Public health transformation requires reimagining and developing a common vision to ensure the mindsets, capacity, resources, and workforce necessary to provide equitable Foundational Public Health Services and Essential Public Health Services, to advance health, wellbeing, and equity. It occurs through a fundamental shift in the way a public health system(s) is structured, functions and interacts through continuous quality improvement, innovation, partnerships, community-led efforts, and systems change. Simply put, it requires sustaining what is working, building on what can be improved, and reimagining what could be so that all people and communities can thrive.

How: Process for Transformation

• Define your state’s goal for public health transformation. For example, California’s Future of Public Health Workgroup aspires that Californians, working together, can enable all to live happier, healthier, and longer lives by closing the gap in life expectancy by 50 percent and reducing the disease burden by 15 percent within the next decade.
• Use a transformation framework to guide your work and make necessary adoptions to fit your state’s unique needs. Transformation frameworks include the Foundational Public Health Services, PHAB accreditation, Public Health Forward, and Public Health. 3.0, among others.
• Engage existing partners and develop partnerships with new and varied organizations; this requires investing in relationships and building trust. This includes engaging local public health departments in the process of identifying priority areas.
• Establish plans and processes and identify resources needed to conduct a statewide assessment. This may consist of engaging a contractor or partner to develop and implement the assessment or deciding to do this work with in-house staff time. In addition, this could include developing planning criteria to help guide the process (e.g., designing/tailoring the assessment tool, developing and implementing assessment activities, providing training and technical assistance, reviewing and analyzing the results, and preparing reports and other materials).
• Complete the assessment that is appropriate for your state context. The results could reveal gaps in your system, as well as the cost to implement capacity and capability needs in order to fill those gaps.
• Secure funding and policy support. Initial funding may be short term, so consider needs to establish a plan for sustainability.
• Continuously reevaluate your transformation efforts based on existing needs. Public health transformation does not end; efforts must continue to evolve. Innovation is one mechanism to support this continuous process.

Additional Factors

• Timing plays a role in transformation
  • For example, the COVID-19 pandemic created challenges and opportunities for all 21C states
• Develop consistent messaging about the need for transformation, your efforts, and your successes
• Consider the role shared services may play in your transformation work
  

The nationally-developed Foundational Public Health Services (FPHS) framework defines the minimum package of public health capabilities and programs that no jurisdiction can be without' this includes the skills, programs, and activities that must be available in state and local health departments everywhere for the health system to work anywhere.

Widespread adoption of the framework has the potential to advance a more unified public health system across the country, both in terms of how governmental public health is described and how it is understood. The framework also provides a much-needed structure to estimate costs in a way that resonates with decision-makers. Furthermore, it provides states with the ability to compare the costs of public health with other states that also have adopted it.

Some 21C states have adopted the national FPHS framework, and others have tailored the framework to better align with their state (state-specific FPHS framework). Reasons for tailoring the FPHS framework range from reflecting state-mandated programs to including language proven to resonate with key audiences to gaining buy-in of those engaged in the transformation process. View examples of state-specific frameworks below.

“Just like our Covid-19 response, transformation of the governmental public health system takes grit and grace among partners.” Sarah Reese, Director, Polk County Public Health

21C states are embedding a variety of innovative strategies into their transformation efforts, with a focus on the areas of health equity, Foundational Capabilities and workforce, and accreditation. Examples of each are shared below:

Health Equity

• Many states have incorporated and specifically called out health equity in their state FPHS models, which serves as a lens through which all public health services should be assured.
  • Kansas
  • Missouri
• The Minnesota Legislature provided funding for local and Tribal public health projects to build public health capacity and pilot new organizational models in health equity. The state is providing training and technical assistance to build knowledge, skills, and abilities across the state, and is also working to increase racial/ethnic diversity in workforce.
• Missouri has developed a facilitated workshop that walks public health professionals through a deeper self-assessment of health equity practices within their agencies. Using a step-by-step workbook, participants will develop action plans to build individual and organizational capacity to assure foundational public health services grounded in health equity.

Foundational Capabilities and Workforce

• North Carolina has a Community Health Worker initiative across all 100 counties, as well as a public-private partnership with community-based organizations, to reach underserved populations. The state also recruits external advisors from historically marginalized populations to contribute to the State Health Improvement Plan and Healthy North Carolina 2030 goals.
• Ohio has used federal and state workforce development dollars to add dedicated communications and regional support staff across the state. These positions help coordinate shared planning and implementation efforts between the state and local governments.

Accreditation

• Nebraska’s strategy to transform and modernize public health includes a commitment to meeting national standards and measures for public health departments. This commitment continues with a vision to have every health department on a pathway to meeting national accreditation standards, which may include at a minimum engaging in regular community health assessment and health improvement planning activities or achieving and maintaining accreditation status.
• Nevada is leveraging accreditation to transform its public health system. Through its commitment and investment in accreditation, Nevada plans to use accreditation as a means to achieve lasting, systemic changes, develop a culture of continuous quality improvement, and enhance performance management to better promote and protect the health of all Nevadans.

“Public Health Transformation is not only important but necessary in redefining public health’s role to acknowledge the social determinants of health and work collaboratively to remove barriers so individuals, families and communities can achieve optimal health.”

Public health transformation is a journey; it is important to acknowledge and celebrate successes and share details across states so that efforts may be replicated. The following examples of legislation, funding, and assessments in 21C states demonstrate the impact of transformation work:

• Colorado
  • In 2019, complete a needs assessment to identify resident needs and inform its statewide governmental public health modernization and transformation plan
  • In 2008, passed Colorado’s Public Health Act which restructured Colorado local public health and set the stage for required statewide assessment and planning as well as the provision of a set of core public health services and standards.
• Kentucky
  • In 2020, House Bill 129 made public health transformation law. The state determined that 3 full-time equivalents (FTEs) per 15,000 population (with an additional FTE per 5,000 population) were needed to do this work, and the current cost per FTE to be $109,000. This cost must be recalculated for each two-year state budget cycle.
• Massachusetts
  • In 2020, passed the original SAPHE Act, statute 72 of the Acts of 2020, entitled An Act Relative to Strengthening the Local and Regional Public Health System. Additional details on the SAPHE program are outlined here.
• Minnesota
  • In 2021, received $15 million annual increase, a historic investment to increase support of their public health system
    • $7 million increase to local public health (LPH) grants; this is an annual increase to the base of the LPH grant. The increase to each community health board is based on a percentage increase to the current award.
    • $500,000 increase to Tribal Health Grants; an increase to the base of the Grant. View bill language on page 450.21.
    • $6 million to New Public Infrastructure Funds; new funds for community health boards and Tribal governments to support their ability to build Foundational Capabilities and meet national public health standards. Minnesota Department of Health (MDG) will work with State CHS Advisory Committee to determine the process for distributing funds. View bill language on page 159.1.
    • $1.5 million to new MDH funding public health system and oversight; funds will be used to assess the capacity of the public health system, estimate costs, and oversee transformation. View bill language on page 451.1.
• Ohio was one of the first 21C states
  • In 2022, they completed a joint Ohio Department of Health and Association of Ohio Health Commissioners (AOHC) Modernization Project.
    • Resulted in an environmental scan and recommendations for the legislature.
  • In 2022, they received $6 million for feasibility studies for smaller city health districts.
  • During COVID response, they used their gap analysis data to identify the gap between the existing contact tracing staff levels at the local level compared to the needed number, resulting in a $37 million investment for LHDs to conduct case investigation and contact tracing.
  • 2017-2019 state budget allocated $3.5 million to address accreditation fees and coordination, as well as infrastructure costs for mergers
  • The State’s Regents Program allocated $5 million to help local health departments become accreditation ready and support specific research projects
  • In 2020, they issued a report on the second Costing of FPHS tool and Annual Financial Report
  • In 2019, they issued a report on the first rollout of the Costing of FPHS tool and Annual Financial Report
  • In 2012, the AOHC released the Public Health Futures Report
• Oregon was one of the first 21C states.
  • In the current biennium, the legislature invested $60.6 million, with the majority of funds allocated to the state’s 32 local public health authorities and some funds allocated to federally-recognized Tribes
  • In 2020, they created a new community engagement team that funds and supports a network of community-based organizations across the state to lessen the impact of the COVID-19 pandemic on black, indigenous, tribal, and people of color, as well as other groups experiencing health inequities.
• Washington was one of the first 21C states.
  • In the 2021-2023 legislative cycle, they requested $285M for communicable disease, environmental health, assessment, and a portion of the cross-cutting capabilities; appropriated a total of $175M and in the subsequent biennium promised a total of $324M (72% of the need), ongoing.
  • In 2021, Engrossed Second Substitute House Bill 1152 was passed to diversify local boards of health to include more voices from the scientific community and community members to address equity as a part of its transformation process and establish a Public Health Advisory Board
  • In the 2019-2021 legislative cycle, they requested $296M for communicable disease, environmental health, assessment, and a portion of the cross-cutting capabilities; appropriated $28M per biennium ongoing.
  • In 2019, the governmental public health system, Foundational Public Health Services, the State’s role, and shared decision-making process for allocations were codified in state law (RCW 43.70.512 & 43.70.515).
  • A 2018 baseline assessment revealed that an additional $450M per biennium is needed to fully implement the FPHS in Washington.
  • In the 2017-2019 legislative cycle, they requested $60M for communicable disease; appropriated $15M one-time funding.