Turning Point is an enlightened initiative because of its inclusiveness and system-wide perspective. On a day-to-day basis, however, engaging a broadly representative group in this transformational process is very challenging. Synchronizing participants in productive, thoughtful work delivered in a timely manner requires constant effort.

One further challenge in Turning Point is managing dialogue with partners that each have responsibilities focusing on different geographic vantage points - (1) local, (2) state, and (3) those trying to create linkages between state and local partners. This article focuses on some of the constraints being experienced primarily at the local level and offers suggestions for addressing these constraints.

Barriers to Success

Shortages of talent, scarcity of resources, and an absence of proven solutions are not the most significant barriers to be faced in Kansas. Three significant, underlying barriers to success relate to (1) delivery of services, (2) allocation of resources, and (3) the nature of communications among stakeholders.

Fragmented Delivery - Delivery of public health core functions, personal care services, education, and other human services in Kansas communities, as elsewhere, is highly fragmented and varies from one community to the next. For example, multiple organizations (clinics, schools, health departments, etc.) provide immunizations locally, while records remain unconsolidated. This results in redundant service delivery and overly complex business processes. Consequently, county commissioners and taxpayers, witnessing competition and duplication of effort in their communities, express skepticism about the real need for additional resources.

Frozen Resources - The bulk of financial and human resources continues to be allocated to the preservation of "legacy" institutional systems that may not always correlate with innovation and collaboration. Budgets in many not-for-profit organizations and government agencies may be stable or declining. Further, most local, state, and federal funding is allocated to clinical and personal care services, not to core public health functions and preventive medicine stakeholders.

Faulty Communications - It is difficult to get a group of stakeholders to set other issues aside, convene a series of meetings, and synchronize their collective efforts toward a common goal. Other than sporadic meetings, communities have few formal channels for effectively communicating, achieving consensus, and implementing coordinated efforts involving multiple institutions. In other cases, poor working relations and inertia impede cooperation. Once organized, community coalitions must decide whether to (1) concentrate resource expenditures in specific neighborhoods or across the entire community, (2) implement programs or formulate policy, and (3) let each workgroup operate independently or encourage more coordinated action.

Strategies for Overcoming Barriers

The following are strategies the Turning Point partnerships in Kansas hope to employ to enliven participation and surmount some of these barriers:

 Strategy 1
Move Toward More Unified Delivery - The Kansas partnerships hope to promote a broader enterprise-wide or community-wide definition of organization that integrates individual organizations' accountabilities. This broadened sense of enterprise lends itself to a population-based framework for organizing and financing the delivery of public health, personal health, environmental health, and other community services.

 Strategy 2
Freeing Up Assets - Once a community-wide view is accepted, organizations can begin to identify ways to free up resources from legacy appropriations. One suggestion is reconstructing business processes by simplifying and combining them across organizations. This may start with stratifying functions across organizations that manage redundant operations (like information systems).

 Strategy 3
Facilitating Communications - Examining partnership structures in Kansas (e.g., linkages between workgroup members and the quality of on-going communications) may indicate where breakdowns are occurring. Also, adopting technologies designed to  promote collaboration and stimulate a more structured dialogue among stakeholders may facilitate progress.

Addressed above are three critical factors impeding the revitalization of the public health infrastructure in many local communities: fragmented service delivery, immobilized  assets, and ineffective communications. Adoption of a community-wide perspective may promote effective communications and release vital resources for use in prevention. The challenge in Turning Point will be to empower a significant number of individuals,  assume a system-wide perspective, reach consensus, commit resources, and synchronize actions aimed at a common goal. Success will be measured by the extent to which each of these objectives is realized.

Dr. Fonner is a member of the Turning Point State Partnership in Kansas and Executive Director of the Governor's Public Health Improvement Commission.