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Introduction: We examined the percentage of local government taxes ("fiscal allocation") dedicated to local health departments on a national level, as well as correlates of local investment in public health., Methods: Using the most recent data available--the 2008 National Association of City and County Health Officials Profile survey and the 2007 U.S. Census Bureau Census of Local Governments-generalized linear regression models examined associations between fiscal allocation and local health department setting, governance, finance, and service provision. Models were stratified by the extent of long-term debt for the jurisdiction. Analyses were performed in 2014., Results: Average fiscal allocation for public health was 3.31% of total local taxes. In multivariate regressions, per capita expenditures, having a local board of health and public health service provision were associated with higher fiscal allocation. Stratified models showed that local board of health and local health department taxing authority were associated with fiscal allocation in low and high long-term debt areas, respectively., Conclusions: The proportion of all local taxes allocated to local public health is related to local health department expenditures, service provision, and governance. These relationships depend upon the extent of long-term debt in the jurisdiction., (Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The 2008 recession had a significant impact on local health departments (LHDs), with more than half of such agencies experiencing job losses and program cuts., Purpose: To identify potential modifiable factors that can protect LHDs from job losses and budget cuts during future economic crises., Methods: This retrospective cohort study used data from 2005 and 2010 surveys of LHDs. The outcome of interest was financial resiliency for maintaining budgets during the recession and was based on the ratio of observed to predicted expenditures (O/E) per capita for 2010. Logistic regression was used to model the resiliency of the LHD with independent variables grouped around domains of organization, revenues, and services, with stratification by size of the LHD jurisdiction. Data were analyzed in 2013., Results: Of the 987 LHDs in the final data set, 328 (33.2%) were categorized as resilient and 659 (66.8%) as non-resilient. Overall, resilient LHDs received a higher percentage of revenues from non-local sources compared to non-resilient LHDs (p<0.05) and had a more diversified service mix, with significantly (p<0.05) more treatment, population, and regulatory services. In the final regression models, findings differed substantially across the stratifications of LHD jurisdictional population size, with no single independent or control variable significantly associated with resiliency across all population categories., Conclusions: Funding streams and service mix may be modifiable characteristics, suggesting possible means for LHDs to weather future economic stress; however, these characteristics may be unique to the size of the population served., (Copyright © 2014 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

In 2007, the World Health Organization published the Global Framework for Immunization Monitoring and Surveillance (GFIMS) outlining measures to enhance national surveillance for vaccine preventable diseases (VPDs). The GFIMS emphasized that VPD surveillance should be integrated and placed in a 'unified framework' building upon the strengths of existing surveillance systems to prevent duplication of activities common to all surveillance systems and to minimize human resource and supply expenditures. Unfortunately, there was little experience in actually developing integrated VPD surveillance. We describe the process of developing operational guidance for ministries of health to implement such an integrated surveillance system for multiple VPDs., (Published by Elsevier Ltd.)

Introduction: Following World Health Organization recommendations set forth in the Global Framework for Immunization Monitoring and Surveillance, Costa Rica in 2009 became the first country to implement integrated vaccine-preventable disease (iVPD) surveillance, with support from the U.S. Centers for Disease Control and Prevention (CDC) and the Pan American Health Organization (PAHO). As surveillance for diseases prevented by new vaccines is integrated into existing surveillance systems, these systems could cost more than routine surveillance for VPDs targeted by the Expanded Program on Immunization., Objectives: We estimate the costs associated with establishing and subsequently operating the iVPD surveillance system at a pilot site in Costa Rica., Methods: We retrospectively collected data on costs incurred by the institutions supporting iVPD surveillance during the preparatory (January 2007 through August 2009) and implementation (September 2009 through August 2010) phases of the iVPD surveillance project in Costa Rica. These data were used to estimate costs for personnel, meetings, infrastructure, office equipment and supplies, transportation, and laboratory facilities. Costs incurred by each of the collaborating institutions were also estimated., Results: During the preparatory phase, the estimated total cost was 128,000 U.S. dollars (US$), including 64% for personnel costs. The preparatory phase was supported by CDC and PAHO. The estimated cost for 1 year of implementation was US$ 420,000, including 58% for personnel costs, 28% for laboratory costs, and 14% for meeting, infrastructure, office, and transportation costs combined. The national reference laboratory and the PAHO Costa Rica office incurred 64% of total costs, and other local institutions supporting iVPD surveillance incurred the remaining 36%., Conclusions: Countries planning to implement iVPD surveillance will require adequate investments in human resources, laboratories, data management, reporting, and investigation. Our findings will be valuable for decision makers and donors planning and implementing similar strategies in other countries., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Context: Public health leaders are making difficult decisions about how to maximize the effectiveness of public health services with diminishing funds. Quality improvement (QI) interventions seek to improve the efficiency and effectiveness of public health programs, services, or organizations. The purpose of this study was to review the literature to describe public health system QI interventions and their impact on public health practices and health outcomes., Evidence Acquisition: A systematic review was conducted using PRISMA guidelines. Three databases were searched for peer-reviewed articles that included public health quality improvement-related terms in their abstracts. Articles published in 1990-2010 that described results from QI interventions conducted within the U.S. public health system were included., Evidence Synthesis: Fifteen studies were identified, reporting on 18 separate QI interventions. Studies fell naturally into three functional categories: organization-wide QI, program- or service-specific QI, and administrative or management function QI. Few of the studies linked their improvements directly to a health outcome or predictors of health outcomes. Studies generally were implemented in state-level or large local public health departments., Conclusions: Formally published QI interventions may not be representative of typical, smaller-scale QI activities. Collection and distribution of QI results associated with proven, effective public health interventions and that quantify the benefits of QI practices in public health should be a goal. More research is needed to definitively "connect the dots" between QI efforts, resulting practice improvements, and actual (or predictors of) health outcome improvements. Future studies should examine QI in diverse public health systems., (Published by Elsevier Inc.)

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., (Copyright © 2012 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Epidemic meningococcal meningitis remains a serious health threat in the African meningitis belt. New meningococcal conjugate vaccines are relatively costly and their efficiency will depend on cost savings realized from no longer having to respond to epidemics., Methods: We evaluated the cost and impacts to the public health system of the 2007 epidemic bacterial meningitis season in Burkina Faso through a survey at the different level of the health system. A micro-economic approach was used to evaluate direct medical and non medical costs for both the public health system and households, as well as indirect costs for households., Results: The total national cost was 9.4 million US$ (0.69 US$ per capita). Health system costs were 7.1 million US$ (1.97% of annual national health spending), with 85.6% for reactive vaccination campaigns. The remaining 2.3 million US$ was borne by households of meningitis cases. The mean cost per person vaccinated was 1.45 US$; the mean cost of case management per meningitis case was 116.3 US$ when including household costs and 26.4 US$ when including only health sector costs. Meningitis epidemics disrupted all health services from national to operational levels with the main contributor being a large increase in medical consultations., Conclusions: Preventive meningococcal conjugate vaccines should contribute to more efficient use of funds dedicated to meningitis epidemics and limit the disruption of routine health services., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The authors review empirical studies published between 1990 and 2007 on the topics of public health organization, financing, staffing, and service delivery. A summary is provided of what is currently known about the attributes of public health delivery systems that influence their performance and outcomes. This review also identifies unanswered questions, highlighting areas where new research is needed. Existing studies suggest that economies of scale and scope exist in the delivery of public health services, and that key organizational and governance characteristics of public health agencies may explain differences in service delivery across communities. Financial resources and staffing characteristics vary widely across public health systems and have expected associations with service delivery and outcomes. Numerous gaps and uncertainties are identified regarding the mechanisms through which organizational, financial, and workforce characteristics influence the effectiveness and efficiency of public health service delivery. This review suggests that new research is needed to evaluate the effects of ongoing changes in delivery system structure, financing, and staffing.

Background: Economic analysis is an important tool in deciding how to allocate scarce public health resources; however, there is currently a dearth of such analysis by public health researchers., Methods: Public health researchers and practitioners were surveyed to determine their current use of health economics and to identify barriers to use as well as potential strategies to decrease those barriers in order to allow them to more effectively incorporate economic analyses into their work. Data collected from five focus groups informed survey development. The survey included a demographic section and 14 multi-part questions. Participants were recruited in 2006 from three national public health organizations through e-mail; 294 academicians, practitioners, and community representatives answered the survey., Results: Survey data were analyzed in 2007. Despite an expressed belief in the importance of health economics, more than half of the respondents reported very little or no current use of health economics in their work. Of those using health economics, cost-benefit and cost-effectiveness analysis and determination of public health costs were cited as the measures used most frequently. The most important barriers were lack of expertise, funding, time, tools, and data, as well as discomfort with economic theory. The resource deemed most important to using health economics was collaboration with economists or those with economic training. Respondents indicated a desire to learn more about health economics and tools for performing economic analysis., Conclusions: Given the importance of incorporating economic analysis into public health interventions, and the desire of survey respondents for more collaboration with health economists, opportunities for such collaborations should be increased.

This article considers three examples of the use of quantitative policy analysis in setting public health policy: (1) benefit:cost and cost-effectiveness studies of influenza immunization and their role in achieving Medicare reimbursement for influenza immunization; (2) the 1993 World Bank World Development Report, which compared the burden of various health problems in different regions of the world and the cost-effectiveness of interventions for these problems, recommending a core set of public health and primary care services as being the most cost-effective; and (3) the role of the Agency for Health Care Policy and Research and how it might change if health care reform legislation such as President Clinton's original proposal were to be enacted. Finally, I describe the use of quantitative policy analysis to guide policy in one government agency--the Centers for Disease control and Prevention (CDC).

This article describes the performance by local health departments of core public health functions. A post hoc analysis based on these essential functions was implemented using the 1994 dataset from a cooperative project with the Centers for Disease Control and Prevention (CDC) and National Association of County and City Health Officials, which involved a survey of the nation's 2,888 local health departments. Applying guidelines for each functional area drafted by the Office of Disease Prevention and Health Promotion/Office of the Assistant Secretary for Health, CDC, and the Public Health Foundation in conjunction with the health officers in five states, a score was created for each core public health function: (1) health-related data collection, surveillance, and outcomes monitoring, (2) protection of environment, housing, food, and water, (3) investigation and control of diseases and injuries, (4) public information and education, (5) accountability and quality assurance, (6) laboratory services, (7) training and education, and (8) leadership, policy development, and administration. The individual and summary scores provide a mechanism to measure and describe the 2,079 local health departments' performance of these core functions and to examine their relationship to several characteristics and practices--planning, administrative units, annual total expenditures, and jurisdiction population size. This article shows that the core performance index is highest for the data function and for local health departments serving a population of 50,000 or more people. In addition, the performance index increases as budget increases and is greater for all eight functions in those local health departments using health planning models such as Assessment Protocol for Excellence in Public Health (APEX-PH), Planned Approach to Community Health (PATCH), Healthy People 2000, or Healthy Communities 2000. These results may be used to facilitate cooperation between local, state, and federal health agencies and the communities they serve; strengthen the core functions at the local, state, and federal levels; and improve public health practice.

This article, presented at the Research and Measurement of Public Health Core Functions Science Symposium sponsored by the Centers for Disease Control and Prevention (CDC) in June 1994, provides selected data from the 1992-1993 National Profile of Local Health Departments. The National Association of County and City Health Officials (NACCHO), in cooperation with the CDC Public Health Practice Program Office, recently completed the 1992-1993 National Profile of Local Health Departments. This study describes public health at the local level and updates the first Profile study, conducted in 1989. The study population included 2,888 local health departments (LHDs) in the United States. Responses were received from 72% of LHDs. Comparisons are made with the 1990 Profile where available. This article provides a selected overview of the information contained in the 1992-1993 Profile and includes structure of LHDs, top agency executive, staffing, expenditures, and planning. The findings have important ramifications for community health planners and policy makers at all levels. With the ongoing potential for change in the U.S. health care system, reliable data establishing baselines and monitoring trends in public health at the local level are important. The information in this report, and the 1992-1993 National Profile of Local Health Departments, updates and expands the available knowledge of LHD structures and activities.