The dissemination and incorporation of the governance concept reflects the growing need for social and intergovernmental policy negotiation. At the national and international levels, the concept reinforces the idea and practices of multilevel action, cooperation in the infra- and supranational coordination of public policies, and territorial policy coordination.
The literature further analyzes the emergence of a new founding social governance with arrangements based on inter-sector collaboration, cooperation, and joint, negotiated action between public and private stakeholders involving the first, second, and third sectors of society, with governments, the market, and community in drafting, implementing, monitoring, and evaluating policies, programs, and political projects In summary, the emergence, dissemination, and use of the governance concept result from important changes in recent decades in contemporary democracies in national states, international relations, the market, and society that have been reconstituting the space of public interventions, especially by governments, at the different scales of territories politically revalued from the development perspective.
Thus, the understanding of political processes that inform and characterize current health policy can benefit from a reading of the sector approach to governing, based on the concept of governance, besides contributing to new analyses on the changes currently under way.
In our view, the concept of territorial governance emerges from the first literature review dealing with the theme of governance, as the one that summarizes the set of approaches examined in the studies. This frame of reference is therefore relevant to our approach to health sector regionalization.
Territorial governance and regionalization The definition of territorial governance used in this essay is based on the concepts of territory and territoriality. Territory is seen as the content, means, and process of social relations, based on which social dimensions are linked in unity with each other and to nature external to man , the historical process, and the multi-scalar dimension of territorial dynamics.
Territoriality is a social construction of territorial reality in a specifically demarcated and partitioned space. Critical geography offers interesting definitions of territory for an approach to the territorial dimensions of processes of public policy regionalization.
It constitutes a dynamic totality, the product of multiple summations to which the process of history is submitted at every instant. Thus, the geographic space, understood as used territory, takes on a new functioning in the contemporary globalized world as the result of vertical and horizontal dimensions that occur simultaneously as networks and as the space of all, as rationalities derived from what he calls world world market and world governments and from ordinary space the domain of contiguity, neighboring places united by a territorial continuity , in their different divisions and scales.
From this perspective, the territory on its different scales — local, regional, national, global — encompasses nature and society, objects and actions, spatial forms and power relations, environmental resources and infrastructure, economic, socio-environmental, political, and cultural interactions, processes, continuities, and discontinuities, materiality and immateriality. The territory is simultaneously unique and multiple, singular and plural and singular in the plural , living space, abstract and concrete According to Dasi 18 , the propositions for the establishment of territorial governance are associated with the debate on sustainable development and assume an innovative form in territorial planning and management roles, based on negotiation and consensus-building among multiple actors that share objectives and know and assume their roles in achieving them.
Further according to the Dasi 18 , in order to ensure and improve the socioeconomic and socioecological functioning of territories, territorial planning oriented towards sustainable development is performed by three functions — ordering, development, and coordination. The idea of ordering the territory refers to the redistributive function of public policies, competitiveness, endogenous development, and sustainability, also considering the existing territorial, social, and cultural values.
The development function includes multi-scalar relations, whether in endogenous development in less developed spaces, valuing the available territorial capital, or in reinforcing developed spaces, seeking to insert them in zones of world economic integration.
And the function of coordination aims at comprehensive and cross-sector planning of the territory, based on multilevel relations, especially between the local and regional scales, proper to its vertical dimension, on horizontal relations between territories, and on participation by individuals and organized groups. In short, territorial governance can be defined as the promotion of greater policy coordination and stakeholder cooperation based on a shared territorial vision.
It implies spatial development strategies, expanded processes of participation, and reinforcement of territorial identity. It can be viewed from two angles: simply as the application of good governance principles to territorial urban policies, or as a process of planning and management of territorial dynamics from an innovative, shared, and collaborative perspective 12 , 18 , the focus of this study.
The following section provides a description of the federal, state, and local governmental agencies that are responsible for protecting the health of the public. Later in the chapter, the committee examines certain aspects of the state and local public health infrastructures that are of special concern. The State and Local Governmental Public Health Infrastructure Although the states carry the primary constitutional responsibility and authority for public health activities in the United States, public health 4 Turning Point, a program funded by the Robert Wood Johnson and W.
Kellogg Foundations, works to strengthen the public health infrastructure at the state and local levels across the United States and spearheads the Turning Point National Collaborative on Public Health Statute Modernization. The burgeoning social problems of industrial cities convinced legislatures to form more elaborate and professional public health administrations within municipal governments Duffy, City boards of health were established to obtain effective agency supervision and control of health threats facing the population.
Only after the Civil War did states form boards of health. County and rural health departments emerged in the early twentieth century Ferrell and Mead, Today, there are more than 3, local public health agencies, 3, local boards of health, and 60 state, territorial, and tribal health departments CDC, b.
Structure and Governance of State and Local Public Health Agencies The organization and authority granted to state and local public health agencies vary substantially across the country. Every state has an agency with responsibility for public health activities.
That agency may be an independent department or a component of a department with broader responsibilities, such as human services programs.
In 31 states, the state health officer is also the head of the larger health and human services agency Turnock, Physicians and nurses often lead state public health agencies. At the local level, however, general managers with business training rather than formal training in public health or medicine may lead public health agencies. States differ in terms of the relationship between the state agency and the agencies serving localities within the state.
In some states e. In other states e. Still other states e. The most common arrangement is a local public health agency LPHA serving a single county, ranging from small rural counties e. LPHAs may also serve single cities of various sizes e. City or township health agencies may operate within counties that are also served by county health agencies.
Multicounty local public health agencies often span large geographic areas in the western United States. For example, the Northeast Colorado Health District serves six counties, an area roughly equivalent in size to that of the state of Vermont. In these local public health agencies, health directors may be accountable to multiple county boards of health or to a combined board of health whose membership represents the counties or other units covered by the local public health agency.
The multicounty local public health agency category also includes state health department regional offices that act as local public health agencies, an arrangement found in several states e. The governance of state and local public health agencies generally fits 6 Home-rule statutes in constitutions or by statute give localities e. In such cases, localities can exercise police powers independently from the state.
In a cabinet model, the head of the agency is appointed by and answers to the governor, mayor, or other executive authority. Under a board-of-health model, the state or local health director reports to an appointed board representing constituencies served by the department. In many cases, however, a board of health functions in a strictly advisory capacity, with no oversight authority.
There are considerable variations within these three models. Thus, it would be important for state agencies to examine their present governance structures and evaluate mechanisms to make these structures more effective.
Doing so should serve to build and strengthen relationships with local public health agencies, coordinate efforts for the delivery of the essential public health services and crisis response services, integrate essential health information, and respond to the changing health needs of the population. Scope of Agency Responsibilities and Activities At both the state and local levels, there are differences among public health agencies in terms of the scope of their authority, responsibilities, and activities.
At the state level, activities such as immunization, infectious disease control and reporting, health education, and health statistics are common to most public health agencies. Another system allows the local units to choose from among several forms of charter provided in a state general law. There is much independence and vigour, no hierarchy, little central administrative control, and much judicial control to hold the units within their charter and statutory position.
The local government system of tsarist Russia was one of absolute centralized hierarchy, executed through the governors of the 78 guberniya, with police, military, and taxation powers and the scantiest recognition of rights of local government. Provincial and village governments were dominated by the landlords who had an ex officio right to chairmanship of local administration, especially of the zemstvo , set up in to govern the provinces under strict control of the imperial governors.
The zemstvo with an indirect and unequal class franchise , nevertheless made progress in educational, health, welfare, and agricultural development in spite of tsarist control. The Soviet constitution of and the decree on the city soviets and specific economic and social planning decrees gave extraordinarily wide specified powers to the local units but very rigorously subjected them to hierarchical control of the next higher authorities upward to the central government of the various republics, and in some cases to the union itself.
Authority and direction were heavily centralized and were animated in the last resort by the All-Union Ministry of State Administration and the public prosecutors. Generally speaking, then, local government as local self-government is discernible more fully in the British and American environment than elsewhere, to some degree in the German, and hardly at all in Russia. Yet centralization and control of units originally holding authority themselves are not inconsistent with vigorous first-line activity by the local units in the matters entrusted to them.
Areas and authorities Local authorities in England and Wales are from smaller units upward : some 9, parishes and town councils; scores of district, borough, and city councils; and dozens of metropolitan boroughs. There is a tendency in all countries to rely more upon such unions where the services are of a large-scale nature compared with the traditional units having responsibility.
Local authorities are mutually independent: unanimity is required for joint schemes, which are amply permitted in the statutes. Even some counties are far too small for large-scale administration, while extremes of size in area and population may be encountered in each of the above-named classes of authorities. The areas of local government in Germany include more than 11, Gemeinden communities. Upward from the Gemeinden are the Kreise equivalent roughly to counties in England and the U.
There are also numerous joint authorities for roads, schools, health, fire, agriculture, water, gas, and electricity. The Gemeinden exhibit an enormous diversity of area and population. There is a rather special kind of holding company local authority, the Amt, to administer the common affairs of some contiguous villages while they still remain separate Gemeinden. More-important area changes require parliamentary statute. Whereas all other nations combine most local government functions in single compendious areas, the U.
The area structure of local government in the U. In the southern and south-central region , the chief unit is the county or parish in Louisiana ; in the north-central, the combined county and township; in New England, the town. The constitution of Alaska vests powers of local government in boroughs and cities. In some states, the people of each county may vote to divide the county into townships. In the early 21st century there were approximately 3, counties or parishes.
The smallest had fewer than inhabitants, the largest Los Angeles county, California more than 10,, Inset in the county is the city , with its own powers, in direct relationship with the state government. Sometimes both city and county conduct for two concentric areas many similar services with substantial duplication of staff and organization. These are provided by the public health system.
Personal health care can help heal injuries, alleviate disorders, and treat many diseases, but it is public health programs that prevent the onset and spread of disease and diminish the likelihood of injury. Yet, the vast bulk of health spending in the United States is in the personal health care system; public health programs are funded by a very small and decreasing portion of health expenditures, with the result that society is not provided with all the public health services necessary to maintain the public's health.
The activities within the public health and personal health care systems must be integrated and coordinated. A better job of integration and coordination needs to occur within each of these systems as well as between them. Functions of Public Health Agencies The public health system forges community partnerships and community action, providing leadership for the integration and coordination of the personal health care and public health systems.
Health departments and agencies can be objective, are publicly accountable, and have legal responsibility for those in their geographical jurisdictions. Improving and maintaining the public's health also requires a concern for social, economic, and environmental hazards that few individuals can avoid without strong governmental protective action.
Prevention of the health consequences of workplace hazards, polluted air and water, and contamination of the food supply requires government action and intervention, as only government has the legal authority to require action. In order to understand the risks and health status of populations, data and surveillance systems must be maintained and improved.
The monitoring of health hazards, including newly emerging diseases, and the creation of standards of protection are important functions of public health agencies. Public health laboratories, other facilities, and the tools for carrying out health hazard appraisals are crucial for maintaining the critical surveillance systems. Public health research allows scientific advancement in protecting the public's health.
Many local health agencies have experience in working with their communities to develop public policies, plan improvements, implement new interventions, and translate research into community-appropriate programs. Within the public health system, governmental health agencies have a legal and constitutional responsibility for protecting the health of the public. The participation of these agencies in such activities should result in the health care system placing greater emphasis on disease prevention and health promotion.
Historically, most health agencies have not been able to act consistently upon such a broad interpretation of their role, nor have they been funded to do so. This results in fragmentation of services. To meet their goals, health agencies must first assess the state of health of their communities, identify variations in health status, and analyze the factors responsible for poor health.
Interventions then must be designed to address these factors. To do so requires a three-pronged approach: developing appropriate social and public policies; developing community-based prevention activities; and assuring the delivery of comprehensive and high-quality personal preventive services.
The social and public policies will need to ensure adequate food and shelter, clean air and water, and protection from workplace hazards. Community-based health promotion programs must be planned with the participation of the community to address its priority areas. Personal preventive services should be part of comprehensive care and meet the standards developed by the U.
Preventive Services Task Force. Rapid changes in the organization and delivery of personal health services, specifically the growth of for-profit medical care and managed care organizations, affect access for vulnerable populations, the health outcomes of the general public, and the activities and abilities of local public health agencies to operate. Public health agencies have a critical new role to play in overseeing these changes in the organization and delivery of services, assuring capacity to care for all populations, monitoring, evaluating, and improving quality, and understanding the relationship between changes in health services delivery and the public's health.
Finally, the effectiveness of these solutions must be reviewed and modified in the light of what was learned. Government health agencies will need to develop comprehensive plans working collaboratively with the community, social agencies, and the personal health care system, including both the public and private sector.
Physicians and nurses often lead state public health agencies.
Census data for show a similar pattern, with 57 percent of individuals who identify themselves solely as Native American or Alaska Native living in metropolitan areas Forquera, Every state has an agency with responsibility for public health activities. Washington: World Bank; Consider the coordination that would be necessary if a biological attack were to occur in the tristate area of New York, New Jersey, and Connecticut. Local finances—called rates—are locally raised in amount and appropriated in detail with little interference by the central government.
National health care reform minus public health: A formula for failure. Some non-governmental organizations and private individuals perform public health activities in cooperation with or at the request of government agencies. State and local health agencies should collaborate with purchasers and providers of personal health care and with community-based organizations representing ethnic and other minorities, women, and vulnerable groups to assure that health plans and health delivery are culturally sensitive and are appropriate to meet population needs. In our view, such formal agreement among the federative bodies in the region through the COAP requires new relations between the Federal, State, and Municipal governments in establishing joint planning in responses with an inter-municipal scope, including the identification of health problems and their causes and necessary interventions and linkage of actions that extend beyond the health sector itself, since this legal instrument expands the political content of intergovernmental relations in the region 5. States must be able to engage in surveillance and respond to health threats in a predictable and consistent fashion, using similar legal structures. Both programs respond to recommendations to improve the overall leadership competencies of public health practitioners.
What is good governance?