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In 2021, the Maricopa County Department of Public Health in Maricopa County, Arizona, modified its subcontracting process to engage more community-based organizations that serve populations disproportionately affected by COVID-19. The change allowed subrecipients to receive 40% of grant funding up front. An evaluation found that providing up-front funding engaged smaller-budget organizations. However, factors such as administrative requirements and formal policies associated with government partnerships limited the perceived benefits of up-front funding. These findings are relevant for entities seeking to improve access to federal funding. ( Am J Public Health . 2024;114(S7):S562-S565. https://doi.org/10.2105/AJPH.2024.307740).

Competing Interests: The authors declare no conflicts of interest.

Objectives: To identify occupations with high-priority workforce development needs at public health departments in the United States., Methods: We surveyed 46 state health agencies (SHAs) and 112 local health departments (LHDs). We asked respondents to prioritize workforce needs for 29 occupations and identify whether more positions, more qualified candidates, more competitive salaries for recruitment or retention, or new or different staff skills were needed., Results: Forty-one SHAs (89%) and 36 LHDs (32%) participated. The SHAs reported having high-priority workforce needs for epidemiologists and laboratory workers; LHDs for disease intervention specialists, nurses, and administrative support, management, and leadership positions. Overall, the most frequently reported SHA workforce needs were more qualified candidates and more competitive salaries. The LHDs most frequently reported a need for more positions across occupations and more competitive salaries. Workforce priorities for respondents included strengthening epidemiology workforce capacity, adding administrative positions, and improving compensation to recruit and retain qualified employees., Conclusions: Strategies for addressing workforce development concerns of health agencies include providing additional training and workforce development resources, and identifying best practices for recruitment and retention of qualified candidates.

Beginning in 2008, the National Association of County and City Health Officials (NACCHO) periodically surveyed local health departments (LHDs) to assess the impact of the economic recession on jobs and budgets (1). In 2014, the survey was expanded to assess a wider range of factors affecting programs, services, and infrastructure in LHDs and renamed the Forces of Change survey (2). The survey was administered in to January-February 2015 to 948 LHDs across the United States to assess budget changes, job losses, changes in services, and collaboration with health care partners; 690 (73%) LHDs responded. Findings indicated a change in LHD infrastructure: compared with the previous fiscal year.* Overall, LHDs reported 3,400 jobs lost; 25% of LHDs reported budget decreases; 36% reported a reduction in at least one service area; and 35% reported serving fewer patients in clinics. In addition, up to 24% of LHDs reported expanding population-based prevention services, and LHDs reported exploring new collaborations with nonprofit hospitals and primary care providers (PCPs).

Objective: We investigated whether or not changes in economic conditions during the 2008-2010 U.S. recession were associated with changes in Connecticut local health jurisdictions' (LHJs') revenue or personnel levels., Methods: We analyzed Connecticut Department of Public Health 2005-2012 annual report data from 91 Connecticut LHJs, as well as publicly available data on economic conditions. We used fixed- and random-effect regression models to test whether or not LHJ per capita revenues and full-time equivalent (FTE) personnel differed during and post-recession compared with pre-recession, or varied with recession intensity, as measured by unemployment rates and housing permits., Results: On average, total revenue per capita was significantly lower during and post-recession compared with pre-recession, with two-thirds of LHJs experiencing per capita revenue reductions. FTE personnel per capita were significantly lower post-recession. Changes in LHJ-level unemployment rates and housing permits did not explain the variation in revenue or FTE personnel per capita. Revenue and personnel differed significantly by LHJ organizational structure across all time periods., Conclusion: Economic downturns can substantially reduce resources available for local public health. LHJ organizational structure influences revenue levels and sources, with implications for the scope, quality, and efficiency of services delivered.

Objectives: In collaboration with Public Health Practice-Based Research Networks, we investigated relationships between local health department (LHD) food safety and sanitation expenditures and reported enteric disease rates., Methods: We combined annual infection rates for the common notifiable enteric diseases with uniquely detailed, LHD-level food safety and sanitation annual expenditure data obtained from Washington and New York state health departments. We used a multivariate panel time-series design to examine ecologic relationships between 2000-2010 local food safety and sanitation expenditures and enteric diseases. Our study population consisted of 72 LHDs (mostly serving county-level jurisdictions) in Washington and New York., Results: While controlling for other factors, we found significant associations between higher LHD food and sanitation spending and a lower incidence of salmonellosis in Washington and a lower incidence of cryptosporidiosis in New York., Conclusions: Local public health expenditures on food and sanitation services are important because of their association with certain health indicators. Our study supports the need for program-specific LHD service-related data to measure the cost, performance, and outcomes of prevention efforts to inform practice and policymaking.

Objectives: We examined the existence and the extent of scale and scope economies in the delivery of public health services. We also tested the strength of agency, population, and community characteristics that moderate scale and scope economies., Methods: We collected service count and cost data for all Florida local health districts for 2008 and 2010, complemented with data on agency, population, and community characteristics. Using translog cost functions, we built models of operating efficiencies for 5 core public health activities: communicable disease surveillance, chronic disease prevention, food hygiene, on-site sewage treatment, and vital records., Results: Economies of scale were found in most activities, with cost per unit decreasing as volume increased. The models did not, however, identify meaningful economies of scope., Conclusions: Consolidation or regionalization might lower cost per unit for select public health activities. This could free up resources for use in other areas, further improving the public's health.

Objectives: We used a cross-sectional, retrospective study design to analyze the association between local health agency regulatory activities and revenues from nonclinical fees and fines (NFF)., Methods: We extracted data from the 2010 National Association of County and City Health Officials (NACCHO) Profile Survey, the most recent report including NFF information, and used 2-part multivariable regression models to identify relationships between regulatory activities and revenue. We also interviewed LHD directors on access to revenue from fines., Results: NFFs generated substantial revenue for most LHDs, increasing in scope and amount with jurisdiction size for all but the largest municipalities. The greatest proportion of net revenue came from public pools, campgrounds and recreational vehicles, and solid waste disposal. For small and mid-sized LHDs, enforcement activities generated revenue in a dose-response pattern, with higher returns for increased activities. LHDs in decentralized governance states collected more NFF revenue than those in centralized states. States vary regarding LHD access to revenue from sanctions., Conclusions: The fiscal impact of changes in regulatory activity needs careful assessment to avoid unanticipated consequences of applicable law.

Objectives: We examined associations between local health department (LHD) spending, staffing, and services and community health outcomes in North Carolina., Methods: We analyzed LHD investments and community mortality in North Carolina from 2005 through 2010. We obtained LHD spending, staffing, and services data from the National Association of City and County Health Officials 2005 and 2008 profile surveys. Five mortality rates were constructed using Centers for Disease Control and Prevention mortality files, North Carolina vital statistics data, and census data for LHD service jurisdictions: heart disease, cancer, diabetes, pneumonia and influenza, and infant mortality., Results: Spending, staffing, and services varied widely by location and over time in the 85 North Carolina LHDs. A 1% increase in full-time-equivalent staffing (per 1000 population) was associated with decrease of 0.01 infant deaths per 1000 live births (P < .05). Provision of women and children's services was associated with a reduction of 1 to 2 infant deaths per 1000 live births (P < .05)., Conclusions: Our findings, in the context of other studies, provide support for investment in local public health services to improve community health.

We examined the effects of local health department (LHD) consolidations on the total and administrative expenditures of LHDs in Ohio from 2001 to 2011. We obtained data from annual records maintained by the state of Ohio and through interviews conducted with senior local health officials and identified 20 consolidations of LHDs occurring in Ohio in this time period. We found that consolidating LHDs experienced a reduction in total expenditures of approximately 16% (P = .017), although we found no statistically significant change in administrative expenses. County health officials who were interviewed concurred that their consolidations yielded financial benefits, and they also asserted that their consolidations yielded public health service improvements.

Objectives: To provide an overview of budget cuts, job losses, and program reductions among local health departments (LHDs) and to examine the association between LHD infrastructure characteristics and the likelihood of budget cuts., Design: Data from 4 waves of the economic surveillance survey (July-August 2009, September-November 2010, January-February 2012, and January-March 2013) conducted by the National Association of County & City Health Officials were analyzed to assess cuts to budgets, jobs, and programs since 2009. Data from the 2013 National Profile of Local Health Departments survey were used to assess the infrastructural characteristics associated with budget cuts., Results: When asked in early 2013, more than a quarter of LHDs (26.9%) reported a reduced budget, continuing the trend of a substantial proportion of LHDs experiencing financial hardship in recent years. The percentages of LHDs that made cuts to programmatic areas fluctuated from year to year but have never been lower than 40%. Maternal and child health services were among areas most often cut during all 4 time points of the survey. Governance type, total expenditures, and percentage of revenues from local sources were significantly associated with LHD budget cuts., Conclusions: Cuts in LHD budgets, staff, and activities have been widespread for a period that lasted long after the official end of the Great Recession. There is a great need for substantive and consistent funding to ensure the retention of the workforce and the delivery of essential public health services.

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.)

Objective: The relationships between characteristics of local public health agencies and their self-reported scores on partnership-related indicators of the Ten Essential Public Health Services were examined., Design: A retrospective cross-sectional study using secondary data from the National Public Health Performance Standards Program (NPHPSP) and the 2005 Profile of Local Public Health Agencies from the National Association of City and County Health Organizations (NACCHO) was completed. Participants. Local public health systems that participated in both the NPHPSP and the NACCHO surveys., Main Outcome Measures: Partnership-related elements from the NPHPSP data set were used as dependent variables, whereas combined focused elements from the NPHPSP and the NACCHO surveys served as independent variables., Results: Local public health agencies' increase in partnerships over the preceding 3 years and involvement in a community health improvement process were significantly related to numerous partnership performance scores--more so than other agency characteristics. Involvement in the Mobilizing Action through Planning and Partnerships process was inversely related to some partnership performance scores., Conclusions: Future research must continue to identify and explore additional community- and agency-level predictors of partnership performance.

In recent years, state and local public health department budgets have been cut, sometimes drastically. However, there is no systematic tracking of governmental public health spending that would allow researchers to assess these cuts in comparison with governmental public health spending as a whole. Furthermore, attempts to quantify the impact of public health spending are limited by the lack of good data on public health spending on state and local public health services combined. The objective of this article is to integrate self-reported state and local health department (LHD) survey data from 2 major national organizations to create state-level estimates of governmental public health spending. To create integrated estimates, we selected 1388 LHDs and 46 states that had reported requisite financial information. To account for the nonrespondent LHDs, estimates of the spending were developed by using appropriate statistical weights. Finally, funds from federal pass-through and state sources were estimated for LHDs and subtracted from the total spending by the state health agency to avoid counting these dollars in both state and local figures. On average, states spend $106 per capita on traditional public health at the state and local level, with an average of 42% of spending occurring at the local level. Considerable variation exists in state and local public health funding. The results of this analysis show a relatively low level of public health funding compared with state Medicaid spending and health care more broadly.

We measured the impact of the 2008-2010 economic recession on local health departments (LHDs) across the United States. Between 2008 and 2010, we conducted 3 Web-based, cross-sectional surveys of a nationally representative sample of LHDs to assess cuts to budgets, workforce, and programs. By early 2010, more than half of the LHDs (53%) were experiencing cuts to their core funding. In excess of 23 000 LHDs jobs were lost in 2008-2009. All programmatic areas were affected by cuts, and more than half of the LHDs had to reduce or eliminate at least 1 programmatic area. The capacity of LHDs to provide core public health services was undermined by the economic recession.

This article explores how health inequalities are constructed as an object for policy intervention by considering four framings: politics, audit, evidence and treatment. A thematic analysis of 197 interviews conducted with local managers in England, Scotland and Wales is used to explore how these framings emerge from local narratives. The three different national policy regimes create contrasting contexts, especially regarding the different degrees of emphasis in these regimes on audit and performance management. We find that politics dominates how health inequalities are framed for intervention, affecting their prioritisation in practice and how audit, evidence and treatment are described as deployed in local strategies., (© 2011 The Authors. Sociology of Health & Illness © 2011 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd.)

Background: In 2006, we conducted case studies of 4 North Carolina local health departments (LHDs) that scored highly on an index of diabetes prevention and control performance, to explore characteristics that may serve as barriers or facilitators of diabetes prevention and control services., Methods: Case studies involving in-depth interviews were conducted at 4 LHDs. Sites were selected on the basis of 2 variables, known external funding for diabetes services and population size, that were associated with performance in diabetes prevention and control in a 2005 survey of all North Carolina LHDs. Fourteen interviews (individual and group) were conducted among 17 participants from the 4 LHDs. The main outcome measures were LHD characteristics that facilitate or hinder the performance of diabetes programs and services., Results: Interviews revealed that all 4 high-performing LHDs had received some sort of funding from a source external to the LHD. Case study participants indicated that barriers to additional service delivery included low socioeconomic status of the population and lack of financial resources. Having a diabetes self-management education program that was recognized by the American Diabetes Association appeared to be a facilitator of diabetes services provision. Other facilitators were leadership and staff commitment, which appeared to facilitate the leveraging of partnerships and funding opportunities, leading to enhanced service delivery., Limitations: The small number of LHDs participating in the study and the cross-sectional study design were limitations., Conclusion: Leadership, staff commitment, partnership leveraging, and funding appear to be associated with LHD performance in diabetes prevention and control services. These factors should be further studied in future public health systems and services research.

Objective: This study presents a model for determining total funding needed for individual local health departments. The aim is to determine the financial resources needed to provide services for statewide local public health departments in Minnesota based on a gaps analysis done to estimate the funding needs., Design: We used a multimethod analysis consisting of 3 approaches to estimate gaps in local public health funding consisting of (1) interviews of selected local public health leaders, (2) a Delphi panel, and (3) a Nominal Group Technique. On the basis of these 3 approaches, a consensus estimate of funding gaps was generated for statewide projections., Setting: The study includes an analysis of cost, performance, and outcomes from 2005 to 2007 for all 87 local governmental health departments in Minnesota., Participants: For each of the methods, we selected a panel to represent a profile of Minnesota health departments., Main Outcome Measures: The 2 main outcome measures were local-level gaps in financial resources and total resources needed to provide public health services at the local level., Results: The total public health expenditure in Minnesota for local governmental public health departments was $302 million in 2007 ($58.92 per person). The consensus estimate of the financial gaps in local public health departments indicates that an additional $32.5 million (a 10.7% increase or $6.32 per person) is needed to adequately serve public health needs in the local communities., Conclusions: It is possible to make informed estimates of funding gaps for public health activities on the basis of a combination of quantitative methods. There is a wide variation in public health expenditure at the local levels, and methods are needed to establish minimum baseline expenditure levels to adequately treat a population. The gaps analysis can be used by stakeholders to inform policy makers of the need for improved funding of the public health system.

We explored the association between changes in local health department (LHD) resource levels with changes in health outcomes via a retrospective cohort study. We measured changes in expenditures and staffing reported by LHDs on the 1997 and 2005 National Association of County and City Health Officials surveys and assessed changes in state-level health outcomes with the America's Health Rankings reports for those years. We used pairwise correlation and multivariate regression to analyze the association of changes in LHD resources with changes in health outcomes. Increases in LHD expenditures were significantly associated with decreases in infectious disease morbidity at the state level (P = .037), and increases in staffing were significantly associated with decreases in cardiovascular disease mortality (P = .014), controlling for other factors.

West Virginia, as is true for the nation as a whole, spends far less on public health interventions than on curative care. In 2008 the United States spent approximately $2.4 trillion on healthcare, of which approximately $72 billion was allocated for public health activities-obviously a very small percentage (Centers for Medicare and Medicaid Services, U.S. Department of Heath and Human Services 2010). In West Virginia the 2006 per capita budget allocation for Local Boards of Health (LBH) for Basic Public Health Services was about $6.91, and total public health funding was between $63 and $91 per capita depending on the definition of public health. At the same time, Medicaid expenditures by the State are approximately $269 per capita with total Medicaid expenditures around $995 per capita. The difference in funding for Medicaid is almost 10 times the amount allocated to public health. The funding differences between curative care and preventive care may not be the result of the public's lack of understanding of the benefits of prevention, but rather its focus on short term rather than long term economic benefits. For a state like West Virginia, in which per capita income is below the national average, Medicaid is good business for the State's economy. Far too often public health funding is viewed as a drain from a state's budget not as an economic contributor to the state's economy. As a result, the funding of LBHs is almost always insufficient. The authors were interested in evaluating the economic impact of Local Boards of Health on West Virginia's economy. Although the authors recognize that the greatest economic benefits of public health are the costs averted through prevention and early detection, they believe that if LBH produce a positive economic multiplier State officials may view public health allocations in a more positive light. To assess the impact of LBH in West Virginia, spending data for each was collected. The direct, indirect, and induced spending resulting from public health activity was considered. The results were modeled using the IMPLAN (IMPLAN Professional 1999) regional input-output simulation software to assess the multiplier effects of direct LBH spending. Findings suggest that LBH produce a positive economic multiplier similar to other service industries in West Virginia. The inferences from this investigation focus on West Virginia however it is possible to make a reasonable argument that the fundamental issues are similar for states with similar economies.

Background: Local health departments contribute to population health improvement through the core functions of assessment, policy development, and assurance. Their capacity to perform these functions may be affected by funding and staffing., Objective: To describe local health department funding and staffing levels and determine the relationship between these measures and county-level health outcomes., Methods: Ten years of total funding, funding by revenue source, and staffing data from local health departments in all 72 Wisconsin counties were collected from the Department of Health and Family Services and analyzed. Summary measures for county health outcomes were obtained from the 2006 Wisconsin County Health Rankings, and a correlation matrix was created to determine associations between outcomes and measures of health department capacity., Results: On average, Wisconsin local health departments spend $20.60 per capita, ranging from $7.50 to $68.30 among counties. While total per capita funding in the state (adjusted for inflation) increased $0.82 per year, a closer look reveals 3 distinct periods: increases of $0.20 per year during 1995-1997 and $1.33 per year during 1997-2001; but a decrease of $0.27 during 2001-2004. Local health departments in counties with worse health outcomes had only slightly higher average funding and staffing levels during 2002-2004., Conclusion: Levels of health department funding in Wisconsin, already low by US standards, declined slightly in the past 3 years. Although counties with the worst health outcomes had slightly higher levels of public health funding, considerable disparities exist. State policymakers might consider investing more resources in counties with the greatest need, to support evidence-based public health programs and reduce existing geographic health disparities in Wisconsin.

Objective: Local environmental public health (EPH) is the foundation of a nation's environmental protection infrastructure. With increasing pressure to demonstrate the ability of EPH activities to effectively protect health, the Johns Hopkins Center for Excellence in EPH Practice, as part of the Centers for Disease Control and Prevention's (CDC's) EPH capacity-building effort, developed the Profile of Maryland Environmental Public Health Practice. This profile offers an examination of front-line local EPH strengths, needs, challenges, and provides recommendations to strengthen the EPH infrastructure., Methods: A multistep process was conducted, including site visits to all of Maryland's 24 local EPH agencies and a questionnaire addressing administrative structure, communication, funding, workforce, crisis management, technology, and legal authority, completed by local EPH directors., Results: The Maryland Profile revealed a dedicated and responsive workforce limited by a neglected, fragmented, and underfunded EPH infrastructure. Recommendations regarding leadership, workforce, training, technology, communication, and legal authority are offered., Conclusions: This research has implications for the national EPH infrastructure. Recommendations offered are consistent with the CDC's findings in A National Strategy to Revitalize Environmental Public Health Services. These findings and recommendations offer opportunities to facilitate the advancement of an EPH system to better protect the nation's health.

Local public health agencies are funded federal, state, and local revenue sources. There is a common belief that increases from one source will be offset by decreases in others, as when a local agency might decide it must increase taxes in response to lowered federal or state funding. This study tests this belief through a cross-sectional study using data from Missouri local public health agencies, and finds, instead, that money begets money. Local agencies that receive more from federal and state sources also raise more at the local level. Given the particular effectiveness of local funding in improving agency performance, these findings that nonlocal revenues are amplified at the local level, help make the case for higher public health funding from federal and state levels.

Public health systems are stressed by increasing demands and inadequate resources. This study was designed to demonstrate how economic impact analysis can estimate the economic value of a local public health system's infrastructure as well as the economic assets of an "Academic Health Department" model. This study involved the secondary analysis of publicly available data on health department finances and employment using proprietary software specifically designed to assess economic impacts. The health department's impact on the local community was estimated at over 100 million dollars, exceeding the economic impact of other recently studied local industries with no additional costs to local taxpayers.

A self-administered survey was distributed to members of The Big Cities Health Coalition, a group of Health Officers/Commissioners from 17 of the largest US metropolitan health departments. The survey asked participants about their chronic disease priorities, data sources, budgets, and funding sources as well as examples of successful chronic disease interventions. Members of the Coalition discussed the survey results in a scheduled conference call. Chronic diseases account for 70% of all deaths nationwide on average, yet the health departments surveyed allocated an average of 1.85% of their budgets to chronic disease. Average chronic disease spending per inhabitant was 2.33 dollars, with a median of 1.56 dollars. Among the group's top chronic disease priorities were asthma, diabetes, tobacco, cancer, and cardiovascular disease (CVD). Nearly half of the group's chronic disease spending was on tobacco. Chronic disease funding sources varied across localities, but direct federal funding was minimal. In 14 cities serving a combined 37 million people (13% of the US population), direct federal chronic disease funding totaled 8.7 million dollars, an average of 0.24 dollars per capita. The group described successful chronic disease interventions, particularly related to tobacco and asthma.

This article aims to fill a gap in the history of medical services in England and Wales in the interwar period by focusing on the historiographically neglected municipal sector--a relative neglect that is particularly unjustified given that this sector provided an increasingly wide array of medical services over the period. Focusing on the highly urbanized county boroughs, this article investigates whether and how expenditure on municipal health services changed over the interwar period, and whether these patterns were replicated by boroughs across England and Wales. It is found that many of the largest personal health services were experiencing a common pattern of growing investment over the period, but that county boroughs did not act uniformly in their spending decisions. Considered regionally, the Northeast and the West Midlands were found to perform poorly in expenditure terms compared to the data set as a whole, while the large conurbations of Leeds, Manchester, and Liverpool raised the average performance of the Northwest and Yorkshire. Regional patterns are found to be less consistent in the south of the country, where voluntary provision and demands arising from the boroughs' geographical position (for example, seaside resorts) may have exerted significant influences over levels of expenditure on health.

Governmental public health activities in the United States have evolved over time as a result of two forces: the nature and perceived importance of threats to the population's health and safety, and changing relationships among the various levels of government. Shifts toward a more state-centered form of federalism in the second half of the twentieth century weakened key aspects of the governmental public health enterprise, including its leadership and coordination, by the century's end. These developments challenge governmental public health responses to the new threats and increased societal expectations of the early twenty-first century.

The untimely death of Dr. Albert D. Kaiser and the numerous tributes recognizing his ten years of unstinted service to the community have stirred a new interest in the history of public health in Rochester. Dr. Kaiser and his predecessors, notably Dr. George W. Goler (first as an assistant in 1892 and as Chief Health Officer from 1896 to 1932), developed an outstanding health department, one that has on these earnest men, and in many instances public lethargy or vested interests effectively blocked the way and left the city at the mercy of known and unknown maladies. Over the years Rochester was not unlike many growing towns in this and other respects, and the awakening of its residents to the need for community-wide precautions, as well as for scientific treatment, comprised an illuminating phase of its history, as the present vigorous programs continue to demonstrate.