Rural Public Health Department Structure and Infrastructure

Lead researcher:
Project completed:
August 2006
This study examined the structure of twelve rural public health departments in six geographically diverse states using a case study approach. Structural functionalism - the idea that functions determine the structure of an organization - provided the conceptual framework for the study. This theory suggests that formal organization is an expression of rational action.

In addition to geographic diversity, cases were chosen for examination that reflected the range of state-local health department relations. From the perspective of the local health department, these relations are characterized as decentralized, centralized, shared and mixed. The states selected for study approximate the distribution of state-local health department relations across the country: two decentralized (Kansas and Washington), one centralized (Louisiana), and three mixed/shared models (Arizona, Georgia, and Pennsylvania).

The twelve rural public health departments studied were highly diverse. They varied on every dimension of structure examined: the size of the geographic area and population they serve, their governance, funding, facilities, staffing, services, public health system development, planning, and evaluation. A primary determinant of variation appears to be the state-local health department relationship. In centralized and mixed/shared model states, a regional office is often interposed between the local health department and the state health department. Local health departments operating under the direction of a regional office tend to have fewer staff members and to offer a smaller array of services than independent departments. They have more timely access to expert resources than independent departments do, and their business documentation systems (i.e., policies, procedures, and forms) are highly structured and are used across the state by other local health departments. Decentralized departments tend more frequently to offer services in response to local need. These services may be highly idiosyncratic, often only tangentially related to public health, and financed by local funds or philanthropic grants.

The rural public health departments examined generally lacked effective mechanisms for including community input into decision-making and have not promoted public health system development within their communities. In some states, undeveloped rural health department infrastructure has been addressed through state-imposed regionalization. But few examples were found of local departments independently coalescing into networks to share scarce resources.