough to exert the leadership and to provide the institutional memory to defend public health agencies and the public health sector from the political winds of the moment. Yet, the committee finds there has been great difficulty in recruiting, developing, and retaining the leaders so vital to the job. Health officials must work with legislators who operate on 2-year terms.
Given that the average tenure of a state health officer is relatively short an average of 3. Additionally, because state health officers report to many governing bodies, they generally have less direct access to policy makers, and state health officials must prioritize the issues that they think deserve the most attention Meit, Political factors at the state level can also have a significant impact on the abilities of public health leadership to influence policy.
To address the specific issues of discontinuity occasioned by the rapid turnover, particularly of state health officials, the Robert Wood Johnson Foundation has funded a unique State Health Leadership Initiative administered by the National Governors Association to immerse newly appointed officials in a curriculum for political leadership and provide a network of resources and mentors. Governmental public health leadership is a critical component of the infrastructure that must be strengthened, supported, and held accountable by all of the partners of the public health system and the community at.
For this reason, the committee recommends that leadership training, support, and development be a high priority for governmental public health agencies and other organizations in the public health system and for schools of public health that supply the public health infrastructure with its professionals and leaders. Credentialing is a mechanism that is used to certify specific levels of professional preparation.
There are many different forms of credentials, including academic degrees, professional certifications, and licenses. For example, medical credentials include medical degrees to certify successful completion of course work, professional testing e. An individual credentialed as a Certified Health Education Specialist CHES has successfully completed a course of study and passed a competency-based test. Although some public health workers are credentialed as physicians, nurses, health educators, or environmental health practitioners, few are credentialed within those professions specifically for public health practice.
Most physicians working in public health lack board certification in preventive medicine or public health; most nurses working in public health lack credentials in community public health nursing; and most individuals working as health educators lack the CHES credential. Furthermore, no single credentialing or certification process has been established to test the various competencies required for the interdisciplinary field of public health; thus, the majority of the public health workforce 80 percent lacks credentials HRSA, CDC d has recommended the use of credentialing.
Such a process would complement efforts to establish national public health performance standards for state and local public health systems based on the essential public health services framework and the related objectives of Healthy People Objective 23—11 DHHS, Although this national effort focuses on experienced public health leaders, support is growing for the concept of credentialing at a basic level all public health workers and at an.
Certification or credentialing would help establish that public health practitioners have a demonstrated level of accomplishment in and mastery of the principles of public health practice. In terms of building the capacity of the public health workforce, the credentialing process could help document the knowledge, skills, and performance of experienced workers who may not have formal academic training and could encourage other workers to seek additional training to meeting credentialing requirements.
An especially important component of this process is that it could play a key role in shaping the training and preparation of future public health practitioners and leaders. The key challenge is whether and how public health organizations can begin to integrate competency-based credentialing in their hiring, promotion, performance appraisal, and salary structures. Although the idea of credentialing has considerable support at the federal level, states and particularly localities have voiced concerns that workforce credentialing mandates may become too closely tied to federal funding mechanisms.
In these situations, the fiscal impact could be grave for public health departments that do not or cannot meet credentialing requirements community informants, personal communications to the committee, The committee finds that in the ongoing debate about public health workforce credentialing, what is most needed is a national dialogue that can address the full range of issues and concerns. Therefore, the committee recommends that a formal national dialogue be initiated to address the issue of public health workforce credentialing.
The Secretary of DHHS should appoint a national commission on public health workforce credentialing to lead this dialogue. The commission should be charged with determining if a credentialing system would further the goal of creating a competent workforce and, if applicable, the manner and time frame for implementation by governmental public health agencies at all levels. The dialogue should include representatives from federal, state, and local public health agencies, academia, and public health professional organizations who can represent and discuss the various perspectives on the workforce credentialing debate.
The role of communication in public health practice cannot be underestimated. Governmental public health agencies must. Informing and advising the public about health promotion and disease prevention are standard duties of both state and local public health agencies, and listening to community voices is also critical for programs to be effective.
In emergency situations, public health professionals must have the ability to communicate clearly and effectively—being aggressive and credible enough to command attention—with both the public and other officials about the nature of the health hazards and the steps necessary to minimize health risks. The response to the discovery of anthrax exposures in the fall of brought into sharp focus the importance of effective communication in the face of serious health risks. According to New York Times medical reporter Dr. Lawrence Altman, lapses and delays in communication with the public and with public health and health care professionals could have made the situation worse had the anthrax exposures been more widespread Altman, Altman suggested, however, that CDC could have issued information as a part of the parallel public health investigation that was already under way.
It should be noted that CDC used the Health Alert Network many times after September 11, , to alert public health officials and to disseminate information. The lack of information from DHHS was also frustrating to other federal, state, and local leaders and governmental public health officials, some of whom learned about new cases and contamination in their states though network and cable television newscasts Connolly, The lesson from these and other communication breakdowns is evident: clear and effective communication, both internal and external, is a critical service of the governmental public health infrastructure.
Because the responsibilities of public health agencies cover all aspects of health, public health officials are in a unique position to provide timely, accurate health-related information to the public on a wide variety of topics, ranging from depression and other mental health issues to obesity and physical activity, environmental health and safety, emergency preparedness, and policies that affect health or health outcomes.
However, few public health agencies have staff members who are trained to interact effectively with the public and to work effectively with the news media. Of these people, most are working in DHHS and other federal health agencies. Of the others, are working in state and territorial public health agencies and 12 are working in voluntary agencies HRSA, Given the tremendous potential of the mass media and evolving information technologies, such as the Internet, to influence the knowledge, normative beliefs, and behavior patterns of individuals and groups, governmental public health agencies must be prepared to use these communication tools.
The public health workforce must have sufficient expertise in communications to be able to engage diverse audiences with public health information and messages and to work with the media to ensure the accuracy of the health-related information they convey to the public. For example, public health officials can develop relationships with journalists and assist them in accurately representing health risks and interpreting the significance of new research findings so that reporting on public health issues is accurate and members of the public can make informed decisions about protecting their health.
For these reasons, the committee finds that communication skills and competencies are crucial to the effective performance of the 10 essential public health services and the practice of public health at the federal, state, and local levels. Therefore, the committee recommends that all partners within the public health system place special emphasis on communication as a critical core competency of public health practice.
Governmental public health agencies at all levels should use existing and emerging tools including information technologies for effective management of public health information and for internal and external communication.follow url
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To be effective, such communication must be culturally appropriate and suitable to the literacy levels of the individuals in the communities they serve. To build this capacity in the public health workforce, communications skills and competencies should be included in the curricula of all workforce. Communication competencies should include training in risk communication, interpersonal and group methods for gathering and transmitting information, and interfacing with the public about public health information and issues, as well as the interpretation of health-related news. Information and the systems through which it is produced are critical tools that enable public health agencies to meet their responsibilities for monitoring health status and for identifying health hazards and risks to the populations they serve.
It is essential that the governmental public health infrastructure have a system that is capable of supporting the collection, analysis, and application of myriad forms of health-related data and information. Without adequate surveillance, local, state, and federal officials cannot know the true scope of existing health problems and may not recognize new diseases until many people have been affected.
Data are the essential elements of information; that is, data are the measurements and facts about an individual, an environment, or a community. Information is what is generated when data are placed in context via the tool of analysis. When rules are applied to the information, knowledge is generated Lumpkin, All of these elements—data, information, and knowledge—are critical products of public health information networks.
The committee emphasizes the need for an integrated information infrastructure to overcome many of these problems. For communicable diseases, effective epidemiological surveillance can make the difference between the rapid identification and treatment of a few cases of disease and an outbreak that debilitates an entire community. Responsibility for surveillance, one of the most important functions of the public health infrastructure, is shared among federal, state, and local public health agencies.
States and localities collect and report data; and federal agencies, especially CDC, in the case of infectious and chronic diseases, provide valuable technical support, training, and grant funding GAO, a. The rapid development of new information technology offers the potential for a greatly improved surveillance capacity. For example, it is now possible to engage in real-time data collection via the Internet and through linkages to electronic patient records.
New technologies also offer the potential for automated data analyses, such as pattern recognition software that would be able to detect unusual disease patterns. Moreover, new technologies offer new options for disseminating the information produced by surveillance efforts Baxter et al. Fragmentation has developed in surveillance systems in part because legal authority for surveillance rests with states and localities and they have not developed uniform standards for data elements, collection procedures, storage, and transmission.
The lack of uniformity has made it difficult for states and localities to work collaboratively among themselves or with the private sector to develop more effective surveillance systems. Although The Future of Public Health recommended the development of a uniform national health data set IOM, , progress has been limited. Another key factor shaping the development of surveillance systems is that, historically, investment in these systems has been largely categorical, resulting in fragmentation of surveillance efforts across the spectrum of infectious disease threats and other programs for other specific diseases and.
An inventory of public health data projects and systems identified more than separate DHHS data systems in seven broad programmatic areas Boufford and Lee, The multiplicity of surveillance systems for food-borne illnesses illustrates the problem see Box 3—3. A lack of integration in federal data systems helps drive fragmentation at the state and local levels.
Data collected in accordance with the specifications of separate federal programs often cannot be accessed at the local level because of differences in formats, definitions, classification systems, personal identifiers, or sampling strategies Lumpkin et al.
The fragmentation means that state and local public health agencies inevitably must spend time on duplicative data-reporting activities that drain already scarce staff resources GAO, a. The current combination of system incompatibility and lack of integration hinders the ability of program managers to know what information exists and how to access that information and hinders the ability of local health agencies to provide integrated care to their communities Lumpkin et al.
Existing surveillance activities contain notable gaps. Similarly, environmental pollutants and toxins are monitored primarily for the purposes of environmental protection and regulation, but no surveillance and tracking system monitors the health outcomes, such as birth defects and developmental disorders, that are potentially linked to toxic exposures.
With an improved awareness of these health risks and a more comprehensive understanding of the health status of the population, public health agencies from the federal to the local level would be able to design better interventions and prevention efforts. The Pew Environmental Health Commission , has called for the development of a national health-tracking network to monitor the prevalence of chronic conditions such as asthma and for the development of national birth defects registries. Ideally, these comprehensive disease registries and surveillance networks would be accessible to and used by state and local public health agencies to better understand and monitor the health status of the communities they serve.
Additionally, these registries would have the potential to be linked with registries from private health care delivery organizations. Of these, only four principal systems focus exclusively on foodborne illnesses and cover more than one pathogen:. It relies on local health officials to take the initiative to report outbreaks to CDC through their state public health officials. CDC and others use this system mainly to maintain awareness of ongoing problems.
Public health officials who participate in FoodNet receive federal funds from CDC to systematically contact laboratories in their general area and solicit incidence data. This system provides more accurate estimates of the occurrence of food-borne diseases than are otherwise available. PulseNet is used to identify whether separate cases of illness are likely to have originated from the same source. Using this system, public health officials can compare the new patterns to other patterns in the database; matches indicate an outbreak. The Surveillance Outbreak Detection Algorithm SODA focuses on Salmonella and Shigella and uses statistical analyses to compare current data against a historical baseline to detect unusual increases in the incidence of these two pathogens.
Increases may indicate an outbreak. Although these four systems have contributed to improved food safety, the usefulness of the systems is marred both by the untimely release of the surveillance data and by gaps in the collected data. Twenty-six of the General Accounting Office survey respondents said that delays in publishing data from the FDOSS diminished the usefulness of the system. CDC attributed the delays in data dissemination to shortages in staffing. Additional staff have been hired since then, and they are training state and local health officials about the reporting needs of both state health departments and CDC GAO, a.
However, CDC also noted that some of the delays in releasing information were due to the occasionally untimely reporting of surveillance data by state and local public health officials. Survey respondents said the problem is caused in part by shortages of trained epidemiologists in state and local health departments and by deficiencies in laboratory capabilities. Survey respondents also noted that the decisions regarding which diseases are tracked are made at the state level, which adds to the variability and incompleteness of the data when they are aggregated at the national level.
To help states address some of these issues and submit more complete information, CDC is providing funds to state and local public health departments to help reduce some of their staffing and technology limitations.
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The committee strongly supports this recommendation and applauds the U. Another gap in the current disease surveillance system is syndrome surveillance, which captures data on the basis of clinical signs and symptoms of illness e. Related indicators for such surveillance might be sales of prescription and nonprescription medications. Interest in syndrome surveillance has grown because of its potential value for early detection of disease outbreaks, including those that might result from a bioterrorist act.
Such a system depends on the rapid aggregation and assessment of data to permit detection of clinical and geographic patterns. Although no national syndrome surveillance network is in operation, some state and local public health agencies are beginning to test and implement such systems. Syndrome surveillance systems played an important role during the anthrax outbreaks in New York City and in the Washington, D. These systems generally require partnerships with practicing physicians, hospital emergency rooms and outpatient departments, community-based clinics, and sometimes neighboring state and county health departments.
RSVP incorporates a realtime medical database and allows electronic data linkages with all local health departments throughout the state, the four district offices and their satellites, and the state offices. During special events, ESP sites monitor data on emergency department visits at sentinel hospitals. These data are analyzed at CDC and reported back to the health departments for confirmation and appropriate follow-up.
DOD , through its Global Emerging Infections Surveillance and Response System, is evaluating a system for the rapid identification of disease-related syndromes in patients at military health care facilities in the Washington, D. The committee notes that although these syndrome surveillance programs show promise, their widespread effectiveness is still being evaluated and no syndrome surveillance system has identified a potential biological emergency. A key report, Integrating Public Health Information and Surveillance Systems , documented the problems and recommended a framework for leadership on the issue as well as specific steps for achieving the long-term vision of integration of public health information and surveillance systems CDC, After publication of that report, CDC estab-.
If adequately supported, the board could provide an ongoing coordinating mechanism for CDC and ATSDR to lead the integration of public health information systems. INPHO was established to foster communication between public and private partners, to make information more accessible, and to allow the rapid and secure exchange of data GAO, a. The system has produced measurable benefits in some states. For example, in Washington State, electronic information-sharing systems reduced the passive reporting time from 35 days to 1 day and gave both local authorities and the School of Public Health at the University of Washington access to health data for analysis Davies and Jernigan, ; P.
Wahl, personal communication, February 2, It is also intended to facilitate more accurate and timely disease reporting to CDC and state and local public health departments. NEDSS will incorporate data standards, an Internet-based communication infrastructure that is designed according to industry and public policy standards on data access and sharing, confidentiality protection, and burden reduction CDC, b. This system, which became operational in November , enables secure, web-based communication among federal, state, and local epidemiologists, laboratories, and other members of the public health community and allows them to instantly notify others about urgent public health events and search the Epi-X database for information on outbreaks and unusual health events.
Another initiative, the Health Alert Network, emphasizes the communication capabilities that are necessary for more integrated information systems. It was designed as a system for electronic communication between health departments and CDC, with the Internet used as its backbone CDC, c.
It also supports distance-learning activities and provides health departments at all levels with the capacity to broadcast and receive health. In support of these various activities, CDC is adopting information technology standards and procedures to establish a secure data network SDN. Network development focuses on the technical requirements for maintaining the confidentiality of data and providing a secure method for encrypting and transferring files from state health departments to a CDC program application via the Internet. The SDN not only gives CDC several ways of obtaining data from states, but it also provides a consistent method for authenticating the transmission source and ensuring data integrity CDC, c.
A public health information network is under consideration at CDC to serve as a vehicle, with an effective governance mechanism, to ensure the integration of existing public health information systems within CDC and coordinated development of future ones with state and local public health agencies. Although the committee applauds the development of these important systems and coordination efforts, it is concerned about the apparent lack of an effective mechanism to ensure their integration or their coordination with future efforts to create a fully developed national health information infrastructure, which we strongly support.
Despite these efforts, the public health information infrastructure is not yet fully capable of handling situations for which rapid, clear communication and information transfer are essential. Because the integration of public health data and information networks has not yet been accomplished, state and local public health agencies are still obliged to operate the more than disparate data systems whose lack of integration slows the flow of information in times of crisis. Data and information network integration must also take into account the new data and information systems under development.
Many of these new systems have not been fully implemented across the nation or, in the case of Epi-X, have been implemented only at the state level, leaving localities with read-only terminals and other tools that prevent interactive access to information or, even worse, leaving them out of. Early detection and response is critical, and it all hinges on communications and information technology. Furthermore, many local public health agencies, especially those in small and remote communities, do not have the resources or technical capacity to handle the implementation of new information technology, which requires expensive and complicated hardware and software.
These disparities result in some states and localities having easy access to updated or urgent information, whereas others must continue to rely on the now-antiquated methods of paper-based reports, telephone connections, and the U. Postal Service as their primary means of retrieving and reporting information. These weaknesses were demonstrated clearly during the bioterrorism events of October Another 20 percent of state, local, and territorial health agencies lacked e-mail and, therefore, were unable to receive electronic updates regarding the anthrax events Brewin, Since September 11, , public health agencies and officials have repeatedly urged the U.
Whereas some parts of the federal government, such as the Department of Commerce and the National Aeronautics and Space Administration, have moved ahead quickly on their NII agendas, the areas. The report Information for Health: A Strategy for Building the National Health Information Infrastructure NCVHS, presents the core of the vision as the pulling together of many separate initiatives and systems into an integrated data system that will give health officials and others optimal access to the information and knowledge they need to make the best possible health decisions for communities.
To ensure that NHII supports all facets of individual health, health care, and community health, it must be developed in a manner that takes into account human factors e. NHII, when implemented, could have a profound impact on the effectiveness, efficiency, and overall quality of health and health care in the United States. It would allow the public health system and others to address concerns such as public health emergencies, medical errors, and health disparities in a more timely and comprehensive fashion NCVHS, The links to data from the health care delivery system are critical to state public health agency efforts to monitor the quality of health care.
The community aspects of population health are ripe for development as part of NHII because of the emerging scientific insight into the nature of health and its determinants see Chapter 2. Better access to information on communities and their subpopulations will help health professionals and others identify various health threats, problems related to social or environmental conditions, and the unique needs of vulnerable populations. More powerful information tools will help identify patterns and trends from isolated events, and the rapid communication afforded by the network will aid in informing and educating individuals and the community at large about critical health issues.
Therefore, the committee recommends that the Secretary of DHHS provide leadership to facilitate the development and implementation of the National Health Information In. Congress should consider options for funding the development and deployment of NHII e. In carrying out this responsibility, CDC should ensure that this system is easily accessible and can be used and maintained by public health agencies at the federal, state, and local levels. This system should include the establishment of standards for consistent data collection and transmission practices, the assurance of privacy protections, the capacity for transmission of urgent health alerts across all levels of the public health system, and the implementation of data systems that facilitate reporting, analysis, and dissemination.
CDC should work with its public health partners to ensure adequate and ongoing training in the effective use of the techniques that comprise this system. Although this system is critical for the fulfillment of the essential services of public health, it should also be both respectful of the need for privacy protections and mindful of the need for efficient data exchange. The exact cost of a comprehensive NHII needs to be determined. Public health laboratories are a critical component of the disease surveillance resources of the public health infrastructure, providing essential capacity to detect, identify, and monitor the presence of infectious or toxic agents in populations and the environments in which those populations live.
Public health laboratories are also described as the safety net between the local water plant and the kitchen tap in many communities APHL, ; they provide laboratory support for epidemiological studies and perform diagnostic tests such as cytology testing and neonatal screening that may influence the treatment of individual patients. Moreover, public health laboratories provide leadership to set laboratory regulations.
About 10, laboratories were in hospitals or were privately operated. Every state public health department operates at least one laboratory, and some local health departments have laboratory facilities. Federal laboratories, such as those operated by CDC, provide testing services and consultation not available at the state level and training in testing methods GAO, b. Highest priority is given to research on testing of diseases that are of the greatest public health importance e. GAO a also recommended that the CDC director lead an effort by federal, state, and local public health officials to establish a consensus on the core laboratory capacities needed at each level of government.
This information will aid policy makers in assessing whether existing resources are adequate and evaluating where investments are most needed. With regard to the financing of state public health laboratories, unpublished survey data from the Association of Public Health Laboratories APHL show that in FY , public health laboratories received a median of 50 percent of their funding from states, with a median of 33 percent from fee-for-service funding and about 15 percent from the federal government S.
Although these percentages reflect the funding data obtained by APHL for both FY and FY , the trend is that state funding for public health laboratories has been decreasing and fee-for-service funding has been increasing, potentially encouraging laboratories to increase their levels of fee-for-service activities. Although federal funding has remained relatively constant, the recent increases in federal funding for bioterrorism. CLIA, enacted by Congress in , mandated a broad and wide-ranging change in the regulation of laboratories that perform testing for medical diagnoses.
The limitations of existing laboratory capacity were clearly demonstrated by the outbreak of West Nile virus in New York State. Federal officials indicated that if another outbreak had occurred simultaneously, CDC would not have been able to respond GAO, b. Many public health laboratories are unable to keep pace with the monitoring and tracking of infectious agents that are already known in communities.
Some states do not routinely test for important infectious diseases. For example, although most states conducted surveillance for tuberculosis, Escherichia coli OH7, pertussis, and cryptosporidiosis, fewer than half of state laboratories tested for penicillin-resistant Streptococcus pneumoniae and hepatitis C GAO, a. Nearly half of the state public health laboratories lacked access to advanced molecular detection systems and other technologies for identifying specific strains of pathogens, information that is valuable to epidemiological investigations to trace the sources of disease outbreaks.
Many state public health directors and epidemiologists report that inadequate staffing and information-sharing problems hinder their ability to generate and use laboratory data for surveillance GAO, a. A recent study conducted by APHL b raised concerns about the public health laboratory workforce. The study found that the country is facing an imminent shortage of qualified public health laboratory directors.
APHL anticipates 13 vacancies over the next 5 years in state public health laboratory directorships, with a replacement pool that current laboratory directors describe as either inadequate or marginally adequate in size to meet future demands APHL, b. Moreover, inadequate laboratory staffing is a problem.