Podcast transcript: Revising the 10 Essential Public Health Services

Listen to this interview as a recording on our podcast page.

This is The Nation’s Health Podcast, I’m your host, Aaron Warnick, reporter for The Nation’s Health.

The word “essential” has taken on new importance in 2020. Shared experiences have made people really reflect on what things define us, define society or, in this case, define a profession.

In 1994, the Centers for Disease Control and Prevention published the 10 Essential Public Health Services. The framework is the bedrock of the public health field. This year, the de Beaumont Foundation and the Public Health Accreditation Board took the lead revising that framework, recently releasing an update.

To talk about the changes, I’m joined by Public Health Accreditation Board Strategic Initiatives Vice President Jessica Solomon Fisher.

Could you tell me a little bit about the 10 essential public health services? What are they and what they're used for? 

The 10 Essential Public Health Services are a framework that were originally developed 25 years ago. They came out of health care reform in that time to really articulate the role of public health and specifically to differentiate it from health care.

Over time, it's been used in both governmental public health and non-governmental public health practice as a key framework that underpins just a lot of practice. It's used by health departments to organize themselves. It's used by organizations like mine, the Public Health Accreditation Board, as the foundation for the accreditation program. It's used as the foundation for Community Health Assessment related tools, such as the National Public Health Performance Standards, it's taught to students and academia. Actually, the World Health Organization has a similar model. So it's used internationally.

And then some sub-specialties within public health, like maternal child health, or like environmental health, have actually taken it and tailored it to meet their own needs. So it's definitely a very widely used framework, very well known in the field, and really often seen as kind of the foundation to really help explain and define what is public health.

 

One of the changes of the updated Essential Public Health Services is that equity has been placed at its center. What does this change say about changes in the field?

The revised framework literally centers equity, so both in the graphic and then throughout each service, it's kind of embedded, as essential in the field to, you know, obviously protect and promote the health of all people in all communities.

We also added an equity statement that serves more or less as a preamble to the framework. Overwhelmingly, the field agreed that equity should have an increased focus and the revised framework.

The task force agreed, the staff agreed, and we just heard that loud and clear from the field. And so our task force actually formed a subgroup that focused on equities, specifically, and made recommendations back to the full task force. And there was consensus, of course, around, you know, the importance of having it in there prominently.

And I think the public health field has recognized the importance of equity for some time. Recently, it's become more commonplace for it to be called out explicitly as a priority. And for organizations to really try to find concrete ways to kind of work on work on it or work on, you know, the achievement or movement toward equity.

I do think that certainly the events of the racial — racial justice movement, and then also the disparities that have really been exacerbated and highlighted by the COVID pandemic, has really helped to shine a light on its importance within the field of public health, but also outside of the field of public health. And, you know, we also know that although not every community is yet willing to address it explicitly.

As a national framework, we really felt strongly that the EPHS needed to be very explicit and very clear, and that it needed to, you know, serve to push the field. And then, you know, we needed to be leaders and using the language that we think was, you know, important and clear and true to what it is, and to that goal, to keep it really at the forefront of the work.

 

Previously, "research" was at the center, so where does research fit into the framework now?

Absolutely. And so, you know, in the original graphic, there were nine wedges with research at the center, you know, and now there are 10 wedges, one for each of the essential services and equity is at the center. So that's how it looks a little different.

But research is absolutely no less important than it was before we tried to work really hard to clarify the role of research in public health. And it's found now in essential service No. 9, which is “improve and innovate public health functions through ongoing evaluation research and continuous quality improvement.”

And, you know, the revised language for central service nine and the descriptors that follow it move away from evaluating the quality of personal health services, to emphasize the public health systems role and innovating evaluating research and improving quality and performance of the public health functions. And we really added language to highlight the importance of engaging with the community and utilizing data to inform decision making processes that are related to research.

So I would say, you know, the revised framework moves the concept of research, identification and monitoring of innovative solutions, linkages between public health practice and academia, health policy analyses and public health systems research from the original No. 10, to here a No. nine, so it hasn't gone away. It's just moved.

And you know, to my earlier point about equity, this is just an example of how we embedded equity here by calling out the value of qualitative data and lived experience as data to inform decisionmaking.

So obviously, that research component, and really to establishing these engagement decision making structures to work with the community in all stages of research. So I would argue, you know, it's still there and perhaps stronger than it was before, and has that lens of equity, again, that we tried to embed throughout the framework.

 

While the framework has been updated, it hasn't been overhauled. That said, could you talk about some of the intentional changes to language? Why are these updates and tweaks important?

A lot has happened in 25 years. And so we definitely spent time making updates to things that just wouldn't have been considered 25 years ago, you know, maybe they didn't exist, or they didn't exist with the same terminology or the same importance in the field.

And, you know, some examples would be the inclusion of the concept of health in, you know, all policies, or community leadership and power, working with health care, but in new ways, in different ways than we did 25 years ago. And obviously, advances in technology and the use of data would be, you know, a few examples.

I do want to point out, we did do a detailed crosswalk that explains essential service by essential service, you know, what changes were made for people who are really interested in kind of that nitty gritty detail. But at a high level, you know, other changes were around the clarification of definitions.

So, you know, we have a definition of equity and community. And we we did that through just publishing a simple glossary. And then obviously, some of the terminology we use like equity and you know, new language that clarifies public health role and health care, were added.

And some of the concepts, you know, related to preparedness and resilience that were obviously not such a large part of public health before 9/11, and anthrax and extreme weather events and climate change. And so while some concepts were always there, we strengthen language, for example, related to multi-sector partnerships, because that's just changed a lot.

And so things like that are seen throughout the revision. But you're right, it's not an overhaul, we really do view this kind of as a refresh. And it really just follows the advances that have been made in public health. So in a way, we're kind of playing catch-up, not only to where to field, you know, is now versus where it was 25 years ago, and also hopefully, looking ahead to where it's going in the future.

Looking forward, do you think that it's something that should be updated more frequently?

We spent a lot of time talking with the task force about that. And we absolutely don’t think it should be 25 years until it's looked at again, and it won't be. So the de Beaumont Foundation, our partner in this, has committed to bringing a group back together again in a few years to look at it, not to do the same kind of refresh.

Because we recognize that, you know, when you do make a change to a framework that is so institutionalized in the field, it has a lot of implications, right? It, you know, it impacts our standards and measures at PHAB and impacts textbooks that, you know, it impacts agency strategic plans we're using as it impacts a lot of things. So we don't want to just make changes kind of, all the time, every few years.

But we do recognize that there's value in looking at it and see whether there are small changes that do need to be made. In particular, if you look at the descriptors that follow each of the statements to, kind of, just make sure that we are staying current with where the field is and look where it's going.
 

What goes into revising a framework that is "essential" to a field, its identity and its priorities?

I really just want to say that we did our best to hopefully reflect current practice. And it's why getting all of the input that we gathered during this process was so important, we really are proud to say that the framework is by the field and for the field, we literally had thousands of comments, we had really robust and thoughtful data analysis.

And all of that was a direct input into the steering of the task force's conversations, and you know, they represented the field from a variety of different vantage points. So we feel like the process worked well.

Our hope is that this more or less stands the test of time, you know, in ways that it's broad enough to reflect the totality of public health and forward enough to move us into the future. And we recognize that the EPHS have been a foundation for so much work in the field. And we you know, we really see that that will continue and that this will be institutionalized as the essential services kind of replacing the 1994 version.

And, you know, the other thing I want to do is just really take the opportunity to thank the field. This was a huge undertaking during really trying times. And the field came together to share their voice and felt it was important enough to take the time — despite everything else going on — to provide those thousands of comments to us and to participate in our events and our conversations, and then our launch event even. And there's been tremendous uptake in the the tools that have been downloaded from our toolkit just since we launched about a month ago.

So, you know, we're really proud of this work. We've gotten positive feedback so far. And we really hope that the essential services stay the bedrock of the public health system and are as useful over you know, the next 25 years, even if they're tweaked a little bit, as they have been for the previous 25 years. So I would just say thank you.

And with that, we thank Jessica for her time and expertise. We also join her in thanking the dedicated public health workers who made the revision of the Essential Public Health Services successful and something to ground us as public health workers contribute to the world’s recovery from the greatest public health emergency in generations.

To read more on the revision process, look for coverage in the November/December issue of The Nation’s Health, in your mailbox or online at www.thenationshealth.org

To read and share the new framework, visit http://ephs. phnci.org/toolkit.

Thank you for listening to The Nation’s Health Podcast