The Value of the “System” in Public Health Services and Systems Research

Public health services and systems research (PHSSR) provides the evidence and scientific foundation for increasing understanding of the public health system, supporting health system improvements, and advancing the field of public health practice. A focus on the “system” in “public health systems and services research” remains as important as ever and is becoming more complex over time. Researchers increasingly need to consider the concept of a system through multiple lenses including: (1) the governmental public health system (the federal, state, tribal, local and territorial agencies that serve as a governmental presence for public health),¹ (2) the public health system or network of partners that contribute to public health in a jurisdiction,² (3) other system and structural components of the public health infrastructure (i.e., information systems, workforce),³ and (4) system science associated with exploring and understanding causal loops and complex dynamics and interactions.⁴

As Don Berwick has stated, “the systems thinker is a perpetually curious person. . . .”⁵ Recognizing the influence of these dynamic and complex elements and relationships on the public’s health, application of systems thinking, research and genuine curiosity provides valuable methods and approaches for expanding the knowledge base in public health.

AN EVOLVING FIELD

When the field first began to emerge, PHSSR—at that time, simply called ‘public health systems research’—was defined as

a field of study that examines the organization, financing, and delivery of public health services within communities, and the impact of these services on public health.^6(p410)

More recently, PHSSR has been defined as a multidisciplinary field of study that recognizes and investigates system level-properties and outcomes that result from dynamic interactions among diverse components of the public health system and how those interactions affect organizations, communities, environments, and the population’s health.⁷ Although both definitions are relevant today, the variation in description reflects the evolution of PHSSR and the multidisciplinary nature of the research.

The field of PHSSR has largely advanced due to the growing recognition of the potential contributions the field has made to improving health systems, but also by the development of two consecutive and consensus-driven research agendas. In 2002, the Institute of Medicine (IOM) recommended that an investment be made in developing a research agenda to guide policy decisions that shape public health practice.¹ The following year, the Centers for Disease Control and Prevention (CDC) convened state and local participants, national organization representatives, foundations, academia, and research institutions to generate a consensus research agenda.⁶ Priorities and key themes identified in the agenda indicate a clear need to accurately describe the dimensions of public health practice, including financing, data, and technology; a competent workforce; efficient organizational operations and structure; and governance. Participants also noted that social determinants of health, emergency preparedness, partnerships, standards and accreditation, and policy were important public health system topics of inquiry.

Almost a decade later in 2011, a second research agenda effort, coconvened by the Robert Wood Johnson Foundation (RWJF) and CDC, produced a comparable list of priority research topics although with updated and more detailed research questions to reflect the dynamic and complex changes occurring in the public health system.⁸ A content comparison between the two agendas yields far more commonalities than differences, illustrating a consistent set of core areas of interest balanced by the inclusion of questions targeting new and emerging themes. To be relevant and actionable, PHSSR priorities and themes should be consistent but continuously refined to reflect the changing context and trends in which health departments operate.

Beyond the establishment of research agendas, there have been other advances to promoting systems thinking and research in public health. While many academic institutions, practice organizations, and foundations have done much to advance PHSSR, drawing solely from CDC examples gives a small sense of the whole. Two notable examples include: the National Public Health Performance Standards Program designed to assess and engage the public health system in improving public health services,⁹ and the development and implementation of a national accreditation program for public health departments.¹⁰ Although these are public health practice endeavors, the potential for contribution to the science base and understanding of the public health system has served as a strong underlying principle for both efforts. A third example, the CDC-funded Preparedness and Emergency Response Research Centers, has prompted much-needed research to improve preparedness and response systems.¹¹ In addition, systems research has been conducted on public health problems such as the public health impacts of flu epidemics on the population,¹² understanding diabetes population dynamics through simulation modeling,¹³ and assessment of the shifting policies and laws on tobacco control and prevention.¹⁴ Beyond US borders, colleagues in CDC’s Center for Global Health and the World Health Organization are applying systems thinking and evidence to assess and build the performance capacity of public health agencies in international settings, thus creating the opportunity for cross-learning and research that spans the globe.¹⁵

PROVIDING VALUE TO PUBLIC HEALTH PRACTICE

PHSSR provides a range of research methods and approaches (i.e., comparative effectiveness analyses, causal process diagrams, social network analyses, adaptive systems theory, and systems thinking) for analyzing system components and factors that influence health. When applied to public health problems, PHSSR provides insight and value to improving public health practice through the following ways:

1. Building the evidence base for describing and understanding system factors that influence population health. In public health as in health care, there is an unprecedented push to develop and use evidence-based strategies. The success of public health interventions is affected by many factors, including efficient and effective public health organizations. Given the complex nature of public health problems and health services delivery today, systems-thinking and research is needed to effectively understand the dimensions and dynamics of public health’s contribution. This includes rigorous studies that produce a deeper understanding of the interdependent relationships among components of the public health system and their influence on public health organizational performance, practice, and ultimately health outcomes. In addition, PHSSR promises to advance the development and translation of evidence-based practices to the field. Although evidence-based strategies to improve health and health services exist, such as those in The Guide to Community Preventive Services,¹⁶ widespread adoption of the recommendations does not always occur. Systems research offers a way to identify and understand factors that hinder or accelerate adoption of evidence-based strategies and promote their use.

2. Providing public health practitioners and leaders with information for evidence-based, science-driven decision-making and action. As noted by the National Coordinating Center for PHSSR, PHSSR “identifies the implementation strategies that work, building evidence to support decision-making across the public health sphere.”¹⁷ Policymakers, public health practitioners, and other leaders need to know not only what works to improve health but also how a given intervention or policy will be influenced by the system and its dynamic components. Important and often multifaceted decisions that health policymakers and public health practitioners need to make rely on understanding the evidence on system factors that influence the health of the communities they serve. Consideration of important system factors along with the implementation of evidence-based programs and policies will provide the information decision-makers and practitioners need to develop policies, allocate scarce resources, and take effective action.

3. Responding agilely to the current and emerging issues faced by public health practitioners in an ever-changing system. The 2002 and 2012 PHSSR research agendas not only reflect a consistent set of core areas of inquiry but also take into consideration the current trends and future directions in public health. For example, questions about accreditation, financing, and health transformation are still as valid as they were when they were posed in 2012 (and even in 2002), but the context and opportunities for researching these topics has evolved. Identifying research questions about current and emerging public health problems is best framed by taking into account the interdependent and bidirectional influence the system has on public health practice. As a result, PHSSR can provide critical information on diverse topics such as adaptation to climate change, reducing health disparities, shifting financing mechanisms, and strategies for effectively coordinating and integrating the public health and health care delivery systems. As one example, the Center for Medicare and Medicaid Innovation, with partnership from CDC, is supporting the testing of health care payment and service delivery models that will improve health system performance, increase quality of care, and decrease costs for Medicare, Medicaid, and child health insurance program beneficiaries. This State Innovation Model (SIM) Initiative includes elements such as the creation of a state plan for improving population health, which should occur in collaboration with public health officials and other partners. The SIM Initiative brings enormous opportunity, and there is a clear need for PHSSR to be agile in exploring these changes. PHSSR can help deliver the promise of transforming the current disease- and treatment-oriented health care system into a system that values prevention and maintenance of health and well-being.¹⁸

THE PATH TO THE FUTURE

In PHSSR, challenges remain that should be addressed to advance the field. To make the research relevant and timely, PHSSR should be field-driven—grounded first in the priorities identified by public health practitioners and translated for use by the practice community. In addition, a large portion of the research to date has yielded descriptive studies, often lacking translatable findings or implications for public health practice. Finally, the value of and need for PHSSR is juxtaposed against the ever-present and well-known challenges in undertaking research of this ilk: the complexities of defining the public health system, the lack of quality and complete data, the limited resources and sustainable funding for research, and the need for innovative and appropriate methods to analyze complex and adaptive system concepts.

A partial solution to many of these challenges may be found in the same concept that is ever present in the research questions in PHSSR: through the concept of system and relationships. Through a growing PHSSR community, which includes academia, practitioners, federal agencies, funders, professional organizations, and others, collaborative efforts can generate new opportunities, insights, and explorations. The National Coordinating Center for PHSSR and Practice Based Networks has played a key role in fostering connections among community-based service providers, partners, and their staff to collaborate with system researchers to understand and address real-world public health problems and generate findings that are relevant and translatable. New connections with research communities that may not view themselves as “PHSSR-focused” may yield previously untapped information or opportunities relevant to PHSSR. Finally, stronger engagement and a more cohesive sense of the system should cultivate greater inclusion of public health practitioners. The role that public health practitioners play, as both the focus of the research as well as the future user of new evidence-based strategies, underscores the importance of ensuring public health leaders recognize the importance of PHSSR. Perhaps through collective efforts and recognition of the complexities faced, new progress can be made in understanding the most effective systems and structures for improving the public’s health.