Section 7. Ten Essential Public Health Services

Note: The Ten Essential Public Health Services framework was revised in 2020. The text below reflects the revised framework and terminology.

Before you read this section's information about the Ten Essential Services, we invite you to take a quiz. Answers are provided at the bottom of this page. See how well YOU do!

As you read the front page of the local news, you notice an alarming article about an outbreak of “disease X” in your community. You read on to learn about the scientifically established cause of “disease X” and precautionary measures for avoiding exposure.

This valuable information was published prominently because:

• The local football team lost its game last night
• The front-page columnist is on vacation
• State and local health officials and their staff have worked to gather data, conduct laboratory and statistical tests, develop and test hypotheses, and collaborate with the media to alert and educate the public about “disease X” as effectively as possible.

On your way into the local grocery store, you notice a flier advertising a toll-free number or website for enrolling eligible uninsured children in a publicly funded health insurance program.

This insurance program and its outreach efforts exist because:

• The federal government has a budget surplus and is looking for a way to spend it
• A telephone company offered the state health department a great deal on toll-free numbers
• Public health professionals have documented gaps in health coverage and worked with federal and state policymakers and community partners to improve outreach and access to health coverage and care.

While shopping in the local mall, you come across a group of nurses offering free blood pressure and cholesterol screenings.

The nurses are offering these screenings because:

• They need to moonlight
• They enjoy people watching at the mall
• They are public health nurses dedicated to community health promotion, including the prevention of heart disease

You and your sweetheart share a romantic dinner at your favorite restaurant. Not only is the meal delicious – you do not get food poisoning!

This enjoyable experience has been brought to you by:

• The restaurant management
• Your local health department
• A joint effort of the restaurant management and your local health department

In an urban area, some liquor stores are gradually being replaced by grocery stores. The public transit system has been rerouted to improve store access for residents without vehicles.

This change in the community’s planning and development is probably a result of:

• The Department of Transportation needing to increase revenue
• The liquor store owners deciding that they weren’t doing enough business and moving elsewhere
• A collaborative effort of community members, public health professionals, city planners, and local government officials working toward shared goals for community health and well-being

Answers: 1. c; 2. c; 3. c; 4. c; 5. c

What, besides the same answer, do the quiz scenarios above have in common? They are real-life, everyday examples of some of the Ten Essential Public Health Services that public health professionals and their partners work to provide in the communities they serve.

This Tool Box section will teach you what the Ten Essential Public Health Services are and illustrate their function in public health. When you have completed the tool, you will be able to identify which Essential Services are reflected in public health activities in your community. More importantly, we hope that you will understand how efforts across all ten Essential Service areas can work together to promote the health of everyone in the community.

To help you get started with identifying how the Ten Essential Public Health Services are reflected in day-to-day public health activities, Table 1 below matches five of the Ten Essential Public Health Services with their corresponding quiz scenarios.

Table 1: Examples of How Essential Services Are Reflected in Day-to-Day Public Health Activities

Quiz Scenario	Essential Public Health Service Implemented
Informing the public about an epidemiological outbreak investigation in the community	“Investigate, diagnose, and address health problems and hazards affecting the population”
Promoting enrollment in publicly funded health coverage	“Assure an effective system that enables equitable access to the individual services and care needed to be healthy”
Health education and health promotion to prevent heart disease	“Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it”
Maintenance of a sanitary restaurant environment for public well-being	“Utilize legal and regulatory actions designed to improve and protect the public's health”
Shaping health policy, city planning, and transportation routes to create an environment that supports healthy behavior	“Create, champion, and implement policies, plans, and laws that impact health”

We hope that you want to read on and learn more. But before we discuss each of the Essential Services, we will visit the broader concept of defining the purpose and function of public health.

What is public health?

As you probably concluded from the quiz scenarios, public health is everywhere – it is part of the infrastructure that keeps our communities safe and healthy.

Definitions of public health vary somewhat among organizations and disciplines. The current Ten Essential Public Health Services framework is organized around protecting and promoting the health of all people in all communities.

Public health services may go unnoticed within a community because much of the work is preventive rather than reactive. For example, which community service are you more likely to notice – an environmental health specialist inspecting the safety of a local university’s food service establishments, or a fire truck speeding down the street with its lights and sirens on?

Despite having a relatively “low profile,” public health services play a key role in protecting and improving the health and well-being of communities. Improvements in sanitation, vaccination, disease prevention and control, safer workplaces, safer food and water, and other public health efforts have contributed greatly to longer and healthier lives.

Who is the typical public health professional?

There really is no “typical” public health professional. The public health workforce includes people with widely varied professional training, expertise, and lived experience.

• Some are nurses, physicians, or laboratory professionals by training.
• Some are educators, nutrition professionals, community health workers, or social workers.
• Some are biostatisticians, epidemiologists, or data professionals.
• Others are economists, planners, communications professionals, or lawyers.
• Community-based and grassroots contributors may include parents, caregivers, community leaders, advocates, and other community members who contribute their experience and time.

How do all of these people, with a common purpose but different skills and perspectives, work together successfully to carry out the work of public health? One framework they can use is the Ten Essential Public Health Services.

The Ten Essential Public Health Services differ in some ways from other logic models presented in Chapter 2 of the Tool Box. Other logic models discussed incorporate prescribed processes – for example, from planning to implementation to evaluation – that can then be applied to one priority goal such as preventing pregnancies among adolescents. In contrast, there is no prescribed order of implementation for the Ten Essential Services and no one specific outcome that results from implementing all ten. Rather, the Ten Essential Services provide a comprehensive framework that can support many different public health priorities in a community.

Although more prescriptive logic models may focus on one defined goal, they can also take a comprehensive approach within a community. For example, a planning phase might involve stakeholders from sectors beyond public health in an effort to create supportive conditions for change. This is not unlike the role of the Ten Essential Services.

You may be wondering,

“Why do people need a common framework for direction if they are already working toward the same mission?”

Because of their diverse backgrounds, professionals and community partners may have been trained to work from different models. One example is the “medical model” compared with the “public health model.” A major distinction is that public health activities generally focus on populations and the conditions affecting them, while clinical care generally focuses on individual patients. Table 2 below summarizes some broad differences between these approaches.

Table 2: Public Health and Medical Models of Professional Practice

Public Health Model	Medical Model
Primary focus on populations	Primary focus on individuals
Public service ethic, with attention to individuals and communities	Personal service ethic, with awareness of broader social responsibilities
Emphasis on prevention, protection, and health promotion across populations	Emphasis on diagnosis, treatment, and care for individual patients
Uses a range of interventions addressing environments, behaviors, systems, policies, and access to care	Places primary emphasis on clinical care while recognizing other influences on health

The Ten Essential Public Health Services provide common ground for people trained in either approach, as well as community-based workers and leaders from outside the traditional public health system, so they can work collaboratively to protect and promote health.

What are the Ten Essential Public Health Services?

In 1988, the Institute of Medicine identified three core functions of public health:

• Assessment
• Policy development
• Assurance

Public health leaders later worked to define a more detailed framework for carrying out those broad functions. The original Ten Essential Public Health Services framework was released in 1994.

The framework was revised in 2020 to better reflect current and future public health practice. The revised framework places equity at its center and gives greater attention to community engagement, social and structural conditions, cross-sector partnerships, and the systems needed to support public health.

Why is it important to implement and monitor the Ten Essential Public Health Services?

The Ten Essential Public Health Services put the public health approach into practice. Key principles include:

• A primary focus on populations and communities
• A commitment to public service and community well-being
• An emphasis on prevention, protection, and health promotion
• Attention to the conditions, systems, policies, environments, behaviors, and services that influence health
• A commitment to equity and to reducing barriers that prevent people and communities from achieving optimal health

Prevention remains a powerful element of public health practice.

• Prevention can reduce injuries, illnesses, and chronic disease.
• Prevention can save lives.
• Prevention can reduce avoidable health care costs and other social and economic costs.
• Prevention can benefit individuals, families, and communities through population-based public health efforts.

It is important not only to implement but also to monitor – track, assess, learn from, and modify as needed – the Ten Essential Public Health Services. Information about implementation, resources, reach, quality, and outcomes can inform decisions about public health programs, policies, priorities, and funding at local, state, tribal, territorial, and national levels.

How are the Ten Essential Services used in community practice?

On the pages that follow, each Essential Service is discussed in order from 1 to 10. Each discussion includes a description of the Service and examples of how it may appear in public health practice. Keep in mind that the Services do not have to be implemented in a “1-10” sequence or independently.

The Ten Essential Services are distinct but complementary areas of public health practice. Communities and public health systems should work across them together rather than treat them as isolated tasks. However, you may find that one or two connect particularly closely to your role in your community’s public health efforts.

Essential Service #1: Assess and monitor population health status, factors that influence health, and community needs and assets.

Public health surveillance – the ongoing, systematic collection, analysis, interpretation, and use of health-related data – is central to this Essential Service. Assessment can also include community knowledge and information about the social, economic, environmental, and structural conditions affecting health.

Essential Service #1 encompasses public health activities such as:

• Identifying threats to health and assessing community health needs and assets;
• Collecting, analyzing, and sharing timely information on health status, access to services, service use, costs, and outcomes;
• Examining differences in health conditions and outcomes among populations and geographic areas; and
• Collaborating with health care providers, community organizations, agencies, and other partners to strengthen information systems and community assessment.

National population-based surveillance systems administered or supported by the Centers for Disease Control and Prevention (CDC) include:

• The Behavioral Risk Factor Surveillance System;
• The National Vital Statistics System;
• The National Health Interview Survey; and
• Cancer registries.

You can access public health data through the Centers for Disease Control and Prevention and other federal, state, and local sources. You may not immediately think to use national data when working at the community level. However, national and state surveillance data can provide useful benchmarks as you assess health measures in your community.

Prior to investing significant resources and time in a program, it is often useful to conduct a needs and assets assessment. Community data can then be compared with state or national information to help determine where attention and resources may have the greatest value.

If you do not have the time or resources to conduct your own comprehensive assessment, community-level information may also be available through sources such as:

• State and local health reports and dashboards;
• School and community health reports;
• Public safety and transportation data; and
• Community surveys, focus groups, interviews, and other sources of local knowledge.

Essential Service #2: Investigate, diagnose, and address health problems and hazards affecting the population.

Essential Service #2 encompasses public health activities such as:

• Epidemiologic identification and investigation of emerging health threats;
• Public health laboratory capacity to conduct timely screening, testing, and analysis;
• Infectious disease investigation and response;
• Investigation of patterns of chronic disease, injury, environmental hazards, and other threats to health; and
• Working with communities and partners to understand and address the conditions contributing to health problems and hazards.

At the national level, the United States Department of Health and Human Services includes agencies such as the Agency for Toxic Substances and Disease Registry (ATSDR), which works to prevent harmful exposures and health effects related to hazardous substances.

At the state and local levels, public health laboratories, epidemiologists, environmental health professionals, and other partners provide testing, surveillance, investigation, applied research, communication, and other essential services to the communities they serve.

These professionals often work behind the scenes on issues that appear in the news – infectious disease outbreaks, foodborne illness, environmental exposures, newborn screening, emerging diseases, and other public health threats and emergencies.

Essential Service #3: Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it.

You have probably encountered – and perhaps participated in – health promotion and public health communication efforts in your community.

Essential Service #3 encompasses public health activities such as:

• Public communication and health promotion through appropriate media and communication channels;
• Providing clear, accessible, and useful health information at the community level;
• Collaborating with health care providers and community partners to reinforce accurate health information;
• Conducting health education with schools, workplaces, faith communities, community organizations, and other partners; and
• Developing culturally and linguistically appropriate communication that reflects health literacy and accessibility needs.

National public health campaigns provide familiar examples. One is Safe to Sleep, formerly known as Back to Sleep, which provides parents, caregivers, and health professionals with information about reducing the risk of sudden infant death syndrome (SIDS) and other sleep-related infant deaths.

Many national awareness events also relate directly to public health efforts. The American Public Health Association sponsors National Public Health Week each year. Communities may also sponsor local events, presentations, health fairs, workshops, or other activities to increase awareness and connect people with useful information and resources.

Essential Service #4: Strengthen, support, and mobilize communities and partnerships to improve health.

These activities represent a comprehensive approach to community health, in which community members, professionals, organizations, and sectors collaborate to understand issues, plan and implement action, monitor progress, evaluate results, and modify their efforts as needed.

Essential Service #4 encompasses public health activities such as:

• Convening, supporting, and engaging community groups and associations, including those not traditionally considered health-related, to work on shared community priorities; and
• Building and sustaining partnerships that draw on the full range of human, organizational, and material resources available in the community.

This is similar in some respects to the PATCH logic model – the Planned Approach to Community Health.

Included in the PATCH strategy are five elements that are fundamental to community health promotion:

• Community members participate in the process.
• Data guide the development of programs.
• Participants develop a comprehensive health promotion strategy.
• Evaluation emphasizes feedback and program improvement.
• Community capacity for health promotion is increased.

You can read about a similar process for mobilizing community partnerships to identify and address health problems in the Community Tool Box's Community Action Guide: A Framework for Addressing Community Goals and Problems.

The overall goal of action planning is to increase your community’s ability to work together to affect conditions and outcomes that matter to its residents – and to do so both over time and across issues of interest.

As your community works toward a broad vision of health for all, creating supportive conditions for change requires comprehensive efforts among diverse sectors of the community. These can include health organizations, community groups, faith communities, schools, businesses, housing organizations, transportation agencies, and others. Representatives and community members can come together to form a community coalition. Your coalition can then work to influence systems – programs, policies, practices, and community conditions – that can enhance or detract from health and well-being.

Essential Service #5: Create, champion, and implement policies, plans, and laws that impact health.

Public health policies and plans can affect health far beyond the boundaries of a single program. Data on health conditions, program performance, community priorities, and disparities can help policymakers and communities determine which policies and plans are working and where changes may be needed.

Essential Service #5 encompasses public health activities such as:

• Leadership development at different levels of public health and community systems;
• Community and jurisdiction-level planning for health improvement;
• Development and tracking of measurable health objectives as part of continuous learning and improvement;
• Collaboration across public health, health care, government, community organizations, and other sectors in policy and planning; and
• Development and implementation of policies, plans, codes, regulations, and legislation that can improve health.

Community design provides one example. Public health professionals can work with city planning, transportation, architecture, recreation, public safety, schools, community groups, and others to create environments that support physical activity and community health. Strategies may address land use, public transit, walking and bicycling, public spaces, parks, trails, and other aspects of the built environment.

Essential Service #6: Utilize legal and regulatory actions designed to improve and protect the public's health.

You may not always be conscious of how laws and public health regulations influence your community environment. Think, for example, about some of the things you see or experience when you visit restaurants. You may notice a certificate or inspection grade showing that the restaurant has been evaluated for compliance with food safety requirements.

You may also encounter smoke-free requirements in restaurants, workplaces, and other public settings. Such policies are examples of legal and regulatory actions intended to protect health.

States also establish vaccination requirements for school attendance, subject to applicable laws and exemptions. When enough people are protected against a contagious disease, transmission becomes more difficult, helping protect the broader community.

Essential Service #6 encompasses public health activities such as:

• Implementing and enforcing food safety and sanitation requirements;
• Protecting drinking water supplies;
• Implementing clean air and environmental health protections;
• Following up on hazards, preventable injuries, and exposure-related conditions identified in occupational and community settings;
• Monitoring compliance with applicable health and safety requirements; and
• Using legal and regulatory tools to address emerging health and safety concerns.

Essential Service #6 may be carried out through local, state, tribal, territorial, or federal law and regulation. Community members and public health professionals can also identify emerging concerns and advocate for appropriate changes in public policy.

Essential Service #7: Assure an effective system that enables equitable access to the individual services and care needed to be healthy.

Essential Service #7 encompasses public health activities such as:

• Helping people experiencing social, economic, geographic, or other barriers connect with coordinated systems of health and social services;
• Providing culturally and linguistically appropriate information and support to connect people with services;
• Helping coordinate care and services when needed;
• Addressing transportation and other practical barriers to care;
• Providing targeted health information and outreach to populations experiencing greater barriers or health risks; and
• Working with health care, social service, workplace, and community partners to strengthen access to prevention and care.

The implementation of this Essential Service is closely linked to social, economic, geographic, and policy conditions. Two important public coverage programs in the United States are Medicaid and the Children’s Health Insurance Program (CHIP).

Medicaid provides health coverage to millions of eligible people, including children, pregnant people, adults, older adults, and people with disabilities. The program is jointly funded by the federal government and the states and is administered by states according to federal requirements.

The Children’s Health Insurance Program (CHIP) provides health coverage to eligible children in families whose incomes are too high to qualify for Medicaid but who may otherwise have difficulty affording private coverage. CHIP is jointly funded by states and the federal government and administered by states according to federal requirements.

To learn more about Medicaid and CHIP, visit the Centers for Medicare & Medicaid Services.

The existence of a program does not automatically mean that everyone who could benefit from it can easily access it. Public health and community partners may therefore provide outreach such as:

• Community education about available programs and services;
• Assistance with applications and enrollment;
• Referrals and connections among related health, nutrition, social service, and community programs; and
• Transportation assistance or other support needed to reach services.

Culturally and linguistically appropriate information is also a critical component of outreach. Community assessments, census data, and other local information can help identify languages spoken and communication needs within a geographic area. Effective outreach should also consider health literacy, disability access, cultural context, and the ways community members prefer to receive information.

Essential Service #8: Build and support a diverse and skilled public health workforce.

Essential Service #8 encompasses public health activities such as:

• Education, training, and professional development needed to meet public and community health needs;
• Appropriate licensure, credentialing, and certification processes where required;
• Continuous learning, professional development, and quality improvement;
• Partnerships with educational and training programs to provide community-relevant learning and practice experiences;
• Management and leadership development for people in supervisory, administrative, and executive roles; and
• Recruitment, support, and retention of a workforce that reflects a broad range of disciplines, backgrounds, perspectives, and communities.

There are many opportunities for education, training, and continuing professional development in public health. The Association of Schools and Programs of Public Health represents accredited schools and programs of public health, while the Council on Education for Public Health is the independent agency recognized by the U.S. Department of Education to accredit schools and programs in public health.

Continuing education is available through professional organizations, conferences, universities, training centers, online programs, and workplace-based learning. Online and hybrid education can make professional development more accessible to public health workers who might otherwise face barriers related to travel, time, or cost.

Building the public health workforce is not limited to formal academic education. It also includes continuing development of practical skills, leadership capacity, cultural responsiveness, communication, data use, emergency preparedness, community engagement, and other competencies needed to respond to changing community needs.

Essential Service #9: Improve and innovate public health functions through ongoing evaluation, research, and continuous quality improvement.

Evaluation helps public health professionals and their partners understand what is working, what is not, for whom, under what conditions, and at what cost. Evaluation findings can then be used to refine programs, improve implementation, allocate resources, and make future decisions.

Essential Service #9 encompasses activities such as:

• Ongoing evaluation of public health programs, policies, services, and systems;
• Using performance management and continuous quality improvement to strengthen public health practice;
• Identifying and testing promising or innovative approaches;
• Connecting public health practice with academic, research, community, and other partners;
• Conducting epidemiologic, policy, economic, public health systems, and other forms of applied research; and
• Using evidence and evaluation findings to improve programs and decision-making.

Surveillance and assessment data from Essential Service #1 can support evaluation. For example, a community may examine baseline data before implementing an initiative and then compare those measures with later data to understand whether conditions or outcomes have changed.

Evaluation plans and concepts are addressed in several chapters and sections of the Community Tool Box. These include:

Chapters 36-39, which fall under the broad topic, “Evaluating Community Programs and Initiatives.”

Research for new insights and innovative solutions can take many forms. Public health agencies may work with universities, health care systems, community organizations, or other partners when specialized expertise or additional capacity is needed.

Economic evaluation is one example. Two commonly used approaches are cost-benefit and cost-effectiveness analysis.

A cost-benefit analysis compares the costs of an intervention with benefits expressed in monetary terms. For example, the cost of a prevention program might be compared with health care costs avoided as a result of the program.

A cost-effectiveness analysis compares program costs with specific outcomes that do not necessarily have to be expressed in dollars. It can be useful for comparing different approaches that pursue the same or similar objectives.

Essential Service #10: Build and maintain a strong organizational infrastructure for public health.

Strong public health practice depends not only on individual programs, but also on the organizations and systems that support them. Public health agencies and partnerships need the leadership, staffing, technology, financial management, planning, communication, and governance capacity necessary to carry out their responsibilities effectively.

Essential Service #10 encompasses activities such as:

• Managing financial and human resources effectively;
• Maintaining strong communication and strategic planning capacity;
• Maintaining information technology systems that meet current operational, privacy, and security needs;
• Understanding how government agencies, elected officials, community organizations, health care systems, and other institutions contribute to the broader public health system;
• Allocating needed resources fairly and effectively to support the public’s health;
• Practicing accountable, transparent, and inclusive decision-making with partners and communities; and
• Providing effective and ethical leadership and governance.

Organizational infrastructure may not be as visible as an outbreak investigation, health campaign, vaccination clinic, or restaurant inspection, but all of those activities depend on it. A health department or community public health system needs functioning financial systems, qualified staff, reliable technology, effective communication, clear leadership, and strong partnerships in order to carry out the other Essential Services.

The Ten Essential Public Health Services are therefore best understood not as ten isolated programs, but as parts of a larger public health system. Assessment, investigation, communication, community partnership, policy, regulation, access to services, workforce development, evaluation and innovation, and organizational infrastructure reinforce one another.

Communities may enter the framework through different activities and priorities, but strengthening the system across all ten Essential Services can improve its ability to protect and promote health, respond to changing needs, and work toward health and well-being for everyone.