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Should They Stay or Should They Go? Leader Duration and Financial Performance in Local Health Departments

Jadhav, Emmanuel D. DrPH, MHM, MSc; Holsinger, James W. Jr PhD, MD; Mays, Glen PhD, MPH; Fardo, David PhD

Journal of Public Health Management and Practice: March/April 2015 - Volume 21 - Issue 2 - p 151–160
doi: 10.1097/PHH.0000000000000119
Original Articles

Context: The delivery of programs by local health departments (LHDs) has shifted from “if we do not have the money we don't do it” to LHD directors should “identify and fund public health priorities.” This shift has subsequently increased performance expectations of LHD leaders. In the for-profit sector the leaders' failure to perform has resulted in a shortening tenure trend. Tenure is a proxy for human capital accumulation. In LHDs, the nature of association, if any, between leader tenure and agency performance is unknown.

Research Objective: Examine association between financial performance of LHDs with short-, average-, and long-tenured LHD leaders.

Study Design: Variation in leader characteristics and percent change in expenditure were examined using a longitudinal cohort design and positive deviance methodology. Bivariate analysis of LHD financial performance and leader characteristics was conducted, and a logistic regression model was developed to test association between leader tenure and LHDs that experienced a positive percentage expenditure change.

Participants: From a total of 2523 LHDs, 1453 were examined. The cross-sectional surveys of US public health agencies conducted by the National Association of County and City Health Officials in 2008 and 2010 contain the leader and LHD variables.

Results: Approximately 44% of LHDs experienced a positive percentage expenditure change. Leader tenure, age, gender, and education status were significantly associated with a positive percentage expenditure change using a chi-square test of independence. From the logistic regression analysis tenure, educational status, employment status, area population, governance, classification, and jurisdiction were statistically significant. Local health departments with leaders whose tenure was less than 2 years were less likely than those with average tenure to experience a positive percentage expenditure change.

Conclusions: The odds ratios for tenure suggest that tenure is positively associated up to a threshold level and then declines. Implying that LHD financial performance is sensitive to leader tenure.

The objective of this research paper was to examine the association between financial performance of local health departments with short-, average-, and long-tenured local health department leaders.

Department of Health Management and Policy (Drs Jadhav, Holsinger, and Mays) and Department of Biostatistics (Dr Fardo), University of Kentucky College of Public Health, Lexington.

Correspondence: Emmanuel D. Jadhav, DrPH, MHM, MSc, Department of Health Management and Policy, University of Kentucky, 111 Washington Ave, Lexington, KY 40536 (

James W. Holsinger Jr is a Board Member of Africa University, Nathaniel Mission, Association of Theological Studies, and Foundation for Evangelism and is also a consultant to Kentucky Health Partners. Glen Mays is the Co-PI at the National Coordinating Center for Public Health Services and Systems Research, which is funded by the Robert Wood Johnson Foundation. For the remaining authors, none were declared.

The authors express appreciation to the National Association of County and City Health Officials for the use of survey data of local health departments.

The authors declare no conflicts of interest.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.