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Background:The Core Functions and Essential Services of Public Health and MAPP

 

Public health in the United States is guided by a set of three principles known as the Core Functions of Public Health.  The three Core Functions; assessment, policy development, and assurance define the roles of federal, state and local public health systems. All public health agencies are responsible for assessing the status of public health in their communities, developing policies to address public health needs, and assuring public health needs are met.

Historically, public health professionals have worked largely behind-the-scenes to improve the health and safety of American communities. Today, public health and its leaders are in the spotlight. Strengthening public health systems and organizations is an enterprise of unprecedented interest. We in public health must capitalize on this interest by seeking new opportunities to assess and improve the ways we deliver public health services in our states and our communities.

The Core Functions and the Ten Essential Public Health Services provide the fundamental framework for the National Public Health Performance Standards Program (NPHPSP), by describing the public health activities that should be undertaken in all communities. The Core Public Health Functions Steering Committee developed the framework for the Essential Services in 1994. This steering committee included representatives from US Public Health Service agencies and other major public health organizations. The Essential Services provide a working definition of public health and a guiding framework for the responsibilities of local public health systems.

Mobilizing for Action through Planning and Partnerships, MAPP, is a strategic health planning model developed by the National Association of City and County Health Officials, the Centers for Disease Control to compliment and support the National Public Health Performance Standards Program - The Core Functions and Ten Essential Services of Public Health. The skills sets of MAPP provide a framework for public health professionals to practice health assessment and improvement planning in accordance with the Core Functions and Ten Essential Services.

Community health assessment and improvement planningis the process of systematically collecting, analyzing and using information to educate and mobilize communities, develop priorities, gather resources, and plan actions to impact the public’s health. Assessment is a core function of public health practice. Assessment is the foundation for the other two core functions of public health; Policy Development and Assurance. 

What is the National Public Health Performance Standards Program?
The National Public Health Performance Standards Program (NPHPSP) is a collaborative effort to enhance the Nation's public health systems. Seven national public health organizations have partnered to develop national performance standards for State and local public health systems.

The stated mission and goals of the NPHPSP are to improve the quality of public health practice and the performance of public health systems by:

1. Providing performance standards for public health systems and encouraging their widespread use;
2. Engaging and leveraging national, state, and local partnerships to build a stronger foundation for public health preparedness;
3. Promoting continuous quality improvement of public health systems; and
4. Strengthening the science base for public health practice improvement.

Partners
The NPHPSP is a collaborative effort of seven national partners:

       Centers for Disease Control and Prevention,

   National Public Health Performance Standards Program

       American Public Health Association (APHA),

       Association of State and Territorial Health Officials (ASTHO),

       National Association of County and City Health Officials (NACCHO),

       National Association of Local Boards of Health (NALBOH),

       National Network of Public Health Institutes (NNPHI), and

       Public Health Foundation (PHF).

These partners represent the organizations and individuals that will use the assessment instruments. Through working groups and as field test sites, hundreds of representatives from these organizations were involved in the development, review, testing, and refinement of the three assessment instruments. Their feedback on the draft instruments assured that the final NPHPSP instruments are practice-oriented and user-friendly. Representatives from other organizations, such as academic partners from the Association of Schools of Public Health, also provided valuable input. Partner contact information is located at http://www.cdc.gov/od/ocphp/nphpsp/Partners

The Ten Essential Public Health Services and MAPP

The Ten essential public health services are used throughout the MAPP process. The ten essential public health services framework was developed in 1994 as a method for better identifying and describing the core processes used in public health to promote health and prevent disease. All public health responsibilities (whether conducted by the local public health agency or another organization within the community) can be categorized into one of the services.  The MAPP model was developed in 1999-2000 to be used as a guide for local and state public health systems in their efforts to achieve the optimal performance standards of the National Public Health Standards Program.

The Ten Essential Public Health Services are:

1. Monitor health status to identify community health problems.
2. Diagnose and investigate health problems and health hazards in the community.
3. Inform, educate, and empower people about health issues.
4. Mobilize community partnerships to identify and solve health problems.
5. Develop policies and plans that support individual and community health efforts.
6. Enforce laws and regulations that protect health and ensure safety.
7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
8. Assure a competent public health and personal health care workforce.
9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
10.  Research for new insights and innovative solutions to health problems.

What is MAPP?
Mobilizing for Action through Planning and Partnerships (MAPP) is a strategic approach to community health improvement. This tool helps communities improve health and quality of life through community-wide strategic planning. Using MAPP, communities seek to achieve optimal health by identifying and using their resources wisely, taking into account their unique circumstances and needs, and forming effective partnerships for strategic action.

The MAPP tool was developed by the National Association of County and City Health Officials-(NACCHO), in cooperation with the Public Health Practice Program Office, Centers for Disease Control and Prevention (CDC). A work group comprised of local health officials, CDC representatives, community representatives and academicians developed MAPP between 1997 and 2000.

The following seven principles are integral to the successful implementation of MAPP:

Systems thinking — to promote an appreciation for the dynamic interrelationship of all components of the local health system required to develop a vision of a healthy community.
Dialogue — to ensure respect for diverse voices and perspectives during the collaborative process.
Shared vision — to form the foundation for building a healthy future.
Data — to provide factual information during each step of the process.
Partnerships and collaboration — to optimize performance through shared resources and responsibility.
Strategic thinking — to foster a proactive response to the issues and opportunities facing the system.
Celebration of successes — to ensure that contributions are recognized and to sustain excitement for the process.

Benefits of MAPP
Listed below are just some of the benefits to be derived from the MAPP process.

• Create a healthier community and a better quality of life. The ultimate goal of MAPP is optimal community health — a community where residents are healthy, safe, and have a high quality of life. Here, a "healthy community" goes beyond physical health alone. According to the World Health Organization, "Health is a dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity." The Institute of Medicine echoes this definition and notes that, "health is…a positive concept emphasizing social and personal resources as well as physical capabilities."
• Increase the visibility of public health within the community. By implementing a participatory and highly publicized process, increased awareness and knowledge of public health issues and greater appreciation for the local health system as a whole may be achieved.
• Anticipate and manage change. Community strategic planning better prepares local health systems to anticipate, manage, and respond to changes in the environment.
• Create a stronger public health infrastructure. The diverse network of partners within the local health system is strengthened through the implementation of MAPP. This leads to better coordination of services and resources, a higher appreciation and awareness among partners, and less duplication of services.
• Engage the community and create community ownership for public health issues. Through participation in the MAPP process, community residents may gain a better awareness of the area in which they live and their own potential for improving their quality of life. Community-driven processes also lead to collective thinking and a sense of community ownership in initiatives, and, ultimately, may produce more innovative, effective, and sustainable solutions to complex problems. Community participation in the MAPP process may augment community involvement in other initiatives and / or have long-lasting effects on creating a stronger community spirit.

The Elements of MAPP
The MAPP tool was designed to include the following key elements.

1) MAPP emphasizes a community-driven and community–owned approach — Because the community's strengths, needs and desires drive the process, MAPP provides the framework for creating a truly community-driven initiative. This creates stronger connections throughout the community and provides access to the collective wisdom necessary for addressing community concerns.

2) MAPP builds on previous experiences and lessons learned — Information from previous planning efforts and established assessment tools was used in developing MAPP. Most notably, MAPP builds on the Assessment Protocol for Excellence in Public Health (APEXPH). Released in 1991, APEXPH has guided hundreds of local health departments through internal organizational capacity assessments and collaborative community health assessment processes. While building on the familiar concepts of APEXPH, MAPP is more progressive in a variety of ways:

APEX PH

• Builds local health leadership
• Assesses local health capacity for delivering public health services
• Provides operational planning
• Focuses on health status
• Develops plans to address needs

MAPP

• Builds local health  leadership, but also promotes community responsibility for the health of the public
• Assesses capacity of entire local health system
• Provides opportunity for strategic planning
• Focuses on health status, community perceptions, forces of change and local health system capacities
• Strategically matches needs, resources, ideas and actions

3) MAPP uses traditional strategic planning concepts within its model — Strategic planning assists communities in more effectively securing resources, matching needs with assets, responding to external circumstances, anticipating and managing change, and establishing a long-range direction for the community. The MAPP model includes basic strategic planning concepts, such as visioning, an environmental scan, the identification of strategic issues, and the formulation of strategies.

4) MAPP focuses on the creation and strengthening of the local health system — Local health systems are the human, informational, financial and organizational resources, including public, private and voluntary organizations and individuals that contribute to the public's health. This focus is important because the public's health depends on the interaction of many factors; thus, the health of a community is a shared responsibility of many entitiesand organizations, in the community.  The MAPP process brings these diverse interests together to collaboratively determine the most effective way to conduct public health activities.

5) MAPP creates health leadership opportunities — While MAPP focuses on the local health system, it is anticipated that leadership roles in initiating MAPP could come from any interested entity - public or private -  in the community. Thus, MAPP will help to create a greater recognition of the importance of the health system and the potential to impact health of the community.

6) MAPP uses the Essential Public Health Services to define public health activities — The Essential Public Health Services and other public health practice concepts have been incorporated into MAPP, providing much-needed links with other public health initiatives. The Essential Public Health Services are a list of ten public health activities that should be undertaken in all jurisdictions. .

The use of the Essential Services framework and the focus on the local health system provides a crucial link with the National Public Health Performance Standards Program (NPHPSP),  developed by CDC, NACCHO, and other national public health organizations. The local-level instrument of the NPHPSP is an integral part of MAPP's Local Health System Assessment.

The Core Function of Assessment and MAPP

Assessment is a significant phase of the MAPP process.

MAPP brings four assessments together to drive the development of a community strategic plan — Four unique and comprehensive assessments gather information to drive the identification of strategic issues. The essential services most associated with the core function of assessment are:

1. Monitor health status to identify community health problems.

2. Diagnose and investigate health problems and health hazards in the community.

3. Inform, educate, and empower people about health issues.

The four MAPP Assessments are:

• The Community Themes and Strengths Assessment identifies themes that interest and engage the community, perceptions about quality of life, and community assets.
• The Local Health System Assessment measures the capacity of the local health system to conduct essential public health services.
• The Community Health Status Assessment analyzes data about health status, quality of life and risk factors in the community.
• The Forces of Change Assessment identifies forces that are occurring or will occur that will affect the community or the local health system.

The graphic of the MAPP model illustrates the phases of MAPP process, shown in the center.  The four MAPP assessments -the key content areas that drive the process - are shown in the outer circle..

To initiate the MAPP process, lead organizations in the community begin by organizing themselves and preparing to implement MAPP (Organize for Success/Partnership Development)). Community-wide strategic planning requires a high level of commitment from partners, stakeholders, and the community residents who are recruited to participate.

The second phase of the MAPP process is Visioning. A shared vision and common values provide a framework for pursuing long-range community goals. During this phase, the community answers questions such as “What would we like our community to look like in 10 years?”

Next, the four MAPP Assessments are conducted, providing critical insights into challenges and opportunities throughout the community:

The Community Themes and Strengths Assessment provides a deep understanding of the issues residents feel are important by answering the questions “What is important to our community?” “How is quality of life perceived in our community?” and “What assets do we have that can be used to improve community health? ”

The Local Health System Assessment is a comprehensive assessment of all of the organizations and entities that contribute to the public’s health. The Local Public Health System answers the questions “What are the activities, competencies, and capacities of our local health system?” and “How are the Essential Services being provided to our community?”

The Community Health Status Assessment identifies priority issues related to community health and quality of life. Questions answered during the phase include “How healthy are our residents?” and “What does the health status of our community look like?”

The Forces of Change Assessment focuses on the identification of forces such as legislation, technology, and other issues that affect the context in which the community and its public health system operates. This answers the questions “What is occurring or might occur that affects the health of our community or the local health system?” and “What specific threats or opportunities are generated by these occurrences?”

 

The Core Function of Policy Development and MAPP

Policy Development is accomplished through the phases of MAPP known as Identifying Strategic Issues and Formulating Goals and Strategies.

The essential services most associated with the core function of Policy Development are:

4. Mobilize community partnerships to identify and solve health problems.

5. Develop policies and plans that support individual and community health efforts

6. Enforce laws and regulations that protect health and ensure safety.

 

Policy Development functions meet the goals and mission of the NPHPSP through the following public health practices:

• • Establishing an effective presence of the local public health system at the community level.
• • Systematic community-level planning for health improvement in all jurisdictions
• • Alignment of local public health system resources and strategies with the community health improvement plan.
• • Development of policies and plans that support individual and community health efforts.
• • Development of policy to protect the health of the public and to guide the practice of public health.

Once a list of challenges and opportunities has been generated from each of the four assessments, the next step is to Identify Strategic Issues. During this phase, participants identify linkages between the four assessments to determine the most critical issues that must be addressed for the community to achieve its vision.  After issues have been identified, participants Formulate Goals and Strategies for addressing each issue. 

 

The Core Function of Assurance and MAPP

The final phase of MAPP is the Action Cycle. It is through the steps of the Action Cycle that the core function of Assurance is practiced.  During this phase, participants plan, implement, and evaluate.  These activities build upon one another in a continuous and interactive manner and ensure continued success. 

The essential services most associated with Assurance are:

7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
8. Assure a competent public health and personal health care workforce.
9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
10.  Research for new insights and innovative solutions to health problems.

 The Action Cycle links three activities— Planning, Implementation, and Evaluation. Each of these activities builds upon the others in a continuous and interactive manner.

The Action Cycle can be a very satisfying phase, as the efforts of the previous phases begin to produce results through the implementation of the action plan. This is also a challenging phase, as it requires substantial effort to sustain the process and continue implementation over time.  

The strategies identified in the previous phase form the foundation for the Action Cycle. Clear strategic goals are another important element. Crisply articulated goals will not only fuel the activities of practical work plans, but will also prompt accountability and evaluation. For the local public health system, such accountability will depend on the specific objectives and components of a work-plan agreed upon by the necessary participants.  

The evaluation component of the Action Cycle answers the following fundamental questions: “With the implementation of activity X, what was accomplished?” and “How does that compare what we said we would accomplish?” In essence, these lead to four questions of practical utility: 1. What have you done? 2. How well have you done it? 3. How much have you done? 4. How effective have you been?  

There are two focal points to MAPP evaluation activities: evaluation of the overall process and evaluation of each strategy and action plan. Both evaluations should rely on objective parameters (e.g., facts and figures), but should also accommodate subjective value judgments. This interplay between objective and subjective aspects provides the MAPP Committee with an opportunity for a well-balanced evaluation process.  

The Action Cycle can be summarized as follows: Planning — Determining what will be done, who will do it, and how it will be done. Implementation — Carrying out the activities identified in the planning stage.   Evaluation — Determining what has been accomplished.   The cycle repeats itself, offering a sustainable method for the community to build upon accomplishments and position itself for even greater achievements.