Date of Award




Document Type


Degree Name

Doctor of Philosophy (PhD)


Department of Public Administration and Policy

Content Description

1 online resource (v, 179 pages) : illustrations (some color)

Dissertation/Thesis Chair

Erika Martin

Committee Members

Ellen Rubin, Gus Birkhead


Applied Econometrics, Contracting, Performance Management, Public Health, Public health administration, Public contracts

Subject Categories

Economics | Public Policy


Contracting out and performance management have been universally adopted in public sector organizations, based on theoretical arguments that they would improve the efficiency and quality of public services. However, this broad adoption was carried out despite minimal empirical evidence that these interventions improve public service outcomes in practice. Traditionally, few studies have attempted to quantitatively link performance management and contracting out interventions to improvements in organizational performance and public service quality. A growing literature has investigated this relationship with inconclusive results, suggesting these interventions do not have a clear ability to improve organizational performance. This dissertation examines these relationships in a national sample of Local Health Departments (LHD). LHDs are public sector organizations that provide essential public services at the local level, often serving an individual city or county. LHDs are a promising setting to investigate these relationships because they have evidenced widespread adoption of contracting out and performance management, and show a wide range of contextual diversity in terms of organizational size, resources, and populations served which are transferable to multiple public sector contexts. The first paper of this dissertation evaluates the relationship between LHD contracting out and changes in population health outcomes in the communities they serve. The second paper evaluates the relationship between LHD performance management and changes in population health outcomes. Two types of LHD performance management practices are evaluated: community health assessments and community health improvement plans, which are used to statistically evaluate community health status and plan interventions to improve population health, and quality improvement, which is used to identify organizational processes which can be improved, and to track measurable progress towards these goals. The third paper investigates the relationship between LHD epidemiology and surveillance capacity, which indicates the ability to manage data and engage in evidence-based decision-making, and quality improvement adoption and implementation. Consistent with prior results, outcomes are not clearly better in LHDs that adopt contracting out and performance management, however there is no evidence that they are damaging to organizational performance, and some results that indicate small performance improvements. These positive results suggest specific attributes of these interventions that may contribute to their success, such as whether they help organizations learn about how to improve their processes, or whether they help organizations mitigate financial constraints. Ultimately, they suggest that future investigations into the relationship between contracting out and performance management and organizational performance and service quality should focus on understanding how implementation of these interventions can contribute to their success.