Abstract

OBJECTIVES: Current approaches to health system reform under the Affordable Care Act include efforts to enhance the delivery of public health services that promote health and prevent disease and injury on a population-wide basis. The nation’s public health delivery system comprises nearly 3000 local public health agencies that vary widely in size, resources, and capabilities. Economic pressures, workforce shortages, and new national accreditation standards are leading these agencies to explore mechanisms for pooling resources and expertise across local jurisdictions to enhance delivery and improve population health. This analysis uses longitudinal observations on a national sample of local public health agencies to estimate the effects of regional delivery models on the availability and effectiveness of public health services.

STUDY DESIGN: A longitudinal cohort design is used to analyze changes in the availability and perceived effectiveness of services delivered by local public health agencies and their community partners. A stratified random sample of the nation’s 3000 local public health officials (n=497) were surveyed in 1998 and again in 2006 and 2011 (70% response) to measure the availability of 20 core public health services within their jurisdictions, the range of organizations that deliver each service, and the perceived effectiveness of services. Survey data were linked with contemporaneous information on agency and community characteristics and measures of population health status. Hierarchical fixed-effects regression models were used to estimate the effects of changes in the scale (population served) and scope (proportion of services delivered) of public health delivery on the perceived effectiveness of these services and on preventable health outcomes. Model estimates were used to simulate the effects of regional service delivery models that pool resources across neighboring public health agency jurisdictions that fall below selected population thresholds.

POPULATION: The population included all U.S. agencies meeting the nationally-accepted definition of a local health department: an administrative or service unit of a local or state government that has responsibility for the health of a jurisdiction smaller than a state.

PRINCIPAL FINDINGS: The scope of public health services delivered in the average U.S. community increased from 64% to 71% during the 14 year period (p<0.05), and increased significantly with the agency’s scale of operations (population size served, p<0.001). Multivariate spline estimates indicated that the perceived effectiveness of services increased nonlinearly with the scale and scope of public health delivery, with gains in effectiveness dissipating after reaching a scale threshold of 150,000 population and a scope threshold of 70%. Simulation results predicted that combining neighboring public health agency jurisdictions serving less than 25,000 residents would produce an average 17% reduction in the per-capita cost of delivery, a 13% increase in the scope of services delivered, and a 9% increase in perceived effectiveness of services, along with statistically significant reductions in selected measures of preventable mortality.

CONCLUSIONS: The delivery of local public health services exhibit sizeable returns to scale and scope. Consequently, pooling the resources of small public health jurisdictions may enhance the quantity and quality of services delivered.

IMPLICATIONS FOR POLICY, DELIVERY AND PRACTICE: Regional strategies to coordinate and/or consolidate the operations of small and rural public health agencies may improve public health delivery and population health.

Document Type

Presentation

Publication Date

6-26-2012

Notes/Citation Information

A presentation at the AcademyHealth Annual Research Meeting in Orlando, FL.

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