The Structure and Organization of Local and State Public Health Agencies in the U.S.: A Systematic Review

doi:10.1016/j.amepre.2012.01.021

American Journal of Preventive Medicine

Volume 42, Issue 5, Supplement 1, May 2012, Pages S29-S41

https://doi.org/10.1016/j.amepre.2012.01.021 Get rights and content

Context

This systematic review provides a synthesis of the growing field of public health systems research related to the structure and organization of state and local governmental public health agencies. It includes an overview of research examining the influence of organizational characteristics on public health performance and health status and a summary of the strengths and gaps of the literature to date.

Evidence acquisition

Data were retrieved through an iterative process, beginning with key word searches in three publication databases (PubMed, JSTOR, Web of Science). Gray literature was searched through the use of Google Scholar™. Targeted searches on websites and key authors were also performed. Documents underwent an initial and secondary screening; they were retained if they contained information about local or state public health structure, organization, governance, and financing.

Evidence synthesis

77 articles met the study criteria. Public health services are delivered by a mix of local, state, and tribal governmental and nongovernmental agencies and delivered through centralized (28%); decentralized (37%); or combined authority (35%). The majority of studies focused on organizational characteristics that are associated with public health performance based on the 10 Essential Public Health Services framework. Population size of jurisdiction served (>50,000); structure of authority (decentralized and mixed); per capita spending at the local level; some partnerships (academic, health services); and leadership of agency directors have been found to be related to public health performance. Fewer studies examined the relationship between organizational characteristics and health outcomes. Improvements in health outcomes are associated with an increase in local health department expenditures, FTEs per capita, and location of health department within local networks.

Conclusions

Public health systems in the U.S. face a number of critical challenges, including limited organizational capacity and financial resources. Evidence on the relationship of public health organization, performance, and health outcomes is limited. Public health systems are difficult to characterize and categorize consistently for cross-jurisdictional studies. Progress has been made toward creating standard terminology. Multi-site studies that include a mix of system types (e.g., centralized, decentralized) and local or state characteristics (e.g., urban, rural) are needed to refine existing categorizations that can be used in examining studies of public health agency performance.

Section snippets

Context

The public health system in the U.S. is made up of a complex network of people and organizations in the public and private sectors who work with varying degrees of collaboration at national, state, and local levels to promote and protect the public's health.¹ The public health system includes all governmental and nongovernmental entities that contribute to three core functions: assessment of information on the health of the community; comprehensive policy development; and ensuring that public

Protocol

A systematic search was conducted according to the PRISMA Statement.⁸ The review of literature was performed between September 1 and November 10, 2010. The first phase of the review entailed the development of a research protocol. The protocol entailed the formulation of primary research questions, a search strategy, inclusion criteria, and a strategy for documenting and synthesizing evidence. Three primary research questions were developed that focus on the structure and organization of

Study Selection and Results

Sixty-three articles and papers were identified (Appendix) that provide descriptive or outcome data on the structure and organization of governmental public health agencies (Figure 1). An additional 14 papers were included that provided contextual information or commentary about public health infrastructure in the U.S. (Appendix). The initial key word search used in MEDLINE and Web of Science resulted in the identification of more than 647,000 records. Additional search limits designed to

Discussion

The IOM's 1988 report on the state of public health in the U.S. sparked a flurry of strategic planning, research, and advocacy on the critical, yet fragile, infrastructure that is in place to protect and promote the health and well-being of the public. National profile surveys supported by the CDC, ASTHO, and NACCHO have provided descriptive data about local and state governmental public health infrastructure. A growing body of research focusing on the relationship between public health

Conclusion

The data reviewed for this study indicate that success in bringing about major infrastructure changes since the release of the IOM's 1988 report on The Future of Public Health has been limited.1, 7 Improvements have been made on some fronts: there is widespread consensus on the three core functions of public health, a national framework for organizing public health services, and measures of performance that are ready for widespread implementation. The public health system still lacks a sound,

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Review articleThe Structure and Organization of Local and State Public Health Agencies in the U.S.: A Systematic Review

Context

Evidence acquisition

Evidence synthesis

Conclusions

Section snippets

Context

Protocol

Study Selection and Results

Discussion

Conclusion

Am J Prev Med

The future of public health

National profile of local health departments 1997

National public health system performance assessment—model standards, version 2.0

Profile of state and territorial public health system, 1991

Strengthening the performance and effectiveness of the public health systemIssue brief (Grantmakers in health)

The future of the public's health in the 21st century

The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration

BMJ

Operational definition of a functional local health department

National profile of local health departments

Roles of local public health agencies within the state public health system

J Public Health Manag Pract

Structure and functions of state public health agencies

Am J Public Health

Reorganizing state health agencies to meet changing needs: state restructuring efforts in 2003

Public health at center stage: new roles, old props

Health Aff (Millwood)

The future of public health: a local health department view

J Public Health Policy

New data, same story?Revisiting studies on the relationship of local public health systems characteristics to public health performance

J Public Health Manag Pract

Financing rural public health activities in prevention and health promotion

Development of a rural public health research agenda

Public Health Rep

National profile: overview of capabilities and core functions of local public health jurisdictions in 47 states, the District of Columbia, and 3 U.S. territories, 2000–2002

J Public Health Manag Pract

1,200 local public health departments for the U.S.

Am J Public Health

Regionalization: collateral benefits of emergency preparedness activities

J Public Health Manag Pract

Regionalization of local public health systems in the era of preparedness

Annu Rev Public Health

State health department structure and pandemic planning

J Public Health Manag Prac

Assessing the performance of local public health systems: a survey of state health agency efforts

J Public Health Manag Pract

Transformations in public health systems

Health Aff (Millwood)

Expenditures for public health: assessing historical and prospective trends

Am J Public Health

Geographic variation in public health spending: correlates and consequences

Health Serv Res

Getting what you pay for: public health spending and the performance of essential public health services

J Public Health Manag Pract

Local public health agency infrastructure: a chartbook

Rural public health financing: implications for community health promotion initiatives

J Public Health Manag Pract

The quest for an accurate accounting of public health expenditures

J Public Health Manag Pract

Aligning public health financing with essential public health service functions and National Public Health Performance Standards

J Public Health Manag Pract

State public health agency expenditures: categorizing and comparing to performance levels

J Public Health Manag Pract

Institutional and economic determinants of public health system performance

Am J Public Health

Local public health agency funding: money begets money

J Public Health Manag Pract

The association of changes in local health department resources with changes in state-level health outcomes

Am J Public Health

Review article
The Structure and Organization of Local and State Public Health Agencies in the U.S.: A Systematic Review