The average lifespan in the United States has extended by 10 years since the 1950s, an achievement made through progress in healthier behaviors, cleaner air, food and water, and breakthroughs in disease diagnosis and treatment. Over the last several years, we have seen critical improvements in access to health insurance coverage and digitizing care. Public and private sectors have also joined forces to innovate the payment system, significantly improving health care quality, experience, and patient safety.
Yet, our work is only beginning. Life expectancy in the United States has been stagnant for three years in a row; in some parts of the country, life expectancy has actually declined. To truly achieve better health for everyone, we must ensure the conditions in which everyone can be healthy, and this will take more than the health care system. We must address the upstream drivers of health that touch everyone, no matter where they are born, live, learn, work, play, worship, and age. Public health is the essential infrastructure for this work, but it needs to innovate, and in many ways, reinvent itself so that we have what it takes to ensure that the American people are healthy, ready, and competitive in this global economy.
An Evolving Approach To Public Health
Public health is what we do together as a society to ensure the conditions in which everyone can be healthy. Public health has been evolving over time. From the late 19th century through much of the 20th century, an era we call Public Health 1.0, public health practice was modernized through the advances in vaccines, antibiotics, epidemiology, and lab sciences, as well as a system of sanitation and standards in food and water safety. The era of Public Health 2.0 was marked by the 1988 publication of The Future of Public Health, an Institute of Medicine report which found that public health authorities were so overwhelmed by the demands of providing safety-net clinical care that they struggled to address the rising burden of chronic disease — not to mention the epidemic of HIV/AIDS. Since its call to action nearly three decades ago, governmental public health agencies have become more professionalized and standardized. The core tenets of Public Health 1.0 and 2.0 remain essential today.
For the U.S. public health system, the past few years have been a trying time. In 2008, the Great Recession decimated public health funding and led to a cut of nearly 40,000 jobs in the public health workforce during 2008-2011. Local public health departments, many of whom provide critical preventive services and safety-net care in their communities, lost substantial funding and clinical revenue. Indeed, two-thirds of the U.S. population in 2012 lived in jurisdictions in which their local health department experienced budget cuts to at least one program area.
The consequence of a crumbling public health infrastructure is often felt most intensely in the communities with the greatest need. Research shows that for someone who is at the bottom of income distribution, the zip code in which he or she lives can mean a difference of 4.5 years in life expectancy. The lead crisis in Flint, Michigan painfully reminded us of the dire consequences when public health interest is not at the center of a community's decision-making process.
On the other hand, many communities have risen up to meet these challenges by pioneering, innovating, and transforming on the front lines to address the full range of factors that influence a person's health — from good schools to safe environments, stable housing to transportation, economic development to access to healthy foods. In these pioneering communities, we see people across different sectors coming together to address upstream determinants and reinvent their local public health system in a strategic and evidence-based fashion. From Nashville to Detroit, from Colorado to Pennsylvania, these stories are what inspired and enriched Public Health 3.0, our proposed blueprint for the future of public health.
We believe that the following five qualities are essential for every community to achieve health for all:
1. Public health leaders should embrace the role of Chief Health Strategist for their communities.
Whether it is the public health agency, the elected official, the hospital, or a major business employer in the area, the Chief Health Strategist should work with all relevant partners so that they can drive initiatives including those that address environmental, economic, and social determinants of health. The workforce must also acquire and strengthen its knowledge base, skills, and tools in order to meet the evolving challenges to population health, to be skilled at building strategic partnerships to bring about collective impact, to harness the power of new types of data, and to think and act in systems perspective.
2. Public health departments should engage with community stakeholders—from both the public and private sectors—to form vibrant, structured, cross-sector partnerships.
These partnerships should share a vision for creating health, equity, and resilience in a community over the long term, with employers and payers among the key partners. The defining feature of these partnerships should be the ability to organize in order to share governance, set shared vision and goals, blend and braid funding, and capture savings for reinvestment upstream.
3. Public Health Accreditation Board (PHAB) accreditation for public health departments should be strengthened to ensure that every person in the United States is served by nationally accredited health departments.
Accreditation has been shown to be an important mechanism for local, state, and tribal public health departments to stimulate quality improvement and enhance their capacity and accountability. As of August 2016, 324 local, state, and tribal health departments have been accredited or are in progress for accreditation, covering 80 percent of the U.S. population. It will take major investment, political will, and efforts from both public and private entities to expand that excellence in service to become the norm.
4. Timely, reliable, granular-level (i.e., sub-county), and actionable data should be made accessible to communities throughout the country, and clear metrics should be developed to document success in public health practice.
Such actionable information including data and metrics that encompass health care and public health is essential to guide, focus, and assess the impact of prevention initiatives, especially those targeting the social determinants of health and enhancing equity. Many of the surveillance data systems rely on surveys collected several years prior, and most of them cannot produce statistics that are geographically granular. There also exist technical and cultural barriers to data sharing and linkage. The public and private sectors should work together to enable more real-time and geographically granular data to be shared, linked, and synthesized to inform action while protecting data security and individual privacy.
5. Funding for public health must be enhanced and substantially modified.
The traditional, categorical funding model for much of the public health service needs to become more flexible and sustainable. Local public health leaders need to define the foundational capabilities, the cost of delivering those services, and the gap in funding. Innovative mechanisms to blend and braid funds from multiple sources should be tested and scaled to support core agency infrastructure and work to address the social determinants of health. By acting on these five areas, communities build a future that ensures health for all people, regardless of income, race and ethnicity, gender identity, sexual orientation, language, and zip code.
It is said that when public health is doing its best work, nothing happens — epidemics do not occur, water and air remain free from contaminants, and people are unencumbered by preventable diseases. We are at a point in history when we have the resources and the track record to make these kinds of substantial changes that will lead to a healthier, more prosperous future. Now, with Public Health 3.0, we have a blueprint for accomplishing it. But these changes and this future can only be achieved if we work together behind a vision we all share.
To learn more about how Public Health 3.0, visit us at HealthyPeople.gov.
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