Succession Planning in Public Health: Just Ask

One issue we don't really deal with in the book, but that we know is important to public health planning and practice, is the idea of succession planning in public health. As the workforce ages and retires, who is going to replace you at the helm (or even in the galley) of these important organizations? Who in their right mind would want to take a job in a public health department, with its maze of bureaucratic requirements, its never ending list of needs and much shorter list of resources, the worries that follow you home after long days that you think will never end? For that matter, in an era when politicians themselves seem to disown the hand that feeds them, complaining about "big government" as they cash their paychecks and enjoy their benefits, who would want to work in government at all?

A recent Gallup Poll had some encouraging advice: just ask.

Despite generational differences in priorities, information sources, and modes of communication, a majority of Americans now say that a job in public service would be appealing. Yet, 60% of those under age 30 say they have never been asked to consider a job in government. However, if asked by their parents (33%)or the newly elected President in 2008 (29%), a significant share of Millennials say they would give such a request a great deal of consideration.

What does that mean for you in public health? One thing it might mean is that there are people in your organization who want to move up the ladder, but haven’t been invited. Think about asking them to join action teams for future projects or decision-making tasks. Consider giving someone on your staff a task you now do, and see how he or she handles it. When you delegate a responsibility, really delegate it: get it off your shoulder and onto theirs, and see how they do without micromanaging. The staff member might find they really like the added responsibility, might discover a skill they didn’t know they had. Finally, introduce them to public health business planning ideas -- to inspire and motivate them to work to build sustainable programs. You might discover someone you want to groom for bigger and better things within the organization.

Local Knowledge

One of the big barriers to getting started on a public health business plan is this: worrying that you don't know enough.

As it turns out, local knowledge is one of the most important factors for business plan success. So you might already know a lot of the important details, or have easy access to them through your local partners.

Yes, the science is important (the general framework provided by national or state-level statistics is nice; the references to model programs are important too). Knowing how to build a budget is important (and it is not hard to learn). Just as important is getting the details right about your local community, local needs, and local assets.

I mention it now because of an interesting article from the New York Times published today: Report Says Public Outreach, Done Right, Aids Policymaking .

For decades, laws have required many government agencies to seek public participation in the establishment of environmental policies. And for decades critics have derided the requirement as producing little more than confusion, delay, expense, distorted science and, as a government report once put it, “a proliferation of opportunities to misinterpret or misapply required procedures.”

But a growing body of evidence suggests that the process, done correctly, can improve policies and smooth their implementation, according to a report issued Friday by an expert panel convened by the National Research Council. Though critics often assert that members of the public are too ignorant to weigh the science involved in environmental policies, “public participation can help get the science right and get the right science,” said Thomas Dietz, the director of the Environmental Science and Policy Program at Michigan State University, who headed the panel.

“A lot of science has to be applied to a very local context,” he said in a telephone interview. “Local knowledge is essential.”

The article includes links to the full report if you're interested.

Health, Obesity and Business

A few weeks ago we got the following comment from David, who quoted Dr. Jim Johnson, a faculty member at the Kenan-Flagler Business School and teacher in the Management Academy for Public Health:

"... In the companies he had consulted with, Dr. Johnson stated that the number
one factor a business looks at is the health status of the community. Why?
Because of the potential cost to the company. Yet, our commissioners continue to
focus on tax rates and education levels, both very important, but with barely a
nod towards the community's health. Wonder what it will take to make us truly
realize what our "good health" is worth to us?"

A recent article in the Charlotte Observer, reprinted in our local Raleigh News & Observer which also quoted Dr. Johnson, looked at the issue of businesses assessing health status before committing to communities from a slightly different angle:

… Among other considerations, companies could be eyeing obesity rates before
deciding where to put new plants and offices. The idea is that by examining
obesity rates and avoiding opening where more obese people live, companies can
cut their future health care costs. For the Carolinas, that could spell trouble,
given that the majority of residents are tipping the scales.

This makes me think of a few things, in no particular order:

- recent data are calling into question the assumption that overweight equals unhealthy. For example, a recent New York Times article cited data from the Archives of Internal Medicine that showed that in a study of cardiovascular risk factors in 5,400 adults, half of those deemed overweight and one-third of those deemed obese were "metabolically healthy" -- that is, they had healthy levels of "good" cholesterol, blood pressure, blood glucose, etc. And, about a quarter of slim, "healthy-weight" individuals had at least two cardiovascular risk factors. So any company thinking of using obesity rates as proxy for health should consult with someone who knows the latest research (i.e., a health care or public health researcher or professional -- someone who understands the big picture about health and all it entails) before using that to determine whether to set up shop.

- As David suggests, a good strategy for communities trying to attract business would be to improve the health of its community. Community health insurance? Community design to encourage safe activity in neighborhoods and public spaces? Community resources toward public swimming pools, parks, playgrounds, tennis courts, basketball courts? Community health clinics? There are a lot of things to think about. They cost money, but so do unhealthy citizens and empty worksites.

- A good business strategy for businesses who are already established would be to improve the health status of their employees. How could they do this? One commenter to the N & O story said she tries to apply to companies that offer a gym or fitness discount, and suggested that companies have subsidized cafeteria and gym on the premises to make it easier for employees to fit healthy living into their schedule. Here at the NC Institute for Public Health we don’t have such facilities, but we do have in our written policy manual the support for staff members’ taking breaks to exercise, the commitment to having healthy food at company events, the support for on-site exercise clubs, etc.

- Several Management Academy teams have been built around partnerships with businesses that want to help their employees be healthier. We wrote a few weeks ago in this space about a team in Oklahoma building a partnership around health insurance and business interests. We write about others in the book – in Chapter 6 we mention a plan in Virginia that aimed to provide health screenings and education at worksites (pg. 55). In their exploration of need that team had found that businesses are desperate for public health help in implementing such programs. Visit the “Business Plan” section of the MAPH website (www.maph.unc.edu) for many more ideas. Note that in general, the plans do not solely address obesity; rather they look at the big picture of overall healthy living.

That's all for today.

-- Anne Menkens

Business Plan idea: farmer's market

Access to fresh fruits and vegetables seems to be a barrier to good health in many places across the U.S.-- especially low-income city areas and poor rural areas. Should public health be involved in creating farmer's markets?

Why not? Columbus, Ohio is doing it-- they have a public health farmer's market in a downtown neighborhood-- and it takes food stamps.

A team from rural eastern North Carolina-- the Northeast Partnership represents a group of counties in the state's northeast corner-- has written a business plan to create a farmer's market in their community. In addition to a market, the Northeast Partnership team plans to use churches as a distribution point for a "CSA" style product. CSA stands for community-supported agriculture; generally a CSA works like a subscription. Every week or so, subscribers get a set amount of produce, whatever is fresh at that point in the season.

The role of public health in this process? Bring together partners, money, and information.

First, assessment: the Northeast Partnership knows that access to healthy food is a major problem for portions of their community. Partners: they have existing partnerships with local churches and church networks that have a strong interest in health ministry. Money: they have grant finding and grant writing skills and a track record of finding start-up funds.

The partnership is now pursuing grants from two different directions: from public health sources that fund healthy food and exercise programs, and from agriculture sources like USDA that support local farmers. That money will be used to jump-start a natural market.

By natural market I mean organic produce-- but I also mean that the market is designed to become self-sustaining, generating enough revenue to go by itself without requiring huge amounts of time and effort from the public health department.

--Stephen Orton

More on the research-practice divide

To follow up on Steve's last post (below) -- Colleen Bridger's point is a good one. A lot of what we've found in evaluating the Management Academy teams is that the barriers to success are not the type of things public health researchers usually look at. For example, as we talk about throughout the book, and I quote from Chapter 15, "the primary reason that business planners fail to implement in public health settings is lack of organizational support." Organizational resistance is not something that researchers deal with when analyzing the efficacy of individual interventions -- organizational support is generally assumed going in. Now this effect can be mitigated by improved planning methods -- improving communication with those who hold the purse strings, aligning strong community partners, etc. -- but sometimes, the research about whether something works has nothing to do with how it can actually work in the real world.


On a related note, one public health director who read our book in manuscript urged us to remind readers, too, that not everything they do can be put into this model. As she said (and we tried to acknowledge in the book), some things partners have no interest in contributing to, some things are just mandated and paid for by the government, some things are just mandated and not paid for but meant to be free. (Although nothing's free; it still behooves you to think strategically about how much these "free" things cost and how you pay for them).


We'd be interested in ideas from practitioners about how they'd like researchers to proceed -- what would they like to see come out of schools of public health, what would really benefit them and their work. We'd also be interested to hear from researchers about things they're doing to acknowledge and maybe fix the disconnect between what they do and what public health practitioners do on a daily basis.


Anne Menkens

Evidence-Based Practice and Business Planning

The Journal of Public Health Management and Practice recently got a compelling letter from Colleen Bridger, the health director of Gaston County NC, about the lack of good public health research that is grounded in real public health practice. Here's the gist of her letter:

My concern is the following: how many times do we locals need to hear from the folks in the academic ivory towers how we are not doing it right, before those folks actually spend some time in our shoes trying to figure out why?

Colleen's concern with the public health research being published is that it is not replicable in the real world-- and researchers aren't helping to figure out why not:

I do not believe it is because local health officials are stubbornly clinging to our tried and true methods, nor do I believe it is because we do not know how to understand or interpret research results. I believe that just like in clinical medicine where there is a vast difference between a drug's efficacy in clinical trials and its actual effectiveness in real-world applications, a parallel exits in real-world public health. Have any academicians tried to implement a best practice obesity prevention intervention in a local community outside the scope of a research project? We cannot exclude participants because they do not meet our selection criteria and we cannot pay them to participate, only cajole. Yes, I understand the need to develop gold standard research studies to identify what works, but we are missing the implementation component.

Obviously, searching for evidence-based interventions is a critical part of any public health business plan. Your communities count on you to do things that are likely to work. Colleen points out that our system throws up barriers though. The gold standard research studies can't be replicated on a budget. The more relevant programs from the practice community can't be evaluated-- or the evaluations can't be published because they aren't up to the standards of academic journals.

And good luck finding the write-ups of the programs that fail.

It is much easier now than it was 10 years ago for managers in public health to do the library work to find the relevant research. With Web 2.0 technologies, it should get easier for managers to find their "community of practice," to communicate with the other people across the country who are doing similar work. Neither of those things addresses Colleen's issue, though. Kellogg's program to fund community-based research scholars is the right approach.

-- Steve Orton

Comments on "important challenges"

We asked a week or two ago about the important challenges facing public health.

In response to your question as to what are the most important public health challenges these days, I would offer the following -- the pressure that the increase in population is putting on our public health systems. These include medical care for different population groups, especially the elderly; increasing amounts of resources for meeting the needs of larger populations, and here I would mention public water supplies , as we are still in a drought; and the effect that development to provide for more people is having on environment, and here I would mention the loss of wildlife habitat, recreational open space, and natural vegetation.

Great point-- as you say, the population pressure comes from the numbers, but also the density and the location of population increases. Note that many of the populations that are increasing are populations that have unmet health needs (immigrants, children, elders, the uninsured).

A friend who attended the Wisconsin Public Health Association Conference added the following:

Youth violence -- it cannot merely be a problem for law enforcement: its causes are broad, and it affects all of us in some way. By the way there was also a talk about the importance of partnerships in public health, which seems right down this book's alley.

Violence is slowly being recognized as a public health issue. I see lots of room for alliances between traditional public health organizations and the many organizations that work on violence prevention specifically. Lots of other groups have a big stake in this issue: law enforcement, health care, economic development, education. A huge challenge but also as you point out a huge opportunity. People who work with the victims of violence are really hungry for solutions on the prevention side.

A central challenge for a violence prevention alliance will be to figure out how to start understanding the issue the same way, and how to start taking useful steps, and how to share the work (and the cost) in a way that is equitable and sustainable.

There are school-based programs and outreach programs that have been rigorously evaluated-- read more about them on thecommunityguide.org.

Americans learned to recycle; most of us quit smoking; a few of us went to the moon; we sent a robot to dig up water from the surface of Mars. The fact that the violence issue is complex could be scary-- or it could keep people interested and motivated!

--Steve Orton

Team Outcomes: bricks and mortar

Outcome story: Gaston County NC put a business plan team together last year that combined representatives from the county public health department with the head of a local community health center. Their goal: to build a shared space for community health and public health clinics and offices. The two groups see the new building as a key part of their strategic alliance-- and a central way to address a serious problem with access to care in a neighborhood called Highland.

Last month, their board of commissioners gave the go-ahead on the Highland project-- including making county land available without cost. Next step: architect drawings!

--Steve Orton