In his new book, A Passion for Leadership: Lessons on Change and Reform from Fifty Years of Public Service, Roberts Gates has written the most candid and accurate summary I’ve seen yet of why public institutions are failing the American people (1). And Dr. Gates has the practical experience to back up his conclusions. He has served as U.S. Secretary of Defense, Director of the Central Intelligence Agency, and president of Texas A&M University. Presented below are three of his barriers to institutional innovation and reform and examples of how they relate to governmental public health based on my observations.
Public bureaucracies report directly or indirectly to elected officials. Gates says that the political interests of these officials (primarily getting re-elected), “are often in direct conflict with efforts to streamline or reform the institutions they oversee (2).” He used his attempts to reduce programs within the Department of Defense, which would have resulted in job losses in elected officials’ home districts, as an example of that conflict. Governmental public health suffers more from the every-changing political winds and shifting priorities of elected officials, principally governors. Their whims include strategic-less attempts to reduce the size of government, untested approaches to improving the health care system, and the appointment of health agency heads whose political agendas differ greatly from their predecessors and successors.
Elective bodies with oversight responsibilities are unreliable, unpredictable, and even irresponsible when it comes to the lifeblood of public institutions—funding. Well, amen to that! Oregon, the state in which I live, was ranked thirty-eighth in the nation on state funding for public health in fiscal year 2012-2013 according to the 2014 Trust for America’s Health report, Investing in America’s Health (3). The state spent $16.08 per capita on public health, which is $11.41 below the national median and $128.91 off of the state with the highest per capita funding (Hawaii). Nationally, public health’s share of total health expenditures has fallen from 3.18% in 2002 to 2.65% in 2014 (4). And let’s call that figure what it is— a pittance—especially given the political jawing by elected officials these days about the importance of prevention. Governmental public health has always seemed so far off of the radar of elected officials that I’ve often wondered how many of them could accurately describe just two of the discipline’s ten essential services.
(A funny side note on this point: During an emergency response a few years ago, an underling of the state’s elected leadership ordered the agency I worked for to make water. Not test it or regulate it, but make it. I did not envy the responder who had to ‘manage up’ and clarify the agency’s capabilities.)
Public health practice would probably disappear if it weren’t for the federal funds it receives for its programs. The discipline has become so politically irrelevant and powerless (except to the fellow who thinks it can create water) that if it did go away, many people may not notice—until the occurrence of another Flint, Michigan-style public health disaster.
The quality of the individuals elected or appointed to fulfill oversight roles of institutions is uneven. Gates talks about how these individuals “vary dramatically in expertise, diligence, understanding, and just plain smarts” (5). Public health practice has a rich history with this barrier. Few things are worse for the discipline than the appointment of agency heads who have no experience with it’s mission. Unfortunately, these appointees typically need to prove their value to their political bosses. Rather than follow the mantra, “first do no harm,” they take blundering actions that further damage the morale and activities of the agency. The favorite—likely because it’s the easiest —is to re-organize the agency, in part or whole, into a new structure that proves equally dysfunctional to the last one. These re-organizations do not work because they are superficial. It’s like putting a new coat of paint on a crack house. A new organizational structure does not touch the deeper dysfunction within.
(Another side note: It would be fun to do a survey of governmental public health employees and ask how many re-organizations they’ve lived through. My guess is that many have lost count.)
Dr. Gates also notes that these appointed individuals hope to be in their position for a short time. As a result, they “measure success by a yardstick other than effective management or successful institutional reform (6).” They see their appointment as a stepping stone to something more exalted. This certainly happens in governmental public health. The average length of tenure for a state public health official is 3.4 years (7). Because these politically savvy individuals know they will not be in their positions long, they search for a single high-profile, resume-building project they can successfully complete. Passing legislation to update laws is one example. They focus their attention almost exclusively on the selected project, complete it in a handful of years, stamp their name on it, and then move on. Professional success is fine, but it should not come at the expense of the health of the agency. Wouldn’t it be refreshing to have a health department director say at the start of his or her tenure: “My top priority will be to reform this agency into one that could win a Great Places to Work award.” If only…sigh.
The short tenure of agency heads makes the bureaucratic culture of governmental public health all the more impenetrable to reform. Employees tire of broken promises, vaporous pet projects, and newbies telling them how to do their jobs. They know the agency’s administrator or department director will not be around long, so they resist change by simply waiting out the person’s tenure. Back in 2007, one manager told me, after a negative encounter with a public health director, “I’ll be around a long time after she’s gone.” And she was right. She’s now on her third director.
Typically, employee resistance to change comes in the form of subtle work slow-downs. But I’ve seen more blatant approaches—such as the mid-level manager who told his staff to ignore the directions of his boss’ boss. This resistance game may be one reason why department directors become so isolated within their agencies. They know it’s too hard to produce change in the lower ranks, so they only focus on what can be accomplished by their small inner circle.
One also sees this barrier at work in who is promoted within governmental public health. Individuals who possess abilities that advance the discipline or reform the agency are not necessarily elevated to leadership positions. Rather, it is the person who dodges controversy, maintains the status quo, and bamboozles a superior or two about their competence that successfully climbs the ladder. Those are the qualities rewarded within dysfunctional public health agencies. That mid-level manager who told his staff to disregard orders from his boss’ boss? In one move, he was advanced two management levels and now oversees multiple programs in a topic area for which he has no background or training.
The next posting of Inside the Health Department will examine three more of Dr. Gates’ barriers to innovation and reform within public institutions.
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All the best! Kathy
- Gates, R. A passion for leadership: lessons on change and reform from fifty years of public service. New York, NY: Alfred A. Knopf; 2016.
- Ibid., 9
- Trust for America’s Health. Investing in America’s health: a state-by-state look at public health funding and key facts. http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf413110. Accessed Feb. 8 2016.
- Himmelstein D, Woolhandler S. Public health. Am J Public Health. 2016 Jan; 106(1):56-7
- Gates, 11
- Ibid., 12
- Association of State and Territorial Health Officials. Issue brief – state health agency workforce, 2014. Available at: http://www.astho.org/Profile/Volume-Three/Issue-Briefs/Workforce/. Accessed Feb. 8, 2016.