1. Baker, Edward L. MD, MPH, MSc
  2. Porter, Janet PhD


The Management Moment" is a regular column within the Journal of Public Health Management and Practice. Janet Porter, PhD, and Edward Baker, MD, MPH, MSc, are serving as The Management Moment Editors. Dr Porter is Associate Dean for Executive Education, The North Carolina Institute for Public Health, School of Public Health, at the University of North Carolina at Chapel Hill, and Dr Baker is Director of The North Carolina Institute for Public Health, School of Public Health, at the University of North Carolina at Chapel Hill. This column provides commentary and guidance on timely management issues commonly encountered in public health practice.


Article Content

In the next set of columns in our series, we will explore the principles described in prior columns of The Management Moment though illustrative case studies drawn from recent public health programs. By selecting cases and reflecting on lessons learned, we hope to bring to light some of the key critical success factors in developing new initiatives.


As we discuss these cases, we will avoid providing names of specific individuals because in doing so we might either overlook someone who played a significant role or might overemphasize the value of another individual. In these discussions, we are not trying to recognize individual contributions, although these were very significant, but rather to use the case to bring out points that may help you in the future. Nevertheless, the attentive reader will, no doubt, identify some of the key actors.


We have chosen to begin with a somewhat chronological review of a companion set of initiatives designed to enhance the public health infrastructure through increased use of information technology. These initiatives were the Information Network for Public Health Officials (INPHO)1 and the Health Alert Network (HAN). In this column, we will focus on the INPHO program.



INPHO was initiated by the Centers for Disease Control and Prevention (CDC) in 1992 as part of its strategy to strengthen the infrastructure of public health in the United States. The INPHO initiative addressed the serious national problem that public health professionals lacked ready access to much of the authoritative, technical information they need to identify health dangers, implement prevention and health promotion strategies, and evaluate health program effectiveness. The INPHO promoted the use of state-of-the-art telecommunications and computer networks to give state and community public health practitioners new command over information resources. There were three essential components of the INPHO vision: linkage, information access, and data exchange. The INPHO computer networks and software linked local clinics, state and federal health agencies, hospitals, managed care organizations, and other providers, eliminating geographic and bureaucratic barriers to communication and information exchange. Through the INPHO initiative, public health practitioners were offered unprecedented electronic access to health publications, reports, databases, directories, and other information, thereby planting a seed for change and innovation. Electronic communications capacity enabled them to communicate and exchange data locally and across the nation on the full universe of public health issues.2


Getting started

The INPHO began with the idea that by giving public health practitioners computers, connecting the computers into networks, providing training, and making information accessible on-line, public health practice would be improved. The idea seems simple enough today, but that was in 1991-1992, when "Internet" was not a household word and most public health agencies did not own a computer and often did not see why they should. At the CDC, pioneering work had been done to explore the use of computers to help in analysis of epidemiological information; programs such as WONDER and EpiInfo were under development to facilitate this application and many elements of the INPHO vision were contained in previous work. However, only a relatively small number of local public health agencies benefited from these early innovations.


Context and empowerment

In 1990, the CDC's newly appointed director articulated three priorities for the agency; the first was strengthening the public health infrastructure. The Institute of Medicine had issued a landmark report3 in 1988 entitled The Future of Public Health, which concluded that public health was in "disarray" and something needed to be done about it!! So, there were both a context for action and an empowering leader who articulated priorities within which the INPHO initiative could take root. The importance of support "from the top" cannot be overemphasized.


Let's say a bit more about empowerment. The CDC director did not spell out exactly what he wanted to happen and how he wanted it done. He empowered others to figure those things out, keeping him informed of progress (and problems) and requesting advice and help when needed. In doing so, he enabled and empowered others to be creative in ways that he and others could never have imagined. It has been our experience over and over again that by empowering others and creating an environment where risk taking and experimentation are encouraged, things happen that could not have been imagined. The key leadership task is creating an environment where people feel supported and protected to explore and be creative. So, the idea of the INPHO emerged from an environment where a priority was given to programs designed to strengthen the public health infrastructure and the director empowered others to be innovative in addressing this priority. But, much more was needed to translated the idea into reality.


Communicating the vision

"A vision is something that you can see."


In the case of INPHO, a few pioneers saw the vision and understood the potential of advanced telecommunications technology and computer networks as essential tools for public health practice. But few others saw the potential and were able to "see" the vision. So, the next challenge was a communications challenge.


In John Kotter's book, Leading Change,3 he emphasizes that you have to communicate a vision not just a few times but hundreds, even thousands of times, before it starts to take hold. Therefore, a vision must be clear and simple enough that it can be faithfully repeated over and over again. Never underestimate the importance of repetition in an organizational context. In fact, the best leaders are those who have the ability to say things the same way each time and also choose their words so that they are easily repeated. How often have you left a meeting with someone in authority and you turned to a coworker and asked, "Now what did he say?" Clarity and repeatability of the vision of a new project are crucial to building support and momentum for a new effort. In the case of INPHO, the vision was to provide public health officials with computers, with training in their use, with means to connect with others electronically, and with access to on-line information.


In addition to a clear vision, strategies must be articulated to guide action and program operations. The three core INPHO strategies flowed from the vision, namely,


1. connectivity,


2. information access, and


3. data exchange.



As it turned out, the first two strategies were much easier to implement than the third one. In fact, methods of electronic data exchange remain major challenges today.


In the case of INPHO, there was also a good name. Never underestimate the value of a good name (and, in government, of a good acronym!!). People liked the name and really liked the acronym, because the initiative was about enhancing access to information. So, choose your acronyms well.


Despite a good name, there needed to be a way to visualize how the INPHO would actually work. It is impossible to get a program off the ground if you cannot explain what is going to happen and how things will work. Fortunately, a professor at a local university stressed the value of a simulation, and since the INPHO was about using computers, it was natural to use a computer-based simulation to illustrate how the system would work. Recall that this was happening at a time well before e-mail and the Internet. (We know that it is hard for you to believe that there was a time before e-mail and the Internet!!)


This simulation tool was used as part of the process of selling the idea to decision makers and potential funders. This relationship-based selling (discussed further below) required a clear presentation and a well-articulated business case (discussed in other The Management Moment columns).


So, at this juncture, there were a supportive environment, a vision, a set of core strategies, a simple and repeatable name, and a simulation of how the INPHO works. But, much more needed to happen before the idea became reality.


The zealots

[horizontal ellipsis] A small group of thoughtful people can change the world. Indeed, it is the only thing that ever has. - -Margaret Mead


In the case of the INPHO initiative, a small band of pioneers (the "zealots") inspired each other, fostered mutual creativity, and provided exceptional amounts of positive energy that allowed the vision to stay alive and ultimately become reality. There is no substitute for optimism and positive energy in the development of a new initiative. Pessimists can play a useful role in some aspects of organizational life, but rarely in the startup of a new initiative. Starting something new is hard work; pessimists can make it much harder. Do you remember our discussion of "derailers" in the last The Management Moment column? A band of zealots will get you much further and with more fun. Look carefully at new initiatives with which you are familiar. Can you see the zealots? What about Microsoft or Apple computer-do you see any zealots there?


Among the zealots was one who stood out as an exceptional collaborator and who became the leader of the INPHO initiative. In our previous columns, we have stressed some of the characteristics that make good partnerships work: humility, sharing risks and rewards, building trust and quality leadership. The leader of INPHO exemplified these and other outstanding qualities that made people simply want to work with him.


In many respects, he embodied the principles of servant leadership ably described by Robert Greenleaf.4 Without this charismatic and committed leader, the INPHO project would never have gotten off the ground.


Mobilizing resources

So, if you want to build something, you need resources. In this initiative and in many other successful ones, it was important to try to identify support, crystallize the vision, and identify a small group of people to actually begin the work before seeking resources to do the job. We want to stress the point that, in an organizational setting, you should get "top-down" support, have a clear and compelling vision of the goal with tools to help in the visualization of the goal, and identify the nucleus of your team before seeking resources.


In the INPHO initiative, two important things happened which helped to garner resources to fund the program. These happened in the same time frame and for different reasons and both rest on the principle that "relationships are everything, all else is derivative." As a government agency, the CDC funding derives from the appropriations process. In that regard, members of congress and their staffs are regularly seeking new ways to benefit their constituents and to support programs that are good for the nation. Ideally, from the perspective of the appropriations process, new programs have the greatest chance of success if there is demonstrable local benefit as well as a pressing national need. In the case of INPHO, both criteria were met and, through a series of conversations, enabled by strong existing relationships, funding was made available to launch INPHO demonstration projects in several states. A second line of support was developed in Georgia through a large foundation that was interested in making Georgia the "flagship" of the INPHO initiative. In the case of the foundation, as was the case with the federal appropriations process, local benefit and national need were critical to gaining the generous support of the foundation.


Initial deployment of resources-The "low-hanging fruit" and tight management

With the resources in hand, the INPHO team set out to implement the vision. The team was looking for some "low hanging fruit"-projects that were ripe for implementation and relatively easy to execute. In the early phases of project implementation, it is best to do a few relatively easy things first, thereby demonstrating results and giving a sense of accomplishment to the team and partners. Also, in view of the substantial funding commitment from the Georgia foundation and the lack of understanding of the INPHO within the CDC, it was essential that value be demonstrated close to home. So, the team decided to identify some early success possibilities. Ultimately, these turned out to be making CDC's Morbidity and Mortality Weekly Report (MMWR) available on-line, creating a model program in a local health agency in a remote area of south Georgia, and structuring a visit to the south Georgia site to demonstrate the value of INPHO to the funding foundation. By making the MMWR available on-line, CDC leaders came to recognize the potential of information technology as a means to disseminate information, well before Web sites became commonplace. So, the lesson of early action is that you should find a few things that are relatively easy and "close to home" early in the course of the project to demonstrate success and the value of the project. In the remote south Georgia health department, the use of a new tool called "e-mail" created a major stir because it provided connectivity in ways never experienced before. (Do you recall when e-mail was a novelty?)


Tight project management was essential to the success of the early phase of the INPHO project in Georgia. With a hand-picked team, early project activities followed a carefully constructed timetable. The first year of the project went exactly on time and within budget, demonstrating that the INPHO team was a reliable partner. Being a reliable partner is something that is demonstrated over time. Trust comes from having accomplished something together.


Taking the program to scale

After some initial successes and the usual growing pains associated with any new venture, the INPHO program reached out to 12 states across the nation, providing modest levels of support for innovative use of information systems in public health programs. The funding was valuable in itself and also as a catalyst for change. At this stage, there were very few standards and so the programs were encouraged to be innovative and flexible in their approach. National conferences were held to bring together these innovators and stimulate the sharing of ideas and opportunities. This stage of growth and expansion was characterized by the development of new applications for existing needs. For example, some states used the INPHO support to develop their first Web site. In other settings, e-mail networks were developed, and on-line information resources were made available. Extensive staff training was central to the success of the INPHO. If there is one major message related to taking the program to scale, it is the need for training. Just as you must "strain to communicate" in sharing the vision early in the course of a new project, a complete commitment to training was essential to the success of early implementation of the vision.


As part of the process of taking the INPHO initiative to scale, a network of pioneers emerged across the country in support of the vision. These individuals led efforts in their own states and provided support and encouragement to colleagues across the nation. Fostering this group of colleagues was essential to the ongoing success of the INPHO program. As you develop your own programs, be sure to nurture these informal "communities of practice"-a concept that has gained much recent attention as vital to the diffusion of innovation.


Laying the foundation for the future

The INPHO program served a crucial role in demonstrating the value of empowering local public health practitioners with information technology and in developing communities of practice across the nation. The foundation was laid for other information technology initiative such as the Health Alert Network (to be discussed in our next column) and the Public Health Information Network. For these and other related initiatives, the INPHO program pioneered the way with respect to the use of information technology throughout the public health system, thereby supporting the priority articulated by the CDC's director in 1990 of strengthening the public health infrastructure.


Lessons learned

As we look back and reflect on what factors contributed to the success of the INPHO program, there were several critical success factors:


1. Support from top leadership and a context for action


2. An environment that encouraged risk taking


3. A clear, compelling vision that was easily communicated


4. A computer-based simulation to aid communication


5. A band of "zealots" committed to the vision


6. A trusted leader skilled in partnership development


7. Resource mobilization based on strong existing partnerships


8. Early demonstration of value close to home through tight management


9. Taking the program to scale through flexible approaches


10. Creation of communities of practice to foster innovation



As you create new initiatives, we hope that some these lessons may be of value and we hope this story of the INPHO initiative has been of interest. We appreciate any comments from readers, particularly from those involved with the INPHO initiative who may have another perspective or recall another success factor that we have not mentioned. In our next column, we will focus on lessons learned from another very successful initiative, the Health Alert Network.




1. Baker EL, Ross D. Information and surveillance systems and community health: building the public health information infrastructure. J Public Health Manage Pract. 1996;2(4):58-60. [Context Link]


2. National Health Information Center and Health Information Resource Database: Information Network for Public Health Officials. Available at: Accessed June 1, 2005. [Context Link]


3. Kotter JP. Leading Change. Boston, Mass: Harvard Business School Press; 1996. [Context Link]


4. Greenleaf RK. On Becoming a Servant Leader. San Francisco, Calif. Jossey-Bass Publishers; 1996. [Context Link]