Business planning for public health

HLTH 8136 Week 10 Group Activity

Setting Metrics for Progress and Success Childhood Obesity

  1. What is the relationship between ROI and evaluation?
  2. How would you measure ROI for your group’s particular program or endeavor? What are the
    metrics you would set by which to measure progress and success? Justify your choices.
  3. What other business skills would be important for a leader to demonstrate in leading this proposed
    change? Explain your views.

The major challenges facing the health sector especially in public health management is the need
for more accountability and effective business management skills. The demand for accountability
and prudent resource management strategies in public expenditure in provision of health care
services is greatly hampered by the need to offer quality services and also the need to increase
accessibility to all areas of public health.
Evaluation refers to the assessment of the performance of the of the Return on Investment (ROI)
strategies that have been implemented at the health facility. Public Health practitioners are
trained to offer services that provide the opportunity for the common public to lead a standard
healthy life. To measure the ROI of a successful health facility, the practitioner collects data on
the number of attendees seeking services at particular health facility that needs to be evaluated.
For example, the number of children brought to the center for immunization against the threat of

HLTH 8136 Week 10 Group Activity 2

rabies, bioterrorism or for checkup on obesity related complications and who are mostly
underinsured or poor. The success rate can be compared to the percentage rate of the number of
immunized children against the estimated number of children in that region (Roper, 2006). An
average rate of about 50% is fair while less than 50% will be considered below average. The
other ROI measures can be implemented on the number of projects that are being undertake in a
particular district for example on such programs like the prevention of lead poisoning and the
support for preterm children. However, the success rates for such projects can be evaluated
through pilot projects to assess their success or failure rates. The data collected in the field can be
analyzed and used to make cross-disciplinary collaraboration in order to improve and protect
public health services.
Finally, the application of Management Academy business models from the University of North
Carolina that combines business models and public health management while utilizing the state-
of-the-art modern business methods to manage the facilities can greatly provide good returns on
investment made (Orton & Menkens, 2006). The entrepreneurial approach of managing public health
aims at maintaining the sustainability of the programs being undertaken by practitioners who are
experienced in business planning skills.

HLTH 8136 Week 10 Group Activity 3


Orton, S. & Menkens, A. (2006). Business planning for public health from the North Carolina institute for
public health. Journal of Public Health Management & Practice, 12(5), 489-492.
Roper, W. L. (2006). The Management Academy for Public Health: Together we can make a difference.
Journal of Public Health Management & Practice, 12(5), 407-408.

The Management Moment
Business Planning for Public Health From the
North Carolina Institute for Public Health
Stephen Orton and Anne J. Menkens

This special issue is centered on case studies of six public health business plans, and the term “public health
business plan” appears throughout the issue. But what
is a public health business plan? And why might you
want one?
First, let us discuss why business planning makes
sense to today’s public health managers. When public
health managers conceive of their work as business
planning, they begin to graft a business-oriented model
of analysis and operation onto the culture of nonprofit
and governmental public health. The goal becomes
customer service,1 and the task becomes creating value.
It means finding new, different sources of support for
programs, diversifying partners, generating revenue,
analyzing efficiency, determining cost per unit of
service, calculating break even points. If public health
were a baseball game, creating a successful business
plan would be like hitting a grand slam to bring home
the resources necessary to improve health in your
The shift toward a more entrepreneurial approach
to planning social interventions comes in the context
of economic uncertainty, rising expectations, and ongoing and emerging health threats. It has roots in the
“reinventing government” movement2 and the concurrent movement in the nonprofit sector toward social
entrepreneurialism.3–6 Four needs are driving public
health ventures in this direction: the needs for sustainable financing, proven results, improved efficiency, and
effective multisectoral partnerships. Federal and state
resources are becoming scarcer and more restrictive;
public officials increasingly want demonstrable results
for those public funds; grants increasingly require hard
outcomes and sustainability plans; and grant funds
continue to run in unpredictable cycles, though they
are very predictably run out. “Doing more with less”
may seem oxymoronic, but the environment requires it.
J Public Health Management Practice, 2006, 12(5), 489–492
C 2006 Lippincott Williams & Wilkins, Inc.
To sustain public health efforts at the community
level, then, managers have to become expert at blending and diversifying funding sources and using those
sources as efficiently as possible to achieve outcomes
that are both measurable and sustainable. Business
planning skills help government speak the language of
business—which is increasingly the language of effective nonprofits as well. Many businesses are looking to
engage in venture philanthropy and achieve a social return on investment; they are increasingly interested in
public health, starting with public health hazards that
could impact their bottom line. Taken together, these
forces are driving public health managers to analyze
and plan for sustainability the way businesses do.
Envisioning sustainability is a mind-set; business
planning is a means to that end. Public health planning
begins with an idea—a perception of a need in the community and a data-driven strategy to address it. Business planning similarly starts with assessment, always
adding the question, “How can I solve this problem in a
financially sustainable way?” To answer this question,
an entrepreneurial public health manager must first
know—in detail—the feasibility of the proposed plan.
What is the evidence that the plan will work, with limited risk, in a way that is sustainable after the grant
● The Feasibility Study
Undertaking a feasibility study will help you begin to
think through the practicability of your project. A feasibility study is the first step in business planning, where

Stephen Orton, PhD, Director, Management Academy for Public Health, North
Carolina Institute for Public Health, School of Public Health, University of North
Carolina at Chapel Hill.
Anne J. Menkens, MA, Director, MAPH Special Issue, North Carolina Institute for
Public Health, School of Public Health, University of North Carolina at Chapel Hill.
490 ❘ Journal of Public Health Management and Practice
you look at the data to determine who needs what, you
analyze the environment in which you will act, study
the relevant models, determine exactly how to measure your success, and insure the sustainability of your
efforts by analyzing the financial picture. A simple feasibility study will help you decide whether to invest
time in a full business plan, and it should serve as a
blueprint for your business plan. The essential distinction between a feasibility plan and a full business plan
is the level of detail. The following are critical components of both.
Narrative description
You should be able to tell your business plan as a story:
this is the problem, and this is the solution. Describe
the plan in two or three short paragraphs, in plain language, giving clear answers to key questions about its
practicability: Is the project justified by the available
needs assessment data? Do you have the resources?
Are there models and evidence suggesting plans of this
type are effective? Can outcomes be measured effectively? Will it support itself financially? Is it the same
old thing, or a creative, fresh, tailored solution? Are the
right community partners at the table and committed?
Demonstration of need and target market
Public health managers are experts on the population
health needs of their communities. Use the data to show
how important a problem is, and who is affected. Describe that data, and convince your audience that the
problem is worth solving. Clarify the nature of the gap
your plan is intended to fill. Define your target market, and use data to demonstrate need in this particular
market. You may need to demonstrate that members
of the target group have had some input into the assessment and planning process. Show what need is not
being met efficiently, or why clients are not benefiting
from current services. Compare benefits of funding the
project to costs of failing to fund it. Think about tangible
and intangible benefits of implementing your project.
In the Dare County case in this issue,7 some of the benefits of having a cadre of peer health educators have gone
far beyond peer education to affect the health habits of
the larger community. And, the New Hanover County
spay/neuter facility8 has led to higher customer satisfaction and subsequent higher rates of pet adoption, an
unexpected benefit that is in the long run just as important as increasing pet sterilization.
Definition of plan
Describe the idea in detail. Outline the size and scope
of your project, as well as your objectives. What specific
services or products or interventions are you planning?
What is your client/geographic focus? What is your
timeline? What are your plan’s resource requirements?
Are your stated objectives achievable? Carefully work
through the many stakeholders involved individually:
How will each be affected? Are your stated objectives
logical? Are they pointed in the same direction? What
are the critical success factors—the one or two things
that have to happen for the plan to succeed? For instance, many existing programs provide access to dental care for children in rural communities; what factors
do successful plans have in common? Ability to bill
Medicaid? Buy-in from dentists? Availability of dental
Describe the health goals you hope to achieve, and plan
for data collection that will show progress toward those
goals. What improvements in community health status
can be expected as a result of your project? What process
measures will you track? How will they be measured?
How will you know if you have hit a “home run” with
your project? Businesses often have very sophisticated
ways of tracking performance: not just sales but sales to
returning customers, marketing impressions, customer
satisfaction, wait times, and return rates. This section of
the business plan challenges you to understand deeply
the process by which your plan will work to achieve
its objectives, and then figure out how to measure it at
each step. In the Wilkes County access-to-care case in
this issue,9 process measures such as physician satisfaction and outcomes such as number of patients served
are important measures of the program’s value and sustainability. Such measurement will add value to the
program when its administrators need to attract new
partners or sponsors, or affect policy makers, or decide
years down the road whether to continue it.
Industry analysis
We pride ourselves on the extent to which public health
is evidence based, but many businesses are just as
“evidence based” in their planning. Typical business
plans include detailed analyses of things like key success factors and life cycle of a particular industry and
market niche. Good public health program plans include similar analyses of the latest medical science and
the evidence for (and against) specific approaches. Describe the “industry” in which your project fits and
what you know about the structure of the industry. Is
it a health promotion project? A screening project? Perhaps, as they did in Buncombe County,10 you want to
start a program that provides behavioral healthcare for
the underserved. What are the key success factors in
The Management Moment ❘ 491
the industry? Are there legal, political, regulatory, technological, or economic obstacles to implementing your
plan? How will you overcome these barriers? Could
partners help?
In the business world, new efforts usually try to escape
competitors, and instead “run to space.” A few decide
to confront competitors head-on. In public health, there
are plenty of health problems to go around: the goal is
generally to describe how your business plan fills a gap
in the public health system. You may have competitors:
for instance, your plan may encroach upon services offered by local hospitals or other healthcare providers,
health clubs, or others. Your plan should describe
how your business plan complements and integrates
with existing efforts in your organization and in the
broader community. Who are the agencies and organizations with interests in this space? Who are the natural
community/state/national partners in this project?
How does this plan fit with their goals and objectives?
Is the local environment receptive to this sort of plan?
What is distinctive about your services relative to those
of competitors in the marketplace?
A detailed listing of key events and specific dates by
which they will happen will help you determine the reasonableness of your idea and your needs for finances,
personnel, and time. This section becomes a critical part
of calculating financial needs in business: you must
have enough cash throughout the process to pay the
bills. In a world where grants or government allocations often cover start-up costs, initial cash flow is less
a concern, but the timeline is critically important for
clarifying steps and assigning roles for multiagency or
multiorganizational efforts.
Risk and exit plan
Launching a program within the government sometimes requires us to soft-pedal the downside and push
the upside to legislators and constituents, but experienced public health managers understand the risks and
pitfalls of different kinds of interventions. The specific
risks for your topic area and organization or community should be listed and analyzed. What are the things
that could go wrong, and what preventive measures
can be taken? How will you know if the program is
not working? How will you shut the program down, if
For public health business plans, exit planning has
an added function: planning the transition of a successful program to another entity. For some public health
programs, success is defined by the ability of the governmental agencies to smoothly hand off day-to-day
operations of an ongoing intervention to organizations
in the nonprofit or perhaps even the business sector: to
assure services, in other words. Both possible “exits”
should be prepared for in the business plan.
Financial resources
Writing a business plan means seeing money as part of
the analytical problem, instead of seeing it as part of
the frame. Often in our work, we start with a certain
amount of money as a constant: such-and-such foundation or agency wants proposals for how we would
spend $500,000 over 3 years on diabetes prevention.
Business plan finance is more dynamic. The task is to
balance resources (including cash) and costs, using the
best possible assumptions to get the best possible recommendation. To return to the dental care example:
How many children can you sign up? How many could
you see, given the staffing and space? What services
will those children need, in what proportions? How
much will it cost to provide fixed items such as personnel, equipment, and space? How much will it cost to
provide service to each child? The revenue side of the
equation is similarly complex: Who pays how much
for what, when? How many children must you see to
break even? What is the estimated 5-year budget for
your business plan? What will have to happen to make
the program sustainable financially in the long-term?
The dynamic nature of this analysis requires detailed
financial projections and assumptions. Public health
business plans often use grants to start up an effort, but
the best go beyond grants and general fund monies.
People who read business plans for a living often
start with the finance section. It provides the framework
on which the more narrative parts of the plan hang. And
the level of detail in this section provides an instant reality check on the assumptions made in the plan. Some
signs that your assumptions may be flawed:
• A nurse is funded half-time—to run a screening program that will triple in size over 3 years.
• The Public Health Department is providing a big
chunk of the required resources as “in-kind” donations of staff time—forever, without new hires.
• Monthly expenses are the same every month—for a
program to deliver influenza shots in schools.
Your finance section will give an early indication of
sustainability. Does the program rely on a grant to come
through in the future, or an existing grant to get extended? Do the revenue projections require unrealistically large utilization rates or market penetration? Does
the program allocate money for evaluation? Are there
492 ❘ Journal of Public Health Management and Practice
agreements in place with partners who are donating
critical resources such as space and equipment? Have
you accounted for “in-kind” contributions?
● The Business Plan
When you have answered the questions above, you
have essentially begun writing a business plan for a
new initiative that addresses a need in your community. You will need a business plan if (1) your sponsors
or political allies (or foes!) want to see one; (2) your
partners want to see one; or (3) you want to generate revenue. In short, if you want to implement your
initiative and do so in a sustainable way, you need a
business plan. A major difference between feasibility
studies and business plans is that the former asks questions and the latter makes statements on the basis of
the answers to those questions. A business plan is an
argument that a new venture should be done and can
be done; it sells the idea, and your capacity to execute
it. It also prepares an important road map for action
that is useful to you and your potential partners and
Business plans are not for internal projects, such as
creating a new HR manual, but for external, revenuegenerating projects. Business plans are not for doing
strategic planning but for executing existing strategies: they are concrete implementation plans within the
broader strategic plans of organizations and communities. And although business plans are designed to sell
ideas, you should not use them to sell yourself on a bad
idea. Business plans are meant to help predict a future
outcome with as much certainty as possible.
Business plans that succeed are often testable (you
could do a pilot version); reversible (can return to status quo); divisible (can be implemented in stages); concrete(with tangible results);supported (cover sunk costs,
building on existing programs and resources); familiar
(models are available); congruent (match goals, initiatives); widely valued (have publicity value that stakeholders will appreciate); marginal (not risky to the complete enterprise); idiosyncratic (you can start it by yourself); and timely (reacts to an emerging crisis or uses a
new means of attacking an old problem). Many business plans do not succeed. Good business planning can
prevent those failures from being catastrophic.

This issue of the Journal of Public Health Management

and Practice (Vol. 12, Issue 5) focuses on the Manage-
ment Academy for Public Health. This is a management

development program jointly offered by the School of
Public Health and the Kenan-Flagler Business School
at the University of North Carolina at Chapel Hill since

  1. Initially funded by the Centers for Disease Con-
    trol and Prevention, the Health Resources Services Ad-
    ministration, the W.K. Kellogg Foundation, and the

Robert Wood Johnson Foundation, and originally tak-
ing students from four southern states, the Manage-
ment Academy is now a revenue-supported program

that attracts participants from every region of the coun-
try. It is an intensive, 9-month, team-based program,

using coursework in Chapel Hill, distance learning ac-
tivities, and a capstone project consisting of a com-
plete business plan that participants are expected to

implement after being graduated from the program. A

hallmark of the program is that it is thoroughly cross-
disciplinary between public health and business, with

the goal of applying business methods of management

and business planning to public health issues. This ori-
entation affects every aspect of the program and models

the type of partnering between public health and busi-
ness people that program planners believe is essential

for successfully meeting the challenges faced by public
health managers every day.
A major theme of my tenure as Dean of the UNC

School of Public Health was collaboration across de-
partments, disciplines, schools, and sectors. I was for-
tunate to have colleagues in the school and across

campus who shared the ideal of strengthening the
whole by cooperative endeavor. We believed—we still

believe—that cross-disciplinary, collaborative initia-
tives can make a real change in important arenas.

When the Request for Proposals for the Management
Academy was issued, we at the University of North
J Public Health Management Practice, 2006, 12(5), 407–408
C 2006 Lippincott Williams & Wilkins, Inc.

Carolina were most excited by the idea of combining

business and public health expertise to improve the ef-
fectiveness of public health systems. Robert Sullivan,

then Dean of the UNC Kenan-Flagler Business School,
and I had spoken about the need for managers in public
health to understand and use state-of-the-art business

methods, strategies, and tools in public health decision-
making. In a time of mounting public health needs and

shrinking resources, increasing the management skills
of senior, midlevel, and entry-level staff clearly was a
critical strategy for addressing tremendous challenges
in local and state health departments throughout the
The first section of articles that follow sketches the

background of the Management Academy’s develop-
ment, describing first the program design and how it

works to develop public health managers (Orton et al),
and then stepping back to trace the broad demographic,
socioeconomic, and political trends reshaping public
health in the 1990s and today that went into the design

(Johnson et al), as well as describing how various part-
ners came together to conceive of the program (Baker

et al) and to design and develop it (Porter et al). These
articles outline the critical success factors that have
made the program so popular and successful.

The second section of articles in this special is-
sue examines the outcomes from the Management

Academy—what this program has made possible in
individual and organizational achievement. Umble
et al provide an overview of the external outcomes

Corresponding author: William L. Roper, MD, MPH, School of Medicine, The
University of North Carolina at Chapel Hill, Campus Box 7000, Chapel Hill, NC
27599 (e-mail:

William L. Roper, MD, MPH, is Dean of the School of Medicine, Vice Chancellor for
Medical Affairs, and CEO of the UNC Health Care System at the University of North
Carolina at Chapel Hill (UNC). From 1997 until March 2004, he was Dean of the UNC
School of Public Health, and was Principal Investigator of the Management Academy
for Public Health at its inception.


408 ❘ Journal of Public Health Management and Practice
evaluation of the program’s pilot years (1999–2003),
defining precisely what the Management Academy is

trying to teach and detailing the impact—on the indi-
viduals and organizations that have participated in the

program—of having addressed these learning goals.

This overview of outcomes is followed by six case stud-
ies written by public health managers who attended the

Management Academy and accomplished with their
learning exactly what the planners intended for them
to do. They took their learning—usually in the form
of the business plan created for the program’s capstone
assignment—and applied it to the challenges they faced

in their home communities. Like public health man-
agers everywhere, these individuals are grappling with

being the provider of last resort for the growing num-
ber of un- or underinsured citizens in their districts;

providing mental health services to the poor and indi-
gent; protecting the population against threats to their

health—from rabies, to chronic disease, to bioterrorism,
and other disasters—and, finally, facilitating the work
of others who work to improve population health by
providing the support, information, and technological
resources for them to do so.
The difficulty (for the editors) in this section was

choosing who among the Management Academy grad-
uates should write—perhaps a team from southern

Georgia that developed a home visitation program to
provide medical care and support to families with a

preterm child; or a Portsmouth, Virginia, team that cre-
ated a fee-based program to prevent lead poisoning; or a

South Carolina program funded by restaurants to create
safety training materials for food workers, or another to
prevent asthma in that state. The decisions came down,

often, to availability to write, for truly scores of gradu-
ates from across the target area would have had inspir-
ing stories to tell about their successes.

One of the greatest challenges facing public health

today is the increased demand for accountability and ef-
fectiveness. Society, in general, is demanding account-
ability for resource expenditure in a variety of ways

and across disciplines and fields. In the case of the pro-
vision of public health services and healthcare delivery,

this demand creates challenges and opportunities as we
strive to strike a balance among efficiency, accessibility,
and quality in all areas of the public’s health. Public
health managers have myriad jobs: they must supervise
people who are providing services; analyze data and

use it to develop new programs, evaluate existing pro-
grams, and make the case for programs to an expanding

and increasingly attentive constituency; and administer

a budget to pay for these efforts. Clearly, strong skills—
gleaned not only from years of experience in public
health management but also from a sound education
in business methods and modes of thinking—will help

the individuals who hold these positions of great re-

But beyond basic business skills, the very act of join-
ing forces with the business community and, by ex-
tension, understanding the concept of partnering more

generally, is an important element of the Management

Academy program. One of our best decisions in cre-
ating the program, and one that mirrors our original

cross-disciplinary collaboration, was to stipulate that
students come in teams, and to suggest that these teams
include community partners. Through these elements
we teach how to create and maintain partnerships—not
only with others involved in protecting and improving
the public’s health, such as healthcare providers, first
responders, law enforcement personnel, etc, but also

with politicians and, of course, the business commu-
nity. Such partnerships not only help individuals but

also improve systems and redefine public health, al-
lowing us to broaden our reach by joining forces with

an ever-widening circle of colleagues. The case studies
included in this issue examine how such partnerships
can work in the real world of public health practice.
Finally, the last submissions in the issue are by noted
personages in the fields of public health and healthcare,

who were solicited, based on their expertise, experi-
ence, and thoughtfulness on these issues, to provide

commentary on the Management Academy for Pub-
lic Health, on management education in public health

more generally, or on the state of public health. They
were asked to think about the implications of applying

a business model to social service allocation, what ele-
ments of the program seemed most and least relevant to

them and their colleagues, or what recommendations
they had for an audience of public health leaders, policy
makers, managers, potential sponsors of public health
initiatives, and others interested in the workings of the
public health system. On the whole, the commentary
writers endorse the Management Academy model, and
each provides valuable advice about how the program
should proceed.
The Management Academy for Public Health, with
its emphasis on bringing people together to think in
new ways about public health, is making a difference in
how public health professionals address the daunting
set of challenges they face today and will face in the

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