Obstacles to Population Health: Is Anyone Accountable?

Originally posted 6/7/2010

Population health policy has been slow to emerge as a useful way to catalyze action regarding community health improvement. What are the barriers between population health knowledge and action, and how can we overcome them? There are no easy solutions, but certainly addressing these obstacles is an essential task for the field over the coming decade.

One critical obstacle is that the multiple factors determining population health —health care, behaviors, genetics, social factors, physical environment, public health—can be seen as so broad as to be overwhelmingly inclusive and therefore resistant to realistic policy action or even scholarly analysis.

 This is a significant challenge for population health policy. The “inconvenient truth” is that since the actors for this range of factors are spread across the public and private sectors (government at all levels, employers, health care organizations, school boards, community organizations), there is no one actor or agent accountable and responsible for such broad population health outcomes as mortality, morbidity, and disparities.

While governmental public health defines its role as assuring the conditions that make us healthy, in this era of shrinking resources, it is increasingly difficult for local public health agencies to carry out their own essential services (much less broader policies such as health care costs, early childhood programs, and economic competitiveness). While some have suggested mechanisms such as a public health “system”, public-private partnerships, health outcomes trusts, and an integrator function for healthcare organizations, none of these mechanisms have been established beyond theory or taken to scale. Obstacles to systematic transformation include not only the inherent tension between  “bottom-up” local community approaches and more centralized state or federal “top-down” planning perspectives, but also communities’ unique strengths and challenges across a broad spectrum of health-related issues.

The bottom line is that no one-size-fits-all formula exists to guide population health improvement through resource allocation and activities across multiple sectors and multiple levels. Communities find their own solutions, by figuring out what their most pressing problems are and then working to address them. Thus, we focus on piecing together only discrete, easily defined sections of the population health policy puzzle (i.g., tobacco use, obesity, child vaccinations, etc.), while leaving – quite understandably —perhaps more root cause and comprehensive solutions unaddressed.

Few would argue against the pragmatism of concentrating effort on a single or several initiatives. In fact, there is some evidence to support such an approach. As Conrad and colleagues’ assert, “Very clearly focused interventions targeted to a clearly defined community population, and implemented and managed by a small number of clearly accountable organizational entities, are more likely to produce community health improvement (1).”

That said, we must recognize that in this resource-limited world, implementation of a broader set of the most cost effective interventions will be necessary to achieve the best outcomes. The 467 objectives in Healthy People 2010 are not ranked in any way, implicitly suggesting that all are equally important—which of course cannot be the case. Highest performance on an individual policy in a given community could become an end in itself rather than a means to the population health outcome goal. It is possible, I suppose, that each individual sector (health care, public health, schools, employers) will arrive at the most robust set of cost effective investments and incentives possible under its control. However, this is unlikely to happen, given that available evidence suggests that “the broader the intervention focus and the more varied the target population, the more achievement of positive community health outcomes will depend on the integration of separate program components (1).”

Hope remains, however, in the potential of cross-sectoral integrating mechanisms. To return to the title of this post, I believe that no one entity today has accountability for population health outcomes. However, there are significant problems both with individual sector solutions described above as well as multisectoral partnerships unless they can be brought to scale and demonstrate effectiveness. Resolving this challenge will be one of several critical tasks as a population health policy framework emerges in the coming decades. I would love to hear critique of this analysis as well as examples of promising practices that might lead the way.


1. Conrad DA, Cave SH, Lucas M, Harville J, Shortell SM, Bazzoli GJ, Hasnain-Wynia R, Sofaer S, Alexander JA, Casey E, Margolin F. (2003). Community care networks: linking vision to outcomes for community health improvement. Med Care Res Rev, 60(4 Suppl), 95S-129S.

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