The recipe to rebuild a more robust and resilient public health system

The COVID-19 pandemic has exposed critical vulnerabilities in our public health system, but it has also created an opportunity to envision a more effective, equitable, and sustainable system. We offer a recipe for that more robust and resilient public health system: start with a base of core funding for public health infrastructure, incorporate national standards for public health practice, and garnish by fostering innovation. This recipe will enable health departments to respond to future emergencies, promote community health, and move towards health equity.

The pandemic has highlighted chronic underfunding of the U.S. public health system. Public health receives approximately 3 percent of national health spending. A strong public health system requires a more serious and sustained investment that is not restricted to disease-specific activities. 

To ensure financial resources are leveraged effectively, we must establish clear expectations and a process to facilitate and assess health departments’ progress towards this vision. 

Leveraging funding for a stronger and innovative public health system 

Health equity 

The glaring racial, ethnic, and socioeconomic disparities in COVID-19 have spotlighted long-standing health inequities. Accredited health departments offer examples of taking an intentional approach to eliminating the structural barriers that lead to inequalities in life expectancy, depending on a person’s zip code. For example, the Los Angeles County health department tackled environmental justice issues facing residents living near a former battery recycling facility. 

Coordination with partners 

Close coordination across multiple sectors is needed to ensure that public health, health care, businesses, and community organizations are working in concert to respond to emergencies like COVID-19 and to address the social determinants of health and inequities. For example, Florida’s Zika response required collaborations among state and local health departments, tourist development councils, and other entities. Accreditation facilitated that coordination in Florida, and other communities across the nation. 

Evidence and data-driven

The rapidly evolving science about COVID-19 requires making strategic, evidence-informed decisions under uncertainty. Surveys of state and local chronic disease directors have shown that accredited health departments engage in more activities to support evidence-based decision making. 

Quality improvement

Quality improvement activities improve the effectiveness and cost-effectiveness of public health programs. Piloting and adapting quality improvement strategies is fundamental to an effective and nimble response to the pandemic. A continuous quality improvement approach strengthened public health laboratory performance in Connecticut and Oregon and communicable disease investigations in New York. Health department leaders consistently cite enhanced engagement in quality improvement as a key benefit of accreditation.

Accountability and transparency 

Accreditation’s rigorous, peer-review process can improve accountability and transparency. Accreditation has been viewed as a “seal of approval,” which can help garner public trust. The public’s confidence in government is a valuable commodity during crises, as evidenced by “anti-lockdown” rallies protesting social distancing orders.  

Following the recipe for a stronger public health system

The pandemic has spotlighted a critical gap in core infrastructure funding for public health. There is a severe need for additional funding, and this investment can be maximized through clear expectations such as the benchmarks used in the national voluntary accreditation process. However, more work is needed to remove critical barriers to accreditation, such as the time and fees involved and, particularly among some smaller health departments, perceptions that accreditation requirements may surpass current capacity. Flexible funding and technical assistance would bolster health departments’ abilities to meet these national standards. 

Similarly, the final garnish of fostering innovation requires an organizational culture to support innovation, such as increased openness to new ideas and risk-taking. This culture can pay dividends as seen in Washington State’s use of workflow-automation to support COVID-19 incident command structures and Chicago’s mobile application to communicate with residents experiencing COVID-19 symptoms. 

In the battle against COVID-19, health departments need considerable resources to support testing and contact tracing to allow for gradual increased economic activity. However, as we invest in immediate needs, we should be guided by a recipe to enable a stronger foundation that better prepares us to address future public health threats and support healthier communities for all.

Jessica Kronstadt, MPP, is the vice president for program, research & evaluation at the Public Health Accreditation Board. She is a public health systems researcher with an emphasis on the performance improvement of governmental health departments. Erika Martin, Ph.D., MPH, is an associate professor of public administration and policy at University at Albany, State University of New York. She researches the allocation of scarce public health resources, the adoption and impact of public health policies, and ways to improve the sustainability and impact of open health data platforms. The information contained in this article reflects the opinions of the authors and does not represent the official Public Health Accreditation Board (PHAB) policy.


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