Presented by Clem Bezold and Trevor Thompson Public health in each city and county in the United States works to ensure the conditions for all to be healthy. Public health investigates disease outbreaks, fosters health promotion and health equity, and assures that health care is available. And it typically focuses on the most vulnerable in the community. There are several forces changing public health—what it does and how it operates. The effects of climate change on local communities, other types of emergencies, future infectious diseases and their surveillance, optimal approaches to health promotion for communities, the role of health care providers in enhancing population health, the state of health equity or fairness—these are among the topics considered in the scenarios. The Institute for Alternative Futures, with funding from the Robert Wood Johnson Foundation and the Kresge Foundation, has developed a national project developing Public Health 2030 Scenarios. This session will present those results.

1. Public Health 2030
Clem Bezold
Trevor Thompson
WFS Orlando July 13, 2014
Supported by
grants from:

2. Introduction
• Public Health is “what we as a society collectively do to ensure the
conditions for people to be healthy.”
• Public health is not medical care (though some PHA’s do that); public
health has traditionally done what needed to be done that no one else
was doing.
• There are over 3000 State and Local Health Departments in the United
States.
• The Who, What, and How of public health is evolving – not always in
consistent directions. Scenarios are an important tool for exploring this
uncertainty.
• Public Health 2030 Scenarios were developed as a foresight
contribution to the field, in conjunction with NACCHO, ASTHO, APHA
and other leaders in the field
2

3. What Public Health Does
• Prevents Epidemics
• Protects the Environment, Workplace, Housing, Food and
Water.
• Promotes Healthy Behavior
• Monitors the Health of the Population
• Mobilizes Communities for Action
• Responds to Disasters
• Assures that Medical Services are High Quality and
Accessible
• Trains Specialists in Investigating and Preventing Diseases
• Develops Policies to Promote Health
3

4. Essential Public Health Functions
• Assessment (Collection and analysis of information to identify
important problems)
– Monitor health status to identify community health problems.
– Diagnose and investigate health problems and health hazards in the community.
• Policy Development (Setting priorities and developing strategies
based on the assessments of health) needs)
– Inform, educate, and empower people about health issues.
– Mobilize community partnerships to identify and solve health problems.
– Develop policies and plans that support individual and community health efforts.
• Assurance (Assuring that appropriate services are available and
accessible to meet the needs of the population)
– Enforce laws and regulations that protect health and ensure safety.
– Link people to needed personal health services and assure the provision of health care
when otherwise unavailable.
– Assure a competent public health and personal healthcare workforce.
– Evaluate effectiveness, accessibility, and quality of personal and population-based
health services.
– Research new insights and innovative solutions to health problems.
4

5. The Public Health 2030 Project
Funded by Robert Wood Johnson & Kresge Foundations
Following Scenarios on Vulnerability 2030, Primary Care 2025, and
Health and Health Care in 2032
• Explore key forces shaping public health
• Consider the future of public health functions,
financing and sustainability
• Build expectable, challenging, and visionary scenarios
that facilitate preparation, imagination, aspiration
• Provide and widely distribute the scenarios as a tool for
public health agencies, organizations, and schools
5

6. Developing the Scenarios
• Considered key drivers shaping public health
• Developed expectable, challenging, and
aspirational forecasts for the drivers
• Interviewed experts, Project advisers
• Developed and used state and local Public
Health 2030 Scenarios
• Developed national Public Health 2030 Scenarios
6

7. Aspirational Futures: Scenario
Zones
Visionary/Surprisingly
Successful
Expectable
Challenging
7

8. State & Local PH2030 Scenarios
Fargo Cass Public Health (ND)
Boston Public Health Commission (MA)
Cuyahoga County Board of Health (OH)
Virginia Department of Health
8

9. National Public Health 2030
Scenarios
• Scenario 1: One Step Forward, Half a Step Back
Significant advances in big data analytics, in access to and quality of
health care; yet recurring fiscal and health challenges for communities
and PHAs.
• Scenario 2: Overwhelmed, Under-Resourced
Economic and environmental challenges, infectious diseases increase,
health care reform halted, public health constrained.
• Scenario 3: Sea Change for Health Equity
PHAs evolve into health development agencies. Economic stability and
value and policy shifts toward equity support this evolution.
• Scenario 4: Community-Driven Health and Equity
Innovation in communities, alternative economics, transformation is
accelerated through technology and recognition of economic and social
injustice.
9

10. Scenario Likelihood and Preferability
Poll
Please use the grid below to assess the likelihood and preferability of each scenario separately.
•100% refers to highly likely or preferable.
•0% means there is nothing desirable or preferable about a particular scenario.
•Percentages can be from 0 to 100 in each cell. Columns or rows need not add up to 100%. For example, you may assign 60% for likelihood and
85% for preferability of a scenario.
Public Health 2030 Scenarios Likelihood Preferability
Scenario 1: One Step Forward,
Half a Step Back
0-100 0-100
Scenario 2: Overwhelmed,
Under-Resourced
0-100 0-100
Scenario 3: Sea Change for
Health Equity
0-100 0-100
Scenario 4: Community-Driven
Health and Equity
0-100 0-100
10

11. SCENARIO 1: ONE STEP
FORWARD, HALF A STEP BACK
Public Health 2030: A Scenario Exploration
11

12. Scenario 1: One Step Forward, Half a Step Back
• Public health agencies (PHAs) advance
capabilities in technology and big data analytics
• Public health is restrained by
–High costs of health care
–Variations in PHAs’ technological capabilities,
funding, services, and effectiveness
12

13. • Public health funding varies widely; Federal funding
for health care programs reduced as access to
health care improves
– PHAs refocus on prevention and improving community
conditions
• PHAs consolidate and share services; most improve
comparability and show positive returns on
investment (ROI)
Scenario 1: One Step Forward, Half a Step Back
13

14. • Emergence of Big Data
• Improved surveillance
and analysis
• PHAs provide quality
control, some “nudge”
social networks toward
better health
Scenario 1: One Step Forward, Half a Step Back
14

15. • When possible, PHAs
– Automate inspections
– Enhance population health monitoring
– Improve emergency preparedness
• Some PHAs are confined to mandated services
• Others are able to emphasize prevention
Scenario 1: One Step Forward, Half a Step Back
15

16. • More extreme
weather events
(EWEs) and vector-
borne infections
– E.g. Lyme disease and
dengue fever
• PHAs use simulations
and gamification to
prepare communities
for emergencies
Scenario 1: One Step Forward, Half a Step Back
16

17. Triple Aim
Electronic
Health
Records
(EHRs)
• Health care reform largely
implemented
• Expansion of Accountable Care
Organizations (ACOs), Triple
Aim, and Patient-Centered
Medical Homes (PCMH)
• Care improved by knowledge
technologies – Doc Watson,
digital health coach
• PHAs focus on prevention, have
varying roles with ACOs
Scenario 1: One Step Forward, Half a Step Back
17

18. • Health care costs continue to rise as access
improves
• Social determinants not addressed
• No “game-changers”
• Continued disparities
Scenario 1: One Step Forward, Half a Step Back
18

19. 19

20. SCENARIO 2: OVERWHELMED,
UNDER-RESOURCED
Public Health 2030: A Scenario Exploration
20

21. • Severe recessions in
2016 and 2023
• PHA funding
reduced, many
programs eliminated
Scenario 2: Overwhelmed, Under-Resourced
21

22. • PHAs blamed for lack of
preparation and
ineffective responses
• Public distrusts PHAs,
federal government in
general, and health care
Scenario 2: Overwhelmed, Under-Resourced
22

23. • Distrust grows, people refuse to
get flu shots
• Highly virulent flu strain in 2020
• Tens of thousands of people die
Scenario 2: Overwhelmed, Under-Resourced
23

24. • Citizen science and
technology grow but serve
affluent and reinforce
disparities.
• PHA health care services
cut while need grows.
• Excellent, personalized care
for those who can afford it.
• Innovative private sector
approaches to health for
those who can afford them.
Scenario 2: Overwhelmed, Under-Resourced
24

25. • “Runaway climate
change” emerges
• Climate refugees and
migrants
• Health, violence, and
discrimination worsen
• PHAs overwhelmed,
struggle to recover
Scenario 2: Overwhelmed, Under-Resourced
25

26. • PHAs understaffed, overwhelmed.
• Many universities shut down public
health programs.
• Private sector innovations ignore
disparities and vulnerability.
• Worsening disparities in health,
quality health care access, effective
prevention, and other public health
services.
Scenario 2: Overwhelmed, Under-Resourced
26

27. 27

28. SCENARIO 3: SEA CHANGE FOR
HEALTH EQUITY
Public Health 2030: A Scenario Exploration
28

29. • Changes in values and demographics.
• Funding improves for public health.
• Public health pursues advanced analytics,
gamification, and multisectoral partnerships.
• Improvements in housing, economic
opportunity, education, and other social
determinants of health.
• Some disparities persist.
• But in 2030, the vast majority of Americans
have attained greater opportunity for good
health.
Scenario 3: Sea Change for Health Equity
29

30. • Support for “common sense” policy
• Public support for opportunity, equity, and
fairness in policies and economics
– National minimum wage, Health in All Policies
• Innovation and use of new tech for outcomes
Scenario 3: Sea Change for Health Equity
30

31. • Public health funding improves
• Economies gradually grow,
reduce fiscal strains and cuts
• PHAs foster additional
resources from business,
foundations, ACOs
• Evaluations show positive ROI
• Congress restores Prevention
Fund restored to $2B level in
2020, add 2% tax in 2022 on
medical services
Scenario 3: Sea Change for Health Equity
31

32. • PHAs become health development agencies,
chief health strategists, shift away from direct
services
• Collaborative
networks and
partnerships
• Simulations,
forecasts, analyses
• Spread best practices
• Identify most cost-
effective and
appropriate providers
Scenario 3: Sea Change for Health Equity
32

33. • Gaming changes communities’ awareness of
and commitment to achieving health
• New tech developments are made to be
affordable and culturally appropriate
• PHAs lead coalitions, recognized by the public
as chief health
strategists
Scenario 3: Sea Change for Health Equity
33

34. • Health care improves
• Capitated, effective, accessed
• Primary Care supports
community prevention
• Cuts in Federal $ to PH
programs for screening and
treatment
Community
Centered
Health
Home
Scenario 3: Sea Change for Health Equity
34

35. By 2030,
• Better health and health equity, less demand
for health care
• Improved community conditions, esp. for low
income communities
Scenario 3: Sea Change for Health Equity
35

36. 36

37. SCENARIO 4: COMMUNITY-DRIVEN
HEALTH AND EQUITY
Public Health 2030: A Scenario Exploration
37

38. • Health improvement initiatives coalesce via
technology and networks into a broad, national
public health infrastructure.
• Value shift to equity was accelerated by another
major recession and economic transformation.
• The nation tries to come to terms with its racial
and socioeconomic histories, and tries to create a
more equitable society.
• Public health sheds many functions and facilitates
these movements to improve health.
Scenario 4: Community-Driven Health and Equity
38

39. • Groupnets used to improve
behavioral health at the
micro-level, often through
“peer uplift”
• Community activity &
organizations focused on
health
• PHAs lead on information
quality & community
facilitation
Scenario 4: Community-Driven Health and Equity
39

40. • Health records integrated with
other personal and community
data to allow advanced health
analysis and targeting
• Community health learning
systems enhance PHAs’ roles
as facilitators and health
strategists
• Games and simulations
improve community
engagement and planning
Scenario 4: Community-Driven Health and Equity
40

41. • Environmental Health
evolves
• PHAs work with
communities, and partners
to reduce environmental
impact and expand
renewable energy.
• Highly effective pre-event
resilience games and
simulations for Extreme
Weather Events.
Scenario 4: Community-Driven Health and Equity
41

42. • Governments spend less and spend “smarter”
• Unemployment accelerates shift to alternative
economics/new community economic models
Scenario 4: Community-Driven Health and Equity
42

43. • Economic and social
justice movement
progressed
• “Truth and
Reconciliation”
processes spread
• New legislation
promotes social and
economic fairness
Scenario 4: Community-Driven Health and Equity
43

44. • Public health graduates are
trained for community
engagement and advanced
analytics
• PHAs serve as effective
chief health strategists
• Disparities are reduced and
the nation is largely unified
in seeking to eliminate
them
Scenario 4: Community-Driven Health and Equity
44

45. 45

46. Scenario 1 Scenario 2 Scenario 3 Scenario 4
MACRO AND OPERATING ENVIRONMENTS
Economy
Fiscal Health
Internet & Social Media
Environmental Threats & Impacts
Health Care
Health Equity
Public Health
Public Health Roles
Funding for Public Health
Public Health & Health Care
Health Care’s Role in Population Health
Surveillance and Epidemiology
Emergency Preparedness
Environmental Health/Safety
Injury and Violence Prevention
Etc.
See the Public Health 2030 Scenario Matrix for a side-by-side
comparison of the scenarios across multiple dimensions
46

47. Scenario Likelihood and Preferability
Poll
Please use the grid below to assess the likelihood and preferability of each scenario separately.
•100% refers to highly likely or preferable.
•0% means there is nothing desirable or preferable about a particular scenario.
•Percentages can be from 0 to 100 in each cell. Columns or rows need not add up to 100%. For example, you may assign 60% for likelihood and
85% for preferability of a scenario.
Public Health 2030 Scenarios Likelihood Preferability
Scenario 1: One Step Forward,
Half a Step Back
69 30
Scenario 2: Overwhelmed,
Under-Resourced
37 6
Scenario 3: Sea Change for
Health Equity
39 79
Scenario 4: Community-Driven
Health and Equity
39 76
47

48. • Reactions, Comments, Questions about the
scenarios?
• What is your sense of the likelihood and
preferability?
Questions, Comments
on the Public Health 2030 Scenarios?
48

49. Public Health 2030
Recommendations
from the
National Workshop
March 6 & 7, 2014
49

50. 50
Rec 1: Transform Public Health Agencies into “Health Development
Agencies” with Dedicated, Sustainable, and Sufficient
Funding.
1A: Develop Dedicated, Sustainable, and Sufficient Funding
1B: Implement Policies for the Systematic Use and
Development of Evidence and Best Practices
1C: Build Public Health Agencies' Role in Fostering Prevention
and Health Promotion Strategies
Rec 2: Partner in Health Care Transformation to Facilitate the
Evolution from a Health Care System to a Health System
Rec 3: Build the Capacity for Dialogue about Inclusion, Opportunity,
and Equity
Rec 4: Dialogue with Other Sectors to Support Innovation

51. Public Health 2030:
A Scenario Exploration
Supported by
grants from:
www.altfutures.org/publichealth2030