| Local public health officials make resource allocation decisions that determine which services departments offer and, therefore, which population groups will benefit. Officials suggest that they lack adequate discretion in allocation to meet community needs. We analyzed data from two national surveys to assess the types of allocation decisions officials make, factors that influence allocation, and the role of bureaucratic discretion in allocation. We also analyzed data from focus groups with members of the public deliberating about allocating scarce resources and implementing social distancing measures during an influenza pandemic.;Officials reported little shifting of funds among population groups but more adjustments to staffing effort. Most did not conduct needs assessments prior to allocation. The effectiveness of activities, being the sole provider in a community, previous budgets and input from Boards of Health were influential factors in allocation. Decision tools or economic analyses, direct public input, needs assessments and input from colleagues were least influential. Officials reported they had discretion to reallocate one third of funds and nearly one half of staff time. Multivariate OLS analyses did not support our hypothesis that higher proportions of revenues from local sources would be associated with higher discretion in allocation. Bivariate analyses indicated a positive association between discretion and the ability to meet community needs.;Focus group participants shared concerns about economic and emotional burdens associated with social distancing measures, including fear of job loss due to illness or school closure. Many objected to closing religious institutions and expressed distrust of government. Groups did not reach consensus on allocation of scarce resources, but they did emphasize fairness. They made utilitarian and egalitarian arguments for giving priority to the most vulnerable, children, and those who could keep society functioning. Some expressed public-spirited attitudes and showed capacity for deliberation.;Together, the findings from these studies suggest that officials' discretion in allocation may be important in meeting community needs and that deliberation may be useful in gauging community support, eliciting community concerns, and garnering public trust. Future research should focus on collecting accurate revenue and expenditure data, producing evidence of effectiveness, and supporting needs assessments prior to allocation. |
