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Building sustainable public health systems change at the state level.

 Reforming the public health infrastructure requires substantial system changes at the state level, including the reorganization of state agencies' plans, roles, and relationships with other sectors and communities. Beyond the limited time period of pilot programs and grants, how are these public health system changes to be sustained? Turning Point is an initiative of The Robert Wood Johnson Foundation to transform and strengthen the public health system. The 21 states participating in this initiative developed multisector partnerships to produce public health improvement plans and from these, chose one or more priorities for implementation. Reform efforts to strengthen the public health system occur within complex fiscal and political environments, however, and must cope with both uncertainty and turbulence in the process of implementing change. Turning Point state partners have developed a variety of approaches to the challenge of incorporating effective community collaborations as a permanent strategy for transforming public health systems. A qualitative, descriptive study design was used to analyze the strategies used by Turning Point state partnerships to meet the challenges of sustaining their system improvements. These strategies included: institutionalization within government, establishing "third sector" institutions, cultivating relationships with significant allies, and enhancing communication and visibility among multiple communities.