Beyond the Status Quo: 5 Strategic Moves to Position State and Territorial Public Health Agencies for an Uncertain Future

Beyond the Status Quo The 75th anniversary of the Association of State and Territorial Health Officials (ASTHO) presents an opportunity to celebrate the past accomplishments of state and territorial health agencies (SHAs) and consider their potential future. Several authors have examined the current and future needs of the governmental public health workforce and future trends impacting the governmental public health system. 1–7 The Institute for Alternative Future's Public Health 2030 Scenarios aptly describe 4 potential futures that public health agencies may face (Table 1), and several of these scenarios would have negative impact on SHA capacity to address public health challenges and improve population health. 8 Brownson and Kreuter described future trends impacting public health in the new millennium in 1997. Their forecast was updated and elaborated upon 20 years later by Erwin and Brownson, who provide an excellent summary of the macrotrends and “forces of change” facing public health today (see Table 2). 3, 4 When these trends are combined with increasing political partisanship, declining support for government, disdain for science, and popular debates over what constitutes fact or truth, we predict an uncertain future for public health. Despite this prevailing uncertainty, one thing is clear: the status quo will not generate the significant improvements in health that we desire and for which so many are working so hard to achieve. TABLE 1 - Public Health 2030 Scenariosa Scenario 1: One step forward, half a step back Amidst continued fiscal constraints, public health agencies and health care slowly advance their capabilities. Many use automation and advanced analytics to improve services and community and population health. However, climate change challenges continue to grow, and there is little progress in improving the social determinants of health. Great variations in technological capabilities, funding, and approaches to prevention—along with a continuous rise in health care costs—significantly limit public health gains. Scenario 2: Overwhelmed, under-resourced Funding cuts and a hostile political context undermine the role of public health agencies, which subsequently fail to attract talented young people. Public health crises grow worse and more frequent, largely due to climate change. Private sector initiatives produce significant innovations for health and wellness, but these primarily benefit the middle-class and affluent groups. Technological, economic, educational, and health disparities grow, and the institutions of public health have little capacity for doing anything about them. Scenario 3: Sea change for health equity National and local economies gradually grow, and changes in values and demographics lead to “common sense” policies and support for health equity. Public health agencies develop into health development agencies that use advanced analytics, gamification, and diverse partnerships to identify problems and opportunities and catalyze and incentivize action to improve community health. While some disparities persist, in 2030, the vast majority of US residents have attained greater opportunity for good health through quality improvements in housing, economic opportunity, education, and other social determinants of health. Scenario 4: Community-Drive Health and Equity Public health agencies, partners, and local health improvement initiatives coalesce via technology and social media into a national web of community health-enhancing networks. These networks help communities exchange their innovations and best practices and leverage the expertise of public health agencies and others. The nation also strives to come to terms with its racial and socioeconomic histories and supports real changes and legislation to create a more equitable society. This value shift to equity is accelerated by the proliferation of new community economic models that help households sustain themselves and improve health and well-being. Public health sheds many functions and facilitates these movements to improved health. aAdapted with permission from Institute for Alternative Futures. 8 TABLE 2 - Macrotrends and Forces of Change Impacting Public Health in the Futurea Brownson and Krueter3 Erwin and Brownson4 Aging population The Patient Protection and Affordable Care Act Changing patterns in the US racial/ethnic composition Public Health Agency Accreditation Changes in health care delivery systems Climate change Explosion of information technologies Health in all policies Changing needs in the public health work force Social media and informatics Growth in health-related partnerships Demographic transitions Antigovernment sentiment and polarization Globalized travel aAdapted with permission from Brownson and Krueter3 and Erwin and Brownson. 4 To help respond to this uncertain future, in late 2016, local, state, and national public health leaders convened to craft “Public Health 3. 0. ” Public Health 3. 0 is a set of recommendations describing the upgrade needed to move public health from its current state of managing various programmatic activities and outcomes toward an intentional, strategic focus on the social determinants of health and wellness that crosscut disease “stovepipes. ”9, 10 The key insight of Public Health 3. 0 is the realization that the most effective interventions to improve health are the result of what local, state, and federal public health organizations do themselves and their collaborative work with other agencies and organizations in health care delivery, housing, education, employment, and economic development. A core concept in Public Health 3. 0 is the need for governmental public health officials to become the “chief health strategists” for their jurisdictions and embrace their leadership roles in moving upstream to address the social determinants of health and well-being. 10, 11 Efforts to imagine an upgraded public health system are needed and welcome. Public Health 3. 0 capitalizes on the idea that the future, however uncertain, holds incredible opportunity for governmental public health but also poses significant challenges. The specific strategies and tactics needed for SHAs to upgrade from Public Health 2. 0 to 3. 0, however, have not been well described. Waiting for the future is a much less effective strategy than working proactively to shape it. In reviewing the perspectives, trends, and approaches that will define the governmental public agency of the future, we propose 5 key strategic moves that leaders of SHAs can take to assure optimal health for all. Despite new investments in health care delivery that incentivize payers and providers to promote population health, we posit that SHAs are the true “accountable care organizations” in their jurisdictions and the natural leaders to convene and align governmental and nongovernmental assets toward achieving both the Institute for Healthcare Improvement's “triple aim” of health care and ASTHO's triple aim of health equity. 12, 13 The 5 Strategic Moves Our use of the term “strategic” refers to the alignment of organizational activities and planning efforts a SHA uses to guide its work toward defined goals and outcomes. It aligns best with the work of Lafley and Martin, 14 who define strategy as making organizational decisions about “where to play” and “how to win. ” Thus, strategic moves are the plays or actions a SHA can take to effectively reach its goals. Our view of strategy is also based on the work of Michael Porter, who views strategy as organizational considerations about trade-offs (what the organization will and will not do) and the alignment or “fit” between the various parts of a business enterprise (how activities join to create a cohesive whole). 15 In sum, the strategic moves described later inform the tactics SHAs can use to align efforts that will lead to better health outcomes. Upgrading from categorical, fragmented Public Health 2. 0 organizations to collaborative Public Health 3. 0 enterprises provides the move needed to fully leverage SHA potential with that of other agencies and organizations that share a mission of improving current and future public health needs. Strategic Move 1: From Programs to Populations The Institute of Medicine's landmark report Future of Public Health expertly characterized the state of public health in the late 1980s as a field in “disarray, ” and its follow-on study made similar observations about where public health stood early in the 20th century. 16, 17 A major factor for this disarray was attributed to inflexible, categorical systems of funding for various disease-specific public health programs. The categorical nature of public health funding is perhaps the greatest barrier and biggest opportunity for SHAs in the future. Funding “stovepipes” create fiefdoms within agencies. Categorical funding limits the drive to collaborate and directs resources to where successful grants are written, not necessarily where there is greatest need. Staff working in silos spend countless hours on separate program reports, separate funding applications, and separate meetings, and they create separate strategic plans, separate logic models, and disconnected work plans. A major cause of programmatic stovepipes is the way federal funding is appropriated by Congress and how the federal agencies implement public health programs. For example, a SHA cannot legally use its human immunodeficiency virus surveillance dollars for surveillance of other sexually transmitted infections. Support for categorical programs is often reinforced by advocates and interest groups that lobby for specific lines in federal and state budgets and define success as sustained or increased funding for those lines even when those increases are obtained by decreasing resources to others. The strategic move from program to population is crucial to positioning SHAs for the future. Flexible funding streams allow SHAs to address local and state priorities that most certainly will differ from those of federal agencies. Public Health 3. 0 calls for innovative funding models that blend and braid funds from a variety of funding streams to support both core public health capacity and community-level efforts to address the social determinants of health and well-being. The Institute of Medicine made a similar call in its 2012 study For the Public's Health: Investing in a Healthier Future. In that report, the Institute of Medicine recommends that the US Department of Health & Human Services allow greater flexibility in the use of grant funds to achieve population health goals at the state and local levels, Congress adopt legislative changes to allow such flexibility, and federal agencies “design and implement funding opportunities in ways that incentivize coordination among public health system stakeholders. ”18 Recognizing that changing the way the Congress appropriates federal resources for state and local public health is a difficult if not impossible task, advocates for SHAs have focused on working with federal agencies to allow for more flexibility in directing programming dollars based on state needs within the administrative authority currently delegated to federal agencies. The Centers for Disease Control and Prevention's (CDC) “State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health” is one example of a federal funding opportunity that addresses several different chronic disease programs at once that are often funded separately (diabetes, heart disease, stroke). 19 The Preventive Health and Health Services Block Grant is the only major source of crosscutting, flexible funding for most SHAs (160 million for all states and territories in FY2017). Created in 1981, the “Prevent Block” allows states to use federal resources to address a variety of state and territorial public health priorities including communicable and noncommunicable disease prevention and health promotion. Similar to the US Congress, state and territorial legislatures also limit funding flexibility to specific program or State and territories may to consider ways to promote the flexibility their agencies have to address health priorities or other grant programs that allow for funds to or to address local needs. and health is one of the best to describe the move from program to population in on interventions to improve health the leaders take a population on health funding through the and Health Services Block Grant is of this when combined with state a flexible for SHAs to use in efforts the with national that for The strategic move from program to population health is in where there is major on to SHA programmatic The move agency stovepipes to address the crosscutting, population needs of and 1 how the Department of Strategic the way that health agency activities the of all residents the from to 1: Strategic Move Programs to Department of with from programs to will take more than changing the way SHAs are The public health workforce and to systems that address the needs of continued of the The National for Public Health the need for public health workforce development efforts to not Despite this many public health workforce development efforts in toward systems and population These approaches can silos and to other activities within the agency or with other of state that lead to One only needs to at the variety of leadership for the public health workforce to that major program its or development most of which are funded by programmatic with little interest in the system as a that lead the way for and systems approaches to workforce development the Public Health for Public Health” and the “State Health funded by the These programs and work that those among the governmental public health Strategic Move 2: From to While several SHAs provide health care services in communities where there is little to other most SHAs have from the of services toward that those services are by health care delivery at the local and state of the for how SHAs need to move upstream toward disease prevention and health in of how the Department of Health to address the health of the and and other use The of the 4 are social and and if interventions these that the work of governmental public health innovative approaches to prevention that public focus on upstream prevention with the health care delivery focus on This of public health and what refers to as the or interventions that care the is with opportunities to and community approaches to health and disease 4 with provides a for efforts to chronic disease within states The is a to share and successful models of public health and the move from to The public health and care providers to identify practices to effective between care and public health. 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The strategic moves are for both to and also moving the field These 5 strategic moves guide public health efforts toward both and programs and to more effective and ways to improve health the future may