Estimating Scale and Scope Effects in Public Health Delivery: Implications for Regionalization

OBJECTIVES: The nation's public health delivery system comprises nearly 3000 local public health agencies that vary widely in capabilities. Economic pressures, workforce shortages, and new national accreditation standards are leading these agencies to explore mechanisms for pooling resources to enhance delivery and improve population health.METHODS: A longitudinal cohort design is used to analyze changes in the availability and perceived effectiveness of services delivered by local public health providers. A stratified random sample of the nation's 3000 local public health agencies (n=497) were surveyed in 1998 and again in 2006 and 2011 (70% response) to measure the availability of 20 core public health services within their jurisdictions, the organizations that deliver each, and the perceived effectiveness of services. Hierarchical regression was used to simulate the effects of regional service delivery models that pool resources across neighboring public health agency jurisdictions that fall below selected population thresholds.RESULTS: The scope of public health services delivered in the average U.S. community increased from 64% to 71% during the 14 year period (p<0.05), and increased significantly with the agency's scale of operations (population size served, p<0.001). Simulation results predicted that combining neighboring public health agency jurisdictions serving less than 50,000 residents would produce a 26% increase in the scope of services delivered, a 19% increase in perceived effectiveness, and statistically significant reductions in selected measures of preventable mortality.CONCLUSIONS: Regional strategies to coordinate and/or consolidate the operations of small and rural public health agencies may improve public health delivery and population health.