The results support the argument that LHDs are relatively central. However, they are not usually the most central organization. The differences between noncore and micropolitan communities in organizational centrality hint that community size may influence the role of LHDs. Smaller communities, due to their limited workforce capacity and economic base, tend to have fewer organizations available to address local health needs and may be more reliant on their LHD to take on that role. In larger communities, public health systems may fragment into specialized collaborations, such as a network organization (Powell 1990
) for children's insurance and health. Perhaps as community size increases, LHDs may not have as central a role in public health systems.
The results suggest that context influences the development of public health systems. Public health system density was highest in decentralized micropolitan communities and lowest in the decentralized noncore communities. Perhaps the former is due to LHDs in decentralized micropolitan communities having a large enough operational scale, enough autonomy, and pressures to be entrepreneurial. Both LHDs in the decentralized micropolitan communities had their own budgets, grant writing infrastructure, as well as control over their hiring and internal procedures. If it is the case that a bureaucratic environment in the centralized state reduces public health entrepreneurial activities, it may be useful for centralized states to encourage more entrepreneurial activity by delegating more responsibility, autonomy, and decision authority to LHDs while holding them accountable for achieving public health goals.
A strength of the centralized state appears to be the provision of stable funding for noncore LHDs. In the decentralized state, site visits suggested that funding in noncore community activities was problematic. Providing state core funding for LHDs in noncore communities in decentralized states may result in significant public health dividends by underwriting a capacity for pursuing more entrepreneurial-based public health activities.
While health status had a significant effect, its effect was mixed. Some of the differences may be due to contextual differences between health domains, community size, and governance. It also may be that there are two causal paths. It may be that poor health outcomes are associated with the formation of dense networks to address the problem. Once the problem is addressed and routine procedures are put in place, the level of collaboration decreases. This results in an inverse relationship between network density and health status. Or it may be that strong ongoing collaborations in public health systems are necessary to obtain in better health outcomes. This results in a positive relationship between network density and health status. Overall, the results suggest that while health status is related to network structure, the nature of the relationship is complicated by contextual factors and causal processes. Significantly more research at the level of a public health system for a health domain in communities will be necessary to understand the effects.
The results for organizational centrality also suggest that there may be significant opportunities for tapping as yet unused resources by reaching out to engage additional community groups. Faith-based organizations and senior volunteers are excellent examples of these untapped resources. Site visit interviews uncovered numerous examples of local stakeholders taking on added responsibilities independent of LHD efforts (e.g., the role of the faith-based community in answering the need for lodging and food by refugees of Katrina and other local natural disasters). Other examples included faith community organized youth teams to build ramps for individuals with disabilities and supporting education and testing services to reduce the rate of STDs. Interestingly, the survey data did not show their strong involvement in public health systems. This may be due to these activities being organized by the faith-based community independently of the public health system.
Even though the pursuit of external funding can be a major source of support for health department activities, our findings revealed a significant lack of collaboration in cofunding activities. The cofunding collaboration that was observed tended to revolve around programs such as emergency preparedness where project goals and objectives were prescribed by the funding agency rather than proposed by the participating organizations in response to a broad project agenda. The success of federal and state programs in encouraging collaboration around preparedness may provide a model for encouraging collaboration around funding in other domains, such as adolescent or senior health.
A barrier to cofunding identified in the site interviews was the lack of skilled grant writers and grant managers. While the micropolitan communities had the scale economies to support individuals with these skills, noncore rural communities often did not. In the decentralized state, regional collaborations between noncore and micropolitan counties proved effective (e.g., with the micropolitan counties providing the specialized grant-related skills). However, even in cases of fundraising success, some communities had difficulty implementing their funded projects because of a lack of trained personnel. For example, one community found funding to support a program to provide discounted pharmaceuticals for the elderly but had difficulty keeping the program going because it was difficult to fill even the part-time position required to implement the program. The biggest difficulty filling the position was that the LHD could not take the risk of hiring someone because of the uncertainty of the funding. Luckily, the local hospital was able to make the financial commitment to cover insufficient funds if the program did not work as expected. Interestingly, it was not the money that was needed—it was the carrying of risk if the program did not work as expected.
State public health policy could provide solutions to these cofunding barriers. The example of micropolitan counties providing infrastructure and expertise for grant writing and management could be duplicated in a centralized state through its regional public health offices or micropolitan health departments. Building public health systems at a local level becomes more likely if a state specifies community responsibilities and holds them accountable for taking the lead in those local efforts. While state and regional health departments can provide invaluable support, state and regional health departments leading and organizing activities such as assessments can be counter-productive if it reduces the engagement at the community level. The state and regional support has to be focused carefully so that it does not become a substitute for community involvement.
Study findings have implications for research, such as measuring the impact of LHDs on health status. Using adolescent health as an example, one might be interested in the impact of LHD funding on STDs and teen pregnancies as health status. If county funding for schools, public safety, and public health is positively correlated, then omitting the funding levels of the other key players in the domain could seriously bias regression results and overstate the effect of local health funding. As Handler, Issel, and Turnock (2001)
point out, “the structural capacity
of the public health system is the cumulative resources and relationships necessary to carry out the important processes of public health.” Obtaining unbiased estimates of the effect of public health spending requires measuring the cumulative resources.
The results also suggest that public health system research should take public health domain into account. In the area of adolescent health, a school district may be resistant to health education campaigns focusing on sexuality because of parental attitudes. This can drive a wedge between local and regional health department actions related to sexual practices and youth education rendering even the most appropriate LHD efforts ineffective. Information provided at the site visits and findings about the across domain differences in organizational centrality are consistent with this argument. For adolescent health, activities such as health education and community centers are organized around involving youth. For senior health, activities are organized around service delivery, such as meals on wheels, senior centers, and elder-focused health care services. For preparedness, activities are organized around federal and state funding that mandate organizational interaction and involvement. Given the variability in the relationship between public health system characteristics and health status within the public health domains included in this study, public health system development and improvement will be difficult without the guidance of domain-specific research. Theoretical models of how organizational participation in domains affects population health are needed to further advance the field of public health systems research.
This study has two key limitations affecting the interpretation of its findings. First, the generalizability of our findings is limited because of the small number of communities included in the study. The importance of conducting an intense examination of each community coupled with limited funding and time for conducting the study precluded the inclusion of additional communities. Extending the research by examining a greater number of communities would allow more precise testing of the relation between health system organization and health status.
The second limitation is related to the way in which the site visits were conducted. LHD administrators assisted in the planning and implementation of the site visits, endorsed the e-mail requests for participation in the web-based survey, and helped follow up contacts to encourage completion of the surveys. The intensity of their involvement may have resulted in an increase in the measured centrality for the LHD. The research team attempted to reduce the risk of this bias by collecting names of potential survey respondents from public listings (e.g., attendance rosters from community meetings on public health issues and staff listings available from the websites of local organizations), including a survey item asking about collaboration with other organizations, and identifying potential participants from community and organizational websites.
In conclusion, the results are very consistent with the view that a public health system “includes the full complement of public and private organizations that contribute to the delivery of public health services for a given population, including governmental public health agencies as well as private and voluntary entities” (Mays et al. 2003
, p. 180). Further, the analysis shows that the organization of the public health system varies by the type of public health domain being addressed. If public health system organization is causally related to improved health status, studying individual components such as LHDs will prove insufficient for the effective study of public health systems.