25 Years of Publication: Twelve Major Themes: Commentary
The evolution of public health practice has been very significant in the past 2 centuries. During the period of the late 19th century and much of the 20th century, Public Health 1.0 accomplished “tremendous growth of knowledge and tools for both medicine and public health.” Shaped by the 1988 Institute of Medicine report The Future of Public Health, Public Health 2.0 was demonstrated through a “systematic development of public health governmental agency capacity across the United States,” with a particular “focus limited to traditional public health agency programs.” Reflecting a new era of innovative public health practice, Public Health 3.0 embraces the approach of “engaging multiple sectors and community partners to generate collective impact” in order to “improve social determinants of health” for the population.1
In the context of Public Health 2.0, previous research on local health departments (LHDs) has mainly focused on examining the impact of characteristics and behavior of LHDs as well as their contextual environmental factors on the performance of LHDs. The Resource Dependence Theory (RDT) can be used to conceptually summarize the research findings from the literature and facilitate a discussion on future direction of research that can be helpful to the practitioner. There are 3 key constructs in the RDT framework: Munificence represents the availability and accessibility of resources to an organization. Uncertainty refers to the unstable nature of environment that an organization faces. Interdependence refers to the extent to which an organization is dependent on other organizations for resources.2 The literature has suggested that uncertainty (eg, budget/funding cuts) has had significantly negative impact on LHDs' performance measures (eg, accreditation readiness and status, provision of services). In addition, the literature has suggested that munificence factors (eg, size, staffing) and interdependence strategy (eg, local governance support, sharing resources with other organizations, effective community partnerships) had significantly positive impact on LHDs' performance measures.
As a result of the 2007-2009 economic recession and the subsequent mild recovery, nearly two-thirds of the US population lived in jurisdictions where LHDs had a budget cut in at least one program area. Facing this great financial hardship and uncertainty, LHDs must confront challenges in innovative ways if they are to impact quality of life and increase life expectancy in their jurisdictions. LHD leaders cannot continue to perform as singular agents of health improvement or function in isolation. Under this context, Public Health 3.0 certainly provides a renewed framework for LHDs to address their challenges in acquiring critical resources. Within this framework, LHDs (or other local public health leaders) should serve as the Chief/Community Health Strategist for their communities in order to engage with relevant stakeholders to form vibrant, structured, cross-sector partnerships. Through this type of partnerships, Public Health 3.0—style initiatives can be designed and developed to better address social determinants of health. Innovation is interesting; anything an organization has not done before is innovative in the sense that implementation of a specific initiative is no longer business as usual. This does not suggest that different is always good, but if LHDs are truly going to be catalysts for change, LHD leaders must embrace the new when needed and realize that it takes a community to change a community, not just the work of an LHD. The evidence has been very clear that community health is dependent on many factors outside the health arena, and if we are to impact those factors, we must create a safe place for all organizations to come together and incentivize them to work toward community health improvement. The work is more important than the organizations doing it. All organizations that have a responsibility for improving the health of citizens want to succeed; imagine if all of us decided to succeed together! As we are propelled into the future, we must consider all attributes and resources researchers and public health practitioners will need to successfully navigate the challenges of tomorrow.
What is the implication of the aforementioned trend in public health practice for future public health systems and practice-based research? We think researchers should adopt and incorporate a systems perspective when designing and conducting research related to LHDs, as we ask the practitioner to consider cross-sectoral partnerships instead of swimming in their own lanes to accomplish community health improvement goals. For instance, methods such as system modeling can be applied to examine how systems-level (eg, level of cross-sector partnership) measures of munificence, uncertainty, and interdependence may impact the performance of LHDs in addressing social determinants of health and improving population health at the community level. Future research is also needed to document the best practices of (and the lessons learned from) developing strategies to form structured cross-sector partnerships, designing flexible funding mechanisms to support social determinants-oriented work, training and developing workforce with knowledge and skills in the concept and application of the collective impact model of social change, identifying the key characteristics of successful local public health models for addressing social determinants of health, and integrating and leveraging data sources between health care, public health, and human services sectors. It is also important for researchers to examine LHDs' role in developing and facilitating these documented best practices mentioned earlier.
This new era of public health creates new challenges and opportunities for both the practice community and researchers. As we reimagine public health of the future, we cannot forget the lessons from the past. These lessons could help frame relevant future research, develop effective health policies, and create a strong public health infrastructure, and that will ultimately improve the health of this country.
1. Public Health 3.0: A Call to Action to Create a 21st Century Public Health Infrastructure. Washington, DC: Office of the Assistant Secretary for Health, US Department of Health and Human Services; 2017.
2. Scott WR, Davis GF. Organizations and Organizing: Rational, Natural, and Open System Perspectives. Upper Saddle River, NJ: Pearson Prentice Hall; 2007.