Building a Strong Foundation for Public Health Transformation

The US public health system is in crisis as a result of chronic underfunding and a fragmented approach to policy making and service delivery at the federal, state, Tribal, local, and territorial levels. In short, we do not have a national public health system. Rather, we have thousands of individual public health departments that offer no guarantee that, regardless of where we live, all people will receive certain basic public health services and protection. Furthermore, the COVID-19 pandemic has highlighted the many chronic stressors resulting in a rising level of distrust among many people living in the United States. A critical component of regaining trust will be public health's ability to deliver on its promise of protecting and promoting health in the postpandemic period. As the United States continues to grapple with response, recovery, and resilience from the COVID-19 pandemic, jurisdictions across the country are seeking ways to build and strengthen public health infrastructure in systematic ways. As Courogen et al1 describe in “Resetting the Course for Foundational Public Health Services (FPHS) During COVID-19,” there is a dire need for sustainable funding for public health infrastructure and intentional approaches to transforming public health through frameworks such as the Foundational Public Health Services (FPHS).2 Their article describes how 3 states have worked, before and during the COVID-19 pandemic, to build the Foundational Capabilities and Foundational Areas so that every jurisdiction is not without these responsibilities to support both the daily work of public health and the work in times of crises. Public health is not alone in this challenge. The COVID-19 pandemic has severely stressed every major sector across all US communities. This includes not only the health care and public health systems but also the systems that support education, transportation, and employment, resulting in disruption at best and, in far too many instances, disintegration. Full-scale modernization of public health in a postpandemic environment requires a commitment to transforming a fragmented public health system to one that, like the interstate highway system, complies with and meets minimum standards that are consistent and in service to all people, in every community. In the same way that when traveling from one state to another, the size of the roads, the signage and “standards” do not change, public health standards should not change based on where you are. We are at a crucial moment in American public health. In response to the pandemic, Congress and the Biden Administration have allocated major new resources needed to modernize and transform public health in the United States—with a particular focus on workforce and data. We must leverage this investment to address the structural inadequacies that the pandemic magnified and exacerbated, caused in no small part by the well-documented chronic underfunding of the US public health system. To sustain policy maker support for modernization, the public health community must be accountable for quality improvement within a framework that ensures that all communities will be equitably served by the public health system. Congress frequently references Foundational Capabilities and accreditation as necessary to achieve public health transformation and modernization. The Public Health National Center for Innovations (PHNCI), a division of the Public Health Accreditation Board (PHAB), is home to the FPHS framework, which represents a minimum set of capabilities and areas that must be available in every community.1 Recently, PHNCI, in partnership with the Funders Forum on Accountable Health, revised the FPHS framework to ensure it continues to be a modern and robust framework. PHAB has also recently updated its accreditation Standards and Measures (version 2022), making more explicit the relationship between accreditation and the FPHS framework, particularly the Foundational Capabilities.3 The FPHS reinforces the fact that no individual's health status should be determined by where he or she lives. The Foundational Capabilities and Foundational Areas represent the infrastructure, services, and protections that “must be available by health departments everywhere for the public health system to work anywhere.”1 The 2022 revision of the FPHS was timely and critically relevant to the reality and needs of the currently disjointed US public health system. It provides clarity and reinforces the urgent need for a rational and inspired approach to public health reform. The framework recognizes that health protection and improvement across all US communities require a commitment and intentional efforts to advance equity and address social determinants of health. Notably, equity was added as a stand-alone Foundational Capability in the 2022 revision. The definitions for Foundational Capabilities and Foundational Areas were refined providing greater clarity and topics critical to public health modernization and transformation, such as equity and social determinants of health, data, technology, and the public health workforce—which are now emphasized within the definitions. In addition, Community-specific Services previously included as “local protections and services unique but critical to a given community” remains, acknowledging the need to accommodate “local” contextual factors unique but critical to a given community. The revised framework graphic fully captures the connectivity among components of the FPHS. The Foundational Capabilities form the base, recognizing the importance of building a strong infrastructure. Foundational Areas and Community-specific Services are supported by the infrastructure, and equity, in addition to being a Foundational Capability, also encircles the Foundational Capabilities and Foundational Areas, emphasizing that public health must be a leader in ensuring opportunity for equitable health for every community and person (Figure).FIGURE: Foundational Public Health Services. Used with permission. This figure is available in color online (www.JPHMP.com).The FPHS update provides clarity for the reform needed within our US public health system. The framework defines the minimum standards to be achieved through modernization and transformation. Meaningful, sustainable system transformation must include the following: Sustainable support for atruepublic health system. Federal, state, Tribal, local, and territorial leadership, authority, and funding must be increased and sustained over the long term to leverage the role and functions of governmental public health within a broader public health system. Policy and authorities must be leveraged to fund and support sustainable workforce, systems, data, and laboratory functions vital to ensuring equitable health across all communities. Leadership for integrated capacities. Public health leaders must be recognized as the health strategists in their communities, supporting an integrated/networked ecosystem that builds upon, supports, and complements governmental public health capacities. In short, public health should build the partnerships, coalitions, and collaboration needed across governmental and nongovernmental sectors to meaningfully address social determinants of health that are so closely linked to improved health outcomes. Metrics and accountability. Public health must be willing to be held more accountable for visible quality improvement. Translating the FPHS framework into measurable benchmarks of progress as the public health system transforms and agencies modernize will be critical. This translation can then ultimately be linked to accreditation, a step some in Congress have suggested be required of all public health agencies that receive federal funds.4 And pathways toward accreditation are being developed, focused on the Foundational Capabilities that are central to the public health system's response to emergencies and to the ongoing public health needs of all people in all communities.5 We are at a crucial moment in the history of US public health. The pandemic has demonstrated the critical need for and importance of a strong public health system and infrastructure. We have the rare opportunity to harness policy maker interest and federal funding to transform and modernize public health in the United States. The revised FPHS framework provides the necessary roadmap for that transformation.

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