Local public health expenditures and COVID-19 mortality in 2020: A two-stage technical efficiency assessment of the 50 largest cities in the United States

The allocation of financial resources represents one of the primary tools available to local governments for protecting public health. Researchers have begun to examine the relationship between the total amount of public health expenditures and public health outcomes during the COVID-19 pandemic, but the efficiency of this spending has not yet been examined. This study reports on a two-stage analysis that explores health system considerations associated with variations in technical efficiency in the 50 most populous cities in the United States. Data relating to public health expenditures from 2015 to 2019 and excess mortality in 2020 were collected and used to construct free disposal hull and data envelopment analysis efficiency frontiers. Input and output efficiency score estimates were generated and used as the dependent variable in Tobit regression models that explored health system considerations associated with relative efficiency. Results suggested that large cities in the United States were inefficient, and Baltimore, Milwaukee, Philadelphia, and Washington, DC were among the least efficient. Oklahoma City and Raleigh were assessed as being the most efficient cities. Local health department jurisdiction was the only health system consideration found to be associated with efficiency scores at a statistically significant level. These findings suggest that in the wake of the COVID-19 pandemic, the jurisdictional scope of local health departments could represent one area to focus structural reform efforts as a means of bolstering efficiency and public health preparedness.