Counties as Service Delivery Agents: Changing Expectations and Roles

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Appropriation of the money through the existing cooperative agreements with the CDC requires that a portion of the emergency preparedness plans address workforce development and education. At the time of this writing, the plans were under review.

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However, it appears many states will use the opportunity provided by this funding to develop strong relationships with schools of public health for the assessment of public health workforce needs and the planning of multiple strategies to meet those needs. Opportunities to enhance the distance learning technology within states also have been provided, using a variety of methods. State health departments would be wise to use this time of resource availability to conduct their own training readiness inventory in order to foster organizational climates that favor strong workforce development programs.

The role of state health departments in assuring a competent public and personal health care workforce has been described in the National Public Health Performance Standards Program, Essential Service 8 ensuring a competent public health and personal health care work force which identifies the responsibilities of state public health departments as including the education, training, development, and assessment of health professionals—including partners, volunteers, and other lay community health workers—to meet statewide needs for public and personal health services. Responsibilities also include the development of processes for credentialing technical and professional health personnel, the adoption of continuous quality improvement and life-long learning programs, and the development of partnerships with professional workforce development programs to assure relevant learning experiences for all participants.

Continuing education in management, cultural competence, and leadership development programs are also responsibilities of the state public health agency. The National Public Health Performance Standards identify indicators of success for a state public health agency to utilize in evaluating whether it is meeting the workforce development needs of its jurisdiction. Indicators of success include the following:.

Identification of the workforce providing population-based and personal health services in public and private settings across the state and implementation of recruitment and retention policies. This indicator includes an assessment of the number, qualifications, and geographic distribution of the public health workforce statewide. Provision of training and continuing education to assure that the workforce will effectively deliver the Essential Public Health Services. These plans involve resource development programs that include training in leadership and management, multiple determinants of health, information technology growth and development, and support of competencies in the specific health professions.

The state public health agency should be instrumental in assuring that these functions are conducted, regardless of whether the agency provides the functions directly or facilitates their provision. Provision of specific assistance, capacity building, and resources to local public health systems in their efforts to assure a competent public and personal care workforce. This indicator includes the collaborative development of retention and performance-improvement strategies to fill.

State public health agencies, working in collaboration with local public health systems, can develop incentives that support workforce development activities. Evaluation and quality improvement of the statewide system for workforce development. These reviews would include current and future workforce distribution and continuing education needs as well as public health system assessment for its success in meeting those needs.

The public health system in the United States has been described as being ill-prepared, in disarray, and under-funded to meet the current much less the future needs of the population IOM, Attention is being paid to the development of multiple strategies to strengthen the public health infrastructure.

If these strategies are to be successful in the future, the developmental and educational needs of the public health workforce must be addressed.

If the historic underfunding of public health human resource development continues, the public health system as a whole will be further weakened. State public health agencies, working in partnership with local public health systems and the federal government, must take the lead in strengthening the quality of the public health workforce.


Federal agencies are important to the development of the public health workforce generally, and specifically to the education of public health professionals. The roles of these agencies have included developing the research base that provides education; testing educational approaches; helping schools develop infrastructure; supporting faculty development; and providing funding for students. They are located within the Department of Health and Human Services DHHS , but the size of the department and the diversity of missions of the component units makes it critical that the discussion be specific to the individual agency.

BHPr puts new research findings into practice, encourages health professionals to serve individuals and communities where the need is greatest, and promotes cultural and ethnic diversity within the health professions workforce. The bureau identifies several specific programs for the public health workforce:. Public Health Training Centers assess workforce learning needs and provide tailored distance learning and related educational programs.

Public Health Special Projects community and academic partnerships improve skills and competencies of the public health workforce, provide distance learning, curriculum revision, and course content in areas of emerging importance. Public Health Traineeships train eligible individuals in public health professions experiencing critical shortages. Preventive Medicine Residencies support existing and develop new residency training programs, and provide financial assistance to enrollees.

Health Administration Traineeships and Special Projects increase the number of underrepresented minority health administrators and the number of health administrators in underserved areas, support academic and practice linkages, and develop outcomes-based curricula. The most recent visible activity of HRSA in public health workforce development has been the funding of 14 Centers for Public Health Training, supporting school of public health-based efforts to strengthen ties between practice and academics, offer improved distance-based continuing education, and work toward a stronger, more diverse public health workforce.

The Public Health Practice Program Office has provided a home base for the multi-organization Public Health Workforce Collaborative, begun in partnership with HRSA and involving nearly every identifiable organization representing some segment of public health workforce develop-.

Counties as Service Delivery Agents: Changing Expectations and Roles

The OWPP assures coordination and accountability for implementing the strategic plan, oversees the development of workforce policies and standards, and convenes partners, as needed, to address issues and to provide support and technical assistance. The goal is to improve the ability of public health workers, nation-wide, to perform the essential services of public health, and to prepare the workforce to respond to current and emerging health threats. This specialized activity has eclipsed the more general support for implementing the Strategic Plan for the Development of the Public Health Workforce created in The potential roles for federal agencies in developing the public health workforce for the 21st century could take several forms, and are in the following categories:.

The education of public health professionals is built on a very slender research base. There is little or no research to support advancing the M. Neither is there a research base on the relationship of staff preparation to outcomes of public health programs.

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While there has been discussion of building a public health systems research base parallel to that available for studying questions about personal care and the medical care system , only the first steps have been taken. The federal agencies, especially CDC and HRSA, should make funds available for this important research, either as specifically funded studies or as components of other research portfolios.

Federal agencies should continue to support schools of public health and other institutions that train public health professionals e. This support could come in the form of institutional grants that can allow for faculty time to develop new courses, development of information technology to support education, support for student experiences in practice settings, and travel to meetings with others developing similar programs.

Special attention should be paid to developing collaborations that can assure that the best of public health education is shared across schools, and re-invention of programs is kept to a minimum. A council parallel to the Council on Graduate Medical Education that is charged with continuous monitoring and improvement of the public health workforce development process could be an immense aid in this effort.

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Federal agencies are in an ideal position to support faculty development. Creation of grants such as those already in place at NIH to support new biomedical and clinical researchers should be explored. Support might take the form of institutional grants e. Other support could be through individual grants e. Expanding the opportunities for early and mid-career faculty to do short-term rotations in government, private, or voluntary public health organizations would foster linkages between academic public health and practice, and the development of the research base.

Fellowship programs to assist those who have extensive practice experience but lack the credentials for academic appointment could bring more practitioners into the ranks of those teaching public health. At one time there were individual fellowship programs that provided financial support to persons employed in public health but lacking finan-.

These programs have become scarce, making it more difficult for persons recruited to public health in mid-career, as is often the case, to obtain the additional training that would make them even more effective and that would encourage them to continue in public health practice. A new degree-oriented fellowship program might include support during pre-professional training to persons who make a commitment to specialty education and later practice, as well as support in collaboration with employing agencies for return-to-school programs for persons already working.

Special attention should be paid to using this student support as a mechanism for increasing the racial and ethnic diversity of the public health workforce. While federal public health agencies have supported much technical and programmatic education for workers in federally funded public health program areas, the more recent work to make this education available via distance technology and to assure that it carries continuing education credits appropriate to the intended audience must be expanded.

It may be that the CDC Public Health Training Network described in Chapter 2 is best suited to acting as a mechanism for disseminating information about programs of suitable quality and connecting the workforce to the rich range of opportunities available. It is also critical that the federal agencies involved in public health practice attend to the continuing education of their own workforce, assuring that federal staff are not only technically competent in specific programs, but also that they are kept abreast of evolving organizational, ethical, and communication concerns of the practice community.


Much attention has been paid to the uneven availability of current information technology across the range of organizations engaged in the public health enterprise. CDC has paid particular attention to this and has invested significant funds in assuring at least a minimum of Internet connectivity for state and local public health agencies. As communications technology and teaching and learning technology continue to advance, federal agencies are in the best position to evaluate the applicability of these advances to the range of practice and educational settings and to provide incentives or other support for adoption of technologies deemed most likely to support an effective public health workforce.

Such a role should not, however, be carried out in a vacuum but, instead, in partnership with practice agencies and schools. A final role that federal agencies can play in supporting the education of public health workers in the 21st century is modeling the best of what is known in recruitment, promotion, and retention policies. This would include assuring that all position descriptions for public health workers are based on public health competencies as developed by the field. Position announcements and recruitment should recognize as many currently do the importance of formal education in public health.

When federal agencies hire persons who lack public health education for particular specialized tasks, on-the-job training, continuing education, and opportunities for formal education should include, at a minimum, a basic orientation to the core competencies in public health. Worker developmental activities should continue to include opportunities for short- and longer-term rotations to other practice agencies and to academic institutions, which are mechanisms through which the overall public health enterprise can be enriched and enlivened.

The presence and leadership of these important federal partners in the public health enterprise cannot be overemphasized. Neither can the need for them to proceed in ongoing partnerships with the range of academic and practice agencies contributing to the same overall goal. Local, state, and federal health agencies all play a critical role in educating public health professionals for the 21st century. Local health departments are the backbone of service in public health, meeting a broad range of public health needs of the diverse communities within their jurisdictions.

To be able to engage in the most effective public health practice, practitioners in local health departments must be well educated and trained to fulfill their roles. To assure this is the case, we need to know what services they provide, and what skills and knowledge they need to ensure that their levels of competency are maintained and improved through appropriate training and educational opportunities.

At the state level, state health departments facilitate the implementation of the Essential Public Health Services either by carrying out these services directly or by supporting the efforts of the local public health agencies. One of these essential services is to assure a competent public. The state health department, in cooperation with local and federal public health agencies, has a major role to play in facilitating the competency of the public health workforce.

Finally, as described earlier, federal public health agencies are crucial to the education of public health professionals and the development of the public health workforce. Federal agencies can and must play important roles in many areas as discussed earlier in this chapter.


These areas include public health research, development of academic programs, development of faculty, support for students, continuing education, technology development, and modeling. The importance of leadership and action at the federal level is critical to success in educating public health professionals if the public workforce is to meet the challenges of the 21st century.

Therefore, the committee recommends that local, state, and federal health agencies:. Assessment of workforce education and training needs and development and implementation of programs to meet these needs are major roles for local, state, and federal agencies. The issue of workforce training and competency is central to the success of any public health system. Ideally, every. While local, state, and federal agencies all play a role in developing a competent workforce, there is a role that is primarily the responsibility of federal agencies, that of providing funding to support efforts throughout the system.

As detailed in Chapter 2 , public health teaching, research, and infrastructure support were well funded during the s and s. Major reductions in funding occurred during the s, with little or no improvement during the s. Meanwhile tuition and other costs increased substantially, with the result that a reduction occurred in the amount of public health professional education actually provided. Renewed interest in public health and the promise of increased funding may mean that needed investments to strengthen the public health infrastructure and workforce will be forthcoming.

However we must ensure that funds are used for more than crash courses in a particular topic area e. We must also build the framework that will allow us, over the longer term, to ensure that public health professionals are prepared with the skills and knowledge necessary to improve population-level health. This means that increased funding must not only be a short-term response to a specific need but, instead, must be sustained over the long term.

Such funding is crucial to developing the educational and research infrastructure necessary. The committee has carefully considered the rationale and feasibility of implementing recommendations to significantly enhance federal funding for both public health education and leadership development and for public health research overall, including research on population health, public health systems, and public health policy. Investment in public health education is inadequate. Federal support for non-physician graduate-level public health training is minimal, as described in Chapter 2.

Therefore, the committee recommends that federal agencies provide increased funding to. It is extremely difficult to specify needed funding levels, given the weak data base on public health outcomes, public health programs, and public health education. This has serious consequences for efforts to mobilize civil society organizations in developing countries.

In practice, donors need to have a much deeper understanding of the configuration and capacity of civil society in the specific locations where they intend to intervene. Donors must also recognize that NGDO efforts, while useful, are limited, and that they cannot substitute for those of the wider civil society. The tasks NGDOs set for themselves, and the expectations of those that finance them, are complex and probably too demanding. They cover most facets of social development: reducing poverty and exclusion; improving access to basic services; conflict prevention; fostering democracy; influencing public policies, etc.

NGDOs also function at multiple levels, from the individual, through households and intermediary institutions into the arena of international relations, conventions and commitments. However, evidence suggests that the NGDO contribution to social change is less substantial and durable than imagined. NGDOs would like to do better and are doing something about it themselves. However, they are limited in this by the unfair, power-imbalanced and donor-serving framework of aid that they operate in. At the same time, NGDOs remain substantially aid-dependent and vulnerable, which can result in questionable motivations and behaviour.

Under existing rules, most recipients of aid are relatively powerless and are kept that way. And this power imbalance generates perverse incentives for aid recipients. It blocks their necessary ownership of and commitment to change. The organization has set up a virtual college, which offers accredited learning and technical training focused on developing competencies in areas like customer-service and call-center skills. Consequently, Centrelink wins consistent acclaim for its customer satisfaction—91 percent of customers agree that staff treated them with respect and 82 percent felt that staff had told them everything they had to know to get the service they needed.

Back-office operations are an equally important part of improving the citizen experience. In fact, speed, simplicity, and efficiency—factors largely driven by the back office—are often the most powerful drivers of citizen satisfaction. Since most customer journeys touch different parts of government, agencies may want to reorganize themselves and their relationships with other departments to create cross-functional teams responsible for the end-to-end customer journey.

In , the agency created Injaz Hall, which standardized application processes for car licenses and building permits, for example across 44 municipalities in nine governorates. This initiative went beyond creating the front-facing one-stop shop—it included more fundamental organizational and process changes, including an integrated IT system. An integrated IT system across municipalities facilitates and improves the quality of not only front-facing services but also back-end administrative procedures. In addition to setting the stage for improved customer satisfaction, this cross-cutting data-sharing approach has enabled the ministry to better plan for new infrastructure projects in each region.

Capability building is a critical part of any transformation program. In the case of citizen-satisfaction transformations, government leaders can use a citizen-centric approach to designing performance management and governance systems so they can continue to drive—and sustain—improvements. When government leaders measure entire journeys, not just touch points, they might want to consider adjusting their performance metrics and analytics accordingly.

This means not just capturing top-line citizen satisfaction with each journey but also their satisfaction with individual factors that affect satisfaction along the way; for example, not just the process of obtaining a permit but also the time it takes to do so. These metrics can then be embedded into a performance-management system. Of course, metrics and performance management are in many ways a means to an end—the ultimate goal is to promote continuous improvement.

Citizencare forums can help. These forums consist of small, cross-functional teams of employees who review decisions that affect the public. Each forum reviews performance-management results, escalates issues to higher-level managers, and also directs feedback downward. Frontline-level forums can take the form of daily huddles to discuss results and resolve issues. Leadership-level forums could be quarterly meetings to review overall citizen service performance or to approve resource allocations.

Although governance models for citizen transformation programs can take different forms depending on the context in which they are operating, most have three things in common. Second, because a single citizen journey can require multiple handoffs among departments or agencies, effective governance models define clear accountability across each function that is involved. Finally, citizen transformation governance models separate governance policy and operations. Policy governance focuses on top-line metrics and monitors overall quality of service to design and maintain a unified, positive citizen experience.

Operational governance tracks citizen satisfaction and metrics at the channel and journey levels and encourages improvements by designing and carrying out customer-care initiatives at a process level. As with any transformation effort, leaders will want to encourage role modeling and will have to invest time as well as financial resources to build the skills and capabilities necessary to deliver and sustain change.

By taking a citizen-centric approach, leaders can better understand the needs of their citizens and translate those needs into targeted, effective service-delivery improvements. In doing so, they can increase citizen satisfaction and also reduce costs. McKinsey uses cookies to improve site functionality, provide you with a better browsing experience, and to enable our partners to advertise to you. Detailed information on the use of cookies on this Site, and how you can decline them, is provided in our cookie policy. By using this Site or clicking on "OK", you consent to the use of cookies.

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Counties as Service Delivery Agents: Changing Expectations and Roles Counties as Service Delivery Agents: Changing Expectations and Roles
Counties as Service Delivery Agents: Changing Expectations and Roles Counties as Service Delivery Agents: Changing Expectations and Roles
Counties as Service Delivery Agents: Changing Expectations and Roles Counties as Service Delivery Agents: Changing Expectations and Roles
Counties as Service Delivery Agents: Changing Expectations and Roles Counties as Service Delivery Agents: Changing Expectations and Roles
Counties as Service Delivery Agents: Changing Expectations and Roles Counties as Service Delivery Agents: Changing Expectations and Roles

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