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Commonwealth:  A Journal of Political Science       Volume 14, Number 1      December 2008 
Special Policy Issue on Public Health             2008 PPSA/LORL, PA House of Reps.  ISSN 0890-2410 

 

 

 
Public Health in Pennsylvania: 
Where Do We Go From Here? 

 

Margaret A. Potter, JD, MS 
University of Pittsburgh Graduate School of Public Health 

 

What is Public Health and Why Does It Matter? 

“Health care” and “public health” are different kinds of activities.  
Health care is about the relief and cure of illnesses and support for 
disabilities.  Public health is about health protection:  preventing illnesses 
and promoting vigor and longevity.  Health care involves diagnosis and 
treatment services for individual patients. Public health involves 
assessment of population-wide health trends (including screenings and 
preventive care for individuals), development of policies and programs to 
optimize healthy conditions, and assurance of access to basic services 
(Institute of Medicine 1988 and 2003).  Health care is largely a private-
sector enterprise, with its organization and financing carried out by non-
profits and businesses through physicians’ offices and clinics, hospitals, 
pharmacies, rehabilitation centers, and nursing facilities.  Public health, 
though sharing some part with the private sector, depends primarily on 
public oversight and accountability – roles that must be grounded in the 
police powers of sovereign states (Institute of Medicine 1988; Gostin 
2000).   

Pennsylvania is health-care rich and public-health poor.  
Pennsylvania has 3.23 hospital beds for every 1,000 residents, well 
above the national average of 2.75 beds per 1,000, and well above the 
number in other populous states such as California (2.00 per 1,000), 
Texas (2.58 per 1,000), and Florida (2.87 per 1,000) (Federal Reserve 
Bank of Minneapolis 2004). Pennsylvania also ranks high in the number 
of physicians per capita with 0.332 per 100 residents, and ranking in the 
top 10 states along with Washington, DC, Massachusetts, New York, and 
Maryland (Statemaster.com 2008). Pennsylvania spends annually more 
per capita on health care than all but six other U.S. states 
(Statemaster.com 2008). But this Commonwealth ranks last among states 



2 PUBLIC HEALTH IN PENNSYLVANIA:  WHERE DO WE GO FROM HERE? 
  

 

 

in the number of public health workers per capita: 37 per 100,000 
compared to a national average of 158 per 100,000 (Gebbie et al. 2000).   
Only six of Pennsylvania’s 67 counties (Allegheny, Bucks, Chester, Erie, 
Montgomery, and Philadelphia) and an additional four cities (Allentown, 
Bethlehem, Wilkes-Barre, and York) have full-service local health 
departments. That leaves about half of the state’s population dependent 
upon the state’s Department of Health, which employs fewer than one-
third of the state’s public health workforce.  

These statistics lead to some difficult questions. Does the 
Commonwealth’s de-emphasis on health protection depress the real 
quality of life for citizens? If so, how much would greater health 
protection cost, and who would pay for it? If health protection depends 
on vigorous oversight and accountability, how should government and 
the private-sector share those duties?   

 

What Defines a Well-Functioning Public Health System? 

A public health system is "the organizations and individuals who 
collectively share the benefits, burdens, and responsibilities for the health 
of a defined population or community" (Halverson 2002). It includes 
many entities besides state and local public health agencies, such as 
health care providers, community-based organizations, emergency 
management, and schools – to name just a few. Health protection 
depends on the strengths of these entities acting in coordination.   

The quality and effectiveness of a public health system depend on its 
laws (Gostin 2000) as well as its financing and organizational structures 
(Mays et al. 2006).  If the laws are unclear, the financing inadequate, and 
the organizations fragmented, then threats to health are likely to be 
unchecked.   

Local-level agencies are the public health system’s hub because they 
can plan for the characteristic needs of local populations, prioritize 
resource allocation, and maintain accountability to local authorities 
(National Association of County and City Health Officials 2007).  
Effective planning among human service and public safety organizations 
depends upon local specificity.  Private rights and interests, which may 
be affected by population-level interventions, are best protected by local 
controls. For example, when quarantines are needed to quench an 



Margaret A. Potter          3 
 
 

 

influenza pandemic, locally knowledgeable officials determine the most 
effective and least intrusive methods.  Without governance and cohesion 
at the county and municipal levels, public health activities may be 
uninformed and resources may be misdirected. Local financing is also 
critical: a recent national study revealed that a relatively high proportion 
of local financing in a local health agency’s budget correlated with high 
performance in rendering essential public health services (Mays et al. 
2006).   

Nevertheless, local governments cannot alone sustain the legal, 
economic, and organizational burden of public health systems. State laws 
delegate the necessary legal authority, even if local codes and official 
discretion determine how the laws are implemented. Except for the 
largest metropolitan areas nationally, local tax bases and local health and 
human service organizations cannot alone sustain the high levels of 
professional expertise and technical facilities that determine 
effectiveness in health protection services. Thus, intergovernmental 
cooperation, as well as partnerships with private-sector organizations, is 
critical to well-functioning public health systems.   

 

How Well Does the Commonwealth’s 
Public Health System Perform? 

Based on this Public Health Symposium issue of Commonwealth, it 
is fair to say that Pennsylvania’s current public health system performs 
inadequately. The system itself is legally ambiguous, comparatively 
under funded, and organizationally fragmented. County governments 
resist making long-term financial and organizational commitments to 
public health activities, despite the availability of state per-capita 
matching grants intended to incentivize such local investment. Public 
health agencies in Pennsylvania exist at multiple levels of government 
(state, county, and municipal); and their respective sources of authority 
are distributed without coordinated oversight and accountability among 
numerous agencies (Health, Welfare, Agriculture, Insurance, 
Environmental Protection, and Labor and Industry).   

In Part I of this Symposium, three papers address some of the critical 
issues in the Pennsylvania public health system.  In a paper titled “Public 
Health Shortage Areas in Pennsylvania: A Barrier to Health 
Information,” Dr. Alberto Cardelle and Ms. Deidre Holland compare the 



4 PUBLIC HEALTH IN PENNSYLVANIA:  WHERE DO WE GO FROM HERE? 
  

 

 

ease and accuracy of accessing basic public health information in 
counties and municipalities without local health departments with that in 
counties and municipalities served by a local health department. Their 
results show that in locales without local health departments, callers 
found it more difficult to access health information, were transferred to 
non-public health entities, and did not speak to a health professional 
early in the inquiry.   

Common Pleas Judge John A. Bozza writes in “Crisis in the Making:  
What’s Wrong with Pennsylvania Public Health Law?” that the system is 
not only straining to meet everyday health-protection needs but is 
particularly vulnerable to failure during emergencies and disasters.  He 
warns that “unless key aspects of Pennsylvania law are clarified and/or 
modified, we risk far from adequate performance from public officials 
responsible for the public’s health.”   

Dr. Mariana Chilton and co-authors Chyatte and Gracely describe an 
evident failure of coordination among human services within the overall 
public health system in their article, “Evidence that Young Children Are 
Falling through the Safety Net: Policy Implications of Hunger and Poor 
Health in Pennsylvania.” This manuscript highlights the disproportionate 
impact of food insecurity on the health and well-being of children of 
color in Philadelphia. It offers policy recommendations to decrease the 
racial-ethnic divide that exists among Philadelphia’s children and protect 
the right to healthy development for all. 

Part II of the Symposium includes two papers describing barriers to 
building health protection capacity in Pennsylvania’s 61 counties that 
lack a comprehensive public health agency. In “Objecting to Public 
Health – Stories from Four Pennsylvania Counties,” Professors Dennis 
Gallagher and Jennifer Kolker report on their recent feasibility studies 
for establishing countywide health departments in Lancaster, York, 
Dauphin, and Berks counties.  This article presents findings about how 
local conditions affect the perceptions of both public health needs and 
the opportunities for enhancing county-based and countywide programs.  
Their stories help make the case for why public health is best understood 
within a very local context. 

In the second of his Symposium articles, “Financial Analysis and 
Structural Considerations to the Problem of Rural Public Health in 
Pennsylvania,” Dr. Cardelle describes his study of 10 rural counties and 



Margaret A. Potter          5 
 
 

 

the potential cost of establishing countywide local health departments.  
This analysis shows that population, geographic area, and the availability 
of primary care services all drive expenses. He also describes the specific 
challenges of establishing and maintaining health departments in rural 
areas and offers policy recommendations to help overcome these 
barriers. 

In the Symposium Part III, authors describe several innovations to 
consider for public health in Pennsylvania. In “A Health Promoting 
Hospital: A Strategy in the Re-Design of the U.S. Health Care System,” 
Dr. Matthew Masiello describes a unique Pennsylvania hospital system 
that took on certain public health responsibilities as a Health Promoting 
Hospital within the World Health Organization’s international network.  
He explains the potential benefits of a Health Promoting Hospital 
initiative within the United States and the use of the World Health 
Organization’s model program.  

Dr. Bernard Goldstein writes, in “Credentialing of the Public Health 
Work Force,” about a new approach to ensuring a highly competent 
public health work force capable of responding to the public health 
challenges facing our state and our nation.  This article discusses the 
rationales behind the newly developed proficiency examination leading 
to a professional credential for public health workers.  

Dr. Judith Lave and I advance an idea for strengthening the public 
health system by building upon an existing health care resource.  Our 
article, “Pennsylvania Medical Assistance: Connections Within the 
Commonwealth’s Public Health System,” describes how that program 
contributes to the public heath system by assuring access to personal 
health care services, evaluating the accessibility and quality of personal 
health services, monitoring health status, and developing policies that 
support individual health efforts. The article suggests some ways that 
Medical Assistance could be better connected to the overall public health 
system. 

 

Where Do We Go from Here? 

These Symposium articles present neither a comprehensive 
assessment of public health system issues nor a complete set of viable 
recommendations for confronting those issues. Rather, the Symposium 
offers insights and ideas for the future of public health in Pennsylvania.  



6 PUBLIC HEALTH IN PENNSYLVANIA:  WHERE DO WE GO FROM HERE? 
  

 

 

This publication in Commonwealth coincides with a time of forward-
thinking for public health in Pennsylvania. As mandated by Senate 
Resolution 194 (Pennsylvania Senate 2007), the Joint State Government 
Commission is undertaking a review of the state’s public health laws.  
The Commission’s work will be guided by an Advisory Committee, 
several of whose members contributed or reviewed the articles appearing 
in this issue. The review and its recommendations can address 
longstanding problems with the legal, financial, and organizational 
aspects of the Pennsylvania public health system.   

 

References 
Federal Reserve Bank of Minneapolis. 2004. “Hospital Beds Per 1,000 Persons, 2004.”  

Fedgazette. http://www.minneapolisfed.org/Research/data/specmap/us07-01.cfm 
(Accessed November 30, 2008). 

Gebbie, K. (principal investigator). 2000. “Public Health Workforce Enumeration 2000.”  
U.S. Health Resources and Services Administration, Bureau of Health Professions, 
National Center for Health Workforce Information and Analysis. 

Gostin, L.O. 2000.  Public Health Law.  Power, Duty, Restraint.  University of California 
Press and Milbank Memorial Fund:  Berkeley, CA. 

Halverson, P.K. “Embracing the Strength of the Public Health System: Why Strong 
Government Public Health Agencies Are Vitally Necessary but Insufficient.”  
Journal of Public Health Management and Practice 2002, 8(1):  98-100, at p. 98. 

Institute of Medicine. 1988. The Future of Public Health. National Academies Press:   
Washington, DC. 

Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century.  
National Academies Press: Washington, DC. 

Mays G.P., M.C. McHugh, K. Shjim, N. Perry, D. Lenaway, P.K. Halverson, and R. 
Moonesinghe. 2006. “Institutional and Economic Determinants of Public Health 
System Performance.”  American Journal of Public Health, 96 (3):523-531. 

National Association of County and City Health Officials. November 2005. Operational 
Definition of a Functional Local Health Department.  NACCHO: Washington, DC. 

Pennsylvania Senate Resolution 194, 2007, "Directing the Joint State Government 
Commission to Establish a Legislative Task Force with an Advisory Committee of 
Experts to Review, Update and Codify Pennsylvania's Public Health Law." 
http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=HTMa
ndsessYr=2007andsessInd=0andbillBody=SandbillTyp=RandbillNbr=0194andpn=14
63. 

Statemaster.com. 2008. Health Statistics. Total Nonfederal Physicians (Per Capita) (Most 
Recent) by State. http://www.statemaster.com/graph/hea_tot_non_phy_percap-total-
nonfederal-physicians-per-capita (Accessed November 30, 2008).   

 


