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

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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.
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.
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