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Chapter 3: Leading Through Influence to Achieve Change

• You Have Power and Influence!
• What Kind of Leverage Does Title V Provide?
• Use the "vision thing"!
• Know Your Key Stakeholders
  
• Understand Your Advocacy Role
  
• External Communications
• Understand the Policy Process
  
• Use Communications and Marketing Strategies
• Resources

You have power, even if buried in the bureaucracy with decimal dust for a budget!

My years of experience in state government have shown me that sometimes people in the highest positions do not see themselves as having power and influence while 'true leaders' at lower levels of the hierarchy assume the leadership role and end up moving mountains. It's up to you! - Joan Wightkin, Director, MCH Program, Louisiana

MCH leaders vary in the degree of power they have by virtue of their positions within state bureaucracies and the magnitude of their budgets and programs. This chapter discusses tools that are available to you, including sources of potential power, statutory leverage, vision, partnerships, advocacy and marketing. Certainly Title V leaders do not have the same kind of power and influence that comes with leading a large state agency or directing a budget as large as Medicaid. But managers responsible for Title V programs have both formal and personal sources of power and influence. The greatest power comes from recognizing potential sources you have and using them strategically and judiciously.

As a Title V leader, you have a number of sources of potential power and influence, including:

• A rich legacy of MCH leadership
• Your knowledge, skills, expertise and passion
• Your staff's knowledge, skills, expertise and passion
• Stature, visibility and direct means of control related to your position
• Budget resources, including the ability to fund agencies and organizations that may be supporters or detractors
• Legislative and regulatory requirements governing your programs that can be used strategically to back up your course of action or requests of others
• Control or influence over contracts, regulations or other legal requirements
• Ability to develop voluntary standards and guidelines, backed by the power of your office and the influence of the stakeholders involved in development
• Data, information and reports needed by others or which can influence others
• Access to other state leaders and managers in your agency, other agencies, the governor's office and the state legislature
• Individuals, organizations and agencies with direct, vested interests in your programs, and those with more indirect investments in your mission, at both state and national levels
• A network of colleagues in other states, accessible via AMCHP

What Kind of Leverage Does Title V Provide?

While statutory requirements for Title V are fairly limited, there are some important tools to exert influence and lead change.

Within Title V

• Needs assessment and performance data can draw public and policy attention to unmet needs and insufficient progress. You can use this data to compare your state to the nation, other states or across political jurisdictions within the state.
• Legal requirements to address identified needs can help protect against changing political priorities.
• So called "30/30 earmarks" designate minimum funding for preventive and primary services for children and youth. These earmarks can help assure continued attention to children's needs and counteract mistaken assumptions that Medicaid and SCHIP can or will meet all needs.
• Requirements that Title V services be provided free of charge to those below the poverty line, and using a sliding scale for those above, can help assure that financial barriers are not erected to block access to services.
• Requirements for interagency coordination can be used internally and externally to place priority on interagency efforts and to help gain a "seat at the table." Requirements for Medicaid coordination are the most detailed and support roles in policy development for EPSDT, outreach and information, including toll-free phone lines.

Language referencing Title V in other programs' statutes

• The Medicaid statute was amended in 1967 to require that states provide for agreements with Title V agencies to deliver Medicaid services. This language has been interpreted to place Title V in the position of payor of last resort, after Medicaid. The language also assures that Title V services can be billed to Medicaid for Medicaid-eligible children and offered free of charge to others. This provision, which is contrary to general Medicaid policy requiring payment for all services, has been used in Title-V-supported, school-based health programs. Finally, some have used the language to argue that Title V programs should receive cost-based Medicaid reimbursement. Federal Medicaid regulations provide additional requirements for Medicaid agreements with Title V.
• Amendments to Medicaid to address managed care made special provisions for children with special health care needs, citing Title V as one category in defining special needs children exempt from mandatory enrollment.
• The federal State Children's Health Insurance Program legislation requires states to coordinate with maternal and child health programs. Although Title V is not specifically cited, this was the intent behind the language.
• In the Supplemental Security Income (SSI) for disabled children program, reference to Title V has provided the basis for state CSHCN programs to receive lists of all children enrolled in SSI. These lists have facilitated Title V outreach and follow-up to assure these children are linked with needed services. This policy also helped support a Title V role in outreach and recertification efforts following changes in federal eligibility rules in the 1990s.
• The authorization for the federal Healthy Start program requires grantees to coordinate their services and activities with state Title V agencies.

Congress enacted most of these provisions in response to recommendations from MCH leaders through AMCHP and its partner organizations. AMCHP continues to seek opportunities to strengthen the statutory basis for effective program coordination.

Use the "vision thing"!

Communicate your vision frequently. Be able to articulate it in 30-second sound bites that your audience will hear and remember. Your passion can be contagious.

One of the most, if not the most, important roles of a leader is to develop, communicate and mobilize others around a vision for the future. If the Title V program previously developed a vision statement, review it and renew or revise it with your internal and external stakeholders. Taking a look at vision statements from AMCHP, MCHB and other states, as well as your agency's, can be useful in this process.

Knowing and passionately communicating your vision can inspire others to work with you. With a vision to work toward, you can align strategies, plans and budgets to support it.

Know your key stakeholders
Stakeholders - those who have or could have a direct interest in your programs - include a wide range of groups, such as:

• Your staff
• Consumers of services your programs directly support
• Providers of services funded by your programs
• Clinical and health professionals and their organizations
• Other state programs and agencies, especially those with overlapping missions, functions or target populations
• Local health agencies
• Community-based organizations
• Your agency's leaders
• Governor, including key staff
• State legislature, especially key committees
• Congressional delegation
• Advocacy and voluntary agencies
• Business community
• Faith community
• Health care providers, including hospitals and community health centers
• Academic institutions, especially schools of public health
• Women, children, youth and families who benefit from population-wide functions

A fundamental part of your job as a state leader is to forge relationships with stakeholders, especially those with strategic importance to achieving your vision, mission and goals.

Tips for building partnerships

• Learn about and actively practice family-centered policies and programs
• Learn about and actively practice cultural competence
• Identify effective committees, associations and other groups with similar missions and contribute to their work
• Identify and cultivate potential champions in key stakeholder groups to help carry your vision
• Learn about the mission, goals and agendas of key stakeholders and help them within the context of your mission
• Learn who your program's detractors are and why; develop strategies to respond to their concerns
• Form task forces, advisory groups and coalitions when appropriate to achieve specific strategic aims

Pearls of wisdom from your colleagues...

• The more difficult the relationship, the more important it is to meet face-to-face
• Assess what you might do differently, but do not take all difficulties personally
• Some responses may be to past history or the legacy of your predecessor. Find out your key stakeholders' views of your programs and learn from that past history and legacy
• Never, ever burn your bridges!

Understand Your Advocacy Role

As we saw earlier, public sector advocacy for maternal and child health has roots dating back to the beginning of the 20th century. A dictionary definition of advocacy is "an act of pleading for a cause." The dictionary definition of the verb to advocate "is to support or urge by argument." Leaders of Title V programs generally have a commitment to the cause of improving health and well-being. MCH leaders need to lay out a vision and support its achievement, using data and evidence to make the argument for specific programs. So, you are an advocate!

Agency culture. The possibilities for advocacy are numerous. It's important to know the limitations, but often you are not as limited as you may assume. There are several parameters for advocacy as a state employee. First is the extent to which your agency fosters or discourages open discussion and diversity of views. All agencies need their senior staff to support the agency's mission and goals, but there are degrees to which agencies seek total adherence to the "party line." This political culture affects the degree to which you may be able to argue or discuss disagreements publicly. Observe and ask colleagues about your agency's culture.

External communications

Another parameter affecting advocacy is agency policy on communications with the state legislature, the governor's office, congressional delegation or the media. Many times, public employees assume that such communications are not possible, when they may be. Sometimes you need advance approval, which seems like a barrier. Learn what your agency's policies are, in statute, written policy and in practice. You can then determine if and how you may use direct communications.

In some states, direct communications with legislators, the governor's office and media may be centralized in the agency. If this is the case in your state, one of your advocacy roles is to educate the individuals in these central offices about your areas of expertise and the MCH programs. If you become a helpful resource to these offices, they are more likely to represent your programs in their communications or even direct questions to you. In some states, it may be routine for such communications to be routed to you, although you may not be allowed to initiate such contacts. Some states allow both response and initiation of contacts by certain senior managers. In these cases, you can build a reputation as a helpful resource with these key external players.

Education versus lobbying. It's useful to bear in mind the distinctions among education, advocacy and lobbying.

There is no blanket prohibition on lobbying by public employees. Again, if you seek to lobby, to affect specific legislation, it is important to know if you are within permissible parameters for your agency. You must also be sure that any time spent lobbying is not charged to federal funding that prohibits use of those funds for that purpose, such as Title V. Finally, you can lobby as a private citizen on your own time.
There may be some real barriers to lobbying, so how else can you advocate for action? Lots of ways!

Public health tools for advocacy

• Sharing newsletters, fact sheets and reports with key stakeholders like advocates and policymakers
• Informational briefings and conferences for advocates and policymakers
• Inviting policymakers to visit programs
• Convening task forces and advisory committees to review information and develop recommendations
• Facilitating or participating in coalitions to stimulate specific action.

External Communications

Another parameter affecting advocacy is agency policy on communications with the state legislature, the governor's office, congressional delegation or the media. Many times, public employees assume that such communications are not possible, when they may be. Sometimes you need advance approval, which seems like a barrier. Learn what your agency's policies are, in statute, written policy and in practice. You can then determine if and how you may use direct communications.

In some states, direct communications with legislators, the governor's office and media may be centralized in the agency. If this is the case in your state, one of your advocacy roles is to educate the individuals in these central offices about your areas of expertise and the MCH programs. If you become a helpful resource to these offices, they are more likely to represent your programs in their communications or even direct questions to you. In some states, it may be routine for such communications to be routed to you, although you may not be allowed to initiate such contacts. Some states allow both response and initiation of contacts by certain senior managers. In these cases, you can build a reputation as a helpful resource with these key external players.

Understand the Policy Process

A former German chancellor noted, "People who love the law or good sausage should never watch either being made." However, if you want to educate, advocate or even lobby to influence policy, its critical to know how public policy is made, both formally through legislation and informally through policymakers.
The governor. The state's chief executive is clearly in a position of power and influence. Gubernatorial priorities are in turn influenced by a number of factors, including not only party and ideology but personal background and experiences. Find out as much as you can about these and their potential link to MCH issues. Does the governor have children? Do the governor or his contributors have any strong ties to health groups? What are the governor's spouse's interests? Spouses often take on campaigns and initiatives relevant to family health. Find out how the governor's office is structured, whether there are advisors on health or families, and what their backgrounds and interests are. Be sure to provide them with information relevant to their interests, if appropriate. The governor's office usually will initiate the state budget, introduce legislation in priority areas and can dictate many aspects of state agency operations.
The state legislature. State legislatures vary tremendously in their make up and operations. Know whether yours is part-time or full-time, paid or volunteer, staffed or not. These characteristics can make a big difference in the timing and information needed to enact legislation. Know which committees in both branches have jurisdiction over budget and policy matters related to health, children and families, and other areas of importance to you. Committees are the next step after introduction of legislation, and committees have the power to stop or significantly alter legislation before it goes to each branch for a vote and, if passed, to the governor for action. Know the chairs and most influential members of the committees, along with those who are most interested in your issues. Attend committee hearings if possible to learn their styles and interests; observe how others before the committees present testimony and respond to questions. Get to know legislative staff, establishing yourself as a helpful expert resource - they will remember!
Congressional delegations. Do not forget the federal policy process! While significant power has been devolved to the state level, Congress still exerts strong influence on what states can do. Congress makes decisions on the federal budget and appropriations for specific programs, including Title V. The Labor, HHS and Education appropriations committees in both the House and Senate are key to Title V and other programs benefiting women, children, youth and families. Authorized under the Social Security Act, Title V is under a different Senate committee than programs authorized under the Public Health Service Act. As with your state legislature, knowing the process and the key players in Congress is important to your ability to assist them with information and recommendations. You also need to know your state's senators and representatives to Congress and their committees that are relevant to your programs. As with state-level policymakers, it is important to develop relationships with these federal staffs, making yourself known as a good source of information.
Influential people in your state. Regardless of the degree of latitude you have to interact directly with policymakers, it's important to know who has influence with them and whether anyone has a connection with your programs. Often, a personal connection to an issue has a strong influence on policies.

Use Communications and Marketing Strategies

Once a dirty word in health and human service circles, marketing has come to be recognized as an important tool in public and nonprofit arenas. At a very basic level, this means thinking beyond the programs to how they are presented and to whom.
Some simple tips for marketing

• Write simply, using plain English and short sentences
• Use easy-to-understand state maps, graphs and pie charts to depict data
• If you can, budget for professional printing of documents that will be disseminated broadly, using colors and plenty of space
• Make your website a priority; keep it up-to-date, interesting and complete with key data, reports, contact information and links, including a link to AMCHP
• Tell stories about your data and programs or, better yet, have families tell stories about the impact of programs

Working with the media. Knowing how to work with the media can do a lot to help you get the word out on your vision, your programs' accomplishments and resources that are needed to achieve goals. Your state agency's public information office can be a resource, and it's well worth your time to inform them about your programs and areas of expertise. That office will be more likely to forward media calls to you or represent your perspectives with the media. Working with this office, you can develop proactive media strategies, using tools like letters to the editor, op-ed columns, press releases and press briefing kits, and human interest pieces profiling local programs and family stories. These tools can get your messages across more powerfully than written reports. As with policymakers, making yourself known as a credible source of information for the media can help assure balanced coverage of issues concerning the health of women, children, youth and families. Consider training for yourself and key colleagues if your senior team doesn't have this expertise.

Resources

• Association of Maternal and Child Health Programs Policy and Advocacy Portal
• Connecticut Health Policy Project has a web based toolbox for state level advocacy
• MCH Leadership Skills Training Institute
• New England SERVE
• Women and Children's Health Policy Center, Johns Hopkins University - including compendium of MCH related legislation