The governmental public health enterprise has been adapting to a rapidly changing environment for several years now. Between the economic recession, health reform, and ever evolving chronic and infectious disease threats, sticking with the status quo has not been an option for some time. Although we do not know exactly what our transformed health system will look like, we do know a few things we will encounter and have devised a short list of promising strategies for continuing the critical work of the public health system into the future.
Although the country seems to be headed toward increasing rates of insurance coverage, we will not reach 100% any time soon. There will continue to be some portion of the population without health insurance, and some portion that is underinsured, for the foreseeable future. We will continue to see a transforming health system in which public health continues to have a critical role in creating a nation in which people have the opportunity to be healthy, regardless of their insurance status.1 Our 3 core functions—assessment, policy development, and assurance—will play an even more important role in a transformed health system.
Ten Effective Strategies
Define what is mission critical
A recent study led by JP Leider and Beth Resnick in collaboration with ASTHO found that state public health agency leaders are already very actively engaged in defining what services are absolutely critical to the mission of the agency in their efforts to allocate scarce resources.2 Defining and focusing intently on what is mission critical will continue to be a key to success in 2013 and beyond (Table).
Last year's Institute of Medicine report on public health finance recommended that the public health system identify a minimum package of public health services every person can have access to, and that all public health agencies have the foundational capabilities that support these services, regardless of what US state or locality the person lives in.3 These foundational capabilities need to include “information systems and resources (including surveillance and epidemiology); health planning (including community health improvement planning); partnership development and community mobilization; policy development, analysis, and decision support; communication (including health literacy and cultural competence); and public health research, evaluation, and quality improvement.”3(p60) Much public health advocacy is focused on programmatic areas such as diseases or services; however, programs do not function in isolation. These foundational capabilities comprise the core infrastructure that is critical to the mission of a public health agency.
Use continuous quality improvement to increase efficiency and effectiveness
In lean economic times, it can be tempting to focus exclusively on cutting budgets. But if we lose sight of efficiency and effectiveness of the programs we continue to offer in the effort to save money in the short term, we will waste money and damage capacity in the longer term. Public health agencies “in survival mode” may be tempted to skimp on quality improvement efforts. Just as continuous quality improvement (CQI) is essential to increasing efficiency and effectiveness in private industry where money is the bottom line, CQI is equally essential in the public health system, where health outcomes are the bottom line, but funding is a critical ingredient. Quality improvement is the foundation of achieving accreditation through the Public Health Accreditation Board. Many state health agencies are already engaged making quality improvement their “way of doing business” throughout the agency. According to the 2010 ASTHO Profile Survey, 77% of state health agencies have some sort of quality improvement in place, although most have not been able to fully implement quality improvement across the entire agency.4 The public health partner associations (ASTHO, NACCHO, APHA, PHF, and NNPHI), with the involvement and support of the Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson Foundation (RWJF), have been working together to integrate quality improvement into the everyday work of public health agencies for years. Current efforts to do so include, among many other projects, the CDC's National Public Health Improvement Initiative and RWJF's National Demonstration Initiative on Quality Improvement. National Public Health Improvement Initiative, which is funded through the Prevention and Public Health Fund, is a 5-year program to support state and local health agencies in their efforts to adopt and institutionalize crosscutting performance management and quality improvement methods to improve the accountability, efficiency, and effectiveness of public health programs. The ASTHO National Demonstration Initiative on Quality Improvement Practices in State Public Health Programs provides funding and consultation to 5 state health agencies as they increase their readiness for accreditation, demonstrate the value of accreditation and quality improvement, improve integration of services among state public health programs, and use standard methodology to manage budgets in difficult times. In our new strategic map, ASTHO has established a crosscutting goal of “cultivating continuous quality improvement” in public health.
Rely on and contribute to the evidence base
Public health practitioners will be better able to increase efficiency and effectiveness if they look to the evidence base for strategies to improve health. Reliance on interventions that are known to be effective will allow for the wisest use of scarce resources. The CDC's Guide to Community Preventive Services (the Community Guide) offers an important source of evidence for public health practitioners. The evidence base, however, does not answer all questions posed by public health practitioners. Often, we need to deal with new threats, address old threats in a new context, or do something better than it has ever been done before. Innovation is critical in these situations, and unflinching reliance on existing evidence does not spark innovation. Furthermore, true innovation is needed when implementing evidence in a particular environment. Many intangibles must be accommodated when moving from theory to practice.
Those who innovate need to share their learning with the rest of the field. Engaging in a learning collaborative, submitting a promising practice to be compiled by ASTHO, NACCHO, AMCHP, or another organization, participating in a research study, and publishing are all ways to contribute to the evidence base. The more information we can add about what works and under what circumstances, the better the public will be served. Health agency leaders are in a unique position to drive practice-based public health services and systems research that will increase our collective effectiveness in years to come.
Use the longest lever possible
Tom Frieden's health impact pyramid5 articulates this concept parsimoniously. The interventions with the most promise of impacting population health are efforts to address the socioeconomic determinants of health and those that change the environment to make healthy choices the default options. “Health in all policies” is a related concept that emphasizes leveraging policies made outside of the health department to impact health, such as using transportation policy to make walking or biking a default choice or using education policy to make healthy food a default choice for kids eating school lunch. Health impact assessments can be a useful tool to ensure that policies being considered outside the health department have neutral or positive effects on population health.6
Use systematic approaches to create sustainable improvements
Sustainable systematic change requires a systematic approach. There is rarely a silver bullet; multiple components of a system must be addressed simultaneously to create meaningful change. Using the socioecological model as a basis of change assures that opportunities are advanced at multiple components of a system. This cannot be done from within a single program but rather requires engagement and mobilization across health agencies and multiple partners in public health and the community. Expertise is needed at the individual level to promote self-efficacy, at the interpersonal level to affect social norms and supports, and likewise at the organizational, community, and policy levels.7
Align governmental public health enterprise
In contrast to the often-repeated sentiment “all public health is local” (and the corresponding concepts that all public health is accomplished at the state or federal levels), public health is most effective when the enterprise is aligned at the local, state, and federal levels and acts in collaboration as a national system.8,9 Each component of the system has unique and complementary capacities. We are most effective when federal, state, and local public health are aligned, with each making a unique contribution of its distinctive competence.
Demonstrate value and be accountable
To many public health practitioners, the value of public health is inherent. The rest of the world, however, needs to hear compelling health stories and see quantitative health and financial results. In contrast to the timeworn adage that public health is invisible when it is at its best, public health is at its best when we make the strongest case for the importance of our work. Making this strong case requires quantification in terms of changes in health outcomes and savings that result from our work. We need to specify to whom and when the savings will accrue (savings to Medicaid in the near future will be especially compelling at the state and federal levels). Demonstrating value will also require a stronger emphasis on evaluation and on the tasteful promotion of what we do; this is why evaluation and communications are both on the list of critical foundational capabilities in the first strategy “Define What Is Mission Critical” mentioned previously. We also need to be willing to be held accountable for achieving the health and financial outcomes we set out to realize.
Walk the walk
The exhortation “do as I say, not as I do” does not work for health agencies any more than it works for parents. Health agencies will be more effective if they lead by example and make the healthy choice the default choice in their own work environments. We must lead by example. For more on walking the walk, please see “State of Public Health: Walking the Walk,” the September 2012 column in this journal.10
Integrate public health and health care
José Montero, director of the Division of Public Health in the New Hampshire Department of Public Health and Human Services and current ASTHO President, has named the integration of public health and health care as his President's Challenge. This new challenge builds upon last year's Institute of Medicine report on the integration of public health and primary care11 and the concept of the triple aim by Don Berwick et al12: “improving the experience of care, improving the health of populations, and reducing per capita costs of health care.” Clearly, neither the health care system nor the public health system can tackle the triple aim alone. “Improving the health of populations” is the mission of the public health system, but transforming the health system so that care can be improved, cost can be decreased, and the health of the population can be improved will require highly effective collaboration and integration between the health care system and the public health system, which often operate separately. Although integration is necessary, differentiation is important too: creating the conditions in which the healthy choice is the default choice happens largely outside of the health care system.
Leverage public and private sector partnerships
The private sector has levers and reaches in areas that public sector organizations do not. Opportunities for public/private partnerships are plentiful. Private sector employers are increasingly seeing the value of worksite wellness programs to increase morale, decrease health care costs, and increase overall productivity.10 Partnerships between health agencies and pharmacies to vaccinate the public during the 2009 H1N1 outbreak provide an excellent example of a mutually beneficial partnership. New IRS requirements that nonprofit hospitals conduct community health needs assessments create additional incentives for collaboration between health agencies and private entities.
Although we cannot predict what the new year will bring, we know that the economy, transformation of the nation's health system, and evolving threats to population health will all continue to conspire to create a backdrop of substantial change. These 10 strategies give us the best hope for meeting the challenges that lie ahead.
2. Jarris PE, Leider JP, Resnick B, Sellers K, Young JL. State of public health: budgetary decision making during times of scarcity. J Public Health Manag Pract. 2012;18(4):390–392.
3. Institute of Medicine. For the Public's Health: Investing in a Healthier Future. Washington, DC: The National Academies Press; 2012.
4. Association of State and Territorial Health Officials. ASTHO Profile of State Public Health. Vol 2. Arlington, VA: Association of State and Territorial Health Officials; 2011.
5. Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health. 2010;100(4):590–595.
6. Lock K. Health impact assessment. BMJ. 2000;320(7246):1395–1398.
7. Bronfenbrenner U. Ecological systems theory. Ann Child Dev. 1989;6:185–248.
8. Jarris PE. Challenging times for the governmental public health enterprise. J Public Health Manag Pract. 2012;18(4):372–374.
9. Jarris PE, Monroe JA, Pestronk RM. Better health requires partnerships and a systems approach. Am J Public Health. 2012;102(11):e4.
10. Jarris PE, Baird JN. State of public health: walking the walk. J Public Health Manag Pract. 2012;18(5):474–476.
11. Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: The National Academies Press; 2012.
12. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health and cost. Health Aff. 2008;27(3):259–269.