Public Health 3 0 Transformation Paper

TRANSFORMATION PAPER

Transformation Paper

Public Health 3.0: A Call to Action to Create a 21st Century Public Health Infrastructure

Introduction

It is unacceptable that in the 21st century, people continue to experience differences in health status as a consequence of their ethnicity, skin color, where they reside, or level of income. As an employee in the state health department (reporting to the State Director of Public Health), I am convinced that we should all play a more active role in efforts to promote the health equity agenda and transform public health practice. It is on this basis that I review a report that purports to explore ways of transforming public health practice and reducing health inequities. The report is titled, “Public Health 3.0: A Call to Action to Create a 21st Century Public Health Infrastructure.”

A Review and Critique of the Report

There is need to ensure that every citizen of this great country has what is, in essence, a just and fair opportunity to achieve what could be deemed their full potential in as far as their health and wellbeing is concerned. Despite having made significant progress on multiple fronts, i.e. with regard to advances in technology and advancement of democracy, the United States is yet to achieve health equity. This has been an elusive goal for a long time. Indeed, as Williams and Sternthal (2010) point out, racial differences in health can be tracked back to the country’s earliest medical records. This is to say that the country still grapples with disparities in as far as health outcomes are concerned. Thus, there exists significant differences in not only health resources distribution, but also health status across different population groups. In addition to identifying the need to ensure that all citizens have a fair chance of achieving the highest level of health, this particular report illustrates the progress that has been made in the past to make this ideal a reality. Strategies that have been deployed have been identified and ideas for further progress floated.

From the onset, the report recognizes that health equity cannot be achieved in a vacuum. This is to say that the achievement of health equity is a collaborative effort in which case all persons should play a meaningful role and share experiences. For this reason, the initiation of what could be deemed a ‘national dialogue’ – i.e. by organizing regional meetings and engaging stakeholders across multiple sectors – is a welcome move. It is also laudable that insights have been sought from communities that are both demographically and geographically diverse. A number of direct benefits were derived from these engagements. For instance, they provided a platform for all those involved in efforts to transform the public health to share their experiences, knowledge, as well as insights. Further, thanks to the said engagements, it was possible to gain better perspective of the challenges that could get in the way of the successful implementation of the health equity agenda. It is also through the insights of participants in regional engagements that we can be able to gain better perspective of how collaboration could be used as a tool for success going forward.

In as far as the consultative agenda is concerned, the report also appears to be appreciative of the fact that officials in the public health realm are not the only custodians of resources, knowledge and insights regarding the promotion and protection of the people’s health. It is for this reason that the regional meetings that were instituted in this case roped in participants from various domains. The regional dialogues gave rise to a number of key findings which ultimately informed the development of a number of recommendations. The five findings have been indicated as; “strong leadership and workforce; strategic partnerships; flexible and sustainable funding; timely and locally relevant data, metrics, and analytics; and foundational infrastructure” (U.S. Department of Health and Human Services, 2020). One of the findings that I find rather intriguing, and relevant in our case, relates to funding. This is especially the case given that because of competing priorities, securing adequate funding for some initiatives could be a tall order – especially when it comes to initiatives at the local level. Various ideas and suggestions were floated by participants in regional meetings. One such idea relates to widening the net in the search for funders and partners. For instance, there may be need to reach out to non-traditional funding sources such as venture capital formations that are passionate about certain social causes. Also, we need to recognize that support is not only financial. Non-financial resources could be thought of in terms of access to information, etc. Participants also floated the need for more flexible funding. This kind of funding would not be overly dependent upon traditional funding sources – which happens to be rather rigid. This does not, however, mean that traditional funding streams should be disregarded.

The other equally intriguing finding sourced from participants relates to the establishment of strategic partnerships. As the report points out, participants were able to not only highlight the relevance of strategic partnerships, but also suggest ways of ensuring that engagements of this nature are fruitful. As has been indicated elsewhere in this write-up, collaboration remains key to the achievement of health equity in this country. It is, thus, encouraging for those on the ground to underline the need for such collaboration and offer suggestions on the way forward. The relevance of collaboration is further reinforced by Marmot, Friel, Bell, Houweling, and Taylor (2008) who point out that “action on the social determinants of health must involve the whole of government, civil society, local communities, business, and international agencies” (1661).

It should, however, be noted that collaboration cannot be pursued in a haphazard manner. Indeed, as has been indicated in this report, participants in the regional meetings were categorical that unstructured collaborative efforts are likely to fail. This is to say that there may be need for deeper assessment of collaborative relationships to ensure that they are meaningful and effective. This could be followed by the establishment of a structure that outlines formats of engagement. Another factor that could be taken into consideration in this case is partnership attributes. This is key to the formation of relationships and associations that are strong and authentic. In any case, we should also be aware of the fact that strong and authentic relationships are not formed or established in a day. Indeed, as participants in the regional engagements indicate, it could take time to ensure smooth communication and develop trust. It is on the strength of this reality that the said participants recommend that certain steps not be overlooked – regardless of how irrelevant they may seem. Thus, some of the details that must not be overlooked are inclusive of, but they are not limited to; “meeting face to face, clearly explaining each partner’s value, setting expectations for how each partner will contribute, and setting deadlines for meeting the group’s goals” (U.S. Department of Health and Human Services, 2020).

It should be noted that various communities across the nation have been keen to address the various determinants of health via the application of a wide range of innovative solutions and approaches. However, the role of the entire public health system in the achievement of public health and reduction of health disparities remains critical. Indeed, in the words of Marmot, Friel, Bell, Houweling, and Taylor (2008), “ministries of health and their ministers are crucial to the realization of change” (1662). This is a fact that has been correctly recognized in the report. Indeed, as has been indicated in the report, “without support from across the broader public health system, however, public health entities will not be able to achieve or sustain their transformation” (U.S. Department of Health and Human Services, 2020).

As has been indicated elsewhere in this write-up, a number of findings were made following the regional dialogues – with the said findings informing the development of a number of recommendations. Thus, these recommendations are themed around the findings. A total of five recommendations were floated. It is important to note that the said recommendations are essentially meant to ensure that the various communities across the U.S. benefit from efforts to strengthen public health. Thus, to an even greater extent, these recommendations would help us understand what is needed for health departments to thrive and play a meaningful role in the promotion of the health and wellbeing across the entire population. The first recommendation relates to the acceptance of a broader role – that of the community Chief Health Strategist – by public health leaders as they seek to engage and rope in all the relevant players involved with undertakings meant to address those social determinants of health classified as ‘upstream.’ Those serving in this role ought to be provided or equipped with skills that enable them to perform optimally. This is a crucial point given that efforts to promote health equity ought to be directed in a deliberate and engaging manner, and the person directing the said efforts ought to have the skills and capabilities needed to address evolving challenges in this realm. The report does capture the need to extend the said training to the entire public health workforce.

The second recommendation has got to do with the establishment of meaningful partnerships between public health departments and other stakeholders – particularly the community. This happens to be one of the most recurrent themes across the entire report. More specifically, the need for such collaboration has been established so as to ease sharing of a wide range of resources and knowledge in the development of the various initiatives meant to promote and/or advance the public health 3.0 agenda. In the light of calls for closer collaboration, the relevance of ensuring that all those involved have a shared vision cannot be understated.

The third recommendation made in this particular report is the enhancement and support of Public Health Accreditation Board’s (PHAB) department accreditation processes and criteria. This would be a move to further entrench the ideals of Public Health 3.0 as efforts continue to be made to ensure that only health departments that are accredited serve the needs of the citizens of this nation. According to the report, available research indicates that the capacity enhancement as well as quality improvement efforts of health departments are greatly supported by such accreditation. Fourth, a recommendation has been made that communities across the U.S. be provided with data that is not only actionable, but also reliable and timely. Such data should also be community-specific. This should be complemented by the development of metrics that can be able to track progress and measure success. This is especially important given that without a way of documenting progress, it would be difficult to establish whether initiatives have a meaningful impact on the ground. In this case, we all need to be aware that in the absence of collaboration, gaining access to meaningful data (i.e. actionable, timely, and relevant data) would likely be a rather difficult and imprecise undertaking. A collaborative spirit is what makes data sharing possible.

The fifth and last recommendation relates to the enhancement and substantial modification of public health funding. More specifically, a call for more innovative approaches in as far as funding is concerned is made. This, as has been indicated elsewhere in this write-up is crucial to the continuity of efforts to achieve health equity. This is more so the case given that from time to time, traditional funding partners may be forced to reevaluate their priorities due to a wide range of factors. Thus, funding models ought to be aware of this fact, and seek to mitigate the same by not only enhancing, but also modifying funding alternatives. The report recommends various strategies on this front, such as reinvestment of revenues generated, ‘braiding’ and ‘blending’ of funds sourced from various quarters, etc. Such innovative approaches could be especially meaningful going forwards as the funding environment gets tighter due to various global events.

The Balance of Health Equity vs. Health Disparity as a Focus of the Report

The report does lend itself to a health equity lens. In line with this perspective, we need to first be appreciative of the right of all citizens of this nation to “have the opportunity to make the choices that allow them to live a long, healthy life, regardless of their income, education or ethnic background” (Robert Wood Johnson Foundation, 2010, p. 7). The report is, however, alive to the fact that regardless of all the progress that the country has made in the public health realm over the last few decades, i.e. with regard to health insurance coverage expansion, increase in life expectancy at birth etc., health gaps that could be deemed significant are yet to disappear. As a matter of fact, as the report indicates, there are significant ethnic and racial disparities that have been rather persistent over time. This is more so the case with regard to, amongst other things; exposure to pollutants, infant mortality, vaccination rates, life expectancy, etc. (U.S. Department of Health and Human Services, 2020). This is collaborated by William (as cited in Malat, Mayorga-Gallo, and Williams, 2018) who are categorical that “people of color are disadvantaged on access to a broad range of health-promoting resources and face higher exposure to multiple stressors, adversities, and social conditions that are linked to poorer health outcomes” (149). It is important to note that all the key claims and assertions made in this particular report are further supported by citations from the relevant agencies (including the National Center for Health Statistics, National Academy of Medicine, Institute for Health Metrics and Evaluation, etc.) and various peer-reviewed journal sources. For this reason, the information presented therein could be considered valid and accurate.

The report does further recognize that in seeking to rein in health disparity, there is need to formulate and implement solutions that are domiciled both within and outside the healthcare system. This could be deemed a welcome move to embrace community-level broad-based solutions to rein in health inequity which, as Williams and Mohammed (2013) indicate, remains evident when we take into consideration the earlier disease onset as well as mortality rates among racial minority populations. As has been indicated in the report, a number of communities have taken deliberate measures to address social determinants of health. The fact that lessons and best practices learnt have been shared presents an excellent platform for exchange of ideas and access to information that could be replicated in other settings.

It is important to note that the various recommendations listed in this report are founded upon deliberations at the community level and with the relevant experts on what has worked and what has not, and the challenges and opportunities that exist to ensure that all persons have just and fair chances of achieving optimal health and wellbeing. Whereas some of the recommendations are rather innovative, others are essentially a restatement of the obvious – which is justifiable given our tendency to favor the esoteric suggestions over the more obvious alternatives even in cases where the latter would be ideal. A good example of this relates to the need for collaboration. Various authors have in the past suggested that it would be largely impossible to rein in the existing health disparities in the absence of collaboration between various stakeholders. Indeed, in the words of Mckenzie, Pinger, and Seabert (2016), “collaboration between healthcare providers, community organizations, policymakers, and individuals is essential to creating effective and sustainable solutions that address the root causes of health disparities” (107). It is encouraging to see this particular issue captured in the report in the form of a recommendation. Thus, to a large extent, this report could be deemed a step in the right direction in ensuring that all citizens of this great nation have access to equal and fair opportunities to achieve their full potential in as far as their health and wellbeing are concerned.

Level of Change

This report is likely to have the greatest influence on the institutional level of change. This is more so the case given that the broad recommendations made are meant to support the transformative agenda of health departments and provide a framework for the broader healthcare system to advance the health equity agenda. For instance, the need for engagement between the relevant departments/agencies and stakeholders at the community level is meant to ensure that cross-sector partnerships are established. It is within this framework that meaningful progress can be made in efforts to rein in health inequities. In the absence of the said collaboration, partners would lack access to pathways towards collective action, governance, as well as funding. It should, however, be noted that to effectively fulfill their mandate, the said partnerships should be structured and vibrant. They should also have a shared vision and be ready to facilitate exchange of information in a way that makes it possible to tackle differences in health status from a united front. As a health department administrator, this particular report persuades me to be more appreciative of structured partnerships roping in those in both the private and public sector. For instance, I now recognize that I can play a more active role to drive community engagement. The National Association of County and City Health Officials – NACCHO (2018) indicates that we all have a duty to make contributions on a daily basis to health equity by virtue of being health practitioners. In seeking to establish local partnerships, I would essentially be playing my part in ensuring that our country rids itself of differences in health between persons based on their skin color, ethnicity, level of income, or where they reside.

Driver of Transformation

The driver of transformation which, in my opinion, would be ideal in as far as the implementation of the recommendations highlighted in the report is concerned is dialogue. This is more so the case given that this would likely result in the identification of shared interests between all stakeholders and, thus, better opportunities for consensus building and embrace of the said recommendations. It should also be noted that dialogue would most likely result in greater efficiency in the long-term owing to the fact that solution pathways will be better assessed and proposals made to further refine the said pathways. Dialogue would also be instrumental in joint planning efforts. To a large extent, cross-sector partnerships would work better when consensus building is integrated therein. Information sharing would also only be possible in settings that embrace shared goals. The same applies to funding – especially when it comes to the embrace of more innovative funding models. In this case, identified solutions can only be implemented when all those who have a stake in the achievement of Public Health 3.0 – and more specifically the achievement of health equity – engage in deliberate conversations, i.e. within a multi-stakeholder dialogue framework. It is for these reasons that multi-stakeholder dialogue should be the driver of transformation when it comes to the implementation of the various recommendations highlighted in the report.

Final Recommendations

One key strength of this particular report is its restatement of the relevance of collaboration. One of the lessons learnt so far is that it can be very difficult to make any meaningful progress in the absence of strong partnerships with diverse stakeholders. This is more so the case when it comes to the exchange of crucial information and sharing of limited resources. As a matter of fact, the achievement of the Public Health 3.0 vision and achievement of health equity is largely rooted upon cross-sector collaboration. Towards this end, we must ensure that we are open to and embracive of inter-organizational collaboration. We need to continually ask ourselves: how can we be better partners in the national journey towards the achievement of health equity?

The report has also clearly identified the relevance of local communities in efforts to reduce health inequity. As it indicates, public health cannot be advanced without involving local communities. This is something we should be well aware of as we sake to make our contribution towards the achievement of health equity.

The insights presented in this report could also be deemed valid based on the nature of consultations undertaken during its development and the caliber of all those who offered their insights. More specifically, a number of communities were visited – with attendees in this case being drawn from a diverse group of persons comprising of both public health experts and players in various sectors including, but not limited to; environmental services, both local and state government agencies, academia, social services, etc.

Thanks to this particular report, we are also persuaded to appreciate the relevance of continuous improvement. This is more so the case given that the effectiveness of building upon past successes have been demonstrated by local communities in their efforts to advance the ideals of health improvement for all. Indeed, the report does demonstrate how present progress and accomplishments in public health is connected to past successes – starting with what has been referred to as Public Health 1.0 to the new Public Health 3.0 era. This, when supported by a collaborative spirit will come in handy in efforts to achieve health equity.

The report does also identify the challenges that have been encountered in the advancement of the Public Health 3.0 efforts. Identifying these challenges is key to the identification of the most effective solutions to ensure that the advancement of the health equity agenda is not stifled. Key challenges on this front relate to access to timely data and funding. Awareness about these challenges ensures that we are better prepared to tackle them going forward.

Opportunities for Improvement

It should, however, be noted that the report fails to fully embrace the fact that the recommendations highlighted therein may not be applicable or ideal in certain settings. This is more so the case given the existing differences between communities. We should be alive to the fact that there is no ‘one-size-fits-all’ approach on this front. For this reason, we need to ask ourselves: what makes our community unique or what circumstances are unique to our community and how can we best replicate the triumphs witnessed elsewhere in our own community? Whereas we identify the need for our approaches to be multi-sector, we must also be aware of the fact that the said approaches should be innovative and appreciative of the reality of varying contexts. It should, however, be noted that the report does indicate the need to rely on analytics, metrics as well as data that is locally relevant. This is one of the findings floated by participants in the regional engagement forms. Decisions made without taking into consideration locally relevant factors could be impractical. Participants however indicate that the relevant data as well as metrics may not be always available – effectively meaning that in some scenarios, community needs may not be fully appreciated or understood. One of the possible solutions that have been proposed to rein in this particular issue is accelerated data sharing and the exploration of new data types. In as far as the latter solution is concerned, it would be prudent to note that “data traditionally collected by local public health officials at times paint an incomplete picture of a community’s challenges and successes” (U.S. Department of Health and Human Services, 2020). For this reason, there may be need to explore other sources that are able to better capture the key trends and circumstances unique to a community.