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local health department, performance measurement, public health, public health statutes, quality improvement, state health planning



  1. Zahner, Susan J.
  2. Vandermause, Roxanne


Compliance with statutes and rules is a measure of local health department (LHD) performance. This study analyzed compliance rates in one state. High overall compliance rates were found, although gaps existed between measured and expected compliance. Factors associated with lower compliance included lower LHD certification level (characteristic of smaller agencies) and human services organizational structure in lower-level LHDs. Improvements in compliance rates will require increased attention to development and documentation of policies, procedures, and local ordinances. Compliance is necessary for LHD effectiveness but may not be a sufficient measure of overall LHD performance.


EFFORTS DIRECTED toward defining and measuring performance of local health departments (LHDs) in the United States have evolved over the past decade. Research examining LHD performance during this time used a variety of performance measures, including organizational practices defined by the Centers for Disease Control and Prevention (CDC), core public health functions defined by the Institute of Medicine (IOM), and essential services defined by IOM's Committee on Public Health.1-4 Many states have ongoing LHD performance measurement systems in place based on essential public health services, compliance with state statutes and rules, other state-specific standards of performance, and external accreditation standards.5-7 In a 1997 survey, Mays and colleagues8 reported that 50 percent of state agencies reporting involvement in LHD performance assessment used an essential services or core function framework while the other half used statutorily defined public health activities or internally developed concepts of public health practice. The recent development of national public health performance standards based on the essential services framework and the inclusion of a goal in Healthy People 2010 to increase the proportion of LHDs that meet these standards will likely lead to more widespread performance measurement by states and local agencies.9,10


Previous review 11 of LHD performance has shown performance to vary between 50 percent and 70 percent, depending on the performance measures used. Various factors associated with greater LHD effectiveness have been identified through these studies. Suen and colleagues 12 reported that agencies serving jurisdictions with a population greater than 50,000, having larger total budgets, and serving larger geopolitical units had higher performance compared with those serving smaller jurisdictions with smaller budgets. Handler and Turnock 13 reported that agencies with full-time directors, larger annual expenditures, greater numbers of staff, budgets derived from multiple sources, income from private health insurance as a signifi cant budget component, and having a female agency director are associated with higher performance.


The study reported here was conducted to analyze the results of a new method for LHD performance measurement recently used in the state of Wisconsin that measured the extent of LHD compliance with applicable state public health statutes and administrative rules. Types of deficiencies in compliance were identified. Associations between LHD performance and a variety of organizational factors were examined in order to explore reasons for variation in performance among LHDs in Wisconsin. The findings of this study were compared with previous reports of LHD performance measurement processes in order to determine the extent to which the results of this new method of performance measurement were consistent with the literature. The information gained through this analysis adds to the understanding of factors associated with LHD performance and can be used by agencies to improve compliance with state statutes and administrative rules.