In 1994, amid discussions of health care reform, it became clear that neither the public nor policy makers had a clear understanding of the scope or importance of public health in our society. In response, the Public Health Functions Steering Committee, with the support of major public health organizations and governmental agencies, developed the 10 Essential Public Health Services (EPHS) as a means of communicating the key public health services needed to protect and promote the health of the public.
The 10 Essential Public Health Services define public health and distinguish it from health care, describing services such as collecting data on the health of the entire population; engaging with community members to co-create solutions to health problems; and ensuring clean air, water, and food. Since their release, these 10 pillars have provided the foundation for: the National Public Health Performance Standards Program; the curriculum of countless schools of public health; the standards and measures for health department accreditation; and the leading model, used by global health professionals, to organize public health on a national scale.
However, as the world and field have evolved, the EPHS framework has remained static, with no plan for the future of public health. Over the past 25 years, we have witnessed the emergence of personal computers and cell phones, the transformation of HIV/AIDS from a certain death sentence to a manageable chronic disease, the origin of the field of informatics, the September 11 attacks and the advent of all-hazards preparedness, the enactment of the Affordable Care Act, and the exponential increase in obesity rates, to name just a few of the major developments. During this period, public health efforts have led to milestone achievements, such as increased occupational safety, decreases in vaccine-preventable diseases, and more effective cardiovascular disease prevention. Yet, without regular updates, the EPHS still reflected a response to a different era, neglecting new realties that directly impacted practice.
It was past time for an update.
The Voice Of The Field
So that’s what our organizations, partners, and the entire field set out to do. The de Beaumont Foundation (Sellers and Castrucci) engaged the Public Health National Center for Innovations (Fisher and Kuehnert), a division of the Public Health Accreditation Board (PHAB), to engage as much of the field of public health as possible to consider updating the EPHS. Kaye Bender, who was CEO of PHAB during most of the process, provided critical leadership and facilitation throughout the entire project.
How a framework is developed can be as critical as what it has to say. The original framework was based on available research and resources at the time, but much has changed since 1994, including the process for developing and revising a public health framework.
Paramount to the new process was ensuring that the framework be developed by the field, for the field. Therefore, it was critical to engage the field in first determining whether they believed it was necessary to revise the framework and then ask them how to make it most relevant for today and the future.
Specifically, we strategically and fully engaged the public health field through a crowdsourced, field-driven process. We collected input from more than 1,300 practitioners across all areas of public health and at all stages of their careers through real-time polling at meetings and events, an online feedback survey, and informal discussions. This process allowed for more diverse participation than was possible when the framework was initially written and should serve as a template for developing future models and frameworks.
The field’s input was complemented by a task force that included experts from federal agencies, national public health organizations, state and local public health agencies, tribes, academia, and nonprofit groups involved in public health issues—some of whom were part of the original 1994 creation.
The Revised 10 Essential Public Health Services
On September 9, 2020, the revised version was formally launched and became available for widespread adoption and implementation. The important, foundational work done in 1994 remains. The updated EPHS still feel familiar, but this revised framework incorporates some key changes, the most significant of which was the choice to center the framework on equity.
Health disparities existed long before public health professionals even measured health outcomes. The injustice of slavery perpetuated by systemic policies that disproportionately impacted people of color has had a direct and undeniable impact on health. The original EPHS was silent on the critical need for public health to confront health disparities and promote equity. In the revised EPHS, this has changed. Not only has equity been included, but it is also now at the center of our practice. Centering equity means that all public health work must reach toward two aims simultaneously: improving overall health and advancing equity. It is unacceptable to intentionally or unintentionally increase health inequities in the interest of improving health for a subset of the population. The focus on equity is reflected in language changes throughout each of the 10 services.
Seeing America’s COVID-19 Response Through Lens Of The Revised Framework
How else has the framework been updated? As you can see in exhibit 1, we have added clarifying language around key concepts such as health in all policies and the role of public health in health care. We have also moved a number of key activities from one service to another, such as public health’s role in ensuring a competent health care workforce, which moved from EPHS No. 8 (public health workforce) to EPHS No. 7 (ensure equitable access to health care services). We also added a service that focuses on the importance of public health infrastructure, which was more assumed than articulated in the previous version. The flaws in the COVID-19 response made it impossible to continue to assume that a robust and functional public health infrastructure exists to support these essential services.
Exhibit 1: The 10 Essential Public Health Services
Source: The Public Health National Center for Innovations, 2020.
The services identified in the EPHS framework are critical to ensuring the health and economic prosperity of our nation. Failure to provide these services creates vulnerabilities that limit our nation’s ability to contain and fight disease and maintain our national security. It is instructive to view the nation’s COVID-19 response through the lens of this revised framework.
Many of the challenges that we have experienced throughout our pandemic response can be directly tied to federal, state, and local governments’ continual underinvestment in the 10 essential services. Our absence of investments in critical data infrastructure has made it difficult to track viral outbreaks in real time and understand the factors that place people at increased risk (EPHS No. 1, No. 2).
The public’s willingness to accept and act on this guidance is dependent on how people perceive the credibility of public health leaders. This is absolutely critical during the COVID-19 pandemic, when efforts to update recommendations based on new information about the virus are hindered by widespread misinformation and politicization. Public health leaders have been tasked throughout the pandemic to communicate with the public about a dynamic situation, translating complex scientific information into action often without the necessary training or support (EPHS No. 3). Research conducted prior to the pandemic found that public health leaders lacked the relationships needed to engender familiarity and trust from leaders of key sectors (EPHS No. 4).
COVID-19 has punctuated the importance of policy (EPHS No. 5) and regulatory action (EPHS No. 6). The disparities that have driven the devastation of COVID-19 in the US are due, in part, to the nation’s legacy of neglectful social policy. Especially at the state and local levels, action to minimize the spread of COVID-19 and mitigate the impacts (for example, eviction relief) are created through policy and regulatory actions.
The importance of the public health workforce (EPHS No. 8) and infrastructure (EPHS No. 10) has never been as apparent. Yet, the US has starved its infrastructure of resources, resulting in fewer public health professionals working to protect and improve the health of our nation. Despite awareness and warnings that a pandemic should be expected, we failed to provide our nation’s public health infrastructure and workforce the equipment and resources they would need to adequately do their job and defend the nation.
Much of the economic and human devastation of COVID-19 was preventable. Our challenges responding to and containing COVID-19 are a study in the consequences of failing to have a public health system that can adequately provide its essential services.
The EPHS is one of the most enduring frameworks in public health. While the 25-year-old version may have been stale, this update and our commitment to revisit this framework regularly ensures a universal, common understanding of public health that cuts across federal, state, and local jurisdictions; government and nonprofit sectors; and other divisions that can blunt our progress.
The COVID-19 pandemic has taught us that the term “essential” to describe these services is not misplaced. Whether it is COVID-19 or other challenges such as climate change or persistent economic and racial disparities, the future prosperity of our nation depends on a robust public health system. The revised EPHS are the necessary components of that system. We have known this, but now the rest of the world does, too.
Readers can use this toolkit to learn more about the new framework, update content and educational material, and promote the 10 Essential Public Health Services far and wide.