The Structure and Organization of Local and State Public Health Agencies in the U.S.

A Systematic Review


      This systematic review provides a synthesis of the growing field of public health systems research related to the structure and organization of state and local governmental public health agencies. It includes an overview of research examining the influence of organizational characteristics on public health performance and health status and a summary of the strengths and gaps of the literature to date.

      Evidence acquisition

      Data were retrieved through an iterative process, beginning with key word searches in three publication databases (PubMed, JSTOR, Web of Science). Gray literature was searched through the use of Google Scholar™. Targeted searches on websites and key authors were also performed. Documents underwent an initial and secondary screening; they were retained if they contained information about local or state public health structure, organization, governance, and financing.

      Evidence synthesis

      77 articles met the study criteria. Public health services are delivered by a mix of local, state, and tribal governmental and nongovernmental agencies and delivered through centralized (28%); decentralized (37%); or combined authority (35%). The majority of studies focused on organizational characteristics that are associated with public health performance based on the 10 Essential Public Health Services framework. Population size of jurisdiction served (>50,000); structure of authority (decentralized and mixed); per capita spending at the local level; some partnerships (academic, health services); and leadership of agency directors have been found to be related to public health performance. Fewer studies examined the relationship between organizational characteristics and health outcomes. Improvements in health outcomes are associated with an increase in local health department expenditures, FTEs per capita, and location of health department within local networks.


      Public health systems in the U.S. face a number of critical challenges, including limited organizational capacity and financial resources. Evidence on the relationship of public health organization, performance, and health outcomes is limited. Public health systems are difficult to characterize and categorize consistently for cross-jurisdictional studies. Progress has been made toward creating standard terminology. Multi-site studies that include a mix of system types (e.g., centralized, decentralized) and local or state characteristics (e.g., urban, rural) are needed to refine existing categorizations that can be used in examining studies of public health agency performance.
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