摘要：Objectives. We investigated the perspectives of local health jurisdiction (LHJ) directors on coping mechanisms used to respond to budget reductions and constraints on their decision-making. Methods. We conducted in-depth interviews with 17 LHJ directors. Interviews were audio recorded, transcribed, and analyzed using the constant comparative method. Results. LHJ directors use a range of coping mechanisms, including identifying alternative revenue sources, adjusting services, amending staffing arrangements, appealing to local political leaders, and forming strategic partnerships. LHJs also face constraints on their decision-making because of state and local statutory requirements, political priorities, pressures from other LHJs, and LHJ structure. Conclusions. LHJs respond creatively to budget cuts to maintain important public health services. Some LHJ adjustments to administrative resources may obscure the long-term costs of public health budget cuts in such areas as staff morale and turnover. Not all coping strategies are available to each LHJ because of the contextual constraints of its locality, pointing to important policy questions on identifying optimum jurisdiction size and improving efficiency. Local public health services in the United States rely on local and state revenues for much of their financial support. 1–3 During the US economic recessions in 1991 and from 2008 to 2010, budgets, staffing, and services of a quarter to a half of local health jurisdictions (LHJs) were reduced. 4–6 Over the past decade, economic conditions in Connecticut have fluctuated substantially. Although Connecticut’s unemployment rate was lower than the national average for most of 2001 to 2010, it followed the overall US trend. 7 The downturn in the housing market between 2008 and 2010 put additional pressure on LHJs in Connecticut because local governments saw their tax base erode as a result of falling real estate prices. In Connecticut, local municipalities are responsible for ensuring that the statutory minimum public health services are available to their population. These minimum services were approved in 1983 and focus on 8 categories: public health statistics, health education, nutrition services, maternal and child health, communicable and chronic disease control, environmental services, community nursing services, and emergency medical services. 8 (In 2014, legislation was passed to change the statutory requirement to adopt the 10 essential public health services, 9 as outlined by the Centers for Disease Control and Prevention.) In Connecticut’s highly decentralized public health system, each municipality can provide those services by creating its own municipal health department or by joining with other municipalities to form a district LHJ. District LHJs are created voluntarily and can be joined and left at will by member towns. Beyond the statutory minimum, individual LHJs determine what programs and services to provide and how they are funded, including setting fee schedules. As cuts in government funds for LHJs have taken place in Connecticut 10 and elsewhere, 11 a better understanding of key influences on resource allocation decisions by health directors could strengthen the ability of public health systems to withstand economic downturns. To build on the previous work of the Connecticut Practice-Based Research Network, we interviewed LHJ directors about their perspectives on (1) coping mechanisms used to respond to reductions in revenue and (2) the constraints and contextual factors that influence directors’ decisions regarding service provision.
