Public Health Infrastructure and Performance: Analyses of Local Health Department Characteristics and Accreditation Performance Scores

Abstract

Local health departments (LHDs) work at the local level, through provision of essential PH services, to promote and protect their communities' health, and maintain effective response to PH crisis. LHDs’ capacities to provide the essential PH services appears to depend on their organizational structure and infrastructures, which varies widely across jurisdictions. With varied LHDs capacities and emerging PH threats such as COVID-19, there is growing interest among PH leaders to understand how LHDs' characteristics and their investments in the core PH infrastructures relate to LHDs’ performance in their PH functions. Public Health Accreditation Board (PHAB) accreditation standards provide means to assess LHDs' abilities to provide the essential PH services through sets of standards and measures that relate to the ten essential public health services. The goal of this study is to examine how LHDs' organization structure and their investments in the core PH infrastructures, including foundational capabilities (FC), relate to their performance in PH functions as measured by PHAB accreditation scores. Aims: 1) Identified clusters of accredited LHDs based on variations in their performance scores in PHAB accreditation standards. Then, describe how the variation in their performance related to LHDs' characteristics in the identified clusters. 2) Examined the association between LHD total FC expenditures, FC funding allocation pattern, and performance score on related PHAB standards. 3) Explored the relationship between LHDs' local board of health (LBoH) authority on LHDs' budget-related activities and their performance scores in the PHAB standards while considering the governance structure under which the agencies operate. Methods. The conceptual framework was based on the Donabedian structure-process-outcome theory that stipulated that when structure-process is good, outcome may as well be good. Statistical analyses employed cluster analysis, and multilevel regression methods. Results. 1) Three clusters emerged showing a range in PHAB accreditation performance scores and differences in organizational and jurisdiction characteristics across clusters, notably in size of the jurisdiction served 2) There is a positive association between total FC expenditures the aggregate performance score in selected PHAB standards as well as the performance score on most of the individual standards examined 3) LHDs' governing authority on budget-related activities is positively associated LHDs' aggregate average performance score in PHAB accreditation, no apparent association between the type of governance structure under which an LHD operates and performance scores in PHAB accreditation standards. Conclusions. 1) Performance scores in PHAB accreditation can be a useful national standardized metric for assessing LHD ability to promote community well-being. Smaller LHDs serving rural populations may require more targeted supports to boost their performance score. 2) Investment in FC could improve LHD performance score in PHAB accreditation standards. More importantly, how LHDs allocate the investment matters; a more evenly distributed Total FC allocation is associated with higher performance scores. 3) LBoHs with authority related to LHDs budget appear to have an influential role in budget-related activities and may improve LHDs' performance scores in PHAB accreditation standards. Vast variation in more specific LBoH roles and characteristics exists; thus, more research is needed to fully understand how the expanded LBoH authority over LHDs' budget-decision influences or benefits LHDs' performance scores in PHAB accreditation standards. Complex LHDs' characteristics have a relationship with their performance in PHAB accreditation scores. Understanding these relationships can allow evidence-based strategies for which PH leaders and policymakers need for a targeted intervention to support improved LHDs' performance in PHAB accreditation standards.