The ongoing COVID-19 pandemic and reckoning with systemic racism in the United States have thrown into sharp focus not only the critical role that a strong public health system plays in building healthy societies, but also the urgent need to reinvigorate and strengthen our public health system. For too long, this system has been underfunded, under-resourced, federated, and siloed. Furthermore, expertise is not uniformly distributed across our system, particularly in rural and other underserved areas, and too frequently, expertise is ignored by both the public and in some cases public officials altogether. Compounding these issues is the problem of systemic inequality, which thus far the public health system has at best failed to mitigate, and at worst, has perpetuated.
COVID-19, combined with renewed interest in infrastructure development, has led to an influx of funding, and thus, an opportunity to address these weaknesses in our public health system in an effective, equitable, and evidence-based manner. This work demands high quality public health services and systems research to both inform and evaluate near-term allocations, as well as establish a strong evidence base to guide future investments to strengthen the public health system.
In August 2021, AcademyHealth and the American Public Health Association (APHA) convened 39 key leaders in the field to begin the critical work of strengthening this evidence base. With a focus on building upon the previous 2012 Public Health Services and Systems Research (PHSSR) agenda, participants from leading public health research, policy, and practice institutions discussed the foundational domains PHSSR needs to address and strategies for how to move forward. In this post, we outline key recommendations that emerged from this convening and a follow-up survey sent to attendees. We highlight key areas for research that were raised and have categorized them into short, medium, and long-term priorities within the following domains: Preparedness and Resilience; Structure; Performance; Workforce; Data and Technology; and Financing and Economics (Exhibit 1). One priority that spanned the three timeframes was applying an equity lens to public health activities and related research in order to effectively address systemic inequalities. Equity must be central to this work.
This table was developed by AcademyHealth to highlight key priorities for public health research based on meeting discussions and follow-up communications with select public health leaders and researchers.
Harness Momentum in the Short-Term
The short-term priorities were deemed most urgent and relatively achievable in one to two years. These priorities primarily centered on harnessing the current momentum, both political and financial, surrounding public health to identify effective, high-impact practices. Recognizing that a significant number of investments have been made in public health recently due to the COVID-19 pandemic and that further investments are likely to follow, participants emphasized the immediate need to examine and understand how state, local and Tribal health departments can make the most of available funds. For example, by developing rigorous evaluations to assess public health responses to COVID-19, including impacts on equity, as well as the scaling up of effective programs. Such system responses, meeting attendees specified, would also benefit from examinations of how to concretely integrate public health practices into health care delivery, most notably primary care, in a manner that benefits practitioners in both fields. Here, lessons from the COVID-19 pandemic are anticipated to be particularly salient.
Building the Vision for a High Performing Public Health System
Looking beyond the most immediate and pressing needs surfaced by the pandemic, meeting attendees identified medium-term priorities that will require additional planning and resources over the next three to five years. Such priorities were focused on public health financial and workforce analyses that together can assess the relative value of and strengthen public health services. Unlike other sectors in health and health care—including hospitals and federally qualified health centers— public health leaders have not routinely conducted financial analyses of the relative costs (including opportunity costs) of public health services in a range of state and community contexts. Similarly, not enough work has been done to understand what a strong and resilient public health workforce looks like, from the number of workers and disciplinary backgrounds to the most critical competencies to the best staffing models and how these vary by setting (e.g. urban vs rural; state, county or city). Meeting attendees emphasized the need to improve public health systems’ abilities to conduct these types of analyses, which will entail a continued emphasis on public health performance standards as well as investments in data and technology for public health monitoring and assessment. Such analyses and attention to data and technology would provide key insights into the types of workforce and system infrastructure investments that have the greatest impact on outcomes and will help policymakers maximize the efficiency of public health expenditures.
Modernizing Public Health for a Resilient Future
Finally, long-term priorities represented research related to major infrastructure changes toward building a resilient and equitable public health system—research that will likely take between five and ten years. These research priorities largely centered on examining and making major changes to modernize the public health infrastructure and increase public health system resilience. Such research would assure that we effectively address gaps in our system that COVID-19 has exposed. Addressing these gaps requires research that guides development of a robust public health workforce that is trained and equipped to address varied community and public health needs. Similarly, an IT infrastructure that can readily capture public health data to ascertain areas of need as well as assess and report on progress is critical to guiding future research and practice efforts. Finally, research is needed with regard to how public health systems can effectively address the broader social determinants of health and structural racism by engagement with other key sectors, which will entail developing funding mechanisms to support cross-sector collaborations. The ongoing, long-term generation of such evidence would support a 21st century system that can effectively respond to new health threats, monitor existing conditions, and equitably support the public’s health and well-being.
The research priorities laid out by the attendees at the strategy session set down a clear path: capitalize on this moment in time to identify high-impact public health practices; improve our ability to conduct workforce and financial analyses that direct infrastructure investments toward those with the greatest impact on outcomes; and finally, develop evidence in support of building a more equitable, resilient, and technologically advanced public health system so that we are prepared for the next crisis. However, one priority loomed above all and is the necessary basis for generating any of this evidence and that is the availability of immediate and sustained funding for PHSSR. Only once we have secured grants to build a funding stream and ongoing pipeline for public health services and systems researchers will we begin to see lasting improvements in both the science and practice of public health. Building on this preliminary convening, AcademyHealth along with key public health partners, seeks to convene a diverse range of stakeholders to develop a robust research agenda for PHSSR. As COVID-19 has shown, we cannot wait until the next crisis to invigorate the generation of this critical evidence base. Our 21st century society needs and expects the provision of a capable, trusted, equitable public health system.