From The Field N O V E M B E R 2 2 , 2 0 0 4 Designing the Public Health System for a Healthier U.S. B O B B I E B E R K O W I T Z , P H . D., R . N., F . A . A . N . Director, Turning Point National Program S U S A N H A S S M I L L E R , P H . D., R . N., F . A . A . N . Senior Program Officer, The Robert Wood Johnson Foundation T he nation relies on the public health system to keep our threats when anthrax was released throughout the U.S. postal population safe from harm, prevent disease, and pro- system. The nation’s response to the anthrax attacks and other mote health. To carry out this mission, public health health threats, such as the SARS outbreak and concerns about practitioners may provide clinical services, such as care for the the West Nile Virus, highlighted the need to strengthen an uninsured, when such services are unavailable from other underfunded and neglected public health system. providers. Public health systems also provide immunizations, treatment of communicable diseases, and programs targeted at PUBLIC HEALTH’S BIGGEST CHALLENGE improving nutrition and maternal/child health. Public health Despite the evolution of public health over the years, the has significant expertise in surveillance and monitoring infec- system remains challenged by economic and policy con- tious disease. They also conduct public education campaigns; straints. The nation is facing health challenges that require enforce health regulations; run outreach programs for people strong systems that are capable of working quickly and collab- at risk for disease, violence, and abuse; and train health care oratively to respond to increasingly complex issues. At a time providers to be “first responders.” Federal public health when a flexible public health system is most needed, the agencies include the Public Health Service, the Centers nation has found itself struggling to solve current problems for Disease Control and Prevention, the U.S. Food and with rigid and atrophied systems. Further, the effects of Drug Administration, the Health Resources and Services system neglect are now vividly being manifested by way of the Administration, and the Substance Abuse and Mental Health nation’s health status. The U.S. desperately needs improved Services Administration. There are also local public health systems to turn the tide on emerging infectious and chronic agencies, organized at the city, county, state, and regional levels. diseases, increasing ranks of the uninsured and underinsured, and worsening health disparities that are widespread through- THE HISTORY OF PUBLIC HEALTH out the country. Early public health efforts focused on promoting hygiene and developing sanitation guidelines. At the start of the 20th cen- TRANSFORMING THE SYSTEM tury, public health priorities shifted to preventing infectious THROUGH PARTNERSHIPS diseases such as polio and tuberculosis. Later, public health Philanthropic organizations and others involved in supporting practitioners began to focus on health care system transforma- public health have begun to focus on ways to improve an ail- tion by working to expand access and control costs. The ing system so that it protects the people it serves. The Robert traditional definition of health was broadened to include issues Wood Johnson Foundation (RWJF) and the W.K. Kellogg like violence prevention and community building, and chronic Foundation, for example, partnered to launch the national diseases emerged as a new concern as prevention efforts turned Turning Point Initiative in 1997. The initiative was launched to smoking-related illnesses, asthma, obesity, and diabetes. in response to the Institute of Medicine’s call for a strength- For many years, the public health system functioned under ened public health system. An innovative partnership between the radar of most Americans. That changed in the wake of the two of the largest philanthropic foundations in the U.S., the terrorist attacks on September 11, 2001. What used to be a Turning Point Initiative represents a community-based and system that focused primarily on health promotion and disease collaborative approach to health status improvement. The ini- prevention became a system dealing with very real bioterrorist tiative devoted funding and technical assistance to helping 21 states and 44 communities bolster their public health systems, multistate National Excellence Collaboratives, coalitions with the ultimate goal of positioning these systems to improve formed by Turning Point partners, have created numerous the health of the populations they serve. Although public products that provide assistance with: health has historically been viewed as a governmental enter- • performance management, prise, the Turning Point Initiative emphasized the need for an expanded view of ownership of public health problems and • information technology, solutions. Grantee states and communities did more than • social marketing, talk about collaboration and long-term planning. Through • public health statute modernization, and intense efforts, they established broad-based coalitions, invit- ing both traditional and entirely new partners to the table to • leadership development. envision an improved future together. Following a two-year planning process, each partnership implemented one or more These products include an on-line information technology of its highest priorities. catalog; literature reviews; models for practice, such as the Model State Public Health Law; a social marketing CD-ROM; INVESTMENT IN PUBLIC HEALTH a performance management model; and curricula on collabora- PAYS OFF tive leadership. What started as a vision of change is fast becoming a reality. EVEN KEY IMPROVEMENTS TAKE TIME System improvements from the Turning Point Initiative are integral to ensuring the conditions that make populations The Turning Point Initiative symbolizes a paradigm shift in healthy. In states where local public health departments were public health. Success has been predicated on the support of nonexistent or highly strained, either new departments have early adopters who believe that systems change, broad-based been created or networks have been established to provide collaboration, and a focus on infrastructure will ultimately services to underserved areas. Workforce training programs have a positive impact on health status. Many foundations now exist to provide high-quality training to frontline public have come forward to support programs that originated health workers in rural and urban areas. Improved data from Turning Point partnership priorities and public health systems create a clearer picture of the problem of health improvement plans. disparities. Public health laws are being examined and Although demonstrating the impact of infrastructure changes updated to ensure they meet the needs of the nation’s on health status outcomes is a daunting task, the effects of a current public health challenges and prepare the nation neglected infrastructure are clear. A strengthened public health for future crises that could potentially have an impact on system is critical to improving the public’s health status. public health. Without prepared frontline workers, critical training, and The foundations’ investment in the Turning Point Initiative efficient systems, epidemiology and health promotion slow has paid off. In Nebraska, for example, only 22 of the state’s to a crawl. 96 counties had health departments. The rest of the counties The Turning Point Initiative continues to innovate and did not have a governmental entity to ensure that the appro- harvest the fruits of its partnerships. Beyond specific changes priate conditions were in place to promote health. Through in states, the key outcome from the Turning Point Initiative is the Turning Point partnership in Nebraska, the coalition really very simple: Collaboration and investment in public created a plan to develop multicounty health departments, health pay off. Today’s public health challenges must be and when tobacco settlement funds became available, these owned by all of us, not just the government. It will take talents departments were equipped with the knowledge of how to and resources from public health, the private sector, and use these resources to strengthen their system. The Turning other partners to ensure a healthier tomorrow for the nation’s Point Initiative’s partnership united community needs, broad- children and generations to come. based support, and RWJF funding to build a new system that provides all Nebraskans with public health services. Nebraska’s public health system has gone from being unpre- pared to being capable of mobilizing to vaccinate for smallpox, as was demonstrated when Nebraska’s system was cited among the most efficient systems in the nation in implement- ing a smallpox vaccination plan. For more information on the Turning Point Initiative, please visit the initiative’s Web site at www.turningpointprogram.org, or INNOVATIVE RESOURCES FOR call 206.616.8410. Turning Point products are available to all PUBLIC HEALTH those interested in improving public health. The Turning Point Initiative’s mission of transforming the Views from the Field is offered by GIH as a forum public health system includes creating tools and resources to for health grantmakers to share insights and experiences. If you are share with other states and communities. To that end, five interested in participating, please contact Anne Schwartz, GIH’s vice president, at 202.452.8331 or aschwartz@gih.org.