The economic, institutional, and political determinants of public health delivery system structures.

OBJECTIVES: A typology of local public health systems was recently introduced, and a large degree of structural transformation over time was discovered in the systems analyzed. We present a qualitative exploration of the factors that determine variation and change in the seven structural configurations that comprise the local public health delivery system typology. METHODS: We applied a 10-item semistructured telephone interview protocol to representatives from the local health agency in two randomly selected systems from each configuration--one that had maintained configuration over time and one that had changed configuration over time. We assessed the interviews for patterns of variation between the configurations. RESULTS: Four key determinants of structural change emerged: availability of financial resources, interorganizational relationships, public health agency organization, and political relationships. Systems that had changed were more likely to experience strengthened partnerships between public health agencies and other community organizations and enjoy support from policy makers, while stable systems were more likely to be characterized by strong partnerships between public health agencies and other governmental bodies and less supportive relationships with policy makers. CONCLUSIONS: This research provides information regarding the determinants of system change, and may help public health leaders to better prepare for the impacts of change in the areas discussed. It may also help those who are seeking to implement change to determine the contextual factors that need to be in place before change can happen, or how best to implement change in the face of contextual factors that are beyond their control.

Understanding the organization of public health delivery systems: an empirical typology.

CONTEXT: Policy discussions about improving the U.S. health care system increasingly recognize the need to strengthen its capacities for delivering public health services. A better understanding of how public health delivery systems are organized across the United States is critical to improvement. To facilitate the development of such evidence, this article presents an empirical method of classifying and comparing public health delivery systems based on key elements of their organizational structure. METHODS: This analysis uses data collected through a national longitudinal survey of local public health agencies serving communities with at least 100,000 residents. The survey measured the availability of twenty core public health activities in local communities and the types of organizations contributing to each activity. Cluster analysis differentiated local delivery systems based on the scope of activities delivered, the range of organizations contributing, and the distribution of effort within the system. FINDINGS: Public health delivery systems varied widely in organizational structure, but the observed patterns of variation suggested that systems adhere to one of seven distinct configurations. Systems frequently migrated from one configuration to another over time, with an overall trend toward offering a broader scope of services and engaging a wider range of organizations. CONCLUSIONS: Public health delivery systems exhibit important structural differences that may influence their operations and outcomes. The typology developed through this analysis can facilitate comparative studies to identify which delivery system configurations perform best in which contexts.

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

This study examined the relationship between community and system characteristics of 353 local public health agencies and local public health system performance by revisiting previous research by Mays et al and Scutchfield et al. More recent and coterminous data were used. Local public health agency characteristics were obtained from the National Association of City and County Health Officials' 2005 National Profile of Local Public Health Departments and performance data were obtained from version 1 of the National Public Health Performance Standards Program local performance assessment instrument. Descriptive analyses and multivariate analyses similar to the two previous studies were employed. Population size, presence of a local board of health and whether the board makes policy, educational background of the local public health agency's top executive, and jurisdiction type were found to be important predictors of local public health performance. These findings support some of the earlier findings but do not support all the findings of the earlier studies. Variances are discussed. This study provides researchers and practitioners with an evidence base from which to make suggestions regarding characteristics, many changeable, which may influence system performance.

Public health performance.

This review examines past, current, and future issues in developing and using public health performance data for improving the public health system. Issues are explored relating to public health performance data collection and analysis, and inferences made from those data, largely by examining public health performance data collected since the Year 2000. More research is needed to improve understanding of the context in which public health systems operate and how that context affects performance and its relationship to health outcomes. There are major areas of concern that must be addressed by the public health practice organizations, governmental public health entities, and the public health systems research communities, such as ensuring that data are collected on public health infrastructure, practice, and performance and that data from various sources are collected in a harmonious fashion. At issue also is the examination of the impact of new arrivals to the public health system, such as accreditation and credentialing of the public health workforce, on public health system performance.

Implementing the National Local Public Health System Performance Assessment: evaluation of a readiness process in Kentucky.

The objectives of the study described in this article were to test training and resource materials for preparing Kentucky public health agency staff to lead the National Local Public Health System Performance Assessment and to identify barriers encountered in implementation. Readiness supports provided to five Kentucky district and county health departments that led the system assessment process in 12 counties were evaluated using training pre- and posttests, performance assessment posttests, observations, and interviews. The training and materials provided in this study appeared to be the minimum needed for these Kentucky health departments. Training sequences need to allow time for independent study of assessment processes, and training in using and interpreting the assessment instrument should be included. Partner orientation materials targeted for nonpublic health partners would be useful. In Kentucky, barriers to completing the assessment included questions about its purpose and benefits and the lack of a self-identified local public health system. Formal training of health department staff, committed leadership, and adequate personnel resources can help overcome these barriers. The health departments that brought together system partners for the performance assessment considered it a valuable community-building educational event.

Local public health agency capacity and its relationship to public health system performance.

he study described in this article identifies local public health agency capacity characteristics that are related to their local public health systems' performance scores on the CDC's National Public Health Performance Standards Program assessment instrument. Public health system performance scores from a test version of the National Public Health Performance Standards instrument (5b) from county and city/county jurisdictions in three states were matched to organizational capacity data from the 1997 National Association of County and City Health Officials profile of health departments, resulting in a sample of 152 jurisdictions. Twenty-eight capacity variables from the profile and all 10 scores on the Essential Public Health Services plus the total performance score were analyzed in 11 separate multivariate regression models. Public health agency capacities in the areas of funding, organizational leadership, and certain nonprovider partnerships were found to be significantly related to public health system performance. Further study is needed to determine if these relationships between agency capacities and system performance are found, with data from other states now using the nationally released performance assessment instruments and with capacity measures that are more specific for evaluating public health system performance.