Oklahoma has had the unfortunate distinction of consistently ranking toward the bottom of national health rankings (3). Despite efforts to reverse these trends during the mid-1980s and through the 1990s, health status indicators in Oklahoma failed to move in a significantly positive direction. In fact, Oklahoma has been the only state since 1988 in which age-adjusted death rates have actually increased (4).

Clearly, this caused a great deal of concern among Oklahoma's health leaders, and innovative solutions were sought to reverse these negative trends. In 1997, an opportunity became available from The Robert Wood Johnson Foundation and the W. K. Kellogg Foundation. Called Turning Point, the program issued a request for proposals that encouraged local and state applicants to rethink the delivery of public health, placing emphasis on state and local collaborative partnerships and eliciting ideas on intervention priorities from community partners. Although implementation of these new approaches would represent a radical change in how public health would be delivered in Oklahoma, the state health commissioner at the time, Dr. Jerry R. Nida, decided to move forward with the Turning Point application because he understood the urgency of needing to change and restructure how public health was delivered in Oklahoma. The application, submitted by the Oklahoma State Department of Health (OSDH) and three community partnerships in Cherokee, Texas, and Tulsa counties in July 1997, included the following opening paragraph:

In January 1998, the OSDH was awarded a 2-year Turning Point planning grant of $300,000, and the three community partnerships were awarded $60,000 each for 3 years. During that period, models for transforming public health through community partnerships were developed in the three pilot sites, and the philosophy of the state partnering with communities for health improvement needs began to take shape. Each model proved successful in assessing local needs, establishing priorities, and implementing interventions tailored to the unique characteristics of the community. In January 2000, Oklahoma was awarded a 4-year grant of $950,000 to implement the Oklahoma Turning Point models on a statewide basis.

To understand the significance of Turning Point for Oklahoma, one must look at the history of public health infrastructure in Oklahoma and the transformations that are beginning to occur. Public health in Oklahoma has evolved into a centralized system, largely as a result of historical actions of the state legislature and categorical funding through federal sources. The central office of the OSDH, located in Oklahoma City, has traditionally directed public health decisions for Oklahoma. Although the centralized system has resulted in some positive outcomes, including a comprehensive bricks-and-mortar infrastructure with county health departments in 69 of 77 counties in Oklahoma, significant improvements in health status indicators have not been realized.

The lack of improvement in health, despite a good physical public health infrastructure and a well-trained workforce, has been an area of tremendous concern for the state board of health and others in the health field. When we examined the possible reasons for the lack of improvement in health, we saw clearly that the missing element was direct involvement of communities in public health decisions. Before Turning Point, decisions about public health were made at the central office and delivered in a cookie-cutter fashion for each county. Such a delivery system resulted in little progress toward local health improvement — each community has its own unique challenges, and the same approaches will not necessarily work in every area of the state. Unless communities are actively engaged in determining their own public health needs and developing and implementing solutions, improvement in community health will not be realized.

The key objective for the Oklahoma Turning Point initiative was to expand community health improvement partnerships into each county in Oklahoma using models developed in three original pilot Turning Point partnerships in Cherokee, Texas, and Tulsa counties.

The key challenge for the Oklahoma Turning Point initiative has been providing enough skilled health department staff support to the community partnerships to ensure their success. Skilled staff support is even more important than having funds directly available for the partnerships. Regional health department field consultants have provided technical assistance in such areas as identifying priorities through data analysis, planning and implementing interventions based on priorities, and evaluating success. In addition, health department field consultants have provided assistance in such basic areas as developing partnership bylaws, conducting efficient and productive meetings, developing meeting agendas, recording partnership decisions through minutes, and communicating partnership activities through the local news media. Regional Turning Point health department field consultants are critical for each of these areas, and partnerships in Oklahoma have been successful because of the support provided by field consultants.

Other challenges that were encountered early but dealt with effectively were challenges common to most partnerships — turf and control issues. The willingness of OSDH to relinquish control and concern about who got credit for accomplishing health improvement efforts quickly nullified turf and control issues and allowed the Turning Point collaborative philosophy to flourish.

Through the Turning Point initiative, three key lessons on community health improvement partnerships were learned:

The success in establishing partnerships across the state — and just as important, the success in ensuring the sustainability of the partnerships — has been better than the most hopeful expectations. There are now 50 partnerships based on the three original models in Cherokee, Texas, and Tulsa counties. The partnerships are in varying stages of development, with several new partnerships in the planning stages. Regional Turning Point field consultants are assisting partnerships in identifying local health improvement priorities, implementing local interventions, and evaluating impacts. Financial and technical resources are being secured from numerous collaborative resources to ensure the sustainability of the partnerships.

Turning Point continues to tailor public health needs in Oklahoma based on the real, perceived needs of community members who have joined public health officials as equal partners in making public health decisions. The Turning Point philosophy of community health improvement through collaborative state and local efforts has taken root in Oklahoma and is now built into the organizational fabric of the OSDH. Not only are the community Turning Point partnerships thriving but services and divisions within the OSDH seek ways to collaborate with Turning Point. In addition, other agencies and organizations outside of the OSDH are very much aware of Turning Point and frequently refer to the community Turning Point partnerships for ways to accomplish their own organizational goals within local communities. Turning Point has transformed public health in Oklahoma, and health status indicators in Oklahoma are beginning to show improvement. Because of Oklahoma's Turning Point initiative, the centralized public health system is reorganizing itself to take the following steps:

These steps — which may appear to be fundamental and obvious — represent an extraordinary system change for Oklahoma. For the first time, communities have an equal voice in public health decisions. For the first time, public health workers within the OSDH see their role as supportive to community-based decisions and initiatives. And for the first time, community members see the important role they play in ensuring a healthier state for future generations. The results have been astounding, with numerous health education initiatives and sustained community system changes (6), including the following:

In addition to the health education initiatives and system changes occurring at the local level, numerous changes are happening statewide, including the following:

The health education initiatives and community system changes in Oklahoma did not happen randomly. It took people who were not afraid to redefine their relationships with each other. Key leaders in Oklahoma's counties and at the OSDH were committed to spending the time necessary to build relationships and think differently about how to approach public health. Now, it's not about the "state" people or the "local" people. It's about us, working together to build healthy communities.

Turning Point will continue in Oklahoma. Organizationally, Turning Point is a division within the OSDH, under the Community Development Service. Plans are underway to hire additional Turning Point staff to support the efforts of Oklahoma's current Turning Point partnerships and expand into additional counties. The expanding activities of Turning Point also include work with faith-based organizations to eliminate health disparities and increase access to primary care services. Turning Point will continue to play a critical role in health improvement efforts in Oklahoma, both inside the OSDH and alongside many other agencies, organizations, and individual partners who have been part of Turning Point since 1997.

Perhaps the impact of Turning Point was best described by Ed Kirtley, past chairman of the Texas County Turning Point initiative: