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  1. Meit, Michael MA, MPH
  2. Sellers, Katie DrPH, CPH
  3. Kronstadt, Jessica MPP
  4. Lawhorn, Nikki ScD, MPP
  5. Brown, Alexa BS
  6. Liss-Levinson, Rivka PhD
  7. Pearsol, Jim MEd
  8. Jarris, Paul E. MD, MBA


Context: Public health practitioners and researchers often refer to state public health systems as being centralized, decentralized, shared, or mixed. These categories refer to governance of the local public health units within the state and whether they operate under the authority of the state government, local government, shared state and local governance, or a mix of governance structures within the state.


Objective: This article describes the development of an objective method of classifying states as centralized, decentralized, shared, or mixed. We also discuss some initial analyses that have been conducted to identify how public health resources and activities vary across states with different classifications.


Design: Cross-sectional study.


Setting: State health agencies.


Participants: Survey respondents were organizational leaders from all 50 state health agencies.


Main Outcome Measure(s): Total full-time equivalent employees, total health agency expenditures, expenditures on clinical services, and provision of clinical services.


Results: Centralized state health agencies employ more full-time equivalent employees, have higher total expenditures, and provide more clinical services than decentralized state health agencies. Although higher expenditures on clinical services were observed, these differences were not statistically significant.


Conclusions: It is important to take governance classification into account when investigating variation in services, resources, or performance of governmental public health systems. As public health systems and services researchers seek to identify best practices in the organization of public health systems, consistent definition of different types of organization is critical. This system provides an objective and reliable system for classifying governance relationships that allows for comparisons that are meaningful to both practitioners and researchers.