Developing a typology of public health systems and dynamics: A qualitative analysis

Utilizing the typology of public health systems structure and composition identified in the quantitative phase of this study, this qualitative phase seeks to build on those findings by 1) gathering information on how different types of local health departments allocate public health responsibilities and resources among key governmental and nongovernmental actors; 2) identifying the political, economic, institutional, and socio-cultural forces that shape the structure and operation of public health delivery systems; 3) assessing how system structure and composition influences the availability and effectiveness of essential public health services. Hierarchical cluster analysis was used to group local public health agencies into seven clusters representing agencies across three domains: differentiation, integration, and centralization. Qualitative interviews were conducted with a sample of appointed directors of local health departments from each of the clusters. In-depth analysis of organizations within each cluster was used to identify the underlying drivers of change including the role of assessment activities, increased funding, and the array of organizations contributing to local public health activities through exploration of the nature and intensity of interaction among the major organizational participants. These findings will enable policymakers and key stakeholders to understand the relative strengths and weaknesses of alternative approaches to delivering public health services and the political, economic, and institutional contexts in which these approaches function best.