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State representatives have this year taken a look at how Georgia’s public health system works and what changes might be needed. A resulting report found that there is a “wide variance” in the public health services offered across the state, with many rural health departments offering fewer services than urban ones, and public health departments facing workforce shortages.
Legislators are trying to address the workforce shortage by allowing county workers to retain their accrued leave time if they go to work for the state.
That’s just a first step, said Rep. Darlene Taylor, a Republican from Thomasville who chaired the legislative study committee and also chairs the health appropriations subcommittee in the House of Representatives.
She said Georgians can expect more reforms in future years. The study committee recommended updating the formula that determines how much counties chip in for local public health budgets, creating more consistency across the state’s public health system, and moving from a system of county boards of health to district boards of health.
Public health advocates say more funding will be needed to ensure that Georgians have access to the services they need. Taylor said she hoped that would happen in future legislative sessions, but this year’s uncertainty about federal funding and other legislative priorities meant the public health budget was kept mostly flat.
Here’s how four other states approached similar processes.
Indiana: More public health funding in a fiscally conservative environment
Indiana made a historic 1500% investment in public health funding in 2023: a $225 million increase over two years.
That influx came with strings attached – and a strong degree of local control. The 95 local health departments could decide to forgo or opt in to the new funding. If they opted in, they agreed to provide a set of core public health services and report twice a year on their progress on “key performance indicators” they chose as priorities for their communities.
For example, Posey County in southwest Indiana focused its key indicators on infant mortality and reducing obesity among adults, while Allen County in northeast Indiana is focused on tracking childhood lead screening and immunization rates.
The website for each county highlights local success stories, local data and budget information, and key partnerships, all published on the Health First Indiana website. By the second year of the program, all Indiana counties had decided to opt in.
Success factors:
- Make the business case: “We hitched our message to something that we knew resonated with the leadership at the time, which was economic security,” said Shane Hatchett, who was deputy health commissioner during the process. Advocates told legislators that Indiana’s decreasing life expectancy “represents empty church pews, empty families, and empty people in the community to be able to fill in the jobs that the state has been working so hard to recruit and bring in.”
- Listen: Then-Gov. Eric Holcomb established a commission to study possible public health reforms and help draft needed legislation. The commission held a listening tour in different parts of the state and met twice each with different organizations to find out what their concerns were, share progress, and build consensus.
That was especially important in the wake of the Covid pandemic, Hatchett said. “We heard a lot about how we got it wrong,” when it came to Covid. “It was them having a chance to tell us face to face what they thought.” The sessions also provided an opportunity to educate people about the basics of public health.
- Focus on the local. Even though the funding was coming from the state, the reforms allowed local departments a great deal of leeway to decide on their priorities as long as they agreed to provide a common set of core services. In addition, counties had to agree to provide 20% of the funding to unlock the remaining 80% from the state. That helped lawmakers feel that local health departments had “skin in the game,” Hatchett said.
Two steps forward, one step back
Indiana’s budget runs on a two-year cycle, and last year the legislature decided to cut funding for public health, from a planned $100 million to $40 million after the state faced a large budget shortfall. That’s meant many recently launched local programs are now facing funding hurdles.
“The program is still funded, not at the same level. They at least recognized it was important to put something there, which I consider a win,” Hatchett said.
Mississippi: A public health report card
Mississippi launched a public health report card in 2023 to provide an easy way to look at more in-depth data included in the Department of Health’s annual report, spokesperson Lauren Hegwood told Healthbeat. The two-page document features easy-to-digest graphics that highlight areas of concern, like the state’s high rate of firearm deaths, and successes, like its high rate of vaccinations in school-age children.
State law requires the department to publish an annual report, but the report card was a voluntary effort on the part of the health agency.
“The goal is to give Mississippians and policymakers a clear, straightforward look at our state’s health status,” she said. It’s also created an opportunity to hold an annual press conference at the Capitol to highlight the findings.
Ohio: Pursuing public health accreditation
In 2013, the Ohio legislature granted the state director of health the authority to require local health departments to secure accreditation from the Public Health Accreditation Board.
One goal was to ensure consistency of services offered across the state, whether in urban centers or rural areas, said Tonni Oberly, a professor of public health at The Ohio State University. Of the state’s 113 local health departments, 107 are accredited, according to the PHAB.
In Georgia, just three of the state’s 18 public health districts and the state health department are accredited.
Oberly said the accreditation process helps health departments adopt a quality improvement mindset and improve resource management. Accreditation can also help departments be better prepared to win competitive grants, Oberly said.
Accreditation can tax already busy staff, especially in smaller departments, she said. That led to resistance from some rural departments, who felt the process was a “heavy lift.” The state health department provided technical assistance and some funding to help with that.
“It does take time, it takes effort, and you have to ensure that you’re building that infrastructure for your health departments to be successful,” Oberly said.
Oregon: Three metrics drive a unified effort
Oregon started a public health modernization process in 2013 and made major revisions to its system after the Covid pandemic. That has resulted in $112 million in funding for the modernization project for the 2025-27 biennium.
A Public Health Advisory Board with representatives of local health departments and community organizations helped establish and monitor the metrics.
The metrics focus on three areas: reducing syphilis rates, increasing vaccination rates for children and older adults, and improving climate resilience for extreme heat and wildfire smoke. Within those, the metrics include outcomes and indicators of progress on public health processes. The team also looked for measures that could be broken down by location and different kinds of populations.
While the process started in the 2010s, a post-pandemic 2023 report sets out new baseline rates and goals for the period until 2030. Local health departments get additional funding – up to a 1% boost – if they meet certain process goals, said Sara Beaudrault, strategic initiatives manager in the Oregon Health Authority’s public health division.
The metrics focus on outcomes and factors like how well local health departments develop community partnership, Beaudrault said.
“We didn’t want to measure everything,” Beaudrault said. “The metrics that we have are really just a small piece of what we do, but it gives us a way to talk about the work.”
The state developed the metrics in consultation with local health departments, which increased buy-in, she said.
“I can truly say that OHA [Oregon Health Authority] is not imposing these metrics on local public health,” Beaudrault said. The goal was to find metrics that would help create a baseline level of services across the state even while allowing for local flexibility.
The metrics have prompted tangible change, Beaudrault said, pointing to the example of public health departments working on making sure long-term care residents are getting the vaccines they need.
The outcomes data has helped build the case for public health with policymakers, she said, resulting in sustained funding, even if it’s not always as much as some advocates would like. For example, in 2017, the legislature provided $5 million for the two-year budget cycle – which has now increased to $112 million for the 2025-27 biennium.
Still, there are factors that affect health outcomes that lie outside the purview of public health departments and that can’t be addressed without increased coordination and funding, like housing, Beaudrault said.
Rebecca Grapevine is a reporter covering public health in Atlanta for Healthbeat. Contact Rebecca at rgrapevine@healthbeat.org.
