Recent changes in selected local health departments: implications for their capacity to guarantee basic medical services.

Local public health departments traditionally have been supported as providers of preventive care and, in some jurisdictions, as guarantors of other essential services to vulnerable populations that usual providers do not reach. In the 1980s, the responsibility for allocating federal grants for public health shifted to the states, and those funds were reduced by about 20 percent. These circumstances, coupled with a deep recession, raised questions about the capacity of public health agencies to guarantee basic medical services for their constituent populations. Comparing information obtained in 1978-1979 with that obtained in 1982-1983 from 15 local health departments geographically dispersed throughout the United States, we found that, in the aggregate, the capacity of the departments to provide and guarantee personal health services had diminished. These departments had maintained what a panel of experts judged to be notable personal health services programs in the late 1970s. However in 1982-1983 (with some exceptions) the departments as a group had smaller budgets and staffs than they'd had four years earlier, had undergone extensive turnovers in leadership, found their relationships with the private sector increasingly strained, experienced a greater demand for their services, accentuated income-producing services, and were realigning themselves politically to interact more with state and local governments than with federal agencies. One department ceased to function as a guarantor of care; the capacity of four others to fulfill this role was jeopardized. The resourcefulness and adaptability of the remaining departments enabled them to continue to guarantee basic medical care for their service populations.