Centralized, decentralized, shared or mixed: What difference does governance of local health departments make?

Each of the fifty states is charged with a responsibility to protect and promote the health of its residents, yet each state satisfies that responsibility in a different way. One way in which states differ is in the governance relationship between the state health agency and the local health departments in the state. In centralized states, the state health agency staffs, funds and essentially operates all of the local health departments in the state. In decentralized states, the local health departments are largely independent of the state health agency. States with mixed and shared governance relationships fall in the middle of that continuum. We used a standardized governance classification system and data from the 2010 ASTHO Profile Survey to explore differences between states that are organized differently. Using descriptive and inferential statistics, we found that centralized state health agencies tend to be larger in terms of number of employees and expenditures per capita; clinical services that are often the responsibility of local health departments are more commonly offered by state health agencies in centralized than in decentralized states; and quality improvement and performance management activities are more prevalent in state health agencies in decentralized states than in centralized states. When health ranking was examined, decentralized states were found to have better health outcomes compared to centralized states. Potential explanations for and implications of these findings are explored.