COVID-19 has made clear that the nation’s safety, health, and economic prosperity depend on its ability to minimize the effects of devastating public health threats. Even in the absence of an emergency, a robust governmental public health system is needed to ensure conditions in which all people can achieve their fullest potential for health and well-being. Although clinical health care plays an important role in treating disease, public health plays an equally important but largely invisible role in keeping people healthy.
Public health seeks to protect the health of entire populations through the promotion of healthy lifestyles; the research and applied practice of disease and injury prevention; and the detection and prevention of, as well as response to, infectious diseases.3 In the 20th century, the average lifespan in the United States increased by 30 years, with 25 of those years attributable to public health advances.4These advances included safer food and water, improvements in motor vehicle safety due to the addition of features such as seat belts and changes in highway design, and widespread vaccinations, which have drastically reduced the rate of many diseases, especially for children. And yet, decades of decreased funding for public health has hampered its ability to make meaningful advances in tackling challenges such as the obesity and opioid epidemics. Chronic underfunding also means that most public health departments do not have the bandwidth to support a growing crisis in mental health or sufficiently prepare for anticipated health crises related to climate change.
Pervasive health inequities, driven by socioeconomic differences in urban, rural, and Tribal communities that have existed for much of the country’s history, were also illuminated during the pandemic. These inequities prevent the United States from meeting its full potential, not only as it relates to the health of affected individuals but also to the estimated $93 billion in excess medical care costs and $42 billion in lost productivity per year attributed to health disparities.5 Because 80% of a person’s health can be attributed to socioeconomic factors such as access to nutritious food, quality education, and a safe physical environment,6 public health should partner with other sectors and government agencies to address these sources of health and reduce inequities.
In addition, the pandemic has worsened behavioral health, with individuals reporting higher levels of stress and more disorders, including depression and anxiety. Traditionally, the health care system has taken a clinical approach to help such individuals. A public health approach to behavioral health as pioneered by cities such as New York and Philadelphia offers promise by strengthening community-based services to meet behavioral needs along a continuum, not just those requiring clinical intervention, and emphasizing prevention and early intervention.7
Compounding all of these challenges, it is an unfortunate reality that public health also has a deep trust problem. Polls conducted in the spring of 2020 showed great support for public health, with 85% of Republicans and 74% of Democrats rating public health officials such as those at the CDC as “doing an excellent/good job responding to the coronavirus outbreak.”8 And yet, an RWJF/Harvard poll conducted from mid-February to mid-March 2021 found something markedly different: Only 44% of respondents trusted the recommendations of their local health department a great deal or quite a lot, and 41% trusted those from their state health department a great deal or quite a lot, leaving the remainder only somewhat trusting them or not trusting them at all.9 Politicization, misinformation, and mixed communication initiatives are some of the factors responsible for these findings. The lack of trust undermines public safety and the purpose of public health now and in the future.
Public Health Forward: Modernizing the U.S. Public Health System defines a vision for a modernized public health system in the 21st century and provides a framework of practical, prioritized, and bipartisan actions for policymakers and public health officials to guide strategic investments and decision-making to help translate the vision into a reality with a focus on equity. The federal government continues to provide critical leadership and funding to navigate the current pandemic and has a responsibility to make significant investments and changes in public health for the post-pandemic future. Long-term, increased, sustainable funding and policy leadership from the federal government will be crucial to support this five-year vision, framework, and set of actions, as most public health departments are concerned over their funding levels, notwithstanding the recent infusion of money.10
Researchers have estimated that it would cost $10.94 billion in additional resources annually, or $34.20 per capita, to fund what experts consider a minimum package of public health services for each state and local public health department.11 Separate from this project, the Bipartisan Policy Center recently published a report that called for Congress to pass $4.5 billion in permanent annual funding to be distributed to states, localities, tribes, and territories to support foundational public health capabilities, and to reform the existing Prevention and Public Health Fund and increase its annual funding to $4 billion to support public health programs and meet local needs. Departments and agencies with jurisdiction over public health such as the CDC, U.S. Department of Agriculture, and U.S. Department of Health and Human Services (HHS) all make meaningful contributions through the development of regulations, standards, and effective public health messaging and guidance. However, this report’s focus is on governmental public health systems at the state, territorial, and local levels, where most public health policy is enacted and critical decisions are made regarding the stewardship and allocation of federal funds. While Tribal health systems and public health departments are critical to community health, this report is not intended to provide recommendations to support the modernization of these systems. The report does include recommendations to improve consultation and collaboration between U.S. and Tribal governments to support shared public health priorities. Policymakers and public health leaders must embrace this unique moment and strategically plan and implement a well-resourced, modern public health system that builds capacity at all levels of government and in every state, territory, and locality.
The infusion of federal COVID-19 relief funds is an opportunity to strategically invest in and modernize the public health system. Legislation to improve the sustainability of public health departments includes $7.4 billion for the recruitment and hiring of public health workers and $2.45 billion for emergency preparedness and response purposes. In addition, some of the COVID-19 relief funding packages can be invested in public health departments to provide long-term benefits by supporting public health science, policy, systems, and infrastructure. (See Appendix 1: Federal Investments in Public Health in COVID-19 Relief Legislation for additional details.) Policymakers should use the growing awareness of the importance of the public health field to set a new course for health in the United States, while also fostering greater trust in government and science.
Public Health Forward provides recommended actions to policymakers and public health leaders to steward the use of this one-time infusion to provide long-term strategic benefits to state, territorial, and local public health systems. As noted above, greater, sustained, and less siloed funding will be necessary in the near future to ensure these benefits continue.
The report’s recommendations build on several national public health frameworks and reports which articulate the foundational requirements for optimal public health systems. These reports include the following:
- Public Health 3.0 describes the role of public health departments in the 21st century and calls on public health leaders to serve as Chief Health Strategists for their communities and departments to engage in cross-sector partnerships; upgrade and monitor data systems with an emphasis on hyperlocal data; hire a diverse and inclusive workforce; and provide foundational public health capabilities. 12
- Foundational Public Health Services defines the cross-cutting skills and capabilities, as well as the core programs, needed in all health departments to fulfill their responsibilities. 13
- Public Health COVID-19 Impact Assessment examines how public health departments fared during the pandemic, including their key contributions and challenges faced, and identifies “priority areas and policy considerations” for policymakers to develop a 21st century public health system.14
- Recommendations by the Robert Wood Johnson Foundation’s National Commission to Transform Public Health Data Systems are targeted at government at all levels, businesses, CBOs, philanthropy, and other parties to “reimagine how data are collected, shared, and used, and identify the investments needed to improve health equity.15
- CDC’s Data Modernization Initiative presents a vision of what the modernization strategy was created to do, guides decisions for allocating resources, and provides a structure to track progress and success along the way.16
- The National Consortium for Public Health Workforce Development’s report, Building Skills for a More Strategic Public Health Workforce: A Call to Action, provides a common framework for modernizing the state, local, territorial, and Tribal public health workforce through recruitment, hiring, and retention priorities.17
Additionally, a number of states, including Indiana,18 Kentucky,19Ohio,20 Oregon,21 Washington,22 and others23 have modernized their public health systems or are in the process of modernizing. These states’ efforts are a natural learning laboratory and provide examples of this report’s recommendations in action.
In short, we already know what needs to be done, and we urge policymakers and public health officials to seize this unique moment and take action.
The Public Health Forward project team was led by a Steering Committee representing national philanthropic foundations, public health membership associations, the Bipartisan Policy Center, and two public health practice consultants. An Advisory Board of national high-level public health leaders and experts also provided valuable input. A research team from the Johns Hopkins Bloomberg School of Public Health reviewed literature on public health frameworks in several focus areas (see Appendix 2) and supported several qualitative research activities to ensure that the project reflected the needs and recommendations from the perspective of public health leaders, practitioners, and community members who have experienced health inequities.
The project team conducted an inclusive mixed methods outreach process that included project oversight, guidance, and key input from critical stakeholders in alignment with the Public Health Forward project goals. This mixed-methods process was designed to capture real-time perspectives from high-level decision-makers, experts, and front-line practitioners on needs, challenges, and best practices to support public health responsiveness, improved health outcomes for all populations, and performance improvement and innovation. The project’s Steering Committee, a Public Health Advisory Board of national public health leaders, and a bipartisan task force representing former elected officials, health care, businesses, and faith-based leaders provided general oversight and guidance to the project team to inform the project goals and recommendations. The team received additional input and feedback throughout the project via:
- Roundtable discussions with experts in each of the six priority areas.
- Listening sessions and town halls with state and local public health officials and staff members (including those in rural areas and big cities); Tribal public health stakeholders; and community-based organizations.
- Follow-up one-on-one interviews to gather additional information on health equity, data transformation, and public health funding challenges.
- An online survey using the Qualtrics XM platform to gather feedback from more than 650 public health stakeholders to understand public health priorities, public health practice opportunities and challenges, and COVID-19 considerations affecting public health system modernization.
- An online survey to gather feedback from roundtable participants on the final actions and recommendations.
All meetings, roundtables, listening sessions, and town halls were conducted and recorded via Zoom. The survey results and session transcripts were analyzed to thematically categorize the responses.
3 CDC Foundation, “What Is Public Health?” 2021. Available at: https://www.cdcfoundation.org/what-public-health.
4 Centers for Disease Control and Prevention, “Ten Great Public Health Achievements — United States, 1900-1999,” Morbidity and Mortality Weekly Report, 48(12): 241-243, April 2, 1999. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm
5 Nambi Ndugga and Samantha Artiga, “Disparities in Health and Health Care: 5 Key Questions and Answers,” Kaiser Family Foundation, May 11, 2021. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-keyquestion-and-answers/
6 Sanne Magnan, “Social Determinants of Health 101 for Health Care: Five plus Five.” NAM Perspectives 7(10), 2017. Available at: https://doi.org/10.31478/201710c.
7 Arthur C. Evans and Lynn F. Bufka, “The Critical Need for a Population Health Approach: Addressing the Nation’s Behavioral Health During the COVID-19 Pandemic and Beyond,” Preventing Chronic Disease, 17(200261), 2020. Available at: https://www.cdc.gov/pcd/issues/2020/20_0261.htm
8 Pew Research Center, “Worries About Coronavirus Surge, as Most Americans Expect a Recession – or Worse,” March 26, 2020. Available at: https://www.pewresearch.org/politics/2020/03/26/worries-about-coronavirus-surge-as-most-americans-expect-arecession-or-worse/
9 Selena Simmons-Duffin, “Poll Finds Public Health Has a Trust Problem,” National Public Radio, May 13, 2021. Available at: https://www.npr.org/2021/05/13/996331692/poll-finds-public-health-has-a-trust-problem
10 Mike Baker and Danielle Ivory, “Why Public Health Faces a Crisis Across the U.S.,” The New York Times, October 18, 2021. Available at: https://www.nytimes.com/2021/10/18/us/coronavirus-public-health.html?action=click&module=RelatedLinks&pgtype=Article
11 C.B.C. Mamaril, G.P. Mays, et. al., “Estimating the Cost of Providing Foundational Public Health Services,” Health Services Research, 53(Suppl Suppl 1): 2803-2820, August 2018. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6056592/
12 K.B. De Salvo, Y.C. Wang, et al., “Public Health 3.0: A Call to Action for Public Health to Meet the Challenges of the 21st Century,” Preventing Chronic Disease, 14: 170017, 2017. Available at: https://www.cdc.gov/pcd/issues/2017/17_0017.htm
13 Public Health National Center for Innovations, “FPHS.” Available at: https://phnci.org/national-frameworks/fphs
14 K.B. De Salvo, B. Hughes, et al., Public Health COVID-19 Impact Assessment: Lessons Learned and Compelling Needs, National Academy of Medicine, April 7, 2021. Available at: https://nam.edu/public-health-covid-19-impact-assessment-lessons-learned-andcompelling-needs/.
15 Robert Wood Johnson Foundation, “Transforming Public Health Data Systems.” Available at: https://www.rwjf.org/en/library/research/2021/10/charting-a-course-foran-equity-centered-data-system.html
16 Centers for Disease Control and Prevention, Public Health Surveillance and Data, “Data Modernization initiative,” April 9, 2021. Available at: https://www.cdc.gov/surveillance/surveillance-data-strategies/data-IT-transformation.html.
17 National Consortium for Public Health Workforce Development, National Consortium for Public Health Workforce Development Common Agenda, September 2021. Available at: https://publichealthworkforcedevelopment.org/wp-content/uploads/2021/10/NC-002-CommonAgenda.pdf
18 Indiana Department of Health, “Governor’s Public Health Commission.” Available at: https://www.in.gov/health/about-the-agency/boards-and-commissions/gphc/
19 Kentucky Legislative Research Commission, “2020 Regular Session: House Bill 129,” October 27, 2020. Available at: https://apps.legislature.ky.gov/record/20rs/hb129.html; Jan Chamness, Public Health Transformation from Planning to Implementation, Kentucky Public Health, August 19, 2021. Available at: https://www.healthy-ky.org/res/uploads/media/FHK-HealthforaChangeSeries-081921.pdf
20 Public Health National Center for Innovations, PHNCI FPHS 21st Century Learning Community Case Study: Ohio, June 15, 2018. Available at: https://phnci.org/uploads/resource-files/PHNCI-21C-Learning-Community-Case-Study-Ohio.pdf
21 Oregon Health Authority, Public Health Division, Public Health Modernization Manual, September 2017. Available at: https://www.oregon.gov/oha/ph/About/TaskForce/Documents/public_health_modernization_manual.pdf.
22 Washington State Department of Health, Washington State Association of Local Public Health Officials, and Washington State Board of Health, PUBLIC HEALTH MODERNIZATION: A Plan to Rebuild and Modernize Washington’s Public Health System, December 16, 2016. Available at: https://www.doh.wa.gov/Portals/1/Documents/1200/FPHS-PublicHealthModernizationPlan2016.pdf
23 Public Health National Center for Innovations, “21C Learning Community.” Available at: https://phnci.org/national-frameworks/21c-learning-community.
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