It may be the largest department in the federal government, spending $2 billion a day, but if the U.S. Department of Health and Human Services is to meet the challenges of the new century it must transform into a “powerful change agent,” according to an Institute of Medicine report.
Released in early December, “HHS in the 21st Century: Charting a New Course for a Healthier America” provides a number of recommendations to help move HHS forward while addressing head-on the fractured processes that have resulted in an agency that is often slow to adapt and so weighed down by a “patchwork of responsibility, structure, influence and oversight (that some observers) occasionally wonder, at least rhetorically, whether such complexity can be managed at all,” the authors wrote. Within the report’s almost 300 pages, the need to strengthen the nation’s public health infrastructure and work force is a major theme, calling on HHS leaders to make such work a “high priority.”
“Over the years, change at HHS has been driven by the piecemeal accretion of programs legislatively mandated by various congressional committees, frequently without commensurate resources or regard for the department’s capacity to manage them,” said the report, which was requested by members of the U.S. House of Representatives Committee on Oversight and Government Reform. “One result is a department that is not optimally designed to meet the nation’s current and future health challenges.”
To confront those challenges, the report identifies five areas in which HHS should take action: defining a 21st century vision, fostering adaptability and alignment within the agency, increasing effectiveness and efficiency within the health care system, bolstering the U.S. public health and health care work forces, and improving accountability and decision-making. Zeroing in on public health in particular, the report recommends that HHS “integrate public health principles across its programs, including the major financing and research programs.” The report also called on the agency to better integrate science and evidence-based practices into its programs and strengthen the science base of its policy decisions, emphasizing that “political considerations cannot be allowed to override scientific evidence in the department’s decision-making.”
HHS Secretary Michael Leavitt visits with evacuees from Hurricane Gustav in Louisiana in 2007. With oversight of programs that range from Medicare to emergency health response, HHS plays a lead role in improving U.S. health.
Photo by Barry Bahler, courtesy Federal Emergency Management Agency
The injection of politics into public health policy and funding decisions has been attracting criticism and frustration from public health circles for some time now. Jeff Levi, PhD, executive director of Trust for America’s Health, said the focus on restoring science to the decision-making process is one of the report’s strongest and most explicit portions.
And while many of IoM’s recommendations require funding — something that could be scarce in the current economic climate — restoring sound science to decision-making would actually save money in the long term, said Levi, an APHA member. An example is using needle exchange programs as part of HIV prevention strategies, said Levi, who noted that the United States has higher rates of HIV infection among injection drug users than countries that support needle exchange. Other areas in which restoring science-based policy-making could save lives and money include sexual health education, stem cell research and climate change, he said. Levi noted that there is recognition within the new presidential administration that investing in public health is a critical part of health reform, adding that he hopes that public health funding is included in federal eco- nomic stimulus measures.
“The gravitas of the IoM (report) gives a lot of credibility to what many of us have been saying in the advocacy world,” he said.
Other public health-focused recommendations in the IoM report include giving a “more prominent and powerful role for the surgeon general, who… should be a strong advocate for the health of the American people and work actively to educate Americans on important health issues.” Also, with serious shortages predicted among health care and public health workers, the report calls on the HHS secretary to “immediately” develop a plan to recruit people to offset the large number of HHS staff expected to soon retire as well as create a comprehensive national strategy to confront public health worker shortages nationwide. Congress is also called upon to continue investing in programs proven effective at recruiting new health professionals. To keep abreast of the agency’s progress, the IoM report recommends that the HHS secretary, in conjunction with the surgeon general, present Congress with a yearly report on the state of U.S. health.
Robert Pestronk, MPH, executive director of the National Association of County and City Health Officials and an APHA member, said that “fundamentally, the (IoM) report is about leveraging a very important asset this nation has…and how to leverage that asset more effectively.” Because when that asset — HHS — is unable to wield its influence and resources successfully, it is often local health workers who experience the adverse effects, he said. One dimension Pestronk said was largely missing from the IoM report was a bigger discussion on the importance of including the social determinants of health in HHS’ overall vision for a healthier nation, describing such determinants as the “elephant in the room.”
“The expenditure of some additional funds to make us the healthiest nation is probably the best investment we can make to ensure we remain competitive…to make sure we as a nation of young people and adults are ready and eager to learn,” he told The Nation’s Health. “We could once again make the United States the envy of other nations and do much to promote the interests of the country and, frankly, of people all over the world.”
For more on the report, visit www.iom.edu.
- Copyright The Nation’s Health, American Public Health Association
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