The Association of State and Territorial Health Officials (ASTHO) supports, equips, and advocates for state and territorial health officials in their work advancing the public's health and well-being. For the past 2 years, ASTHO has provided technical assistance to one of its members—the Ministry of Health and Human Services (MOHHS), Republic of the Marshall Islands (RMI), on improving grants/contracts management. To undertake this complex work, ASTHO actively partnered with the Pacific Island Health Officers Association (PIHOA) and offices within the Centers for Disease Control and Prevention (CDC) (specifically, the Office of State, Tribal, Local, and Territorial Public Health Professionals [OSTLTS] and US Department of Health and Human Services [HHS] Region IX office). The effort involved a process mapping workshop convened in the spring of 2017, in-person collaborative standard operating procedure (SOP) development in the fall of 2017, and the signing of a Memorandum of Understanding (MOU) between cabinet-level ministries and offices in the spring of 2018. This effort is described here along with lessons learned, providing insights into spreading this important work to other jurisdictions.
Those residing in the US territories and sovereign nations holding a compact of free association (COFA) with the United States face what has been termed a “‘perfect storm' of social, economic, environmental, political, and health complexities,” posing challenges to improving both the practice of public health and the public health outcomes on which services and activities are focused.1 Always complex and multilayered, the funding relationship between the United States and the territories (Puerto Rico, the US Virgin Islands, the Northern Mariana Islands, Guam, and American Samoa) and the freely associated states (FAS—Marshall Islands, the Federated States of Micronesia, and Palau) creates both opportunities and challenges.2
Funding agencies have growing concerns about the efficiency of public health spending in the territories and freely associated states. The Department of the Interior, Office of Insular Affairs, has identified the following challenges to effectively implementing grants and spending federal funds: (1) insufficient project planning resulting from frequently changing local government decisions and natural disaster impacts; (2) project management challenges including limited capacity for implementing projects and poor performance; and (3) external obstacles including issues such as declining economic conditions and unsupportive policies.3 In addition, the World Health Organization has noted that despite an increase in available funds, health outcomes are not being reached and weak health systems are an obstacle to achieving the maximum benefit possible from the resources available.2
Some of these challenges undoubtedly result from somewhat ill-fitting federal funding structures and administrative mechanisms. Typically, the same ones applied to the states are applied to the Pacific and Atlantic jurisdictions without regard to important differences in geography, population size and distribution, infrastructure, workforce issues, and communication challenges between islands and with the states. Federal funding can be siloed in ways that do not fit staffing patterns in small jurisdictions, leading to compliance issues. For instance, the nurse staffing Tuberculosis checks also staffs other communicable diseases and also puts in shifts in the Obstetrics ward.
Closely aligned issues were frequently raised during ASTHO-facilitated strategic planning sessions with jurisdictions in the Pacific and the Atlantic. Specifically, jurisdictions raised concerns on the need to improve their business processes related to managing grants and contracts, procuring needed goods and services, and hiring and onboarding staff. Staff noted the following challenges: (1) business processes were often needlessly bureaucratic and inefficient, requiring redundant approval of procurements and staffing external to the public health agency—sometimes even requiring legislative or gubernatorial approval; (2) communication between agencies was poor, resulting in additional delays; (3) financial systems and/or staff training in these systems were insufficient, meaning that program and finance staff did not have access to the financial information needed to effectively plan and carry out grant activities; (4) internal tracking and management SOP and systems were underdeveloped and were not equipped to issue alerts if spending was offtrack; and (5) program staff were also tasked with financial oversight for which they had inadequate training. As a result, grant administrative activities were often reactive and were not proactively planned, resulting in lapses in seeking federal funding reimbursement postaward. Often, federal grant funding expired without being fully disbursed to the jurisdiction.
Recognizing this as a need among its members, ASTHO undertook a series of process mapping workshops with several jurisdictions. Process mapping is defined as a process that “uses a technique that breaks down complex events into individual processes and evaluates how these processes can be made more efficient.”4 (p14) The “easy-to-visualize method allows people to analyze and agree on the most efficient routes for reengineering or improving a process. It aids in determining redundant tasks, [and] uncovering hidden interactions between processes and people....”5 (p10)
To date, ASTHO has facilitated workshops in a number of jurisdictions, during which staff were engaged in mapping procurement and recruitment processes on conference room walls. Within each map, “swim lanes” were defined representing the various groups or offices involved with producing, reviewing, and approving different types of procurement or recruitment packages. Idealized processes for effectively managing grants and contracts were also mapped. Participants from all program areas of public health including finance and human resources were involved. Mapping revealed the complexity of these processes and multiple, repetitive transfers between swim lanes for even the simplest of procurements. In one workshop, processes filled a total of 3 conference room walls.
While the first proceedings and outputs were rated as valuable by the participants and quality improvement changes were made, there were also implementation challenges. Why? Upon reflection it became clear that (1) the federal perspective needed to be enhanced as many of the issues centered on federal practices, rules, and regulations; (2) agencies other than public health within the jurisdiction that played key roles in these business processes needed to be actively engaged in the process; and (3) within-area consultants and expertise were needed, given vast distances that bogged down follow-up and training. Efforts to improve grants and contracts management currently underway in the US Virgin Islands, and more recently in RMI, are bearing fruit based on adjustments made in these areas.
Efforts in RMI rest upon a solid foundational partnership between the jurisdiction, ASTHO, CDC, and PIHOA. During preparatory phone calls, the roles of each were defined and leadership from the MOHHS was tasked with reaching out to other agencies within the jurisdiction playing key roles. The first process mapping workshop was convened in Majuro, RMI, in early April 2017. New ground was broken as external agencies participated including the Ministry of Finance that approves spending packages submitted by the RMI ministries and the Public Service Commission (PSC) charged with recruitment and hiring across government. The effort built on previous work by MOHHS and PIHOA to define key health sector performance indicators for quarterly monitoring and annual health sector reports in RMI. Among these are several grants management–related summary indicators. These include percent drawdown for major budget lines and average time for execution of contracts, purchases, and personnel actions. Linking new processes to preexisting capacity-building initiatives ensures that changes in processes are supported within the routine monitoring infrastructure of MOHHS.
The workshop began with a review of data collected by federal partners on CDC grants awarded to RMI. The status of each CDC grant was reviewed, and actions needed to avoid funding expiration were identified. Grant-specific corrective action plans were developed. Importantly, similar data from RMI assembled prior to the workshop by MOHHS were reviewed and discrepancies between the federal and RMI data were identified and discussed. Common themes across grants informed the mapping of process improvements in 3 areas: (1) grants management; (2) procurement; and (3) recruitment. Following the finalization of these maps, SOPs were collaboratively developed through virtual and on-site works. Federal finance system access was granted to MOHHS staff along with training at multiple levels so that RMI and federal program staff could view the same data at the same time. Thus far, the work has culminated in a cabinet-level meeting during which the recommendations of the working group were reviewed and discussed. The daylong meeting culminated in the signing of an MOU outlining the process for continued joint work and implementation. The MOU was signed by Health Minister Kalani Kaneko, Finance Minister Brenson Wase, Chief Secretary Ben Graham, Acting Attorney General Claire Loeak, and PSC Commissioner Justina Langidrik.6
Key success factors included the following: (1) active participation of RMI ministries from across government; (2) participants expressing a willingness to look critically at existing processes and explore and identify areas in need of improvement; (3) active leadership engagement; (4) partners providing technical assistance bringing critically important complementary skills and expertise; and (5) broad, sustained commitment to planning, implementation, and performance management on the part of all involved. Each of these is discussed here.
The development, processing, and approval of procurement and recruitment packages are complex with involvement of external agencies occurring at multiple points in the process. The active engagement of all agencies involved proved to be critically important to identify bottlenecks, communication breakdowns, and stalled handoffs. Although the conversations were sometimes difficult, there was open and honest discussion of needed changes. The new SOPs call for joint planning meetings beginning with the pregrant application stage and continuing quarterly to the end of the contract year. These meetings facilitate a proactive approach to obtaining key approvals, ensuring corrective midyear action, and planned closeout. Monthly meetings internal to the Ministry of Health reconcile projected expenditures with actuals and help inform the broader, collaborative meetings.
Within RMI, Health Minister Kaneko and his leadership team were instrumental in bringing the leadership of other agencies to the table. Ultimately, leaders of all 5 cabinet-level ministries and offices realized the common good, making a public commitment to work together to improve the jurisdiction's business procurement and recruitment processes. The active engagement of the PIHOA Executive Director and the ASTHO Chief Executive Officer underscored each supporting organization's commitment to the effort.
The partners providing technical assistance to the effort brought complementary skills and abilities. A staff person from HHS Region IX brought a working knowledge of other federal initiatives and projects and the implementation of the bilateral COFA through which freely associated states such as RMI are currently awarded funding. Set for expiration or renewal in 2023, the Compact provides an important incentive to improve business processes throughout government. Within CDC, OSTLTS played a key role assembling information on the status of grants awarded to the jurisdiction by the various CDC centers. One individual from that office had previously been assigned to the then CDC Procurement and Grants Office (now the Office of Grants Services) and therefore brought a wealth of knowledge in federal grants and contracts requirements. The Executive Director from PIHOA brought a deep knowledge of the jurisdiction, including key stakeholders, and expertise derived from the organization's work in the Pacific. Several PIHOA consultants provided needed follow-up training and assistance. ASTHO staff brought proven knowledge of facilitation and process mapping skills, and their application in the field in Pacific and Atlantic jurisdictions. Organizationally, ASTHO also brings the ability to link RMI with peer support at all levels.
Given their complexity and multiple contributing factors, change on these issues can seem slow, but each of the partners has committed to a sustained effort improving essential business processes. Each has a vested stake in a successful outcome as well and is committed to seeing the efforts through the long haul. The successes gleaned from the work undertaken in RMI provide a working model for other jurisdictions and the potential for peer-to-peer consultation.