Consolidating Local Health Departments in the United States: Challenges, Evidence, and Thoughts for the Future

Local health departments (LHDs) in the United States face many challenges, including limited local capacities (eg, staffing, expertise), financial pressures, and potentially strained interactions with affiliated local and state governments that are facing fiscal uncertainties. At the same time, demands on LHDs continue to grow. Old nemeses such as infectious diseases and natural disasters are being supplemented with growing challenges such as bioterrorism and chronic diseases, and this change requires greater LHD capacities for providing essential services. Some of these challenges cannot be addressed adequately by LHDs acting individually, particularly by small LHDs. So, LHDs are seeking to collaborate with one another. Collaborative relationships between LHDs develop in various ways, ranging from the establishment of loose organizations that aid in the sharing of information, resources, expertise, and capacity to fullfledged consolidations (Figure 1). In this commentary, we discuss legal structures and trends affecting LHDs and their abilities to address the challenges they face in the 21st century. We focus on the consolidation of LHDs, which researchers suggest may result in benefits, particularly for communities served by small LHDs. More specifically, we address the extent to which LHD consolidations are occurring and the ways in which they are done, the factors that facilitate these consolidations, and the effects they may have on services and finances. We also summarize recent literature on LHD consolidation and close with thoughts on the state of knowledge on LHD consolidation and areas for future research.