1. Lenihan, Patrick PhD

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The notion of the public health system is one of the most important concepts to emerge in public health thinking in the past 20 years, yet it has remained illusive to practice and therefore difficult to apply at the state and local level. Consequently, the public health community has yet to fully experience the transformation benefits that a systems approach to public health can yield. A major legacy of Turning Point has been to move the public health system from ellusive concept to practice example through the 14 state and 41 local experiments in systems building that were funded by the initiative. The experiences of 3 states reported here-Maine, New Hampshire, and Nebraska-not only demonstrate the importance of the public health system as an essential building block of public health practice, but also provide some concrete advice on how that concept can be made real.


The principal value of the public health system as a concept is that it brings together, in a near literal sense, other important conceptual and practice elements that have emerged in public health thinking. These include: the establishment of partnerships, community engagement, promotion of accountability and performance measurement, and standardization of public health practice.


Beyond this integrating value, the systems concept held out the prospect of solutions to some thorny problems long faced by public health agencies. By building a public health system, public health agencies would be able to address the chronic underfunding that perennially tops their lists of struggles-not simply by arguing for more public funding, but by leveraging existing resources in the system. Similarly, the members of a functional system would provide the missing constituency for public health efforts; help in communicating the value of public health to a broader audience, especially policy makers; and allow public health agencies to achieve a visibility and broader relevance beyond crisis and outbreak response.


The systems concept alone has been valuable in suggesting alternative organizational arrangements for public health beyond those narrowly associated with units of state and local government. Systems thinking has shifted the focus beyond the public health agency to those community resources that could be marshaled toward health improvement. These resources could be assembled and focused through traditional, formal organizational structures, such as government agencies, but this might also be accomplished through less formal organizational structures like consortiums or associations or even through virtual organizations such as networks of resource holders.


The public health system entered the conceptual lexicon when the 1988 IOM report on The Future of Public Health1 defined the system in a footnote to a discussion largely focused on the disarray of the governmental elements of that system. The report recognized that the great diversity of public health across the country challenged efforts to characterize that system in a way that would apply to any one jurisdiction. Local public health agencies (LPHAs) found themselves dealing with this new concept from polar extremes of their experience. At one end, they looked upon a landscape strewn with such diversity of size and function that it defied generalization; at the other end, thinking on organizational structure was limited to the governmental health department.


While capturing the interest of the public health community, this introduction to the public health system left much unanswered. How would the elements of this system come together? What would the new system look like when it was in place; what structures would give this system shape? How would it operate, be governed, and be managed? What roles would state and local public health agencies play in these systems? How would these systems be financed, and who would pay for these operations?


The answers to these questions were not only relevant to the public health agencies, the system's backbone, they were critical to building the system. They would need to be communicated persuasively to other potential system partners who lacked even a basic understanding of traditional public health, let alone this new conceptualization (and without that understanding, their participation and the system itself would be in question).


The importance of the public health system as a seminal concept to public health thinking is reinforced in the major writings on public health practice since the 1988 IOM report. 1 In a 1992, CDC's then-Director William Roper called for a strengthening of the public health system focusing on critical capacities that public health agencies would need for the more comprehensive approaches required to address the country's increasingly complex health problems. 2 These capacities included more sophisticated organizational development adequate to project leadership and orchestrate community involvement. In their 1993 article, Baker and Melton 3 linked public health reform with health systems reform. They explicitly defined the public health system, adding specificity for the roles of nongovernmental public health agencies and prescribing capacities that governmental public health would need to effectively build and manage these systems. By 2000, the CDC report 4 to Congress on the state of public health imbedded governmental infrastructure within the larger public health system context, effectively connecting public health agency capacities to broader system effectiveness. Defining public health as a system has gained such acceptance that it has moved beyond the pages of academic journals to find its place in one of the most popular public health introductory texts, whereas in another popular text used just 15 years earlier, the notion of a public health system is not even mentioned. 5,6


These writings in turn prompted consideration of the implications for the organization and structure of local public health agencies. In a 2001 JPHMP commentary, Milne 7 noted that most small LPHAs lacked the capacity to assure the 10 Essential Services, a functional cornerstone to the public health system. He questioned whether every LPHA would ever have the resources needed to perform optimally and suggested that scale could only be achieved by sharing resources through partnerships between LPHAs and other sectors, and by consolidation of LPHA resources across jurisdictions, such as through regional LPHAs covering multiple counties. 7 Milne 7 concluded that the optimal organizational structure of public health agencies would have to be addressed if policy makers were to be convinced of the importance of public health and the need for increased investments.


Baker and Koplan, 8 in their 2002 Health Affairs article, picked up on these themes, stressing the importance of the public health system-"the broad range of organizations and partnerships needed to carry out the essential public health services, such as hospitals, voluntary health organizations, and the business community"-in handling routine public health situations and emergencies such as a terrorist event. They note several challenges that will face public health agencies within these public health systems, including the need for case reports and studies to document the value of public health efforts and the likely consolidation of smaller LPHAs through regionalization to gain the infrastructure capacities for the broader range of services that are now required. 8


The focus of some of the most recent writings has shifted away from governmental public health agencies to the broader public health system as the entity though which the vision of a healthy community is realized. This shift is most apparent in the 2003 IOM report, The Future of the Public's Health, 9 which, unlike its 1988 forerunner, devotes much more attention to the public health system and its nongovernmental players than to the role of state and local health departments.


The growing emphasis on the public health system creates an imperative for public health agencies to achieve effectiveness-not just in a narrow technical, internal sense, but in a much broader strategic sense. This is especially important at the local level where services are delivered and where the components of the local public health system exist. The Turning Point initiative has been instrumental in bridging the gap between concept and practice through the resources created by the Turning Point National Program Office and its partner organizations, including the National Association of County and City Health Officials. Of particular relevance to public health agencies attempting to build capacity and make strategic transformations are the individual experiences of the Turning Point sites, 3 of which are documented in this JPHMP issue.


While the 3 sites may not be typical given the great diversity of public health, common themes do emerge that resonate with my experience in a much larger jurisdiction-the city of Chicago, also a Turning Point site. These include:


* The need for a process to organize, manage, and direct the change initiative. Two used strategic planning approaches in their processes. The processes were highly participatory involving members of the public health system in decision-making roles in each state.


* All employed catalyzing circumstances to trigger and mobilize their process to action. Whether it was the awareness of bioterrorism in New Hampshire, the documentation of "serious health problems" in Maine, or the realization that the current system was not effective in Nebraska, all created a common dissatisfaction with the status quo and motivation to move forward.


* The state public health agency provided key leadership in triggering and championing change, both at the state and local levels and in supporting the change process.


* Although the change in each case was dramatic, it was planned and not precipitous. The plans developed made the direction and the route predictable with pathways and transition opportunities to get from here to there.


* Consistent with some of the thinking cited above, new regional organizational structures were created, recognizing the need for structural change and rejecting the "mirage" of expecting that new resources would materialize without significant change. Structural change had a functional basis in that each case uses the Essential Services as decision criteria.


* New resources provided the incentive for change and the short-run financing to make it possible. The Turning Point grant, federal bioterrorism funds, and tobacco settlement dollars became the working capital for investment in the new systems. State agency leadership was most evident here in resisting pressures to use the new funds to prop up old dysfunctional systems.


* Governance principles guaranteed autonomy for local decision making within a framework that had clear parameters but avoided a one-size-fits-all structure.


* Accountability and performance outcomes were documented to demonstrate the success to both participants and elected policy makers whose long-term financial support was crucial.



Beyond these practical lessons, an additional value of these cases is the documentation that they provide toward the evidence base needed to support the organization and structure of public health systems that has been called for in some of the articles noted above. Just as public health interventions must be grounded in science, so, too, must the organizational arrangements and management practices that apply to public health agencies. As noted in the Maine article in this issue, appealing to tradition as a basis for future decisions becomes unacceptable.


The generalizability of these 3 smaller, primarily rural states with minimal local public health may be limited, especially to larger states with existing local public health agencies, but it is noteworthy to see what decisions are made when the slate is largely clean and existing local structures do not have be politically accommodated. Beyond that, while these 3 experiences might not be replicable in their entirety, the examples and lessons they provide can inform efforts at public health systems building in jurisdictions across the country.




1. Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1988:73-106. [Context Link]


2. Roper WL, et al. Strengthening the public health system. Public Health Reports. 1992;107(5):609-615. [Context Link]


3. Baker EL, et al. Health reform and the health of the public. Journal of the American Medical Association. 1994;272(16):1276-1282. [Context Link]


4. The Department of Health and Human Services, Center for Disease Control and Prevention (CDC). Public Health's Infrastructure-A Status Report for the Appropriations Committee of the United States Senate in Response to Senate Report. Atlanta, GA: CDC; 1999. [Context Link]


5. Turnock BJ. Public Health, What It Is and How It Works. Gaithersburg, MD: Aspen Publications; 2001:11-14. [Context Link]


6. Hanlon JJ, Pickett GE. Public Health Administration and Practice. St. Louis, MO: Times Mirror/Mosby; 1984. [Context Link]


7. Milne TL. Strengthening local public health practice: a view to the millennium. Journal of Public Health Management and Practice. 2001;6(1):61-66. [Context Link]


8. Baker EL, Koplan JP. strengthening the nation's public health infrastructure: historic challenge, unprecedented opportunity. Health Affairs. 2002;21(6):17-25. [Context Link]


9. Institute of Medicine. The Future of the Public's Health in the 21st Century. Washington, DC: National Academy Press; 2003:96-395. [Context Link]