545303 research-article2014
RSH0010.1177/1757913914545303Current topics & opinionsCurrent topics & opinions
Current Topics & Opinions
Transforming public health in the United States Paul Kuehnert and Herminia Palacio of the Robert Wood Johnson Foundation (RWJF) explore the public health structure in the United States, and describe how the RWJF has been influencing the public health system to prevent public health from being marginalized, and to advance and prepare the US public health workforce of the future.
For decades, governmental public health in the United States has been relegated to operating at the margins of the country’s massive healthcare system that drives nearly 20% of the US economy.1 Further buffeted in recent years by a variety of external forces (including the 2008 economic recession, shifting demographics, a high and complex population burden of chronic disease, and a rapidly changing health care delivery system), public health leaders and policymakers increasingly recognize that the existing practice models are no longer adequate for the task of protecting and promoting the public’s health.2 Put simply, US public health risks moving from being marginalized to becoming irrelevant if public health practice is not transformed. The challenges embedded in changing public health practice are multiple, and are made more complex by the decentralized structure of public health in the United States. Public health here is a federated enterprise that includes national entities such as the Center for Disease Control and Prevention, the Food and Drug Administration, and others; state and local governmental health departments; non-governmental organizations at the national, state, and community levels that are organized around single or multiple health-related issues; and public and private colleges and universities that provide education and training to the multiple disciplines making up the public health workforce. National study committees convened by the National Academy of Science’s
Institute of Medicine over the past 30 years3–5 have consistently found the US public health system to be in a state of disarray: misunderstood by elected policymakers and the general public; under-resourced in financial, technological, and workforce spheres; and highly variable in practice and services provided by over 2500 state and local governmental public health departments. For more than 20 years, the Robert Wood Johnson Foundation (RWJF) has made significant investments in advancing public health in the United States. This includes multi-million dollar, flagship investments in public health accreditation and in public health systems and services research, with both efforts broadly directed toward improving the quality and impact of public health practice. It also includes more recent, and more narrowly concentrated, investments in engaging public health leaders in focused dialogues on critical operational issues as well as on more aspirational strategic thinking about how to catalyze and support transformational change in public health practice. Three current examples of these strategic investments include: 1. Building consensus around a set of core and foundational public health capabilities and services; 2. developing an aspirational vision for US public health in 2030; and 3. identifying leadership and educational preparation needed to prepare the public health workforce of the future.
Foundational Capabilities Recognition of the significant variability in the type, amount and financing of public health services led the Institute of Medicine in 2012 to call for a ‘… minimum package of public health services, which includes the foundational capabilities and an array of basic programs no health department can be without…’.5 Through funding a Public Health Leadership Forum (PHLF), RWJF convened a diverse group of federal, state, and local public health leaders and stakeholders in April 2013 to review this recommendation and operationalize it. Over the course of the next nine months, the group developed consensus around a foundational capabilities and services framework6 (see Figure 1) and operationalized them with enough specificity that a costing model is now being developed. The framework is being systematically vetted with the broader US public health community by way of presentations at multiple conferences, webinars, and social media. Once vetted, it is hoped that the foundational capabilities and services framework will be utilized by state, local, and federal policymakers and result in increased resources for public health while decreasing variability in practice and, ultimately, improve population health outcomes.
Aspirational Futures Concurrent with efforts to establish consensus around foundational capabilities and services, RWJF supported efforts to engage public health leaders in developing aspirational visions for public health agencies in a five- to 15-year timeframe. One effort, also facilitated via the PHLF resulted in the development of a white paper7 that:
Copyright © Royal Society for Public Health 2014 September 2014 Vol 134 No 5 l Perspectives in Public Health 251 SAGE Publications Downloaded from rsh.sagepub.com at GEORGIAN COURT UNIV on April 18, 2015 ISSN 1757-9139 DOI: 10.1177/1757913914545303
Current Topics & Opinions Figure 1 Foundational Public Health Services consist of core capabilities and programs
and recommend strategies that will advance public health and help shape a more preferred future for the field.8
Leadership and Workforce Implications
Similar aspirations, identified as a key recommendation to ‘…transform health departments into health development agencies…’8 were identified through a separate visioning process, Public Health 2030, conducted by the Institute for Alternative Futures (IAF) with funding from both RWJF and the Kresge Foundation. Through this project, IAF developed four scenarios describing plausible alternative futures for public health in 2030. The scenarios were developed in partnership with three local and one state health department. IAF then convened a national workshop with 35 leaders from multiple sectors who used the national Public Health 2030 scenarios to develop
Both the High-Achieving Governmental Health Department in 2020 and Public Health 2030 are being promoted by RWJF and discussed actively through Internet, social media, and conference presentations. Leadership and workforce preparation and competencies are chief among the challenges raised in discussions of barriers to realizing public health’s aspirations. RWJF has recently issued a call to design four new human capital programs to develop the types of leaders that will be needed in multiple sectors to advance our nation’s health. One example of these programs, the RWJF Multi-Sector Leaders for Health will be designed to ‘develop a diverse group of…leaders who…will take their leadership and influence to the next level to lead communities, organizations, and the country toward a culture of health’. In summary, while as a philanthropy RWJF has no designated authority within the US public health enterprise or the larger healthcare system, it has the ability to influence these systems by making direct investments in a variety of arenas, convening diverse leaders, and facilitating dialogue. We hope these strategic investments help catalyze efforts to transform public health practice to not only meet the protean challenges facing our populations today but also to ready the public health enterprise for effectively meeting the challenges of tomorrow.
4. Institute of Medicine. The Future of Public Health in the 21st Century. Washington, DC: The National Academies Press, 2002. 5. Institute of Medicine. For the Public’s Health: Investing in a Healthier Future. Washington, DC: The National Academies Press, 2012. 6. RESOLVE – Public Health Leadership Forum. Defining and Constituting Foundational Capabilities and Areas (Version 1). RESOLVE Health, March 2014. Available online at: http://www.resolv.org/sitehealthleadershipforum/files/2014/03/ Articulation-of-Foundational-Capabilities-andFoundational-Areas.v1.May_.pdf (Last accessed 14th June 2014).
7. RESOLVE – Public Health Leadership Forum. The High Achieving Governmental Health Department in 2020 as the Community Chief Health Strategist. RESOLVE Health, May 2014. Available online at: http://www.resolv. org/site-healthleadershipforum/files/2014/05/ The-High-Achieving-Governmental-HealthDepartment-as-the-Chief-Health-Strategistby-2020-Final.pdf (Last accessed 14th June 2014). 8. Institute for Alternative Futures. Public Health 2030. altfutures.org, June 2014. Available online at: http://www.altfutures. org/public_health (Last accessed 19 th June 2014).
HD: health department.
… zeroes in on what a high-achieving public health department of the future will be doing differently. It does so not with a comprehensive inventory of tasks but rather with a distillation of the most important new skills and activities essential to be highachieving and serve in the role of the community chief health strategist.7 Furthermore, as a ‘chief health strategist’, the high-achieving health department of the future will ‘…emphas[ize]…catalyzing and taking actions that improve community wellbeing, and…will play a vital role in promoting the reorientation of the health care system towards prevention and wellness’.7
References 1.
Wayne A. Health Care Spending to Reach 20 of US Economy by 2021. Bloomberg, 13th June 2012. Available online at: http://www.bloomberg. com/news/2012-06-13/health-care-spending-toreach-20-of-u-s-economy-by-2021.html (Last accessed 14th June 2014). 2. Trust for America’s Health (TFAH). A Healthier America 2013: Strategies to Move from Sick Care to Health Care in the Next 4 Years. TFAH.org, January 2013. Available online at: http://tfah.org/ assets/files/TFAH2013HealthierAmericaFnlRv.pdf (Last accessed 14th June 2014). 3. Institute of Medicine. The Future of Public Health. Washington, DC: The National Academies Press, 1988.
252 Perspectives in Public Health l September 2014 Vol 134 No 5 Downloaded from rsh.sagepub.com at GEORGIAN COURT UNIV on April 18, 2015
RSH0010.1177/1757913914545303Current topics & opinionsCurrent topics & opinions
Current Topics & Opinions
Transforming public health in the United States Paul Kuehnert and Herminia Palacio of the Robert Wood Johnson Foundation (RWJF) explore the public health structure in the United States, and describe how the RWJF has been influencing the public health system to prevent public health from being marginalized, and to advance and prepare the US public health workforce of the future.
For decades, governmental public health in the United States has been relegated to operating at the margins of the country’s massive healthcare system that drives nearly 20% of the US economy.1 Further buffeted in recent years by a variety of external forces (including the 2008 economic recession, shifting demographics, a high and complex population burden of chronic disease, and a rapidly changing health care delivery system), public health leaders and policymakers increasingly recognize that the existing practice models are no longer adequate for the task of protecting and promoting the public’s health.2 Put simply, US public health risks moving from being marginalized to becoming irrelevant if public health practice is not transformed. The challenges embedded in changing public health practice are multiple, and are made more complex by the decentralized structure of public health in the United States. Public health here is a federated enterprise that includes national entities such as the Center for Disease Control and Prevention, the Food and Drug Administration, and others; state and local governmental health departments; non-governmental organizations at the national, state, and community levels that are organized around single or multiple health-related issues; and public and private colleges and universities that provide education and training to the multiple disciplines making up the public health workforce. National study committees convened by the National Academy of Science’s
Institute of Medicine over the past 30 years3–5 have consistently found the US public health system to be in a state of disarray: misunderstood by elected policymakers and the general public; under-resourced in financial, technological, and workforce spheres; and highly variable in practice and services provided by over 2500 state and local governmental public health departments. For more than 20 years, the Robert Wood Johnson Foundation (RWJF) has made significant investments in advancing public health in the United States. This includes multi-million dollar, flagship investments in public health accreditation and in public health systems and services research, with both efforts broadly directed toward improving the quality and impact of public health practice. It also includes more recent, and more narrowly concentrated, investments in engaging public health leaders in focused dialogues on critical operational issues as well as on more aspirational strategic thinking about how to catalyze and support transformational change in public health practice. Three current examples of these strategic investments include: 1. Building consensus around a set of core and foundational public health capabilities and services; 2. developing an aspirational vision for US public health in 2030; and 3. identifying leadership and educational preparation needed to prepare the public health workforce of the future.
Foundational Capabilities Recognition of the significant variability in the type, amount and financing of public health services led the Institute of Medicine in 2012 to call for a ‘… minimum package of public health services, which includes the foundational capabilities and an array of basic programs no health department can be without…’.5 Through funding a Public Health Leadership Forum (PHLF), RWJF convened a diverse group of federal, state, and local public health leaders and stakeholders in April 2013 to review this recommendation and operationalize it. Over the course of the next nine months, the group developed consensus around a foundational capabilities and services framework6 (see Figure 1) and operationalized them with enough specificity that a costing model is now being developed. The framework is being systematically vetted with the broader US public health community by way of presentations at multiple conferences, webinars, and social media. Once vetted, it is hoped that the foundational capabilities and services framework will be utilized by state, local, and federal policymakers and result in increased resources for public health while decreasing variability in practice and, ultimately, improve population health outcomes.
Aspirational Futures Concurrent with efforts to establish consensus around foundational capabilities and services, RWJF supported efforts to engage public health leaders in developing aspirational visions for public health agencies in a five- to 15-year timeframe. One effort, also facilitated via the PHLF resulted in the development of a white paper7 that:
Copyright © Royal Society for Public Health 2014 September 2014 Vol 134 No 5 l Perspectives in Public Health 251 SAGE Publications Downloaded from rsh.sagepub.com at GEORGIAN COURT UNIV on April 18, 2015 ISSN 1757-9139 DOI: 10.1177/1757913914545303
Current Topics & Opinions Figure 1 Foundational Public Health Services consist of core capabilities and programs
and recommend strategies that will advance public health and help shape a more preferred future for the field.8
Leadership and Workforce Implications
Similar aspirations, identified as a key recommendation to ‘…transform health departments into health development agencies…’8 were identified through a separate visioning process, Public Health 2030, conducted by the Institute for Alternative Futures (IAF) with funding from both RWJF and the Kresge Foundation. Through this project, IAF developed four scenarios describing plausible alternative futures for public health in 2030. The scenarios were developed in partnership with three local and one state health department. IAF then convened a national workshop with 35 leaders from multiple sectors who used the national Public Health 2030 scenarios to develop
Both the High-Achieving Governmental Health Department in 2020 and Public Health 2030 are being promoted by RWJF and discussed actively through Internet, social media, and conference presentations. Leadership and workforce preparation and competencies are chief among the challenges raised in discussions of barriers to realizing public health’s aspirations. RWJF has recently issued a call to design four new human capital programs to develop the types of leaders that will be needed in multiple sectors to advance our nation’s health. One example of these programs, the RWJF Multi-Sector Leaders for Health will be designed to ‘develop a diverse group of…leaders who…will take their leadership and influence to the next level to lead communities, organizations, and the country toward a culture of health’. In summary, while as a philanthropy RWJF has no designated authority within the US public health enterprise or the larger healthcare system, it has the ability to influence these systems by making direct investments in a variety of arenas, convening diverse leaders, and facilitating dialogue. We hope these strategic investments help catalyze efforts to transform public health practice to not only meet the protean challenges facing our populations today but also to ready the public health enterprise for effectively meeting the challenges of tomorrow.
4. Institute of Medicine. The Future of Public Health in the 21st Century. Washington, DC: The National Academies Press, 2002. 5. Institute of Medicine. For the Public’s Health: Investing in a Healthier Future. Washington, DC: The National Academies Press, 2012. 6. RESOLVE – Public Health Leadership Forum. Defining and Constituting Foundational Capabilities and Areas (Version 1). RESOLVE Health, March 2014. Available online at: http://www.resolv.org/sitehealthleadershipforum/files/2014/03/ Articulation-of-Foundational-Capabilities-andFoundational-Areas.v1.May_.pdf (Last accessed 14th June 2014).
7. RESOLVE – Public Health Leadership Forum. The High Achieving Governmental Health Department in 2020 as the Community Chief Health Strategist. RESOLVE Health, May 2014. Available online at: http://www.resolv. org/site-healthleadershipforum/files/2014/05/ The-High-Achieving-Governmental-HealthDepartment-as-the-Chief-Health-Strategistby-2020-Final.pdf (Last accessed 14th June 2014). 8. Institute for Alternative Futures. Public Health 2030. altfutures.org, June 2014. Available online at: http://www.altfutures. org/public_health (Last accessed 19 th June 2014).
HD: health department.
… zeroes in on what a high-achieving public health department of the future will be doing differently. It does so not with a comprehensive inventory of tasks but rather with a distillation of the most important new skills and activities essential to be highachieving and serve in the role of the community chief health strategist.7 Furthermore, as a ‘chief health strategist’, the high-achieving health department of the future will ‘…emphas[ize]…catalyzing and taking actions that improve community wellbeing, and…will play a vital role in promoting the reorientation of the health care system towards prevention and wellness’.7
References 1.
Wayne A. Health Care Spending to Reach 20 of US Economy by 2021. Bloomberg, 13th June 2012. Available online at: http://www.bloomberg. com/news/2012-06-13/health-care-spending-toreach-20-of-u-s-economy-by-2021.html (Last accessed 14th June 2014). 2. Trust for America’s Health (TFAH). A Healthier America 2013: Strategies to Move from Sick Care to Health Care in the Next 4 Years. TFAH.org, January 2013. Available online at: http://tfah.org/ assets/files/TFAH2013HealthierAmericaFnlRv.pdf (Last accessed 14th June 2014). 3. Institute of Medicine. The Future of Public Health. Washington, DC: The National Academies Press, 1988.
252 Perspectives in Public Health l September 2014 Vol 134 No 5 Downloaded from rsh.sagepub.com at GEORGIAN COURT UNIV on April 18, 2015
