A Mixed Methods Inquiry of North Carolina Local Health Department Budget and Workforce

Abstract

Local health departments (LHDs) serve as the frontline infrastructure of the United States public health system but have experienced decades of chronic underfunding and workforce instability. This mixed methods study examines long-term workforce and funding trends among North Carolina LHDs and explores contextual factors influencing these changes. A quantitative analysis utilized data from the National Association of County and City Health Officials (NACCHO) Profile of Local Health Departments for 2008-2019. The percentage change in full-time equivalent employees (FTEs) and CPI-adjusted expenditures per FTE are examined to determine whether North Carolina trends differ from national patterns across jurisdiction types and population categories. Qualitatively six focus groups with North Carolina Local Health Directors examined perceived barriers, strategies for improvement, and priorities for strengthening the public health system. Guided by a public health systems framework adapted from Handler and the CDC’s Essential Public Health Services framework, this study combines quantitative findings with leadership perspectives to inform policy and practice aimed at strengthening local public health capacity.