by Kristine M. Gebbie
Kristine M. Gebbie, RN, DrPH, is Elizabeth Standish Gill Assistant Professor of Nursing at Columbia University School of Nursing in New York, New York.
ABSTRACT: Many in public health seek to build a constituency to speak on behalf of public health and population-based approaches to health improvement. The head of a state health agency has unique opportunities to facilitate building a constituency. Defining the mission of public health and of the public health agency, building relationships with local public health entities and use of an advisory board are all effective methods. The task can only be done, however, when the director is visible, vulnerable to criticism, open to change and input, and willing to collaborate creatively even with those holding strongly divergent views.
Many public health professionals believe they lack the powerful constituency that will push for improved funding and visibility, in contrast to the many groups that rally to support a hospital threatened with closure or to support an emerging, promising, but unfunded medical procedure. In fact, powerful groups that have frequent contact with public health agencies too often become critics of them: businesses subject to public health regulation intended to control environmental threats or to assure the quality of health-related services are often found lobbying against the public health structure.
Concerned about this apparent lack of support, public health leaders have become aware that they need to build a constituency. They seek groups to speak on behalf of public health and population-based approaches to health improvement. The relatively new Partnership for Prevention organization represents a national coalition-building effort; Public Health Week activities each April include state and local outreach. Public health leaders also want some groups to support specific agencies in specific areas of interest, such as annual budget debates or legislative work.
As a public health director, I have also experienced those needs for support, and I have attempted to build constituencies that would be there when needed. This case study is based on my 11 years as head of the Health Division, Oregon Department of Human Resources, the agency responsible for preserving and protecting the health of all Oregonians. The study describes building the components of a constituency for public health, specifically for the state public health agency in Oregon, an effort that I believe is closely related to building a more generic advocacy for the health of the public of the state.
The Case of Oregon
In 1978, I arrived in Portland to become head of the state's public health agency. In the approximately six years since the state had merged its board of health, alone with seven other agencies, into the Department of Human Resources, the Health Division had experienced five administrators in quick succession, the Iongest tenured of whom had stayed in office for just over 18 months. None of the administrators had previous health-related clinical or management experience. The general expectation of staff was that administrators would continue to come and go, and that the best course of action was to keep your head down, perform your job very quietly, and hope no one would ever notice you.
Both state and local public health staff believed that these administrators were not to be trusted because they would sacrifice good public health for political peace, and therefore difficult public health decisions were to be kept away from the top staff of the agency. Failure to build a constituency for public health in the state could well make this expectation real. And if that state of affairs continued, there would be little interest in investing new resources in the Health Division, little public support in the case of conflict, and a decreasing likelihood that the legislature would strengthen the capacity of the division to respond to threats to the health of Oregonians.
Complicating any efforts at constituency building were three environmental factors: the nature of being a chief public health official within an umbrella agency, the legacy of relationships (not always positive) between the state and local public health agencies, and the economic climate in Oregon at that time. With regard to the structure of state government, it is generally accepted by public health officials that it is better to be an independent cabinet appointee (preferably with the political cushion of a board of health) than to report through someone to the governor. In Oregon, during the time I was there, Department of Human Resources division administrators worked directly with the governor, attending cabinet meetings with the Department of Human Resources director and working directly with other executive branch agencies, albeit always in collaboration with the department as a whole.
The significant negative, in my experience, was the distinctly different worldview of the other agencies of the department and its central management staff. Other constituencies were very specific, associated with a relatively small proportion of the state's population: only a limited number of persons were on public assistance, in a state mental hospital or prison, or on the unemployment rolls at any one time. The common language of "caseload" and "stakeholder" assumed a very different meaning when applied to the Health Division, for which the entire state population was the "client" all of the time.
After creation of the Department of Human Resources, the local health departments had never developed a strong relationship with any of the Health Division administrators, concentrating instead on fairly independent projects (such as establishing standards for local health department performance) and on relationships with individual programs within the Health Division. To the extent that the local health departments could speak with one voice, they represented public health in the state, and to the extent that they built up their most important constituency-- local elected officials--they could command a good deal of attention from the legislature or other decision makers. Any effort by the Health Division to build a constituency that might be interested in statewide concerns and that did not fully support the individual autonomy of local public health efforts was seen as a potential threat and could trigger a high level of opposition.
Finally, Oregon entered the economic downturn of the early 1980s earlier, and more severely, than many other states. A dramatic drop in timber sales and timber-related employment, with associated losses in public revenue, meant that budget cutting and staff layoffs became the order of the day. This was exacerbated, following Reagan's election to the presidency, by the introduction of block grants and what was termed the "new federalism", which meant state agencies had to take responsibility for making cuts in programs and resources actually stemming from federal decisions. Building a constituency when resources are shrinking is extremely difficult, because it takes a long-term perspective and a higher level of confidence to step back from individual interests to consider a more general good. It would have done public health no good to stimulate individual constituencies that then publicly competed with one another for shrinking resources. I had to look for support for the whole.
There were several strong advantages I enjoyed as a new player to a state needing to build public health constituencies. The first was the apprenticeship in management that I had served in my previous employment as an assistant director in a university medical center. My supervisor there was a strong member of the medical center management team, with an outcome-oriented approach that required stating and then working to achieve goals. I had been taught to identify internal and external constituencies and then work with them to fulfill my share of the organization's goals. Second, I joined a strong leadership team in Oregon, in a department that at that time was invested in management development. Soon after arriving in the state, I was able to spend a week with other senior managers under the tutelage of an expert in organizational development. The role of stakeholders and constituencies was a significant portion of the material taught, and I had the opportunity to reflect on what needed to be done.
Within six months of my arrival, I had made two management decisions, one regarding a personnel matter, the other a public health regulatory issue that became an issue in which the media was strongly interested. The public response reinforced my awareness of the need to have a constituency that understood public health, the role of the state's public health agency, and me as its leader. Finally, because of my training and experience in health systems, community development, and nursing, I was perceived as a professional appointee, rather than a political one. The public and the staff believed that I could be trusted and should be supported because I would understand the public health rationale for decisions and would support public health in the face of political pressures.
Defining the Mission and the Caseload
The efforts devoted to building the internal constituency included many familiar in management development: involving management staff in writing an agency mission statement; creating and sustaining, an agency-wide new employee orientation; and devoting careful attention to ensure that internal documents and materials leaving the agency were consistent in framework and language. I also attempted to regularly visit agency staff in their workplaces, providing them an opportunity to show off new projects or activities; at the same time, I was becoming familiar with the day-to-day work environment. While this was helpful, hindsight suggested that I did not do enough in the first year, partly because of the time I committed to learning about the local health departments, as discussed later.
Document development had particular importance in building the department's central staff as a potential constituency for the division. Although, through experience, budget and policy staff at the Department of Human Resources expected the Health Division to provide uncoordinated and often inconsistent materials, this was tolerated because it was the smallest division in staff and budget, and so the problems were seen as relatively unimportant. The division followed standardized formats, making no attempt to clarify how such formats might distort the case of public health. For example, in answering the question of caseload served, the division might list the number of epidemiological investigations rather than acknowledge that the prompt investigation and check of food or waterborne disease outbreaks served all Oregonians. There was no systematic way to identify the staff, budget, or workload of the local public health agency partners in routine reports. It was a major step when I was able to get agreement that the service offered by the Health Division was to support local public health through laboratory, epidemiology, public health nursing, and sanitation consultation. The alternative--- describing those services as the responsibility of the central administration--- was shelved.
This process extended to using the biennial budget development process as a major communications tool. Historically, most attention had been given to the numbers, with individual programs writing required narratives independently. After one legislative cycle under this system, I made the decision that we needed a coherent narrative that would tie together all budget parts and that would clearly identify priorities and decisions. This meant increasing management time in collective budget work. We wanted to make certain that program intersections, were identified and that the highest priority goals were consistently highlighted. An individual with strong writing skills completely rewrote the entire document to deliver a single message. Doing this was painful; not all programs were described as most critical to keeping the state healthy! But despite the pains, organizational strength was built as staff learned to work as a team and as the department and legislature learned that they could expect consistency across the division. A consistent building toward priorities requires time.
An interrelated development was the long-term effort to strengthen the Health Division's information capacity. While there had been a vital records program for three-quarters of a century, and while epidemiological reports were published regularly. It was not unusual for state or local program decisions to be based on disease or health status reports two years old or more. And there was no assurance that relevant health information was getting to health professionals or the public in a timely and useful manner. To do so would require the upgrading of an information-processing capacity. Over several budget cycles, funds were allocated for upgrading, computer capacity, health statistics and epidemiology were combined into a new health status monitoring unit, and the publication of timely information in readily accessible form was made a priority. This increased media use of our information, and those institutions that were able to make use of the improved information, including health professional associations, academic centers, and local health departments, became greater advocates of public health.
Speaking with one voice was also associated with increasing the public visibility of the division, primarily through the administrator's media presence. Some of this was inadvertent, springing from the negative publicity surrounding, the two early decisions mentioned above. The first was about the abrupt termination of two long-time staff due to mismanagement of income from the sale of vital records.
I had originally supported the action, basing my decision on a staff recommendation without fully exploring either the reason for the action or the due process system in place. But both employees were popular, and friends went to the media on their behalf. Taking a second look, I created an investigatory team to review both the original offenses and the discipline proposed; that report prompted a much lower level of discipline. The fact that I took a second look, that I met with the involved employees personally and that I was open within the agency and with the media (within constraints of personnel law) were taken as positive signs. While this did not eliminate concern about the original action and my error in supporting it, it did establish a climate of openness to employee concerns and honesty about actions that were important to building staff constituency. Further, the media learned that I was accessible and began turning to the division for information and commentary on a more regular basis.
In the second case, just before a holiday weekend, I concurred in a staff recommendation to announce restrictions in use of drinking water in a coastal resort town. Several hotels and eating facilities were closed. While I did several of the "right" things, such as verifying the laboratory findings of fecal contamination of the water and alerting the department and governor's offices prior to any public announcement, there were problems. I did not know that this particular resort area was home to many "old Oregon" families, who expected to spend their Labor Day weekend as usual and did not appreciate my attempts to improve their health. I did not fully know the history of sanitary regulation in the county, where the Health Division had just assumed jurisdiction due to failure of the county health department to enforce regulations. This meant that in a small county, where people were used to familiar, face-to-face interactions, their first encounter with the new sanitarians was an announcement from Portland that their water was too dirty to use.
In hindsight, I should have ensured that personal calls were made to county commissioners and state legislators from the area (one of whom was on my budget committee); I should also have sought a negotiated interim plan for water management prior to the public warning. As it was, all planning, for an upgraded water system and reopening, of public eating facilities were conducted under media and legislative scrutiny. Strong voices argued that I was one more example of big city, big government run amok. Over a year later, I joined a number of state, federal, and local officials in dedicating the town's new water treatment plant, one of the best in the state. The long-term, constituency-building impact of this incident was to affirm to the public health community that I would support appropriate public health actions, and to the political community that I would honestly own the negative effects of my communication decisions-without backing down on protecting the public's health.
Relationships with Local Health Departments
Local health departments are important partners of state health agencies, tailoring programs to local needs and priorities that may vary widely across a state. In Oregon, local government is a very important constituency for all state agencies, and the Oregon Conference of Local Health Officials (CLHO) was an active member of the Association of Counties. As mentioned earlier, this group had become quite critical of the Health Division structure within the Department of Human Resources and was concerned that the division pay more attention to local needs and become a more vocal advocate for resources. In the legislative session just prior to my appointment, they had succeeded in creating, a general subsidy for local public health (at the small sum of $0.25/capita/ year), and they expected the Health Division to advocate for an increase in this fund.
A county commissioner and a local health director were on the interview panel that assisted in my hiring process, and it was made clear that I needed to develop a good relationship with staff throughout the state. For that reason, I set the goal of visiting each of the local health departments serving Oregon's 36 counties. These visits, which took a year to complete and limited my time with my own staff, provided an important firsthand view of the local health department partners in the state. In addition, I made a point of attending public health meetings within the state, including the annual CLHO meeting, held in conjunction with the state Public Health Association meeting. These interactions, which were a marked change from my predecessors, contributed to a common base of understanding of what might be done, or should be done, on behalf of public health in Oregon.
The shift in federal funding to block grants in the early 1980s led to one of the first tests of the relationship that was emerging. Before that time, federal funds for local public health were made available on a competitive basis. My travels had revealed the serious flaw in the method: those departments that had a stronger infrastructure were able to compete and win more resources, and smaller departments scraped by on the minimum available. The look at statewide priorities necessitated by the conversion to block grants allowed us to consider the use of a formula approach, which could assure Oregonians equitable access to supported services regardless of which county they lived in. Appointment of an advisory committee with representation from local health departments of several sizes, as well as other interest groups, provided the forum for discussing and eventually designing a workable allocation system that could be phased in over several years.
The emerging statewide public health constituency supported a collaborative effort to ensure that no public health block grant funds would be diverted elsewhere and that the maximum possible amount of additional state funds would augment the amount to be distributed by the new formula. Had state funds been available, this would have also been the time to increase the general public health funding but the statewide economic recession made this impossible.
The struggle over the balance between local public health and the state health division continued. While the local health departments wanted a strong voice for public health, they would have preferred that the voice only raise issues central to local concerns and advocate solely for local resources. Caught up in local struggles to support county allocations for public health, they often lost sight of the need for resources at the state level for activities with which they had little day-to-day contact. There were conflicting agendas among the local representatives, without a single voice from any one county being evident. For example, the administrator might agree with a priority-setting exercise for the budget, in which cutting back on support for dental health or swimming pool inspections made sense to preserve critical epidemiology, infectious disease control, and drinking water consultation capacities. Yet in public testimony or meetings, other officials from that same administrator's agency might vehemently attack the state budget decisions as irrational and irresponsible. Statewide professional associations of nurses, sanitations, or public health professionals were at times used as the vehicle for these contradictory messages.
The continuing confrontation led to an extraordinary meeting of the local health directors (without any other supervisory staff) and the executive staff of the Health Division. At this retreat, we reconfirmed our awareness of the damage we could do to public health by not forming a solid, mutually supportive constituency, what we called a "public health management team for the state." State and county officials chaired alternately, working on a mutually developed agenda. Items could only be added if they were of interest to more than one county or to more than one state pro-ram, and if there was evidence that an effort had been made to resolve the issue at a lower level. While these may sound like obvious ground rules, making them explicit gave the entire group a share in controlling maverick members who might care more about singling out an issue than developing a stronger public health system. This forum worked well to defuse arguments and push staff at both state and county levels to work collaboratively.
A Public Health Advisory Board
Advocates for public health in Oregon often referred fondly to the "good old days," when a Governor-appointed board of health had regulatory authority in public health and assisted in hiring and supervising the director. The board had been eliminated when the Health Division became a part of Department of Human Resources, in part because of management studies suggesting that the independent board or commission form of government previously popular in Oregon did not allow the Governor to effectively manage the executive branch. What was lost was a public forum for debate of public health issues.
A board of health, even one lacking administrative power, can explore issues publicly, giving voice to alternatives and providing a place where those interested in public health issues can seek attention. Unlike legislative hearings, which are tied to the political agendas of the participants even under the best of circumstances, or regulatory hearings, which are tied to rules or specific cases, a board of health can explore issues in advance of any decision needed and can provide opportunities for education and information-sharing. It took a number of years of building relationships before the idea of reestablishing a board of health could be successfully broached, first within the executive branch and then later with the legislature.
Use of advisory committees has long been a part of public life in Oregon. The strong, open meetings and sunshine laws meant that interested parties could follow or participate in matters being considered by public officials. The Health Division had established a tradition of using advisory bodies regularly, even when not required by law. My approach was to consider all meetings open unless there were a strong legal reason otherwise (such as having a personnel issue under consideration). Work done on revising the state's drinking water laws, developing a statewide trauma system, and revising local health funding formulas all included use of advisory committees representative of divergent interests. None of these bodies could develop a long-term, statewide, public health view, however. And while the CLHO clearly had long-term and statewide views, it was hard for them to step out of their local government positions to look at other issues. Establishment of a public health advisory board would provide a common forum for all of these and other interests and would reduce the need to establish shorter-term groups.
Once established by the legislature and appointed, the Public Health Advisory Board (PHAB) did begin to provide a wider voice for public health issues. Its members were in a position to take public health issues back to their constituencies, including the CLHO, individual professional associations, and the Association of Counties, educating them about the role of public health in the public life of the state.
Long-Term Results
Two long-term results of constituency building are cited here: the development of state goals for Healthy People 2000 and Oregon's updated disease-reporting laws. Each accomplishment benefited from the constituency building activities reported above.
Oregon was the first state in the nation to publish health goals for the year 2000. These were developed in the late 1980s, during the time when the national Healthy People 2000 goals were under development. Oregon had not done anything specific to adapt the Goals for 1990 to the state, mostly because there were higher priorities for action early in the decade, and as time went on it seemed less important to do so. Many in the state also felt that the format for the existing, national goals was too bureaucratic to be useful. In 1998, I challenged a small group of Oregonians, including representatives from the state's PHAB and CLHO and advocates for several age groups (children, the elderly) to identify a relatively small number of goals that the state should try to achieve by the end of the century. The resultant publication, which was both eye-catching and readable, triggered a great deal of attention and provided a useful template for budget and organizational decisions. It also became an early part of the state's discussion of the statewide goal-setting process, in which Oregon is leading the nation. It is unlikely that the Health Division would have succeeded in publishing any widely read and used document if it had not developed the constituencies for public health in the preceding years.
In the early years of the human immunodeficiency virus (HIV) epidemic, many states struggled with questions about the appropriateness of applying old communicable disease control statutes to current realities. Oregon was one of those states. There had been some interest in updating laws to include non-communicable diseases and conditions such as chemical exposures, injury, and birth defects. Advocates for those with HIV infection wanted to be assured that no arbitrary reporting or limitation of liberty would be imposed on those at risk of HIV. Use of a widely based working group, which included those with HIV infection and their caregivers, members of professional associations, members of bar and civil liberties associations, and others, provided a forum for debating possible statutory adjustments. In the end, a bill was sent to the legislature that proposed completely rewriting statutes covering "conditions of public health importance."
The new law ensured that any reporting was confidential and that any imposition of restrictions on an individual with a communicable condition was done only after all voluntary efforts failed and in the least restrictive manner possible. The law allowed for flexibility in specific regulations over time, rather than spelling out all details in the law. In front of the key legislative committee, representatives of many constituencies (some in almost constant conflict with one another in other settings) concurred that this statute was appropriate and should be passed; it was. The Oregon law is now mentioned by analysts of HIV legislation as one of the best in the nation. Without the support of a public health constituency to say that HIV must be considered in conjunction with other public health issues, and without the constituency support to take time to work through issues prior to legislative consideration, it is unlikely that this law would ever have been passed. Oregon might well have been saddled with some of the problematic reporting or restriction laws passed elsewhere.
Lessons Learned
The level of funding available for public health through the budget-cutting years; the strong laws on conditions of public health importance, on trauma systems, and on drinking water protection; and the enthusiastic involvement of Oregon public health practitioners in national efforts to improve public health all speak to the strengthening of constituencies for public health in the state. Further evidence comes from the involvement of public health officials in devising the Oregon plan for extension of medical care benefits to the poor and in planning for revisions of Medicaid funding. In Oregon's benchmarking approach to statewide goal achievement, public health activities are seen as essential to achieving goals: given the state's interest in assuring that all children are prepared to learn in school, and to stay in school, support for child health and adolescent pregnancy prevention programs has been very strong.
The role played by any one individual in building public health over a decade is relatively small: many dedicated individuals committed themselves to the effort. There are, however, some things that were probably best done by or with the direct support of the agency director. I learned how difficult it is to keep an eye on the overall goal and work toward a long-term result. For example, as the interest in public health crew in the state, many local environmental health workers wanted to move quickly to rewrite the state's very weak drinking water protection law. I wanted that law rewritten, and I wanted the support of local environmental health workers. However, my assessment was that this effort would not be successful until a better track record under the existing program was in place, and after some of the year-to-year budget consistency discussed above had been demonstrated. With great effort, it was possible to hold back the enthusiasts while developing the legislative package that eventually passed. Had the question been raised before my encounter with residents and legislators over the quality of the coastal water system, I believe my enthusiasm would have led me to join local lobbying- efforts, and we would have needlessly lost an important struggle.
Another important lesson is that of mastering multiple vocabularies and communication styles. Many of us are familiar with profiling, used to identify the various preferred work and communication styles of people who find themselves working together. It took me a long time to understand fully the enormous cap that can occur when these differences are not taken into account. Many public health practitioners are trained in scientific disciplines, in which details and factual evidence predominate. Work in the decision-making arena of government involves a large number of people for whom intuition is more important than evidence. Constituency building means crossing those lines and finding ways for the detail-oriented individuals to feel comfortable without driving the big picture enthusiasts crazy with repetition. My interest in getting on with things often frustrated epidemiologists and others who wanted to be sure I understood all the details; I was often too willing to assume that something said once had been understood and agreed to by those in the room. Learning mutual ground rules within the public health community strengthened our ability to work with the outside constituency when we needed to make desired improvements.
Constituencies are built around clear goals and need positive feedback and flexible support over time. As state health director, I had extraordinary opportunities to support the emergence of a constituency for public health. This case report has described some of the activities and opportunities I was able to use to strengthen public health in Oregon. It could only be done by making myself visible and vulnerable to criticism, open to change and input, and willing to collaborate creatively, even with those holding strongly differing opinions. It was an experience well worth the effort.
Reprinted/adapted with permission from the Journal of Public Health Management Practice, 1997, 3(l), 4-11 © 1997 Aspen Publishers, Inc.
Building a Constituency for Public Health Case Study last updated April 20, 2004 (epowell)