The Public Health Systems Research Interest Group (PHSR IG) selected Timothy T. Brown, Ph.D. to receive the 2014 PHSR Article of the Year Award for his article “How effective are public health departments at preventing mortality” (Economics and Human Biology, October 2013). The blog below, by Felicia E. Mebane, Ph.D., M.S.P.H., describes the article and its implications for public health practice and policy.

The May 2014 release of Investing in America’s Health highlights a key challenge in public health systems research (PHSR) and reinforces the value of this year’s PHSR article of the year. The report makes a case for why public health departments need more funds. In response, Glen Mays, Ph.D., M.P.H. has called for better data to validate the report’s conclusions.

This recent dynamic highlights the need for credible evidence of the value of public investments. This year’s winning article is a prime example of a creative and sophisticated methodological approach yielding results that can be used as an underpinning of future public health policy and research.

In “How effective are public health departments at preventing mortality,” Timothy T. Brown starts with a straightforward question. What is the impact of county public health systems on the population demand for health? He answers the question by modeling the cumulative impact of per capita public health expenditures for 56 of 58 counties in California on all-cause mortality from 2001 – 2008.

For this model, expenditures represent the full complement of county-level public health services in California, ranging from immunizations and infectious disease surveillance to inspection of public swimming pools and food safety education. To fully explain variations in all-cause mortality and isolate the impact of expenditures, Brown’s model also includes the price of medical care and per capita income and other factors affecting population health.

Brown’s use of sophisticated econometric methods allows him to paint a more realistic picture of the impact of public health expenditures and lays the groundwork for much needed additional research linking public health investments to health outcomes. In particular, his model accounts for lagged, cumulative and short and long-term effects. Brown’s methodological decisions are well grounded and explained in this paper.

Brown’s findings show that an additional $10 per capita of public health expenditures reduces all cause mortality by 9.1 deaths per 100,000. And, in terms important to policymakers who make budget decisions, the annual value of the lives saved is estimated to be worth $2.95 billion for these counties.

Recognizing that policy choices are often about comparisons to existing investments, Brown compares his finding of $109,514 in public health expenditure cost per life saved to familiar existing interventions such as mammography, which saves one statistical life per $100,000 spent, and flu vaccinations for people 50 and older, which saves one statistical life for about every $35,000 spent.

Brown is also thoughtful in his discussion and conclusions. He notes limitations of his study, including external validity beyond California and differences based on longer time frames. He also highlights a need to model differences in cost-effectiveness among specific program categories and to find an optimal mix of public health activities that will yield the greatest benefits for a population.

In an era of reduced government resources and ongoing allocations that will not stop to make way for better quality data, we applaud Brown’s contributions. His work epitomizes high-quality systems level analysis and takes us one step closer to an optimal understanding of public health expenditures and filling gaps in our knowledge of the concrete impact of public health investments.


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