Perceived Need Versus Current Spending: Gaps in Providing Foundational Public Health Services in Communities

OBJECTIVE: Our objective was to estimate the gap between the costs for local health jurisdictions (LHJs) to provide foundational public health services (FPHS) and actual spending on FPHS and to examine factors associated with that gap. DESIGN: We employed resource-based cost estimation methods for this observational study and conducted multivariate analyses with measures derived from secondary administrative data. We used primary data collected from LHJ leaders that depicted 2014 spending and perceived need. We also included secondary administrative data depicting annual 2000-2013 expenditures organized into categories containing key elements of FPHS areas. SETTING: We included primary data from a representative sample of 10 LHJs in Washington State and secondary data for all 35 LHJs in Washington. PARTICIPANTS: Participants were public health practice leaders from each sample LHJ. MAIN OUTCOME MEASURE: Our main outcome of interest was the gap identified between current spending and the perceived spending needed to provide FPHS in a jurisdiction. RESULTS: Actual FPHS spending was approximately 65% of spending needed to provide overall FPHS for our sample LHJs, but the size of the gap varied substantially by program. Some gaps also varied widely by LHJ, with spending gaps widest among rural and high poverty communities. Percent poverty and the metropolitan nature of a jurisdiction were factors significantly related to FPHS spending in our multivariate analyses. CONCLUSIONS: Actual spending lags far behind local officials' estimates of spending needed to provide FPHS and is likely influenced by local conditions. Major apparent gaps between spending and need, particularly in areas such as costly Business Competencies, underscore the need for cross-cutting capabilities to support public health system responsiveness and for attention to be paid to local conditions.