摘要：Objectives . Although a growing body of evidence demonstrates that availability and quality of essential public health services vary widely across communities, relatively little is known about the factors that give rise to these variations. We examined the association of institutional, financial, and community characteristics of local public health delivery systems and the performance of essential services. Methods. Performance measures were collected from local public health systems in 7 states and combined with secondary data sources. Multivariate, linear, and nonlinear regression models were used to estimate associations between system characteristics and the performance of essential services. Results. Performance varied significantly with the size, financial resources, and organizational structure of local public health systems, with some public health services appearing more sensitive to these characteristics than others. Staffing levels and community characteristics also appeared to be related to the performance of selected services. Conclusions . Reconfiguring the organization and financing of public health systems in some communities—such as through consolidation and enhanced intergovernmental coordination—may hold promise for improving the performance of essential services. A growing body of evidence demonstrates that the availability and quality of essential public health services vary widely across communities. 1 – 7 These services include population-based efforts to investigate community health threats, promote healthy lifestyles, prevent disease and injury, and ensure the quality of water, food, air, and other resources necessary for good health. 8 Unfortunately, relatively little is known about the factors that give rise to variation in local public health services delivery, and many existing studies are quite dated and do not reflect contemporary public health issues ranging from obesity to bioterrorism. 9 , 10 In many communities, public health services are produced through the collective actions of numerous governmental agencies and private organizations that vary widely in their resources, missions, and operations. 11 – 13 As such, public health delivery systems exist as complex and adaptive systems that operate through the interactions of multiple heterogeneous actors, 14 including local and state public health agencies, law enforcement and public safety agencies, community-based organizations, health care providers and insurers, businesses, educational institutions, and many other types of organizations. 15 A better understanding of how attributes of the local public health system influence the availability and effectiveness of public health services is a critical first step in elucidating pathways for improving public health service delivery. Theories of organizational sociology and industrial organization suggest that the activities performed by a public health system are likely to be shaped by the resources available to the system, the ways in which the resources are organized, and the characteristics of the community or market served by the system. 16 – 18 The most basic resources available to local public health systems include funds and personnel. Funding often determines the amount of human, technological, and other resources that can be engaged to perform public health activities. Many local public health systems depend heavily on local governments and their ability and willingness to draw on local tax bases and other revenue sources to support public health activities. 19 Nationally, local governmental public health agencies obtain an average of 44% of their funding from local governmental appropriations, with the remainder derived from state government (30%), fee-based revenue (19%), and direct federal appropriations (3%). 20 Although funding is often a major determinant of staffing levels, even well-funded public health systems experience difficulties in recruiting and retaining a sufficient volume and mix of staff in view of persistent shortages in key health professions and competition with other employment settings including medical care provision and health insurance. Previous studies have documented wide variations in both funding and staffing levels across local public health systems, 21 , 22 suggesting that disparities in these 2 types of resources may account for much of the variation in public health system performance observed across communities. The activities performed by a public health system also may be shaped by the structure of the system itself and the ways in which resources are organized. One potentially important structural characteristic is the size of the public health system as reflected by the number of people served by the system. Large public health systems may be able to realize economies of scale in performing activities such as disease surveillance and health education by spreading the fixed costs of public health infrastructure over larger populations of beneficiaries and taxpayers. Large public health systems may also benefit from larger pools of organizations in the community that may be enlisted to participate in public health activities, including medical care providers, community organizations, educational institutions, local media, businesses, and government agencies. 11 , 13 , 23 Several previous studies have found evidence that larger public health systems perform better than their counterparts in carrying out activities considered to be important elements of public health practice. 1 , 3 , 5 Another organizational characteristic that may influence public health system performance is the type of government authority and control within the system. In some states and communities, local governmental public health agencies operate as centralized administrative units of a state health agency, whereas in other communities these agencies operate as decentralized, autonomous units of local government. 24 In still other communities, public health agencies operate under the shared authority of both state and local governments. One theory of political economy suggests that decentralized governmental authority and decisionmaking may yield superior public services because local governments, as opposed to state administrative units, may be more informed of and responsive to local community needs. 25 – 27 Alternative theories suggest that centralized provision of services may be more effective and efficient because central governments can coordinate resources and activities across local jurisdictions, thereby addressing any spillover effects and correcting inequities in resources across communities. 28 The empirical evidence on this issue, however, is limited and mixed. 1 , 3 Other aspects of government authority and control may influence public health system performance, including the types of governmental jurisdictions and governance structures that exist within the systems. As with decentralization, it is difficult to know a priori the net effects of various approaches to organizing governmental public health responsibilities. Some local public health agencies serve the jurisdiction of a single city or county and therefore act as the public health arm of a single local government. 12 , 20 Other agencies, however, serve consolidated city–county or multicounty jurisdictions and operate as agents for multiple local governments. Consolidated jurisdictions may achieve a level of intergovernmental coordination that enhances the delivery of public health services; alternatively, these jurisdictions may face complexities in authority and reporting relationships that pose barriers to effective public health action. Governance structures also vary across local public health agencies, with some agencies reporting directly to elected local legislative bodies such as county commissions or city councils and others reporting to boards of health that are appointed or elected specifically to provide strategic direction for public health agencies. Where they exist, local boards of health may improve public health performance by enhancing public oversight, engagement, and accountability, or they may inhibit performance by making policy and administrative decisionmaking more cumbersome and time consuming. Evidence from prior studies is lacking in these areas. Finally, the activities performed by a local public health system are likely to reflect the health resources and needs within the community that it serves. In communities that are underserved by medical care resources such as physicians and hospitals, public health systems may devote larger a share of their resources to ensuring that people receive access to needed medical care, thereby leaving fewer resources available for other important public health responsibilities. 8 Similarly, public health systems serving impoverished communities with low rates of insurance coverage and high rates of social and behavioral health risks may devote more of their resources to health promotion and health care initiatives—all at the expense of other activities. These communities also are likely to have limited tax bases and many competing human services needs, leaving fewer resources available to invest in public health activities of any type. Rural systems may experience unique challenges in performing core public health activities if geographic barriers make activities such as health risk investigation and regulatory enforcement more difficult and costly. 29 Collectively, community characteristics may give rise to substantial differences in the scope and intensity of activities performed by local public health systems across the nation. Recognizing that many different factors potentially play a role in determining local public health practice, this study provides an exploratory analysis of the institutional, financial, and community characteristics most strongly associated with public health system performance.
