A renewed framework for the essential public health functions in the Americas.

This report presents the results of a consensus decision making process conducted to elaborate a renewed conceptual framework of the essential public health functions for the Americas. The emerging framework consists of four pillars encompassing action-oriented components relating to the new scope and concerns of public health. The four pillars call for adopting a human rights approach to public health, addressing the social determinants of health, ensuring access to both individuals and population-based services, and expanding the stewardship role of health authorities through a collaborative implementation of public health functions. Public health functions were conceptualized as a set of capacities that are part of an integrated policy cycle the encompasses four stages: assessment, policy development, allocation of resources, and access. The framework provides a road map for evaluation and development by health authorities of integrated enabling public health policies through intersectoral collaboration. The application of the framework would require engaging countries working to improve public health through national assessments and systematic incorporation of these findings into quality improvement efforts and sectoral and intersectoral decision-making processes around policy and investments priorities promoted by governments. Work is ongoing in the definition of a list of public health functions that gives operational clarity to each dimension of this framework and guides performance evaluation.

During more than three decades, governments and the international community have made substantial work to define and operationalize public health functions, in an effort to clarify what public health entails on a practical level and strengthen governmental public health agencies (1, 2, 3).

In 1997, the World Health Organization (WHO) presented the first global list of essential public health functions (EPHF) (4). Building on this list, some of WHO regional offices developed measurement tools to assist health authorities in assessing their performance. The largest effort came from the Pan American Health Organization (PAHO, which is WHO’s Regional Office for the Americas) in 2000 (5). The PAHO tool was widely used upon the launch of the Public Health in the Americas Initiative (2001-2002), when it was applied in 41 countries under the leadership of PAHO in conjunction with country teams (5).

The greatest strength identified in the PAHO initiative was its theoretical content and operationalization of the EPHF (1,5,6). However, its application was restricted to the health sector, while the participation of other government sectors, civil society and private sector was weak. This limited the use and scope of the EPHF and their influence on health sector reform agendas in the region (1,6).

As public health experts have increased their understanding of the social factors that can be influenced by policies and shape health across populations, they are calling for the field of public health to widen its focus (1,7,8). This vision has led to intense debates over the scopes and boundaries of public health practice (1,7,8). Particularly, in relation to the responsibilities of government, civil society, private and individual actors; the role of policies and practices in non-health sectors; and the role of medical care (1,8).

The discussion on the need of a paradigm shift in the approach to public health has also been shaped by global and regional mandates adopted by governments in the midst of recent public health outbreaks and disasters (e.g., Ebola virus outbreak in West Africa and introduction of Zika in the Americas), whose strategic lines of action call for strengthening public health capacities within national health systems and the elimination of barriers to access population-based and individual health services (9-13).

The international response to the ongoing pandemic of coronavirus disease 2019 (COVID-19) has further exposed the weaknesses in the health systems, and further highlights the need to strengthen the EPHF in the Americas encouraging health authorities to prioritize public health policies and measures, ensure that effective structures and resources are available, build institutional capacity, and include people and communities in this process (14).

The obstacles to meet these goals are the lack of a clear understanding and consensus on the new scope of public health functions, and gaps in the existing health system frameworks that fail to incorporate the role that public health plays in contributing to health and equity goals, including universal health and development goals, and integration of key actions toward global health security (6,9-14). A new framework of the EPHF could help in reaching regional consensus on exactly what activities fall under the public health remit, and in aligning efforts under a broad policy umbrella that embed the EPHF in health goals, health security requirements, and broader efforts on health systems strengthening. This report presents the results of a consensus decision making process conducted to develop a renewed conceptual framework of the EPHF for the Americas.

METHODS

The EPHF framework was developed in a three-phase, consensus decision making process carried out between July 2017 and April 2020 (Table 1):

TABLE 1.

Phases in the development of the essential public health functions framework

	Phase 1	Phase 2	Phase 3
Objectives	Discuss lessons learned from PAHO’s experience with the implementation of the previous EPHF approach. Review values and criteria underpinning public health action	Explore areas of consensus and conflict underpinning three overarching criteria. Validate the contents and structure of the EPHF framework	Harmonize the EPHF framework with regional mandates and PAHO’s lines of action for technical cooperation
Methodology	Desk review and participatory meetings	Modified Delphi (introductory meeting, e-survey and follow-up interviews)	Participatory meetings and follow-up interviews
Actors	Interdepartmental PAHO team (CDE, EIH, HSS, FPL, NMH) and government officials from Ministries of Health	National schools of public health from Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, United States of America, México, Nicaragua and Peru	Interdepartmental PAHO team (CDE, EIH, HSS, FPL, NMH)
Professional occupations	Managers, health systems regional advisors, public health regional advisors or specialists, senior research advisors	Deans, professors, senior researchers, public health advisors	Managers, health systems regional advisors, public health regional advisors or specialists, senior research advisors
Experience (years)	15 to 30 years	25 to 40 years	15 to 30 years
Location	PAHO headquarters, Argentina, Bolivia, Costa Rica, Dominican Republic, Ecuador and Panama	Bogota, Colombia; virtual meetings	PAHO headquarters

EPHF, essential public health functions; PAHO, Pan American Health Organization; CDE, (PAHO) Department of Communicable Diseases and Environmental Determinants of Health Department; EIH, Department of Evidence and Intelligence for Action in Health; HSS, Department of Health Systems and Services; FPL, Department of Family, Health Promotion and Life Course; NMH; Department of Noncommunicable Diseases and Mental Health

The first phase included a literature review, conducted in both peer-reviewed databases and the gray literature published in English and Spanish by national and international bodies. The search focused on conceptual models related to public health practice, services, functions and operations; assessment tools; and public health planning, evaluation and improvement.

This background research was used to make a first draft of the framework, which was further validated through iterative stakeholder consultations with approximately 71 international experts, representing a broad range of expertise in measurement, public health research, health system reform implementation, and public health practice and leadership. An interdepartmental PAHO advisory team, with 37 professionals with experience in management, public health or healthcare policy and research from the technical areas relevant to the implementation of public health functions (Table 1), attended the initial regional meeting in July 2017. Two subsequent meetings were attended by PAHO’s advisory team in September 2017 and August 2018.

In addition, early versions of the EPHF framework were validated in a select group of countries through participatory meetings with governments officials from the ministries of health of Argentina, Bolivia, Costa Rica, Dominican Republic, Ecuador and Panama. These experiences aimed at discussing the range of criteria underpinning public health action as well as the lessons learned from the implementation of the EPHF agenda in the Americas over the past 20 years. Country meetings provided further feedback on the relevance of the conceptual framework to different health systems and contexts.

In the second phase of development of the EPHF framework, a modified Delphi survey was undertaken to explore areas of consensus and conflict underpinning three overarching criteria that were identified from the preceding stage. These criteria relate to (1) role and responsibilities of governments and civil society, as it relates to the implementation of public health functions; (2) innovative approaches that address the wider determinants of health and that require multi-disciplinary partnerships; and (3), integration of individual and population-based public health actions, as a way to incorporate EPHF across a comprehensive health systems-strengthening approach.

An introductory meeting was arranged in July 2018 with 22 public health experts through purposive sampling. The expert panel consisted of international professionals and senior members of national schools of public health representing 12 different countries (Table 1). The participating professionals were medical doctors (78.5%) or social scientists (21.5%), most of whom had a master’s or doctorate degree in public health (85.7%). Experts were selected according to the following inclusion criteria: i) outstanding academic or professional career in public health; ii) academic interest shown in the area; iii) proven experience in public health practice: leaders and professionals involved in decision making, and iv) participation in some type of program or technical unit related to public health issues, at the national or local level.

In the introductory meeting, all criteria identified from phase 1 received additional suggestions that were incorporated in a e-Delphi questionnaire. The questionnaire was subsequently distributed to the expert panel in December 2018, of whom 16 provided complete responses (response rate of 73%). Those consenting were given a web link to the survey and provided with an early version of the EPHF framework. In the e-Delphi survey, respondents were requested to complete 3 activities. First, they were asked to rate on a 4-point Likert scale whether they believed each of the following criteria should be included in the scope of public health practice and functions: (i) role and responsibilities of governments and civil society; (ii) innovative approaches that address the wider determinants of health; and (iii) integration of individual and population-based public health actions. Second, they were asked whether they believed that the EPHF approach should be integrated into the greater policy cycle and to rate on a Likert scale if certain categories of public health functions should be “included,” “included with adaptation,” or “excluded” from a framework that reflects their role in the policy cycle. Third, they were asked for additional comments and recommendations. Follow-up interviews were conducted to give participants the opportunity to elaborate on why they held the views they expressed or endorsed (15).

During the final third phase, additional input was provided through plenary sessions and follow-up interviews with members of PAHO’s interdepartmental team. This stage consisted in the validation and harmonization of the conceptual framework with PAHO’s technical cooperation initiatives and regional mandates (Table 1). To align technical guidance, current mandates and regional strategies adopted by Member States were reviewed during this stage (9-13, 16-18).

RESULTS

Pillars of the new public health functions for the Americas

The consultation process revealed critical consensus across the different stakeholders for the substantive argument that public health needs to redefine itself and expand its remits into new areas of intervention and collaboration with other actors, beyond the health sector, with shared responsibility in the execution of the EPHF. The expert panel further stressed the importance of expanding the scope of public health action (93.8% strongly agreed/agreed) in their replies to the Delphi questionnaire. Four pillars that contribute to this vision were identified. These are described in Table 2 and outlined below.

TABLE 2.

Pillars of the new public health functions for the Americas

Pillar	Identified issues	Identified strategies
Introducing ethic values into public health action to address health inequities and its root causes.	• Persistent and avoidable health inequities. • Health systems strengthening initiatives fail to prioritize public health.	• The right to health the right to health, solidarity and equity as principles as the primary ethical principle guiding public health practice and policy.
Tackling the social, economic, cultural and political conditions that influence population health through multisectoral partnerships.	• Rapid changes in health conditions and their determinants. • Complex and multifactorial public health problems that are often outside the traditional scope of public health. • Limited success in addressing wider determinants of health and equity.	• Develop innovative responses to address socio-economic and political issues that determine health and equity. • Strengthen intersectoral coordination. • Coordinate actions across a broad range of disciplines and stakeholders and across all levels of government.
Guaranteeing universal access to comprehensive public health services, both individual and population based.	• Lack of coherence and rigor in the planning of public health activities, including a failure to link individual health services with traditional public health services. • Public health agencies and health systems operate under fragmented and often incoherent institutional structures. • Recent disease outbreaks and disasters revealed the fragility of national health systems and demand for integrated emergency health services. • Many public health policies continue to have an exclusive focus on specific diseases and are not well coordinated with other related social fields.	• Integrate the EPHF with health systems functions. • Expand health systems scope beyond the delivery of personal health care services. • Strengthen health systems based on primary health care, with people- and community-centered care models. • Expand integrated actions aimed at promoting health, preventing disease, and implementing population-based interventions. • Adopt integrated approaches to help individual public health programs achieve rigorous and consistent planning. • Ensure health systems respond and adapt to immediate and short-term health risks and address other ongoing risks to the health and well-being.
Expanding the stewardship role of health authorities through a collaborative implementation of public health functions.	• Implementation and assessment of the EPHF in the Americas has been often restricted to the health sector. • Health authorities lack capacities to address social determinants influencing population health. • Public health actions have less emphasis on interdisciplinary and intersectoral participation.	• Expand the implementation of the EPHF beyond health authorities. • Develop mechanisms for collaboration between government and nongovernmental sectors including private, voluntary, social and academic groups.

EPHF, essential public health functions

First, introducing ethics values into public health action to address health inequities and its root causes. The right to health, equity and solidarity were identified as core values of this pillar. Second, tackling the social, economic, cultural and political conditions that influence population health through multisectoral partnerships. Third, guaranteeing universal access to comprehensive public health services, both individual and population based. Fourth, expanding the stewardship role of health authorities through a collaborative implementation of public health functions across other government sectors as well as civil society (including private, voluntary, social and academic groups).

An integrated approach to strengthen public health functions in the Americas

Expert participants stressed the need for collaboration and coordination to implement a comprehensive approach to current public health problems. Within this context, experts also held the common view that the EPHF be incorporated into a framework of health systems strengthening that can guide health authorities in the development of comprehensive plans and policies that work in collaboration with the community and the different agencies within and outside the health sector.

Participants also agreed (86.7% strongly agreed/agreed) that the EPHF be understood as “the capacities of health authorities, in all institutional levels, together with civil society, to strengthen health systems and ensure a full exercise of public health, acting on the factors and social determinants that affect population health”. Responses from the Delphi questionnaires further showed that there was critical consensus (100.0% strongly agreed/agreed) to incorporate the EPHF approach into the greater policy cycle, and to categorize (93.3% strongly agreed/agreed) public health functions based on their role in this cycle.

Accordingly, the EPHFs were conceptualized as an ongoing cycle of four stages: assessment, policy development, allocation of resources, and access assurance (Figure 1). The different stages were defined to incorporate major themes and activities identified through the expert consultations and literature review (Table 3), which make explicit the role of public health into institutional aspects of the health system and create a real link between public health and health systems planning.

FIGURE 1.

An integrated approach to strengthen public health functions in the Americas

TABLE 3.

Stages of the integrated approach to strengthen public health functions in the Americas

Stage	Description	Activities
Assessment	Health authorities, with the community and stakeholders, lead assessments of the health status of their communities, identify risks and analyze the factors responsible for poor health. These data inform policies and offers evidence on the health systems capacity to respond to the health needs of the population	• Health surveillance • Monitoring and evaluation of public policies and factors contributing to poor health • Health systems performance assessment • Assessment of population- and community-based services, and individual health services • Health research and innovation
Policy development	Health authorities lead a collective action with the community and stakeholders to develop health and social policies aimed at strengthening health systems, addressing the social determinants of health, and improving the health of the population	• Health and social policies and interventions to address health determinants and improve population health • Policies to strengthen health systems that prioritize public health • Social participation and mobilization • Involvement of key actors for accountability and feasibility
Allocation of resources	Health authorities enact laws and regulations that seek to strengthen institutional arrangements and mechanisms whereby critical resources of the health systems are allocated and prioritized to support public health actions	• Health professionals with required public health competencies and skills • Professional profiles aligned with people- and community-centered models of care • Proper availability and distribution of public health professionals • Financial resources allocated to public health actions, and efficiency and equity in the health system • Technological innovation focused on responding to the health needs of the population
Access	Health authorities, in coordination with other public and private actors, and local governments, implement policies that seek to guarantee universal and equitable access to all public health interventions, both individual and population-based	• Access to comprehensive and integrated public health services • Multisectoral, population-based, and community-based interventions to address social determinants • Health promotion and disease prevention services • Prevention and control of events and emergencies

DISCUSSION

The new EPHF framework presented in this report consists of four pillars encompassing action-oriented components relating to the new scope and concerns of public health. In addition, the framework articulates the EPHF as a set of capacities that are part of an integrated policy cycle: assessment, policy development, allocation of resources, and access. The framework promotes a new approach for public health actors to better integrate the EPHF across health system strengthening policy initiatives. This offers an opportunity to help catalyze the political commitment and support needed for ensuring universal health access, global health security and greater health equity in the Americas. These innovations are discussed in the following sections.

Why expand the scope and concerns of public health?

The proposed framework introduced a new paradigm for public health based on four pillars. The first pillar calls for the need to incorporate human rights in public health policy. The right to health, solidarity and equity are recognized as overarching values on which governments can formulate policies and implement actions to strengthen public health functions. The recognition of these values draws from regional and global mandates that have already adopted human rights as the guiding principles of their strategies (9-13, 16-18). Governments in the region have also proclaimed health as a human right in their constitutions, adopting a wide array of state obligations in their national policies and plans in health and social protection (19).

Taking a human rights-based approach requires public health policies that ensure a fair and equitable distribution of resources, addressing the social determinants of health and understanding the factors that undermine the right to health (20). Therefore, the second pillar calls for public health to expand its focus to have a broader approach to the social determinants of health. Indeed, there is broad recognition that public health is multisectoral and thus require the coordination of actors from other sectors of government, academia, the private sector, and others sectors not directly responsible for health, in order to cope with increasingly complex public health problems, such as chronic diseases, aging, violence and climate change (21-25).

The vision of the third pillar is that public health has a role in ensuring access to both population-based interventions and quality health care. To achieve that goal, experts stressed the need to give more prominence to the EPHF within the broader health systems strengthening agenda. The rationale is that most health systems remain heavily focused on the provision of medical care and do little to improve the underlying conditions for health (26). Indeed, many experts call for the integration of public health and primary health care (PHC) to enhance the capacity of both sectors and foster PHC-based health systems through collaborative and intersectoral actions (27-30). Such efforts would require properly designed and adequately funded policies that support people-centered models of care that promote multidisciplinary team practices in primary care settings and increase social participation during priority-setting and implementation of actions (27-30).

The final pillar recognizes that public health is an umbrella for many different actors and sectors. Therefore, health authorities need to act in collaboration with other sectors and civil society to undertake public health functions. In this endeavor, health authorities should lead and ensure that the various actors contribute to the construction of equitable health systems and policies, in order to defend health as a social right (31, 32). That means that implementing the EPHF should be regarded as the fulfillment of the stewardship function of health authorities, particularly given their leading role in strengthening public health, either directly or through other social actors. In this regard, the EPHFs should be broad-based and versatile enough to be implemented at the different levels of authority and in different political and legislative contexts. This should be done systematically, encompassing not only all levels of authority, but all actors that participate in the promotion, restoration, and maintenance of health (31, 32).

Why an integrated approach to public health functions?

The EPHF were contextualized in terms of capacities and articulated in four stages of the policy cycle. This model provides a clear structure for categorizing public health functions and linking them to an analysis of the contribution of different actors within the policy process. It also guides the development of integrated public health policies through intersectoral collaboration in all four stages of the cycle.

Several factors justify the adoption of that integrated approach to public health policy. First, while the EPHF agenda for the Americas has gained important visibility and acceptance, efforts have tended to focus on measurement exercises alone, which has limited the presence and influence of the EPHF approach in main policy streams and health sector reform initiatives (6).

Second, the ongoing pandemic of COVID-19, and previous events such as the Ebola outbreak and the introduction of chikungunya virus and Zika in the Region of the Americas, have demonstrated that inequitable and fragmented health systems that cannot meet the needs of the population under normal circumstances cannot cope effectively with epidemics and other health emergencies (10, 12, 33). As a result, public health leaders are increasingly recognizing the need to strengthen public health functions within health systems as a way to make them more resilient to changing needs and threats (10, 12).

Moreover, the COVID-19 pandemic has presented unprecedented challenges that demand an increase in public health preparedness and response to emergencies aligned with health systems capacities. At the same time, health systems need to adapt to the new challenges of COVID-19 to be able to respond to the new programmatic context and make sure that non-COVID-19 health needs are met. These strategies include giving priority to first level of care facilities as the first resort when people are sick, expanding telehealth, and bringing and blending funds from multiple public health programs to improve delivery of health care and services. These innovations shall not end with the crisis and should be allowed to play a greater role in the future (34).

Related to that challenge is the persistence of factors that affect the sustainability, adaptiveness and responsiveness of health systems. These include inadequate availability and distribution of resources (human, financial, technological, infrastructure and information systems), and weak policies and execution of disease prevention and health promotion strategies (9,10,12). These deficiencies also represent a lack of coherence in the planning of public health activities, including the lack of integration between individual and collective health services (28), and more broadly, the difficulties that health authorities face to act consistently with an integrated interpretation of their functions (28).

In addition, public health actions are usually managed by different government agencies operating under fragmented, and often incoherent, institutional structures with different interventions and public health programs (30). At the same time, many public health policies remain vertical, with their exclusive focus on specific diseases, and are not well coordinated with other related social fields, limiting their impact on the health outcomes (25-30). In this scenario, it is necessary to strengthen an integrated approach to help individual public health programs achieve rigor and consistency in their planning (25-30)

Many experts have already stressed the need to tackle the growing complexity of public health issues by means of an integrated approach (25-30). Of the existing frameworks for assessing public health functions, the U.S Institute of Medicine framework (2) is arguably the most closely aligned with the approach advocated in this article, although it diverges in its unique applicability to the overall health systems planning in two specific areas. First, allocation of critical resources of the health system was included as a new stage of the EPHF cycle. This stage was considered an enabling condition and includes the regulation and planning of human, financial and health technology resources. Second, the Access stage now includes three different types of public health interventions: (1) interventions aimed at addressing the social determinants of health (e.g., poverty reduction and improvements to education), (2) population-based interventions that seek to change contextual factors that endanger health (e.g. access to clean drinking water and safe roads); and (3) individual interventions, including traditional public health services (e.g., access to immunization and screening services) and individual care interventions.

Considerations and recommendations for the application of the EPHF framework

There are limitations arising from the methods used to develop this framework. The tool reflects the findings from a literature review and the opinions of the research team and experts committee. Although efforts were made to incorporate a diversity of sources and perspectives, additional alternative input would likely lead to slight differences in the framework. However, the findings suggest that there is not only a large degree of consensus across many of these issues, but also a healthy level of debate in some important areas. In addition, the Delphi technique has been used extensively within health and social science research and offers a reliable data collection method in circumstances where there is uncertainty or a paucity of knowledge surrounding the topic area under investigation (15).

Additionally, while the framework exhibits an overall directionality of influence, where Assessment influences Policy Development, which affects the Allocation of Resources, which subsequently affects Access Assurance; there is overlap among the different stages, and therefore the framework cannot be understood as a linear process, but rather as a schematic simplification of the complexity of public health. In practice, strengthening public health would require improving coordination among different national and subnational levels of government, and among several public and private actors and agencies inside and outside the health sector.

This has important implications for the applicability of the EPHF approach to assessing performance and improving capacity. First, it would require engaging countries working to improve public health through national EPHF assessments (6). Findings from such exercises need to be part of quality improvement efforts and sectoral and intersectoral decision-making processes around policy and investments priorities promoted by governments (35). Second, a bottom-up approach for developing EPHF list and performance measures that emphasizes country needs to improve performance rather than the data country needs to be regionally comparable may be preferable for the EPHF framework. Because PAHO works with countries, trust is also critical. One priority area for ongoing work in this area is the definition of a list of EPHF that gives operational clarity to each dimension of this framework and guides evaluation. Finally, since actors in the political arena have different interests, promoting integrated approaches requires to adapt to a different set of interests in accordance to the institutional, political and social context of each country.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or PAHO.