Contracting-Out Decisions in Local Health Services: A Quantitative Analysis of Institutional Isomorphism

Local governments do not make service delivery decisions in isolation or based purely on economic considerations. Instead, they operate within a complex institutional environment shaped by the behaviors of neighboring organizations, political pressures, and professional norms. Missing from the current literature on public health governance is a comprehensive understanding of how these institutional pressures influence local governments’ decisions to contract out public health services. The purpose of this dissertation is to fill this gap by examining how mimetic, coercive, and normative isomorphic pressures shape contracting-out behavior in local health departments (LHDs). First, this dissertation investigates whether mimetic, coercive, and normative pressures influence LHDs’ decisions to contract out public health services. Second, it examines whether the effects of these institutional pressures vary across service types with different levels of asset specificity and service measurability. Using logistic regression analysis on nationally representative data of LHDs from the 2016 and 2019 National Profile of LHDs, this dissertation finds that coercive pressures significantly increase the likelihood of contracting out, while normative pressures, such as accreditation, are associated with lower contracting rates. Mimetic pressures do not show statistically significant effects. Service-level analysis further reveals that institutional influences vary depending on asset specificity and service measurability. By applying neo-institutional theory to a critical yet understudied domain of public service delivery, this dissertation offers new theoretical and empirical insights into how institutional environments shape local policy decisions in decentralized public health governance.