Public health care professionals face a number of challenges. Five years after the 2007 recession began, many public health districts are still experiencing budget reductions.1 Such cuts put pressure on administrators and policy makers to reduce staffing, services, or both. Making these decisions can be difficult because it involves balancing cuts in water inspections, surveillance, prenatal services, nutrition education, and other services across multiple locations. A lack of effectiveness studies complicates matters further, making it hard to compare the impacts of a $20 000 reduction in air quality monitoring with an identical cut in tobacco control. Adding more ambiguity, there is often an absence of clearly defined outcomes. In this time of fiscal urgency, answers are nonetheless needed, and public health leaders are being asked to make optimal decisions using incomplete evidence to reach imprecise goals.

Present

Practitioners and researchers have been working to improve resource allocation decisions for several decades. The funding cuts in the last few years have put even more focus on the current state of knowledge. Although by no means complete, significant progress had been made.

One of the primary building blocks of improved understanding is comprehensive data. The National Association of County & City Health Officials (NACCHO) compiles a national profile of local health department (LHD) organization characteristics, funding, expenditure, staffing, and services.2 The Association of State and Territorial Health Officials (ASTHO) compiles similar data at the state and territory levels.3 The NACCHO and ASTHO data sets both monitor change over time, which is helpful in public health where it can take years for an investment in prevention to demonstrate benefits. These organizations also perform special studies on rapidly developing changes, giving practitioners and researchers time to react. For example, to gauge how state health administrator set priorities amid budget changes, ASTHO and Johns Hopkins Bloomberg School of Public Health collaborated on a survey in 2011.1

Measures of health outcomes are constantly improving. The National Center for Health Statistics at the Centers for Disease Control and Prevention tracks trends in chronic conditions, infections, mortality, and many other key indicators of population health.4 Community Health Status Indicators, Trust for America's Health, and the County Health Rankings track morbidity, health behaviors, and environmental conditions over time, allowing apples-to-apples comparisons of different areas.

This growing library of resources is giving researchers and practitioners fuel for more sophisticated analysis of the links between funding, staff, services, and outcomes.5 Starting with the link between funding and service "production," some studies measure the strength of the connection between expenditures and essential services, with higher spending LHDs providing a broader range of services.6,7 Other studies focus on the source of funds, finding that local contributions have a stronger positive impact on essential service performance than funds derived from state or federal sources.8 Adding detail to the links between funding and services, some studies explore the intermediate decisions regarding staff, finding that higher spending per employee led to better LHD performance.6 Qualitative studies deepen the understanding of processes and decisions, such as the weight that community health needs carry in resource allocations made by boards of health and directors9 or the importance of sustainable, stable streams of funding.10

As the study of public health finance matures, standardized analysis tools are being developed to produce comparable findings in less time. Operating efficiencies can be improved with ratio analysis tools.11 The Public Health Uniform Data Set under development provides the double benefit of standardizing the entry of financial and operating data and easily comparing one LHD with peers,12 both of which facilitate the identification of best practices. Another tool simplifies the comparison of alternative fund allocations, determining whether expenditures align with measures of need.13

Many of these studies are made possible only with the help of practice-based research networks (PBRNs). Budgetary pressures can increase the urgency of moving ideas from theory to practice, allowing LHDs to implement cuts in a manner that does the least harm. The involvement of practitioners and PBRNs can yield research that is more immediately practical and implementable. In addition to practitioners, a number of organizations provide valuable support to the study of public health, including the Robert Wood Johnson Foundation, NACCHO, ASTHO, Centers for Disease Control and Prevention, the Department Health and Human Services, Trust for America's Health, and the Institute of Medicine. Giving a forum to this work, the Journal of Public Health Management and Practice has been an invaluable ally, disseminating findings quickly to both practitioners and researchers. This is the third time this journal has dedicated an issue to public health finance.

Challenges

It is worth pausing to recognize that the research done to date, beyond just those explicitly mentioned, has been substantial. This is especially noteworthy, given the difficulties involved in studying public health. Unlike hospital or physician data, there are few reporting standards for financial or operating statistics, making it difficult to compare LHDs, even within the same state or county. Funding comes from multiple sources, some with proscribed spending rules that constrain attempts to put resources where they do the most good. Many studies have to do costly, time-consuming primary data collection. Outcomes for some services, such as emergency preparedness, are difficult to measure since it is a capacity that is not often fully tested. Surveillance, inspection, and monitoring activities are considered effective when no adverse events occur, but determining whether less investment would have returned the same null outcome can be both difficult and dangerous. Other services, such a nutrition education, may have outcomes that take years to develop.

In the light of such hurdles, past research accomplishments are evidence that upcoming challenges can be met. Currently, one of the most pressing concerns is reductions in public health funding. More than half of all LHDs saw budget reductions between 2008 and 2010 in a recent NACCHO survey, with more than 23 000 estimated jobs lost.1 With continued pressures on state and federal budgets, deeper reductions are possible, further compounding the loses.14 Another related concern stems from the trend toward privatizing public health functions.15 This shift started before the 2007 recession and continued budgetary pressures could make it even more attractive today. Although it may be financially appealing, quality concerns require privatization to be accompanied with performance standards.

Future

Outcomes are one of the ultimate goals of public health. There is a long chain of decisions and actions that occur between the receipt of funding and the achievement of goals. First, the funds must be divided among various programs. Second, functions must be staffed with a mix of people having the right background and skills. Third, staff may need office space and equipment. Fourth, offices should be positioned to serve the largest number of people while balancing travel time constraints. Services may need to be tailored on the basis of cultural and socioeconomic factors. There may be interaction benefits between programs, such as immunization and school health programs. Even if practitioners do everything right up to this point, the last links are sometimes out of their control. For example, patient education participants must decide to change behavior. And even then, genetic and environmental factors may reduce the effectiveness of a perfectly implemented intervention.

Intertwined with each decision in this process are the resource constraints that limit the spending, staffing, or facilities used to provide services. A great deal of research has already been done on the costs, effectiveness, and benefits of public health. Some studies focus on specific programs, such as immunization,16 where the benefits include reduced influenza infection rates, fewer physician visits, and less absenteeism from work or school. Scores of studies focus on conditions such as obesity, with some programs costing as little as $900 per quality-adjusted life-year saved.17 Yet, other studies look at the effectiveness of staff credentials on disparities in health outcomes.18 Adding depth to the picture of staff performance, qualitative studies explore practitioner reactions to measures of quality.19 Often working with limited data, the practitioners and researchers behind these studies have provided invaluable insights that can make a positive difference in the lives of millions.

To maximize the benefits derived from limited public health resources, a comprehensive set of outcome measures is essential for the future. Beyond the work already discussed, a broader focus is needed to create "uniformly stated aims to serve as systemwide indicators of quality."20 Although studies already completed can help judge individual programs, it is difficult to decide whether $200 000 in discretionary funds is best spent on obesity prevention, tobacco control, or air quality. These overarching goals can help balance funding between programs and can be incorporated into privatization quality requirements.

As researchers and practitioners begin to better understand the production process of public health, a comprehensive set of outcomes will help ensure that limited resources yield the maximum benefit. This evidence on the costs and benefits of investments in public health will also inform funding formula decisions. In this regard, a focus on demonstrating the benefits of public health-in the dollars and cents terms of budget-conscious public officials-may be a promising route to expanded funds in the future.

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