The Public-Administration Quandary: ‘Who’ vs. ‘What’

In the end, it's usually better to define what a service should be before deciding who should deliver it.
December 17, 2014
Feather O'Connor Houstoun
By Feather O'Connor Houstoun  |  Contributor
A senior adviser to the Wyncote Foundation

Every senior public administrator has on occasion wondered whether a leadership position should be filled by someone with deep content knowledge or by a person whose executive skills and proclivities embody the process sensibilities thought essential to getting something done. Can't we all wince at memories of a promising individual with deep knowledge who foundered in execution because he or she lacked the skills of community consultation, adaptation and finding workable consensus? Conversely, can't we all recall the talented person who never seemed to "get" the cultural nuances of a field he or she did not know from long experience and was defeated in the trenches of change leadership?

There is no pat solution to this quandary. It is part of the mystery and challenge of public administration. But lest we forget that it happens at all levels, consider the sharp relief coming into view with recent federal-level crises. In replacing the secretary of veterans affairs, the Obama administration went not for the military veteran steeped in the organization or in medicine but for an individual who understood corporate culture and customer orientation. Conversely, what about the long-time Secret Service official, elevated in the face of earlier scandals, who crashed and burned in the face of spectacular security breaches at the White House?

Where is the guide for these critical management decisions? I think it forces the question of "who" vs. "what?" It is rare that the "who" question can be answered if one has not answered the "what" question first. And it takes open-minded, system-based thinking to figure out just what the "what" is.

This isn't just a question of individuals or personalities to fit a perceived gap or public-relations need. It is far deeper than that.

Some years ago, I was confronted with a public-policy question that was garbed in a "who" choice. I headed a state department responsible for mental-health programs, and I needed to decide what entity should be the local delivery system for Medicaid behavioral-health services.. If we followed the physical-health model, we would contract with commercial and nonprofit managed-care organizations to subcontract, manage and deliver behavioral-health services.

The mental-health community strongly objected, favoring the counties as deliverers, pointing to profits believed lost to the system through subcontracting and a lack of connection with county-based behavioral-health systems. The counterpoint from the commercial side argued that professionally managed health-care systems could produce efficiencies along with best practices and physician health coordination.

To that point, it was entirely a "who should control" conversation. The turning point came when it became a "what" conversation. What should consumers of behavioral health services expect from the system, whoever was running it? Why should who is managing it affect how long one should wait for an appointment? What standard of practice should guide community- and institutional-care decisions? What formulary should be in place to determine drugs offered under varying circumstances?

Over time, the advocacy community, the county program officials and the commercial managed-care organizations agreed on system specifications that were the basis for a uniform contract that spelled out service expectations for consumers, payers and service deliverers.. The "what" was key. Not surprisingly, the "who" question was answered in many ways in the end. One county set up a nonprofit entity with some institutional separation from county government. Another county delivered the programs directly. Other counties passed on direct delivery and contracted with managed-care entities that they selected competitively. But regardless of the "who," the "what" was defined by consumers and by program administrators who were empowered to assure delivery.

It was a lesson in how important was determining the product -- the "what" -- before deciding the best choice of deliverer -- the "who."