Those forces are in Harrisburg, where Gov. Corbett last month announced that he was firing six state employees and changing the way Pennsylvania's Departments of State and Health perform inspections.
And the city?
"People expect that local problems get solved locally, and that's what they want to hear," said Arthur Caplan, director of the University of Pennsylvania Center for Bioethics. But he said the way oversight is set up around the country means that, for city leaders, making it easier to report problems to the state is "about all they can do."
Philadelphia is actually doing slightly more than that.
In an interview, Health Commissioner Donald F. Schwarz listed changes by his agency:
To help the public report problems, it has posted a "Concerns About Medical Providers" section on its home page (www.phila.gov/health), with links to other appropriate agencies, phone numbers, and complaint forms.
The city's "311" phone operators have been trained on where to direct callers with complaints about providers.
The department has encouraged staff to think beyond their job descriptions. If they notice something amiss, they are now expected to report it directly to the appropriate state agency - and directly to Schwarz as well.
As an extra prod to the state - the grand jury report in January found that state officials had not acted on some complaints that were sent to them - Schwarz will also personally communicate his staff's complaints to his cabinet-level counterparts.
Schwarz said that reviews of city records going back many years and discussions with staff throughout the department had turned up "a handful" of complaints or questions raised about medical providers; Gosnell's Women's Medical Society was the only abortion clinic that turned up. Those are now being investigated.
Two city employees who were named by a grand jury as knowing about but not aggressively pursuing horrid conditions at Gosnell's clinic have been interviewed, but no disciplinary action was taken against the one who still works for the city.
Schwarz said much of the city's failure to spot problems came down to bureaucracy and the mind-set that was shaped by it.
It is not uncommon. What accountant, engineer, or journalist hasn't noticed a problem in another department and not reported it - or reported it once and then gave up?
The Gosnell case was disastrous, but there is no indication that the people who saw something amiss knew or even wondered whether babies were being killed after birth.
While the city has no power over doctors, it regulates 10,000 sites that dispose of medical waste but inspects them only in response to complaints, which average about nine a year, Public Health Department spokesman Jeff Moran said. About 200 medical providers participate in the federal Vaccines for Children program; the city inspected refrigerators and vaccine-handling practices at 86 percent of them last year, he said, triple the requirement.
It was inspectors for those programs who had noticed problems at Gosnell's clinic.
When the state, which had simply stopped inspecting abortion clinics more than a decade ago, resumed doing so after police and federal drug agents raided Gosnell's clinic last fall, it found issues with two others, since closed, in Germantown and Bensalem.
David C. Damsker, director of the Bucks County Health Department, said Tuesday that he had not even been aware of the Bensalem clinic, which was registered with the state in 1987, until the news came out last week. Had he received complaints, Damsker said, he would have sent them to the state, since he, too, has no authority to act.
In Philadelphia, public-health leaders used the shock over news from the Gosnell clinic as a sort of in-house teachable moment.
"If you go into an office to drop off vaccines, what is it that you are looking for?" said Nan Feyler, the chief of staff. "Some of these people are more like delivery people. . . . In some ways it is kind of a commonsense test."
Feyler, a public-interest lawyer, directed AIDS and immigrant organizations before Schwarz hired her three years ago. "For me," she said of the Gosnell case, "it raises the issue of what do you do when you feel you have the responsibility and no authority?
"To some extent I come to this job from my work as an advocate: How do you inspire a staff to be more proactive?"
Contact staff writer Don Sapatkin at 215-854-2617 or email@example.com.