This issue of the Journal of Public Health Management and Practice (JPHMP 8:1) focuses on the Turning Point initiative, an effort that began in 1997 by The Robert Wood Johnson Foundation and W.K. Kellogg Foundation. Turning Point's mission is to transform and strengthen the public health system in the U.S. so that it is more effective, more community based, and more collaborative in protecting and improving the public's health and well-being. Turning Point has created a formalized network of public health partners across the country to broaden community participation in defining and assessing health, in prioritizing health issues, and in taking collective action to address such priority health issues as elimination of health disparities, increasing access to quality care, aggressive prevention of infectious disease, promotion of healthier lifestyles, and protecting the population from hazards and toxins in the environment.
The initial idea for Turning Point came from the foundations' concerns about the capacity of the public health system to respond to emerging challenges in public health, specifically the system's capacity for collaboration in improving the health status of our population.
As the issue editors considered the various aspects and multiplicity of Turning Point efforts, three themes emerged related to the core strategies of the initiative: (1) innovations in collaboration for the public's health, (2) increasing capacity for policy development, and (3) alternative structures for improving the public's health. Turning Point's underlying philosophy is that public health agencies and their partners can be strengthened by linking to other sectors (not just the private health care sector, but education, criminal justice, faith communities, business, and others) because the underlying causes of poor health and quality of life are entrenched inextricably in social issues that transcend contemporary practice based primarily on disease models of intervention. Turning Point attempts to engage a diversity of partners from different sectors and disciplines who are committed to participating in collaborative public health practice to protect and improve population health. The pertinent idea here is collaborative practice-sharing resources, developing shared visions, adjusting policies to support collaborative action, engaging community voice (an expression of the feelings of the community) in decision making that impacts investment and allocation of resources. Different communities and different states have translated the structure or form of collaborative practice in different ways. The issue editors believe strongly in the importance of sharing with practitioners these innovative approaches of working with other sectors, examples of different institutional structures for achieving improved community health objectives, and examples of efforts that strengthen the ability of communities, states and tribes to develop health policy.
In addition to showcasing Turning Point efforts in these three areas, included herein are commentaries from a variety of individuals with important public health roles. These writers were asked to share their reactions and observations to the three articles in their respective sections. This approach attempts to provide thoughtful observations that stimulate further reflection on the approaches and strategies of Turning Point.
This issue begins with the perspective of the two foundations: Hassmiller summarizes The Robert Wood Johnson Foundation's effort to revitalize public health at the state level. Sabol gives an historical perspective of W.K. Kellogg Foundation programming for collaborative public health practice. The foundations frame Turning Point in the context of a broader strategy of population-based health improvement. Each foundation has its own focus and strategies for health improvement, but both see the advantages of collaborating to strengthen and transform the public health system. 1
The initial article in the first section, innovations in collaboration for the public's health, describes the process of community collaboration in Alaska's Sitka Turning Point partnership. Working on a goal together with others requires flexibility and artistry similar to the process of weaving a basket. Using native basketry as a unifying metaphor, Cavanaugh and colleagues share many valuable lessons on how to weave a successful collaboration for public health system improvement on their Alaskan island.
One of the innovations in Turning Point has been the collaborative identification of best practices and development of policy recommendations. Turning Point states are grouped together in five National Excellence Collaboratives that work with local and federal partners as well as national associations to improve public health system capacity in information technology, leadership development, performance management, social marketing, and public health statute modernization. Wilson, representing Virginia as the lead state in the Leadership Development Collaborative, writes about the progress to date in strengthening collaborative leadership throughout the public health system.
Working with communities in large metropolitan areas differs significantly from working with those in small rural areas. The New York City Public Health Partnership collaborates with the communities in New York boroughs by involving residents and neighborhood organizations in convening community forums, developing regional planning committees, and creating and implementing a public health agenda for New York City. Cagan and her colleagues in New York City highlight the programmatic and organizational decisions that establish mechanisms designed to promote and sustain community voice in public health policy making and action.
The second group of articles addresses different aspects of increasing capacity for policy development. A primary assumption of Turning Point is that community health will be improved by increasing social capital. Social capital is broadly defined as an asset that inheres in social relations and networks. Robert Putnam in the article, "Bowling Alone," describes social capital as a measure of civic engagement and social connectedness. 2 The public policy-making process in the United States is structured so that public perceptions about health issues drive policy formulation. It is here that the Turning Point strategies of cross-sector collaboration and increased community involvement to increase social capital can have a major effect on policy development.
Erickson describes the multi-state effort of a Turning Point National Excellence Collaborative whose goal is "to transform and strengthen the legal framework for the public health system through a collaborative process to develop a model public health law." The membership of the Public Health Statute Modernization Collaborative represents a broad array of system participants, including the National Governors Association, National Council of State Legislatures, and individual legislators.
Harrowe and colleagues review the critical policy issues that were needed to transform the Gila River Department of Public Health into a tribal health department that truly incorporated the values and health concerns of the Gila River reservation community situated outside of Phoenix, Arizona.
Batson describes how developing principal policy guidance developed as a framework to address health disparities can lay the groundwork for community accomplishments in the rural American town of Roswell, New Mexico.
The final group of articles explores alternative structures for improving the public's health. Kimbrell et al. review the history and raison d'etre for the Louisiana Public Health Institute, a new governance structure embodying cross-sector approaches to improving the public's health. Kimbrell's Louisiana group also is leading the development of a new national network to support the development of public health institutes in many states.
Peterson and Lake explore how Turning Point in Virginia led to the Virginia Center for Community Health, a joint effort of the state health department and the state association of hospitals and health systems. They detail the difficult steps taken to establish and support a new way of doing business in Virginia that broadens participation in the public health venture.
Reynolds and Leahy describe a public health training institute in Montana that has origins in a 1995 Public Health Improvement Act that established a new state health department and launched a health improvement task force. As in many states, the renewal of the public health system in Montana began immediately prior to the announcement of the Turning Point initiative and a group of public health leaders already had identified strategies for improving health-including the support of a well-trained public health work force.
What leads to improved health? One certainly must have valid scientific information on relationships between risk factors and health outcomes. This is the role of epidemiology and biostatistics. In addition, however, Turning Point emphasizes the commitment of those living in the community; that is, improved health in a community requires that people in the community agree to improve aspects of their environment. Turning Point focuses on improving the systems in place to facilitate shared accountability and action most importantly at the community but also at the state level and at the national policy level. Rather than choosing between specific strategies, Turning Point supports a broad approach to health improvement, one that encourages resident involvement in health decisions and actions to improve health and quality of life. Just as the professions of medicine and nursing have shifted the locus of control from the practitioner to the patient, effective public health practitioners are shifting the locus of control from the agency to the community.
In accord with the recent National Association of County and City Health Officials (NACCHO) report, Advancing Community Public Health Systems in the 21st Century, 3 three themes are central to Turning Point's public health systems improvement experiments: "a broadening vision of what public health activity is; a sharing of responsibility for public health across the community; and a drive to put the public voice back in public health activity."
How effective has Turning Point been? Individual communities and states have reported wide variations in achievement of public health goals and in levels of enthusiasm for public health agendas. The overall scorecard is not yet completed. Our measurement of long-term progress in Turning Point, as in other health initiatives, is improving health outcomes. Some health outcome improvements can be measured in a few years. Other health outcomes measurements require significant portions of individual lifetimes. So how do we measure progress in the mid-term? One intermediate indicator of success is increased social capital. Many efforts measure social capital by recording and tracking the amount of participation in social events and activities in the community. Although individual states may have their own means of evaluation, the overall Turning Point effort recently has started to record changes in state systems relating to health.
Given that Turning Point partnerships are engaged in diverse and complex work, it is difficult to distill, capture, and share the complete story of what participants are learning. Articles included in this Journal issue attempt to portray the diversity of activity and approaches currently being tested by only a handful of partnerships. From a national perspective, Turning Point's lessons suggest that public health practice in the U.S. can be strengthened by strategically focusing on six primary areas of activity: (1) expand the scope of public health practice to address social, economic, and environmental determinants of health and quality of life issues; (2) create sustainable organizational structures that transcend sole governmental ownership to support collaborative decision making and action; (3) build local and tribal capacity that is supported by state efforts for assessing, monitoring, and reporting community health and well-being measures; (4) adjust policy environments and policy development processes to advance this expanded vision of collaborative public health practice and to support collaborative action; (5) foster broad public awareness and active engagement in the work of public health; and (6) strengthen the human resources of broadly defined public health systems.
These six broad areas of strategy depict a perspective transformation taking place among partnerships. Moreover, Turning Point's field-tested lessons strongly suggest that improving public health practice in the U.S. requires a philosophical shift from conceptualizing public health activity as a function of the work that governmental public health agencies do and moves to envisioning contemporary public health practice as the collaborative work that public and private health agencies and their partners do to protect and improve health and well-being. Such collaborative practice better enables partnerships to address the wide range of medical and social factors that impact health and well-being. Partnerships are learning that these collaborative approaches do not result in giving up control or access to resources, but instead they yield increased capacity to protect and improve health, as there are critically important roles and responsibilities for both public and private sector participation to share. Thus, these collaborative approaches demonstrate that infrastructure includes-but clearly transcends-bricks, mortar, and independently operated agencies to create a web of interconnected activities, services, and efforts that are supported broadly by committed people and organizations.
This philosophical shift expands the contemporary framework of direct service provision (e.g., the U.S. Public Health Service's essential public health services model) 4 by increasing policy support for process-directed capacity development that shares resources among participating groups. In this light, Turning Point defines policy broadly to include public policy as well as inter- and intra-organizational policy development efforts that facilitate sharing of human, information, and financial resources across organizations, communicating with and actively engaging new partners in public health decision making and collaborative action, and measuring performance of these newly formed arrangements of collaboration to ensure increased efficacy of population-based interventions. These newly established policy supports are evidenced in the work of the Turning Point National Excellence Collaboratives, which, in some instances, are working across community and state jurisdictional boundaries for the first time to build shared capacity that is available to any interested party. Consequently, Turning Point is expanding the national public health infrastructure by adding and making available additional interconnections and capacities beyond those that previously existed primarily within federal, state, and local governments. Moreover, as information technology continues its rapid evolution, Turning Point clearly demonstrates that while poor health and quality of life impact people living, working, and recreating in specific communities and jurisdictions, the resources available for community generated solutions to impact the causes of health outcomes can be shared more broadly across the U.S. and hence be made more readily accessible to those responsible-as well as those interested-in protecting and improving population health and well-being.
The commentary writers in this issue were passionate in their views and were of two schools. One school recognizes that there is a danger in collaboration-the danger of abrogating governmental authority, responsibility, and resources to the private sector. Another school embraces collaboration across societal sectors as the only effective strategy for achieving public health's goals in the face of complex multi-factorial health problems. The Issue Editors agree strongly with the latter notion while recognizing that not all situations are amenable to the strategy of collaboration.
Turning Point has made great progress in some states and communities, but others are struggling. While we could not have possibly predicted at the time of Turning Point's commencement the tragic events of September 11, 2001, there is no stronger precedent in recent history that would better support the urgency to transform and strengthen America's capacity to protect and promote the public's health and well-being. Although we must keep in mind many cautions pointed to by the issue's commentators, the collaboration modeled in Turning Point is our path to improved health for the nation's population and our path to a better society.
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