State Funding Formulas for
Local Public Health:
A Look Back at the Literature
A Look Back at the Literature
OVERVIEW
This project is a study of methods used within state
public health
systems to fund local public health services and a preliminary analysis of the relationship of funding formulas to public health activities and performance.
METHODS
We review published literature for the past 30 years
reporting on 1)
classification methods for state-local relationships relevant to public health financing;
and 2) funding formulas
in effect for local public health activities including per-capita allocations, block grants, competitive grants, performance-based funding, mandated funding “floors,” performance standards, and population-density allocations.
RESULTS
At least five different classification systems
focusing on the
state-local relationship have been reported over the past three decades that have relevance for states’ financing of local public health services
and programs.
Additionally, previously reported study of 8 states using well-established performance-based approaches to funding local public health units provide evidence that financing can be tied to performance and accountability.
CONCLUSIONS
Classifications of the state-local relationship have
direct relevance to
the states’ use of various funding formulas for
local public health programs and activities.
Further insight may be gained by conducting in-depth
case study of
funding formulas in use among states selected on the basis of how their state-local relationships are classified.
Margaret A. Potter, JD, Associate Dean and
Director, Center for Public Health Practice, Graduate School of Public Health,
University of Pittsburgh
Tiffany Fitzpatrick, BASW, Fellow, Center for Public
Health Practice, Graduate School of Public Health, and Master’s Degree
Candidate, School of Social Work, University of Pittsburgh

For additional information please contact:
Margaret A. Potter, JD
Center for Public Health Practice
Graduate School of Public Health
University of Pittsburgh
Finance-Relevant
Classification Systems
for States as Reported in Literature: 1977 through 2005
In the table at
right, states selected for subsequent funding-formula case
study are printed in green.
Organizational relationship between state
and local health departments: Miller
et al. (1974 survey, published 1977); DeFriese et al. (survey data re-analyzed, 1981). Centralized (state authority for local units); decentralized (local
gov’t authority); shared
(local operation with state appointive, budgetary, or planning oversight). More highly centralized states may distribute block grant funds with
greater discretion and less
autonomy for local programs.
Local control and spending relative to state:
Wall, Urban Inst. (1988),
“Assessing the New Federalism Project.” Local agency (12 states’ data) has: Low control/low spending: High
control/ low spending: Low control/
high spending: High control/high spending. Local control of programming may
be offset by relatively high spending of state funds; high proportion
of local funding suggests greater
vulnerability of programs
and services to resource fluctuation.
Statutory authorization for 10 essential services of
public health: Gebbie & Hwang (1997). Statutes are: Highly Congruent (7+ essential services): Congruent (4-6
essential services): Divergent (<4 essential services).
Greater “congruence” between
state-law mandate and individual essential
services may be associated with more direct state funding targeted to specific essential services at the local level.
Distribution of Public Health responsibilities: Gostin
& Hodge (2002),
Turning Point. Top-down(7 states): Hybrid/shared (22 states):
Bottom-up(17 states). More
“top-down” states may provide
more direct methods of funding local services, such as state general revenues, tax set-asides for
specific programs, and state
grants for local need-based initiatives.
Performance case study: Thielen, Robert
Wood Johnson Fndn (2004),
Accreditation of Health Agencies.
Eight-state performance-program
case study. Accreditation, credentialing, and certification of local agencies
indicates state funding tied
to performance and accountability.
Proportion of
Local budget administered by
state: Public Health
Fndn (2002) – Performance Mgmt. Survey.
Groupings: 0-25%; 26-50%; 51-75%; 76-100%. Performance management by state at local level is associated with receiving more than half of funding
from state
76-100%
hybrid
Shared
West
Wyoming
0-25%
bottom-up
high control/high spending
Shared
Midwest
Wisconsin
25-50%
hybrid
Shared
South
West Virginia
51-75%
X
bottom-up
low control/high spending
Decentralized
West
Washington
76-100%
top-down
Centralized
South
Virginia
n/a
n/a
Northeast
Vermont
26-50%
bottom-up
Decentralized
West
Utah
51-75%
hybrid
high
control/high spending
Decentralized
South
Texas
76-100%
hybrid
Centralized
South
Tennessee
76-100%
hybrid
Decentralized
Midwest
South Dakota
76-100%
top-down
Centralized
South
South Carolina
n/a
n/a
Northeast
Rhode Island
26-50%
hybrid
Shared
Northeast
Pennsylvania
0-25%
bottom-up
Decentralized
West
Oregon
51-75%
hybrid
Shared
South
Oklahoma
0-25%
X
hybrid
Decentralized
Midwest
Ohio
0-25%
bottom-up
Centralized
Midwest
North Dakota
0-25%
X
hybrid
Decentralized
South
North Carolina
51-75%
hybrid
high
control/low spending
Decentralized
Northeast
New York
76-100%
top-down
Centralized
West
New Mexico
0-25%
X
bottom-up
low control/high spending
Shared
Northeast
New Jersey
0-25%
hybrid
Decentralized
Northeast
New Hampshire
n/a
bottom-up
Centralized
West
Nevada
26-50%
bottom-up
Decentralized
Midwest
Nebraska
unknown
bottom-up
Centralized
West
Montana
0-25%
X
bottom-up
Shared
Midwest
Missouri
76-100%
top-down
Centralized
South
Mississippi
0-25%
hybrid
high control/low spending
Centralized
Midwest
Minnesota
unknown
X
hybrid
high control/low spending
Shared
Midwest
Michigan
n/a
hybrid
low control/high spending
Decentralized
Northeast
Massachusetts
51-75%
hybrid
Centralized
South
Maryland
n/a
bottom-up
Decentralized
Northeast
Maine
76-100%
top-down
Centralized
South
Louisiana
51-75%
hybrid
Shared
South
Kentucky
n/a
hybrid
Decentralized
Midwest
Kansas
25-50%
bottom-up
Decentralized
Midwest
Iowa
0-25%
bottom-up
Shared
Midwest
Indiana
26-50%
X
hybrid
Decentralized
Midwest
Illinois
n/a
bottom-up
Decentralized
West
Idaho
unknown
Centralized
West
Hawaii
25-50%
hybrid
Shared
South
Georgia
76-100%
X
top-down
low control
& spending
Centralized
South
Florida
76-100%
n/a
South
Delaware
0-25%
bottom-up
Centralized
Northeast
Connecticut
51-75%
bottom-up
low control/high spending
Shared
West
Colorado
n/a
hybrid
high
control/low spending
Decentralized
West
California
76-100%
top-down
Centralized
South
Arkansas
51-75%
bottom-up
Shared
West
Arizona
51-75%
hybrid
Shared
n/a
West
Alaska
76-100%
hybrid
low control & spending
Shared
South
Alabama
% of local budget administered by state
Performance assessment case study
Distribution of public
health responsibilities: state/local
Local control and local spending
Organizational relationship: state/local
DHHS Region
(U.S. Census)
STATES