When public health is different: Divergence in local health department structure

Some states grant local government considerable autonomy through constitutional or statutory home rule, while others retain greater control over cities and counties. Division of authority between local and state health departments typically follows the model of other local agencies. However, in 12 states, over 58 million Americans have local health departments (LHDs) with structures at odds with those of other government units. Nine states' local public health agencies have more autonomy than local government in general, while in 3, authority over LHDs is concentrated at the state level although other local government functions are devolved. In this era of repeated funding cuts, the long debate over distribution of powers and resources among levels of government has gained urgency. Some argue that centralizing power at the state level supports equitable resource distribution among local entities. Others counter that local governments know their constituents' needs and should have the power to meet them. The 12 states where LHD structure is different provide a set of natural experiments to test these assertions. We identify the legal and historical roots of these governmental divergences, and analyze related public health policy issues. The impact of tension between local agencies with disparate levels of autonomy is illustrated with three brief case reports. Based on these findings, we develop process models that suggest areas where service delivery is facilitated or impeded when public health authority is not aligned with other local government agencies.