Thinking holistically, planning strategically: Challenges in developing a public health strategic plan

The connection between the physical and social environments and health outcomes is well documented. However, in a budgetary climate that dictates doing more work with less funding, public health departments are challenged to address issues outside the customary purview of public health. The Los Angeles County Department of Public Health has developed a strategic plan to guide its work over the next several years. Intended to expand beyond traditional functions such as communicable disease control, the plan seeks to address the underlying determinants of poor health outcomes, which are largely preventable. As such, the physical and social environments are important objectives, as they contain opportunities for individuals and communities to make healthier choices. Implementing the plan, however, has encountered several challenges, including the inflexibility of categorical funding for mandated programs, diminishing local funding, and training staff to take a policy-oriented approach to public health. Additionally, an already heavy workload for staff trying to fulfill mandated or traditional functions presents a challenge in identifying potential lead managers to direct issues surrounding the social environment which do not clearly fall within a particular program. Nevertheless, Public Health succeeded in incorporating this holistic approach into its work: a new Chronic Disease division is working with community agencies to develop innovative ways to address the physical environment; a health inequities workgroup is developing an approach to address health disparities; and perhaps most significantly, Public Health field nurses have incorporated this broader focus into their everyday work with individuals and communities.