Introduction: In 1993 health care reform including universal coverage appeared imminent. Some county health departments elected to discontinue provision of direct services including sexually transmitted disease (STD) care. County A moved in this direction with final clinic closure in 1996. Coincidentally, two other counties elected to continue their STD treatment services. These events have created a "natural experiment" in which to evaluate the contrasting strategies among three counties. Methods: This report describes the changes in local delivery over a three-year period (1993-1995). Measurements were carried out in three counties in two states. STD program capacity, service delivery, and morbidity rates for STDs (chlamydia and gonorrhea) were monitored in each study county. Quantitative data were complemented by a qualitative patient survey at each site. Results: Capacity changed dramatically in County A as compared with the other two over the three-year period. Major declines in STD clinic visits (-43%) and laboratory testing (-46%) occurred. A major drop in reported STD incidence (-23% for chlamydia and -49% for gonorrhea) also occurred, including a drop in public provider reporting. Conclusions: In County A, a decision to end delivery of personal health services led to a divestiture in STD service delivery and a decline in all measured parameters. Etiology of concurrent declined in reported STDs is unclear. Possibly decreased public services led to a spurious decline in reporting. Alternatively, an overall strategy of shifting care to private providers has succeeded in reducing disease. Public health surveillance may be less accurate in such settings.
