Decentralization in the New York City Department of Health: Reorganization of a Public Health Agency ANTHONY C. MUSTALISH, MD, MPH, GARY EIDSVOLD, MD, MPH, AND LLOYD F. NOVICK, MD, MPH
Abstract: Since the World War I era there has existed within the New York City Department of Health a basic internal struggle between staff directing the bureaus at the central office and the district health officers operating field health centers throughout the city. Recently, in a five-year period, there was a dramatic reorganization of the Department which markedly affected its orientation and programs. In 1972 a new Commissioner initiated a reorganization of the Department which succeeded in decentralizing field opera-
tions in contrast to earlier efforts which had failed to reach this objective. The roles of bureaus and districts were redefined, with the latter receiving budgetary authority, authority to supervise personnel, assignment of health managers, and the implementation of a district cost accounting system. While operational decentralization has occurred, policy setting and resource allocation in response to local needs remain central functions. (Am. J. Public Health 66:1149-1154, 1976)
Introduction
success, their right to direct and supervise resources and staff within the various clinics and health centers. Many bureau directors were nationally known specialists with recognized competence and expertise in their field. Using a categorical approach, city-wide efforts in Child Health, Venereal Disease Control, School Health, and Tuberculosis Control were successful in improving the public health of New York City. This success supported an organizational structure where bureau directors were in charge. The generalist or district health officer, typically, had only marginal input into field operations of his or her own district. As "generalists" they were not recognized as "experts" within the Department of Health, but were viewed as "coordinators" of the various specialized operations under the roof of the district health centers. In contrast to this view, district health officers claimed that local services could not effectively meet local health needs unless budgetary authority and direct responsibility for the personnel working in clinics were placed in their hands. This problem is not unique to the New York City Department of Health, but it is inherent in any agency effort to decentralize authority. The conflict was a major theme in the New York City Department of Health as documented in a study by Herbert Kaufman covering a 40-year period up to 1958.1 The present report describes a five-year period in which there was a significant reorganization of the Department which markedly affected its orientation and programs.
The function and effectiveness of governmental agencies are dependent upon the interaction and relationship of personnel, organizational structure, and resources. Appropriate organizational structure has long been a subject of debate. Centralized decision-making at headquarters versus decentralization of authority at field locations both have proponents in the administration of large and complex agencies. Many of the classic elements illustrating organizational ambivalence and controversy are illustrated by the experiences of the New York City Department of Health. The New York City Department of Health has played a prominent role in protecting the health of the public and providing health care services since the New York City Metropolitan Board of Health was formed in 1866. Since the World War I era, conflict existed within the Department between personnel directing bureaus at central office and district health officers operating health centers throughout the city. Sporadic internal struggles occurred between central and field staff over policy, operation, and control of Department services in district health centers. Throughout most of this period chiefs of the specialized bureaus asserted, with much From the New York City Department of Health. Address re-
print requests to Dr. Anthony C. Mustalish, Deputy Commissioner,
NYC Department of Health, 125 Worth Street, New York, NY 10013. Dr. Eidsvold is Regional Health Director, Bronx, and Dr. Novick is Associate Commissioner, NYCDH. This paper, submitted to the Journal in March 1975, was revised and accepted for publication August 10, 1976.
AMJPH December, 1976, Vol. 66, No. 12
Background When the Department of Health was formed in 1866, or1149
MUSTALISH, ET AL.
ganization was along functional lines with Sanitary Inspections and Vital Statistics being the first of the bureaus. Child Hygiene, Public Health Education, Infectious Diseases, Laboratories, and other bureaus were later formed in response to a need for other services. Even after the establishment of 30 local health districts in the 1930s, the Department continued to be administered along functional rather than areal lines. At the time of the Kaufman study in 1959 the bureau directors prepared budgets for their services in the districts, hired personnel to deliver these services, and had regional supervisors who directed the services. Conflicts arose frequently between the central bureau director and the district health officer, with the latter believing that his knowledge of community people, facilities, needs, and priorities made him the logical director and coordinator of district health services. The impetus for decentralization came from a recognition of the complexity of a metropolis such as New York City, the changing focus of public health, and the need to provide an integrated broad spectrum of specific health services to communities. Commissioners, from S. S. Goldwater in 1915 until the present, have expressed the desirability of having health districts in order to provide coordinated services closer to the people. They attempted from time to time to decentralize district operations in order to respond to this aspiration. The decentralization pendulum swung between districts and bureau directors, creating conflict which Commissioners attempted to resolve by issuing executive orders, establishing high level positions in central office for district representation, and by increasing the number of district health officers. The Kaufman study documented the dual channel of administrative decision-making within the New York City Department of Health. Kaufman cited five factors which inhibited local district administration. They included: 1. The tradition of distinguished authoritative bureau directors who set program policy; 2. Professional rapport between the central office specialists and field specialists assigned to the district health center; 3. Ease of communication between the bureau officials and district staff; 4. Lack of local public interest constituencies to support the district health officer; and 5. Departmental policy that technical matters were within the bureau's area of expertise. At the time of the Kaufman study (1959) there were five borough director positions (New York City has five geographic sub-divisions known as boroughs, which also function as counties). The borough director was intermediate between the district health officer and an Assistant Commissioner for District Health Services. Kaufman predicted that neighborhood districts would be allowed to languish and that emphasis would be placed on boroughs rather than districts as a new unit of administration. Borough directors, however, were unable to develop an effective role. The districts continued to be administered in the same way; strife between the district health officer and the bureau director continued as well. Lacking authority, the 1150
district health officer was unsuccessful in integrating the variety of programs for which he was responsible. The borough directors, in effect, became merely another hierarchical level between district health officers and the Commissioner.
1959-1966 Until 1966 little change occurred in the Department's administrative structure. Internal programmatic changes did occur, however, influenced by the external, social, and political changes of the 1960s. In the early 1960s there was increased community demand for ambulatory care services and federal funding became available at the same time. In attempting to respond, the Health Department established a pilot geriatric unit, pediatric treatment clinics, and a generalized medical care program for all ages in certain areas. Prenatal services, which had been discontinued shortly after World War II, were re-established. Tuberculosis clinics started treating other diseases of the chest and became affiliated with hospitals. By the end of 1965, 14 of the 22 districts provided one pr more of these medical care services that were once outside the purview of public health. Although several Commissioners stressed, during this period, the principle that the district health centers should integrate therapeutic with preventive medicine, all these efforts were planned, implemented, and directed by bureau directors.
1966-1971 The changes which ultimately contributed to another shift in emphasis from central office to the community and district health centers took place during the period 19661971. This shift can be ascribed to a convergence of the following forces favoring decentralization: 1. National legislation supporting local programs; 2. City administrative reorganization; 3. Resurgence of community activism and participation in health services; 4. Community demands for improved health services; and 5. Ineffectiveness in the delivery of municipal health
services. Federal legislation was important in creating a favorable climate for local change. The Economic Opportunities Act of 1964 and its subsequent ammendment in 1966 allocated funds for neighborhood health centers. Eventually, seven of these centers were established in New York City with "maximum feasible community participation" written into the guidelines. This new concept encouraged community antipoverty agencies to generate requests for health services. These requests called for the creation of neighborhood family care centers and the augmentation of Health Department services at the local level. The Model Cities and Comprehensive Health Planning legislation also mandated resident consumer participation and planning of services and accentuated the movement in which communities asked for an increase in health care. Federal legislation promoted the AJPH December, 1976, Vol. 66, No. 12
DECENTRALIZATION IN THE NYC HEALTH DEPARTMENT
setting up of local community organizational structures so that requests from the community came first to the district health officer. In turn, many of the district health officers helped the community groups plan their programs and forward these proposals to city or federal health officials. District health officers in East and Central Harlem, Central Brooklyn, and the South Bronx played important roles in assisting the community to plan Model City health programs. In the course of this activity, district health officers formed close relationships with various community groups. The district health officer, with his still limited authority to improve services, was now placed in a new role. Community demands were being made upon the "downtown" Health Department, or Central Office. The Central Office in turn began to rely on the district health officer for assessing community health needs and services so that the Department could make an appropriate response.
The Health Services Administration In 1966 Mayor John Lindsay appointed the Commission on the Delivery of Personal Health Services (Piel Commission) and charged it "to make a thorough inquiry into the institutional, administrative and fiscal aspects of the system through which public funds deliver personal health services to one-third of the people of New York City." In 1967 the Commission reported to the Mayor and its recommendations included the consolidation of city health agencies into a single Health Services Administration and the creation of a
nonprofit Health and Hospitals Corporation. A city superagency, the Health Services Administration, was formed in 1967 and included the Department of Health, Department of Hospitals, Department of Mental Health, and the Medical Examiner's Office. The Health Services Administration (HSA) was heralded as an effort that would result in improved planning and administration of municipal health services. For the first three years physician administrators directed the agency. In 1970 the first non-physician administrator was appointed to this senior health position in city government. Large numbers of planners and analysts were recruited to staff the superagency which produced a planning, productivity, and management-oriented agency. New lead poisoning and methadone maintenance programs were started outside of the traditional bureau structure. The costs for superagency staff and new programs were met, in part, through diversion of Health Department operating funds from other programs. The authority of the Commissioner of Health and bureau chiefs diminished due to loss of staff, restrictions on hiring, and inability to begin new projects. Bureaus which once had the ability to direct services were bypassed in the decision-making processes concerning public health programs and operation. Introduction of treatment services in Department of Health child health stations, for example, was planned and implemented by superagency staff with virtually no involvement of the Bureau of Child Health. In late 1971 management staff from the superagency analyzed service provision at a district health center and found AJPH December, 1976, Vol. 66, No. 12
poorly administered clinics where no single person was held accountable for performance. Nurses reported to several different supervisory personnel, as did other staff. In one clinic (venereal disease treatment), the physicians and nurses reported primarily to the central Bureaus of Venereal Disease and Nursing but related also to the district health officer while clerical personnel reported to the health officer; outreach staff reported to still another central unit. This pattern was repeated for every clinical service in the district health center. The findings of the superagency analysts pointed to a lack of accountability for operations and the inability to implement change with this administrative structure. A subsequent HSA report recommended that one individual be assigned responsibility for district health center operations and that a reporting system be developed to measure and evaluate district activities.
1972-1975 In January 1972 the HSA administrator selected a public health physician as the new Commissioner of Health. This Commissioner and the newly appointed First Deputy, a nonphysician administrator, instituted another reorganization of the Department of Health. Over the next 18 months, major innovations in structure and function resulted in the most significant change in the administration of Health Department district services since the local health district concept was espoused by Commissioner S. S. Goldwater in 1915. The new Commissioner set out to overcome many of the obstacles that thwarted previous attempts at reorganization. He reviewed all bureau programs, policies, and services and met with all bureau directors and district health officers to prepare them for administrative changes. The Department had a long tradition of general staff meetings which were almost always held at central office. These were now to be held at the district health centers to bring to the forefront district operations and problems. At the first meeting in a Brooklyn center, the Commissioner opened by announcing that "the day of the districts has arrived." A plan for administrative decentralization of personal health services* was outlined that redefined the roles of bureaus and districts and included transfer of budgetary authority for local services to the districts, assignment of district health managers, and the implementation of a district cost accounting system. An executive order was issued that requested bureau directors to submit for discussion a "list of functions over which ... the bureau would retain control, and the reasons therefor."2 The redefined role of the bureau in district health services* was to be that of evaluation and standard setting. Other health service programs operated by bureaus were not affected. The Bureau of Child Health continued operational responsibilities for day care centers where they assigned physicians and operated the health programs in these centers. *Environmental health services were not involved in the decentralization scheme. 1151
MUSTALISH, ET AL.
The responsibility of the Bureau for Handicapped Children remained intact for delivering health services to special schools and centers for the handicapped. Specialized tuberculosis chest clinics, located in hospitals for the treatment of tuberculosis patients who have other diseases, remained the responsibility of the Bureau of Tuberculosis. District Health Services were the focus of the decentralization efforts. These efforts resulted in the "giving of responsibility and authority for operation to the district health officer."2 Most bureau directors were reluctant to give up the operational functions, claiming as their predecessors have done that their expertise was needed in the day-to-day delivery of
services. The Commissioner responded through issuance of an executive order stating: (1) "No position for an employee who is to work in the health district shall be filled without obtaining clearance from the appropriate district health officer"; and (2) "No employee shall be transferred into or out of a district without the approval of the affected district health officer."3 Initially this order was violated. The Commissioner supported the health officer in these conflicts and eventually he received compliance from the bureau directors. Lines of communication were established between the Commissioner and the district health officers. A formal channel of communication was created through the formation of the Health Officers Advisory Committee which met periodically with the Commissioner. The Committee worked with bureau directors in establishing policies that were to be implemented in the districts. While the bureau structure was revised to permit decentralization, the administrative structure at the district level also underwent change. There was recognition that a district health officer would need staff support to assume the increased responsibility for operations. The First Deputy Commissioner recruited district health managers, a new category of health personnel, who were assigned to district health centers after being interviewed by the health officer. The health manager reported to the health officer and was made responsible for the day-to-day operation of all clinical and administrative services within the districts. By July 1973, 20 of the 22 health centers had managers. Conflicts developed during this period between the managers and health officers. The latter were divided in their support of the managers' role. While an executive order explicitly stated the manager was to be supervised by the health officer, the district manager also had an official channel of communication to the First Deputy Commissioner who held him accountable for district operations. A district reporting and accounting system was introduced that provided clinic utilization and unit cost data on a decentralized basis by districts. A program budgeting system was introduced that gave the districts, for the first time, an input into the allocation of their assigned resources. Responsiveness increased to district personnel requests. Purchasing of supplies and equipment, long a source of field frustration, was decentralized. By the fall of 1973 the reorganization of Department activities was evident. Health officers and managers had author1152
ity and accountability for operations in their respective districts. Personnel functions, purchasing and budgeting, and program administration were now largely local functions. Bureau activity for district health operations was predominantly advisory, consultative and evaluative. There were, however, problems with this new structure: (1) the direct communication between the First Deputy's office and the 16 health officers and 22 managers was a logistical nightmare; (2) lines of decision-making between the district health officer and the manager were unclear. On November 1, 1973 the Commissioner of Health issued an executive order establishing six regions throughout the city to be headed by a regional health director, a former district health officer. The regional health directors replaced the borough health director position that was established in 1954. Under this plan the regional director had two health officers and four managers reporting to him. The regional director reported to the First Deputy Commissioner. The managers had operational responsibility for the district activities. The health officers functioned as staff to the regional director on program planning and evaluation.
Present Status Shortly thereafter, in January 1974, a new Mayor of New York City appointed a new Commissioner of Health. The Mayor wanted the Health Services Administration dismantled to upgrade the role of the Department of Health by removing the superagency administrative structure that hampered communications between his office and the city departments. The new Commissioner directed his attention towards restructuring the city's health care system. Municipal hospitals and comprehensive health planning received top priority. Objectives for the Department of Health were clearly outlined in speeches and presentations. He proposed "that the Health Department must assume responsibility for watching over quality of all types of health care, whether this care is administered under public or even under so-called private auspices."4 The administrative structure within the Department was reorganized to reflect new priorities and to improve the responsiveness of the agency. A commitment remained for decentralization as the modus operandi for district services. Although the services themselves received less emphasis from the new administration, district operations-as in previous administrations-reverted to being directed by the Deputy Commissioner for District Services rather than the First Deputy Commissioner. Regionalization was retained and strengthened. Managers remain responsible for administering the services of the district. Managers now report, however, to health officers who in turn report to the regional director. The role of the health officer and regional health director was expanded to reflect the new priority of the Department. The Commissioner directed that they be active in the monitoring and evaluation function and to serve as the Department's representative to the sub-area councils of the health planning agency. The role of the public health officer was AJPH December, 1976, Vol. 66, No. 12
DECENTRALIZATION IN THE NYC HEALTH DEPARTMENT
shifted from the delivery of clinical services towards regulatory and health planning functions. In the nearly three years since the departure of the Commissioner who initiated the process of decentralization, the New York City fiscal crisis has exerted severe fiscal constraints upon the Department, including budget reductions resulting in discontinuation or curtailing of services. Health services-including school health, dental, health, tuberculosis control, and hypertension screening programs-have been sharply reduced. Seven of 27 health centers and 21 of 76 child health stations have been closed. These decisions relating to services and programs were made by the Commissioner of Health and his deputies with district health officers and managers utilizing the new reporting system to provide the basic data for this decision process. Implementation of the reduction and reorganization of existing programs and services was done by district staff in consultation with bureau directors. Effective management and decision making during this difficult period was facilitated as a result of the new administrative structure that has been accepted as the "modus operandi" for the Department. The Department now had the capability to determine program costs for each decentralized area. For example, each district health center, child health station, or clinic had cost and productivity indicators. The Department was able to establish priorities and know the effect of closing or reducing a local program. Under the traditional centralized system, the total cost or impact of reducing resources available to a specific bureau could not be determined since local services are usually supported by several bureaus. A child health station would have had personnel from the Bureau of Laboratories, Nursing, Child Health, and District Services. A reduction in budget in any or all of these bureaus would result in a loss of operating personnel affecting the whole system. After the decentralization, each unit of service could be evaluated with all cost known and identified. Required budget modifications or reductions were accomplished with full knowledge of cost and impact without disrupting the system as a whole.
Discussion In an evaluation of the decentralization of the Philadelphia Department of Health performed in 1963, Purdom5 defined decentralization as ". . . the intentional division of authority with a unified agency at a single level of government. In the public health framework, the term has had application to efforts to vest such authority in district offices serving a defined geographical area but all within the same political jurisdiction." The findings of this study demonstrated that despite the decentralized organization plan of the Philadelphia Department of Public Health, the district director was a manager for minor routine administrative matters rather than involved with program needs and community relations. One of the questions to be answered in the present New York City organization is whether the current structure and operations reflect a decentralization of the decision-making AJPH December, 1976, Vol. 66, No. 12
process rather than a kind of "pseudo-decentralization". The value of decentralization is that the health officer will have leeway within the framework of city-wide public health policy to utilize available resources in shaping programs to local needs. To what extent did this reorganization result in increased local authority to make decisions affecting health regions (communities) in New York City? The reorganization has not changed the locus of decision-making affecting the local communities on the centralfield axis. Policy relating to changes in service delivery, discontinuation of programs, or phasing out of facilities are clearly central functions. District health officers and managers may be participants in this process where they play an information provider role. In two area, the reorganization has resulted in change: responsibility for operations, and capability to provide information on local services. Health officers and managers are clearly operating the health programs within their districts. Operational decisions such as staffing patterns and scheduling of services are the responsibility of the local manager and health officer rather than fragmented between the various services directed by central bureaus. As a necessary adjunct to administrative decentralization, management systems were introduced that were field based rather than service or bureau based. A district reporting system was established that monitors individual district expenditures and productivity and makes comparisons with services delivered in other districts. The capability to establish unit costs and the inclusion of the district manager and health officer into the budgeting process facilitated management decisions by the central office. Were services in health districts improved by this reorganization? This complex question has not been fully answered both because of a lack of defined evaluative criteria, and associated changes in the Department and New York City which mask the efforts of the reorganization itself. The ability of district staff to operate the programs within local areas resulted in improved staffing patterns, better utilization of personnel, and better equipment and material support for clinics. Space utilization within health facilities was improved and clinic schedules were rearranged to make services more available to the community and people who utilized them. Quality standards were set by the bureaus and districts now had the authority over resources to meet these standards. The establishment of program targets allowed top management to evaluate productivity as well as quality. Some services were expanded such as converting a number of child health stations to treatment centers.6 Clearly some of these changes required increased resource allocation but they were facilitated by decentralized management. Recently, reductions in services resulting from the New York City fiscal crisis have been the predominant factor in shaping the programs of the Department. Decentralized district operations have influenced the mix of remaining services. A reorganization of the New York City Department of Health has occurred under the banner of decentralization. Local managers were introduced into the health districts and
1153
MUSTALISH, ET AL.
together with the health officers assigned responsibility for functions previously carried out by service specific bureaus. The local level now has responsibility for service operation and providing utilization, cost, and productivity information. As operators of services and providers of essential management information, communication between field and central levels has become important in policy decision. Districts now have an increased capability to influence policy in allocating Department resources in accord with community priorities although the present fiscal crisis and scarcity of resources has become a major factor in the decision-making process.
REFERENCES 1. Kaufman, H. The New York City Health Centers. University Ala., University of Alabama Press, p.5, 1959. 2. The City of New York, Department of Health, Executive Order #1298, Reorganization of District Services, February 8, 1972. 3. The City of New York, Department of Health, Executive Order #1308, Assignment of Personnel to Districts, March 9, 1972. 4. Bellin, L. E. The Fall and Rise of the New York City Department of Health. Address before the annual meeting of the Public Health Association of New York City, May 29, 1974. 5. Purdom, P. W. An evaluation of decentralized public health administration. Am. J. Public Health 57:509-517, 1967. 6. Novick, L., Mustalish, A. C. and Eidsvold, G. Converting child health stations to pediatric treatment centers, Medical Care, 13:744-752, 1975.
A Farewell to Tobacco Jhou in such a cloud dost bind us That our best friends cannot find us .... Thou through such a mist dost show us That our best friends do not know us ... Stinking'st of the stinking kind Filth ofthe mouth andfog ofthe mindNay, rather Plant divine, of rarest virtue; Blisters on the tongue would hurt you. 'Twas but in a sort I blamed thee; None e'er prospered who defamed thee; Irony all, and feigned abuse, Such as perplex'd lovers use ... . Or as men, constrain'd to part With what's dearest to their heart While their sorrow's at the height,
1154
.
Lose discrimination quite And their hasty wrath let fall, To appease their frantic gall. For I must (nor let it grieve thee, Friendliest of plants, that I must) leave thee. For thy sake tobacco, I Would do anything but die.... . . . Though I, by sour physician, Am debarred the full fruition Of thy favours, I may catch Some collateral sweets, and snatch Sidelong odours, that give life Like glances from a neighbour's wife; And still live in the by-places And the suburbs of they graces... Charles Lamb (1775-1834)
AJPH December, 1976, Vol. 66, No. 12
Abstract: Since the World War I era there has existed within the New York City Department of Health a basic internal struggle between staff directing the bureaus at the central office and the district health officers operating field health centers throughout the city. Recently, in a five-year period, there was a dramatic reorganization of the Department which markedly affected its orientation and programs. In 1972 a new Commissioner initiated a reorganization of the Department which succeeded in decentralizing field opera-
tions in contrast to earlier efforts which had failed to reach this objective. The roles of bureaus and districts were redefined, with the latter receiving budgetary authority, authority to supervise personnel, assignment of health managers, and the implementation of a district cost accounting system. While operational decentralization has occurred, policy setting and resource allocation in response to local needs remain central functions. (Am. J. Public Health 66:1149-1154, 1976)
Introduction
success, their right to direct and supervise resources and staff within the various clinics and health centers. Many bureau directors were nationally known specialists with recognized competence and expertise in their field. Using a categorical approach, city-wide efforts in Child Health, Venereal Disease Control, School Health, and Tuberculosis Control were successful in improving the public health of New York City. This success supported an organizational structure where bureau directors were in charge. The generalist or district health officer, typically, had only marginal input into field operations of his or her own district. As "generalists" they were not recognized as "experts" within the Department of Health, but were viewed as "coordinators" of the various specialized operations under the roof of the district health centers. In contrast to this view, district health officers claimed that local services could not effectively meet local health needs unless budgetary authority and direct responsibility for the personnel working in clinics were placed in their hands. This problem is not unique to the New York City Department of Health, but it is inherent in any agency effort to decentralize authority. The conflict was a major theme in the New York City Department of Health as documented in a study by Herbert Kaufman covering a 40-year period up to 1958.1 The present report describes a five-year period in which there was a significant reorganization of the Department which markedly affected its orientation and programs.
The function and effectiveness of governmental agencies are dependent upon the interaction and relationship of personnel, organizational structure, and resources. Appropriate organizational structure has long been a subject of debate. Centralized decision-making at headquarters versus decentralization of authority at field locations both have proponents in the administration of large and complex agencies. Many of the classic elements illustrating organizational ambivalence and controversy are illustrated by the experiences of the New York City Department of Health. The New York City Department of Health has played a prominent role in protecting the health of the public and providing health care services since the New York City Metropolitan Board of Health was formed in 1866. Since the World War I era, conflict existed within the Department between personnel directing bureaus at central office and district health officers operating health centers throughout the city. Sporadic internal struggles occurred between central and field staff over policy, operation, and control of Department services in district health centers. Throughout most of this period chiefs of the specialized bureaus asserted, with much From the New York City Department of Health. Address re-
print requests to Dr. Anthony C. Mustalish, Deputy Commissioner,
NYC Department of Health, 125 Worth Street, New York, NY 10013. Dr. Eidsvold is Regional Health Director, Bronx, and Dr. Novick is Associate Commissioner, NYCDH. This paper, submitted to the Journal in March 1975, was revised and accepted for publication August 10, 1976.
AMJPH December, 1976, Vol. 66, No. 12
Background When the Department of Health was formed in 1866, or1149
MUSTALISH, ET AL.
ganization was along functional lines with Sanitary Inspections and Vital Statistics being the first of the bureaus. Child Hygiene, Public Health Education, Infectious Diseases, Laboratories, and other bureaus were later formed in response to a need for other services. Even after the establishment of 30 local health districts in the 1930s, the Department continued to be administered along functional rather than areal lines. At the time of the Kaufman study in 1959 the bureau directors prepared budgets for their services in the districts, hired personnel to deliver these services, and had regional supervisors who directed the services. Conflicts arose frequently between the central bureau director and the district health officer, with the latter believing that his knowledge of community people, facilities, needs, and priorities made him the logical director and coordinator of district health services. The impetus for decentralization came from a recognition of the complexity of a metropolis such as New York City, the changing focus of public health, and the need to provide an integrated broad spectrum of specific health services to communities. Commissioners, from S. S. Goldwater in 1915 until the present, have expressed the desirability of having health districts in order to provide coordinated services closer to the people. They attempted from time to time to decentralize district operations in order to respond to this aspiration. The decentralization pendulum swung between districts and bureau directors, creating conflict which Commissioners attempted to resolve by issuing executive orders, establishing high level positions in central office for district representation, and by increasing the number of district health officers. The Kaufman study documented the dual channel of administrative decision-making within the New York City Department of Health. Kaufman cited five factors which inhibited local district administration. They included: 1. The tradition of distinguished authoritative bureau directors who set program policy; 2. Professional rapport between the central office specialists and field specialists assigned to the district health center; 3. Ease of communication between the bureau officials and district staff; 4. Lack of local public interest constituencies to support the district health officer; and 5. Departmental policy that technical matters were within the bureau's area of expertise. At the time of the Kaufman study (1959) there were five borough director positions (New York City has five geographic sub-divisions known as boroughs, which also function as counties). The borough director was intermediate between the district health officer and an Assistant Commissioner for District Health Services. Kaufman predicted that neighborhood districts would be allowed to languish and that emphasis would be placed on boroughs rather than districts as a new unit of administration. Borough directors, however, were unable to develop an effective role. The districts continued to be administered in the same way; strife between the district health officer and the bureau director continued as well. Lacking authority, the 1150
district health officer was unsuccessful in integrating the variety of programs for which he was responsible. The borough directors, in effect, became merely another hierarchical level between district health officers and the Commissioner.
1959-1966 Until 1966 little change occurred in the Department's administrative structure. Internal programmatic changes did occur, however, influenced by the external, social, and political changes of the 1960s. In the early 1960s there was increased community demand for ambulatory care services and federal funding became available at the same time. In attempting to respond, the Health Department established a pilot geriatric unit, pediatric treatment clinics, and a generalized medical care program for all ages in certain areas. Prenatal services, which had been discontinued shortly after World War II, were re-established. Tuberculosis clinics started treating other diseases of the chest and became affiliated with hospitals. By the end of 1965, 14 of the 22 districts provided one pr more of these medical care services that were once outside the purview of public health. Although several Commissioners stressed, during this period, the principle that the district health centers should integrate therapeutic with preventive medicine, all these efforts were planned, implemented, and directed by bureau directors.
1966-1971 The changes which ultimately contributed to another shift in emphasis from central office to the community and district health centers took place during the period 19661971. This shift can be ascribed to a convergence of the following forces favoring decentralization: 1. National legislation supporting local programs; 2. City administrative reorganization; 3. Resurgence of community activism and participation in health services; 4. Community demands for improved health services; and 5. Ineffectiveness in the delivery of municipal health
services. Federal legislation was important in creating a favorable climate for local change. The Economic Opportunities Act of 1964 and its subsequent ammendment in 1966 allocated funds for neighborhood health centers. Eventually, seven of these centers were established in New York City with "maximum feasible community participation" written into the guidelines. This new concept encouraged community antipoverty agencies to generate requests for health services. These requests called for the creation of neighborhood family care centers and the augmentation of Health Department services at the local level. The Model Cities and Comprehensive Health Planning legislation also mandated resident consumer participation and planning of services and accentuated the movement in which communities asked for an increase in health care. Federal legislation promoted the AJPH December, 1976, Vol. 66, No. 12
DECENTRALIZATION IN THE NYC HEALTH DEPARTMENT
setting up of local community organizational structures so that requests from the community came first to the district health officer. In turn, many of the district health officers helped the community groups plan their programs and forward these proposals to city or federal health officials. District health officers in East and Central Harlem, Central Brooklyn, and the South Bronx played important roles in assisting the community to plan Model City health programs. In the course of this activity, district health officers formed close relationships with various community groups. The district health officer, with his still limited authority to improve services, was now placed in a new role. Community demands were being made upon the "downtown" Health Department, or Central Office. The Central Office in turn began to rely on the district health officer for assessing community health needs and services so that the Department could make an appropriate response.
The Health Services Administration In 1966 Mayor John Lindsay appointed the Commission on the Delivery of Personal Health Services (Piel Commission) and charged it "to make a thorough inquiry into the institutional, administrative and fiscal aspects of the system through which public funds deliver personal health services to one-third of the people of New York City." In 1967 the Commission reported to the Mayor and its recommendations included the consolidation of city health agencies into a single Health Services Administration and the creation of a
nonprofit Health and Hospitals Corporation. A city superagency, the Health Services Administration, was formed in 1967 and included the Department of Health, Department of Hospitals, Department of Mental Health, and the Medical Examiner's Office. The Health Services Administration (HSA) was heralded as an effort that would result in improved planning and administration of municipal health services. For the first three years physician administrators directed the agency. In 1970 the first non-physician administrator was appointed to this senior health position in city government. Large numbers of planners and analysts were recruited to staff the superagency which produced a planning, productivity, and management-oriented agency. New lead poisoning and methadone maintenance programs were started outside of the traditional bureau structure. The costs for superagency staff and new programs were met, in part, through diversion of Health Department operating funds from other programs. The authority of the Commissioner of Health and bureau chiefs diminished due to loss of staff, restrictions on hiring, and inability to begin new projects. Bureaus which once had the ability to direct services were bypassed in the decision-making processes concerning public health programs and operation. Introduction of treatment services in Department of Health child health stations, for example, was planned and implemented by superagency staff with virtually no involvement of the Bureau of Child Health. In late 1971 management staff from the superagency analyzed service provision at a district health center and found AJPH December, 1976, Vol. 66, No. 12
poorly administered clinics where no single person was held accountable for performance. Nurses reported to several different supervisory personnel, as did other staff. In one clinic (venereal disease treatment), the physicians and nurses reported primarily to the central Bureaus of Venereal Disease and Nursing but related also to the district health officer while clerical personnel reported to the health officer; outreach staff reported to still another central unit. This pattern was repeated for every clinical service in the district health center. The findings of the superagency analysts pointed to a lack of accountability for operations and the inability to implement change with this administrative structure. A subsequent HSA report recommended that one individual be assigned responsibility for district health center operations and that a reporting system be developed to measure and evaluate district activities.
1972-1975 In January 1972 the HSA administrator selected a public health physician as the new Commissioner of Health. This Commissioner and the newly appointed First Deputy, a nonphysician administrator, instituted another reorganization of the Department of Health. Over the next 18 months, major innovations in structure and function resulted in the most significant change in the administration of Health Department district services since the local health district concept was espoused by Commissioner S. S. Goldwater in 1915. The new Commissioner set out to overcome many of the obstacles that thwarted previous attempts at reorganization. He reviewed all bureau programs, policies, and services and met with all bureau directors and district health officers to prepare them for administrative changes. The Department had a long tradition of general staff meetings which were almost always held at central office. These were now to be held at the district health centers to bring to the forefront district operations and problems. At the first meeting in a Brooklyn center, the Commissioner opened by announcing that "the day of the districts has arrived." A plan for administrative decentralization of personal health services* was outlined that redefined the roles of bureaus and districts and included transfer of budgetary authority for local services to the districts, assignment of district health managers, and the implementation of a district cost accounting system. An executive order was issued that requested bureau directors to submit for discussion a "list of functions over which ... the bureau would retain control, and the reasons therefor."2 The redefined role of the bureau in district health services* was to be that of evaluation and standard setting. Other health service programs operated by bureaus were not affected. The Bureau of Child Health continued operational responsibilities for day care centers where they assigned physicians and operated the health programs in these centers. *Environmental health services were not involved in the decentralization scheme. 1151
MUSTALISH, ET AL.
The responsibility of the Bureau for Handicapped Children remained intact for delivering health services to special schools and centers for the handicapped. Specialized tuberculosis chest clinics, located in hospitals for the treatment of tuberculosis patients who have other diseases, remained the responsibility of the Bureau of Tuberculosis. District Health Services were the focus of the decentralization efforts. These efforts resulted in the "giving of responsibility and authority for operation to the district health officer."2 Most bureau directors were reluctant to give up the operational functions, claiming as their predecessors have done that their expertise was needed in the day-to-day delivery of
services. The Commissioner responded through issuance of an executive order stating: (1) "No position for an employee who is to work in the health district shall be filled without obtaining clearance from the appropriate district health officer"; and (2) "No employee shall be transferred into or out of a district without the approval of the affected district health officer."3 Initially this order was violated. The Commissioner supported the health officer in these conflicts and eventually he received compliance from the bureau directors. Lines of communication were established between the Commissioner and the district health officers. A formal channel of communication was created through the formation of the Health Officers Advisory Committee which met periodically with the Commissioner. The Committee worked with bureau directors in establishing policies that were to be implemented in the districts. While the bureau structure was revised to permit decentralization, the administrative structure at the district level also underwent change. There was recognition that a district health officer would need staff support to assume the increased responsibility for operations. The First Deputy Commissioner recruited district health managers, a new category of health personnel, who were assigned to district health centers after being interviewed by the health officer. The health manager reported to the health officer and was made responsible for the day-to-day operation of all clinical and administrative services within the districts. By July 1973, 20 of the 22 health centers had managers. Conflicts developed during this period between the managers and health officers. The latter were divided in their support of the managers' role. While an executive order explicitly stated the manager was to be supervised by the health officer, the district manager also had an official channel of communication to the First Deputy Commissioner who held him accountable for district operations. A district reporting and accounting system was introduced that provided clinic utilization and unit cost data on a decentralized basis by districts. A program budgeting system was introduced that gave the districts, for the first time, an input into the allocation of their assigned resources. Responsiveness increased to district personnel requests. Purchasing of supplies and equipment, long a source of field frustration, was decentralized. By the fall of 1973 the reorganization of Department activities was evident. Health officers and managers had author1152
ity and accountability for operations in their respective districts. Personnel functions, purchasing and budgeting, and program administration were now largely local functions. Bureau activity for district health operations was predominantly advisory, consultative and evaluative. There were, however, problems with this new structure: (1) the direct communication between the First Deputy's office and the 16 health officers and 22 managers was a logistical nightmare; (2) lines of decision-making between the district health officer and the manager were unclear. On November 1, 1973 the Commissioner of Health issued an executive order establishing six regions throughout the city to be headed by a regional health director, a former district health officer. The regional health directors replaced the borough health director position that was established in 1954. Under this plan the regional director had two health officers and four managers reporting to him. The regional director reported to the First Deputy Commissioner. The managers had operational responsibility for the district activities. The health officers functioned as staff to the regional director on program planning and evaluation.
Present Status Shortly thereafter, in January 1974, a new Mayor of New York City appointed a new Commissioner of Health. The Mayor wanted the Health Services Administration dismantled to upgrade the role of the Department of Health by removing the superagency administrative structure that hampered communications between his office and the city departments. The new Commissioner directed his attention towards restructuring the city's health care system. Municipal hospitals and comprehensive health planning received top priority. Objectives for the Department of Health were clearly outlined in speeches and presentations. He proposed "that the Health Department must assume responsibility for watching over quality of all types of health care, whether this care is administered under public or even under so-called private auspices."4 The administrative structure within the Department was reorganized to reflect new priorities and to improve the responsiveness of the agency. A commitment remained for decentralization as the modus operandi for district services. Although the services themselves received less emphasis from the new administration, district operations-as in previous administrations-reverted to being directed by the Deputy Commissioner for District Services rather than the First Deputy Commissioner. Regionalization was retained and strengthened. Managers remain responsible for administering the services of the district. Managers now report, however, to health officers who in turn report to the regional director. The role of the health officer and regional health director was expanded to reflect the new priority of the Department. The Commissioner directed that they be active in the monitoring and evaluation function and to serve as the Department's representative to the sub-area councils of the health planning agency. The role of the public health officer was AJPH December, 1976, Vol. 66, No. 12
DECENTRALIZATION IN THE NYC HEALTH DEPARTMENT
shifted from the delivery of clinical services towards regulatory and health planning functions. In the nearly three years since the departure of the Commissioner who initiated the process of decentralization, the New York City fiscal crisis has exerted severe fiscal constraints upon the Department, including budget reductions resulting in discontinuation or curtailing of services. Health services-including school health, dental, health, tuberculosis control, and hypertension screening programs-have been sharply reduced. Seven of 27 health centers and 21 of 76 child health stations have been closed. These decisions relating to services and programs were made by the Commissioner of Health and his deputies with district health officers and managers utilizing the new reporting system to provide the basic data for this decision process. Implementation of the reduction and reorganization of existing programs and services was done by district staff in consultation with bureau directors. Effective management and decision making during this difficult period was facilitated as a result of the new administrative structure that has been accepted as the "modus operandi" for the Department. The Department now had the capability to determine program costs for each decentralized area. For example, each district health center, child health station, or clinic had cost and productivity indicators. The Department was able to establish priorities and know the effect of closing or reducing a local program. Under the traditional centralized system, the total cost or impact of reducing resources available to a specific bureau could not be determined since local services are usually supported by several bureaus. A child health station would have had personnel from the Bureau of Laboratories, Nursing, Child Health, and District Services. A reduction in budget in any or all of these bureaus would result in a loss of operating personnel affecting the whole system. After the decentralization, each unit of service could be evaluated with all cost known and identified. Required budget modifications or reductions were accomplished with full knowledge of cost and impact without disrupting the system as a whole.
Discussion In an evaluation of the decentralization of the Philadelphia Department of Health performed in 1963, Purdom5 defined decentralization as ". . . the intentional division of authority with a unified agency at a single level of government. In the public health framework, the term has had application to efforts to vest such authority in district offices serving a defined geographical area but all within the same political jurisdiction." The findings of this study demonstrated that despite the decentralized organization plan of the Philadelphia Department of Public Health, the district director was a manager for minor routine administrative matters rather than involved with program needs and community relations. One of the questions to be answered in the present New York City organization is whether the current structure and operations reflect a decentralization of the decision-making AJPH December, 1976, Vol. 66, No. 12
process rather than a kind of "pseudo-decentralization". The value of decentralization is that the health officer will have leeway within the framework of city-wide public health policy to utilize available resources in shaping programs to local needs. To what extent did this reorganization result in increased local authority to make decisions affecting health regions (communities) in New York City? The reorganization has not changed the locus of decision-making affecting the local communities on the centralfield axis. Policy relating to changes in service delivery, discontinuation of programs, or phasing out of facilities are clearly central functions. District health officers and managers may be participants in this process where they play an information provider role. In two area, the reorganization has resulted in change: responsibility for operations, and capability to provide information on local services. Health officers and managers are clearly operating the health programs within their districts. Operational decisions such as staffing patterns and scheduling of services are the responsibility of the local manager and health officer rather than fragmented between the various services directed by central bureaus. As a necessary adjunct to administrative decentralization, management systems were introduced that were field based rather than service or bureau based. A district reporting system was established that monitors individual district expenditures and productivity and makes comparisons with services delivered in other districts. The capability to establish unit costs and the inclusion of the district manager and health officer into the budgeting process facilitated management decisions by the central office. Were services in health districts improved by this reorganization? This complex question has not been fully answered both because of a lack of defined evaluative criteria, and associated changes in the Department and New York City which mask the efforts of the reorganization itself. The ability of district staff to operate the programs within local areas resulted in improved staffing patterns, better utilization of personnel, and better equipment and material support for clinics. Space utilization within health facilities was improved and clinic schedules were rearranged to make services more available to the community and people who utilized them. Quality standards were set by the bureaus and districts now had the authority over resources to meet these standards. The establishment of program targets allowed top management to evaluate productivity as well as quality. Some services were expanded such as converting a number of child health stations to treatment centers.6 Clearly some of these changes required increased resource allocation but they were facilitated by decentralized management. Recently, reductions in services resulting from the New York City fiscal crisis have been the predominant factor in shaping the programs of the Department. Decentralized district operations have influenced the mix of remaining services. A reorganization of the New York City Department of Health has occurred under the banner of decentralization. Local managers were introduced into the health districts and
1153
MUSTALISH, ET AL.
together with the health officers assigned responsibility for functions previously carried out by service specific bureaus. The local level now has responsibility for service operation and providing utilization, cost, and productivity information. As operators of services and providers of essential management information, communication between field and central levels has become important in policy decision. Districts now have an increased capability to influence policy in allocating Department resources in accord with community priorities although the present fiscal crisis and scarcity of resources has become a major factor in the decision-making process.
REFERENCES 1. Kaufman, H. The New York City Health Centers. University Ala., University of Alabama Press, p.5, 1959. 2. The City of New York, Department of Health, Executive Order #1298, Reorganization of District Services, February 8, 1972. 3. The City of New York, Department of Health, Executive Order #1308, Assignment of Personnel to Districts, March 9, 1972. 4. Bellin, L. E. The Fall and Rise of the New York City Department of Health. Address before the annual meeting of the Public Health Association of New York City, May 29, 1974. 5. Purdom, P. W. An evaluation of decentralized public health administration. Am. J. Public Health 57:509-517, 1967. 6. Novick, L., Mustalish, A. C. and Eidsvold, G. Converting child health stations to pediatric treatment centers, Medical Care, 13:744-752, 1975.
A Farewell to Tobacco Jhou in such a cloud dost bind us That our best friends cannot find us .... Thou through such a mist dost show us That our best friends do not know us ... Stinking'st of the stinking kind Filth ofthe mouth andfog ofthe mindNay, rather Plant divine, of rarest virtue; Blisters on the tongue would hurt you. 'Twas but in a sort I blamed thee; None e'er prospered who defamed thee; Irony all, and feigned abuse, Such as perplex'd lovers use ... . Or as men, constrain'd to part With what's dearest to their heart While their sorrow's at the height,
1154
.
Lose discrimination quite And their hasty wrath let fall, To appease their frantic gall. For I must (nor let it grieve thee, Friendliest of plants, that I must) leave thee. For thy sake tobacco, I Would do anything but die.... . . . Though I, by sour physician, Am debarred the full fruition Of thy favours, I may catch Some collateral sweets, and snatch Sidelong odours, that give life Like glances from a neighbour's wife; And still live in the by-places And the suburbs of they graces... Charles Lamb (1775-1834)
AJPH December, 1976, Vol. 66, No. 12
