RESEARCH AND PRACTICE

Assessing Entrepreneurship in Governmental

Public Health
| Peter D. Jacobson, JD, MPH, Jeffrey Wasserman, PhD, Helen W. Wu, PhD, and Johanna R. Lauer, MPH

Despite the public health systems significant

past achievements, many observers have
questioned whether it can adequately respond
to the nations existing public health needs,
let alone to emerging disease threats.1 The
governmental public health system faces
declining public investment, sustained attacks
from opponents (including affected industries
and antigovemment political groups), limited
O bjectives. W e a s s e s s e d t h e f e a s i b i l i t y a n d d e s i r a b i l i t y o f p u b l ic h e a lth
e n tr e p r e n e u r s h ip (P H E ) in g o v e r n m e n t a l p u b lic h e a lth .
M ethods. U s in g a q u a lit a t iv e c a s e s t u d y a p p r o a c h w it h s e m is t r u c t u r e d in
t e r v ie w p r o t o c o ls , w e c o n d u c te d in t e r v ie w s b e tw e e n A p r il 2 0 1 0 a n d J a n u a r y
2 011 a t 3 2 lo c a l h e a lth d e p a r t m e n ts (L H D s ) in 18 s ta te s . R e s p o n d e n ts in c lu d e d
c h ie f h e a lth o ff ic e r s a n d s e n io r L H D s ta ff, r e p r e s e n ta tiv e s f r o m n a tio n a l p u b lic
h e a lth o r g a n iz a tio n s , h e a lth a u th o r it ie s , a n d p u b lic h e a lth in s titu te s .
Results. R e s p o n d e n ts id e n t if ie d PHE t h r o u g h 3 o v e r la p p in g p ra c tic e s : s t r a te
g ic p la n n in g , o p e r a t io n a l e ffic ie n c y , a n d r e v e n u e g e n e r a t io n . C lin ic a l s e rv ic e s

political power, and competitors encroaching o f f e r th e s tr o n g e s t r e v e n u e - g e n e r a tin g p o te n t ia l, a n d t r a d it io n a l p u b lic h e a lth

on its responsibilities. From 2 0 0 8 to 2010,
the local health department (LHD) workforce
declined by approximately 19/o.2'3 As a result,
the governmental public health system must
either develop new and innovative strategies to
generate revenue or face increasing declines in
its ability to protect the publics health.4
If maintaining the status quo is untenable,
what alternatives might be considered? One
possibility is for public health to develop an
s e r v ic e s o f f e r o n ly l im it e d e n tr e p r e n e u r ia l o p p o r t u n it ie s . B a r r ie r s in c lu d e c iv il
s e r v ic e r u le s , a ris k - a v e r s e c u ltu r e , a n d c o n c e r n s t h a t P H E w o u ld c o m p r o m is e
c o re p u b lic h e a lth v a lu e s .
C onclusions. O n g o in g PHE a c t iv it y h a s t h e p o te n t ia l t o r e d u c e L H D s ' r e lia n c e
o n u n s ta b le g e n e r a l p u b lic r e v e n u e s . Y e t u n d e r th e b e s t o f c ir c u m s ta n c e s , it is
d i f f i c u l t to g e n e r a te r e v e n u e fr o m p u b lic h e a lth s e rv ic e s . A lt h o u g h g o v e r n m e n
ta l p u b l ic h e a lth c o n t a in s p o c k e ts o f e n t r e p r e n e u r ia l a c t i v i t y , its c u l t u r e d o e s
n o t s u s t a in s i g n i f i c a n t e n t r e p r e n e u r i a l a c t i v i t y . T h e q u e s t i o n r e m a in s a s t o
w h e t h e r L H D s ' c u r r e n t p u b l i c r e v e n u e s o u r c e s a r e s u s t a i n a b le a n d , i f n o t,
w h e t h e r PHE is a fe a s ib le o r d e s ir a b le a lte r n a t iv e . [A m J P u b lic Health. 2 0 1 5 ;1 0 5 :
S 3 1 8 -S 3 2 2 . d o i:1 0 .2 1 0 5 /A J P H .2 0 1 4 .3 0 2 3 8 8 )

entrepreneurial strategy that supplements

public funds with revenues from other sources,
what we call public health entrepreneurship
(PHE). W e conducted an exploratory case
study examining PHE and assessing its
feasibility within governmental public health.
Because there is no consensus definition of
entrepreneurship as applied to governmental
activities,5"8 we define PHE as the application of
entrepreneurial skills to advance the public
health mission. Indicia of PHE include skills in
appraising human and resource needs, building
constituent and stakeholder partnerships, gen
erating revenue, and ensuring sustainability.9
PHE describes 2 closely linked dimensions:
public health as an economic activity generating
revenue and entrepreneurial innovations to
provide more efficient services.
METHODS
Our research question was whether
governmental public health officials pursue
PHE to generate new sources of revenue and
new service delivery innovations. To address
this question, we used a multiple-site qualita
tive case study, with LHDs as the unit of
analysis. Using a sem istructured protocol, we
conducted interviews betw een April 2 0 1 0
and January 2011 with chief health officers
(CHOs) and m em bers of the senior m anage
m ent staff (e.g., financial officer or assistant
director) at 32 LHDs in 18 geographically
dispersed states. For other perspectives, we
interviewed representatives from 3 fiscal
sponsorship organizations, 3 po rt authorities,
each of the major national public health
associations, 5 health authorities o r taxing
districts, and 4 public health institutes.
Each interview was designed to ascertain
the range of PHE initiatives and potential
barriers and lasted approximately 1 hour.
To identify en trep ren eu rial LHDs, we
conducted an in-depth literatu re review,
spoke w ith relev an t experts (including
representatives from the m ajor national
public h ealth associations), and exam ined
N ational Association of C ounty and City
H ealth Officials survey d a ta .10 W e used
a snow ball sam ple, asking each expert to
identify specific e n trep ren eu rial program s
o r individual contacts to pursue. The
sam ple varied geographically to include
a mix of ru ral and u rb a n departm ents,
sm all and large departm ents, and central
ized and decentralized governance
structures.
For the analysis, we synthesized the
interview data and docum entary evidence
collected to portray current entrepreneurial
strategies. The prim ary form of analysis
was descriptive, comparing and contrasting
inform ation across sites along several
dim ensions of interest.
RESULTS
Given the abstract nature of entrepreneur-
ship, it is difficult to depict PHEs scope.
Nevertheless, respondents generally identified
practices that fell into 3 overlapping tiers:

S 318 | Research and Practice | Peer Reviewed | Jacobson et al. American Journal o f Public Health | Supplem ent 2, 2 0 1 5 , Vol 10 5, No. S2

strategic planning, operational efficiency, and
revenue generation.
S t r a t e g ic P la n n in g
According to our interviews, strategic
planning is a foundation for entrepreneurship.
Strategic planning is focused primarily on
whether to establish or expand private-sector
partnerships to better meet public health goals.
As one respondent explained,
If youre going to follow your mission and serve
those individuals that are underserved, you cant
do it if youre in a weak position. So you need to
think of it strategically to be a strong, viable
health department.11
Approximately 50% of respondents
preferred to retain services rather than contract
to the private sector because retaining services
allowed them to control quality, keep qualified
employees, and ensure the primacy of the
public health mission. As a strong PHE pro
ponent observed, It would be a fools errand to
make public health a fee-for-service enterprise.
The danger is the loss of mission, vision, and
passion.
By contrast, the other 50% mentioned
several important benefits of private-sector
partnerships. First, private entities can fill gaps
in expertise and provide services when current
demand might not warrant hiring government
employees. Second, they can hire staff quickly
and use accountability metrics, improving
operational efficiency. Third, partnering with
private entities allows LHDs to focus on core
competencies. As one health official explained,
In the area of primary care, we didnt do
a good job. It was not our core strength, and
it was costing us $800 to see a client.. . .
We werent doing immunizations and
communicable disease or family planning,
which are all part of the core mission of public
health.
O p e ra tio n a l E ffic ie n c y
The second type of entrepreneurial practice
is operational efficiency, in which
improvements can yield significant cost
savings. Entrepreneurship proponents
indicated that the systematic examination of
business processes can reduce waste and costs
and improve client and employee satisfaction.
As one CFIO stated, The best way to get more
money is to prove how efficient youve been.
Other respondents mentioned organizational
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RESEARCH AND PRACTICE
improvements, such as combining programs
under 1 manager instead of maintaining
multiple programs and managers. In this
context, entrepreneurship is consistent with
the emphasis on assessing the quality of
public health services12 (see also http://www.
phaboard.org for more information).
Focusing on efficiency can lead to revenue
generating programs and building public
healths political capital. For example, an
LHD director made a deal with the board
of supervisors, promising not to ask for
any funding increases until he made the
department more efficient. In 1 year, the LHD
made operational improvements that doubled
its client load without a budget increase.
Consequently, the department avoided budget
cuts and gained the boards trust; the board
then agreed to create a public health district
with designated sales tax revenue.
A smaller number of LHDs targeted clinical
services for efficiency improvements, such as
co-locating similar programs to achieve savings.
Larger LHDs invested in practice management
systems and eligibility verification software
to increase reimbursement. In conjunction
with these systems, the LHDs also applied
efficiency strategies to nonclinical services to
improve customer satisfaction. Using business
process analysis techniques,
we got all our environmental health inspections
completed at a higher rate than weve ever done,
so even though its a down economy, weve
collected more revenue than in the past. Every
number is up. We didnt add staff, we just
improved the processes.
Unfortunately, large quality improvement
and efficiency initiatives can be difficult to
implement in small LHDs, particularly those
with limited access to discretionary funding
and staff with advanced training. Strict dvil
service systems can also limit the use of
incentives. At one smaller LHD, the pressures
of responding to HINI and reduced funding
forced the organization to put its quality
improvement initiative on hold. Theres no
discussion of what could we do differently or try
to do better. I dont see us doing planning ahead.
N e w R e v e n u e S o u rc e s
In the final PHE tier, LHDs develop new
programs that generate revenue through
fees, reimbursement, or grants. Almost all
Jacobson et al. | Peer Reviewed | Research and Practice | S 319
respondents acknowledged the need for LHDs
to diversify revenue streams to address
growing financial constraints.
Public goods. Respondents also acknowl
edged the limitations of finding sources of
revenue for services that are purely public
goods and the difficulty of sustaining
the initiatives. For instance, even though a
majority of respondents have successfully
received grants that stay within the department,
most indicated that grant funding is not sus
tainable, often citing their experience with
bioterrorism preparedness grants.
Likewise, most respondents were skeptical
that marketing public health services, such as
surveillance surveys, is a sustainable revenue
measure. As a respondent explained, Public
health functions are not billable services.. . . If
there was money, the private sector would be
providing the service. Another added that
it is hard to make an overarching for-profit
business model to provide 3 core functions and
10 essential services.
Finally, respondents voiced concerns about
political or philosophical issues related to
developing revenue-generating programs. For
example, several respondents argued that
because LHDs serve as the provider for
low-income populations, fees for services
should be as low as possible. Nonetheless,
other respondents are raising fees to replace
declining general revenue.
Strategies. An alternative strategy for
generating revenue is providing services to
other governmental entities. For instance, one
LHD now handles safety and occupational
health for the city at a lower cost than a private
contractor, which brings in a steady stream
of funding. By successfully reducing the
number of accidents, thus lowering workers
compensation insurance rates, it saves the city
money. Consistently, however, respondents
noted that the savings from similar efforts
rarely accrue to the department. A city
health department developed wellness and
occupational safety programs for city agencies,
but concluded that
both the wellness and the occupational safety
[programs] are internal entrepreneurial things
th at... save dollars, but dont really make money
for us. But its strategic, because . . . the more
I can get staff showing some sort of revenue or
being part of a valued program, the more secure
they are.

In a related approach, a few respondents
were able to generate revenue through
financing mechanisms. Four respondents
created independent 501(c)(3) organizations
to capture private funds from foundations
or donors who only contribute to a non
governmental entity. Significantly, after
raising more than $ 1 million to create a new
health center, a CHO noted that as important
as the money is, its really about getting
influential people involved.
Aside from creating independent financing
mechanisms, several LHDs are funded through
stable property tax revenues. Reflecting on the
LHDs that have an independent source of
funds from dedicated property taxes relative to
those without, one CHO noted,
We are independent. We have millage from
the property tax. Its a pretty stable source of
funding for us; its more stable than state
funding.. . . We havent laid anyone off
during the recession, but the state has had
to cut a number of positions. The health
departments that rely on a property tax are
doing well. W ere not flush, but we can begin
new programs.
A skeptical CHO remarked, If you just wait for
a property tax to be passed, youre going to
have difficulty. More important, this option
may not be legally available in all states. In any
event, similar strategies are legally complex.
A number of respondents argued that
clinical services present revenue-generating
opportunities. Although many LHDs
nationwide have abandoned clinical services,
proponents indicated that they raise revenue
through established reimbursement methods.13
For example, one LHD runs a highly produc
tive dental practice that has been expanded to
10 local cities, improving access to care with
little cost to local governments because of
a strong Medicaid patient base. At another
LHD, administrators developed a nurse mid
wife program to manage the prenatal care of
and delivery for undocumented mothers. The
midwives have achieved significantly lower
rates of infant mortality and cesarean deliveries
than the rest of the community. Both programs
improve community health while simulta
neously securing stable Medicaid revenue.
Proponents of using clinical services
suggested that the Patient Protection and
Affordable Care Acts14 worksite wellness
programs and the community health needs
S 320 | Research and Practice ] Peer Reviewed | Jacobson et at.
RESEARCH AND PRACTICE
assessment process are feasible revenue
opportunities. However, generating revenue
through wellness programs or the acts
population health provisions is a work in
progress that not all respondents agree is
feasible.
Generating revenue allows LHDs to retain
reserves that can lead to significant public
health benefits. As a CHO noted,
It allows you to be like a business and anticipate
the economic cycle and squirrel away some
money. It has helped us weather the economic
downturn since we could use our strategic
reserves. We did have to throttle back a little
during the recession, but we could still maintain
some measure of continuity.
Recently, the LHD built a new $7 million
health center, paid for in cash.
B a rrie rs F a c in g P u b lic H e a lth
E n tre p re n e u rs h ip
Our interviews revealed substantial
barriers to PHE. A key concern is the risk to
governmental public healths mission and
core values when the emphasis shifts to
profit-oriented services and strategies.
Politics. The obstacles to PHE are largely
rooted in a governance model that is generally
unsuited to developing revenue-generating
programs. Respondents consistently mentioned
politics as a barrier because entrepreneurship
requires more independence than most elected
officials are willing to provide. As one respon
dent put it, in most communities, theres not
much political will, theres not much courage,
theres not much vision, and it takes guts to do
these things. To be sure, political consider
ations are a fundamental and appropriate
aspect of governmental public health delivery.
Yet the willingness to lessen political control, a
precondition for PHE, rarely exists. There were
only 2 exceptions in our sample in which
elected officials permitted LHDs to convert to
independent health authorities.
Bureaucratic barriers. The most commonly
cited bureaucratic hurdles to PHE are related
to personnel and purchasing. Almost every
respondent dted staff hiring and firing as major
governmental constraints. Civil service rules
make it difficult to fire underperforming
employees and limit pay to levels that are too
low to attract the best candidates. Workforce
capacity constraints are serious limitations,
American Journal o f Public Health | Supplement 2, 2 0 1 5 , Vol 105, No. S2
both in staffing size and in the skills needed to
be entrepreneurial.
Public budgets. PHE is dependent on retained
earnings that can be reinvested in strategic
opportunities, but fees and revenues that LHDs
raise are usually returned to general funds.
Because many respondents suggested that the
county would cut the departments budget by
the amount of the new revenue stream, they
lack incentives to grow the business, because
the money doesnt come back to the health
department. Indeed, many respondents
expressed concern that elected officials might
reduce future funding for efficient health
departments, believing that they do not need
the same level of funding to provide the
mandated serviceseffectively punishing
successful organizations.
Culture. The vast majority of respondents
indicated that the current governmental
public health culture does not support PHE.
Governmental public health tends to be risk
averse and rule bound and cannot move fast
enough to take advantage of entrepreneurial
opportunities.15 According to respondents,
entrepreneurship would be a disruptive change
to the existing culture because public health
professionals are averse to business concepts.
Therefore, LHDs would need to inculcate
a new philosophy of business.
Visionary leaders and project managers
are needed to develop a culture of en
trepreneurship. As 1 respondent explained,
You need a motivated staff who look outside
the box and ask how it can be done better.
They need to ask, what are we doing that we
dont need to do? The skills respondents
identified as most lacking, and essential for
entrepreneurship, are grant writing, data
analysis, and basic financial aptitude.4 A lack
of employees with these essentia] skills inhibits
innovation.
F a c to rs S u p p o rtin g P u b lic H e a lth
E n tre p re n e u rs h ip
An important prerequisite for entrepre
neurship is access to stable and discretionary
funding as seed money for new programs or
developing new strategies and approaches.
Traditionally, much of public health has been
funded with categorical grants for predefined
programs. By contrast, our entrepreneurial
respondents reported receiving a fraction of

their local property tax levy or, alternatively,
generating a percentage of their revenue
through reimbursement for clinical services. In
both, the funding tends to be relatively stable,
allowing LHDs to respond rapidly to entrepre
neurial opportunities.
Given the benefits of discretionary funding,
a few respondents recently embarked on a
political campaign to secure a portion of their
local tax revenue for public health.16 In one
county, voters agreed to create a public health
taxing district, which could generate as much as
$5 million annually for the LHD, relieving the
pressure to be subject to the disease of the
month. For most LHDs, though, tax funding
may not be an option.
The second factor is political independence.
The most entrepreneurial organizations we
found were public health authoritiespolitically
independent governmental entities with an
entrepreneurial governance model. Health
authorities usually have their own board,
a separate hiring system, and the ability
to retain reserves. This model allows the
director to manage staff without civil service
constraints, improve accountability, retain
adequate funds to take advantage of
entrepreneurial opportunities, and make
quick decisions.
DISCUSSION
Our case study suggests ongoing PHE
activity that has the potential to reduce LHD
reliance on unstable general public revenues.
Yet under the best of circumstances, it is
difficult to monetize public health services.
With rare exception, our interviews revealed
that traditional public health services were not
consistent revenue sources. The results also
provide insight into process-related dynamics
of pursuing PHE, including barriers and other
organizational characteristics.
We conclude that governmental public
health currently contains pockets of entrepre
neurial activity, but it lacks a culture and other
supporting factors to sustain significant entre
preneurial activity. Changing the culture of
public health involves several simultaneous
considerations and a long-term strategy. First,
our results suggest considerable disquiet
about the sustainability of the current public
health system, but no consensus on what the
Supplem ent 2, 2 0 1 5 , Vol 10 5, No. S2 | American Journal o f Public Health
RESEARCH AND PRACTICE
optimal structure would be. We therefore
encourage health officials to consider PHE
as an important component of meeting the
public health mission. To begin the process
of changing the culture, health departments
should invest in training leaders and staff to
develop the entrepreneurial skill set described
earlier.16
Second, the major national public health
organizations should collect data to provide
a more detailed portrayal of entrepreneurial
activities and results. Entrepreneurial
innovations, both successes and failures,
should be shared widely and debated.
Third, state legislators should reconsider the
nature of political control over public health.
A key lesson from the more entrepreneurial
organizations in our sample is that political
independence both encourages and permits
entrepreneurial initiatives. This is not to
suggest removing political control; instead,
expanding special taxing districts or health
authorities is a cost-effective way to generate
the revenue necessary for sustainable
governmental public health.
Fourth, the Patient Protection and
Affordable Care Act presents new PHE
opportunities through the community health
needs assessment and community transformation
grants processes. The act also encourages the
integration of population health and personal
medical care, which could stimulate new
strategies to improve population health.
The question remains whether the current
organizational structure, heavily reliant on
intergovernmental transfers of funds or
contracting to purchase public health services,
is sustainable. Moving toward PHE would
represent disruptive change, with uncertain
consequences.17,18 It is important to consider
that LHDs are not operating in either an
organizational or a services deliveiy vacuum.
Beyond competition from the private sector,
our interviews (not reported here) suggest that
public health institutes and health authorities
are emerging as competitors to LHDs for grants
and other revenue sources. As entrepreneurial
organizations unconstrained by governmental
restrictions, they pose a potential threat to the
current structure, financing, and delivery of
public health services.
The primary limitation of our study is the
range of interviews conducted. As with any
J a c o b s o n e t a l.
qualitative research, generalizability of the
results is a concern. Although our sampling
strategy was designed to identify organizations
likely to be engaged in PHE, we have no way of
knowing whether our respondents represent
the full range of entrepreneurial activities
underway, particularly PHE focused on
expanding social or policy networks. Given
the absence of data to guide site selection, we
decided that a snowball selection strategy
would provide the most useful information,
just as important, our case study will generate
research hypotheses and questions for others
interested in PHE to explore.
The public health system is not a static
structure. Instead, it evolves and adapts
incrementally as the scientific basis of
population health changes and as new threats
emerge. Right now, disruptive change, in the
form of PHE, may be necessary, even though
we acknowledge the inherent risk of this
approach.
About the Authors
Peter D. Jacobson and Johanna R. Lauer are with the School
o f Public Health, University o f Michigan, A nn Arbor. Jeffrey
Wasserman and Helen W. Wu are with the RAND
Corporation, Santa Monica. Helen W. Wu is also with
the Pardee RAND Graduate School, Santa Monica, CA.
Correspondence should be sent to Peter D. Jacobson, JD,
MPH, University o f Michigan School o f Public Health,
1 4 1 5 Washington Heights, A nn Arbor, M I 4 8 1 0 9 -2 0 2 9
(e-mail: j@umich.edu). Reprints can be ordered at
http://www.ajph.org by clicking the Reprints link.
This article was accepted October 7, 2014.
Contributors
P. D. Jacobson and J. Wasserman designed the study,
conducted many of the interviews, and participated in
all aspects of data analysis and article preparation.
H. W. Wu and J. R. Lauer conducted interviews and
participated in data analysis and article preparation.
Acknowledgments
W e appreciate the financial support we received
from the Robert Wood Johnson Foundations Public
Health Systems Research Program at AcademyHealth.
P. D. Jacobson has been a board member of Public
Health Foundation Enterprises, Inc. (a nonprofit fiscal
sponsor). His board duties have not been in conflict with
this research project.
We especially express our gratitude to Sharon Arnold,
Bonnie Austin, and Kate Papa for their input and support
throughout the project. In conducting the research, we
were fortunate to have outstanding student research
assistants. They are Dustin Lipson, MHSA, Michelle Yu,
MHSA, Sejica Kim, MHSA, and Shelley Jazowski, MPH.
We also thank the National Association of County and
City Health Officers for making its health department
profile surveys available for this project. We are also
grateful for the excellent suggestions from 2 anonymous
| Peer Reviewed | Research and Practice | S321
 RESEARCH AND PRACTICE

reviewers. Finally, we express our gratitude to the many
individuals whom we interviewed. It is their insights that
have shaped this article.
Human Participant Protection
Institutional review boards from the University of
Michigan and the RAND Corporation determined that
the project was exempt from ongoing institutional review
board review per Exemption 2 of 45 CFR 46.101(b).
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DESIGNING beginning to overwhelm the country. It is a companion book for
H E A L T H Y C O M M U N IT IE S
10. National Association of County and City Health the upcoming special PBS broadcast that describes how the
Officials. Model practices. Available at: http://www. design of the built environment impacts our health, with
naccho.org/topics/modelpractices. Accessed September an additional emphasis on the inequities of social and environ
8, 2014.
mental justice. In this book, Dr. Jackson explores how the built
11. Cox G. The clean sheet exercise in Tulsa
environment has contributed to the fact that two-thirds of Americans are overweight, 70 million
health planning. Available at: http://w w w .
publichealthgrandrounds.unc.edu/cleansheet/Qean_ are obese and many suffer from an array of other chronic but preventable diseases. The book
Sheet.pdf. Accessed March 15, 2009. and series looks upstream at the root causes of our malaise, and highlights actionable best
12. Corso LC, Lenaway D, Beitsch LM, Landrum LB, practices based on real people with real solutions.
Deutsch H. The National Public Health Performance
Co-published with Jossey-Bass
Standards: driving quality improvement in public health
systems. J Public Health Manag Pract. 2010;16(1):1923.
ORDER TODAY!
13. National Association of County and City Health
Officers. Billing for clinical services: findings from the
2012,450 pp hardcover, ISBN 978-111803-3661
APHA PRESS
AN IMPRINT OF AMERICAN PUBLIC HEALTH ASSOCIATION
2014 Forces of Change Survey. Available at: http://
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upload/Billing.pdf. Accessed September 8, 2014. ORDER ONLINE: www.aphabookstore.org
14. Patient Protection and Affordable Care Act, Pub
Law No. 111-148, 42 U.S.C. 18001-18121 (2010).
E-MAIL: APHA@PBD.COM TEL: 888.320.APHA FAX: 888.361.APHA

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