Structure and Dynamics of Public Health Delivery Systems

The availability of essential public health services varies widely across states and communities. Despite rising national concerns about public health threats ranging from bioterrorism to obesity, very little evidence currently exists to inform decisions about how best to organize, finance, and deliver these services. To begin building this evidence, we propose to conduct the first national study of tbe structure, composition, and dynamics of public health delivery systems-defined as the array of governmental and nongovernmental organizations that contribute to the delivery of pnblic health services at state and community levcls. The objectives of this study are: (1) to develop An evidence-based typology of public health system composition and structure that allows assessments of how systems vary across communities and change over time; (2) to identify the political, economic, institutional, and soclO~ cultural forces that contribute to this variation and change; and (3) to identify the effects of system characteristics on the availability and effectiveness of essential public health services. We will use survey data collected on a national sample of local health department jurisdictions in 1998 and again in 2006 to analyze system composition and structure both cross-sectionally and longitudinally and to examine relationships between system structure and performance. In-depth interviews with key stakeholders in a selection of state and local public health systems will be llsed to assess the forces that shape system structure and composition and the mechanisms through which system characteristics influence the availability and effectiveness of public health services. Findings from the srudy will provide policymakers with a clearer understanding of the relative strengths and weaknesses of alternative approaches to organizing and delivering public health services, and the political, economic, and institutional contexts in which these approaches appear to function best. The proposed study will be conducted over an 18-month period from July 1, 2005 to December 31, 2006 and will disseminate findings through a series of journal articles, presentations at major health policy conferences, and a monograph.