Successful public health agencies recognize that meeting the challenges of the 21st century is more than expanding their budget or increasing their staff. Successful public health leaders recognize that to be successful, one must gain common recognition of community ownership for the health of the public. Accomplishing this task requires the understanding that achieving real public health improvement probably means moving beyond the statutory minimum mandates of the health department; accepting responsibility for ensuring the actions of a larger set of organizations for which the health department may not provide funding or necessarily regulate. The public health system is a term that describes the organizations and individuals who collectively share the benefits, burdens, and responsibilities for the health of a defined population or community. At the heart of most successful public health systems is a highly effective government public health agency that facilitates the actions of others in accomplishing systemwide goals. The degree to which the public health system is effective therefore is related, in large measure, to the effectiveness of the public health executive who, like an orchestra conductor, brings a divergent collection of sounds into harmony.

Turning Point embraces the notion that success comes from combined effort and shared vision. The objective of this bold initiative funded by the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation was to "transform and strengthen the capacity of State and local public health systems in the 21st century." 1 To accomplish this goal, they created incentives for public health agencies to think more expansively regarding their mission as well as the means by which this mission is accomplished. The experiences of three state public health systems in Louisiana, Montana, and Virginia are described within the framework of a public health system. Each of the organizations describes interaction with non-government organizations that played key roles in its plans for system transformation.

In Virginia, the interaction between the State Health Department and the Virginia Health Research and Education Foundation is described. According to Peterson and Lake (see article in this issue), "Turning Point came at a time when public health in Virginia had already begun to examine its relationship with various partners in view of changes in the health care market place. We were convinced that such a partnership outside government was necessary for systems change." The partnership provided the organizational vehicle by which the state public health system was organized and where productive work was accomplished in meeting the Turning Point objectives.

In Montana, the state public health system was organized in part through the Public Health Training Institute for the purpose of developing workforce strategies within a decentralized state public health system. The workforce training partnership recognizes the importance of bringing "system partners" together as they target participants who will be a "team" of state and local public health officials, tribal health officials, policy makers, private and non-profit health organizations staff members, and board of health members. In addition, the article describes the "valuable" contribution of an academic partner (the University of Washington School of Public Health) as having been instrumental in their success (see article by Reynolds and Leahy in this issue).

In the case of Louisiana, a new organization was established that brings together public health system partners in a formal organization: the Louisiana Public Health Institute (LPHI). LPHI is a state recognized non-government organization that-like nearly a dozen other non-profit public health institutes throughout the country-was formed to provide an alternative organizational structure for accomplishing public health system objectives through partnerships between government and non-government organizations. According to Kimbrell and colleagues (see article in this issue), "LPHI was independent of any one agency or sector, and yet representative of many. The sense of neutrality that LPHI provided was critical for bringing various partners to the same table and particularly for eliciting candid discussion about the challenges inherent in the current health system."

Each of the articles describes various organizational forms that have facilitated their development of state public health systems. They describe an acknowledgement of partner organizations toward a common goal and how they are working together to accomplish specific projects aimed at improving the health of the public within the state. Local health departments have reported similar experiences as they are implementing Mobilizing for Action through Planning and Partnerships (MAPP), a community health improvement process developed as a partnership between the National Association of County and City Health Officials (NACCHO) and the Centers for Disease Control and Prevention (CDC). 2,3 MAPP uses as its conceptual framework the local public health system as fundamental to the entire process.

In addition to community health improvement efforts, the state and local public health system framework is also common to the newly released National Public Health Performance Standards Program, which has as its primary goals quality improvement, providing tools for accountability, and building the science base for public health practice. The National Public Health Performance Standards Program is a joint effort between the American Public Health Association (APHA), the Association of State and Territorial Health Officials (ASTHO), NACCHO, the National Association of Local Boards of Health (NALBOH), and the Public Health Foundation (PHF). 4,5 The Performance Standards Program itself is an example of the national public health system with government and non-government organizations working together to bring about public health system improvement. The Performance Standards Program provides guidance through the use of comprehensive assessment tools that are used by state and local public health system partners in the assessment of organizational capacity and performance with an initial concentration on public health infrastructure.

Another concrete example of the public health system is in the recently enacted Frist-Kennedy Public Health Infrastructure legislation. 6 This law was designed to focus on building infrastructure to strengthen the public health system at national, state, and local levels. While grant funding from this law is aimed at state and local public health agencies, it is clear that government public health agencies act as the apex of action on behalf of the public health system. Whether it is preparing for a potential bioterrorism attack, addressing issues related to antimicrobial resistance, or addressing the reduction of risk factors for chronic disease, public health agencies work collaboratively with a variety of other organizations like hospitals, physicians, educational institutions, and other government agencies to accomplish these important goals.

Research on local public health agencies demonstrate that frequent interaction by the health department with other organizations within the community is linked to increased effectiveness of public health within the community. 7,8 It seems to make intuitive sense: public health goals are those related to the health of the entire community. The collective action of many different organizations in support of these common goals is much more likely to be achieved than when any one organization is tasked with the responsibility. For example, it seems highly unlikely that the public health department working alone would be able to make much of an impact on preparedness efforts for bioterrorism. Whether the issue is surveillance for detection of suspected bioterrorism agents or in the prophylactic use of stockpiled vaccines, the ability of the government public health agency to assume sole responsibility for all actions even with a significant increase of its current budget and staff seems implausible. Therefore, a focus on the government public health agency as the leader or facilitator of combined action seems both appropriate and necessary. To accomplish this role, significant improvement in the basic infrastructure of public health must occur. Each of the three primary areas of public health infrastructure recently was reviewed in a report to the Senate Appropriations Committee. 9 Explicit in the report was the importance of strong public health departments that work at the state and local level to mobilize action within the community to build strong public health systems.

Building and maintaining strong and effective public health systems is done neither easily nor quickly. As Mays points out in his commentary within this issue, there are many barriers to effective collaboration between multiple partners within the public health system. Much has been written about the success and failure of interorganizational relationships and those factors that facilitate or inhibit successful interaction. 10-14 One thing is certain: strong and effective leadership in building effective partnerships and systems is a critical component. Those of us in leadership positions within public health should become more knowledgeable and expert in this area if we expect to be effective public health leaders in this century. In the final analysis of our leadership ability, it probably won't be about how well we controlled our budget or grew our agency but how well the public health system performed when it faced the challenge. Certainly management is important, but leadership is critical if we expect to meet the growing expectations of our community.

According to Louisiana's Kimbrell, "As a result of Turning Point, it was apparent that it would not be sufficient to just do the same things more efficiently. To really address the challenges facing public health in the 21st century, things would have to be done differently."

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