RESEARCH AND PRACTICE
How Connecticut Health Directors Deal With Public Health Budget Cuts at the Local Level Margaret L. Prust, MPH, Kathleen Clark, MPH, Brigette Davis, MPH, Sarah W. Pallas, PhD, Jennifer Kertanis, MPH, Elaine O’Keefe, MPH, Michael Araas, MPH, Neel S. Iyer, MPH, Stewart Dandorf, MPH, Stephanie Platis, MPH, and Debbie Humphries, PhD, MPH
Local public health services in the United States rely on local and state revenues for much of their financial support.1---3 During the US economic recessions in 1991 and from 2008 to 2010, budgets, staffing, and services of a quarter to a half of local health jurisdictions (LHJs) were reduced.4---6 Over the past decade, economic conditions in Connecticut have fluctuated substantially. Although Connecticut’s unemployment rate was lower than the national average for most of 2001 to 2010, it followed the overall US trend.7 The downturn in the housing market between 2008 and 2010 put additional pressure on LHJs in Connecticut because local governments saw their tax base erode as a result of falling real estate prices. In Connecticut, local municipalities are responsible for ensuring that the statutory minimum public health services are available to their population. These minimum services were approved in 1983 and focus on 8 categories: public health statistics, health education, nutrition services, maternal and child health, communicable and chronic disease control, environmental services, community nursing services, and emergency medical services.8 (In 2014, legislation was passed to change the statutory requirement to adopt the 10 essential public health services,9 as outlined by the Centers for Disease Control and Prevention.) In Connecticut’s highly decentralized public health system, each municipality can provide those services by creating its own municipal health department or by joining with other municipalities to form a district LHJ. District LHJs are created voluntarily and can be joined and left at will by member towns. Beyond the statutory minimum, individual LHJs determine what programs and services to provide and how they are funded, including setting fee schedules. As cuts in government funds for LHJs have taken place in Connecticut10 and elsewhere,11 a better understanding of key influences on
Objectives. We investigated the perspectives of local health jurisdiction (LHJ) directors on coping mechanisms used to respond to budget reductions and constraints on their decision-making. Methods. We conducted in-depth interviews with 17 LHJ directors. Interviews were audio recorded, transcribed, and analyzed using the constant comparative method. Results. LHJ directors use a range of coping mechanisms, including identifying alternative revenue sources, adjusting services, amending staffing arrangements, appealing to local political leaders, and forming strategic partnerships. LHJs also face constraints on their decision-making because of state and local statutory requirements, political priorities, pressures from other LHJs, and LHJ structure. Conclusions. LHJs respond creatively to budget cuts to maintain important public health services. Some LHJ adjustments to administrative resources may obscure the long-term costs of public health budget cuts in such areas as staff morale and turnover. Not all coping strategies are available to each LHJ because of the contextual constraints of its locality, pointing to important policy questions on identifying optimum jurisdiction size and improving efficiency. (Am J Public Health. 2015;105:S268–S273. doi:10.2105/AJPH.2014. 302499)
resource allocation decisions by health directors could strengthen the ability of public health systems to withstand economic downturns. To build on the previous work of the Connecticut Practice-Based Research Network, we interviewed LHJ directors about their perspectives on (1) coping mechanisms used to respond to reductions in revenue and (2) the constraints and contextual factors that influence directors’ decisions regarding service provision.
METHODS We conducted in-depth interviews with LHJ directors to investigate perceptions of key influences on revenue streams, services offered, and mechanisms used to cope with revenue decreases. We selected qualitative research methods because local economic conditions, revenue streams, and service provision are complex and often context specific, requiring an open-ended method of data gathering that
S268 | Research and Practice | Peer Reviewed | Prust et al.
allows previously unanticipated variables to emerge.12 This research was 1 component of a mixed-methods study investigating whether changes in economic conditions during the 2008 to 2010 recession were associated with changes in Connecticut LHJ fee revenue or service provision.
Sample Selection and Interview Procedures LHJ directors have firsthand knowledge of the revenue streams for their jurisdictions and are best able to provide information on decisions about prioritizing services and coping mechanisms available to respond to changes in revenue. Connecticut has 3 types of LHJs: (1) a health district that provides services to a conglomeration of towns, (2) a municipal health department that serves a single town with a full-time LHJ director, and (3) a municipal health department that serves a single town with a part-time LHJ director. These 3 types of LHJs are referred to in Connecticut as
American Journal of Public Health | Supplement 2, 2015, Vol 105, No. S2
RESEARCH AND PRACTICE
full-time and part-time, respectively. Because quantitative analysis conducted previously has shown that revenues and services vary by rural or urban location of the LHJ and by LHJ type (i.e., district, full-time, or part-time), we used purposive sampling across 5 strata of LHJs: rural---district, rural---part-time, urban--district, urban---part-time, and urban---full-time (there were no rural---full-time LHJs). Rural LHJs are those in which a majority of the population lives in a town or census area designated as rural; multitown district LHJs may include rural towns but be designated as urban if the majority of the district’s population resides in urban areas.13 Respondents were selected from the 5 strata until theoretical saturation was achieved, which occurred when no new themes emerged from successive interviews.12,14,15 One or more members of the research team conducted in-person or telephone interviews from September to November 2011 using an open-ended interview guide. Participants were asked questions related to the local economic climate, service provision, revenue streams, and reporting mechanisms. Participants were not compensated for the interviews.
Data Analysis A 5-person research team coded transcripts using the constant comparative method to develop a constructivist grounded theory of the coping mechanisms LHJ directors use to respond to budget cuts.16 The full group coded each transcript in a phased approach, using regular in-person meetings to discuss essential concepts and organize them into codes. As new transcripts were reviewed, sections were constantly compared with previously coded sections to determine whether the same codes were relevant. If emerging concepts could not be classified using existing codes, we expanded or refined the definitions of codes and established new codes until we developed a final, comprehensive coding structure.14 In the final stage of analysis, 2 or more team members independently recoded each of the transcripts using the final coding structure and compared codes to ensure consistency. Eight domains of codes and, for each domain, as many as 4 levels of subcategories were identified. The final coding structure is provided in Appendix A (available as a supplement to the online version
TABLE 1—Sample Characteristics of Local Health Jurisdiction Directors: Connecticut, September–November 2011 Characteristic
Total
Urban District
Rural District
Urban Full-time
Urban Part-time
Rural Part-time
Total in CT
77
18
2
32
12
13
Interviewed
17
6
1
6
2
2
% covered
22.1
33.3
50.0
18.8
16.7
15.4
13.6 (11.5)
14.2 (10.9)
38 (0)
7.4 (7.3)
25 (2.8)
6.7 (7.5)
0.7–38.0
4.5–35
38.0
0.7–19
23.0–27
1.3–12
Director years in service Mean (SD) Range
Note. A district is a type of LHJ that provides services to a conglomeration of towns. Full-time is defined as a municipal health department that serves a single town with a full-time LHJ director. Part-time is defined as a municipal health department that serves a single town with a part-time LHJ director.
of this article at http://www.ajph.org). We used qualitative analysis software (ATLAS.ti 6.2, Scientific Software Development GmbH, Berlin, Germany) to facilitate data organization and retrieval.17,18
Quantitative Data Sources The Connecticut Department of Public Health provided data from the LHJ annual reports. All LHJ revenues were deflated to a common year (2009) using the Bureau of Economic Analysis’s implicit price deflator for state and local government consumption expenditures and gross investments.19
RESULTS Of the 77 LHJs in existence in 2010, 30 were invited to participate and 17 directors, representing 20 LHJs, were interviewed, for a response rate of 67%. The sample represented 26% of Connecticut’s LHJs and included between 15% and 50% of the LHJs in each strata (Table 1). The average length of time that respondents had served as LHJ director was 13.6 years (SD = 11.5 years), and time in service ranged from 8 months to 38 years (Table 1). Patterns of per capita revenue, grants, and fees showed wide variation among different types of LHJs (Table 2). Although each LHJ type reported decreased per capita funds during the recession, districts and full-time LHJs showed increased state funds during the recession. In addition, the per capita total revenue for part-time LHJs was about one
Supplement 2, 2015, Vol 105, No. S2 | American Journal of Public Health
tenth that of full-time LHJs prerecession, and part-time LHJs saw a more than 50% decrease in total revenues per capita during the recession. Directors confirmed that economic recessions can lead to reductions in LHJ revenue in direct and indirect ways. Governments may react to budget limitations by directly reducing allocations for LHJs. Also, LHJ budgets may be indirectly reduced if the demand for fee-related services decreases or as a result of changes in the tax base. As one urban health district director put it: The housing market bust had a particularly significant impact on our agency. Less houses were being built so we’re pulling in less revenue from permits and service fees such as well permits and septic permits, soil testing. . . . We’ve had a reduction in the number of food service establishments that we’re permitting. Some of the mom and pops are going out of business.
Coping Strategies LHJ directors described a variety of strategies for coping with these budget reductions, which we grouped into 5 thematic categories: revenuegenerating activities, services, staffing, politics, and partnerships. Some directors sought to increase LHJ revenue through revenue-generating activities, such as raising fee levels, increasing grant applications, and identifying new revenuegenerating activities beyond public health service delivery (e.g., renting the LHJ building for other uses). Per a rural health district director, “We can’t control the per capita . . . and we can charge fees for service. So we started charging fees for service.” Other directors accommodated changes in revenue by making adjustments to the services
Prust et al. | Peer Reviewed | Research and Practice | S269
RESEARCH AND PRACTICE
TABLE 2—Revenue Sources and Characteristics of Participant Local Health Jurisdictions: Connecticut, 2005–2010 Mean Total Revenue per Capita, $
Mean Local Funds per Capita, $
Mean State Funds per Capita, $
Mean Federal Grants per Capita, $
Mean Total Fees per Capita, $
Mean License Fees, %
Mean Program Fees, %
Mean Nonfee Revenue, %
15.23 13.68
5.23 5.53
3.74 4.33
2.66 0.41
3.14 2.50
12.7 13.5
7.9 4.1
78.3 80.6
Prerecession
65.64
32.43
11.03
17.32
4.17
12.5
1.8
92.7
Recession
47.04
25.12
12.82
5.56
4.14
4.5
1.3
83.9
Prerecession
6.50
5.34
0.21
0.02
0.76
16.1
3.9
80.0
Recession
2.47
1.68
0.11
0.00
0.57
49.2
0.0
50.8
LHJs Districta Prerecession Recession Full-timeb
Part-timec
Note. LHJ =local health jurisdiction. Prerecession period, 2005–2007; recession period, 2008–2010. In 2005, there were 91 total LHJs in Connecticut; by 2010, because of mergers among LHJs, there were 77 total LHJs. All LHJ revenues were deflated to a common year (2009) using the US Bureau of Economic Analysis implicit price deflator for state and local government consumption expenditures and gross investments.18 a Type of LHJ that provides services to a conglomeration of towns. b Municipal health department that serves a single town with a full-time LHJ director. c Municipal health department that serves a single town with a part-time LHJ director.
provided, which included adjusting the type or level of services provided, providing only localand state-mandated services, and using strategic planning to prioritize needs. “When financial resources are cut, we have—in the past—cut services to accommodate that,” stated an urban health district director. Administrative or staffing adjustments were also used as a coping strategy. Directors sought to reduce staff costs by eliminating personnel, adjusting hours worked, and changing staff responsibilities and salaries. Nearly all of the respondents indicated that financial constraints had forced them to make staffing adjustments at some point: “Over last year we had a serious deficit, which led to a number of layoffs and reductions in programs” (urban full-time health department director). Some respondents also mentioned that such adjustments had severely affected operations and staff morale, although these adjustments may not be reflected in traditional reporting indicators. Per a rural health district director: If money starts to fall short—which it did about 5 years ago—I came up with a list of things. . . . We may have to not have the building cleaned professionally, we will have to do it as employees. . . . The [lead sanitarian] and myself worked one day per week for free for 3 months. All the other employees worked a half day on Friday[s], so their hours were cut and their wages got cut, but they didn’t work. [The lead sanitarian] and I actually worked. We were taking a 20% pay cut.
Using political influence and relationships with municipal authorities to obtain local funds was another way of coping with budget cuts. Maintaining close relationships with political officials and presenting data about the LHJ’s work to political officials were specific approaches mentioned: The selectmen—our relationship is close. They walk right by my door to go to the men’s room or ladies’ room, and they swerve in here every now and then to talk with me, or if they receive phone calls about anything related to public health, I’m right here, in the same building. (urban part-time health department director)
Finally, LHJ directors expressed the importance of partnership building as another mechanism for adjusting to decreased revenue. Partnership strategies included developing collaborative initiatives with other organizations, such as primary and secondary schools, universities, other service providers, field experts, and surrounding towns. Partnerships were seen as a way to enhance the public health services offered with a lower expenditure. They were used to collect data, reduce duplication of efforts, pool resources, and apply for funding: [This town] is partnered with two local towns on what we call our pandemic flu committee, but it’s basically [a] public health emergency response committee, and we receive some indirect funding which I believe comes down through [the
S270 | Research and Practice | Peer Reviewed | Prust et al.
Centers for Disease Control and Prevention] through the state health departments. (urban part-time health department director)
Constraints and Context of Decisions About Services Although, collectively, directors used a wide range of coping strategies to accommodate or counteract reductions in funding, the decisions of any single director about revenue and services were also constrained by contextual and structural factors. The full range of coping strategies may not have been available to each of the directors because of the unique context of his or her LHJ. When considering the key constraints or contextual factors influencing LHJ decisions, themes fell into 4 primary areas: (1) state and local statutory requirements, (2) political climate and priorities, (3) pressures from neighboring districts, and (4) LHJ structure or type. State and local statutory requirements have a significant influence on the services provided by health departments and districts. In addition to the state-mandated public health services, local laws create additional demands, and several directors highlighted that outsiders often fail to recognize the role of these local requirements. Locally enacted laws and requirements may limit directors’ ability to make decisions to adjust an LHJ’s services:
American Journal of Public Health | Supplement 2, 2015, Vol 105, No. S2
RESEARCH AND PRACTICE
The number one reason for offering services is because they are required. . . . A code says you must do it, or a local ordinance says you must do it. That’s the thing the state forgets about. Our towns have local ordinances that we have to deal with. (urban health district director)
However, these influences are not apparent in many statewide comparisons because the complexities of local politics are not easily captured. In addition to local statutes and formal requirements, many directors discussed the more informal ways that local political priorities and climate can affect health departments and districts. In particular, some directors expressed frustration over the impact of changes in political leadership in their areas. In cases in which the priorities of the health departments and districts depend heavily on the guidance of elected representatives, transitions in leadership were identified as a cause for disruption within an LHJ: The mayor . . . one of his important topics is litter and blight, so we have two sanitarians that he gave us and a full-time clerk that he gave us to do nothing but litter and blight. . . . Ask me in a year if we have a new mayor. You know, maybe litter and blight won’t be a priority. (urban full-time health department director) From a local health department perspective, the most important change comes when a mayor or first selectman says, “I know it’s a fine health department but actually we don’t need all the services you’re doing. We just need basic environmental services. All the rest of the things that you do, they’re wonderful but that’s for another time when we can afford them. So all these things about communicable diseases and obesity and nutrition and physical activity and blah blah, they’re luxuries right now.” . . . That’s the nexus of the economic and the political scene, which has brought about the most fundamental “changes” in this health district. (urban health district director)
LHJ directors also reported pressure from other LHJs to maintain low per capita fees for member municipalities and license and inspection fees for businesses. Singlemunicipality full-time or part-time LHJs in Connecticut can choose to merge into a multitown district LHJ; district LHJs then charge member towns on a per capita basis for the public health services provided. When a municipality borders or is near multiple district LHJs, there is pressure among the district LHJs to keep their per capita charges relatively low so as to not lose their member municipalities to
another district. As an urban health district director stated, The biggest influencing factor [on revenue] are our neighbors because if we go up [raise per capita charge] to meet our needs and they’re not happy, they’ll look to neighboring health districts, and if it looks better on the other side because it’s less expensive—doesn’t mean the services are better, or comparable probably—then it becomes a threat and we haven’t had a lot of that but that’s because everybody tries to stay in their own lane. But for example, [a neighboring district] staying so low and being on my border, it keeps my per capita low because he just gets bigger and bigger.
When an LHJ examines and sets its licensing and fee structure for local businesses, there is also pressure to consider what neighboring LHJs are charging, so as to be comparable, and not lose potential commercial activity to neighboring towns: We usually change our fees, increase our fees, every few years. The last time I changed our fees was 2009. . . . Our fees are usually adjusted in accordance with reviewing neighboring town fees and also those fees are associated with the time and effort necessary to provide that service. (urban part-time health department director)
Finally, the LHJ structure, or the type of health jurisdiction, is reported to influence funding opportunities and the political relationships of the health director. As previously noted, Connecticut has full-time and part-time LHJs that provide services to single municipalities, as well as district LHJs that are composed of multiple municipalities that jointly employ a full-time director. Traditional singlemunicipality LHJ directors and district LHJ directors reported different access to funding opportunities and different political challenges. District directors indicated that challenges related to the timing and availability of funds could be mitigated by their ability to use financial reserves or shift funding among programs to fill short-term gaps. This was a key difference between the options described by the directors of full-time and part-time LHJs compared with district LHJs. As an urban health district director mentioned, “Fortunately for us as a district we have the ability to upfront money. Municipalities don’t have the ability to do that and that’s a big problem for them.” Single-municipality health departments’ lack of buffer funds and autonomy also limit their flexibility in applying for grant funding, and
Supplement 2, 2015, Vol 105, No. S2 | American Journal of Public Health
they often face challenges in getting approval to apply for grants in the first place: [Applying for grants] tends to be a district vs. municipality issue. A lot of municipalities, it’s difficult to get the funds up front. . . . Often they have to go through the town council or city council to get approval to even apply for a grant, where at a district level you can usually get the authority to apply for a grant without getting board approval. . . . There’s definitely a difference between how municipalities and districts apply for grants. (urban health district director)
At the same time, the LHJ structure may also be related to variation in political opportunities, which in turn influences service decisions. In particular, directors of district LHJs faced unique challenges in building political relationships because of the multiple political authorities present: Each of those towns [that make up the district] are a little different. They all have a different view of what the role of government is. . . . The more towns that you have, the more difficult it is to come up with some kind of commonly agreed upon unmet need that government should be involved in. (urban health district director)
DISCUSSION Several recent studies have looked at influences on resource allocation decisions of different segments of the public health system. Baum et al. conducted a Web-based survey of a stratified random sample of local health departments across the United States and identified effectiveness of the activity, previous allocations, being the sole provider of a service, reluctance to lay off staff, and input from the board of health as the most influential factors associated with resource allocations.20 Jarris et al. surveyed state health department leadership in all 50 states and identified seriousness of the consequences, within-core public health services, available funds, federal or state mandates, and magnitude of the problem as the most influential factors.21 In Washington State, Bekemeier et al. conducted in-depth interviews with leaders of 11 LHJs and identified legal mandates and categorical funding limitations as key constraints on health directors’ decisions. 22 Chen et al. conducted case studies of 2 regional health departments in Nebraska and found that directors attempted to balance the needs of different populations and communities in making resource allocation decisions.23 Our study built
Prust et al. | Peer Reviewed | Research and Practice | S271
RESEARCH AND PRACTICE
on this research by examining the coping strategies available to LHJs and the constraints facing some LHJs in their resource allocation decisions when faced with revenue adjustments. In this study, we used qualitative data to describe LHJ directors’ perspectives on key coping mechanisms used to respond to revenue reductions, as well as contextual influences on LHJs’ decision-making processes. Directors identified alternative revenues, service changes, staffing changes, support from local political leaders, and partnerships as key approaches to maintaining their public health system in the face of budget cuts. This study supports findings from previous studies, such as the 2012 National Association of County and City Health Officials survey of LHJ directors,6 which found that more than 50% of LHJs reported increasing revenues through alternative sources and partnerships with other LHJs and non-LHJs to mitigate the effects of funding cuts. Interestingly, its survey also showed that 61% of respondents reported using technology to mitigate effects, and 37% reported hiring subcontractors.6 This study also revealed other factors that can affect decision-making in the face of budget reductions, such as the pressures that LHJs experience to keep fees on par with those of neighboring jurisdictions. Although this dynamic may be attributed to the particular structure of Connecticut’s local public health system and the sometimes-competitive nature of operating in this environment, it may be operative in other states in which county structures are absent and may produce behavior contrary with the fundamentally collaborative ethos of public health practice. In Connecticut’s currently decentralized system, state health authorities have little role in regulating competition or supporting partnerships among LHJs. However, recent state legislation in Connecticut adopting the Centers for Disease Control and Prevention’s 10 essential public health services as the new public health system framework9 may further standardize service delivery requirements across LHJs. This could potentially reduce the competition associated with differing LHJ costs resulting from differing service packages and present opportunities to improve the structure, cost-effectiveness,
sustainability, and impact of local public health services across the state. Although LHJs respond creatively in the face of budget cuts to maintain important public health services, some of these coping mechanisms could have long-term consequences. Attempts to maintain staffing by reducing hours, decreasing salaries, shifting responsibilities, and shrinking other capital expenditures, such as office space, could have long-term impacts on staff morale, retention, and quality of services. Tracking and monitoring the future impacts of such changes is important for understanding longer-term effects. However, changes to the internal management of staff time and administrative resources may not be captured in annual reporting to the Connecticut Department of Public Health. This was identified as a challenge in a previous quantitative study, in which annual LHJ data from Connecticut were used to investigate relationships between local economic indicators and LHJ revenues and services.24 On the basis of data limitations, some long-term consequences of public health budget cuts may be obscured. Routine data monitoring for LHJs should consider potentially available coping mechanisms. LHJ directors reported constraints on coping mechanisms, such as local statutory requirements, political priorities, pressures from other LHJs, and LHJ structure or type. The constraints of legal mandates on services have also been noted by researchers working with LHJs in Washington State22 and state health department leadership across the United States.21 This study revealed that, compared with municipal health departments, directors of district LHJs were better equipped to mitigate the impact of the timing and availability of funds on services through the use of financial reserves, relying on multiple funding streams, and shifting funding among programs to fill short-term gaps. A survey of Minnesota local health directors also identified variation in decisionmaking authority across health directors.25 The importance of political influences and the difficulty of building strategic political relationships in combined jurisdictions are also important factors to consider in identifying optimum jurisdiction size for efficient delivery of public health services. The consolidation of health departments into multiple-municipality districts has been viewed as a path to improving
S272 | Research and Practice | Peer Reviewed | Prust et al.
efficiency23 but, as in this study, previous analyses have also identified political heterogeneities in Connecticut LHJs that affect consolidation.26 Recent work in Nebraska has also highlighted limitations of district consolidation in cases in which funding issues continue to generate conflict and tension.23 Negotiating political relationships was particularly challenging for directors of multiple-municipality health districts because they have to negotiate with multiple political bodies. A study investigating perspectives on the collaboration of local public health officials and county commissioners found that public health officials identified a number of political barriers to collaboration, including commitment to home rule, loss of local input into public health services and priorities, perceived threats to local elected officials, and lack of collaborative government and staffing models.27 In light of these findings, the strengths and challenges of combined jurisdictions are important to consider in identifying optimum jurisdiction size for efficient delivery of public health services. The question of imposed competition and structural barriers to enhanced collaboration among LHJs merits consideration in future research on the organization of local public health system. Future research should also consider the effects on public health service delivery and impact at the local level of a state-mandated regional public health structure versus the more diverse municipal public health structures that have evolved in parts of the United States. Although this study offers valuable insight into the influences on decision-making processes within LHJs, these results should be considered in light of several limitations. The sampling strategy for this study was intentionally focused on saturation and is not necessarily representative of the views of all Connecticut LHJ directors. As such, the results are best used to inform the development of hypotheses and questions for future research. Of the LHJ directors invited to interview, 67% agreed and were interviewed. Directors who did not participate might have held views that were different from those of our participants. Directors identified a variety of coping mechanisms, although the effects of different coping mechanisms on the quality and effectiveness of service provision is an area for further research.
American Journal of Public Health | Supplement 2, 2015, Vol 105, No. S2
RESEARCH AND PRACTICE
The results of this study may be most relevant in states that are similar to Connecticut in geopolitical and socioeconomic characteristics. j
About the Authors At the time of the study, Margaret L. Prust and Brigette Davis were with the Division of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. Kathleen Clark, Sarah W. Pallas, and Stephanie Platis were with the Division of Health Policy and Administration, Yale School of Public Health, New Haven. Jennifer Kertanis is with the Connecticut Association of Directors of Health, Hartford. Elaine O’Keefe is with the Office of Community Health and Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven. Michael Araas, Neel S. Iyer, and Stewart Dandorf were with the Division of Chronic Disease Epidemiology, Yale School of Public Health, New Haven. Debbie Humphries is with the Division of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven. Correspondence should be sent to Debbie Humphries, P.O. Box 208034, New Haven, CT 06520-8034 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted November 25, 2014.
Contributors S. W. Pallas, J. Kertanis, E. O’Keefe, and D. Humphries conceptualized and designed the study. K. Clark and D. Humphries conducted the interviews. M. L. Prust and D. Humphries wrote the first draft of the article. M. L. Prust, K. Clark, B. Davis, M. Araas, N. S. Iyer, S. Dandorf, S. Platis, and D. Humphries performed the analysis and interpretation of data. All authors contributed to critical revisions to the article and approved the final version of the article.
Acknowledgments This study was funded by the Robert Wood Johnson Foundation through the Connecticut Practice-Based Research Network (project no. 67023). We thank the many directors of health and other local health department staff who participated in this study for their time and insights. Note. The funding organization had no role in the research design, data collection and analysis, or writing of the article.
Human Participant Protection The study protocol was reviewed by the Yale University human investigation committee (protocol no. 1104008345) and granted an exemption under 45 CFR 46.101(b)(2).
References 1. Bernet PM. Local public health agency funding: money begets money. J Public Health Manag Pract. 2007;13(2):188---193. 2. Livingood WC, Morris M, Sorensen B, et al. Revenue sources for essential services in Florida: findings and implications for organizing and funding public health. J Public Health Manag Pract. 2013;19(4): 371---378. 3. National Association of County and City Health Officials. Local Public Health Agency Infrastructure: A Chartbook. Washington, DC: National Association of County and City Health Officials; 2001.
4. Wasserman MP, Rawding N, Aberle-Grasse JM. A survey of local health officials’ views on current resources for public health services. J Public Health Policy. 1992;13 (3):261---266. 5. Willard R, Shah GH, Leep C, Ku L. Impact of the 2008-2010 economic recession on local health departments. J Public Health Manag Pract. 2012;18(2):106--114. 6. National Association of County and City Health Officials. Local Health Department Job Losses and Program Cuts: Findings From the January 2012 Survey. Washington, DC: National Association of County and City Health Officials; 2012. 7. Connecticut Department of Labor. Historical Labor Force Monthly Data w/Annual Averages by Town (LAUS)— State of Connecticut. Wethersfield: Connecticut Department of Labor. 8. Connecticut Department of Public Health. Connecticut Public Health Code 19a-76-2: Basic Local Health Program. Hartford, CT: Connecticut Department of Public Health; 1983. 9. An act concerning essential public health services and the euthanization of animals in a facility subject to regulation by the United States Department of Agriculture, Substitute House Bill No. 5528, Connecticut Public Act No. 14-226. 10. Gregorio D. Preliminary Report: Local Reponses to State Public Health Funding Reductions. Hartford, CT: Connecticut Association of Directors of Health; 2011.
21. Jarris PELJ, Resnick B, Sellers K, Young JL. Budgetary decision making during times of scarcity. J Public Health Manag Pract. 2012;18(4):390---392. 22. Bekemeier B, Chen AL, Kawakyu N, Yang Y. Local public health resource allocation: limited choices and strategic decisions. Am J Prev Med. 2013;45(6):769--775. 23. Chen LW, Jacobson J, Roberts S, Palm D. Resource allocation and funding challenges for regional local health departments in Nebraska. J Public Health Manag Pract. 2012;18(2):141---147. 24. Humphries D, Kertanis J, O’Keefe E, et al. Revenue streams and service delivery in Connecticut local health jurisdictions (2001-2010): Connecticut Practice Based Research Network; 2012. Available at: http://www.cadh. org/program-areas/practice-based-research-network. html. Accessed February 24, 2013. 25. Gearin KJM, Thrash AMR, Frauendienst R, et al. Measuring the authority of local public health directors in the context of organizational structure: an exploratory, multimodal approach. J Public Health Manag Pract. 2012;18(6):545---550. 26. Bates LJ, Lafrancois BA, Santerre RE. An empirical study of the consolidation of local public health services in Connecticut. Public Choice. 2011;147(1-2):107---121. 27. Felton J, Golbeck AL. Interjurisdictional collaboration: local public health officials versus county commissioners. J Public Health Manag Pract. 2011;17(1):E14--E21.
11. National Association of County and City Health Officials. Survey Findings: Local Health Department Job Losses and Program Cuts: Findings From the January 2012 Survey. Washington, DC: National Association of County and City Health Officials 2012. 12. Creswell J. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Thousand Oaks, CA: Sage; 2007. 13. Connecticut State Office for Rural Health. Connecticut Rural Towns. Winsted, CT: Connecticut State Office for Rural Health; 2011. 14. Glaser B, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research. Piscataway, NJ: Transaction; 1967. 15. Morse J. The significance of saturation. Qual Health Res. 1995;5(2):147---149. 16. Charmaz K, ed. Shifting the Grounds: Constructivist Grounded Theory Methods. Walnut Creek, CA: Left Coast Press; 2009. 17. Richards L. Rigorous, rapid, reliable and qualitative? Computing in qualitative method. Am J Health Behav. 2002;26(6):425---430. 18. Weitzman EA. Analyzing qualitative data with computer software. Health Serv Res. 1999;34(5 pt 2):1241---1263. 19. Bureau of Economic Analysis. Table 1.1.9: implicit price deflators for gross domestic product. In: National Income and Product Accounts Tables. Washington, DC: Bureau of Economic Analysis, US Department of Commerce. 20. Baum NM, DesRoches C, Campbell EG, Goold SD. Resource allocation in public health practice: a national survey of local public health officials. J Public Health Manag Pract. 2011;17(3):265--274.
Supplement 2, 2015, Vol 105, No. S2 | American Journal of Public Health
Prust et al. | Peer Reviewed | Research and Practice | S273
How Connecticut Health Directors Deal With Public Health Budget Cuts at the Local Level Margaret L. Prust, MPH, Kathleen Clark, MPH, Brigette Davis, MPH, Sarah W. Pallas, PhD, Jennifer Kertanis, MPH, Elaine O’Keefe, MPH, Michael Araas, MPH, Neel S. Iyer, MPH, Stewart Dandorf, MPH, Stephanie Platis, MPH, and Debbie Humphries, PhD, MPH
Local public health services in the United States rely on local and state revenues for much of their financial support.1---3 During the US economic recessions in 1991 and from 2008 to 2010, budgets, staffing, and services of a quarter to a half of local health jurisdictions (LHJs) were reduced.4---6 Over the past decade, economic conditions in Connecticut have fluctuated substantially. Although Connecticut’s unemployment rate was lower than the national average for most of 2001 to 2010, it followed the overall US trend.7 The downturn in the housing market between 2008 and 2010 put additional pressure on LHJs in Connecticut because local governments saw their tax base erode as a result of falling real estate prices. In Connecticut, local municipalities are responsible for ensuring that the statutory minimum public health services are available to their population. These minimum services were approved in 1983 and focus on 8 categories: public health statistics, health education, nutrition services, maternal and child health, communicable and chronic disease control, environmental services, community nursing services, and emergency medical services.8 (In 2014, legislation was passed to change the statutory requirement to adopt the 10 essential public health services,9 as outlined by the Centers for Disease Control and Prevention.) In Connecticut’s highly decentralized public health system, each municipality can provide those services by creating its own municipal health department or by joining with other municipalities to form a district LHJ. District LHJs are created voluntarily and can be joined and left at will by member towns. Beyond the statutory minimum, individual LHJs determine what programs and services to provide and how they are funded, including setting fee schedules. As cuts in government funds for LHJs have taken place in Connecticut10 and elsewhere,11 a better understanding of key influences on
Objectives. We investigated the perspectives of local health jurisdiction (LHJ) directors on coping mechanisms used to respond to budget reductions and constraints on their decision-making. Methods. We conducted in-depth interviews with 17 LHJ directors. Interviews were audio recorded, transcribed, and analyzed using the constant comparative method. Results. LHJ directors use a range of coping mechanisms, including identifying alternative revenue sources, adjusting services, amending staffing arrangements, appealing to local political leaders, and forming strategic partnerships. LHJs also face constraints on their decision-making because of state and local statutory requirements, political priorities, pressures from other LHJs, and LHJ structure. Conclusions. LHJs respond creatively to budget cuts to maintain important public health services. Some LHJ adjustments to administrative resources may obscure the long-term costs of public health budget cuts in such areas as staff morale and turnover. Not all coping strategies are available to each LHJ because of the contextual constraints of its locality, pointing to important policy questions on identifying optimum jurisdiction size and improving efficiency. (Am J Public Health. 2015;105:S268–S273. doi:10.2105/AJPH.2014. 302499)
resource allocation decisions by health directors could strengthen the ability of public health systems to withstand economic downturns. To build on the previous work of the Connecticut Practice-Based Research Network, we interviewed LHJ directors about their perspectives on (1) coping mechanisms used to respond to reductions in revenue and (2) the constraints and contextual factors that influence directors’ decisions regarding service provision.
METHODS We conducted in-depth interviews with LHJ directors to investigate perceptions of key influences on revenue streams, services offered, and mechanisms used to cope with revenue decreases. We selected qualitative research methods because local economic conditions, revenue streams, and service provision are complex and often context specific, requiring an open-ended method of data gathering that
S268 | Research and Practice | Peer Reviewed | Prust et al.
allows previously unanticipated variables to emerge.12 This research was 1 component of a mixed-methods study investigating whether changes in economic conditions during the 2008 to 2010 recession were associated with changes in Connecticut LHJ fee revenue or service provision.
Sample Selection and Interview Procedures LHJ directors have firsthand knowledge of the revenue streams for their jurisdictions and are best able to provide information on decisions about prioritizing services and coping mechanisms available to respond to changes in revenue. Connecticut has 3 types of LHJs: (1) a health district that provides services to a conglomeration of towns, (2) a municipal health department that serves a single town with a full-time LHJ director, and (3) a municipal health department that serves a single town with a part-time LHJ director. These 3 types of LHJs are referred to in Connecticut as
American Journal of Public Health | Supplement 2, 2015, Vol 105, No. S2
RESEARCH AND PRACTICE
full-time and part-time, respectively. Because quantitative analysis conducted previously has shown that revenues and services vary by rural or urban location of the LHJ and by LHJ type (i.e., district, full-time, or part-time), we used purposive sampling across 5 strata of LHJs: rural---district, rural---part-time, urban--district, urban---part-time, and urban---full-time (there were no rural---full-time LHJs). Rural LHJs are those in which a majority of the population lives in a town or census area designated as rural; multitown district LHJs may include rural towns but be designated as urban if the majority of the district’s population resides in urban areas.13 Respondents were selected from the 5 strata until theoretical saturation was achieved, which occurred when no new themes emerged from successive interviews.12,14,15 One or more members of the research team conducted in-person or telephone interviews from September to November 2011 using an open-ended interview guide. Participants were asked questions related to the local economic climate, service provision, revenue streams, and reporting mechanisms. Participants were not compensated for the interviews.
Data Analysis A 5-person research team coded transcripts using the constant comparative method to develop a constructivist grounded theory of the coping mechanisms LHJ directors use to respond to budget cuts.16 The full group coded each transcript in a phased approach, using regular in-person meetings to discuss essential concepts and organize them into codes. As new transcripts were reviewed, sections were constantly compared with previously coded sections to determine whether the same codes were relevant. If emerging concepts could not be classified using existing codes, we expanded or refined the definitions of codes and established new codes until we developed a final, comprehensive coding structure.14 In the final stage of analysis, 2 or more team members independently recoded each of the transcripts using the final coding structure and compared codes to ensure consistency. Eight domains of codes and, for each domain, as many as 4 levels of subcategories were identified. The final coding structure is provided in Appendix A (available as a supplement to the online version
TABLE 1—Sample Characteristics of Local Health Jurisdiction Directors: Connecticut, September–November 2011 Characteristic
Total
Urban District
Rural District
Urban Full-time
Urban Part-time
Rural Part-time
Total in CT
77
18
2
32
12
13
Interviewed
17
6
1
6
2
2
% covered
22.1
33.3
50.0
18.8
16.7
15.4
13.6 (11.5)
14.2 (10.9)
38 (0)
7.4 (7.3)
25 (2.8)
6.7 (7.5)
0.7–38.0
4.5–35
38.0
0.7–19
23.0–27
1.3–12
Director years in service Mean (SD) Range
Note. A district is a type of LHJ that provides services to a conglomeration of towns. Full-time is defined as a municipal health department that serves a single town with a full-time LHJ director. Part-time is defined as a municipal health department that serves a single town with a part-time LHJ director.
of this article at http://www.ajph.org). We used qualitative analysis software (ATLAS.ti 6.2, Scientific Software Development GmbH, Berlin, Germany) to facilitate data organization and retrieval.17,18
Quantitative Data Sources The Connecticut Department of Public Health provided data from the LHJ annual reports. All LHJ revenues were deflated to a common year (2009) using the Bureau of Economic Analysis’s implicit price deflator for state and local government consumption expenditures and gross investments.19
RESULTS Of the 77 LHJs in existence in 2010, 30 were invited to participate and 17 directors, representing 20 LHJs, were interviewed, for a response rate of 67%. The sample represented 26% of Connecticut’s LHJs and included between 15% and 50% of the LHJs in each strata (Table 1). The average length of time that respondents had served as LHJ director was 13.6 years (SD = 11.5 years), and time in service ranged from 8 months to 38 years (Table 1). Patterns of per capita revenue, grants, and fees showed wide variation among different types of LHJs (Table 2). Although each LHJ type reported decreased per capita funds during the recession, districts and full-time LHJs showed increased state funds during the recession. In addition, the per capita total revenue for part-time LHJs was about one
Supplement 2, 2015, Vol 105, No. S2 | American Journal of Public Health
tenth that of full-time LHJs prerecession, and part-time LHJs saw a more than 50% decrease in total revenues per capita during the recession. Directors confirmed that economic recessions can lead to reductions in LHJ revenue in direct and indirect ways. Governments may react to budget limitations by directly reducing allocations for LHJs. Also, LHJ budgets may be indirectly reduced if the demand for fee-related services decreases or as a result of changes in the tax base. As one urban health district director put it: The housing market bust had a particularly significant impact on our agency. Less houses were being built so we’re pulling in less revenue from permits and service fees such as well permits and septic permits, soil testing. . . . We’ve had a reduction in the number of food service establishments that we’re permitting. Some of the mom and pops are going out of business.
Coping Strategies LHJ directors described a variety of strategies for coping with these budget reductions, which we grouped into 5 thematic categories: revenuegenerating activities, services, staffing, politics, and partnerships. Some directors sought to increase LHJ revenue through revenue-generating activities, such as raising fee levels, increasing grant applications, and identifying new revenuegenerating activities beyond public health service delivery (e.g., renting the LHJ building for other uses). Per a rural health district director, “We can’t control the per capita . . . and we can charge fees for service. So we started charging fees for service.” Other directors accommodated changes in revenue by making adjustments to the services
Prust et al. | Peer Reviewed | Research and Practice | S269
RESEARCH AND PRACTICE
TABLE 2—Revenue Sources and Characteristics of Participant Local Health Jurisdictions: Connecticut, 2005–2010 Mean Total Revenue per Capita, $
Mean Local Funds per Capita, $
Mean State Funds per Capita, $
Mean Federal Grants per Capita, $
Mean Total Fees per Capita, $
Mean License Fees, %
Mean Program Fees, %
Mean Nonfee Revenue, %
15.23 13.68
5.23 5.53
3.74 4.33
2.66 0.41
3.14 2.50
12.7 13.5
7.9 4.1
78.3 80.6
Prerecession
65.64
32.43
11.03
17.32
4.17
12.5
1.8
92.7
Recession
47.04
25.12
12.82
5.56
4.14
4.5
1.3
83.9
Prerecession
6.50
5.34
0.21
0.02
0.76
16.1
3.9
80.0
Recession
2.47
1.68
0.11
0.00
0.57
49.2
0.0
50.8
LHJs Districta Prerecession Recession Full-timeb
Part-timec
Note. LHJ =local health jurisdiction. Prerecession period, 2005–2007; recession period, 2008–2010. In 2005, there were 91 total LHJs in Connecticut; by 2010, because of mergers among LHJs, there were 77 total LHJs. All LHJ revenues were deflated to a common year (2009) using the US Bureau of Economic Analysis implicit price deflator for state and local government consumption expenditures and gross investments.18 a Type of LHJ that provides services to a conglomeration of towns. b Municipal health department that serves a single town with a full-time LHJ director. c Municipal health department that serves a single town with a part-time LHJ director.
provided, which included adjusting the type or level of services provided, providing only localand state-mandated services, and using strategic planning to prioritize needs. “When financial resources are cut, we have—in the past—cut services to accommodate that,” stated an urban health district director. Administrative or staffing adjustments were also used as a coping strategy. Directors sought to reduce staff costs by eliminating personnel, adjusting hours worked, and changing staff responsibilities and salaries. Nearly all of the respondents indicated that financial constraints had forced them to make staffing adjustments at some point: “Over last year we had a serious deficit, which led to a number of layoffs and reductions in programs” (urban full-time health department director). Some respondents also mentioned that such adjustments had severely affected operations and staff morale, although these adjustments may not be reflected in traditional reporting indicators. Per a rural health district director: If money starts to fall short—which it did about 5 years ago—I came up with a list of things. . . . We may have to not have the building cleaned professionally, we will have to do it as employees. . . . The [lead sanitarian] and myself worked one day per week for free for 3 months. All the other employees worked a half day on Friday[s], so their hours were cut and their wages got cut, but they didn’t work. [The lead sanitarian] and I actually worked. We were taking a 20% pay cut.
Using political influence and relationships with municipal authorities to obtain local funds was another way of coping with budget cuts. Maintaining close relationships with political officials and presenting data about the LHJ’s work to political officials were specific approaches mentioned: The selectmen—our relationship is close. They walk right by my door to go to the men’s room or ladies’ room, and they swerve in here every now and then to talk with me, or if they receive phone calls about anything related to public health, I’m right here, in the same building. (urban part-time health department director)
Finally, LHJ directors expressed the importance of partnership building as another mechanism for adjusting to decreased revenue. Partnership strategies included developing collaborative initiatives with other organizations, such as primary and secondary schools, universities, other service providers, field experts, and surrounding towns. Partnerships were seen as a way to enhance the public health services offered with a lower expenditure. They were used to collect data, reduce duplication of efforts, pool resources, and apply for funding: [This town] is partnered with two local towns on what we call our pandemic flu committee, but it’s basically [a] public health emergency response committee, and we receive some indirect funding which I believe comes down through [the
S270 | Research and Practice | Peer Reviewed | Prust et al.
Centers for Disease Control and Prevention] through the state health departments. (urban part-time health department director)
Constraints and Context of Decisions About Services Although, collectively, directors used a wide range of coping strategies to accommodate or counteract reductions in funding, the decisions of any single director about revenue and services were also constrained by contextual and structural factors. The full range of coping strategies may not have been available to each of the directors because of the unique context of his or her LHJ. When considering the key constraints or contextual factors influencing LHJ decisions, themes fell into 4 primary areas: (1) state and local statutory requirements, (2) political climate and priorities, (3) pressures from neighboring districts, and (4) LHJ structure or type. State and local statutory requirements have a significant influence on the services provided by health departments and districts. In addition to the state-mandated public health services, local laws create additional demands, and several directors highlighted that outsiders often fail to recognize the role of these local requirements. Locally enacted laws and requirements may limit directors’ ability to make decisions to adjust an LHJ’s services:
American Journal of Public Health | Supplement 2, 2015, Vol 105, No. S2
RESEARCH AND PRACTICE
The number one reason for offering services is because they are required. . . . A code says you must do it, or a local ordinance says you must do it. That’s the thing the state forgets about. Our towns have local ordinances that we have to deal with. (urban health district director)
However, these influences are not apparent in many statewide comparisons because the complexities of local politics are not easily captured. In addition to local statutes and formal requirements, many directors discussed the more informal ways that local political priorities and climate can affect health departments and districts. In particular, some directors expressed frustration over the impact of changes in political leadership in their areas. In cases in which the priorities of the health departments and districts depend heavily on the guidance of elected representatives, transitions in leadership were identified as a cause for disruption within an LHJ: The mayor . . . one of his important topics is litter and blight, so we have two sanitarians that he gave us and a full-time clerk that he gave us to do nothing but litter and blight. . . . Ask me in a year if we have a new mayor. You know, maybe litter and blight won’t be a priority. (urban full-time health department director) From a local health department perspective, the most important change comes when a mayor or first selectman says, “I know it’s a fine health department but actually we don’t need all the services you’re doing. We just need basic environmental services. All the rest of the things that you do, they’re wonderful but that’s for another time when we can afford them. So all these things about communicable diseases and obesity and nutrition and physical activity and blah blah, they’re luxuries right now.” . . . That’s the nexus of the economic and the political scene, which has brought about the most fundamental “changes” in this health district. (urban health district director)
LHJ directors also reported pressure from other LHJs to maintain low per capita fees for member municipalities and license and inspection fees for businesses. Singlemunicipality full-time or part-time LHJs in Connecticut can choose to merge into a multitown district LHJ; district LHJs then charge member towns on a per capita basis for the public health services provided. When a municipality borders or is near multiple district LHJs, there is pressure among the district LHJs to keep their per capita charges relatively low so as to not lose their member municipalities to
another district. As an urban health district director stated, The biggest influencing factor [on revenue] are our neighbors because if we go up [raise per capita charge] to meet our needs and they’re not happy, they’ll look to neighboring health districts, and if it looks better on the other side because it’s less expensive—doesn’t mean the services are better, or comparable probably—then it becomes a threat and we haven’t had a lot of that but that’s because everybody tries to stay in their own lane. But for example, [a neighboring district] staying so low and being on my border, it keeps my per capita low because he just gets bigger and bigger.
When an LHJ examines and sets its licensing and fee structure for local businesses, there is also pressure to consider what neighboring LHJs are charging, so as to be comparable, and not lose potential commercial activity to neighboring towns: We usually change our fees, increase our fees, every few years. The last time I changed our fees was 2009. . . . Our fees are usually adjusted in accordance with reviewing neighboring town fees and also those fees are associated with the time and effort necessary to provide that service. (urban part-time health department director)
Finally, the LHJ structure, or the type of health jurisdiction, is reported to influence funding opportunities and the political relationships of the health director. As previously noted, Connecticut has full-time and part-time LHJs that provide services to single municipalities, as well as district LHJs that are composed of multiple municipalities that jointly employ a full-time director. Traditional singlemunicipality LHJ directors and district LHJ directors reported different access to funding opportunities and different political challenges. District directors indicated that challenges related to the timing and availability of funds could be mitigated by their ability to use financial reserves or shift funding among programs to fill short-term gaps. This was a key difference between the options described by the directors of full-time and part-time LHJs compared with district LHJs. As an urban health district director mentioned, “Fortunately for us as a district we have the ability to upfront money. Municipalities don’t have the ability to do that and that’s a big problem for them.” Single-municipality health departments’ lack of buffer funds and autonomy also limit their flexibility in applying for grant funding, and
Supplement 2, 2015, Vol 105, No. S2 | American Journal of Public Health
they often face challenges in getting approval to apply for grants in the first place: [Applying for grants] tends to be a district vs. municipality issue. A lot of municipalities, it’s difficult to get the funds up front. . . . Often they have to go through the town council or city council to get approval to even apply for a grant, where at a district level you can usually get the authority to apply for a grant without getting board approval. . . . There’s definitely a difference between how municipalities and districts apply for grants. (urban health district director)
At the same time, the LHJ structure may also be related to variation in political opportunities, which in turn influences service decisions. In particular, directors of district LHJs faced unique challenges in building political relationships because of the multiple political authorities present: Each of those towns [that make up the district] are a little different. They all have a different view of what the role of government is. . . . The more towns that you have, the more difficult it is to come up with some kind of commonly agreed upon unmet need that government should be involved in. (urban health district director)
DISCUSSION Several recent studies have looked at influences on resource allocation decisions of different segments of the public health system. Baum et al. conducted a Web-based survey of a stratified random sample of local health departments across the United States and identified effectiveness of the activity, previous allocations, being the sole provider of a service, reluctance to lay off staff, and input from the board of health as the most influential factors associated with resource allocations.20 Jarris et al. surveyed state health department leadership in all 50 states and identified seriousness of the consequences, within-core public health services, available funds, federal or state mandates, and magnitude of the problem as the most influential factors.21 In Washington State, Bekemeier et al. conducted in-depth interviews with leaders of 11 LHJs and identified legal mandates and categorical funding limitations as key constraints on health directors’ decisions. 22 Chen et al. conducted case studies of 2 regional health departments in Nebraska and found that directors attempted to balance the needs of different populations and communities in making resource allocation decisions.23 Our study built
Prust et al. | Peer Reviewed | Research and Practice | S271
RESEARCH AND PRACTICE
on this research by examining the coping strategies available to LHJs and the constraints facing some LHJs in their resource allocation decisions when faced with revenue adjustments. In this study, we used qualitative data to describe LHJ directors’ perspectives on key coping mechanisms used to respond to revenue reductions, as well as contextual influences on LHJs’ decision-making processes. Directors identified alternative revenues, service changes, staffing changes, support from local political leaders, and partnerships as key approaches to maintaining their public health system in the face of budget cuts. This study supports findings from previous studies, such as the 2012 National Association of County and City Health Officials survey of LHJ directors,6 which found that more than 50% of LHJs reported increasing revenues through alternative sources and partnerships with other LHJs and non-LHJs to mitigate the effects of funding cuts. Interestingly, its survey also showed that 61% of respondents reported using technology to mitigate effects, and 37% reported hiring subcontractors.6 This study also revealed other factors that can affect decision-making in the face of budget reductions, such as the pressures that LHJs experience to keep fees on par with those of neighboring jurisdictions. Although this dynamic may be attributed to the particular structure of Connecticut’s local public health system and the sometimes-competitive nature of operating in this environment, it may be operative in other states in which county structures are absent and may produce behavior contrary with the fundamentally collaborative ethos of public health practice. In Connecticut’s currently decentralized system, state health authorities have little role in regulating competition or supporting partnerships among LHJs. However, recent state legislation in Connecticut adopting the Centers for Disease Control and Prevention’s 10 essential public health services as the new public health system framework9 may further standardize service delivery requirements across LHJs. This could potentially reduce the competition associated with differing LHJ costs resulting from differing service packages and present opportunities to improve the structure, cost-effectiveness,
sustainability, and impact of local public health services across the state. Although LHJs respond creatively in the face of budget cuts to maintain important public health services, some of these coping mechanisms could have long-term consequences. Attempts to maintain staffing by reducing hours, decreasing salaries, shifting responsibilities, and shrinking other capital expenditures, such as office space, could have long-term impacts on staff morale, retention, and quality of services. Tracking and monitoring the future impacts of such changes is important for understanding longer-term effects. However, changes to the internal management of staff time and administrative resources may not be captured in annual reporting to the Connecticut Department of Public Health. This was identified as a challenge in a previous quantitative study, in which annual LHJ data from Connecticut were used to investigate relationships between local economic indicators and LHJ revenues and services.24 On the basis of data limitations, some long-term consequences of public health budget cuts may be obscured. Routine data monitoring for LHJs should consider potentially available coping mechanisms. LHJ directors reported constraints on coping mechanisms, such as local statutory requirements, political priorities, pressures from other LHJs, and LHJ structure or type. The constraints of legal mandates on services have also been noted by researchers working with LHJs in Washington State22 and state health department leadership across the United States.21 This study revealed that, compared with municipal health departments, directors of district LHJs were better equipped to mitigate the impact of the timing and availability of funds on services through the use of financial reserves, relying on multiple funding streams, and shifting funding among programs to fill short-term gaps. A survey of Minnesota local health directors also identified variation in decisionmaking authority across health directors.25 The importance of political influences and the difficulty of building strategic political relationships in combined jurisdictions are also important factors to consider in identifying optimum jurisdiction size for efficient delivery of public health services. The consolidation of health departments into multiple-municipality districts has been viewed as a path to improving
S272 | Research and Practice | Peer Reviewed | Prust et al.
efficiency23 but, as in this study, previous analyses have also identified political heterogeneities in Connecticut LHJs that affect consolidation.26 Recent work in Nebraska has also highlighted limitations of district consolidation in cases in which funding issues continue to generate conflict and tension.23 Negotiating political relationships was particularly challenging for directors of multiple-municipality health districts because they have to negotiate with multiple political bodies. A study investigating perspectives on the collaboration of local public health officials and county commissioners found that public health officials identified a number of political barriers to collaboration, including commitment to home rule, loss of local input into public health services and priorities, perceived threats to local elected officials, and lack of collaborative government and staffing models.27 In light of these findings, the strengths and challenges of combined jurisdictions are important to consider in identifying optimum jurisdiction size for efficient delivery of public health services. The question of imposed competition and structural barriers to enhanced collaboration among LHJs merits consideration in future research on the organization of local public health system. Future research should also consider the effects on public health service delivery and impact at the local level of a state-mandated regional public health structure versus the more diverse municipal public health structures that have evolved in parts of the United States. Although this study offers valuable insight into the influences on decision-making processes within LHJs, these results should be considered in light of several limitations. The sampling strategy for this study was intentionally focused on saturation and is not necessarily representative of the views of all Connecticut LHJ directors. As such, the results are best used to inform the development of hypotheses and questions for future research. Of the LHJ directors invited to interview, 67% agreed and were interviewed. Directors who did not participate might have held views that were different from those of our participants. Directors identified a variety of coping mechanisms, although the effects of different coping mechanisms on the quality and effectiveness of service provision is an area for further research.
American Journal of Public Health | Supplement 2, 2015, Vol 105, No. S2
RESEARCH AND PRACTICE
The results of this study may be most relevant in states that are similar to Connecticut in geopolitical and socioeconomic characteristics. j
About the Authors At the time of the study, Margaret L. Prust and Brigette Davis were with the Division of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. Kathleen Clark, Sarah W. Pallas, and Stephanie Platis were with the Division of Health Policy and Administration, Yale School of Public Health, New Haven. Jennifer Kertanis is with the Connecticut Association of Directors of Health, Hartford. Elaine O’Keefe is with the Office of Community Health and Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven. Michael Araas, Neel S. Iyer, and Stewart Dandorf were with the Division of Chronic Disease Epidemiology, Yale School of Public Health, New Haven. Debbie Humphries is with the Division of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven. Correspondence should be sent to Debbie Humphries, P.O. Box 208034, New Haven, CT 06520-8034 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted November 25, 2014.
Contributors S. W. Pallas, J. Kertanis, E. O’Keefe, and D. Humphries conceptualized and designed the study. K. Clark and D. Humphries conducted the interviews. M. L. Prust and D. Humphries wrote the first draft of the article. M. L. Prust, K. Clark, B. Davis, M. Araas, N. S. Iyer, S. Dandorf, S. Platis, and D. Humphries performed the analysis and interpretation of data. All authors contributed to critical revisions to the article and approved the final version of the article.
Acknowledgments This study was funded by the Robert Wood Johnson Foundation through the Connecticut Practice-Based Research Network (project no. 67023). We thank the many directors of health and other local health department staff who participated in this study for their time and insights. Note. The funding organization had no role in the research design, data collection and analysis, or writing of the article.
Human Participant Protection The study protocol was reviewed by the Yale University human investigation committee (protocol no. 1104008345) and granted an exemption under 45 CFR 46.101(b)(2).
References 1. Bernet PM. Local public health agency funding: money begets money. J Public Health Manag Pract. 2007;13(2):188---193. 2. Livingood WC, Morris M, Sorensen B, et al. Revenue sources for essential services in Florida: findings and implications for organizing and funding public health. J Public Health Manag Pract. 2013;19(4): 371---378. 3. National Association of County and City Health Officials. Local Public Health Agency Infrastructure: A Chartbook. Washington, DC: National Association of County and City Health Officials; 2001.
4. Wasserman MP, Rawding N, Aberle-Grasse JM. A survey of local health officials’ views on current resources for public health services. J Public Health Policy. 1992;13 (3):261---266. 5. Willard R, Shah GH, Leep C, Ku L. Impact of the 2008-2010 economic recession on local health departments. J Public Health Manag Pract. 2012;18(2):106--114. 6. National Association of County and City Health Officials. Local Health Department Job Losses and Program Cuts: Findings From the January 2012 Survey. Washington, DC: National Association of County and City Health Officials; 2012. 7. Connecticut Department of Labor. Historical Labor Force Monthly Data w/Annual Averages by Town (LAUS)— State of Connecticut. Wethersfield: Connecticut Department of Labor. 8. Connecticut Department of Public Health. Connecticut Public Health Code 19a-76-2: Basic Local Health Program. Hartford, CT: Connecticut Department of Public Health; 1983. 9. An act concerning essential public health services and the euthanization of animals in a facility subject to regulation by the United States Department of Agriculture, Substitute House Bill No. 5528, Connecticut Public Act No. 14-226. 10. Gregorio D. Preliminary Report: Local Reponses to State Public Health Funding Reductions. Hartford, CT: Connecticut Association of Directors of Health; 2011.
21. Jarris PELJ, Resnick B, Sellers K, Young JL. Budgetary decision making during times of scarcity. J Public Health Manag Pract. 2012;18(4):390---392. 22. Bekemeier B, Chen AL, Kawakyu N, Yang Y. Local public health resource allocation: limited choices and strategic decisions. Am J Prev Med. 2013;45(6):769--775. 23. Chen LW, Jacobson J, Roberts S, Palm D. Resource allocation and funding challenges for regional local health departments in Nebraska. J Public Health Manag Pract. 2012;18(2):141---147. 24. Humphries D, Kertanis J, O’Keefe E, et al. Revenue streams and service delivery in Connecticut local health jurisdictions (2001-2010): Connecticut Practice Based Research Network; 2012. Available at: http://www.cadh. org/program-areas/practice-based-research-network. html. Accessed February 24, 2013. 25. Gearin KJM, Thrash AMR, Frauendienst R, et al. Measuring the authority of local public health directors in the context of organizational structure: an exploratory, multimodal approach. J Public Health Manag Pract. 2012;18(6):545---550. 26. Bates LJ, Lafrancois BA, Santerre RE. An empirical study of the consolidation of local public health services in Connecticut. Public Choice. 2011;147(1-2):107---121. 27. Felton J, Golbeck AL. Interjurisdictional collaboration: local public health officials versus county commissioners. J Public Health Manag Pract. 2011;17(1):E14--E21.
11. National Association of County and City Health Officials. Survey Findings: Local Health Department Job Losses and Program Cuts: Findings From the January 2012 Survey. Washington, DC: National Association of County and City Health Officials 2012. 12. Creswell J. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Thousand Oaks, CA: Sage; 2007. 13. Connecticut State Office for Rural Health. Connecticut Rural Towns. Winsted, CT: Connecticut State Office for Rural Health; 2011. 14. Glaser B, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research. Piscataway, NJ: Transaction; 1967. 15. Morse J. The significance of saturation. Qual Health Res. 1995;5(2):147---149. 16. Charmaz K, ed. Shifting the Grounds: Constructivist Grounded Theory Methods. Walnut Creek, CA: Left Coast Press; 2009. 17. Richards L. Rigorous, rapid, reliable and qualitative? Computing in qualitative method. Am J Health Behav. 2002;26(6):425---430. 18. Weitzman EA. Analyzing qualitative data with computer software. Health Serv Res. 1999;34(5 pt 2):1241---1263. 19. Bureau of Economic Analysis. Table 1.1.9: implicit price deflators for gross domestic product. In: National Income and Product Accounts Tables. Washington, DC: Bureau of Economic Analysis, US Department of Commerce. 20. Baum NM, DesRoches C, Campbell EG, Goold SD. Resource allocation in public health practice: a national survey of local public health officials. J Public Health Manag Pract. 2011;17(3):265--274.
Supplement 2, 2015, Vol 105, No. S2 | American Journal of Public Health
Prust et al. | Peer Reviewed | Research and Practice | S273
