Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

Perceived Need Versus Current Spending

Gaps in Providing Foundational Public Health Services in Communities

Bekemeier, Betty PhD, MPH, FAAN; Marlowe, Justin PhD, MA; Squires, Linda Sharee PhD, BSN; Tebaldi, Jennifer BS, MBA; Park, Seungeun MSN, RN

Journal of Public Health Management and Practice: May/June 2018 - Volume 24 - Issue 3 - p 271–280
doi: 10.1097/PHH.0000000000000612
Research Reports: Research Full Report

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.

Department of Psychosocial and Community Health, University of Washington School of Nursing, Seattle, Washington (Drs Bekemeier and Squires and Ms Park); University of Washington Daniel J. Evans School of Public Policy and Governance, Seattle, Washington (Dr Marlowe); and Washington State Department of Health, Tumwater, Washington (Ms Tebaldi).

Correspondence: Betty Bekemeier, PhD, MPH, FAAN, University of Washington School of Nursing, Box 357263, Seattle, WA 98195 (

This study was funded by a Robert Wood Johnson Foundation's (RWJF's) Public Health Practice-Based Research Network grant (#71132). The authors gratefully acknowledge the support of the many practice partners who were integral to this study in terms of providing data, helping ensure data integrity, aiding study interpretation, and identifying study implications.

The authors have no conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.