Making the case: leveraging resources toward public health system improvement in Turning Point states.

Leveraging funds to sustain the efforts of a grant-funded initiative is often an explicit, or implicit, expectation in philanthropy. However, the magnitude of funds leveraged and the factors that facilitate success in leveraging are rarely researched. An example of one of these grant-funded initiatives is the National Turning Point Initiative. Twenty-one states received funding from The Robert Wood Johnson Foundation as part of this initiative to establish and implement strategic goals for achieving significant statewide public health system improvement through diverse, cross-sector partnerships. Leaders from 17 of these 21 states participated in a two-phased study regarding the leveraging of additional funds for their public health infrastructure improvement activities. This article reports on the second phase of the study. In this phase, key informant interviews were conducted to examine how leveraging of resources occurred as part of this large national initiative. Findings indicate that the combination of a comprehensive planning process and a broad-based partnership was crucial in securing resources to expand their efforts. The ability to strategically respond to unexpected events and opportunities also helped states use their plans and partnerships to "make the case" for additional resources to improve their public health infrastructure.     

Collaborative partnerships at the state level: promoting systems changes in public health infrastructure.

Reforms in the public health infrastructure such as those called for in recent Institute of Medicine reports require stakeholder engagement on different levels than traditional grass-roots community work. The Turning Point Initiative, funded by The Robert Wood Johnson Foundation, involves 21 state-wide partnerships established for systems change and focused in specific areas of public health innovation and policy development. These partnerships represent a different model of strategic alliances and relationship-building than has been previously described in the literature on community-level and health-promotion collaborations. This article utilizes qualitative data to illustrate the ways in which state-level partnerships for systems change both confirm and extend previous models. Findings indicate that state-level public health partnerships share many of the challenges and opportunities of locally-based and health-promotion-oriented partnerships. Collaboration at the state level, however, involves more attention to organizational alliances, coordination of institutional change, and strategic responses to political changes. These partnerships depend on a combination of interpersonal skills, material resources, and organizational savvy to manage complex planning and implementation processes. Influencing policy development and organizational redesign in public health systems requires nuanced understanding of the opportunities provided by various kinds of organizational partners.     

Partnering with communities to improve health: The New York City turning point experience

Concurrent with the New York City Department of Health’s reorganization efforts, the Robert Wood Johnson and W.K. Kellogg Foundations launched Turning Point, a national initiative designed to strengthen the nation’s public health system. The Turning Point initiative has emphasized broad-based partnership building and planning as key prerequisites for improving public health practice. In response to the foundations’ request for proposals, the department formed a New York City Public Health Partnership, which in turn applied for and was granted a Turning Point planning grant. This funding allowed New York City Turning Point to initiate a public health planning process, part o f which involved convening forums in each of the five boroughs. With over 1,100 community participants, these forums provided both a starting point for establishing public health priorities and an interactive setting for sharing health and demographic data. Included among the issues that emerged as priorities were: access to care, environmental health, mental health, housing, asthma, education, and dietary issues. Building on the forum outcomes, the New York City Public Health Partnership developed a public health system improvement plan. The goals delineated in this plan are: (1) to create and support public health partnerships at the community, borough, and citywide levels; (2) to identify community health concerns and develop strategies responsive to these concerns; and (3) to develop policies to support and sustain a community health approach to improve health status. This article also discusses possible roles for local health departments in promoting a community health approach to address public health concerns.     

Public health infrastructure system change: outcomes from the turning point initiative.

The Robert Wood Johnson and W.K. Kellogg Foundations created the Turning Point initiative to transform and strengthen the public health infrastructure. This study examined 135 public health system changes for their links to multiple sector collaborative engagement, essential public health services, health outcomes, and infrastructure building strategies. An on-line documentation system developed by the University of Kansas was used to record and analyze these linkages. The results showed that each state accomplished notable system changes; the majority involved more than one sector and primarily related to increasing local public health system capacity and organizational change.     

Utilizing a national performance standards local public health assessment instrument in a community assessment process: the Clarendon County Turning Point Initiative.

The Clarendon County Turning Point Initiative was launched with the goals of conducting a community-wide health assessment and developing a community health improvement plan. For the community assessment, the National Association of County and City Health Officials' (NACCHO's) Mobilizing for Action through Planning and Partnerships (MAPP) model was used. One of the assessments conducted through the MAPP model was the National Public Health Performance Standards Local Public Health Systems Assessment. The process for conducting the assessment using the local performance instrument is described. Clarendon County Turning Point Initiative conducted a one-and-a-half-day retreat to complete the local performance instrument. The committee planning the process identified and recruited stakeholders, collected data/information from stakeholders, and hired a consultant to facilitate the one-and-a-half-day retreat. The data analyzed with the local performance instrument identified opportunities and gaps in public health services in Clarendon County.     

The New Hampshire public health network: creating local public health infrastructure through community-driven partnerships.

In 1997, under the auspices of the Turning Point program, New Hampshire's public health stakeholders convened a strategic planning process to transform the state public health system. What emerged was a fundamental vision that the public health system could only be improved by strengthening the capacity of local communities to address local health issues. A plan was developed to create regional public health structures, in areas with no local health departments, to deliver essential public health services at the local level. Seven years later, that plan has become the New Hampshire Public Health Network. The network now covers 67% of the New Hampshire population and includes 113 (48%) cities and towns. Pre- and postevaluations to assess local public health infrastructure at the inception of the program and following 2 years of funding and technical assistance showed significant improvement in local public health capacity and performance. This article describes the development of local public health structures in New Hampshire where none had previously existed.     

Hearing the voice of the community above the din of the city: New York City Turning Point.

The New York City Public Health Partnership came together to guide the Turning Point Initiative and to involve communities in activities related to improving the health of the city's residents. Early decisions of the Partnership led to the convening of community forums, development of borough planning committees, and creation and implementation of a public health agenda--all of which have fostered community input and participation. Four years later, the Partnership continues to build upon lessons learned and explore ways of ensuring that community voice is incorporated into New York City's public health improvement efforts.     

Turning Point's National Excellence Collaboratives: assessing a new model for policy and system capacity development.

This article reviews the factors leading to successful collaborations and observations about the functioning of groups of states in collaborative coalitions by examining one specific collaboration--the Turning Point initiative. Turning Point is an initiative funded by The Robert Wood Johnson Foundation (RWJF) to transform and strengthen the US public health system so that it is more effective, more community based, and more collaborative in protecting and improving the public's health and well-being. A unique aspect of the Turning Point initiative is the creation of 5 National Excellence Collaboratives, with participating members from multiple Turning Point state partnerships, national public health associations, federal agencies, and diverse other organizations appropriate to each Collaborative's focus. Over 5 years, Turning Point Collaboratives developed educational materials, practice tools, and policy recommendations aimed at improving the public health system at the state and local levels and, ultimately, improving the health of the US population. The literature on collaborative partnerships and coalitions describes key elements and factors among successful partnerships. Areas of importance to success in Turning Point Collaboratives that have implications for future efforts include: continuity of leadership and membership, adequate technical assistance, diversity of Collaborative membership, regular feedback, and incentives.     

Turning point sets the stage for emergency preparedness planning.

Nearly a billion dollars were made available to state health departments through federal grants in the spring of 2002 for public health emergency preparedness plans. Twenty-one states had already been participating for some years in The Robert Wood Johnson Foundation's Turning Point Initiative. This article illustrates how earlier practice and experience in developing cross-sector collaborations and institutionalizing a model of broad-based partnerships for public health decision making can increase effectiveness and efficiency in responding to a call for action around an emergency.     

An alternative structure for improving the public's health.

The emergence of public health institutes outside government is one of many innovative approaches to promote community health improvement. This article describes the state of Virginia's current model of government public health and provides a context for Virginia's approach to the Turning Point initiative. The article explores the reasons why Virginia chose to establish its public health institute outside government and demonstrates how development of the institute is changing community health improvement in the state. The article also describes a new initiative to create a national network of public health institutes.     

Innovations in collaboration for the public's health through the Turning Point Initiative: the W.K. Kellogg Foundation perspective.

The need for a more integrated public health system led the W. K. Kellogg Foundation (WKKF) to establish Turning Point (TP): Collaborating for a New Century in Public Health, with a goal of transforming and strengthening the current public health infrastructure. WKKF partners with the Robert Wood Johnson Foundation (RWJF), the National Association of County and City Health Officials, the University of Washington, the Lewin Group, and the New York Academy of Medicine to support activities of 41 community and tribal jurisdiction grantee partnerships in 14 states. Preliminary evaluation of partnerships participation indicate: (1) most have accomplished breadth; (2) many did not achieve depth prior to the end of initial recruitment and (3) when the mission was internalized, penetration occurred. Strengthening public health systems requires redevelopment of human, organizational, financial, educational and information resources, and as in the past, WKKF will work to this end.     

Turning point: the Robert Wood Johnson Foundation's effort to revitalize public health at the state level.

The Robert Wood Johnson (RWJ) Foundation initiated Turning Point in collaboration with the W.K. Kellogg Foundation (Kellogg) in 1997. The purpose of this major national initiative was to strengthen the public health infrastructure in the United States so that states, local communities, and their public health agencies might respond to the challenge to protect and improve the public's health in the 21st century. RWJ funded 21 states and Kellogg funded 43 communities to work together to create a new way of thinking about how health could be improved and who should be involved. Although the ultimate outcome was to improve health, both foundations expected diverse partnerships to work together to create strategic health improvement plans at both the community and state levels. The foundations funded a variety of strategies within those health improvement plans during an implementation phase. The premise in funding partnerships, as opposed to a single entity, was that effective public health systems would be developed best through a shared responsibility (including the private sector) for the health of a community.     

The Louisiana Public Health Institute: a cross-sector approach for improving the public's health.

The Louisiana Public Health Institute (LPHI) is a new governance structure that embodies cross-sector approaches to improving the public's health. Formed in 1996, LPHI's first grant was from the Robert Wood Johnson Foundation for the Turning Point initiative. The lessons learned from Turning Point have been instrumental in developing the strategic direction of LPHI and Turning Point will be sustained through ongoing projects at LPHI. LPHI is part of a growing trend in America, and a new national network has been created to support the development of public health institutes in many states.     

Designing and building new local public health agencies in Nebraska.

Prior to 2001, the local public health system in Nebraska was weak, fragmented, and severely under funded. Local public health departments covered only 22 of the state's 93 counties. The Turning Point project provided the impetus for change by allowing a diverse group of public health stakeholders to develop a strategic plan for strengthening and transforming the public health system. The plan acted as a catalyst to use some of the Nebraska Tobacco Settlement Funds to provide dedicated state funding to build the local public health system. By June 2002, 16 new local public health departments had been organized, ultimately covering all of the 93 counties in the state. Some of the keys to long-term sustainability are creating a network of community health partners that support collaborative decision making, continually seeking input from the community, developing and implementing an education and training plan for public health professionals and local board of health members, and demonstrating accountability by documenting results and communicating them to policy makers and the general public.     

Building community capacity in public health: the role of action-oriented partnerships.

Public health practice increasingly is concerned with the capacity and performance of communities to identify, implement, strengthen, and sustain collective efforts to improve health. The authors developed ways to assist local Turning Point partnerships to improve their community public health system as a secondary outcome of their work on the expressed needs of the community. Using focus groups, meeting minutes, attendance records, and meeting observation, the authors fed information back to the partnerships on systems change. A public health systems improvement plan supportive of local partnerships' work on specific health issues was funded and the collaborative research agenda was further refined.     

Public health laws and implications for a national accreditation program: parallel roadways without intersection?

Public health law has been one of the leading contributors to the extension of life expectancy in the 20th century. Nonetheless, the legal infrastructure supporting public health law in the United States is underdeveloped and nonuniform. With national interest growing in public health agency accreditation, the individual legal approach taken by states may pose an obstacle to wholesale adoption of a proposed voluntary national model. This article describes the legal foundations supporting accreditation or assessment programs in states participating in the Multi-State Learning Collaborative, a project funded by the Robert Wood Johnson Foundation. The Turning Point Model State Public Health Act is recommended as one option to resolve the current impasse, assist in acceptance of a national accreditation model, and provide a common public health legal infrastructure.     

The Public Health Statute Modernization National Collaborative: developing a model state public health law.

It is through laws that state governments set forth the policy statements describing their responsibilities and authorities for promoting and protecting the public's health. A number of Turning Point states identified the need for strengthening the legal foundation for their public health systems. The Public Health Statute Modernization National Collaborative is working to address this need by providing a tool for public health law reform in the form of a Model Public Health Act for states.     

Using information technology to improve the public health system.

Information technology can be both a vital tool and critical link in the modern public health system. This article discusses the role of information technology in public health and the activities of the Information Technology Collaborative, one of the collaboratives that comprise the national Turning Point initiative. Data are presented from a nationwide survey investigating local health department information technology needs and information technology use. This data, and data from an investigation of state-level public health information technology, will be presented in a more complete format on the Information Technology Collaborative's online Public Health Information Systems Catalog, a free resource for individuals interested in public health informatics. Recommendations for future initiatives, policy changes, and information technology standards are discussed.