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The Role of Local-State Public Health Integration in Health Security

The Case of Florida

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Nathan Myers
August 12, 2016

The state of Florida has recently found itself on the front lines of U.S. efforts to prepare for local transmission of the Zika virus. During a recent conversation with Wayne North, the director of the Division of Emergency Preparedness and Community Support in the Florida Department of Health, he pointed to the state’s public health structure as one of Florida’s strengths.

“One of the unique things about the state of Florida is that our county health departments are part of the state Department of Health,” North said. “The good thing about that is it keeps us totally integrated at the local level which is where disaster preparedness really comes to ground.” He also points to all 67 Florida counties having a state-operated public health office as an asset for building and maintaining collaboration. “As a county health agency,” said North, “they are constantly working with various community groups and making sure that all groups in the state of Florida, including those traditionally considered underrepresented, are receiving the same level of care.”

medic-563423_640North’s suggestion that the integration of local and state public health operations in Florida is an asset to preparedness efforts raises larger questions about which kinds of public health structures are successful at maintaining health security. One potential model, based on Florida’s structure, is to use state-operated local offices. To explore the relationship between greater state involvement at the local level and public health emergency preparedness, information from a 2012 report from the Association of State and Territorial Health Offices (ASTHO) was used to create a cohort of states with a structure similar to Florida’s. States were included in this cohort if 90 percent or more of local public health officials are employees of the state. Including Florida, 14 U.S. states were part of this cohort. The level of public health preparedness of these states was then assessed using the National Health Security Preparedness Index (NHSPI) for 2015. The index has a scoring system of 0-10, with 6.7 as the national average. Seven out of 14 states in the cohort met or exceeded this average (Florida received a 6.7).

As North pointed to more local-state integration as a strength of the Florida model, domains in the index that related to integration were considered individually (health care delivery and environmental/occupational health were excluded). Looking at the domain for community engagement, eight states met or exceeded the national average of 5.4. Florida received a 6.

North noted that the Department of Health maintains strong relationships with hospitals, trauma centers and other health organizations throughout the state. “It’s really valuable for us, because it’s that constant back-and-forth conversation between us and those actually providing the health care that continually strengthens those relationships and continually makes sure that we can maintain, sustain and then recover in the event of an emergency,” said North.

On the incident management domain, six states in the cohort met or exceeded the national average of 8.4 (Florida received an 8.8). North noted that the state successfully activated its ICS during the Ebola emergency in 2014 and it has also been operational since February 2016 in response to Zika. Disease surveillance is another domain where Florida exceeded the national average (8.3 as compared to 7.5). Five other states in the cohort met or exceeded the average.

North pointed to the Florida Public Health Risk Assessment Tool as an instrument used to track potential dangers across the state. “It comes back to our outreach into the individual communities and the different challenges that each of our 67 counties have,” North noted. North went on to explain that the tool is used to identify challenges that a county has in meeting any of the 15 emergency response capabilities determined by the federal government. It is then used to determine how the state can provide assistance. These capabilities include community recovery, information sharing and mass casualty management.

There was one domain, countermeasure management, where Florida did not meet the national average (6.5 compared to a national average of 7). Six states in the cohort did meet or exceed the national score. North said that he was pleased with how Florida managed emergency personal protective equipment and other emergency material during the Ebola preparation, but noted the state did learn some valuable lessons to improve performance in future emergencies.

The evidence suggests that Florida and some similar states do well in domains of public health emergency preparedness associated with a significant state presence at the local level. More consideration should be given by policy makers and scholars to the benefits and drawbacks of different approaches to structuring public health organizations. This knowledge could help to ensure a successful response during a future emergency. It is important to understand the efficacy of integrating local and state public health activities in different state and regional contexts.


AuthorNathan Myers is an assistant professor of political science at Indiana State University. He primarily teaches courses in the Master of Public Administration program. Myers is also a member of the ISU Center for Genomic Advocacy. His teaching and research interests include organizational behavior, public health policy, and biotechnology policy associated with genomic research. 

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