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Governance for population health*
Alina Baciu
Senior Program Officer, Institute of Medicine of the National Academies
Email: abaciu@nas.edu
Martin Sepulveda
Member of the IOM Committee on Public Health Strategies to Improve Health and IBM Fellow & Vice President Health Systems and Policy Research, IBM Corporation
Email: mjs851@us.ibm.com
George Isham
Member of the IOM Committee on Public Health Strategies to Improve Health and Senior Advisor, HealthPartners and Senior Fellow, HealthPartners Institute for Education and Research, HealthPartners, Inc.
Email: George.J.Isham@HealthPartners.Com
Rose Marie Martinez
Senior Board Director, Board on Population Health and Public Health Practice, Institute of Medicine of the National Academies
Email: rmartinez@nas.edu
*The views expressed in this article represent those of the authors and not the Institute of Medicine or National Academies
Context and overview
Kickbush and Gleicher (2012) distinguish “the governance of the health system and the strengthening of health systems, which is called health governance” from “the joint action of health and non-health sectors, of the public and private sectors and of citizens for a common interest in what is called governance for health.” This paper focuses on the latter, but offers a glossary that includes the clinical realm of health governance.
It is important at the outset to clarify the meaning of terms that are sometimes used imprecisely, including public health and population health (see Box 1). The term governance, defined in different but usually overlapping ways by the World Bank and the World Health Organization (WHO) and others with reference to its multiple dimensions (e.g., rule of law, transparency, fairness, government effectiveness, voice and accountability), is fundamentally about leadership and the rules by which leaders lead.
Box 1: Glossary
Health: The World Health Organization (WHO) has defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
Public health: The Institute of Medicine has described public health as “what we as a society do to collectively assure the conditions in which people can be healthy.” In practice, the public health is typically used to refer to governmental public health agencies, or to the governmental public health infrastructure more broadly.*
Population health: Although “public health” is sometimes used to refer to the health of the public, the term population health (as defined by Kindig and Stoddard [2003] and Jacobson and Teutsch [2012]) is more current.
Health care: The health care delivery system, sometimes health system for short, refers to the array of health care providers, organizations, and payers (i.e., employers) that provide clinical care services.
Intersectoral health system: Although health system is often used as a short-hand to denote the health care delivery system, a 2010 report from the Institute of Medicine described the health system beyond clinical care, explaining that governmental public health agencies should be working in concert with clinical partners, and many others, including schools and the education sector, business, and communities.
* public health is sometimes incorrectly used to refer to publicly funded clinical care services
Although the Institute of Medicine (IOM), the health arm of the U.S. National Academy of Sciences, has not had any consensus committees deliberate and make findings and recommendations specifically on the subject of governance, the concept of governance is woven through many reports and also appears in some summaries of IOM convening activities (i.e., roundtable and forum workshops). Governance for health has been addressed most substantively in work from the IOM’s Board on Population Health and Public Health Practice.
In the U.S. context, governance for health traditionally referred to governmental public health agencies. It includes legislated authorities, funding, organization, leadership structure, functions and accountability at national, state and local levels. Although this paper does not address health governance (i.e., in the clinical care sector) at length, it is important to mention that health care delivery institutions and entities have independent governance structures, and these may be affected by various government requirements such as reporting and disclosures, disease notification, licensure, hazardous waste management and approvals or certifications for facilities and certain types of equipment, and by patient advocacy.
Due to the nature of the American government, the role of the federal agencies in governance for health is somewhat limited, and the influence of the federal level of government is leveraged largely through funding programs. The United States does not have a ministry of health, and the U.S. Constitution bestows the authority over health matters on the 50 states. The relationship between state and local public health agencies varies greatly. The common typology of state-level governance models consists of: (1) centralized, with local public health departments operating under the authority of state governments; (2) decentralized, or operating under local authority; (3) shared, where health departments operate under shared state and local authority; and (4) mixed governance models within a given state (Meit et al., 2012).
In recent decades, there has been greater recognition of the fact that local public health agencies (also known as health departments) are often one of multiple entities in a community focusing on health issues, or making contributions to improving health and its correlates (livability, well-being, etc.). A nation’s or a community’s interests in improving livability, economic vibrancy, and sustainability are connected and cannot be effectively addressed in piecemeal fashion by one sector or one field at a time, or in the local setting, by one organization or neighborhood working in isolation. This means that any discussion about governance for health must account for the added complexity of the health system (broadly defined, as above).
The need for intersectoral health governance
Intersectoral health governance for improved population health is needed because numerous non-health care sectors contribute to societal conditions affecting health such as the physical environment, mobility and transport, housing, public safety, air quality, employment and education. The engagement of all health relevant sectors is vital so that priorities for multi-sectoral health systems improvement as well as potential approaches respect and account for impacts on each individual sector. Intersectoral governance for health provides the structure for transparency of deliberations and actions and facilitates access to data, information and expertise. It also creates a framework for improving coordination and communication between sectors, for strengthening measurement and evaluation systems, and for diffusing innovation.
An intersectoral framework for a population health, systems-based approach has been emphasized by the WHO in the 1986 Ottawa Charter and elsewhere, and has been described by many researchers of health in all policies (or HiAP) approaches (Sihto et al., 2006; Stahl et al., 2006). In the United States, some states and local jurisdictions have initiated approaches to facilitate intersectoral health planning using a HiAP strategy (see, for example, Rudolph et al., 2013). HiAP approaches integrate the assessment of potential downstream or lateral impacts on population health of policies, practices or programs in non-health care sectors such as transportation or zoning ordinances and requirements. At the U.S. federal level, the President, authorized in part by the Affordable Care Act (ACA) on health care reform, created a National Prevention, Health Promotion, and Public Health Council (National Prevention Council, in short) reflecting the multi-sectoral nature of population health. The Council brings together the heads of the U.S. Departments of Health and Human Services, Transportation, Education, Agriculture, Defense under the leadership of the U.S. Surgeon General. The Council developed the landmark National Prevention Strategy and related action plans which highlight “the important contributions that each member department is making to ensure the health, well-being, and resilience of the American people.” Moreover, the Department of Transportation, the Environmental Protection Agency, and the Department of Housing and Urban Development sponsored a joint Sustainable Communities Initiative, one of a number of additional initiatives that are multisectoral in nature (Bostic et al., 2012).
Multiple types of partnerships have emerged to address the various facets of health in communities. Examples include the California Strategic Growth Council’s HiAP Task Force and the intersectoral collaboration in the Massachusetts Healthy Transportation Compact. At the local level, examples may be found in the work of communities awarded the Robert Wood Johnson Foundation’s Roadmaps to Health Prize, and of groups such as Healthy King County Coalition in Seattle, Washington state, and Live Well San Diego, in California, which have brought together community-based organizations, local city and county governments (including parks and recreation departments), school districts, and community health centers.1, 2, 3
Below, we discuss the work of IOM and especially the Board on Population Health and Public Health Practice projects on three dimensions of governance: accountability, fairness, and voice.
On accountability
The absence of intersectoral governance for health creates an environment where there is fragmentation of accountability overall and where accountability for health impact within sectors is uneven. Of all health system sectors, governmental public health has the clearest accountability for health of populations. Its role, functions and authorities are governed by law, largely at the state and municipal levels (Gostin, 2008). However, there is considerable variation in public health statutes from state to state and municipality to municipality. Model public health laws have been proposed to standardize authorities and accountability, but have not been widely adopted.
Health care delivery system enterprises have very narrow accountability which is focused on individual patients served and the safety and efficacy of products and services rather than community populations. The 2010 ACA in the U.S. provides new mechanisms for strengthening and extending the accountability of health care delivery organizations both for clinical and financial outcomes. These mechanisms include mandated coverage for 10 essential services such as maternal and newborn care, in-patient and ambulatory care, mental health and rehabilitative services.4 Also included are changes to payment for health care providers requiring improved access to care, care coordination, care management and other functions in new models of care such as primary care medical homes or financial risk bearing systems of care such as accountable care organizations (MPAC, 2014; Robert Graham Center, 2007).
Contemporary governance structures in governance for health will need to account for hybrid arrangements of multiple sectors working together in improving health. The Institute of Medicine has contributed to evolving notions of governance for health in several ways. IOM reports over the past 25 years have called for implementation of several important concepts:
System quality and accreditation processes as a way to establish common standards for a high level of performance for public health agencies (following the model of the health care delivery system, which began this work much earlier).
The 1988 report The Future of Public Health first called for accreditation of governmental public health agencies, and the recommendation was reiterated in the 2003 report The Future of the Public’s Health in the 21st Century. It was only in 2007 that the public health community, with leadership and financial support from the Robert Wood Johnson Foundation established the Public Health Accreditation Board (PHAB), which established a process for accreditation of public health agencies. The PHAB domains for accreditation include Governance (Domain 12): Maintain capacity to engage the public health governing entity.5
The multi-sectoral health system, introduced in the 2003 report hinted at the potential need for multi-sectoral governance. A health system (which is a system of sectoral systems) was again described by an Institute of Medicine committee in 2010. Sectoral system components include: governmental public health, health care, business, media, education, transportation, housing, food, and environment. Reports in 2011 and 2012 further built on that foundation, and described the potential of hybrid governance entities, such as coalitions or boards designed to ensure implementation and accountability in settings that “span public and private action and investments” (IOM, 2011: 91; IOM, 2012). The report For the Public’s Health: the Role of Measurement in Action and Accountability offered a framework for compact or shared accountability (IOM, 2010). Sectors outside health have little accountability for population health in communities. Health outcome responsibilities in these are related to factors such as products, services, emissions, waste, safety and injury on premises or in the workplace. There is a need for a different type of accountability to improve health system performance and population health in communities that goes beyond current models. The 2010 IOM report indicates the need for agreement among implementing partners on specific plans of action for targeting health priorities; for holding of implementing partners accountable for execution of agreed on plans (strategies, interventions, policies, and processes); and for measurement of execution and outcomes of the agreed on plans and agreement on revisions to a plan of action. The report also describes core elements required for accountability:
- an identified body with a clear charge
- a body with the capacity to undertake activities that will respond to the charge
- the ability to measure what is accomplished against the charge
- the availability of tools to assess and improve effectiveness (e.g., a learning system, incentives, technical assistance)
The IOM report’s authoring committee acknowledged that the contract model of accountability typical of governmental public health agencies may be less effective for multi-sectoral governance and accountability. In this model, a health department is accountable to a legislative body (city council or state legislature), to taxpayers and or to federal agencies providing funding for services. When statutes and financial contracts do not bind the parties, a mutual, or compact, model of accountability may be useful. These models often involve instruments such as memoranda of understanding and periodic reports to coalition members to establish accountability and to demonstrate compliance or follow-through.
The structure of health-in-all-policies governance
Greer and Lillvis (2014) have found that the literature shows two kinds of challenges with intersectoral governance: coordination problems and sustainability or durability problems, the former relating to the difficulty of bringing multiple organizations to operate harmoniously and efficiently, and the latter addressing the difficulty of sustaining a multi-actor effort over a long time.
In 2008, Berwick and colleagues described the concept of integrator in the health care delivery context--an entity that “accepts responsibility for all three components of the Triple Aim for a specified population” (better care, lower cost, better health)—but functionally, and with applicability beyond the clinical care context, the entity would both link organizations and “induce coordinative behavior” (Berwick et al., 2008).
The integrator concept has been adapted to the population health improvement context and the terms quarterback and population health integrator are both used to refer to an entity that coordinates cross-sector interventions (Chang, 2012; Erickson, 2013). Hanleybrown and colleagues (2012), writing about collective impact partnerships, have described an analogous concept of backbone organization. Hester and Stange (2014), in a discussion paper for the Institute of Medicine Roundtable on Population Health Improvement described the integrator role as one that could be fulfilled by a “community health system” (citing IOM, 2010), whose key ingredients they described as: convening function, the crafting of a shared vision and goals, the assessment of needs, the management of resources, and the management of an information system for performance measurement and rapid cycle changes. Baker and colleagues (2012) similarly identified from their research on Active Living by Design partnerships across 25 different U.S. communities the following structural and functional characteristics of successful multisectoral partnerships: “flexible governance structures, leadership, group management, action planning, and assessment/evaluation” (Baker et al., 2012: S290). Kindig and Isham (2014) have also discussed the role of integrators or equivalent entities in aligning investments and activities across multiple sectors in the context of community health business partnership models.
An integrator would address the coordination challenge, and if properly equipped to assess needs and manage resources, as described by Hester and Stange (2014), could also address the durability challenge, ensuring that community health improvement efforts can be sustained indefinitely.
Voice
Several IOM publications have highlighted the importance of community voice and agency in governance for health. In a 2003 report, the authoring committee asserted that “health departments can become the facilitators and supporters of strong local public health systems that are informed by community voices, responsive to community needs, and linked to community assets” (IOM, 2003: 1865). The committee described its support for “shared governance” in which communities “own” the agenda for population health improvement, and described a simple framework for collaborative community action on health, informed by previous work in the field (Kreuter, 1992; Fawcett et al., 2000; Foster-Fishman et al., 2001).
The Roundtable on Population Health Improvement has held workshops to examine lessons from social movements and the role and potential of communities in improving health (IOM, 2014a, 2014b). Common themes have included the range of community representation in activities that claimed a level of community engagement, with approaches that differ in terms of the level of agency communities have in the process, e.g., the extent to which community members and organizations can lead and make decisions to serve their aims. For example, engaging the community can be accomplished through town halls or focus groups to inform a health promotion effort, but such activities are not equivalent to working with the community to help them find and use their voice, identify and mobilize their assets, and effect change. Intersectoral governance for health is incomplete and will ultimately not succeed without authentic representation of the community’s needs and priorities, beginning with techniques such as “ground-truthing” (Sadd et al., 2013; IOM, 2014b; and also see Pastor, 2014).
Fairness
A core concern of health in all policies efforts in the U.S. (as elsewhere), is the issue of equity, and in particular the inequities of opportunity and in the determinants of health that are the result of deliberate policy decisions made over many decades. For example, two workshop summaries from the IOM Roundtable on Population Health Improvement included discussions of the legacy of residential segregation, and its continuing effects on populations across the United States. Lending policies such as redlining (denying loans or insurance to individuals deemed to reside in high-risk areas) and the racially restrictive covenants supporting by the U.S. Federal Housing Administration in the early half of the 20th century created neighborhoods that were deprived of resources and vulnerable to predatory lending and additional inequities (IOM, 2014). At a workshop on the role and potential of communities, roundtable members learned about widespread zero-tolerance policies in the public school systems across the country that “push out” students for a variety of infractions, creating a hostile environment for learning and initiating a downward spiral that leads vulnerable students to drop out of school and incur a range of associated, negative consequences.
Such exclusionary policies marginalize and isolate groups of people, leading to a devaluing of essential human capital. Intersectoral governance for health would require attention to the potential consequences of policy in the realm of housing, transportation, education, and other sectors. Jurisdictions around the United States are using health impact assessments (HIA) as a tool to assess the likely effects of a policy under consideration. Examples include a Los Angeles county HIA of the effect on truancy of providing no-cost public transportation bus passes to primary and secondary school students, and an HIA in a Massachusetts town that examined the potential effects of removing an old elevated highway and replacing it with several different options (County of Los Angeles, 2013; IOM, 2013).
Conclusion
As the recognition of multisector responsibility for health has grown, so has the need for governance concepts and models that are similarly multisectoral. The Institute of Medicine’s body of work has explored this emerging area and especially three dimensions of governance: accountability, fairness and voice. IOM work, both in consensus studies and in dialogue and writing facilitated by the Roundtable on Population Health Improvement, has explored how multi-sector accountability could operate, the centrality of equity as an issue for health in all policies approaches, and the importance of identifying needs and making decisions to address them in partnership with communities and vulnerable populations.
Notes
http://www.healthykingcounty.org http://www.countyhealthrankings.org/roadmaps/prize http://livewellsd.org/ The essential health benefits are a set of health care service categories defined by the Centers for Medicare and Medicaid Services that must be covered by certain plans starting in 2014. The list of benefits is provided at https://www.healthcare.gov/what-does-marketplace-health-insurance-cover/ The standards that must be met for accreditation under Domain 12 include: maintain current operational definitions and statements of the public health roles, responsibilities, and authorities; provide information to the governing entity regarding public health and the official responsibilities of the health department and of the governing entity; encourage the governing entity’s engagement in the public health department’s overall obligations and responsibilities.
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