Research Brief Report Local Health Departments’ Approaches to Deal With Recession: What Strategies Are Used to Minimize the Negative Impact on Public Health Services to Community? Gulzar H. Shah, PhD, MStat, MS; Jiali Ye, PhD; Carolyn J. Leep, MS, MPH; Jonathon P. Leider, PhD rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Context: Local health departments (LHDs) are crucial components in the public health system. As with their state counterparts, operating since the 2008 recession has proven financially difficult for the majority of the nation’s 2800 LHDs. These health departments have elected to employ a variety of strategies to maintain operations and public-facing services and programs. Objectives: This study aimed to assess strategies used by LHDs to minimize the negative impact on services to community and to examine variation in these strategies by the size of population in LHD jurisdiction. Design and Participants: The design of this research brief report is observational, based on cross-sectional data from a nationally representative sample of 957 LHDs that enumerates and characterizes the nature of their responses to austerity. Outcomes Measures: The main outcome measures included 19 strategies. We used descriptive and bivariate analyses to highlight our study findings. Results: LHDs use a variety of strategies to mitigate negative impacts on the public health services in their communities, focusing on workforce, funding, service referral, and several other areas. The most frequently used strategies include cross-training staff, increasing work hours, pursuing new funding, resource sharing, and seeking fees for services provided. Some minor variation by the size of jurisdiction population existed in frequency of top 10 strategies used by LHDs. Conclusions: Some of the LHD strategies to deal with the impact of recession address immediate issues caused by budget cuts and might be J Public Health Management Practice, 2015, 00(00), 1–5 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
short-term fixes, including increasing workload of employees, and pay freezes. Other strategies, such as seeking new sources of revenues and resource sharing, can have potentially positive effects in the long run. KEY WORDS: budget cuts, local health departments, public
health workforce, resource sharing, strategies to deal with recession
The economic recession of 2008-2009 has adversely impacted the public health enterprise.1,2 Between 2008 and 2010, demand for public health services at the local level increased, during which time a large proportion of local health departments (LHDs) reported a loss of staff through layoffs and/or attrition due to a budget reduction.3-5 Although funding and staff Author Affiliations: Department of Health Policy and Management, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro (Dr Shah); and National Association of County & City Health Officials, Washington, District of Columbia (Drs Ye and Leep). Dr Leider is an independent consultant at JP Leider Research & Consulting, LLC in Minneapolis, MN. No financial disclosures were reported by the authors of this article. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (http://www.JPHMP.com). Correspondence: Gulzar H. Shah, PhD, MStat, MS, Department of Health Policy and Management, Jiann-Ping Hsu College of Public Health, Georgia Southern University, 501 Forest Dr, Hendricks Hall, Bldg 303, Statesboro, GA 30460 ([email protected]). DOI: 10.1097/PHH.0000000000000260
1 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
2 ❘ Journal of Public Health Management and Practice cuts have not been uniform in scale or scope, many jurisdictions have reported profound challenges associated with the recession. Some jurisdictions have seen modest growth in public health spending between 2008 and 2010 (eg, in the year 2010, 24.7% of LHDs reported an increased budget compared with previous year),6 although this has occurred in the context of a greater need for safety-net services and renewed political interest in governmental spending (and decreasing said spending) at the local, state, and national levels.7 Effects of the economic recession have been catalogued by the National Association of County & City Health Officials (NACCHO). Studies have noted compound effect of the cuts, that is, many LHDs have experienced staff and/or program losses successively since 2008. A large proportion of LHDs repeatedly reported reduced budgets compared with the previous years: 27% in December 2008, 45% in August 2009, 38% in February 2010, 44% in November 2011, 45% in July 2011, 41% in January 2012, and 27% in January 2013.8 In addition, many LHDs indicated they had laid off staff or otherwise decreased the size of their workforce due to retirements, lack of rehiring, and/or other forms of attrition. Some of these jobs were regained, but loss of skilled workforce remains an issue.8 Practitioners and scholars have studied resource allocation decision making in individual health departments and across categorical programs, generally through case studies and surveys.9,10 These studies highlight a serious challenge: that politicians and the public, to a lesser extent, seem to expect “business as usual” despite reductions in financial support to governmental public health agencies.4,8,11 Legislative and regulatory mandates, whether funded or unfunded, posed significant challenges when trying to reconcile budgets during the recession. Similarly, those who have studied priority setting broadly in LHDs, as well as at the state health agency level, have found that truly “eliminating” a program may be implausible and so other tactics may be employed, including across-theboard cuts, cost shifting, cross-training, reduced pay, or other administrative maneuvers (eg, furloughs).8 This brief systematically examines the types of strategies used by local public health leaders during resource allocation decision making after the economic recession. It does so by means of a nationally representative survey of LHDs. The gap in existing literature led to 2 research questions that inform our policy recommendations:
1. Since the recession began in December 2007, what specific strategies are used by LHDs to manage program and/or staffing cuts in an effort
to minimize the negative impact on services to community? 2. Do the types of strategies and the prevalence of their use differ across LHDs serving different jurisdictional sizes?
● Methods Data for this research come from NACCHO’s survey on Job Loss and Program Cuts, conducted in January 2012. Using a semistructured questionnaire, a Webbased survey was administered to a nationally representative stratified sample of 957 LHDs, in which larger LHDs were oversampled to ensure a sufficient number of responses from larger LHDs for purpose of comparison. The stratification was based on state in which the LHD was located and size of LHD population (3 population categories, representing large, medium, and small LHDs). A total of 663 LHDs completed the survey, a response rate of 69%. Additional details on sampling and data collection methodology are available at: www.naccho.org/lhdbudget.
Variables in the analysis Survey participants responded to the following question: “Since the recession began in December 2007, have you employed any of the following strategies to manage program and/or staffing cuts in order to minimize the negative impact on services to your community? Check all that apply.” This item contained a list of 22 options including an “Other” option. This list of strategies was developed through analysis of responses to an open-ended question about strategies, used in the July 2011 wave of the Job Loss and Program Cuts survey, conducted by NACCHO. The primary independent variable in the bivariate analysis was the size of population in LHD jurisdiction, grouped as less than 25 000, 25 000 to 99 999, and 100 000+.
Data analysis Statistical analyses were conducted using Stata (version 11; StataCorp LP, College Station, Texas). Statistical weights were used to account for an oversampling of the larger LHDs and disproportionate response rates by LHD jurisdictional size. Descriptive analyses included computation of percentages and confidence intervals. For the bivariate analyses, analysis of variance was conducted, followed by the post hoc analysis (Tukey test) for multiple comparisons for data presented in Supplemental Digital Content Table 2, available at: http://links.lww.com/JPHMP/A149.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Local Health Departments’ Approaches to Deal With Recession
● Results LHDs tried to minimize the impact of financial crises through a myriad of strategies. The majority of these strategies fall into 5 broad categories (Table): (1) adjustments pertaining to workforce; (2) changes in budget or revenues; (3) service referrals or broader cuts before program elimination; (4) contracting out services/employees; and (5) resource sharing. Overall, the following strategies were employed most frequently: cross-training or sharing staff within LHD (82%); increasing workload of existing staff (77%); pursuing new funding (59%); utilizing technology to improve efficiency (59%); charging or increasing fees for services provided (55%); and identifying other providers in the community for referrals (51%). For most of the identified strategies, significant variation was observed by the size of population in LHD jurisdiction (see Supplemental Digital Content Table 2, available at: http://links.lww.com/JPHMP/A149). Sharing staff with another LHD or non-LHD orga-
❘ 3
nization, sharing equipment with another LHD or non-LHD organization, and increasing or beginning billing to insurance were the strategies used equally by LHDs of all sizes. With the exception of one strategy—contracting with another LHD for services, which was significantly more prevalent among smaller LHDs—all other remaining strategies were more frequently used by larger LHDs. The test of significance for multiple comparisons showed that in most cases, the LHDs with smallest population size (
Context: Local health departments (LHDs) are crucial components in the public health system. As with their state counterparts, operating since the 2008 recession has proven financially difficult for the majority of the nation’s 2800 LHDs. These health departments have elected to employ a variety of strategies to maintain operations and public-facing services and programs. Objectives: This study aimed to assess strategies used by LHDs to minimize the negative impact on services to community and to examine variation in these strategies by the size of population in LHD jurisdiction. Design and Participants: The design of this research brief report is observational, based on cross-sectional data from a nationally representative sample of 957 LHDs that enumerates and characterizes the nature of their responses to austerity. Outcomes Measures: The main outcome measures included 19 strategies. We used descriptive and bivariate analyses to highlight our study findings. Results: LHDs use a variety of strategies to mitigate negative impacts on the public health services in their communities, focusing on workforce, funding, service referral, and several other areas. The most frequently used strategies include cross-training staff, increasing work hours, pursuing new funding, resource sharing, and seeking fees for services provided. Some minor variation by the size of jurisdiction population existed in frequency of top 10 strategies used by LHDs. Conclusions: Some of the LHD strategies to deal with the impact of recession address immediate issues caused by budget cuts and might be J Public Health Management Practice, 2015, 00(00), 1–5 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
short-term fixes, including increasing workload of employees, and pay freezes. Other strategies, such as seeking new sources of revenues and resource sharing, can have potentially positive effects in the long run. KEY WORDS: budget cuts, local health departments, public
health workforce, resource sharing, strategies to deal with recession
The economic recession of 2008-2009 has adversely impacted the public health enterprise.1,2 Between 2008 and 2010, demand for public health services at the local level increased, during which time a large proportion of local health departments (LHDs) reported a loss of staff through layoffs and/or attrition due to a budget reduction.3-5 Although funding and staff Author Affiliations: Department of Health Policy and Management, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro (Dr Shah); and National Association of County & City Health Officials, Washington, District of Columbia (Drs Ye and Leep). Dr Leider is an independent consultant at JP Leider Research & Consulting, LLC in Minneapolis, MN. No financial disclosures were reported by the authors of this article. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (http://www.JPHMP.com). Correspondence: Gulzar H. Shah, PhD, MStat, MS, Department of Health Policy and Management, Jiann-Ping Hsu College of Public Health, Georgia Southern University, 501 Forest Dr, Hendricks Hall, Bldg 303, Statesboro, GA 30460 ([email protected]). DOI: 10.1097/PHH.0000000000000260
1 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
2 ❘ Journal of Public Health Management and Practice cuts have not been uniform in scale or scope, many jurisdictions have reported profound challenges associated with the recession. Some jurisdictions have seen modest growth in public health spending between 2008 and 2010 (eg, in the year 2010, 24.7% of LHDs reported an increased budget compared with previous year),6 although this has occurred in the context of a greater need for safety-net services and renewed political interest in governmental spending (and decreasing said spending) at the local, state, and national levels.7 Effects of the economic recession have been catalogued by the National Association of County & City Health Officials (NACCHO). Studies have noted compound effect of the cuts, that is, many LHDs have experienced staff and/or program losses successively since 2008. A large proportion of LHDs repeatedly reported reduced budgets compared with the previous years: 27% in December 2008, 45% in August 2009, 38% in February 2010, 44% in November 2011, 45% in July 2011, 41% in January 2012, and 27% in January 2013.8 In addition, many LHDs indicated they had laid off staff or otherwise decreased the size of their workforce due to retirements, lack of rehiring, and/or other forms of attrition. Some of these jobs were regained, but loss of skilled workforce remains an issue.8 Practitioners and scholars have studied resource allocation decision making in individual health departments and across categorical programs, generally through case studies and surveys.9,10 These studies highlight a serious challenge: that politicians and the public, to a lesser extent, seem to expect “business as usual” despite reductions in financial support to governmental public health agencies.4,8,11 Legislative and regulatory mandates, whether funded or unfunded, posed significant challenges when trying to reconcile budgets during the recession. Similarly, those who have studied priority setting broadly in LHDs, as well as at the state health agency level, have found that truly “eliminating” a program may be implausible and so other tactics may be employed, including across-theboard cuts, cost shifting, cross-training, reduced pay, or other administrative maneuvers (eg, furloughs).8 This brief systematically examines the types of strategies used by local public health leaders during resource allocation decision making after the economic recession. It does so by means of a nationally representative survey of LHDs. The gap in existing literature led to 2 research questions that inform our policy recommendations:
1. Since the recession began in December 2007, what specific strategies are used by LHDs to manage program and/or staffing cuts in an effort
to minimize the negative impact on services to community? 2. Do the types of strategies and the prevalence of their use differ across LHDs serving different jurisdictional sizes?
● Methods Data for this research come from NACCHO’s survey on Job Loss and Program Cuts, conducted in January 2012. Using a semistructured questionnaire, a Webbased survey was administered to a nationally representative stratified sample of 957 LHDs, in which larger LHDs were oversampled to ensure a sufficient number of responses from larger LHDs for purpose of comparison. The stratification was based on state in which the LHD was located and size of LHD population (3 population categories, representing large, medium, and small LHDs). A total of 663 LHDs completed the survey, a response rate of 69%. Additional details on sampling and data collection methodology are available at: www.naccho.org/lhdbudget.
Variables in the analysis Survey participants responded to the following question: “Since the recession began in December 2007, have you employed any of the following strategies to manage program and/or staffing cuts in order to minimize the negative impact on services to your community? Check all that apply.” This item contained a list of 22 options including an “Other” option. This list of strategies was developed through analysis of responses to an open-ended question about strategies, used in the July 2011 wave of the Job Loss and Program Cuts survey, conducted by NACCHO. The primary independent variable in the bivariate analysis was the size of population in LHD jurisdiction, grouped as less than 25 000, 25 000 to 99 999, and 100 000+.
Data analysis Statistical analyses were conducted using Stata (version 11; StataCorp LP, College Station, Texas). Statistical weights were used to account for an oversampling of the larger LHDs and disproportionate response rates by LHD jurisdictional size. Descriptive analyses included computation of percentages and confidence intervals. For the bivariate analyses, analysis of variance was conducted, followed by the post hoc analysis (Tukey test) for multiple comparisons for data presented in Supplemental Digital Content Table 2, available at: http://links.lww.com/JPHMP/A149.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Local Health Departments’ Approaches to Deal With Recession
● Results LHDs tried to minimize the impact of financial crises through a myriad of strategies. The majority of these strategies fall into 5 broad categories (Table): (1) adjustments pertaining to workforce; (2) changes in budget or revenues; (3) service referrals or broader cuts before program elimination; (4) contracting out services/employees; and (5) resource sharing. Overall, the following strategies were employed most frequently: cross-training or sharing staff within LHD (82%); increasing workload of existing staff (77%); pursuing new funding (59%); utilizing technology to improve efficiency (59%); charging or increasing fees for services provided (55%); and identifying other providers in the community for referrals (51%). For most of the identified strategies, significant variation was observed by the size of population in LHD jurisdiction (see Supplemental Digital Content Table 2, available at: http://links.lww.com/JPHMP/A149). Sharing staff with another LHD or non-LHD orga-
❘ 3
nization, sharing equipment with another LHD or non-LHD organization, and increasing or beginning billing to insurance were the strategies used equally by LHDs of all sizes. With the exception of one strategy—contracting with another LHD for services, which was significantly more prevalent among smaller LHDs—all other remaining strategies were more frequently used by larger LHDs. The test of significance for multiple comparisons showed that in most cases, the LHDs with smallest population size (
