Governance: Enhance Public Health Infrastructure through Regionalization and Shared Services

By Lizzi Weyant, Mark Fine, and Barry Keppard, Metropolitan Area Planning Council (MAPC)

Kristina Kimani, Massachusetts Public Health Association (MPHA)

April 8, 2021

For over a year now, our municipal leaders have been at the front line of dealing with the COVID-19 crisis. From the very first days of the pandemic, they came together to urge the Governor to close schools and implement statewide shutdowns. Mayors and Managers immediately realized that while we still knew very little about the virus, shutting schools, businesses, and daycares would be the fastest way to protect people from the virus, avoid an exorbitant loss of life, and limit exposure for essential employees, all while sending the message that people needed to stay home in order to stay safe. Municipal leaders worked closely with the Administration, urging creation of a clear statewide response to the pandemic in order to avoid the confusion and pain of an ad hoc municipal response.

As the early panic of the pandemic gave way to the realization that we would be living with the virus for months and likely years, municipal leaders started coming together to share best practices, communications plans, and support. Through the tiny windows of their Zoom screens, Mayors and Managers worked tirelessly to save as many people as they possibly could.

As hard as the Mayors and Managers were working, another group of individuals mostly outside the limelight were working just as hard. The heroes that we spoke of most often may have been the nurses and doctors working in hospitals, emergency rooms, and clinics to save lives. But our local public health leaders, often overlooked, were laboring alongside Mayors and Managers around the clock to keep residents safe in every corner of the Commonwealth. One thing was eminently clear: Our public health infrastructure in Massachusetts is inadequately funded and our approach is too fragmented across 351 separate cities and towns.

The Special Commission on Local and Regional Public Health was created in 2019 to closely examine public health delivery across the Commonwealth. It had become clear that the demands on local public health were huge and ballooning; the Commission’s goal was to figure out how to strengthen local public health infrastructure. The primary recommendations of the Commission’s report called for creating minimum public health standards, cross-jurisdictional or regional public health services, increasing funding for local public health, and making our data standards consistent and transparent. The Governor and the Legislature made a commitment to address the recommendations outlined in the report. When the pandemic hit just nine months later, it put a spotlight on the immediacy of the needs outlined in the report.

Under the duress of the pandemic, cities and towns did something that we had been urging for years: They started working together, across municipal boundaries, to meet the needs of residents. The examples were amazing. Communities north of Boston came together to set up testing sites. When it felt like the state contact tracing system wasn’t working fast enough, municipalities collaborated to hire and staff local contact tracing initiatives. Communities in Metro Boston set up quarantine and isolation hotels, working ahead of the Commonwealth and with their own money to create places where people could safely quarantine for two weeks to protect themselves and their families. As the news started to turn toward vaccination options, local public health leaders were the first to elevate the ways that regional vaccination efforts could support the statewide effort.

Basically, in real time, in the middle of the biggest public health crisis of our lifetimes, cities and towns were collaborating to enhance their public health services for as many residents as possible, as quickly as possible.

And yet, from the earliest reported surges of COVID-19, we saw that not only would it be unsustainable for our existing public health infrastructure to protect residents of the Commonwealth as currently configured and funded, but that underlying disparities make it extremely difficult for certain populations to even access the care they needed. In the early part of this century, the World Health Organization started studying what we now call the social determinants of health and it has become a principle among public health experts that the conditions and places where people are born, grow, live, and work are the drivers of individuals’ and our communities’ health outcomes.

When we talk about “hard hit” communities in the Commonwealth, it would be hard to argue that good public health outcomes would be met if only we had the right public health infrastructure or regionalized public health systems. Those 20 communities that were disproportionately affected by COVID-19 shared some strikingly similar characteristics: They bear the burden of a history of being underserved, constrained by discriminatory systems and policies, and they are disproportionately communities of color.

Our big idea for rebuilding from the pandemic is not a new idea. And it’s not an idea that we come to alone. In fact, public health experts, community advocates, and even our own statewide commission came to this conclusion a while ago: We need to reshape our public health infrastructure and service delivery, and we need to center this work in equity. Specifically, when we create minimum public health standards, we must incorporate the social determinants of health. Data collection and reporting must include data that can shine a light on racist policies and disparities, and funding must be distributed in such a way that our most underserved communities have a chance to redress past harms. The regional approach will enable a more holistic picture of health across the Commonwealth and help create a sustainable, long-term public health model to address the underlying disparities.

Fortunately, the blueprint for this structural change has already been laid, and filed in the state legislature as the Statewide Accelerated Public Health for Every Community Act or SAPHE 2.0. This legislation, once passed, will put into practice the key recommendations of the Special Commission and work to transform the local public health system in Massachusetts by accelerating improvements to the system so that it adequately serves all residents, regardless of race, income or zip code. Faced with the inequities of this pandemic, we must seize this opportunity to make change.

The success of this effort lies in not just passing this legislation and providing significant investments (though we absolutely need to pass SAPHE 2.0 and to increase funding for local public health, and we would strongly urge the Legislature and the Administration to make significant investments in public health with state and federal recovery funding). Success is also about taking the best initiatives that were born out of the crisis and cementing them so that we can weather our next public health crisis in a way that doesn’t result in the drastic and overwhelming loss of life for so many of our neighbors. Shared services will give municipalities an opportunity to ensure that public health delivery across the Commonwealth, even in non-pandemic times, is coordinated and streamlined, and uses resources in a more effective way.

We expect these shared services models to look a little bit different across the state. But no matter what those models look like, a successful reshaping of our public health infrastructure will make it easier for cities and towns to work together and will make a significant investment in historically underserved communities and lower-income communities of color.