We need to build on lessons learned in developing and implementation of a Uniform Chart of Accounts to foster a post-pandemic public health finance infrastructure that will support a robust and accountable public health future.

The US public health system has very limited means of consistently accounting for the resources that flow from its varied funding sources to state and local health departments. While we know those resources have long been grossly inadequate, we have also had a terrible time quantifying how much we really need and for what purposes. And we will now have difficulty describing how new funds, since the COVID-19 pandemic, are being spent. Much of this mystery exists because governmental state and local public health agencies have no common, standardized approach to accounting for their specific revenues and expenditures. Yet, for decades, other fields of government and industry have had established mechanisms for common reporting of standardized metrics around spending, revenue, staffing, and service provision.

In our recently published article titled “A Uniform Chart of Accounts: Strengthening Public Health Practice and Research Through Standardized Financial Data,” we describe the development of a Uniform Chart of Accounts (UCOA) for public health, including its implementation and operationalization in public health planning, policymaking, and advocacy. We also argue for the institutionalization of such a UCOA in state and local governmental public health practice. Without broad support for and use of the UCOA as a common means of tracking resources and benchmarking detailed public health spending across agencies and overtime, we lack key tools for equitably and thoughtfully allocating resources and demonstrating accountability to the public.

WHAT DID WE FIND?

In working with practice partners toward the development, pilot testing, and limited uptake of the UCOA we frequently heard from practitioners that such a standardized means of reporting and comparing financial data was important for accountability, resource allocation, benchmarking, and supporting the ‘value’ of public health resources to their communities. We also found the generated data to be of great interest for examining detail regarding spending and revenue patterns, tracking specific funding streams, and supporting public health services and systems research. At the same time, technical support is clearly needed for providing the definitions, guidelines, data visualizations, financial support, incentives, and data linking that are necessary to assure the uptake and use of the UCOA and its related data.

KEY TAKEAWAYS

In our experiences with developing and implementing the UCOA from 2016-2021 we learned many critical lessons that must not be lost for when the institutionalization of a UCOA becomes a funded national priority.

Data accessibility

While we created a UCOA for and with public health practice, we found that the effort it takes to crosswalk their financial data to the UCOA is a barrier. For the effort to be worthwhile to public health agencies, they need the data accessible to them through user-centered visualizations or dashboards and combined UCOA data from other agencies.

Practical relevance

The UCOA must be and remain aligned with other national efforts, including the Foundational Public Health Services (FPHS) and public health accreditation. We worked closely with practice- and national-partners to have the UCOA help reflect FPHS-related spending and support agencies in meeting accreditation standards.

Research data

While we have been able to support some limited research with the UCOA data collected, wide adoption of the UCOA is needed to provide the rich data source needed to describe what types of resources public health agencies need, for what purposes, and under what conditions.

Institutionalization

As money flows into public health systems on the heels of the pandemic, policymakers and the public will (and should) expect that we can account for how these resources were spent and to what end. We will not have such a means of accounting for resources across our systems and overtime, without institutionalizing financial data standardization. Yet, asking public health agencies to prioritize their time and effort to crosswalk their financial data to a UCOA and without additional resources or incentives is more than can be expected of them. We argue that such institutionalization and even mandatory integration of the UCOA be accompanied by significant implementation resources, technical assistance, incentives, and user-centered access to the data they provide.

Our findings and key takeaways are critical to advancing national efforts to establish wide UCOA use and are described in our article “A Uniform Chart of Accounts: Strengthening Public Health Practice and Research Through Standardized Financial Data.” But without these findings and lessons maintained and without making the standardization of public health financial data a funded national priority, the UCOA we developed and implemented with practice partners from 2016-2021 will not serve to guide practice or provide the accountability we so desperately need to demonstrate that governmental public health agency resources are dollars well spent.

RELATED ARTICLES:

• Orr, J., Leider, JP, Kuehnert, P., & Bekemeier, B. COVID has much to teach us about the money troubles facing public health. What will we learn from it? Health Affairs. 2023;42(31):374-382.
• Dada, O.O., Bekemeier, B., Flaxman, A, & de Castro, B. (2022). Associations Between Local Health Department Expenditures on Foundational Capabilities and PHAB Accreditation Standard Scores, Frontiers in Public Health, 10:861587.
• Yeager VA, Balio CP, McCullough JM, et al. Funding Public Health: Achievements and Challenges in Public Health Financing Since the Institute of Medicine’s 2012 Report. Journal of Public Health Management & Practice. 2022;28(1):E244-E255.
• Bekemeier B, Singh SR, Schoemann A. A Uniform Chart of Accounts for Public Health Agencies: An “Essential Ingredient” for a Strong Public Health System. Journal of Public Health Management & Practice. 2018;24(3):289-291.
• Bekemeier B, Park SE, Whitman G. Challenges and lessons learned in promoting adoption of standardized local public health service delivery data through application of the PHAST model. Journal of the American Medical Informatics Association. 2018;26(12):1660-1663.

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Coauthors

Elizabeth Heitkemper, RN, PhD is an Assistant Professor at the University of Texas at Austin School of Nursing with specific expertise in user-centered design and adaptive informatics tools for supporting health promotion and using data in decision-making. She leads research that incorporates information technology into practice for underserved populations.

Dana L. Zaichkin, MHA, PhD, RN, is an Associate Professor at Pacific Lutheran University School of Nursing with expertise in healthcare administration, finance, economics, and public policy and the applications of these to public health systems and practice. 

Greg Whitman is Project Manager for Public Health Activities and Services Tracking (PHAST) at the University of Washington School of Nursing. His role with PHAST has been to work closely with public health practice partners to develop tools and resources for obtaining, visualizing, and applying data for practice.

Simone R. Singh, PhD, is an Associate Professor at University of Michigan School of Public Health. Her program of research includes the costing of public health services, including the productivity and efficiency of service delivery and the impact of spending on population health outcomes.

Jonathon P. Leider, PhD, is a senior fellow at the University of Minnesota School of Public Health and founding director of their Center for Public Health Systems. He has a strong program of research that includes public health policy, financing, and workforce development.