Transforming Public Health – When will we get there?

Jaime Bodden, MSW, MPH, is the Managing Director of the Washington State Association of Local Public Health Officials. In this commentary, she discusses public health system transformation through a Foundational Public Health Services framework. This piece is part of a series of commentaries focused on transforming public health that will be released throughout this week. 



Washington’s public health system is long overdue for transformation. And no one knows this better than the people in the system itself. Public health leaders know they are working within a broken system and they are desperately trying to change it. For the last ten years, state and local public health leaders have advocated for this in two ways – first by seeking full funding of the public health system and second by supporting innovation and modernization through a framework known as Foundational Public Health Services (FPHS).

FPHS offers a new public health system that defines the core functions and services needed to protect communities from health threats, prevent disease and disability, and promote opportunity and economic vitality. This doesn’t come cheap – in fact there is an estimated $225 million annual shortfall between our current broken public health system and what is needed for this transformation.

Washington is already seeing the return on recent state investments through improved communicable disease infrastructure and disease investigation. These gains were critical in the COVID-19 response, but the larger FPHS transformation plan has stalled. The entire public health system has shifted focus to address the COVID-19 pandemic, stagnating the momentum gained in larger system transformation. But even these recent gains are incremental. Without a dedicated and sustainable funding source, transforming public health is beholden to the availability of state revenues that are unpredictable, and insufficient and less attractive than issues that tend to make headlines.

The COVID-19 pandemic has proven that the time-tested strategies of public health are effective. But it can do little to anticipate and plan when it is focused on reacting to disease outbreaks. Current public health systems move from crisis to crisis, but more is needed – the system must be nimble and adaptive, capable of moving swiftly from one emergency to another while simultaneously deploying resources to help predict and prevent future crises.

For example, recent FPHS funding has built a network of regional epidemiologists who provide support for local jurisdictions as they work through disease outbreaks. This workforce can quickly identify these outbreaks and collaborate with state experts to predict disease trends and target our most vulnerable community members. Simultaneously, local jurisdictions provide ‘boots on the ground’ capability to adjust the information for local community-specific outreach and disease investigation. This balance of a well-rounded public health system leverages the benefits of working at the community level while connecting to highly skilled technical experts.

The scope and range of public health practice – even focusing solely on governmental public health – is immense.  Work has long been siloed into distinct focus areas, creating a disjointed and rigid approach.  The practice is focused on internal processes and ‘turf’- emphasizing the regulation and implementation of state statutes over innovation and performance. The practice risks losing the larger system changes outlined in national public health frameworks such as Public Health 3.0 and the concepts of Chief Health Strategist that seek to align public health, care coordination, and healthcare delivery.

FPHS goes beyond regulation and enforcement. It shifts the policy focus to innovation and promoting economic opportunity in our state. A good example of this is food safety. To prevent foodborne outbreaks, state health agencies set food codes and regulations, and local health jurisdictions inspect food establishments. New business models like shared kitchen space, food trucks, and expanded ‘cottage’ foods have challenged our system’s current practice and policies. Recognizing this as an opportunity not only to update statutes and codes but also to rethink food practices allows space for more diverse business models, cooking practices, and stakeholders. The public health system can support larger social and cultural issues such as social justice, food access, and entrepreneurship.

Could a similar approach be taken to larger threats to our health and social framework like housing, racism, and climate change? With a transformed public health system – absolutely.

Through FPHS, opportunities to dismantle these silos are evolving. Adopting an equity framework shifts the focus from individual impacts and services to multi-dimensional approaches that impact system structures. FPHS is a systems approach between state, local, and tribal agencies that has allowed public health to test new practice models, identify policies that inhibit economic opportunity for marginalized and disadvantaged communities, and shift policy thinking from a rigid interpretation of regulation to a focus on innovation.

Innovation is only possible when public health is not forced to focus its full attention on responding to crises and emergencies, yet it has long been in that position – inadequate infrastructure and resources prevents this dual approach. The FPHS framework needs advocates, champions, and funders who will support this transformation. Without it, public health must continue to focus on the crisis of the day rather than move to a system of prepared readiness.