Mayor Anthony A. Williams's bid to remake the city's troubled health care system is being hindered by his inability to find someone to head the D.C. Health Department--a post that has been vacant for 14 months in part because of the District's nationwide reputation for having a slow-moving bureaucracy overwhelmed by a range of problems.

Williams (D) and the previous mayor, Marion Barry, have courted a parade of doctors from across the country, but everyone who has been offered the job so far has declined at the last minute. The leadership vacuum at one of the District's most important departments has forced the new mayor to be the city's de facto health director, leaving health bureaucrats without the full-time leadership many observers say is necessary to pursue the type of detailed changes Williams wants.

Aides to Williams--who during the first six months of his administration also has taken on other budget and administrative duties because of staff vacancies--say they know that the Health Department cannot go on this way indefinitely.

"The organization is not doing well," said Abdusalam Omer, the mayor's chief of staff. "It's drifting."

But Omer said the administration would rather take a long time to pick the right person than quickly select someone who won't be able to overhaul a department long known as an intransigent bureaucracy.

He expressed frustration with Robert K. Ross, a San Diego County health official who tentatively accepted the job last month before backing out.

"The mayor and I and the director of personnel had a binding verbal agreement with him," Omer said. "That's not professional. He apologized, and now we are starting at square one. To be honest, Dr. Ross was just what the District needs."

The city has had five health directors since 1990, not counting interim leaders. The last one, Allan S. Noonan, was fired by then-Chief Management Officer Camille C. Barnett in May 1998. Within the nation's public health community, the job is known for its instability.

"The position is haunted by that legacy," Ross said. "That job is generally considered as among the toughest, if not the toughest, in the country. The word is out that it's a job that has chewed up and spit out some decent and capable public health professionals."

Among the stress factors are D.C. health statistics that, in many categories, rank the city well behind other major cities and the nation as a whole. They include life expectancy, infant mortality, maternal mortality, HIV-AIDS, teenage pregnancy, drug abuse and chronic diseases, the number of residents without health insurance and the number of neighborhoods with few doctors.

But there's also the multilayered oversight from the D.C. Council, the mayor, the presidentially appointed financial control board and Congress, said Georges C. Benjamin, a former D.C. health director who now is Maryland's secretary of health. And not enough money.

"There are not enough funds to do everything they need to do," Benjamin said. "Those were my challenges. You have to really rebuild that department."

Faced with such stark needs for improved public health services, Williams swiftly pushed numerous health care issues after he took office in January.

With local health care institutions watching nervously, he proposed extending Medicaid coverage to most of the city's uninsured, bailed out a failing hospital and forced three rival hospitals to engage in continuing consolidation talks.

Then Williams created a commission that soon will begin searching for ways to improve basic medical services for the poor, and he endorsed the idea of cuts in Medicaid payments to hospitals and nursing homes because of a budget squeeze.

Meanwhile, the $1.3 billion Health Department--the largest of several D.C. health care agencies and the operator of the Medicaid program--temporarily is headed by Marlene Kelly, a civil service physician.

One of the few bright spots is the city's HIV-AIDS administration, once the target of relentless complaints by activists, who said it was inefficient. Critics say that agency has improved under its new chief, Ronald Lewis.

But many other problems await the next health director. The city's public health laboratory is a deteriorating and lacks modern testing facilities that are essential in monitoring food and water quality, a city health official said.

There is only one city-run clinic devoted to treating sexually transmitted diseases; a satellite clinic was closed a few years ago.

The District's overall health plan, a document that enables regulators to deny applications for duplicative health services, is out of date and needs to be rewritten to keep hospitals from overspending, critics say.

Meanwhile, demand for hospital care continues to slide because of cost-cutting by government and private health plans. The city's 11 locally controlled acute care hospitals are struggling to stay solvent. Several have announced huge losses, and two have filed for bankruptcy in the past 18 months.

The Commission on Mental Health, which runs St. Elizabeths Hospital and provides outpatient treatment to thousands of city residents, is in receivership and under the control of a judge.

The second-largest city health agency, the quasi-independent Public Benefit Corp., which runs D.C. General Hospital and a string of clinics and school health programs, receives about $50 million a year in city subsidies.

But it often is at odds with Williams, and its leaders and supporters on the D.C. Council fiercely resist any talk of diluting its role or assigning any of its functions to lower-cost providers.

"There are so many health issues confronting this government that require good, forceful experienced leadership," said one city official who asked not to be identified. "The question is, how long is this drift going to continue?"

Ross, 44, said he negotiated for a salary in the $150,000 range, but said the city is going to have to compete with private employers that can pay up to $500,000 for the kind of expertise and political leadership the Health Department needs.

Ross said he was concerned that the Health Department is reputed to be laden with bureaucrats who would resist change. He said he was willing to take on the challenge. But his family's preference to remain in Southern California, where he heads a $1 billion health and human services agency, ultimately trumped his desire take on the challenge here.

"When I was interested in the position, I talked to people about the job," Ross said. "I would say 80 percent of the answers I got from public health colleagues was that I was nuts."

CAPTION: Many of Mayor Anthony A. Williams's health care initiatives have been stymied because the District's Health Department has gone leaderless.

CAPTION: Abdusalam Omer, Williams's chief of staff, said the administration wants to select the right person to overhaul the D.C. Health Department.