Magda G. Peck ScD Founding Dean and Professor Joseph J. Zilber School of Public Health

1. Leadership for a Change: Using the Life Course Perspective to Reduce Inequalities and Achieve Health Equity Magda G. Peck ScD Founding Dean and Professor Joseph J. Zilber School of Public Health University of Wisconsin – Milwaukee Founder and Senior Advisor, CityMatCH

2. GROWING GREAT LEADERS IN GREATER ORGANIZATIONS FOR THE GREATEST GOOD • Founding CEO, CityMatCH • Founding Director, UNMC/UNO MPH Program • Founding Director, Great Plains Public Health Leadership Institute • Founding Director, Great Plains Public Health Training Center • Associate Dean, Community Engagement and Practice, UNMC College of Public Health

3. Ten Great Public Health Achievements -- United States, 1900-1999 Healthier mothers and babies Family planning Fluoridation of drinking water Recognition of tobacco use as a health hazard • Vaccination • Motor-vehicle safety • Safer workplaces • Control of infectious diseases • Decline in deaths from coronary heart disease and stroke • Safer and healthier foods

5. 3 Dynamics IMPEDING AND PROPELLING IMPACT • INCREASING COMPLEXITY

7. Life Course Perspective White Primary Care for Children Early Intervention African American Prenatal Care Prenatal Care Primary Care for Women Interconception Care Adverse Birth Outcomes Age 0 5 Puberty Pregnancy Source: Michael Lu, 2003

10. “Public Health” is…. Creating conditions for everyone, every day, everywhere to have equal chances and fullest choices to be healthy and thrive, and live well and long, from generation to generation. (Peck, 2012)

11. 3 Dynamics IMPEDING AND PROPELLING IMPACT • INCREASING COMPLEXITY • RAPIDLY CHANGING CONTEXT

12. CHANGING CONTEXTS INTERDISCIPLINARY INTER-PROFESSIONAL GLOBAL DIGITAL DEAN JOHN FINNEGAN, UMinnSPH, 02.03.12 Framing the Future of Public Health

13. Government’s Role and Value

14. 3 Dynamics IMPEDING AND PROPELLING IMPACT • INCREASING COMPLEXITY • RAPIDLY CHANGING CONTEXT OF WORK • REQUIRED COLLABORATION

15. Broad social, economic, cultural, health, and environmental conditions and policies at the global, national, state, and local levels • Living and working conditions may include: • Psychosocial factors • Employment status and occupational factors • Socioeconomic status (income, education, occupation) • The natural and builtc environments • Public health services • Health care services Living and working conditions a Social, family and community networks Individual behavior Innate individual traits: age, sex, race, and biological factors --- The biology of disease Over the life span b NOTES: Adapted from Dahlgren and Whitehead, 1991. The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman, 1999). Public Health’sEcological Model IOM 2003: Committee on Educating Public Health Professionals for the 21st Century

16. Health care delivery systems “Community” Assuring Conditions for Population Health Governmental Public Health Infrastructure Employers and Business Academia The Media We all are part of the Public Health System …assuring the public’s health.

17. 3POWER TOOLS FOR CHANGE LEADERSHIP MASTERY

18. “If you are working for the public’s health, you don’t get to opt out of leadership.”-MP

19. ‘Mighty 7’ Leaders Needed Now for the Public’s Health • Values-Driven/EthicalLeaders • Visionary Leaders • Servant Leaders • Collaborative Leaders • Systems-Oriented Leaders • NavigationalLeaders • Transformational Leaders M Peck, 2008, 2012, 2013

20. 3POWER TOOLS FOR CHANGE LEADERSHIP MASTERY SYSTEMS THINKING

21. Greater Milwaukee: The Number One Most Segregated Metro Area in the United States

26. Health Equity Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. It is this that we label health inequity. Putting right these inequities – the huge and remediable differences in health between and within countries – is a matter of social justice. World Health Organization Commission on Social Determinants of Health

27. Social Determinants of Health • The social determinants of health are those factors which are outside of the individual; they are beyond genetic endowment and beyond individual behaviors. They are the context in which individual behaviors arise and in which individual behaviors convey risk. The social determinants of health include individual resources, neighborhood (place-based) or community (group-based) resources, hazards and toxic exposures, and opportunity structures. Camara Jones, 2010

28. Racism and Health It is impossible to have a frank discussion of inequality…without confronting the continuing blight of racism head on… long established and growing health disparities are rooted in fundamental social structure inequalities, which are inextricably bound up with the racism that continues to pervade U.S. society. Cohen and Northridge, AJPH, June 2000, p841

29. Preconception Health: Risks Identified at the Time of a Negative Pregnancy Test Source: Jack B, Campanile C, McQuade W, Kogan M. Arch Fam Med 1995:4:340-45

30. 10 Recommendations to Improve Preconception Health and Health Care • Individual responsibility across the lifespan • Consumer awareness • Preventive visits • Interventions for identified risks • Interconception care • Pre-pregnancy check ups • Coverage for low-income women • Public health programs & strategies • Research • Monitoring improvements National Preconception Health and Health Care Initiative, October 2010

31. 3 Questions – Sort it Out WHY?(Health Equity, Human Rights) HOW?(Social Determinants of Health, Health Inequities, Health Disparities, Racism) WHEN?(PPOR, Preconception Health, Life Course)

32. 3POWER TOOLS FOR CHANGE LEADERSHIP MASTERY SYSTEMS THINKING COLLECTIVE IMPACT

33. “Collective Impact” The commitment of a group of important actors from different sectors to a common agenda solving a specific problem.KANIA AND KRAMER, STANFORD SOCIAL INNOVATION REVIEW, 2011

34. ‘Isolated’ Impact Individual projects, fund most promising solutions Separate work, competition, independent action Evaluation of specific organization’s impact Large scale change = scale up Separation of sectors HANLEYBROWN, KANIA ANDKRAMER, STANFORD SOCIAL INNOVATION REVIEW, 2012 HANLEYBROWN, KANIA ANDKRAMER, STANFORD SOCIAL INNOVATION REVIEW, 2012

35. “Collective” Impact Social problems/solutions require interactions across organizations Large scale impact achieved by aligning across sectors Partner corporate and government sectors Coordinated actions and lessons learned HANLEYBROWN, KANIA ANDKRAMER, STANFORD SOCIAL INNOVATION REVIEW, 2012

36. Conditions Required for Collective Impact 1. Common Agenda Shared Measurement Mutually Reinforcing Activities Continuous Communication Backbone Support HANLEYBROWN, KANIA ANDKRAMER, STANFORD SOCIAL INNOVATION REVIEW, 2012

38. 3POWER TOOLS FOR CHANGE • RESEARCH AND DATA • EVIDENCE-BASED STRATEGIES

39. Prevention in the Patient Protection and Affordable Care Act (ACA) “We know that prevention helps people live long and productive lives and can help combat rising healthcare costs.” Department of Health and Human Services (HHS) Secretary, Kathleen Sebelius

40. Background • Section 2713 of the ACA, requires that a group health plan and a health insurance issuer offering group or individual health insurance coverage provide benefits for and prohibit the imposition of cost-sharing requirements with respect to: • Evidence-based items or services that have a rating of A or B in the current recommendations of the USPSTF. • Immunizations that have a recommendation from ACIP – the Advisory Committee on Immunization Practices.

41. Background (cont.) • With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in HRSA supported, comprehensive guidelines in the AAP’s Bright Futures report. • With respect to women, evidence-informed preventive care and screenings not otherwise addressed by current recommendations.

42. Why Women? Women’s Health Amendment (in the ACA) Requires that all private health plans cover – with no cost sharing requirements for patients – a newly identified set of women’s preventive services Women have longer life expectancies, a greater burden of chronic diseases and disability, reproductive and gender specific conditions …and women often have different treatment responses than men.

43. Clinical Preventive Services for Women:Closing the Gaps Committee on Preventive Services for Women Institute of Medicine, National Academy of Sciences The National Academies Press, 2011 Released July 19, 2011 www.iom.edu (free PDF Downloads)

44. Recommendation 5 The full range of FDA-approved contraceptive methods, sterilization procedures, and patient education and counselingfor women with reproductive capacity. Supporting Evidence: Specific to preventing unintended pregnancy. Based on systematic evidence reviews and other peer-reviewed studies. Current federal reimbursement policies provide coverage for contraception and contraceptive counseling and most private insurers also cover contraception in their health plans. Numerous professional associations recommend family planning services as part of preventive care for women. Reduction in unintended pregnancies a specific goal in Healthy People 2010 and 2020 USPSTF Grade – Not Addressed

45. Recommendation 8 At least one well-woman preventive care visit annually for adult women to obtain the recommended preventive services, including preconception and prenatal care. The committee also recognizes that several visits may be needed to obtain all necessary recommended preventive services, depending on a woman’s health status, health needs, and other risk factors. Supporting Evidence Based on federal and state policies (such as included in Medicaid and Medicare and the State of Massachusetts), clinical professional guidelines (such as those from the AMA and AAFP, and private health plan policies (such as Kaiser Permanente). USPSTF Grade – Not Addressed Note: well-child visits include adolescent girls under Bright Futures

46. THE BOTTOM LINE (IOM report brief July 2011) “Positioning preventive care as the foundation of the U.S. healthcare system is critical to ensuring Americans’ health and well-being…. …The inclusion of evidence-based screenings, counseling and procedures that address women’s greater need for services over the course of a women’s lifetime may have a profound impact for individuals and the nation as a whole.”

47. AFFORDABLE CARE ACT EXPANDS PREVENTION COVERAGE FOR WOMEN’S HEALTH AND WELL-BEING “The HRSA-supported health plan coverage guidelines developed by the IOM will help ensure that women receive a comprehensive set of preventive services without having to pay a co-payment, co-insurance, or deductible….HRSA is supporting the IOM’s recommendations that address health needs specific to women and fill gaps in existing guidelines.” New private health plans must cover the guidelines on women’s preventive services with no cost sharing in plan years starting on or after August 1, 2012. www.hrsa.gov/womensguidelines

48. Opportunities… (New) Standard of Coveragefor Women (decrease variability, establish new threshold) e.g. new insurance industry standards: comprehensive contraception and enhanced STD, HIV, HPV prevention for women MP Commentary 2012

49. Opportunities…for greater integration and quality Well-woman preventive visits – -reducing fragmentation -increasing likelihood of access -life course approach -medical homes for women’s health MP Commentary 2012

50. 4 Questions MCH Champions Must Ask About the ACA: • How can we work together to assure that policymakers will incorporate expanded preventive services for women in (state level) health reform design and implementation? • How can we use expanded coverage for women as a catalyst for greater integration of programs and services across the life course in the public (STD, MCH, IPV, chronic disease…) and private sectors? • How can we also champion filling the gaps in (clinical) preventive services beyond women? • How can public health leaders influence the next updating of prevention services? MP Commentary 2012