Graduation Year


Document Type




Degree Granting Department

Public Health

Major Professor

Barbara L. Orban, Ph.D.

Co-Major Professor

James Studnicki, Sc.D.

Committee Member

Ann L. Abbott, J.D., Ph.D.

Committee Member

M. R. Francois, M.D., Ph.D.

Committee Member

Yougui Wu, Ph.D.


Health care cost /financing, Health care service availability, Health science research, Medically underserved populations, Outcomes research, Public health


Since the mid-1970s, top managers, politicians, and officials in both public and private institutions have promoted contracting-out services (privatization) as a means of increasing efficiency, flexibility, and quality. The privatization trend has occurred in many public sector organizations particularly in city services and prisons. Public health services are not immune to this trend. Today many county health departments have contracted the provision of public health services like womens health, primary care, and laboratory services. However, very few studies have analyzed the impact of these privatizations on cost, access, and health outcomes. Proponents favoring the private provision of these services argue that private providers are more efficient and can deliver these services at a lower cost. Also, because of better innovation, private providers can even improve quality. However, among opponents there is concern that a for-profit private provider might cut costs that adversely affects the quality of these services.

The purpose of this dissertation is to analyze the effects of the privatization of primary care services on cost, access, and health outcomes in nine large counties in the state of Florida. In a survey of county health departments conducted in 1999, 61 out of 67 counties had outsourced at least one service. Primary care was the second most frequently privatized program. Womens health was the program most often privatized by counties. Using mixed models and logistic regression, a comparison was made between large counties that outsourced primary care services and counties that did not. Multiple years of data were obtained from federal and state sources for analysis. This study answers the following research questions: 1) What are the costs of primary care services provided by contracted service providers compared to services provided by the public health department? 2) Where primary care services have been privatized, what is the effect on access to care for the Medicaid and uninsured patients? 3) What is the effect of privatization on health outcomes in privatized and non-privatized counties?