Within each site we interviewed the senior leadership of the department, division and branch chiefs, and other key informants with knowledge about the department s process for setting departmental vision, working with external partners, and making and communicating decisions. The discussion guide was based on the input of an expert panel of organizational theorists who identified key variables that seem related to organizational resiliency in complex environments. The environment in which public sector organizations operate tends to limit the applicability of organizational theory built on private sector experience. They do not have the flexibility to add or abandon lines of business that their private sector counterparts may have. Top leadership of health departments changes rapidly while the middle and lower levels may be long-time employees.
Health departments are collections of fiefdoms.
These outside requirements mean that change strategies must address not only the concerns of staff, but also their responsibility to the outside funder. And consequently, departments often find themselves in the position where change that is good for the whole department is stymied because it runs afoul of the needs of categorical funders. Health departments have suffered from too much, not too little autonomy. Oddly and counter-intuitively, more centralization, more integration, and more standardization may be the route to increasing flexibility and resilience in health departments. Support functions are such complex and mysterious processes, governed by staff and laws two and three levels up from the health department that the department s support staff, far from being seen as impediments to change, are often seen as essential to negotiate the process.