1. Berkowitz, Bobbie PhD, RN, FAAN
  2. Nicola, Ray M. MD, MHSA
  3. Lafronza, Vincent EdD, MS
  4. Bekemeier, Betty MSN, MPH, RN

Article Content

More than two years ago, a collection of articles featuring the Turning Point initiative was published as a special issue of the Journal of Public Health Management and Practice (JPHMP 8:1). At that time, Turning Point was early in its implementation phase, and the National Excellence Collaboratives were a little over a year old. The focus of that special issue was on innovations in collaboration, increasing capacity for policy development, and alternative structures for improving the public's health. 1 With this second special issue, we take a look back on the outcomes achieved by the communities and states that have participated in Turning Point, and we look forward to the potential that remains for this initiative. The articles featured in this issue tell stories that in many ways serve as exemplars for public health systems change fueled by a commitment to the use of collaboration and partnerships.


At the beginning of 1998, when Turning Point was a fledgling initiative focused primarily on planning, our country faced significant challenges in public health. Despite improvements in many areas since 1998, health status data have continued to show health disparities in conditions such as heart disease and preventive care. 2 In 2003, the United States ranked 26th 3,4 in life expectancy, and in 2000 ranked 24th 5 for infant mortality. We still do not have a system to manage, measure, and report public health performance. The longevity of our public health leaders in state level public health agencies remains a stunning 18 to 24 months. Funding for public health has not stabilized nor is it more predictable. Our medical and public health systems operate on parallel tracks with limited interaction and little integration. Nevertheless, public health continues to carry out its mission of prevention, health promotion, and protection from threats in our environment. Historically, our public health culture championed a scientific approach to emerging threats and supported the principals of social justice and improved health and health care for all. That culture has shifted in a post-September 11, 2001, world. Driven primarily by federal policy and funding, the public health system turned its planning and research focus to bioterrorism and has been building a workforce whose emphasis is emergency preparedness.


Although strengthening our nation's public health system capacity to respond to emergencies is part of ensuring effective population health protection, the overemphasis on this area is forcing many state and local government funding cuts to many vital public health activities, putting health status in many areas at greater risk. Additionally, federal emergency preparedness funds granted to states and communities failed to address the well-defined weaknesses identified in both the 1988 6 and the 2003 7 Institute of Medicine reports. Despite the troubling shift in the focus of public health, the direction taken in Turning Point has continued to pursue the use of collaborative models to build infrastructure in public health supporting the core functions and essential services of public health. We have built the relationships necessary to create an environment for public health improvement and have developed a model for public health accountability and methods to improve population health outcomes. We have held discussions with policy makers about public health effectiveness and have worked to strengthen public health technology. We have enhanced the skills of our public health workforce, including our leaders, and have contributed to the public health research base. The articles in this issue examine some of these actions and outcomes that give us reason to hope.


The lessons learned and outcomes achieved through the Turning Point initiative have been studied extensively by the Turning Point National Program Office (NPO) and by the National Association of County and City Health Officials (NACCHO). The NPO, in partnership with NACCHO, has been responsible for guiding the development and implementation of Turning Point from the national level and serving as technical assistants to the states, communities, and the National Excellence Collaboratives. The first section of this issue contains the results of three studies undertaken by the NPO on the effectiveness of a national collaborative model, the characteristics of sustainable system change, and the utilization of public health institutes as administrative vehicles for building public health capacity and infrastructure. Our issue begins with a discussion of the utilization of the national collaborative model to enhance policy and system capacity in public health.


Ray Nicola describes the goals of each of the 5 Turning Point National Excellence Collaboratives and analyzes their newly acquired capacity as a function of key factors associated with successful collaboration. The discussion provides a critique of the findings in the literature associated with successful collaboration as a method of practice. Among the numerous critical influences, Nicola concludes that 6 factors played important roles in supporting each Collaborative. These factors included the ability to design a formalized coalition structure and to ensure adequate staffing to support the work of the Collaboratives. In addition, he found that it was critically important to leverage influential champions for the work of the Collaboratives. His conclusions suggest that the factors associated with successful state collaboratives, described in previous studies, also apply to multistate collaboration, such as those found in the Turning Point National Excellence Collaboratives.


Padgett, Bekemeier, and Berkowitz present findings from a qualitative study involving the 21 Turning Point states with the specific aim of identifying sustainability strategies employed by the partnerships. They found that securing long-term funding was challenging for all collaborative efforts, and the high turnover of elected officials consistently challenges public health practice at all levels of government. The authors identified 5 sustainability strategies tested by partnerships. Interestingly, but not surprisingly, public and private sector organizations experimented with different strategies. Attempts to institutionalize reforms can work, but the approaches must be strategic and deliberate.


Padgett, Kinabrew, Kimbrell, and Nicola present a compelling qualitative case study that enumerates the benefits of newly formed Public Health Institutes. Study participants included 18 states that have an established or emerging Public Health Institute. Eleven of these states have both a Public Health Institute and a Turning Point partnership. These freestanding organizations enjoy many advantages over public sector vulnerabilities for public health practice. The authors explore interrelationships among organizational models and cross-organizational and cross-sector relationships. Six organizational models are described, along with their particular advantages and disadvantages. The authors found that flexibility and political independence were the primary benefits associated with freestanding entities. Navigating an advocacy role while sustaining effective collaboration remains a primary challenge, since public employees must steer clear of participation in private, nonprofit sector advocacy efforts.


Under the guidance of 5 National Excellence Collaboratives, members of state and community Turning Point initiatives invited organizational partners and content experts to join in the development and testing of a suite of products designed to increase the effectiveness of public health, improve the quality of practice, and advance national public health priorities. These products include a social marketing CD, a model public health law, a performance management model and curriculum, a collaborative leadership curriculum, and an information technology gateway, along with numerous monographs, reports, and guides. In the previous special issue on Turning Point, we featured articles on the Leadership Development Collaborative and the Statute Modernization Collaborative. This next section begins with a discussion of the Information Technology Collaborative.


Magruder, Burke, Hann, and Ludovic discuss the broad role of information technology within public health and report for the first time on a software survey of all local public health agencies conducted by the Information Technology Collaborative. Although only 11% of agencies around the country responded, the data revealed that both human and technology capacities need considerable additional support in local public health agencies. A Public Health Information Systems Catalog has been created that will provide a new mechanism to collect ongoing information technology data from both local and state public health agencies.


Pirani and Reizes describe how using concepts from marketing to implement programs designed to bring about behavior change that benefits individuals and society is a promising tool for public health prevention efforts. Social marketing has not been used extensively in public health, in part because of a lack of understanding on the part of public health practitioners and leaders about how it works. Through the creative efforts of many partners of the Social Marketing Collaborative, including social marketing experts, a CD-based tool was created that will help users to systematically plan, implement, and evaluate social marketing programs.


Achieving the vision put forth by Turning Point will require more than good intentions and good works. Indifference to public health policy and research has plagued the advancement of many of our goals, including the expansion of local public health infrastructure to all regions of the United States. It has also hampered the development of a robust agenda for the examination and description of emerging public health issues and the development of evidence-based interventions. The Turning Point initiative has appealed to policy makers who see the wisdom of a strong local public health system. We begin the discussion of local health improvement with a miracle of sorts in rural Nebraska.


Dave Palm describes the development of the local public health system and how Turning Point funds helped to develop the original 4 multicounty public health partnerships. These original partnerships were instrumental in acting as public health system models and mentors that contributed to the success of all of the additional multicounty partnerships and their health departments. The establishment of the Nebraska Health Care Funding Act played a significant role, along with the Nebraska Turning Point partnership. Today, local health departments have been established to cover all of Nebraska. Many of the new multicounty public health partnerships have leveraged additional local funding. The state's Office of Public Health has been working systematically to develop these local entities-providing local staff with training, mentorship, communication strategies, and assistance with developing their new structures.


Kassler and Goldsberry describe the development of a regional network in New Hampshire that has brought essential public health services to the local level in 67% of the state. The state health department was a critical asset in the development of the public health networks-bringing training, backup support, and technical assistance to the local health officials. Along with creating new infrastructure, the authors report that significant improvement in local public health capacity and performance has been achieved.


Campbell and Conway provide insight into the current public health problems in Maine and how its political and social structures hamper the development of broad-based public health improvement. Maine has a municipality structure rather than a county structure and has a strong emphasis on local autonomy. The authors make a good case for why these structures are not effective and how they are ultimately costly. Campbell and Conway describe the establishment of multimunicipality regional entities that came together and cooperated effectively on reducing Maine's high rate of teen pregnancy. The Maine Turning Point initiative has established cross-sector local partnerships across Maine that are funded to address community-wide health issues. They have been successful in leveraging state tobacco funds to monitor ongoing public health system-related work at the local level.


The evaluation, critique, and insights of our many partners have been immensely valuable during Turning Point's tenure. As is tradition with Turning Point, we ask for the opinions of others and do our best to respond to their wisdom. This final section provides an opportunity to "listen" through the art of commentary to some of our valued partners.


Patrick Lenihan reflects on the value of an initiative that has devoted its focus to systems development at the local level, in particular, the importance of "bridging the gap between concept and practice." He reviews a number of practical lessons learned in Turning Point at the local level that provide evidence that capacity building within the organizations and structures of public health has been essential.


Leah Devlin, providing insight from the state public health perspective, highlights the activities of the Turning Point initiative in its strategic approach to health improvement through the development of tools for social marketing and support of communication and informatics through the Information Technology Collaborative. She urges public health leaders to sustain the momentum that Turning Point has built in developing and improving public health system capacity at the local and state levels.


Todd Rogers, Dianne Barker, and Wendi Siebold have served as the evaluators for the Turning Point initiative during the implementation phase and throughout the development of the National Excellence Collaboratives. They cite evidence that the process and products of Turning Point have resulted in the leveraging of resources that have benefited public health systems. The principal source for leveraged funds highlighted in their commentary is the tobacco settlement fund. Given that the original purpose of this fund was vague when it was created and that many states have used their funding for nonpublic health related activities, the authors salute the Turning Point states that have used these funds for public health infrastructure improvement.


What's next for this initiative? The NPO asked that question of a group of health and health care experts at a recent meeting at The Robert Wood Johnson Foundation (RWJF) headquarters. Their responses were insightful and emphasized that while funding for the initiative through RWJF will be ending, the legacy of Turning Point must continue. We expect that Turning Point's legacy will include the institutionalization of the collaborative partnership approach, permanent broad-based citizen involvement in public health, full use of emergency preparedness funding, steady and predictable funding for public health, increased collaboration with American Indian and Alaska Native communities and their governments, informed and engaged policy makers, and the application of Turning Point models and best practices in all local, state, and national public health related organizations.




1. Nicola R, Berkowitz B, Lafronza V. A turning point for public health. Journal of Public Health Management and Practice. 2002;8(1):iv-vii. [Context Link]


2. Leatherman S, McCarthy D. Quality of Health Care in the United States: A Chartbook. New York: The Commonwealth Fund; 2002. [Context Link]


3. Population Health Forum [Web site]. Available at: Accessed July 5, 2004. [Context Link]


4. United Nations Development Program. Human Development Report 2003 [pp. 237]. Available at: Accessed July 5, 2004. [Context Link]


5. Central Intelligence Agency. The World Factbook 2002. Washington, DC: Central Intelligence Agency; 2002. [Context Link]


6. Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1988. [Context Link]


7. Institute of Medicine. The Future of the Public's Health in the 21st Century. Washington, DC: National Academy Press; 2003. [Context Link]