CELEBRATING TWENTY
YEARS IN “The Future of
Public Health”
OPPORTUNITIES FOR
TOMORROW’S
LEADERSHIP
Ned Baker Annual Lecture, NALBOH
Bowling Green, Ohio
April 3, 2008
CELEBRATING TWENTY
YEARS IN ‘THE FUTURE OF
PUBLIC HEALTH’
Hugh H. Tilson MD, DrPH
Public Health Leadership Program
UNC School of Public Health and
Member of the Panel, IOM, 1988
But FIRST … a word about
the Health of the Public in
the 21st Century
“The Future of the
Public’s Health” 2003
A Report from the Institute of Medicine
Follow-up Study of the 1988 “Future of
Public Health” and its implications for
NALBOH’s Public Health Leadership
THE FUTURE OF
THE PUBLIC’S HEALTH
in the 21st Century
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Committee on
Assuring the Health
of the Public in the
21st Century
What’s “ASSURING”??
Whaddya’ mean “keeping
pace”? In THIS mess?
We regret that the program
… originally scheduled for
this time … could not be
CANCELLED!!
The National Academies
The National Academy of Sciences (1863)
The National Research Council (1916)
The National Academy of Engineering (1964)
The Institute of Medicine (1970)
Why a new study about
the future of public health?
NOT BECAUSE THE ‘OLD’
REPORT WAS WRONG
Why a new study about
the future of public health?
NOT BECAUSE THE ‘OLD’
REPORT WAS WRONG …IN
FACT, IT IS ‘EVERGREEN’!!
IOM’s LANDMARK REPORT ON
“THE FUTURE OF PUBLIC
HEALTH” 1988
CELEBRATING TWENTY
YEARS OF PROGRESS:
1988-2008
Why a new study about
the future of public health?
NOT BECAUSE THE ‘OLD’
REPORT WAS WRONG … IT IS
‘EVERGREEN’!! And
DEFINITELY worth a careful look
The LANDMARK report on the
“Future of the Public Health”
IOM 1988: BACKGROUND

--The Swine Flu fiasco of 1976
 --The Model Standards for Community
Preventive Health Services weak response
 --The inability of the local infrastructure to
respond to the Model Standards
 --The crumbling of Federal support
 --The politicization of the Federal Public
Health leadership
The 1988 Panel

21 of the Brightest and the Best (plus me)
 All the right domains represented
 All the public health professions
 Elected officials
 Superb high level professional staffing
 Adequate resources … Kellogg, CDC,
HRSA funding
The 1988 Report: the
approach
“check your assumptions at the door”
 Used classic social science methods …
broad fact finding, literature reviews, expert
testimony, and field site visits
 Asked: what is your definition of public
health
 Used: “tracers”: what was the problem,
what did you do about it, who made it
happen?

1988: The Big News

“… this nation has lost sight of its public
health goals and has allowed the system of
public health activities to fall into
DISARRAY!”
1988: the critical reconception of public health
“The committee defines the mission of
public health as fulfilling society’s interest
in assuring conditions in which people can
be healthy”
 “The committee finds that the core
functions of public health agencies at all
levels of government are assessment, policy
development, and assurance”

1988: the Core Functions
Assessment: … regularly and systematically
collect, assemble, analyze, and make
available information on the health of the
community …
 Policy Development: … Agencies must take
a strategic approach, developed on the basis
of a positive appreciation for the democratic
political process

1988: The core functions
Assurance: … assure their constituents that
services necessary to achieve agreed upon
goals are provided … encouraging actions
by other entities …. Requiring such action
through regulation, or by providing services
directly
 … a set of high-priority personal and
communitywide health services that
governments will guarantee to every
member …

IOM 1988: Recommendations
States: “… are and must be the central force
in public health”
 Localities: “no citizen from any community,
no matter how small or remote, should be
without identifiable and realistic access to
the benefits of public health protection,
which is possible only through a local
component of the public health delivery
system.” “the AGPALL” concept

1988: Fulfilling the
Government Role:
Implementing
Recommendations
Statutes: … reform; delineate
responsibilities and authorities and a core
set of functions
 Organizational Structure: … an identifiable
state department of public health … state
health council .,.. Establish standards for
local public health functions

1988: Organizational Structure

Localities: “… the larger the population
served by a single multipurpose
government, as well as the stronger the
history of local control, the more realistic
… promote local accountability
1988: Organizational Structure
Localities: “… the larger the population
served by a single multipurpose
government, as well as the stronger the
history of local control …… clear focal
point: “where the scale of local government
activity permits, localities should establish
public health councils to report to elected
officials on local health needs and on the
performance of the local health agency.”
 (NOTE TO NALBOH … what happened
THREE years after this recommendation?)

1988: Special linkages

Environmental health
 Mental Health
 Social Services
 Care of the indigent: “… until adequate
federal action is forthcoming, public health
agencies must continue to serve …to the
best of their ability, the priority personal
health care needs of the uninsured,
underinsured, and Medicaid clients.”
1988: Strategies for Capacity
Building

Technical: uniform data set; Institutional
home for new knowledge; research
 Political: relationships with elected
officials; competence in community
relations; working partnerships and support
among local, state, and national medical and
professional societies …
1988: Strategies for Capacity
Building
Managerial: … training … on managerial
and leadership skills; demonstrated
management competence … should be a
requirement; salaries and benefits
 Programmatic: … more emphasis on
“factors that influence health-related
behavior …”
 Fiscal: … Fed to State and State to local,
with incentives and sanctions

1988: Education for Public
Health
Schools … firm practice links; resources to
governments; students “an opportunity to
learn the entire scope of public health
practice”; research … applied and
implementation; full advantage of other
faculties; full support to other faculties
 Education programs … should be informed
by comprehensive and current data on
public health personnel…”

Why a new study about
the future of public health ?
2000: IOM commissioned a
systematic review of progress as
part of its commitment to followIO
through.
Progress was dramatic on every
front. However, challenges and
frustrations abounded as well.
Why a new study about
the future of public health ?
IOM commissioned a systematic
review: PROGRESS is IMPRESSIVE
IO
Conceptualization: The public
health working group and the ten
essential services
Organization: NACCHO, NALBOH,
Council on Linkages
Workforce: PHLI, Management
Academy
Why a new study about
the future of public health in
2000-2003?
Still, due to the rapidly changing (“flat”)
world, public health systems were under
greater stress than ever before
Additionally, these changes bring
increasingly diverse demands, expectations,
opportunities, and resources for public
health
Oh, yes … and then there’s the MONEY
$$$$$$$$$$$$$$$$$$$
WE interrupt this program
for the following
announcement
Why a new study about
the future of public health in
2003?
And then came September 11th …
And the Anthrax attacks that followed
… that changed ‘everything’
… and for the IOM Committee, the
urgency for a report to galvanize to
concerted action was CLEAR
Why talk about a twenty year old
and a five year old study about
the future of public health
HERE/NOW?
…because the Nation and States need
help from our leadership …a.k.a. YOU !
But first...
a word from
our sponsors!
The 2003 study sponsors

Centers for Disease
Control and
Prevention (CDC)

National Institutes of
Health (NIH)

Substance Abuse and
Mental Health Services
Administration
(SAMHSA)

Office of the Secretary,
Assistant Secretary for
Planning and Evaluation
(OS/ASPE)

Health Resources and
Services
Administration (HRSA)

Office of Disease
Prevention and Health
Promotion (ODPHP)
Assuring the Health of the Public
in the 21st Century
Who?
The 2003 Committee
Jo Ivey Boufford
 Christine Cassel
 Kaye Bender
 Lisa Berkman
 JudyAnn Bigby
 Thomas Burke
 Mark Finucane
 George Flores
 Lawrence Gostin
 Pablo Hernandez

Judith Lave
 John Lumpkin
 Patricia Peyser
 George Strait
 Thomas Valente
 Patricia Wahl
 Gail Warden
 Hugh Tilson (Liaison)
 George Isham
(Liaison)

Assuring the Health of the Public
in the 21st Century
Who?
What?
When?
Where?
How?
Addressing the charge
required...JUST WHAT YOU REQUIRE
TODAY …
Methodology
Literature review on all relevant topics
Hearings and expert testimony at Committee
meetings
Input from the Committee’s Liaison Panel and
from the general public
Qualitative and quantitative data from
Federal, state, and local public health systems
State and local community organizations
National and professional organizations
Site visits
Futures visioning and scenario building
Today’s forecast is limited by
lack of vision ….
Futures visioning and
scenario building
The committee examined the drivers, or
the forces that are likely to shape the
future, and used “visioning” to generate
scenarios, or potential realities for which
public health must be prepared.
Futures visioning and
scenario building
The committee ascertained the drivers, or
the forces that are likely to shape the
future, and used visioning to generate
scenarios, or potential realities for which
public health must be prepared. .. AND a
great way for YOU to LEAD, too”
Some important “drivers” of
population health
Changes in the
environment
Infectious
disease threats
Advances in
biotechnology and
information technology
Disparities in health
status and access to care
Globalization
A social and political
environment that
prioritizes health
Some important “drivers” of
population health
Changes in the
environment
Infectious
disease threats
Including MANMADE ONES!!
Advances in
biotechnology and
information technology
Disparities in health
status and access to care
Globalization
A social and political
environment that
prioritizes health
Public health
is preparing for
whatever comes next.
Some important “drivers” of
population health
Changes in the
environment
Infectious
disease threats
Including MANMADE ONES!!
Advances in
biotechnology and
information technology
glumbert/media/shift
Disparities in health
status and access to care
Globalization
A social and political
environment that
prioritizes health
THE FUTURE OF
THE PUBLIC’S HEALTH
in the 21st Century
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
WWW.NAP.EDU
The Context for the Report
1988 report is ‘evergreen’ and there is
GREAT National Health Achievement in
the 20th Century BUT …
 US falling short in international
comparisons
 Poor return on investment in health
 Concern about the government public health
infrastructure’s ability to meet future health
challenges, both local and global

Background in the Report

Health = Public Good
 Government has fundamental, statutory
duty to assure the health of the public
Background in the Report

Health = Public Good
 “Without Health there can be no happiness”
(attributed to Thomas Jefferson IOM p xi)
 Government has fundamental, statutory
duty to assure the health of the public
Background in the Report






Health = Public Good
Government has fundamental, statutory duty to
assure the health of the public, BUT …
Government cannot do it alone
Need for inter-sectoral engagement in partnership
with government (the 1988 report mission
statement is indeed EVERGREEN!)
Health = social goal of many sectors and
communities
The root causes of ill health must be addressed by
many outside the public health system
The Committee’s Conclusion

An inter-sectoral public health system is
needed
 In 1988 report, public health refers to the
“organized efforts of society, both
government AND OTHERS, to assure
conditions in which people can be healthy”
 THIS report elaborates on the efforts of the
other potential public health system actors.
The Committee’s Vision

The committee adopts as its vision the
vision of Healthy People 2010: Healthy
People in Healthy Communities
 NOTE: The committee explicitly elected
NOT to ‘re-discover the wheel’ … a good
principle to keep the pace!
MAJOR opportunities for
NALBOH from the 1988 and
2003 IOM Reports






The SYSTEM components and their roles
The TEN Essential Services
Core Competencies
Public Health SYSTEM Performance Standards
Certification
Accreditation
Really embracing the
“SYSTEM” as proposed by the
1988 report
The Committee’s Conception:
The Public Health SYSTEM!!



The Official Public
Health Agency
Infrastructure

The Medical Care
System

The Media

Academia
The Community
The Private
Sector/Industry
What is the Public Health
System?
 More than just the
public health
agency

“Public health
system”
– All public, private, and
voluntary entities that
contribute to the
delivery of public
health services within a
jurisdiction.
Community
Governmental
Public Health
Infrastructure
Health
care delivery
system
Assuring the
Conditions for
Population
Health
Academia
Employers
and Business
The Media
(IOM, 2003)
The Public Health System …
… GREAT progress since 1988
 …”Despite this progress, the Committee
found that in many important ways, the
public health system that was in disarray in
1988 remains in disarray today.”

The Public Health System …

And so how can NALBOH’s members help
public health agencies to gain the status,
recognition, and respect to lead the system
while we must “run the business…”?
NALBOH in the lead: putting
the essential in “ESSENTIAL
SERVICE”??
The Essential Public Health
Services building
on
1988
9. Evaluate health services
Monitor health status
2. Diagnose and investigate
health problems
3. Inform and educate
4. Mobilize communities to
address health problems
5. Develop policies and plans
6. Enforce laws and
regulations
7. Link people to needed
health services
8. Assure a competent health
services workforce
1.
10.
Conduct research for new
innovations
THE TEN Essential Services
Monitor health status …
 Diagnose and investigate health problems ..
 Inform, educate and empower people …
 Mobilize community partnerships …
 Develop policies and plans that ….
 “My Day Is Made Pushing …”

THE TEN Essential Services
(cont)






Enforce laws and regulations …
Link people to needed personal health svcs..
Assure a Competent public health AND personal
health care workforce
Evaluate effectiveness, accessibility and quality of
personal and population based Services
Research for new insights and innovative solutions
to health problems
…”Everything Likely to Win Some Resources!!”
NALBOH leadership: finding
the core in “CORE
COMPETENCY”??
THE EIGHT Core
Competencies
(Council on Linkages building
on 1988)








Analytic/Assessment Skills
Policy Development/program planning
Communication
Cultural Competency
Community Dimensions of Practice
Basic Public Health Sciences
Financial Planning and Management
Leadership and Systems Thinking

THE EIGHT Core
Competencies
and CERTIFICATION
What are the credentials needed to work in
the public health system?
 How can these be tied to competencies?
 How should we go about documenting
competency to practice?
 If “certification”, how should we certify,
and whom, and for what?
THE EIGHT Core
Competencies
and
CERTIFICATION
 What are the credentials needed to work in the




public health system?
How can these be tied to competencies?
How should we go about documenting
competency to practice?
If “certification”, how should we certify, and
whom, and for what?
What challenges lie ahead for the “American
Board of Public Health”?
THE EIGHT Core
Competencies
and CERTIFICATION

AND MOST IMPORTANT: HOW CAN
WE DO ALL OF THIS WHILE
ADDRESSING THE CRITICAL
WORKFORCE SHORTAGE FOR
PUBLIC HEALTH IN THE DECADE
AHEAD??
NALBOH in the leadership:
using the “system
performance standards”
The National PH Performance
Standards Program(NPHPSP)
building directly on the Model
Standards in the 1988 report





THREE “instruments”
OMB approved with
‘control numbers’
STATE
LOCAL
GOVERNANCE
Four Concepts Applied in
NPHPSP
Based on the ten Essential
Public Health Services
2. Focus on the overall public
health system
3. Describe an optimal level of
performance
4. Support a process of quality
improvement
1.
The local public health system
assessment instrument

OMB Control Number
0920-0555
 24 hours per response
 “…ALL entities that
contribute to the
delivery …”
The local public health system
assessment instrument
“How much of this
Model Standard is
achieved by the local
PHS collectively?”
 What percent of the
answer reported in Q 1
is the direct
contribution of the
local PH agency?

The local public health system
assessment instrument
For the LPHS … asks
about
GOVERNANCE
 For the
GOVERNANCE
instrument, critical
issues to NALBOH
include …

Mobilizing for Action
through
Planning and Partnerships (MAPP)

Developed by NACCHO and CDC
 Based on the 1988 recommendations,
development began in 1996, released in 2001
 Community strategic planning tool
 Web-based tool – www.naccho.org
NPHPSP and MAPP

NPHPSP Local
Instrument used
within MAPP to
assess public health
system capacity

MAPP provides the
process for addressing
weaknesses and
building on strengths
NACCHO Operational
Definition of a
Functional Local Health
Department

Co-funded by CDC and RWJF
 Goal: Shared understanding of what
people can reasonably expect from LHDs
 Builds on the “AGPALL” 1988
 Framed around the ten Essential Services
but presented in more common language
 Accommodates variety in LHD structure
and governance
“Public health is a complex
concept, but the operational
definition can help dispel the
mystery. Eventually public health
can be recognized and valued
even when—particularly when—
things are going well.”
Susan Gerard
Director, Arizona Department of Health Services
Public health is a complex
concept and so we need to
develop a meaningful identifiable
BRAND
IOM Reports 1988/2003 –
National Catalyst for
Accreditation

Establish a “national
commission to explore
accreditation”

Further states…
– “This (accreditation)
commission should focus on
the development of a system
that will further the efforts of
NPHPSP.”
Building on the 1988
recommendations:
Exploring Accreditation


Co-funded by CDC and RWJF
Jointly led by NACCHO, ASTHO,
NALBOH and APHA
 Informed by the Multi-State Learning
Collaborative
 Model addressed governance, standards,
financing and incentives, and evaluation
 Model for voluntary accreditation
developed and approved
Accreditation for state and
local health departments is
both desirable and feasible!
THE TEN Essential Services
(cont)
Enforce laws and regulations …
Link people to needed personal health svcs..
Assure a Competent public health AND personal
health care workforce
 Evaluate effectiveness, accessibility and quality of
personal and population based Services
 Research for new insights and innovative solutions
to health problems
 Oh, yes … and number ELEVEN: Governance
and management of heath department resources



Public health system
assessment instruments and
A CCREDITATION

Can achievement of a
“passing grade” on a
performance
assessment be used for
accreditation?
 How should WHO
accredit WHOM and
HOW? (not to
mention WHY?)
Public health system
assessment instruments and
ACCREDITATION



Can achievement of a
“passing grade” on a
performance assessment
be used for accreditation?
How should WHO
accredit WHOM and
HOW? (not to mention
WHY?)
SEE: “Exploring
Accreditation” and CDC’s
NPHPSP website
Public health system
assessment instruments and
ACCREDITATION

AND MOST
IMPORTANT, HOW
CAN WE KEEP ON
TOP OF THE
SPECIFIC HEALTH
CHALLENGES
WHILE WE TEND
TO THE
INFRASTRUCTURE
??
LEADERSHIP Questions for
NALBOH:
How can Essential Services,
Competencies, and
Performance Standards
inform accreditation and
certification?
Especially NOW!!
Essential Services=Essential,
Competencies=Unique and
necessary, and Performance
Standards and a new
formulation can inform
advocacy for public health!
Especially NOW!!
Sometimes the best way to
lead progress is to take a
moment to look back
SO … let’s celebrate
twenty years of “the
future”
IOM’s LANDMARK REPORT ON
“THE FUTURE OF PUBLIC
HEALTH” 1988
THE FUTURE OF
THE PUBLIC’S HEALTH
in the 21st Century
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
… and FIVE years
into Assuring the
Health of the Public
in the 21st Century
The best way to predict the
future is to CREATE it. (P
Drucker)
SO .. LET’S TALK…
NALBOH’s leadership
counts!!!
THANKS!

BACKUP SLIDES FOLLOW
The Public Health System:
What We Don’t Know but
YOU can help us to find out!!
RESEARCH … the tenth “essential service” … ie
not someone else’s job
 Public Health Systems Research … much in need
of help but enormous progress (Council on
Linkages!)
 FAILURE to collect the evidence base precludes
evidence-based policy
 (witness the IOM report)

The Public Health System:
What We Don’t Know but
YOU can help us to find out!!

What is the optimal allocation of responsibilities
among partners?
 What is the appropriate funding formula for the
system?
 What is the minimal staffing for a competent local
official health agency?
 What is the minimum size below which an
efficient/effective infrastructure is not possible?
The Public Health System:
What We Don’t Know

What is the largest population to be served
and still be ‘local’?
 What is the optimal mix of disciplines or
competencies in the competent agency?
 How far is too far away for a local agency?
 What is the appropriate or optimal
relationship between the State Health
Agency and the local official agency(ies)?
The Public Health System:
What We Don’t Know but
YOU
need
to
help
with!
 What do we know about governance and what do
we need to know? How does this differ across the
“five … or is it more? … Americas”
 What is the evidence for best performance from a
Local Agency or Board of Health?
 How many jurisdictions can a local agency
manage or a board of health “govern”?
 How can public health most effectively relate to
local general purpose government?
Ahead of the pace … “Who will
Keep the Public Healthy?”

The PIPELINE is dangerously empty and
the audience is dangerously “graying”
 SO: we needed to assess the past and
current state of training and education for
public health professionals and develop
recommendations for strengthening public
health education
Companion Study
“Who will keep the Public
Healthy?”

Utilize recommendations and other
information from the Assuring the Health
report

Ten-year look forward
Companion Study
“Who will keep the Public
Healthy?

Kristine Gebbie
 Linda Rosenstock
 Susan Allan
 Kaye Bender
 Dan Blazer
 Scott Burris
Mark Cullen
Bob Goodman
Alan Guttmacher
Rita Kukafka
Sheila Smythe
Roxanne Parrott
Companion Study
“Educating Public Health
Professionals for the 21st
Century”

Process and development of
recommendations similar to “Future of the
Public’s Health” study

Final Report issued on November 4 and
‘launched’ at APHA in the late fall 2002!
Companion Study
“Educating Public Health
Professionals for the 21st
Century”

A MODEL of health that emphasizes the
linkages and relationships among multiple
factors (or determinants) affecting health is
an ECOLOGICAL MODEL”
“Educating Public Health
Professionals for the 21st
Century”
KEY Recommendations

SIX major responsibilities: Educate the
leaders; focal point for Transdisciplinary
Research; contribute to policy; collaborate
with other schools for public health content;
life-long learning; engage actively with
various communities to improve the
public’s health
“Who will Keep the Public
Healthy?” Keep the basics;
ADD Eight new competencies

Epidemiology, Statistics, Health Policy,
Environmental Health, Social and
Behavioral Sciences
 Informatics, genomics, communication,
cultural competence, community based
participatory research , global health, policy
and law and public health ethics
“Educating Public Health
Professionals for the 21st
Century”
KEY Recommendations

Primary Educational Mission: the
preparation of individuals for positions of
senior responsibility
 Emphasize the centrality of the ECOLOGIC
Approach
 NEW competencies in genomics,
communications, leadership, policy, law
and ethics
“Who will Keep the Public
Healthy?” For EACH of the Eight
new content areas

Competencies be identified;
 Each area be included in graduate level
public health education;
 Continuing development and creation of
new knowledge be pursued; and
 Opportunity for specialization be offered.
NALBOH … a ‘closing keynote’ …
a new time of oppor-TUNE-ity

G-minor: Gee, there are certainly some minor
problems (ahem!!) getting there
 B-flat: Be flat-out proud of what our field and
this state have already accomplished
 B-sharp: There are wonderful opportunities
ahead, but it will take a trained eye to see
them in the current context
 C-major!!
The best way to keep pace
with progress is to be
ahead of it!!
SO .. LET’S TALK…
YOUR leadership
counts!!!
After all, Public Health is a
work in progress...
I want to hear from YOU
NOW … and always!
HUGH_TILSON@UNC.EDU