Douglas County, OR: A harbinger for public health?

Is the transformation of public health in Douglas County, Oregon a harbinger for how others will control the fate of governmental public health?

Background

Douglas County is located in southwest Oregon. It is large in size with over 5,000 square miles of land area, but small by population at 106,972 residents (2014 estimate) (1).  The median household income of $40,524 is $9705 below the state median (1). Nearly 19% of Douglas County children live below the poverty level compared to 16.2% across Oregon (1). As stated on the county’s website, the core responsibilities and programs of Douglas County Public Health were typical of local health departments. They included environmental health, communicable disease control, immunizations, tobacco prevention, and the Women, Infants and Children (WIC) nutrition program (2).

In June 2014, the director of the county’s Department of Health and Human Services sent a letter to the State of Oregon giving notice that it planned to terminate its intergovernmental agreement with the state to provide local public health services; the county would return those responsibilities to the state by October 2014 (3). The effort was led by a county commissioner with little notice to, or input from, health care partners or the public (3). Others stepped in and the return of services to the state was put on hold while the issue was discussed and a feasibility study was commissioned (4).  Last month, it was announced that the new Douglas Public Health Network, a consortium of non-governmental organizations, would contract with the county to provide public health services (5). Budget, staffing and scope for the network still need to be worked out with the county (5), but:

  • WIC will be run by a non-profit that oversees a food bank and assists residents with energy and heating (5)
  • Immunizations and reproductive health services will be provided by a hospital and community health centers (5)
  • Environmental Health programs will be run by the county’s Planning Department (3)

It begs the question

The commissioner who spearheaded the effort to dismantle public health gave the following reasons for doing so:

1) Concerns over costs:

Douglas County has lost timber revenue over the years (5) and has been dipping into its reserves to maintain county programs (3).  The county spent $889,000 from its $68.8 million general fund in fiscal year 2014 to pay for public health, and $250,000 to maintain the building (3).  But those two costs only amount to 1.7% of the county’s general fund, and as pointed out by public health supporters, staff could have been relocated and the building sold as surplus (3). That begs the question: Why target only Public Health? Why not reduce funding across the board to other programs listed on the county’s site map (6)?

2) Greater access to health care through coordinated care organizations (7)

This is a fair point. One of the current trends in health care is to integrate primary care and public health (8). Within the new Douglas Public Health Network, health centers and a hospital will provide more hours for reproductive health and immunization services (5). But did local governmental public health need to be dismantled to achieve these partnerships?

3) Consistently low county health rankings (3)

The low rankings were interpreted to mean that governmental public health had been doing a poor job, but who actually faltered on their responsibilities?  County commissioners have an obligation to monitor the effectiveness of their agencies, assess challenges, and oversee corrective actions.  Did Douglas County Public Health receive the support it needed to identify and address factors associated with those low rankings? Will the commissioners even be able to hold the non-profits in the new network accountable if the low rankings continue?

Social determinants of health, such as access to education, jobs, transportation, safe and clean environments, play a strong role in the health of individuals and communities (9).  Governmental public health cannot tackle these issues by itself, so it leverages partnerships with educators, the business sector, non-profits, health care partners, and others to develop policies to do so. Perhaps the remaining governmental public health staff in Douglas County will be able to work more on policy issues now that they no longer have to provide clinical services. The commissioners should pay for an impact evaluation in the coming years to determine the effectiveness of the new public health network on the county’s health rankings.

Lesson learned?

Counties in home-rule states have the right to design a public health system that best suits their needs and available resources, and perhaps other, not-yet-revealed, motives were behind the Douglas County affair. As such, this situation cannot wholly be extended to other local public health jurisdictions. There is a lesson to be learned here, though. I did a simple qualitative analysis of the seven news articles (3-5,7,11,12) and one online television spot (10) I could find on the topic. I counted the number of times local health care executives, county commissioners, and public health officials or employees were mentioned by name in the reports.  A county commissioner was named 40 times, a health care executive was named 26 times, and a local public health official or employee was named five times. These figures seem a little unbalanced to me.

In this era of health care transformation, governmental public health must step out of the shadows (its traditional comfort zone) and into the spot light. It must advocate for itself proactively during times when there is no threat to its existence so that it does not become an easy target for budget cuts or elimination. When it does come under attack, it must engage fully in its defense. (Douglas County public health employees may not have been allowed to do so (12)). Otherwise, governmental public health will find itself sitting on the sidelines watching others determine its fate.

It’s your turn

It remains to be seen what value Douglas County will see from the transformation of its governmental public health agency into a network of non-profits. What do you think are the risks and benefits to the health of communities if governmental public health programs are split off from each other and run by separate private organizations?

All the best!  Kathy

References:

  1. US Census. Douglas County, Oregon. Available at: http://quickfacts.census.gov/qfd/states/41/41019.html. Accessed Nov. 8, 2015.
  1. Douglas County Health and Social Services, Public Health website. Available at: http://www.co.douglas.or.us/health/PH/. Accessed Nov. 8, 2015.
  1. Cegavske C. What’s the rush? News Review, Nov. 23, 2014. Available at: http://www.nrtoday.com/news/13877506-113/health-county-public-morgan. Accessed Nov. 8, 2015.
  1. Cegavske C. County approves study to privatize public health. News Review, May 18, 2015. Available at: http://www.nrtoday.com/news/16346313-113/county-approves-study-to-privatize-public-health. Accessed Nov. 8, 2015.
  1. Gray C. New Public Health network emerges as Douglas County hands off services. The Lund Report, Oct, 27, 2015. Available at: https://www.thelundreport.org/content/new-public-health-network-emerges-douglas-county-hands-services. Accessed Nov. 8, 2015.
  1. Douglas County, Oregon. Site map. http://www.co.douglas.or.us/site_map.asp. Accessed Nov. 8, 2015.
  1. Heun C. Will Douglas County pull the plug on its Public Health Division? The Lund Report, Dec. 11, 2014. Available at: https://www.thelundreport.org/content/will-douglas-county-pull-plug-its-public-health-division. Accessed Nov. 8, 2015.
  1. Shat GH, Madamala K. Knowing where public health is going: levels and determinants of workforce awareness of national public health trends. J Public Health Management Practice. 2015; 21(6 Supp), S102-S110. Available at: http://journals.lww.com/jphmp/toc/2015/11001. Accessed Nov. 8, 2015.
  1. Healthy People 2020. Social determinants of health. Available at: http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health. Accessed Nov. 8, 2015.
  1. KPIC News. Three Douglas County health clinics closing this month. http://www.kpic.com/news/local/Three-Douglas-County-health-clinics-closing-this-month-306332521.html. Accessed Nov. 8, 2015.
  1. Leman C. Oregon county turns public health function over to state. NW News Network, July 23, 2014. http://nwnewsnetwork.org/post/oregon-county-turns-public-health-function-over-state. Accessed Nov. 8 2015.
  1. Cegavske C. Public Health advocates turn out in force to second town hall meeting. News Review, April 1, 2015. Available at: http://www.nrtoday.com/news/15693138-113/public-health-advocates-turn-out-in-force-to-second. Accessed Nov. 8, 2015.

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