The Vision of the Future

In 2026, as the nation paused to celebrate its 250th birthday, one thing was clear. We had become a remarkably healthier nation. And, since the beginning of the 21st century, the nation's public health system and its governmental public health departments had played an important role in this progress. The health departments' emphasis on policy and service promoted equity and health, prevented disease, lowered healthcare costs, and protected health.

Polls indicated that people in every community, regardless of who they were or where they lived, trusted their local, state, tribal, and federal health departments. People knew to expect effectiveness and efficiency from their health department, reversing images from the latter part of the 20th century.

Public health departments and their governance entities were aligned in a functional system with a common mission to improve the health of the nation. Their hallmark was a systemwide, organization-wide, and individual-specific culture of continuous quality improvement that simply "was" the standard operating procedure for governmental public health. Public, private, academic, and not-for-profit partners worked together to ensure that "never events"-disease outcomes that could have been prevented and should never occur in a well-functioning system-did not occur. There was consensus on benchmarks that defined high-quality performance and valid and reliable methods to measure performance. Public health practice was synonymous with excellence.

The Present

But now, in 2009, we can only aspire to that vision and plant the seeds for its growth. The current structures, statutes, mandates, and allocation of resources do not support governmental and nongovernmental public health systems that can create conditions in which populations can be healthy and in which healthier choices are the default options that enable healthy behavior. Instead, our complex patchwork of public health services results in unacceptable variation in health status. Our dysfunctional system is constrained by persistent underfunding, while our overinvestment in "sick care" fixes people once they are broken rather than keeping them well in the first place. Although public health practitioners from all sectors have developed effective methods for assessing health risks and capturing the aspirations of community residents for health, equity, and quality of life, current plans, programs, and policies fail to deliver on these hopes.

So What Happened Between 2009 and 2026?

Together, leaders and practitioners in the governmental public health system led the demand for change in their own organizations first, by creating a work environment that stimulated the craving for constant improvement, providing the skills, tools, and resources needed to achieve high-quality performance from all staff regardless of position, and second, by demonstrating leadership through inspiration, motivation, and financial reward.

Public health practitioners and policy makers at all levels realized that addressing public health issues of significance required the alignment of the many components of the public health system. Federal, tribal, state, local, and territorial health agencies became collaborators in a functional system in which each contributed its unique strengths and worked mutually to improve the health of our people and nation. Stakeholders recognized their common vision and then worked together on implementing quality improvement using a systems approach. Partners shared information, broke down silos, and coordinated efforts to avoid redundancy and conflicting messages. The common objective was to improve the public's health and draw on the strengths inherent in every community. The stakeholders recognized that the variation in organization and practice provided natural experiments to determine what worked and what did not, and the results guided change. Incentives and training reinforced adoption of best practices.

Academic training raised a new generation for the public health workforce that valued work at all levels of governmental and nongovernmental practice and exposed young students to the range of careers available. Public health practitioners and those who trained them acquired the theoretical background and practical skill to turn quality improvement into everyday practice. A culture of quality improvement turned public health staff into researchers on a daily basis: determining the root causes of a problem, performing an intervention, and measuring the effect of the change. They began to use the basic scientific method to discover what works best to improve performance and health outcomes in community practice. When asked about their jobs, staff members in a governmental public health practice gave a two-part response-first, their specific title and function, and second, that they work to perform better all the time.

Transformation to a culture of quality improvement required leadership; it happened by design and with strategic intent. It happened because resources were available and efforts were expended. Leadership gave clear vision, rationale, and support for improvement. Providing incentives and demonstrating rewards for continuous improvement of performance and outcomes were keys to success. Organizations that worked well were given more flexibility to use funds to meet their own needs and the priorities of the communities they served. Recognition by governance and funders, along with additional resources, were frequent.

To achieve this vision of what public health could look like in 2026, we, who are the governmental "backbone" of the public health system, must embrace a culture of quality improvement with a constant focus on meeting the needs and improving the equity, health, and well-being of the people we serve.