Mays, Glen P. PhD, MPH; Scutchfield, F. Douglas MD
Ten years ago in this journal, we proposed a definition for an emerging field of applied research devoted to learning better ways of delivering public health services in real-world community settings.1 Our intent at that time was to call attention to the work of a small group of researchers and “pracademics”—those individuals who span the worlds of practice and scholarship in public health—in applying a variety of techniques from the social and behavioral sciences to better understand public health delivery systems and their opportunities to advance population health. At the time, this type of applied research received relatively little attention in scientific and professional communities. Very little funding was devoted to this type of inquiry by the major institutions that support health-related research in the United States, and as a consequence the volume and scope of research underway within the field was quite modest. Nevertheless, the nation was taking a renewed interest in the public health system, as concerns about bioterrorism and the growing obesity epidemic permeated policy circles and the public at large. The time was right, we thought, to take stock of the emerging field of public health services and systems research (PHSSR) and determine how this field could be activated to guide the nation's public health system toward improved effectiveness, efficiency, and value.
Fast forward 10 years, and we find the PHSSR enterprise in a markedly different place. The Robert Wood Johnson Foundation (RWJF) now supports a large and growing collection of research projects that are producing a steady stream of new evidence about the organization, financing, and delivery of public health services. The nation's leading public health professional associations–-the National Association of County & City Health Officials and the Association of State and Territorial Health Officials–-maintain staff dedicated to collecting and analyzing data about public health agencies on a routine basis that have served to fuel PHSSR. Practice-based research networks (PBRNs) in public health have been formed in nearly half of the US states, bringing together more than 900 state and local public health agencies and more than 30 academic institutions to collaborate in the design, implementation, and translation of PHSSR studies. Several national meetings annually showcase the methods and findings from PHSSR studies, including AcademyHealth's Public Health Systems Research Interest Group Meeting, the National Association of County & City Health Officials Annual Meeting, and the University of Kentucky's Keeneland Conference on PHSSR. A National Coordinating Center for PHSSR now exists to support, synthesize, and integrate major scientific endeavors within the field. And a new vehicle for rapidly disseminating emerging findings from PHSSR studies to practice and policy audiences has recently been launched.2
The federal government has taken steps to advance the PHSSR field as well, through the US Centers for Disease Control and Prevention (CDC) Preparedness and Emergency Response Research Centers program and through the US Department of Health and Human Services' Framework for Quality in Public Health.3 Most recently, the federal Affordable Care Act created a Public Health and Prevention Fund to support expanded public health delivery and authorized a new federal research program devoted to “research on optimizing the delivery of public health services” (42 USC §30011-15) to inform these new investments.
This expansion of the PHSSR enterprise is occurring at a time when the public health delivery system faces looming uncertainties and unprecedented pressures for change. The Great Recession of 2008 has precipitated sharp reductions in the public finances and human capital used to deliver public health services, forcing many state and local agencies to downsize their service mix, target populations, and delivery processes. In this environment, public health administrators are seeking new knowledge about how to achieve efficiencies in service delivery and staffing so as to produce more health with fewer resources. Policy makers are demanding new information about the health and economic value–-the return on investment–-that can be realized from resources devoted to public health services and delivery systems, to make informed decisions about how best to deploy scarce resources. In the midst of these fiscal pressures, a national voluntary accreditation program for public health agencies has been launched, stimulating demand in the public health practice community for cost-effective strategies that can help their agencies prepare for and achieve accreditation standards. At the same time, the implementation of health care reform under the federal Affordable Care Act is leading public health agencies to examine new ways of working with the medical care delivery system to improve health outcomes and reduce costs, including working with and through accountable care organizations, patient-centered medical home models, health insurance exchanges, and health information exchanges.
This environment challenges the PHSSR field to prove its value to the public health practice and policy communities in new and more powerful ways. Can the field generate evidence that decision makers can use now and in the near-term to improve the effectiveness and efficiency of public health delivery? A review of recent developments in the field suggests that it can.
Defining the Field
Our original assessment of the field used the name “public health systems research” and defined it as “a field of study that examines the organization, financing, and delivery of public health services within communities, and the impact of these services on public health.”1(p180) A few years later, we proposed adding the word “services” to the name, seeking to draw a clearer connection to the larger field of health services research and provide an enticement to scientists working in this larger field to bring the tools they employ for medical care research to this pioneering area of investigation.4(p169) The inclusion of “services” explicitly in the PHSSR moniker also emphasized that delivery systems achieve much of their health impact through the public health programs, policies, and interventions that they mobilize and support.
AcademyHealth, the nation's professional association for health services research, expanded upon the PHSSR field definition, describing it as “a multidisciplinary field of study that recognizes and investigates system-level properties and outcomes that result from the dynamic interactions among various components of the public health system and how those interactions affect organizations, communities, environments, and population health status.”5 AcademyHealth also provided an explicit definition of the public health system as comprising “governmental public health agencies engaged in providing the ten essential public health services, along with other public and private sector entities with missions that affect public health.”5 It went on to define public health services broadly to include “programs, direct services, policies, laws, and regulations designed to protect and promote the public's health and prevent disease and disability at the population level.”5
Although PHSSR may appear to be a recent area of study, research on the organization, structure, and resources of local and state health departments has a long history, dating back to the early 20th century works of the American Medical Association and the American Public Health Association.6 The modern incarnation of PHSSR dates back to the Institute of Medicine's 1988 report on the Future of Public Health, which defined the overarching mission of public health around 3 core functions and offered a set of recommendations for improving public health in the areas of finance, governance, organizational structure, and workforce development.7 This report triggered a resurgence of attention to the infrastructure of public health and prompted studies about how to measure and improve this infrastructure.
Using the report of the Institute of Medicine as a guide, the CDC played a major role in the continued development of PHSSR, providing resources and leadership through its Public Health Practice Program Office. This work originally centered around developing performance standards and measures for public health agencies, eventually leading to the development of CDC's National Public Health Performance Standards Program and the antecedents for the voluntary national accreditation program now administered by the Public Health Accreditation Board.6 This work also led to a partnership between the CDC and AcademyHealth to create a special interest group devoted to PHSSR as a venue for research development and networking and to maintain some continued research funding for new projects in the field.
The RWJF took a major interest in developing the PHSSR field, beginning in 2004, as part of its larger effort to advance the science and practice of public health. A key focus of the foundation was to develop better evidence to guide public health agencies in developing their capacity to improve population health. The support of the foundation over the last 8 years has transformed the PHSSR enterprise and attracted many other stakeholders to the field as both producers and consumers of the evidence base.8
Beginning in 2005, the RWJF established a program for funding investigator-initiated research projects in PHSSR, modeled after its highly successful Changes in Healthcare Financing and Organization research program for health care research implemented with AcademyHealth. Through annual proposal solicitations, this program has rapidly increased the volume, scope, and quality of research being conducted in the field. The foundation invested in efforts to expand and enhance the data collection activities of National Association of County & City Health Officials, Association of State and Territorial Health Officials, and others, which capture key data on local and state public health agencies and activities. It supported the development of a national scientific meeting devoted to PHSSR, the Keeneland Conference, which brings together researchers and users of research in April every year to exchange information on the latest findings, methods, and opportunities for research.
To realize greater synergy across this expanding array of activities, the foundation established the National Coordinating Center for PHSSR at the University of Kentucky to coordinate the future development of the field. The activities of this center include a mini-grant program to help predoctoral investigators and junior faculty become engaged in the field; a mentored career development program to help junior investigators advance in the field; an extramural research program that currently focuses on studies of natural experiments in public health organization, financing, and delivery; and initiatives to promote translation of research into practice and attract additional funders and funding mechanisms in supporting PHSSR, including working with AcademyHealth to reach out to policy makers.
Regarding the prospects for expanded research funding, the federal Affordable Care Act authorized a new federal program of research in PHSSR, but federal appropriations in the area have not yet been forthcoming. A recent Institute of Medicine report calls on the federal government to take action in this area by investing in a robust research enterprise to inform public health decision making and action.9 The National Coordinating Center for PHSSR is working with a variety of federal agencies to identify collaborative research opportunities where there is a shared sense of need, direction, and interest in PHSSR. The Clinical and Translational Science Award program of the National Institutes of Health is one such program that shares a goal of research translation to public health and community settings. The CDC's Prevention Research Centers program is another enterprise that has the potential for enhanced engagement in PHSSR, along with the Preparedness and Emergency Response Research Centers program, the new National Public Health Improvement Initiative, and other CDC programs, centers, and institutes. Potential exists to link PHSSR with a wide variety of categorical programs in public health, allowing these programs to learn about the delivery system attributes that are needed to implement their strategies effectively while also producing more fundamental “delivery system” evidence that generalizes across categorical program areas. Although this potential for synergy between PHSSR and program evidence certainly exists with CDC programs, it is also exists with other federal programs, such as the maternal and child health programs administered by the US Health Resources and Services Administration and the nutrition programs administered by the US Department of Agriculture.
Making Research Relevant and Actionable
A major concern with any research endeavor is the interplay between scientific discovery and practical application. As with other scientific pursuits, the research questions in PHSSR are most relevant when they are informed by information needs and uncertainties encountered in real-world practice settings, representing the questions for which answers are most likely to make a difference in public health practice that improves the health of communities. And research findings are much more likely to have practical relevance and application when studies are designed and implemented in real-world practice settings and in collaboration with practicing professionals.10 For these reasons, a program to develop PBRNs in public health was launched in 2008 with support from the RWJF. Modeled after the successful PBRNs in primary care, these public health PBRNs bring multiple state and local public health agencies into collaboration with academic research institutions for the purpose of designing, implementing, and translating PHSSR studies in real-world public health settings.11 The overarching goal is to produce both rigorous and relevant PHSSRs that can be rapidly applied and adopted into practice and policy.
Another recent effort to steer the PHSSR field toward the most relevant and actionable areas of inquiry can be found in an initiative sponsored by the RWJF and the CDC to develop a shared national research agenda for the PHSSR field.12 Informed by systematic reviews of the existing evidence and information needs articulated by a wide range of public health stakeholders at national, state, and local levels, the national agenda for PHSSR provides a sense of direction and establishes priorities for PHSSR over the next few years. The ability to work from a shared vision of progress provides an opportunity to focus new lines of inquiry on issues that have the greatest potential for informing practice and improving population health, particularly in areas that have been overlooked by the field to date.
Articles in This Special Issue
This special issue of the Journal of Public Health Management and Practice profiles the results of recent advances in PHSSR. The issue reflects the contemporary character of research in the field, including a broad cross section of topics, methodologies, and practical applications. The articles span topics in public health organization, governance, financing, workforce, and decision making. Many of the articles make use of the new PHSSR data resources that have been developed through the work of Association of State and Territorial Health Officials, National Association of County & City Health Officials, and others with support from the RWJF and the National Coordinating Center for PHSSR. More than half of the articles present research that has been developed and implemented through collaboration with public health PBRNs in the United States. In deference to the Journal's focus on management and practice, the articles in this issue give particular emphasis on the administrative, policy, and practice implications that derive from the studies. Collectively, the articles in this issue provide an updated benchmark for where the PHSSSR field is and where it still needs to go. To be sure, the field is still early in its developmental history and it generates at least as many questions as it answers at this stage. The field must adopt improved measurement approaches and analytic methods, and cultivate improved data sources, to produce more definitive evidence and make good on its promise. Nevertheless, with continuing efforts to enhance the rigor and relevance of its work, PHSSR can provide valuable guidance to the public health community in navigating contemporary uncertainties and forces of change within the larger health system toward the goal of improved population health.
1. Mays GP, Halverson PK, Scutchfield FD. Behind the curve? What we know and need to learn from public health systems research. J Public Health Manag Pract. 2003;9:179–182.
2. Mays GP, Halverson PK, Riley W, Honoré P, Scutchfield FD. Accelerating the production and application of evidence for public health system improvement: the search for new frontiers. Front Public Health Serv Syst Res. 2012;1:1–4.
3. Honore PA, Wright D, Berwick DM, et al. Creating a framework for getting quality into the public health system. Health Aff (Millwood). 2011;30:737–745.
4. Scutchfield FD, Marks JS, Perez DJ, Mays GP. Public health services and systems research. Am J Prev Med. 2007;33:169–171.
6. Turnock BJ, Handler AS. From measuring to improving public health practice. Annu Rev Public Health. 1997;18:261–282.
7. Institute of Medicine, National Academy of Sciences. The Future of Public Health. Washington, DC: National Academies Press; 1988.
8. Scutchfield FD, Mays GP, Lurie N. Applying health services research to public health practice: an emerging priority. Health Serv Res. 2009;44:1775–1787.
9. Institute of Medicine, National Academy of Sciences. For the Public's Health: Investing in a Healthier Future. Washington, DC: National Academies Press; 2012.
10. Green LW. Public health asks of systems science: to advance our evidence-based practice, can you help us get more practice-based evidence? Am J Public Health. 2006;96:406–409.
11. Mays GP. Leading improvement through inquiry: practice-based research networks in public health. Leadersh Public Health. 2011;9:1–3.
12. Consortium for Advancing Public Health Services and Systems Research. A national agenda for public health services and systems research. Am J Prev Med. 2012;42:S72–S78.
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