Public Health 3.0: Transforming Infrastructure for Health Equity

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, place of residence, or income level. 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 explores 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.

There is a need to ensure that every citizen of this country has a just and fair opportunity to achieve their full potential in terms of health and wellbeing. Despite significant progress on multiple fronts — including advances in technology and the expansion of democracy — the United States has yet to achieve health equity. This has been an elusive goal for a long time. As Williams and Sternthal (2010) point out, racial differences in health can be traced back to the country's earliest medical records. The country still grapples with disparities in health outcomes, and significant differences exist in both the distribution of health resources and 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 report illustrates the progress that has been made in the past and identifies strategies that have been deployed, as well as ideas for further progress.

Review and Critique of the Report

From the outset, the report recognizes that health equity cannot be achieved in a vacuum — it is a collaborative effort in which all persons should play a meaningful role and share experiences. The initiation of a national dialogue — organized through regional meetings and stakeholder engagement across multiple sectors — is therefore a welcome development. It is also laudable that insights were sought from communities that are both demographically and geographically diverse. These engagements provided a platform for those involved in public health transformation to share experiences, knowledge, and insights. They also shed light on the challenges that could hinder the successful implementation of the health equity agenda and demonstrated how collaboration could serve as a tool for success going forward.

The report acknowledges that public health officials are not the only custodians of resources, knowledge, and insights regarding the promotion and protection of public health. For this reason, regional meetings included participants from various domains. These dialogues produced a number of key findings that ultimately informed the report's recommendations. The five findings are identified 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 particularly intriguing finding relates to funding. Given competing priorities, securing adequate funding — especially at the local level — can be extremely challenging. Participants in regional meetings suggested widening the search for funders and partners, including non-traditional sources such as venture capital organizations passionate about social causes. They also noted that support need not be exclusively financial; non-financial resources such as access to information are equally valuable. Participants further emphasized the need for more flexible funding models that are not overly dependent on traditional, relatively rigid funding sources — while also noting that traditional funding streams should not be entirely disregarded.

Another important finding concerns the establishment of strategic partnerships. As the report notes, participants highlighted the relevance of strategic partnerships and suggested ways to make such engagements productive. The importance of collaboration is reinforced by Marmot, Friel, Bell, Houweling, and Taylor (2008), who argue that "action on the social determinants of health must involve the whole of government, civil society, local communities, business, and international agencies" (p. 1661).

Collaboration, however, cannot be pursued in a haphazard manner. Participants in the regional meetings were categorical that unstructured collaborative efforts are likely to fail. There is a need for deeper assessment of collaborative relationships to ensure they are meaningful and effective, followed by the establishment of structures that outline formats of engagement. Partnership attributes are also a key consideration, as strong and authentic relationships take time to develop. Trust and smooth communication do not emerge overnight. Participants therefore recommended that certain foundational steps not be overlooked, including "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).

Various communities across the nation have sought to address the determinants of health through a wide range of innovative solutions. However, the role of the broader public health system remains critical. As Marmot et al. (2008) note, "ministries of health and their ministers are crucial to the realization of change" (p. 1662). The report correctly acknowledges this, stating that "without support from across the broader public health system, public health entities will not be able to achieve or sustain their transformation" (U.S. Department of Health and Human Services, 2020).

Five recommendations emerged from the regional dialogues. The first calls on public health leaders to accept a broader role — that of community Chief Health Strategist — engaging all relevant players to address upstream social determinants of health. Those serving in this role should be equipped with the skills needed to perform optimally and to address evolving challenges. The report also captures the need to extend this training to the entire public health workforce.

The second recommendation concerns the establishment of meaningful partnerships between public health departments and other stakeholders, particularly the community. This theme recurs throughout the report. Such collaboration is intended to facilitate the sharing of resources and knowledge in the development of initiatives meant to advance the Public Health 3.0 agenda. A shared vision among all partners is essential to making these efforts effective.

The third recommendation is the enhancement and support of the Public Health Accreditation Board's (PHAB) department accreditation processes and criteria. This would entrench the ideals of Public Health 3.0 and ensure that only accredited health departments serve the needs of the nation's citizens. Available research, as cited in the report, indicates that accreditation greatly supports capacity enhancement and quality improvement efforts within health departments.

Fourth, a recommendation is made that communities across the U.S. be provided with actionable, reliable, and timely data that is also community-specific. This should be complemented by the development of metrics capable of tracking progress and measuring success. Without a means of documenting progress, it would be difficult to establish whether initiatives have a meaningful impact. Collaboration is integral to this recommendation as well, since gaining access to meaningful data without a collaborative framework would be a difficult and imprecise undertaking.

The fifth and final recommendation calls for the enhancement and substantial modification of public health funding. More innovative approaches to funding are needed to ensure the continuity of health equity efforts, especially as traditional funding partners may be forced to reevaluate their priorities. Funding models must account for this reality by enhancing and modifying available alternatives. The report recommends strategies such as reinvestment of generated revenues and the "braiding" and "blending" of funds sourced from various quarters. Such innovative approaches will be especially important as the funding environment tightens due to various global pressures.

The report adopts a clear health equity lens. In line with this perspective, it affirms the right of all citizens "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 also candid about the fact that despite progress in public health over recent decades — including expanded health insurance coverage and increased life expectancy at birth — significant health gaps persist. Ethnic and racial disparities have remained persistent over time, particularly with regard to exposure to pollutants, infant mortality, vaccination rates, and life expectancy (U.S. Department of Health and Human Services, 2020). This is corroborated by William (as cited in Malat, Mayorga-Gallo, and Williams, 2018), who notes 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" (p. 149). All key claims and assertions in this report are further supported by citations from authoritative agencies — including the National Center for Health Statistics, National Academy of Medicine, and the Institute for Health Metrics and Evaluation — as well as peer-reviewed journal sources, lending the report credibility and validity.

The report further recognizes that addressing health disparity requires solutions both within and outside the healthcare system. This embrace of broad-based, community-level solutions is a welcome development. As Williams and Mohammed (2013) indicate, health inequity remains evident in the earlier disease onset and higher mortality rates among racial minority populations. A number of communities have taken deliberate measures to address social determinants of health, and lessons and best practices from these efforts have been shared, providing an excellent platform for the exchange of ideas that can be replicated in other settings.

The Balance of Health Equity vs. Health Disparity

The recommendations in this report are founded on community-level deliberations and expert input regarding what has worked, what has not, and what challenges and opportunities exist for ensuring that all persons have just and fair chances of achieving optimal health. Some recommendations are innovative; others restate established principles — which is justifiable, given the tendency to favor novel suggestions over more straightforward solutions even when the latter may be more appropriate. The importance of collaboration is a prime example. As Mckenzie, Pinger, and Seabert (2016) argue, "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" (p. 107). Seeing this principle formalized as a recommendation is encouraging and represents a meaningful step forward.

This report is likely to have the greatest influence at the institutional level of change. The broad recommendations 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 call for engagement between public health departments and community stakeholders is designed to facilitate the establishment of cross-sector partnerships. Within this framework, meaningful progress can be made in reining in health inequities. Without such collaboration, partners would lack access to pathways toward collective action, governance, and funding. To effectively fulfill their mandate, these partnerships must be structured and vibrant, with a shared vision and a readiness to facilitate the exchange of information in a unified effort to tackle health disparities. As a health department administrator, this report persuades me to be more appreciative of structured partnerships spanning both the private and public sectors. The National Association of County and City Health Officials (NACCHO) (2018) notes that health practitioners have a daily duty to contribute to health equity. By working to establish local partnerships, I would be playing my part in ensuring that our country eliminates health differences rooted in skin color, ethnicity, income level, or place of residence.

The driver of transformation best suited to implementing the report's recommendations is dialogue. Multi-stakeholder dialogue would likely result in the identification of shared interests, better opportunities for consensus building, and the adoption of the report's recommendations. Dialogue would also promote greater long-term efficiency, as solution pathways can be better assessed and refined through sustained conversation. Dialogue is also instrumental to joint planning, and cross-sector partnerships are most effective when consensus building is integrated into their operations. Information sharing and innovative funding approaches are similarly dependent on settings that embrace shared goals.

Identified solutions can only be implemented when all those who have a stake in achieving Public Health 3.0 — and health equity more broadly — engage in deliberate conversations within a multi-stakeholder dialogue framework. For these reasons, multi-stakeholder dialogue should be the primary driver of transformation in implementing the report's recommendations.

One key strength of this report is its restatement of the importance of collaboration. One of the enduring lessons in public health is that meaningful progress is very difficult to achieve without strong partnerships with diverse stakeholders — particularly when it comes to the exchange of critical information and the sharing of limited resources. The achievement of the Public Health 3.0 vision and the broader goal of health equity are fundamentally rooted in cross-sector collaboration. We must remain open to and supportive of inter-organizational collaboration, continually asking ourselves: how can we be better partners in the national journey toward health equity?

Conclusion

Williams, D.R., & Sternthal, M. (2010). Understanding racial-ethnic disparities in health: Sociological contributions. Journal of Health and Social Behavior, 51(S), S15–S27.

Williams, D.R., & Mohammed, S.A. (2013). Racism and health I: Pathways and scientific evidence. American Behavioral Scientist, 57(8), 1152–1173.