An International Perspective on California’s Population Health Challenges

Written by: Mia Bladin, Jeremy Cantor, and Kiely Houston

International health and domestic health work often feel like they exist in parallel worlds, even within the same organization. At JSI, our domestic and international health teams both face difficult challenges, struggle with scarce resources and complex systems, and aim to improve health and health equity (addressing the structures and systems that lead to disparate health outcomes) in close partnership with the communities we serve. Yet the venues for dialogue and cross-pollination are few and far between. A few of the staff from the JSI California team were recently leading a project that involved getting multiple perspectives on California’s population health landscape. We took the opportunity to engage leaders from our international projects. The result was valuable input on our project as well as insights on how to structure such exchanges in the future.

Moving from the Individual to the Population

As part of a project with Blue Shield of California Foundation, we set out to create an ambitious yet practical vision for improving health in California over the next 5–7 years. The effort was framed by the question:

In five years, how do we move from a health system that thinks about the individual and produces disparate outcomes, toward one that thinks about populations and produces equitable opportunity?

In approaching this task, we conducted a literature review and asked dozens of key informants throughout the state about the trends, barriers, and leverage points for improving health and health equity. To complement our qualitative research, we engaged our international colleagues for perspectives outside our usual informants. In particular, we were interested in solutions that have developed in relatively “low-resource” environments that might be applicable in the paradoxical U.S. systems (high-cost, poor outcomes).

California’s health landscape reflects variation and inequities.

Creating the Space for Open Dialogue

We scheduled a 1-day in-person meeting with colleagues who have directed projects in over 100 countries. Setting up a dialogue across domestic and international sectors takes careful planning in order to balance information and context-sharing with focused and pragmatic thinking. Given the trope that if “you’ve seen one country/local health agency…you’ve seen one country/local health agency”, many hours could be spent sharing stories, challenges, and successes. On the other hand, asking for input without providing any background or “socialization” time would likely lead to ideas and strategies that were not relevant or useful.

In pursuit of the right balance, we took the following steps:

  • Selected experienced systems-thinkers who had worked in multiple settings.
  • Provided a synthesis of the California context both in writing before the meeting and as a short presentation.
  • In order to get participants thinking and talking together, we worked on a participatory, neutral challenge in small groups: “How would we engineer a health system that produces the worst outcomes?”

Worldwide Brainstorming for Statewide Solutions

Our group then moved to a more explicit investigation of ideas and strategies that could be relevant in California. A number of ideas emerged that were particularly provocative and distinct from those that we’d heard from in-state stakeholders, including:

  • Adaptive risk profiles. We are still working on having high-quality, granular, timely data that can be disaggregated in meaningful ways. Are there other parameters, aside from basic demographics and health status that could help guide resource allocation decisions and “target” interventions? We discussed the rise of digital communities and changing patterns of health-seeking and health-affecting behaviors that cross the traditional demographic categories of income, gender, race, and physical place. In the future, will other individual characteristics, such as physical activity patterns tied to the type of employment and or digital connectedness, predict risk factors and health outcomes? As we head into the era of “big data” in health care, are there different ways to think about “population” and “risk”?
  • Focus on a charismatic issue. Successful examples of multi-sector initiatives in international contexts often begin with a single issue, which is usually tied to change in multiple sectors, is easily relatable and meaningful for many stakeholders, and charismatic enough to gain the attention of elected officials and other high-profile decision-makers. For example, progress on the global issue of child stunting has required collaboration across sectors that has lead to progress on multiple other issues.
  • Importance of clarifying the problem and using appropriate indicators. When health improvement efforts focus on populations rather than individuals, there is an even greater need for monitoring appropriate measures. Defining health as the ‘absence of disease’ inevitably leads to health systems focused on curing disease as their primary function. Are there other endpoints in measurement that would lead to different strategies and emphasis? For example, Bhutan’s Gross National Happiness measure and India’s livability index and standards have both had significant impacts on policy decisions. Using composite indicators can also serve to illustrate high-level issues and patterns (the forest, not just the trees). For example, The 2018 multidimensional poverty indicator includes 3 dimensions, one of which is health, providing a broad view of progress on intersecting issues.

Looking Forward

Collaborating with our international health colleagues was a genuinely productive exercise: The preparation, meeting, and follow-up all served to expand our perspectives and sharpen our strategic ideas. Participants reported that it was thought-provoking and exciting to apply their experience and knowledge to a very different health context. The experience also stimulated discussions about how to create more opportunities for such engagements. One participant remarked afterward, “To do this kind of cross-sector thinking makes me realize how much expertise we really have to share.”

JSI is a public health consulting firm that works to improve the health and well-being of underserved and vulnerable people and communities throughout the world