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LETTER |
The authors are with the Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pa.
Correspondence: Requests for reprints should be sent to Christopher Keane, 211 Parran Hall, 130 DeSoto St, Pittsburgh, PA 15261 (e-mail: crkcity{at}pitt.edu).
We appreciate Pierce’s and Blackburn’s comment on our article and share their interest in evaluating the effects of privatizing services formerly provided by local health departments.1 A few resources are available, including a workbook that the National Association of County and City Health Officials designed to help local health departments examine their role in the provision of clinical services.2 Also, we recently completed a study of privatization’s effect on access of the uninsured to certain health services. Elsewhere, we reported outcomes of privatization as perceived by local health department directors.3,4 These perceptions reveal a variety of ways that privatization affects the public health infrastructure and suggest some of the measures of process and outcome that should be included in structured evaluations. Such measures include not only indicators of access and outcome associated with specific services but also broader indicators of public health capacity.3–5 Unfortunately, access and public health infrastructure frequently have not been priorities among politicians exerting political or financial control over local health departments.
Many local health departments have faced external pressures to privatize. These pressures often have been based on general state or local governmental policies, such as hiring freezes, or general ideologically oriented premises, such as the stance that less government is better.6,7 Carefully designed evaluation studies could provide a factual basis for privatization decisions. Such evaluations should not rely solely on the outcome measures typically used in studies of personal health services; they must also find ways to measure the impact of privatization on broader public health infrastructure. Our survey revealed that many local health department directors were concerned that contracting out certain services, particularly those relating to communicable disease, can result in a loss of capacity to respond to disease outbreaks and other public health crises.1,3
A final point concerns the design of evaluation studies. It was helpful that Pierce and Blackburn compared local to statewide trends in immunization coverage. National and statewide secular trends may be attributable to a variety of factors, such as the Clinton administration’s efforts to increase childhood immunization rates. Ideally, an evaluation study could control for a range of potential confounders, but elaborate evaluations of individual public health privatization initiatives rarely have been funded (one exception was the evaluation of Pennsylvania’s "Community Health Project").8
It is also important to monitor trends within vulnerable populations. For example, the statewide survey cited by Pierce and Blackburn indicated that vaccination coverage, as defined in the Texas Immunization Survey, decreased among children without health insurance in Texas, while coverage increased among insured children.9 Evaluators should confirm that any overall increase in access associated with privatization is not masking declines in access among the uninsured.
References
1. Keane C, Marx J, Ricci E. The services privatized in local health departments. Am J Public Health.2002;92:1250–1254.
2. National Association of County and City Health Officials. Making strategic decisions about service delivery (Partnerships Project). Available at: http://www.naccho.org/project52.cfm. Accessed February 3, 2003.
3. Keane C, Marx J, Ricci E. Perceived outcomes of privatization in local health departments. Milbank Q.2001;79:115–137.[ISI][Medline]
4. Keane C, Marx J, Ricci E, Barron G. The perceived impact of privatization on local health departments. Am J Public Health.2002;92:1178–1180.
5. Keane C, Marx J, Ricci E. The privatization of environmental health services. Public Health Rep.2002;117:62–68.[ISI][Medline]
6. Keane C, Marx J, Ricci E. Public health privatization: proponents, resisters and decision-makers. J Public Health Policy.2002;23(2):133–152.[ISI][Medline]
7. Keane C, Marx J, Ricci E. Managerial and professional beliefs influencing public health privatization: results of a national survey of local health department directors. J Health Soc Behav. In press.
8. Buchanich J, Keane C, Lin C, et al. Evaluation Study of the Community Health Project: Findings and Recommendations. Pittsburgh, Pa: Center for Public Health Practice, University of Pittsburgh; 1999.
9. Texas Department of Health, Immunization Division Web site. Texas immunization survey. Available at: http://www.tdh.state.tx.us/immunize/tis.htm. Accessed February 3, 2003.
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