Tradeoffs in resource allocation at state health agencies.

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.