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Research Objective: The purpose of this study was to identify potential modifiable factors that can protect local health departments from job losses and budget cuts during periods of economic stress.

Study Design: This was a retrospective cohort study which used data from census surveys of local health departments (LHDs) which were conducted in 2005 and 2010 by the National Association of County and City Health Officials. The 2005 survey data served as the source of independent variables, which were grouped around domains of organization, revenue, and services. The outcome of interest - resiliency of the LHD - represented financial resiliency for maintaining budgets in the face of the recession, and was based on the ratio of observed-to-predicted expenditures per capita for 2010. Control variables included several measures known to influence both LHD performance and health outcomes, including jurisdictional population, poverty, race, education, age distribution, and health insurance status. An ordered logistic regression was used to model the dependent variable with three attributes - resilient, variously resilient, and non-resilient - with independent and control variables as described above.

Population Studied: Data from 987 local health departments comprised the final dataset for analysis.

Principal Findings: LHDs above the 95% confidence interval for the mean observed-to-predicted expenditures per capita ratio for 2010 (n=338) were defined as resilient; those within the 95% confidence interval (n=85) were defined as variously resilient; and LHDs below the 95% confidence interval (n=564) were defined as non-resilient. In the final ordered logistic regression model, there were significant differences across the three categories of resiliency for presence of a board of health and a board of health without hire/fire authority; percentage of revenues from Medicaid, Medicare, and federal pass-through funding; number of services categorized as screening, treatment, and population services; and community characteristics including percentage of African-Americans, percentage of the population greater than 65 years, and the percentage of uninsured persons. Marginal effects estimates from the ordered logit model indicate that an agency's probability of being resilient increased by 9% for agencies governed by a board of health, compared to agencies without a board (p

Conclusion: Local health departments which successfully weathered the economic recession of 2008 were more likely to have had a board of health (but without the authority to hire/fire), have a greater diversity of funding sources (relative to local sources only), and provide a larger number of treatment and population services compared to LHDs which experienced significant losses in funding by 2010.

Implications for Policy, Delivery or Practice: Since advocacy for LHDs (through a board of health), revenue mix, and array of services may all be modifiable and adaptable characteristics, the findings suggest possible means for LHDs to attain resiliency in the face of future economic crises.

Funding Source(s): No Funding


Slides presented here are provided with permission of the author, who retains all copyright. Presentation slides originally obtained from Academy Health.


Presentation at Academy Health Annual Research Meeting in session title: Public Health Systems in Flux: Social, Economic, and Political Influences