by Betty Bekemeier, PhD, MPH, RN, FAAN

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Current Trends

Population health has become “fashionable” again, it seems. Early in the last century, governmental public health departments, and the services they provided, were considered the backbone of the US health system, with public health practitioners recognized as crucial protectors of population health. Much of that changed with the modern and more “privileged” position of traditional medicine and individually focused healthcare delivery (more here). But, thankfully, the term population health has recently become a more common part of the health system lexicon. National attention to elements of the Triple Aim made population health improvement a necessary leg of the Triple Aim stool, and the Robert Wood Johnson Foundation’s (RWJF) focus on achieving a Culture of Health is generating a national movement toward addressing the complex social factors that impact health. National academic program requirements for accreditation, such as those for the Master in Public Health or the Doctor of Nursing Practice, are also increasingly articulate about educational requirements for competencies in population health improvement. At my own institution, the University of Washington (UW), our university president recently challenged UW faculty, staff, and students to improve population health through a “doubling down on our commitment to reducing health disparities here and around the globe.” She’s also establishing a UW Population Health Leadership Council to develop a related “University-wide plan.”

With population health now on the lips of influential organization, system, and university leaders, why has the proverbial hub of population health improvement—our governmental public health systems—suffered such a dramatic loss of resources and capacity in recent years? Indeed, public health systems have had to reluctantly compete with school districts and fire departments for recognition and resources, even as progressive public health systems pursue modernization efforts intended to maximize their responsiveness to state and local needs and to gain support for core capabilities and programs that will assure foundational public health services are available in every community. The troubling mismatch between attentions being paid to the latest population health “fashion” and the lack of recognition and support for the critical role governmental public health systems play in improving health and promoting health equity has occurred when we might need this public health system capacity and support the most. Concerns regarding the Zika virus, resurgences of vaccine preventable diseases such as measles, shocking epidemics of opioid addiction and gun violence, and distressingly persistent health disparities could be reason enough for turning to governmental public health systems as being central to addressing the Triple Aim’s population health mission or achieving a culture of health. But health departments have not been on the lips of these influential leaders.

Governmental public health systems do not tend to be gaining from this fashion trend (and, thus, nor is the public) for several reasons. High among these reasons is the lack of adequate evidence regarding the effectiveness of governmental public health systems in impacting the health of populations, and even less evidence regarding their impact in reducing disparities and establishing a culture of health. Thankfully, there is growing evidence generated by public health services and systems researchers (PHSSR) and public health practice-based research networks (PBRN) in the last decade, however, that consistently points to the positive impact of health departments on the health of the populations they serve and their value to communities in preventing disease and disability.

Another, and related, reason for the lack of benefit to public health systems from this focus on population health has been the inconsistent links that exist between academia and governmental public health systems. Opportunities such as the RWJF’s formation of public health PBRNs in states around the US and the Health Resources and Services Administration-funded university-based Public Health Training Centers help support meaningful links between academia and practice through collaborative research activities and a focus on assuring a competent workforce and have helped to strengthen academic and practice ties. Nonetheless, academic researchers and health department leaders have not taken adequate advantage of developing and leveraging the connections between academia and governmental public health systems that could generate research to improve population health, reduce disparities, and promote health equity.

Further establishment, development, and strengthening of academic health departments (AHD) has the potential to bolster this important academic-practice link as well as provide a sustainable focal point for much-needed PHSSR that is practice-based and immediately relevant. AHDs are arrangements between governmental public health departments and academic intuitions that provide “mutual benefits” related to teaching, research, and service. Modest, occasional funding to specifically support AHDs has come from agencies such as the Centers for Disease Control and Prevention and the Association of Schools and Programs of Public Health. Embracing and furthering the growth and development of AHDs and their potential for practice-based research could help generate more of the evidence needed for guiding practice and demonstrating the critical role of governmental public health systems in population health improvement.

Benefits of Academic Health Departments

AHDs may not seem like a new idea for facilitating the generation of this evidence, yet various emergent factors point to their promise as an increasingly important research resource. First, the Triple Aim’s goals regarding “population health improvement” and “reducing cost per capita” cannot be achieved without public health system improvement and a focus on prevention. This requires the generation of PHSSR evidence and practice-based research relationships to assure research relevancy, rigor, and the immediate translation of findings to prevention practice and communities. AHDs bring together practice partners with data and research questions, and researchers with sophisticated research methods and approaches. AHDs can provide a stable “home” for PBRNs and partnerships like these to thrive. Second, emerging accreditation priorities for both health departments and academic programs include “engagement between academia and practice” and a focus on population health for general graduate programs, for example, in public health and nursing. Third, nonprofit hospitals are now required, in collaboration with public health departments, to conduct triennial community health needs assessments and develop strategic plans that provide substantive community benefits and address identified needs. These hospitals need evidence to support their approaches and the outcomes of their community investments. More data and evidence generated from practice-based PHSSR regarding the value of prevention for improving population health and reducing costs, would provide the guidance hospitals need for investments in primary prevention; would help health departments inform and improve their performance; and could be used to support the generation of additional related data and research. AHDs can be leaders in this data and evidence-generation space.

But growing and strengthening these formal, strategic partnerships may need to be different from our early iterations of many AHDs. While AHDs may emerge and develop through early wins with student arrangements or practice-based research experiences, the AHD model also needs to be expanded to include community healthcare partners such as nonprofit hospitals. Galea and Annas suggest that it is precisely our “narrow” view of “traditional public health functions” that has been responsible in part for public health systems “losing ground” to the nation’s focus on medical care. Strengthening and broadening our view of these partnerships could go a long way toward assuring an effective prevention backbone exists in our nation’s health system.

Future of Public Health Services and Systems Research

To advance the generation, rigor, and relevance of PHSSR to guide prevention systems and population health improvement, the field must:

1. Expand the AHD model to include health system partners outside of governmental public health, particularly healthcare and nonprofit hospital leaders. New AHDs may need to expand incrementally as they establish trust, mutual support, and resource systems. But expanded partnerships could also leverage additional resources even as they broaden our view of public health systems and of PHSSR.
2. Leverage current efforts in public health system modernization to make AHDs central features in highlighting, examining, and guiding these advancement efforts, including specific modernization efforts recently funded by the RWJF in Ohio, Oregon, and Washington. This can take the form of conducting rigorous research related to system modernization efforts and through AHDs—measuring and examining outcomes, population health improvements, per capita cost savings, and other changes over time or in comparison to other states or jurisdictions. As some public health modernization activities include development of legislation, such activities present opportunities for building AHDs into a state’s legislative agenda and funding streams.
3. Leverage the AHD model to generate interest among new investigators (students and junior faculty) into PHSSR by capitalizing on the practical relevance and the opportunities for timely research translation that exist in conducting research through and with AHDs.

Together, these recommendations can help fill crucial PHSSR research needs regarding the impact of prevention and public health modernization, the role of governmental health departments and prevention in advancing the goals of the Triple Aim and health system transformation, and the identification of system efficiencies and effective practices that will support health equity and population health improvement. When the academic, public health, and community institutions of AHDs maximize their collective strengths and work together to answer vital questions around building healthier communities, they have the potential to establish a greater sum of the parts that make up the AHD’s whole. Jointly they can help address the mismatch between population health “fashions” and the critical role of governmental public systems in health improvement.

Acknowledgement: This commentary was commissioned by AcademyHealth for the 15th Annual Public Health Systems Research Interest Group Meeting in 2016 under the generous support of the Robert Wood Johnson Foundation.

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Betty Bekemeier, PhD, MPH, RN, FAAN, is an Associate Professor in the University of Washington (UW) School of Nursing and Director of the Northwest Center for Public Health Practice at the UW School of Public Health. She is PI of the Public Health Activities & Services Tracking (PHAST) Study and her research focuses on the structures and practices of state and local health departments in relation to health outcomes and eliminating system inequities. [Full bio]