THE IMPACT OF HEALTH-CARE MARKET CHANGES ON LOCAL DECISION-MAKING ANDSTD CARE - EXPERIENCE IN 3 COUNTIES

Introduction: In 1993 health care reform including universal coverage appeared imminent. Some county health departments elected to discontin ue provision of direct services including sexually transmitted disease (STD) care. County A moved in this direction with final clinic closur e in 1996. Coincidentally, two other counties elected to continue thei r STD treatment services. These events have created a ''natural experi ment'' in which to evaluate the contrasting strategies among three cou nties. Methods: This report describes the changes in local delivery ov er a three-year period (1993-1995). Measurements were carried out in t hree counties in two states. STD program capacity, service delivery, a nd morbidity rates for STDs (chlamydia and gonorrhea) were monitored i n each study county. Quantitative data were complemented by a qualitat ive patient survey at each site. Results: Capacity changed dramaticall y in County A as compared with the other two over the three-year perio d. Major declines in STD clinic visits (-43%) and laboratory testing ( -46%) occurred. A major drop in reported STD incidence (-23% for chlam ydia and -49% for gonorrhea) also occurred, including a drop in public provider reporting. Conclusions: In County A, a decision to end deliv ery of personal health services led to a divestiture in STD service de livery and a decline in all measured parameters. Etiology of concurren t declined in reported STDs is unclear. Possibly decreased public serv ices led to a spurious decline in reporting. Alternatively, an overall strategy of shifting care to private providers has succeeded in reduc ing disease. Public health surveillance may be less accurate in such s ettings.