When Budgets Shrink, Mission’s Must Converge

Or…How to Improve Our Quality of Life and Get Maximum Leverage from Limited Public Resources by Integrating Complementary Aspects of Policy & Programs in Transportation, Health, Development, Environment, Energy – and everything else!

I was once one of those people who joined in the American chorus of contempt about the inefficiency and incompetence of public programs.  Until I began working in the private sector.  I quickly learned that the dearth of really good managers, the culture of petty bickering and buck-passing, the incredible lack of inter-departmental coordination and inter-subsidiary synergy was just as common in business as it was in government – if not worse because it was hidden from public view behind the narrow window of bottom line results.  So long as the ink was black, internal corporate operations could get away with utterly amazing amounts of wastefulness, nastiness, short-sightedness, and bungling – often because the competition was doing the same!

But times have changed.  We now need to rethink the way we do business or run public programs.  We need to foster a new kind of leadership, one that uses resources to catalyze and shape broad coalitions rather than go it alone.  And it is likely that public health, with its history of concern for the built environment and population-wide campaigns, might be the right base from which to make this happen – in transportation, land use, energy, environment, and community development. 

Our society has run through the incredible wealth we inherited via expropriation of Native American land and slave labor, emerging unscathed from two World Wars, and inheriting Europe’s international commercial dominance.  We’ve spent it, too often in ways that didn’t replenish our domestic productive capabilities.  Now, it’s gone.  As a result, Thomas Friedman wrote in his NY Times column (“The Fat Lady Has Sung”, 2/20/10), we’ve now moved from the “fat years” to the “lean years,” from government’s being able to give things away based on an assumption of future growth to “taking things away… to trim, to fire or to downsize services, programs or personnel.”

This puts the public sector in a particularly difficult spot.  From the time that humans first gathered in tribes we’ve come to expect that our increasingly complex collective organization would help us through the lean years.  It’s the government’s job to not only help people help themselves but to fill the needs that can’t be otherwise met.  But today, while it is likely that needs will increase in coming years, it is also likely that there will be fewer resources available to meet them.

Furthermore, the best chance we have to replenish our resources is to upgrade the systems we depend on:  transportation, energy, construction, manufacturing, health, and all the others.   This, too, has become more difficult because as the world we live in gets more complex, the more its different systems interact.  Transportation shapes land use, which creates the context for economic development, which impacts food and housing patterns, which influences family structures and community dynamics, and on and on with endless permutations.

While all these systems involve both private and public sector actors, it is the public sector that ends up providing or facilitating most of the investment.  And the public sector is, and is likely to remain, in a jam as revenue shortfalls have crashed into escalating social needs, infrastructure requirements, and future growth expectations.  How to do more with less?

One strategy for dealing with the situation is to foster greater coordination among agencies dealing with once-separate issues.  For example, Transportation decision-makers need to become responsible for more than mobility.  They need to also, directly or indirectly, be concerned with fostering lower energy use, reducing pollution and noise, facilitating physical activity, encouraging “smart growth,” and much more.  Environmental leaders need to not only think about clean water and air but also about the development of “green jobs,” better insulated buildings, and more efficient vehicles.  Public Health has to get involved with zoning and the fresh food delivery system as it broadens its scope to include “primary prevention” – improving the built and social “determinants of health” that help people stay well.

Progressive public leaders have always been aware of the inter-connection of each of their areas.  But it has often been difficult to operationalize these insights – the demands of their own primary mission have been difficult enough to address, much less any “secondary” issues.   However, today’s circumstances require a fresh appraisal that starts with the understanding that Government’s true value is not the sum of its separate actions but the totality of its presence, the synergistic impact of everything it does.

The good news is that many state and community agencies, including many in New England, have been exploring ways to leverage their overlapping missions or to simply explore ways they can adjust their operations or policies to reinforce other public sector goals beyond their own primary function.  Massachusetts’ Healthy Transportation Compact brings together the Secretaries of Transportation/Public Works, Energy/Environment, and Health/Human Services to create a sustainable, health-promoting, transportation system.  And the state’s Mass In Motion wellness campaign builds on the all-encompassing “Shape Up Somerville” model to involve mayors and private sector leaders.  In Rhode Island, government office buildings are hosting Farmers’ Markets and sponsoring “Shape Up” Teams.  In New Hampshire, the HEAL program is using its grants to foster local coalition building to bring together public, private, and non-profit leaders with the ability to coordinate medical “walking prescriptions” with improved intersection safety and construction of new bike lanes.  Maine, Connecticut, and Vermont have similar examples.

Common to all these efforts is a new framework for thinking about public sector activity.  Instead of running programs, public agencies are now trying to facilitate the creation of broad campaigns.  Instead of being in charge, they are now trying to partner with everyone.

However, these efforts – and others like them – are still seen as experiments rather than as standard operating procedure.  It is time to expand awareness of their existence and value to more decision-makers and a broader audience.  While not all of them are explicating about public health, it seems that many have public health implications – especially from the perspective of primary prevention – and that public health might be a good umbrella under which to gather people together to begin the process.

Unfortunately, as government budgets shrink it is often the Public Health prevention programs that are most drastically reduced – pot holes are visible, future health impacts are mere possibilities.  But Public Health, at its best, if precisely about long-term, population-wide, primary prevention – creating the conditions that promote wellness and keep people from getting sick in the first place.  It is possible that Public Health’s best chance of continuing relevance during this difficult time is to make convergence one of its core strategies – to take the idea of “health in every policy” from slogan to operational imperative.  It is likely that there are more situations where the mission of non-health agencies has significant overlap with Public Health as there are situations where the missions are inherently in conflict.  And even if their missions neither overlap nor conflict, there may be possible to make minor “tweaks” in the programs so that they reinforce each other, even if from a distance.

The first step should be an information gathering process to identify as many of these convergent efforts as possible around New England, particularly those with a Public Health impact.   A series of small seminars would then bring together the people involved in creating convergence to share experiences, lessons learned, and strategic insights.  All of this would be summarized in a report describing and analyzing these innovations.  This will be followed by a conference pulling together key public sector and non-profit decision-makers to discuss this emerging best practice and explore ways it can be effectively used in their own areas of activity.  If appropriate, academics from relevant fields will be asked to provide overviews of the historical, legal, and operational basis and challenges for converging strategies.  Regional media will also be invited. The report, conference presentations, and related materials will be published on the web.

The goal of all this is to help define and promote this important strategic trend, bringing together the state and local leaders – as well as some national pioneers – who are already trying or interested in trying it, and set the stage for its continued expansion.

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