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Objective: The US federal government invests in the development of medical countermeasures for addressing adverse health effects to the civilian population from chemical, biological, and radiological or nuclear threats. We model the potential economic spillover effects in day-to-day burn care for a federal investment in a burn debridement product for responding to an improvised nuclear device., Methods: We identify and assess 4 primary components for projecting the potential economic spillover benefits of a burn debridement product: (1) market size, (2) clinical effectiveness and cost-effectiveness, (3) product cost, and (4) market adoption rates. Primary data sources were the American Burn Association's 2015 National Burn Repository Annual Report of Data and published clinical studies used to gain European approval for the burn debridement product., Results: The study results showed that if approved for use in the United States, the burn debridement product has potential economic spillover benefits exceeding the federal government's initial investment of $24 million a few years after introduction into the burn care market., Conclusions: Economic spillover analyses can help to inform the prioritizing of scarce resources for research and development of medical countermeasures by the federal government. Future federal medical countermeasure research and development investments could incorporate economic spillover analysis to assess investment options. (Disaster Med Public Health Preparedness. 2017;11:711-719).

Context: The National Research Agenda for Public Health Services and Systems Research states the need for research to determine the cost of delivering public health services in order to assist the public health system in communicating financial needs to decision makers, partners, and health reform leaders., Objective: The objective of this analysis is to compare 2 cost estimation methodologies, public health manager estimates of employee time spent and activity logs completed by public health workers, to understand to what degree manager surveys could be used in lieu of more time-consuming and burdensome activity logs., Design: Employees recorded their time spent on communicable disease surveillance for a 2-week period using an activity log. Managers then estimated time spent by each employee on a manager survey. Robust and ordinary least squares regression was used to measure the agreement between the time estimated by the manager and the time recorded by the employee., Main Outcome Measures: The 2 outcomes for this study included time recorded by the employee on the activity log and time estimated by the manager on the manager survey., Setting: This study was conducted in local health departments in Colorado., Participants: Forty-one Colorado local health departments (82%) agreed to participate., Results: Seven of the 8 models showed that managers underestimate their employees' time, especially for activities on which an employee spent little time. Manager surveys can best estimate time for time-intensive activities, such as total time spent on a core service or broad public health activity, and yet are less precise when estimating discrete activities., Conclusions: When Public Health Services and Systems Research researchers and health departments are conducting studies to determine the cost of public health services, there are many situations in which managers can closely approximate the time required and produce a relatively precise approximation of cost without as much time investment by practitioners.

Modern healthcare contracting is shifting the responsibility for improving quality, enhancing community health and controlling the total cost of care for patient populations from payers to providers. Population-based contracting involves capitated risk taken across an entire population, such that any included services within the contract are paid for by the risk-bearing entity throughout the term of the agreement. Under such contracts, a risk-bearing entity, which may be a provider group, a hospital or another payer, administers the contract and assumes risk for contractually defined services. These contracts can be structured in various ways, from professional fee capitation to full global per member per month diagnosis-based risk. The entity contracting with the payer must have downstream network contracts to provide the care and facilities that it has agreed to provide. Population health is a very powerful model to reduce waste and costs. It requires a deep understanding of the nuances of such contracting and the appropriate infrastructure to manage both networks and risk. Cite this article: Bone Joint J 2017;99-B:1431-4., (©2017 The British Editorial Society of Bone & Joint Surgery.)

Background: To address challenges in public health supply chain performance, Tanzania invested in a national logistics management unit (LMU) and a national electronic logistics management information system (eLMIS). This evaluation examined the impact of those 2 key management upgrades approximately 1 year after they were introduced., Methods: We used a nonexperimental pre-post study design to compare the previous system with the upgraded management system. We collected baseline data from August to November 2013. We conducted round 1 of post-implementation data collection during April and May 2015, about 1 year after implementation of the upgrades. We evaluated key indicators of data use and reporting; supply chain management practices such as storage and supervision; supply chain performance including stock-out and expiry rates; and supply chain cost and savings. We analyzed the data using a range of techniques including statistical testing of baseline and round-1 results, and cost, cost-effectiveness, and return on investment analysis., Results: The upgrades were associated with improvements in data use, accessibility, visibility, and transparency; planning, control, and monitoring; support for quantification; stock-out rates; stock-out duration; commodity expiry; and forecast error. The upgraded system was more costly, but it was also more efficient, particularly when adjusting for the performance improvements. The upgrades also generated substantial savings that defrayed some, but not all, of the investment costs., Conclusion: Upgrades to Tanzania's supply chain management systems created multiple and complex pathways to impact. One year after implementation, the LMU and eLMIS brought about performance improvements through better data use and through improvements in some, but not all, management practices. Furthermore, the upgrades-while not inexpensive-contributed to greater system efficiency and modest savings., (© Mwencha et al.)

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.

Background: The contemporary environment is a complex of interactions between physical, biological, socio-economic systems with major impacts on public health. However, gaps in our understanding of the causes, extent and distribution of these effects remain. The public health community in Sandwell West Midlands has collaborated to successfully develop, pilot and establish the first Environmental Public Health Tracking (EPHT) programme in Europe to address this 'environmental health gap' through systematically linking data on environmental hazards, exposures and diseases., Methods: Existing networks of environmental, health and regulatory agencies developed a suite of innovative methods to routinely share, integrate and analyse data on hazards, exposures and health outcomes to inform interventions., Results: Effective data sharing and horizon scanning systems have been established, novel statistical methods piloted, plausible associations framed and tested, and targeted interventions informed by local concerns applied. These have influenced changes in public health practice., Conclusion: EPHT is a powerful tool for identifying and addressing the key environmental public health impacts at a local level. Sandwell's experience demonstrates that it can be established and operated at virtually no cost. The transfer of National Health Service epidemiological skills to local authorities in 2013 provides an opportunity to expand the programme to fully exploit its potential., (© The Author 2016. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

From the summer of 2014 to the spring of 2016, the United States was involved in the Ebola response on both the national and international levels. The United States received 2 imported cases from West Africa and had 2 locally hospital-acquired cases, which spurred a massive and unprecedented public health response. As the domestic response stabilized and the epidemic in West Africa slowed, the Association of State and Territorial Health Officials (ASTHO) and the National Association of County and City Health Officials (NACCHO), through a cooperative agreement with the Centers for Disease Control and Prevention (CDC), led an in-progress review to assess the national public health response to Ebola. The goal was to identify opportunities to improve the Ebola response and best practices to inform future responses. To inform the review, NACCHO and ASTHO relied on feedback collected from several sources, including a stakeholder meeting held in August 2015, a series of key informant interviews, ASTHO's and NACCHO's internal response assessments, and perspectives shared by state and local health department members and workgroups and national partner organizations. ASTHO and NACCHO engaged experts and practitioners in public health, health care, emergency management, laboratory sciences, environmental health, occupational health, homeland security, communications, and public works from US federal, state, and local governments, the nonprofit community, and private industry. This article summarizes feedback and lessons learned as shared by these sources. Additionally, this article presents recommendations for federal, state, local, and nongovernment partners to improve current and future preparedness and response efforts to infectious disease threats.

In recent years, English local authorities have been forced to make significant cuts to devolved expenditure. In this paper, we examine the impact of reductions in local expenditure on one particular public health target: reducing rates of teen pregnancy. Contrary to predictions made at the time of the cuts, panel data estimates provide no evidence that areas which reduced expenditure the most have experienced relative increases in teenage pregnancy rates. Rather, expenditure cuts are associated with small reductions in teen pregnancy rates, a result which is robust to a number of alternative specifications and tests for causality. Underlying socio-economic factors such as education outcomes and alcohol consumption are found to be significant predictors of teen pregnancy., (Copyright © 2017 Elsevier B.V. All rights reserved.)

This paper describes the review process of the Agency of Public Health of Barcelona's service portfolio in response to the budget cuts introduced since 2010 in the public administrations in Spain. A working group reviewed the different business activities, taking into account their costs and generated revenue and their justification, assessing factors such as the existence of legal constraints, tied funding, explicit demands from the founding administrations and other actors that may be capable of undertaking particular activities. The changes and their consequences are described. The new service portfolio has been consolidated and is considered ratified by the Agency board, which was renewed after political changes. We conclude that this is because it was based on professional consensus and management criteria, which are key for the smooth operation of a public autonomous executive organisation., (Copyright © 2016 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: The aim of this study is to analyze the production of 76 specialist hospitals for the morbidly obese in Brazil's public healthcare system (SUS) from 2010 to 2014 in terms of quantity and costs of bariatric surgery and its complications., Methods: Secondary data from the SUS Hospital Information System and the National Healthcare Establishments Registry were used. Current spending on bariatric surgery and its medical and postoperative complications were analyzed., Results: There was a 60 % rise in the number of surgeries between 2010 and 2014. This increase was not homogeneous among the hospitals studied, since only 19 performed the minimum number of surgeries required. Women accounted for 85 % of the surgeries carried out, and 32 % were aged between 35 and 44 years. The Roux-en-Y technique was the most widely used (93.7 % of the total), followed by sleeve gastrectomy. The ratio between the occurrence of medical complications and total number of surgeries performed in each hospital varied significantly (between 0 and 5.97 %) but was lower for postoperative complications, ranging from 0 to 1.7 %. There was a nominal increase of 44 % in average expenditure on postoperative complications between 2013 and 2014, while the average cost of medical complications decreased by 8.7 % in the same period., Conclusions: Despite the rise in the number of bariatric surgeries in Brazil, there is still a high demand for surgeries that is not being met, while most specialist hospitals fail to perform the minimum number of surgeries stipulated by the Ministry of Health.

Importance: Patient advocacy organizations (PAOs) are influential health care stakeholders that provide direct counseling and education for patients, engage in policy advocacy, and shape research agendas. Many PAOs report having financial relationships with for-profit industry, yet little is known about the nature of these relationships., Objective: To describe the nature of industry funding and partnerships between PAOs and for-profit companies in the United States., Design, Setting, and Participants: A survey was conducted from September 1, 2013, to June 30, 2014, of a nationally representative random sample of 439 PAO leaders, representing 5.6% of 7865 PAOs identified in the United States. Survey questions addressed the nature of their activities, their financial relationships with industry, and the perceived effectiveness of their conflict of interest policies., Main Outcomes and Measures: Amount and sources of revenue as well as organizational experiences with and policies regarding financial conflict of interest., Results: Of the 439 surveys mailed to PAO leaders, 289 (65.8%) were returned with at least 80% of the questions answered. The PAOs varied widely in terms of size, funding, activities, and disease focus. The median total revenue among responding organizations was $299 140 (interquartile range, $70 000-$1 200 000). A total of 165 of 245 PAOs (67.3%) reported receiving industry funding, with 19 of 160 PAOs (11.9%) receiving more than half of their funding from industry. Among the subset of PAOs that received industry funding, the median amount was $50 000 (interquartile range, $15 000-$200 000); the median proportion of industry support derived from the pharmaceutical, device, and/or biotechnology sectors was 45% (interquartile range, 0%-100%). A total of 220 of 269 respondents (81.8%) indicated that conflicts of interest are very or moderately relevant to PAOs, and 94 of 171 (55.0%) believed that their organizations' conflict of interest policies were very good. A total of 22 of 285 PAO leaders (7.7%) perceived pressure to conform their positions to the interests of corporate donors., Conclusions and Relevance: Patient advocacy organizations engage in wide-ranging health activities. Although most PAOs receive modest funding from industry, a minority receive substantial industry support, raising added concerns about independence. Many respondents report a need to improve their conflict of interest policies to help maintain public trust.

Background: In 2008, the line item supporting sexually transmitted disease (STD) services in the Massachusetts state budget was cut as a result of budget shortfalls. Shortly thereafter, direct provision of STD clinical services supported by the Massachusetts Department of Public Health (MDPH) was suspended. Massachusetts Department of Public Health requested an initial assessment of its internal response and impact in 2010. A follow-up assessment occurred in September 2013., Methods: In 2010 and 2013, 39 and 46 staff, respectively, from MDPH and from clinical partner agencies, were interviewed about changes in the role of the MDPH, partnerships, STD services, challenges, and recommendations. Interview notes were summarized, analyzed, and synthesized by coauthors using qualitative analysis techniques and NVivo software., Results: The withdrawal of state funding for STD services, and the subsequent reduction in clinical service hours, erected numerous barriers for Disease Intervention Specialists (DIS) seeking to ensure timely STD treatment for index cases and their partners. After initial instability, MDPH operations stabilized due partly to strong management, new staff, and intensified integration with human immunodeficiency virus services. Existing contracts with human immunodeficiency virus providers were leveraged to support alternative STD testing and care sites. Massachusetts Department of Public Health strengthened its clinical and epidemiologic expertise. The DIS expanded their scope of work and were outposted to select new sites. Challenges remained, however, such as a shortage of DIS staff to meet the needs., Conclusions: Although unique in many ways, MA offers experiences and lessons for how a state STD program can adapt to a changing public health context.

Background: Following the Health and Social Care Act in England, public health teams were formally transferred from the NHS to local authorities in April 2013., Methods: Online survey of Directors of Public Health (DsPH) in local authorities in England (n = 152) to investigate their experience within local government 1 year on. Tests of association were used to explore relationships between the perceived integration and influence of public health, and changes in how the public health budget was being spent., Results: The organization of and managerial arrangements for public health within councils varied. Most DsPH felt that good relationships had been established within the council, and the move had made them more able to influence priorities for health improvement, even though most felt their influence was limited. Changes in commissioning using the public health budget were already widespread and included the de-commissioning of services., Conclusions: There was a widespread feeling amongst DsPH that they had greater influence since the reforms, and that this went across the local authority and beyond. Public health's influence was most apparent when the transfer of staff to local government had gone well, when collaborative working relationships had developed, and when local partnership groups were seen as being effective., (© The Author 2015. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

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).

Public health, like politics, is the art of the possible. To maximize effectiveness, public health officers in any jurisdiction should (1) get good data and ensure timely and effective dissemination; (2) prioritize and tackle more difficult initiatives first; (3) find, fight, and win winnable battles in areas where progress is possible but not ensured without focused, strategic effort; (4) support and hire great people and protect them so they can do their jobs; (5) address communicable diseases and environmental health effectively; (6) do not cede the clinical realm-public health programs depend on clinical care and on effective coordination between health care and public health; (7) learn and manage the budget cycle; (8) manage the context; (9) never surprise their boss; and (10) follow core principles.

Background: Amid local government budget cuts, there is concern that the ring-fenced public health grant is being appropriated, and Directors of Public Health (DsPH) find it difficult to make the case for investment in public health activity. This paper describes what DsPH are making the case for, the components of their case and how they present the case for public health., Methods: Thirteen semi-structured telephone interviews and a group discussion were carried out with DsPH (November 2013 to May 2014) in the Southern region of England., Results: DsPH make the case for control of the public health grant and investing in action on wider determinants of health. The cases they present incorporate arguments about need, solutions and their effectiveness, health outcomes, cost and economic impact but also normative, political arguments. Many types of evidence were used to substantiate the cases; evidence was carefully framed to be accessible and persuasive., Conclusions: DsPH are responding to a new environment; economic arguments and evidence of impact are key components of the case for public health, although multiple factors influence local government (LG) decisions around health improvement. Further evidence of economic impact would be helpful in making the case for public health in LG., (© The Author 2015. Published by Oxford University Press on behalf of Faculty of Public Health.)

Objectives: A major responsibility of a local health department (LHD) is to assure public health service availability throughout its jurisdiction. Many LHDs face expanded service needs and declining budgets, making billing for services an increasingly important strategy for sustaining public health service provision. Yet, little practice-based data exist to guide practitioners on what to expect financially, especially regarding timing of reimbursement receipt. This study provides results from one LHD on the lag from service delivery to reimbursement receipt., Methods: Reimbursement records for all transactions at Maricopa County Department of Public Health immunization clinics from January 2013 through June 2014 were compiled and analyzed to determine the duration between service and reimbursement. Outcomes included daily and cumulative revenues received. Time to reimbursement for Medicaid and private payers was also compared., Results: Reimbursement for immunization services was received a median of 68 days after service. Payments were sometimes taken back by payers through credit transactions that occurred a median of 333 days from service. No differences in time to reimbursement between Medicaid and private payers were found., Conclusions: Billing represents an important financial opportunity for LHDs to continue to sustainably assure population health. Yet, the lag from service provision to reimbursement may complicate budgeting, especially in initial years of new billing activities. Special consideration may be necessary to establish flexibility in the budget-setting processes for services with clinical billing revenues, because funds for services delivered in one budget period may not be received in the same period. LHDs may also benefit from exploring strategies used by other delivery organizations to streamline billing processes.

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.)

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.

The Affordable Care Act presents financial challenges and opportunities for publicly funded service providers. We assessed billing practices and anticipated barriers to third-party billing among organizations in Texas that provide publicly funded HIV, sexually transmitted diseases, tuberculosis, and viral hepatitis services. One third to one half of the organizations did not bill for medical services. The most common barrier to third-party billing was lack of staff knowledge about billing and coding. Future research must evaluate options for organizations and communities to maintain access to infectious disease services for vulnerable populations.

In an era of severe funding constraints for public health research, more efficient means of conducting research will be needed if scientific progress is to continue. At present major funders, such as the National Institutes of Health, do not provide specific instructions to grant authors or to reviewers regarding the cost efficiency of the research that they conduct. Doing so could potentially allow more research to be funded within current budgetary constraints and reduce waste. I describe how a blinded randomized trial was conducted for $ 275,000 by completely automating the consent and data collection processes. The study used the participants' own computer equipment, relied on big data for outcomes, and outsourced some costly tasks, potentially saving $1 million in research costs.

Objectives: We estimated the effect of economic constraints on public health delivery systems (PHDS) density and centrality during 3 time periods, 1998, 2006, and 2012., Methods: We obtained data from the 1998, 2006, and 2012 National Longitudinal Study of Public Health Agencies; the 1993, 1997, 2005, and 2010 National Association for County and City Health Officials Profile Study; and the 1997, 2008, and 2011 Area Resource Files. We used multivariate regression models for panel data to estimate the impact of economic constraints on PHDS density and centrality., Results: Findings indicate that economic constraints did not have a significant impact on PHDS density and centrality over time but population is a significant predictor of PHDS density, and the presence of a board of health (BOH) is a significant predictor of PHDS density and centrality. Specifically, a 1% increase in population results in a significant 1.71% increase in PHDS density. The presence of a BOH is associated with a 10.2% increase in PHDS centrality, after controlling for other factors., Conclusions: These findings suggest that other noneconomic factors influence PHDS density centrality.

Background: In order to address several health challenges, the Chinese government issued the National Essential Public Health Services Package (NEPHSP) in 2009. In China's large cities, the lack of funding for community health centers and consequent lack of comprehensive services and high quality care has become a major challenge. However, no study has been carried out to estimate the cost of delivering the services in the package. This project was to develop a cost estimation approach appropriate to the context and use it to calculate the cost of the NEPHSP in Beijing in 2011., Methods: By adjusting models of cost analysis of primary health care and workload indicators of staffing need developed by the World Health Organization, a model was developed to estimate the cost of the services in the package through an intensive interactive process. A total of 17 community health centers from eight administrative districts in Beijing were selected. Their service volume and expenditure data in 2010 were used to evaluate the costs of providing the NEPHSP in Beijing based on the applied model., Results: The total workload of all types of primary health care in 17 sample centers was equivalent to the workload requirement for 14,056,402 standard clinic visits. The total expenditure of the 17 sample centers was 26,329,357.62 USD in 2010. The cost of the workload requirement of one standard clinic visit was 1.87 USD. The workload of the NEPHSP was equivalent to 5,514,777 standard clinic visits (39.23 % of the total workload). The model suggests that the cost of the package in Beijing was 7.95 USD per capita in 2010. The cost of the NEPHSP in urban areas was lower than suburban areas: 7.31 and 8.65 USD respectively., Conclusions: The average investment of 3.97 USD per capita in NEPHSP was lower than the amount needed to meet its running costs. NEPHSP in Beijing is therefore underfunded. Additional investment is needed, and a dynamic cost estimate mechanism should be introduced to ensure services remain adequately funded.

Background: Invasive meningococcal disease (IMD) incidence in Germany is low, but management of contacts to prevent subsequent cases still requires resources. Local public health authorities (LHA) advise antibiotic post-exposure prophylaxis (PEP) and vaccination to close contacts as defined in national guidance. We aimed to audit implementation of recommendations for IMD public health management in the state of Baden-Wuerttemberg, Germany, and to estimate associated costs., Methods: We surveyed all 38 LHAs in Baden-Wuerttemberg to evaluate knowledge of national guidance and implementation of IMD contact management using standardized questionnaires. For IMD cases notified in 2012, we requested numbers of household and other contacts ascertained, including advice given regarding PEP and post-exposure vaccination, plus staff time required for their management. We estimated costs for advised antibiotics, LHA staff time and visits to emergency departments according to published sources. The cost of preventing a subsequent case was estimated based on the number of household contacts that received PEP per IMD case and on the previous finding that ~284 household contacts must receive PEP to prevent one subsequent IMD case., Results: Although LHAs were familiar with national recommendations, they did not advise PEP to 4% of household contacts, while 72% and 100% of school and health provider contacts, respectively, were advised PEP. Only 25% of household contacts of a case with a vaccine-preventable serogroup were advised post-exposure vaccination. A mean of 11.0 contacts/IMD case (range 0-51), of which 3.6 were household contacts, were recommended PEP. Per IMD case, mean costs for LHA staff were estimated at €440.86, for antibiotics at €219.14 and for emergency department visits to obtain PEP at €161.70 - a total of €821.17/IMD case. Preventing a subsequent IMD case would cost ~ €65,000., Conclusions: Our results provide insight into costs of IMD public health management in Germany. We identified marked underuse of post-exposure vaccination in household contacts and overuse of PEP in school and health care contacts. In view of an estimated 3-6 quality-adjusted life years lost per case of IMD, our estimated cost of €65,000 for preventing a subsequent case seems justifiable.

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 public health system responses to economic shocks using longitudinal observations of public health activities implemented in US metropolitan areas from 1998 to 2012., Methods: The National Longitudinal Survey of Public Health Systems collected data on the implementation of 20 core public health activities in a nationally representative cohort of 280 metropolitan areas in 1998, 2006, and 2012. We used generalized estimating equations to estimate how local economic shocks relate to the scope of activities implemented in communities, the mix of organizations performing them, and perceptions of the effectiveness of activities., Results: Public health activities fell by nearly 5% in the average community between 2006 and 2012, with the bottom quintile of communities losing nearly 25% of their activities. Local public health delivery fell most sharply among communities experiencing the largest increases in unemployment and the largest reductions in governmental public health spending., Conclusions: Federal resources and private sector contributions failed to avert reductions in local public health protections during the recession. New financing mechanisms may be necessary to ensure equitable public health protections during economic downturns.

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.

Objectives: We examined state-specific administrative barriers to allocating 2009 H1N1 influenza public health emergency response (PHER) funds., Methods: We conducted a qualitative review of PHER grants management reports to identify and code barriers reported by states in allocating funds. Using linear regression, we examined the relationship between the percentage of funds allocated and each individual barrier and, separately, the cumulative effect of multiple barriers., Results: States reported 6 barrier types, including regulatory issues (n = 14, or 28%), contracting issues (n = 14, or 28%), purchasing issues (n = 6, or 12%), legislative issues (n = 5, or 10%), staffing issues (n = 5, or 10%), and issues transferring funds between state and local health departments (n = 4, or 8%). In multivariate models, having experienced a purchasing barrier was associated with a significant decrease in PHER allocation (B = -26.4; P = .018). Separately, the cumulative effect of having 3 barriers was associated with a decrease in PHER allocation (B = -16.0; P = .079)., Conclusions: Purchasing barriers were associated with delayed use of PHER funds. Moreover, the cumulative effect of any 3 barriers hampered the allocation of funds. Understanding barriers to using funds can inform future funding guidance for improved efficiency of response efforts.

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.

This article analyzes the historical background of the institutionalization of user fees and their subsequent abolition in West Africa. Based on a narrative review, we present the context that frames the different articles in this supplement. We first show that a general consensus has emerged internationally against user fees, which were imposed widely in Africa in the 1980s and 1990s; at that time, the institutionalization of user fees was supported by evidence from pilot projects funded by international aid agencies. Since then there have been other pilot projects studying the abolition of user fees in the 2000s, but these have not yet had any real influence on public policies, which are often still chaotic. This perplexing situation might be explained more by ideologies and political will than by insufficient financial capacity of states.

When user fee exemptions were introduced for children under five years of age in Niger, front-line staff in the health system were not consulted in advance, and various obstacles seriously hindered the policy's implementation. Health workers developed two types of coping strategies. The first dealt with shortcomings of the policy implementation process related to management tools, drug stocks, co-existence of the fee exemption and cost recovery systems, and, above all, supply management for medicines (ordering from private companies, issuing makeshift prescriptions). The second involved clientelism, circumvention of regulations, and misappropriation of resources. Adverse effects have arisen due to both the failings of the health system and the practices of health workers. These include a focus on the commercial management of patients, the most 'costly' of whom sometimes find themselves being refused treatment, patients roaming in search of medicines and treatment, and a decline in quality of care.

The paper is a case-study introducing a national project in Hungary establishing a countrywide public administration customer service system where accessibility was a key issue. Starting from the concept the paper describes the methods and organisational background how accessible design was integrated in the planning method and gives a feedback of site experiences.

This article uses history to stimulate reflection on the present opportunities and challenges for public health practice in English local government. Its motivation is the paradox that despite Department of Health policy-makers' allusions to 'a long and proud history' and 'returning public health home' there has been no serious discussion of that past local government experience and what we might learn from it. The article begins with a short resumé of the achievements of Victorian public health in its municipal location, and then considers the extensive responsibilities that it developed for environmental, preventive and health services by the mid-twentieth century. The main section discusses the early NHS, explaining why historians see the era as one of decline for the speciality of public health, leading to the reform of 1974, which saw the removal from local government and the abolition of the Medical Officer of Health role. Our discussion focuses on challenges faced before 1974 which raise organizational and political issues relevant to local councils today as they embed new public health teams. These include the themes of leadership, funding, integrated service delivery, communication and above all the need for a coherent vision and rationale for public health action in local authorities., (© The Author 2014. Published by Oxford University Press on behalf of Faculty of Public Health.)

Context: Discipline-specific workforce development initiatives have been a focus in recent years. This is due, in part, to competency-based training standards and funding sources that reinforce programmatic silos within state and local health departments., Objective: National leadership groups representing the specific disciplines within public health were asked to look beyond their discipline-specific priorities and collectively assess the priorities, needs, and characteristics of the governmental public health workforce., Design: The challenges and opportunities facing the public health workforce and crosscutting priority training needs of the public health workforce as a whole were evaluated. Key informant interviews were conducted with 31 representatives from public health member organizations and federal agencies. Interviews were coded and analyzed for major themes. Next, 10 content briefs were created on the basis of priority areas within workforce development. Finally, an in-person priority setting meeting was held to identify top workforce development needs and priorities across all disciplines within public health., Participants: Representatives from 31 of 37 invited public health organizations participated, including representatives from discipline-specific member organizations, from national organizations and from federal agencies., Results: Systems thinking, communicating persuasively, change management, information and analytics, problem solving, and working with diverse populations were the major crosscutting areas prioritized., Conclusions: Decades of categorical funding created a highly specialized and knowledgeable workforce that lacks many of the foundational skills now most in demand. The balance between core and specialty training should be reconsidered.

Objectives: HIV case surveillance is a primary source of information for monitoring HIV burden in the United States and guiding the allocation of prevention and treatment funds. While the number of people living with HIV and the need for surveillance data have increased, little is known about the cost of surveillance. We estimated the economic cost to health departments of conducting high-quality HIV case surveillance., Methods: We collected primary data on the unit cost and quantity of resources used to operate the HIV case surveillance program in Michigan, where HIV burden (i.e., the number of HIV cases) is moderate to high (n=14,864 cases). Based on Michigan's data, we projected the expected annual HIV surveillance cost for U.S., state, local, and territorial health departments. We based our cost projection on the variation in the number of new and established cases, area-specific wages, and potential economies of scale., Results: We estimated the annual total HIV surveillance cost to the Michigan health department to be $1,286,524 ($87/case), the annual total cost of new cases to be $108,657 ($133/case), and the annual total cost of established cases to be $1,177,867 ($84/case). Our projected median annual HIV surveillance cost per health department ranged from $210,600 in low-HIV burden sites to $1,835,000 in high-HIV burden sites., Conclusions: Our analysis shows that a systematic approach to costing HIV surveillance at the health department level is feasible. For HIV surveillance, a substantial portion of total surveillance costs is attributable to maintaining established cases.

In Italy, public health is experiencing a phase of crisis. A contraction of services and a staff reallocation have affected in particular Food Hygiene services. We explored Pubmed and Google Ngram Viewer© to define the state of the art of research in food and nutritional field from a quantitative point of view and we focused on some areas of interest in terms of improvement of professional practice. The Italian contribution to food and nutritional research is still limited. Our findings seem to demonstrate the need of an alliance between the world of research and Public Health services, so as to develop a sustainable and effective health system.

Background: Priority setting is at the core of resource allocation. In recent years, priority setting in public health has occurred in the context of a difficult authorizing environment, one in which politicians have shown increasing interest in reducing the footprint of government, even during times of increased demand for social services. In this context of austerity, tradeoffs abound. These tradeoffs may occur not only within a single programmatic area in public health (e.g., cutting an infant mortality program vs a "Children With Special Health Care Needs" program) but also at a broader, more abstract level (e.g., favoring programs that are relatively more efficient for one population vs less efficient for programs serving a population in greater need of services)., Objectives: This project was undertaken to provide more insight into tradeoffs within state health agencies with regard to what types of tradeoffs exist and how often they occur., Methods: To characterize these tradeoffs, we engaged in a mixed-methods project where we first conducted 45 semistructured interviews with public health leaders across 6 state health agencies. Tradeoffs were elicited through open-ended questions and probes and qualitatively coded and analyzed. Next, we conducted a national survey across all state health agencies, receiving 207 responses (66% response rate). Survey respondents were asked to rate how frequently they encountered particular tradeoffs and how difficult they were to resolve., Results: The most frequently encountered tradeoffs were "insufficient funding for a program versus no funding for a program" (84% rating as frequently/very frequently encountered) and prioritizing "current versus future need" (80% rating as frequently/very frequently). More than 50% of respondents said that they encountered 7 of the 11 tradeoffs frequently or very frequently and found 10 of the 11 difficult or very difficult to resolve. Forty-two percent of respondents rated "services for younger groups versus services for older groups" as difficult/very difficult to resolve.