National Program Office Research

About the Research

Systems for Action (S4A) is a national program of the Robert Wood Johnson Foundation (RWJF) that aims to discover and apply new evidence about ways of aligning the delivery and financing systems that support a Culture of Health. Since 1998, the National Longitudinal Survey of Public Health Systems or NALYSYS has followed a nationally representative cohort of U.S. communities to measure the implementation and impact of multi-sector population health improvement activites. The following studies were conducted by the S4A intramural team using NALSYS data.



Who Delivers Maternal and Child Health Services? The Contributions of Public Health and Other Community Partners

Improving maternal and child health (MCH) care requires solutions to address care access and the social determinants that contribute to health disparities. Direct service provision of MCH services by local health departments (LHDs) may substitute or complement public health services provided by other community organizations. The S4A intramural team measure MCH service provision among LHDs and examine its association with patterns of social service collaboration among community partners.

Equity-Focused Efforts of Local Public Health Systems and Disparities in Community Health

Disparities in health delivery continue to act as barriers to equitable outcomes in health. Public health system efforts connect local health systems to their network and community members. Public health system capital may play a role in improving community health; however, there may be inequities in local public health system efforts across the United States. S4A intramural investigators examine the relationship between public health system capital and the proportion of community health initiatives and action plans aimed at reducing health inequities/disparities.

The Growing Divide in the Composition of Public Health Delivery Systems, in US Rural and Urban Communities, 2014-2018

S4A investigators examined changes in the scope of activity and organizational composition of public health delivery systems serving rural and urban U.S. communities between 2014 and 2018. Urban public health systems enhanced their scope of activities and organizational networks since 2014, while rural systems lost capacity. These trends suggest that system improvement initiatives have had uneven success, and they may contribute to growing rural-urban disparities in population health status. 

Evaluating Inclusiveness in Multi-Sector Public Health Networks: The Case of Tribal Organizations

Public health networks that include tribal organizations have the potential to better serve American Indian/Alaskan Native residents living in and outside of tribal lands. In this study, we aim to understand the variation of inclusion of tribal organizations to deliver public health services and the predictors of inclusion. We find that the vast majority of public health networks do not report inclusion of tribal organizations. Even when Indian Health Services (IHS) health facilities are present, reported inclusion of tribal organizations remains low.

Investigating the Dynamics of Local Public Health System Capabilities and its Implications on Public Health


Health Reform Implementation and Multi-Sector Contributions to Public Health Delivery Systems

The Affordable Care Act established new resources and incentives for hospitals, insurers, public health agencies, and others to contribute to disease prevention and health promotion activities, potentially changing the structure of public health delivery systems and expanding the implementation of strategies that improve population health. This study uses data from the 1998-2014 National Longitudinal Survey of Public Health Systems to examine: (1) the degree and nature of change in multi-sectoral contributions to public health activities; and (2) the extent to which these system changes are attributable to key ACA provisions including coverage expansions, Prevention and Public Health funding, and adoption of public health accreditation standards.

Preventable Death Rates Fell Where Communities Expanded Population Health Activities Through Multi-Sector Networks

The US health system faces mounting pressure to improve population health. Research suggests a need for greater coordination and alignment across the sectors that deliver medical, public health, and social services. This study uses sixteen years of data from a large cohort of US communities to measure the extent and nature of multisector contributions to population health activities and how these contributions affect community mortality rates. The results show that deaths due to cardiovascular disease, diabetes, and influenza decline significantly over time among communities that expand multisector networks supporting population health activities. The findings imply that incentives and infrastructure supporting multisector population health activities may help close geographic and socioeconomic disparities in population health.

Public Health Spending and Medicare Resource Use: A Longitudinal Analysis of U.S. Communities

Preventable health conditions account for more than 75 percent of annual health care expenditures in the U.S., yet less than 5 percent of these expenditures are devoted to public health programs and services that are designed to prevent and control disease and injury rather than to treat the downstream consequences of these conditions. This study examined data on local public health spending and area-level Medicare expenditures over a 20-year period from 1993 to 2013. Between 1993 and 2013, local public health spending increased from $32 to $55 per capita for the average community. Nearly two-thirds of communities experienced positive growth in per capita public health spending of nearly $4, unfortunately, a third of the communities though suffered a loss of more than $11 per capita. Findings indicate that the degree of inequality in local public health spending closely mirrors the level of income inequality observed among U.S. households such that the public health spending levels ranged from less than $1 per capita to as high as $400 per capita. The results indicate a 10 percent increase in local public health spending per capita is associated with a 0.8 percent reduction in Medicare expenditures per person after 1 year and a 1.1 percent reduction after 5 years. These results suggest Medicare could recover an average of $1.10 for each dollar invested in public health activities after 5 years. If the spending offsets we estimate in this study apply to other populations beyond Medicare, the societal return on investment could be even larger. Finally, results also showed that Medicare spending offsets are more pronounced in low-resource communities, such as areas with higher poverty, lower rates of health insurance coverage, and substantial health professional shortages.

Multi-Sector Population Health Activities Reduce Income-related Disparities in Life Expectancy

Landmark research by Raj Chetty and colleagues at Health Inequality finds wide geographic and intertemporal variation in the relationship between income and life expectancy in the U.S., using 1.4 billion administrative tax records from the IRS linked to nearly 7 million federal death records. Many questions remain about the underlying causes of these findings and their implications for policy.  This study links Chetty’s income and life expectancy data with the 1998-2014 National Longitudinal Survey of Public Health Systems to examine whether the existence and strength of multi-sector population health improvement activities influence income-related disparities in life expectancy over time. Communities attaining the highest level of multi-sector population health activities increased from 24% of the sample in 1998 to 37% in 2006, but fell to 31% in 2012 and recovered modestly to 33% in 2014.  Within sectors, hospitals increased their contributions to population health activities by nearly 20% between 2012 and 2014, while insurers, employers, and nonprofit community-based organizations showed smaller but significant increases in contributions (p<0.05).  Residing in a community with the highest level of population health activity was associated with a 3.9 year gain in life expectancy for individuals in the bottom quartile of the income distribution after controlling for observed and unmeasured confounders (p<0.05), but no significant gain in life expectancy for the top income quartile.  Differences in life expectancy between the top and bottom income quartiles declined by an estimated 2.1 years in communities with the highest level of activity (p<0.01).  Community capacity to implement widely-recommended population health activities is one important contributor to geographic variation in the relationship between income and life expectancy.   

The Effect of Uncompensated Care Costs on Hospital Contributions to Population Health Improvement Activities

The Affordable Care Act (ACA), along with Medicaid expansion, was expected to reduce the rising burden on hospitals from uncompensated care provision to uninsured people while creating new resources and incentives for hospitals to contribute to disease prevention and health promotion activities. By examining the association between area-level hospital uncompensated care provision and hospital contributions to public health activities for the period 2006-2016, our analysis lends empirical evidence to the hypothesis from the extant literature that reducing uncompensated care costs might enable hospitals to re-allocate resources for population health improvement. Hospital participation in public health activities increased from 41% in 2006 to 47% in 2016 with hospitals most likely to contribute to assessment and policy related core public health functions. In 2014 constant dollar terms, relevant area-level uncompensated care costs were estimated to decline from 126 dollars per capita in 2006 to around 103 dollars per capita in 2016. Results from the multivariate model indicate that a one percent increase in the total cost of area-level hospital uncompensated care is associated with a 9 percentage point decrease in hospital contributions to public health activities (p<0.05). Our findings suggest that hospital contributions to population health activities increase as uncompensated care provision declines, consistent with a substitution effect.

Rural vs. Urban: Differences in the Implementation of Population Health Activities

Research indicates that the United States lags behind other high-income countries in public health. This lag relates directly to variable health system quality across U.S. communities, which have different resource bases, different healthcare needs, and different institutional structures to support those needs. In contrast to urban sites, rural communities tend to have fewer available resources for public health, weaker political institutions, and different public health challenges. Understanding variation across urban and rural public health delivery systems is crucial to improving health. This study examines local health systems in both urban and rural communities to better understand how and why differences across communities exist. Using a retrospective design based on a national sample of communities from the 2016 National Longitudinal Survey of Public Health Systems (NLSPHS), the researchers formed a three-tiered measure of public health system quality: comprehensive, conventional, and limited. Initial findings indicate that differences between rural and urban systems persist even when accounting for variables known to drive system quality.

Classifying Multi-Sectoral, Multi-Organizational Health Communication Networks

Facilitating population health and well-being requires organizations and individuals to share information and strategies across systems. Local public health agencies, healthcare providers, and their multi-sectoral partners often lead the way in testing and implementing evidence-based health messages, programs, and practices, sometimes partnering with academic researchers to become hubs for information-sharing among both public and private stakeholders. However, these organizations themselves exist within complex and varied communication networks that incorporate different systems and sectors. The resulting network heterogeneity has important implications for the reach, effectiveness, adoption, implementation, and maintenance of evidence-based projects and programs, but little is known about the composition of these communication networks or how different network constellations drive information dissemination and program implementation activities.

National Longitudinal Survey of Public Health Systems Publications and Products

Since 1998, the National Longitudinal Survey of Public Health Systems (NLSPHS, as of 2018 NALSYS) has followed a nationally representative cohort of U.S. communities in order to study the implementation and impact of multi-sector population health activities.  The survey captures information about the types of health improvement activities that are implemented in U.S. communities, and the array of organizations that contribute to these activities.  By collecting this information consistently in more than 500 U.S. communities over a span of 20 years, the NALSYS has become the nation’s only national, longitudinal source of information about the actions that local communities undertake to protect and improve the health status of their residents.  

This page serves as a home for all NALSYS publications and products that result from the NALSYS dataset. 


National Longitudinal Survey of Public Health Systems

Principal Investigator: Glen P. Mays, PhD, MPH

Since 1998, the National Longitudinal Survey of Public Health Systems (NALSYS) has followed a nationally representative cohort of U.S. communities to measure the implementation and impact of multi-sector population health improvement activities. The survey asks local public health officials in each community to report information on a set of 20 activities that are nationally recommended for monitoring, protecting and improving health status at the population level.