Public health privatization: proponents, registers, and decision-makers.

We previously documented the extent and consequences of the privatization of public health, using a nationally representative sample of 347 Local Health Department (LHD) directors. Here we present the directors' descriptions of the actors involved in the privatization of services. LHD top administrators are the most influential privatization decision-makers in about half of LHDs. But other groups significantly influence privatization decisions, particularly state governments, state health departments, and local officials. Nearly two thirds of LHDs experienced pressures to privatize, either from state legislatures, state health departments, funding organizations, or other source of political pressure. Almost half of LHD directors reported resistance to privatization, often from employees. The majority of directors did not believe it was desirable to put employees on a temporary, contractual basis. Many directors believed that retaining permanent, full-time employees was fairer as well as necessary to maintain a cadre of experienced public health professionals.