According to this literature review, progress since a 1988 report on infrastructure development of the public health system has been limited. More research is needed to help policy-makers determine how to build an effective and equitable system with limited resources.

The purpose of this systematic review is to “synthesize what is known about the organization and structure of local and state public health agencies,” focusing on three key questions: (1) what descriptive research exists; (2) what is known about the relationship between health agency organization/structure and performance and capacity; and (3) what is the relationship between agency organization/structure and population health outcomes. Seventy-seven records related to U.S. research between January 1990 and September 2010 were included.

Key Findings:

• One of the strongest, most consistent findings across studies is that the greater the population size served by an agency, the more likely that agency will provide the 10 “Essential Public Health Services.” This suggests consolidation or regional cooperation is desirable, although the evidence to still insufficient.
• There is “relatively strong evidence” public health expenditures and per capita funding are associated with performance, but this analysis is hampered by lack of data uniformity.
• Evidence of other structural characteristics is mixed, which may be due in part to inconsistent measurement.
• There is a “surprising lack of research” regarding “best practices” for public health agencies serving small and rural populations.
• There is a notable gap in evidence to back up the hypothesis that better public health performance leads to better population health outcomes. This link is complicated to prove but is key to justifying investments in funding and organizational strategies.

The authors note multisite studies are needed to examine capabilities and organizational structures within different settings, such as urban, rural, alternative governance structures, etc.