State and Local Health Departments
STATE AND LOCAL HEALTH DEPARTMENTS
State and local health departments fulfill important governmental roles for protecting and assuring the health of the public. Health departments have a well-established, yet complex and slowly evolving, history in the United States. According to the Institute of Medicine's book The Future of Public Health (1988):
New ideas about causes of disease and about social responsibility stimulated the development of public health agencies and institutions. As environmental and social causes of diseases were identified, social action appeared to be an effective way to control diseases. When health was no longer simply an individual responsibility, it became necessary to form public boards, agencies, and institutions to protect the health of citizens. Sanitary and social reform provided the basis for the formation of public health organizations (p.62).
Baltimore, Maryland, established the first city health department in 1798. In general, city health departments were established before state health departments, and well before county health departments. State health agencies developed first in Massachusetts and then across the country during the latter half of the nineteenth century. As American ambivalence about government gave way to a desire for the benefits that local government intervention could provide to the public through sanitation and control of communicable disease, several more health departments were formed in the first half of the twentieth century. In 1953, Joseph Mountin reported that there were 1,239 local health departments in the United States. By 2000, there were state health agencies in every state, and approximately 2,832 local health departments nationwide. The state health departments, and many of the local health departments, were developed and have evolved independently. As a result, health departments vary considerably from state to state and from community to community in their organizational structure, responsibilities, funding mechanisms, performance of core services and competencies, and in the implications for agency accreditation and workforce certification.
A state health department is a centralized unit of state government with overarching responsibility for protecting, assuring, and improving the health of the state's citizens. A unit of state government that matches this broad definition exists in each of the nation's fifty states. The National Association of County and City Health Officials (NACCHO), in collaboration with the Centers for Disease Control and Prevention (CDC), defines a local health department as "an administrative or service unit of local or state government, concerned with health, and carrying some responsibility for the health of a jurisdiction smaller than the state." This definition is very broad and is intended to be inclusive of units that vary in size, including local service units of a state health department. However, the definition does not take into consideration organizational capacity to perform basic or essential services. Units of local government that have health departments include cities, towns, and counties (or equivalents), and there are combinations such as city-county and multiple county. Not all units of local government have health departments.
RESPONSIBILITIES AND ORGANIZATIONAL STRUCTURE
National standards or guidelines do not exist to delineate specific responsibilities for state and local health departments, and there is a wide degree of variation in their roles across the country. As suggested previously, some state health departments perform both state and local roles. In general, however, state health departments operate out of a central location, often the state capital, and represent the principal public sector locus of responsibility for health. The committee formulating the 1988 Institute of Medicine (IOM) report on public health recommended that states should be responsible for the following:
- Assessment of health needs in the state based on statewide data collection.
- Assurance of an adequate statutory base for health activities in the state.
- Establishment of statewide health objectives, delegating power to localities as appropriate and holding them accountable.
- Assurance of appropriate organized statewide effort to develop and maintain essential personal, educational, and environmental health services.
- Provision of access to necessary services.
- Solution of problems inimical to health.
- Guarantee of a minimum set of essential health services.
- Support of local service capacity, especially when disparities in local ability to raise revenue and/or administer programs requires subsidies.
- Technical assistance, or direct action by the state to achieve adequate service levels.
Other responsibilities that are commonly fulfilled by state departments of health include the distribution of federal and state funds to local health departments and other service providers; the assurance of contracts compliance and service quality; and maintenance of a variety of information and data sets, including records of births and deaths, infectious diseases, injuries, hospital admitting diagnoses, health care facilities, and health workforce information. Laboratory services—especially for more complex tests, and in support of smaller local health departments—and epidemiology services—including support of larger outbreaks of infectious diseases—are also provided by state health departments. In addition, states are responsible for agency and health workforce licensure, health planning and administration, and special research projects.
State departments of health are organized in a variety of ways. Some are cabinet-level departments, with the director reporting to the governor or governor's chief of staff. Some departments include responsibility for mental health, substance abuse, and other areas. Other state health departments are subunits of a larger organization such as a department of human services. These organizations are often responsible for the state's Medicaid agency, managed care, hospital and/or insurance regulation, welfare, and, in some cases, corrections.
The roles assumed by local health departments are dependent on the roles of the associated state health department, on the resources available to the local department, and on other local arrangements for services. While many provide environmental health services, local arrangements in some jurisdictions, for example, place such services in other departments of local government. In some states, larger local health departments may have responsibility for some hospital services. In general, larger local health departments serve larger communities, have more resources, and assume a broader array of responsibilities. Most local health departments, however, are small organizations. According to NACCHO, of the approximately 3,000 local health departments in the country in 1997, two-thirds served populations of 50,000 or less, with the mediansized health department having a staff of twenty.
Responsibilities of local health departments generally include the following:
- Monitoring for outbreaks of infectious diseases (e.g., measles, tuberculosis, meningococcal disease), and outbreak response when necessary.
- Health promotion.
- Nutrition programs (e.g., the Women, Infants, and Children [WIC] Program).
- Home visits for infectious disease followup, sudden infant death syndrome prevention, and child abuse prevention.
- Limited "personal health" services, including childhood and adult immunizations; sexually transmitted disease diagnosis, treatment, and followup; HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) testing, counseling, and support services; family planning; and well-baby services.
- Advocacy for and referral of people without health care resources.
- Inspection of eating establishments (e.g., restaurants, bars, fairs) and licensure of food handlers in such establishments to assure food safety.
- Inspection and approval prior to installation of private drinking water wells, septic tanks, and small scale sewage systems.
- Completion of community assessments to determine the strengths and needs of the communities in the jurisdiction.
- Collection and maintenance of vital statistics for the community.
Local health departments are structured in a variety of ways. County health departments are the most common. Such agencies are usually governed by a local board of health comprising the county commissioners (or equivalent) or a panel of citizens appointed by the commissioners. Other models include city health departments (usually governed by a city council), city-county health departments (with shared governance), and multijurisdictional health districts (often governed by stand-alone boards). In many instances, the local health department is governed by a board of political appointees, with few or no elected officials on the board.
In most states, particularly in the West, local public health agencies are usually units of local government. In about one-quarter of the states, nearly all of the local agencies are units of state government and are accountable to the state health department director. Even in these cases, however, the local health departments serving the larger cities is often locally governed. Finally, Native Americans living on reservations are usually served by tribal health departments governed by tribal governments.
In some states, significant portions of the population are not served by local public health services. Only one state, Rhode Island, has no local health departments. A number of counties in some states have no local health department presence. Other parts of the country, such as certain areas within Massachusetts and Connecticut, are served principally by very small local health departments with few employees and very little capacity. In at least one state, Pennsylvania, a few cities and/or counties are served by local health departments, while the majority of counties are served by small regional offices of the state health department. In New Jersey, the city, town, and an array of county and regional health departments provide services through the hundreds of separate boards of health representing each municipality in the state. To further complicate this configuration there exists autonomous municipal-level health departments functioning separately within the counties where county health departments operate.
This confusing and inconsistent organization of local public health services is strong evidence that the nation's local public health infrastructure is weak. The lack of uniform protection of the country's citizens from outbreaks of infectious diseases and other hazards represents potential harm to all residents. In the late 1990s this state of affairs led to the development of national performance standards, to congressional consideration of public health infrastructure needs, and to consideration of alternative methods of providing local public health services.
There are two major barriers to implementing significant improvements in the local public health system: disagreement about the relative importance of local control versus meaningful capacity, and availability of public resources. Some communities and states continue to operate under a tradition that places emphasis on local governance of operations rather than efficiency and service capacity. Other states have chosen to regionalize services or to share resources in order to achieve the capacity to provide essential services. Local offices of regional, multicounty health districts, for example, serve all counties in the state of Idaho. Multiple-county public health districts are employed to a significant degree in Michigan, Washington, and Utah as well. In some states, there is a significant level of resource sharing among smaller health departments (e.g., sharing health officers or administrators in Oklahoma and Washington).
State and local health departments receive their funding primarily from governmental sources. In 1997, sources of the funds expended by state health departments included state funds (55 percent); federal funds (30 percent) and a variety of miscellaneous revenue sources (15 percent). Among local health departments in 1995, 46 percent of total funds came from state and federal sources, 34 percent from local sources, and 10 percent from Medicare and Medicaid, with fees and other sources accounting for the rest.
Public health accounts for very little of the nation's overall health budget. The overwhelming majority of health care dollars are directed to the treatment of illness and injuries, and particularly to those who are in their last year of life. Very little goes to prevention. Total health expenditures in the United States for 1991 were $752 billion. Expenditures by state health agencies and local health departments in that year represented only1.9 percent of all health spending. (Discontinuation of a reporting system in the early 1990s eliminated collection of state and local public health expenditure data. Consequently, more recent data is not available.) For comparison purposes, 2.6 percent of all health spending was attributed to state and local health departments in 1978.
In terms of absolute expenditures, 1991 expenditures of state health agencies were $11.3 billion, more than double the level of expenditures in 1982. The 1991 total included $9.3 billion in direct expenditures and $1.9 billion in transfers to local health departments. Total combined state and local health department expenditures were $14 billion in 1991. Thus, although expenditures for state and local public health have increased over the past two decades, they account for the declining proportions of total national health expenditures.
Some of the categorical funding streams supporting state and local health departments have been capped, and others have decreased. Indeed, Congress and state legislatures provide resources for public health programming principally through categorical grants supporting relatively narrow, often disease–specific, uses of the appropriations. This shifting, disease-of-the-year approach to financing public health is difficult to administer, leaves large gaps, is not tied explicitly to the nation's objectives (e.g., Healthy People 2010), and limits the tailoring of programs to match local and state needs and priorities. In response to these limitations, state and local health departments in many parts of the country increasingly are looking to partnerships with foundations, businesses, and other community organizations to market public health and prevention programs, address infrastructure deficiencies, and initiate efforts to improve health status in their communities.
The workforce employed by state departments of health varies from state to state. In some states, political appointees with little or no expertise in public health fill the executive positions. In others, there is a statutory requirement that physicians who are board certified in preventive medicine fill such positions. A typical state department of health employs a number of professionals to fulfill planning, data analysis, contract compliance, epidemiology and laboratory functions, technical assistance, and other state functions. Typical employees include physicians, nurses, nurse practitioners, dentists, veterinarians, nutritionists, health educators, planners, social workers, epidemiologists, laboratory technicians, biostatiticians, computer technicians, and communications specialists.
As with state health departments, the workforce requirements of local health departments vary widely. The executives of about 35 percent of local agencies have medical degrees (a few states still require that local health directors be licensed physicians). Other professional positions most commonly found in local health departments include nurses, environmental health specialists (sanitarians), health educators, and nutritionists. In addition, larger health departments often employ physicians, nurse practitioners, epidemiologists, dentists, dental hygienists, social workers, outreach workers, planners, and computer specialists.
It has been estimated that between 50 percent and 80 percent of public health workers in state and local agencies have no formal training in the field. A number of resources for workforce development have evolved to address this concern. The Health Resources and Services Administration (HRSA) provides grants for postgraduate studies and public health residencies. The CDC provides a broad range of training, accessible by mail, Internet, satellite downlinks, and on-site classes. The number of accredited schools of public health rose by 20 percent between 1990 and 2000, increasing from twenty-four to twenty-nine schools located around the country. Many have begun providing continuing education offerings for public health professionals. Several offer graduate degrees in public health through courses of study designed for midcareer workers.
In addition, in 1999, both CDC and HRSA received funds for training the existing public health workforce. In July 2000, HRSA announced grants to eight Public Health Training Centers (PHTC's), which provide assistance to workers in 28 states. In September 2000, CDC's four Centers for Public Health Preparedness (CPHPs) awards were announced. Although the PHTCs and CPHPs are funded separately by the two agencies, both require a partnership with an accredited school of public health.
Many essential practice skills, however, are not typically addressed in traditional public health training. Work completed in the late 1990s, for example, showed that, of public health workers across the range of professions, most needed training in leadership, communication, and management. A number of resources to address these needs developed during the 1990s. For example, the Public Health Leadership Institute was established in 1991 through a partnership of California universities with funding from the CDC. Public health workers in nearly every state now have access to smaller state or regionally based leadership institutes. In the late 1990s, the CDC, the HRSA, the W. K. Kellogg Foundation, and the Robert Wood Johnson Foundation funded basic management skills training for teams of middle and upper management workers from local health departments. This pilot program is provided through the University of North Carolina School of Public Health.
CORE FUNCTIONS AND ESSENTIAL SERVICES
In 1988 the Institute of Medicine published its landmark report, The Future of Public Health. This report identified a number of problems with the public health system, including an appalling lack of resources, a confused mission, poor leadership, and a prevailing view among policymakers that public health challenges like infectious diseases, unsafe food, and contaminated drinking water were all resolved. The report concluded with its most frequently quoted phrase, "public health is in disarray."
The IOM report has contributed significantly to the practice of public health. It proposed a simple but powerful mission statement: "to fulfill society's interest in assuring conditions in which people can be healthy" (p. 17). The report also proposed a more comprehensive operational framework for governmental public health with the elucidation of three core functions: assessment, policy development, and assurance (see Figure 1).
The assessment function requires public health agencies "to regularly and systematically collect, assemble, analyze, and make available information on the health of the community, including statistics on health status, community health needs, and epidemiologic and other studies of health problems" (p. 7). The report emphasized that "this basic function of public health cannot be delegated." Within a decade of the report's release, about 70 percent of local health departments had completed assessments of the communities they serve. Many have developed fairly sophisticated subunits of their organization to conduct assessment activities on an ongoing basis.
A number of assessment tools evolved in the early 1990s. Those most commonly used through the decade included Assessment Protocol for Excellence in Public Health (APEXPH) (developed by the National Association of County and City Health
The second core function, policy development, was portrayed as what policymakers, particularly in government, do with the results of assessments. If an assessment defined the problems of a community, the policy development process would yield priorities and produce plans to address the problems. In the words of the report, public health agencies should "serve the public interest in the development of comprehensive public health policies by promoting the use of the scientific knowledge base in decision-making about public health and by leading in developing public health policy. Agencies must take a strategic approach, developed on the basis of a positive appreciation for the democratic political process" (p. 8).
The assurance function called for public health agencies "to assure their constituents that services necessary to achieve agreed upon goals are provided, either by encouraging actions by other entities (private or public), by requiring such action through regulation, or by providing services directly" (p. 8). This function might be seen as the implementation step, following policy development. Thus, the three core functions are tightly linked with one another, with assessment leading to policy development, resulting in assurance, leading again to assessment to evaluate the results and continue the process.
While the core functions represented a new framework for considering the practice of public health, the framework was rather sparse in detail and did little to explain the practice to those outside public health. In 1994, the Public Health Functions Steering Committee, chaired by the Surgeon General, adopted the Ten Essential Public Health Services. While based on the core functions, the more expansive list is more precise in describing specific capacities that all levels of governmental public health should have.
Development of the core functions and the essential services had a profound impact on the practice of public health through the 1990s. State and local health departments have dramatically increased the number and the level of involvement of partners in conducting assessments, developing policy, and in assuring the delivery of services. In some locales, the partnerships have led to innovation in how services are delivered, loosening two long-held perspectives: that only public health agencies can serve the poor, and that "public health is what public health departments do."
Many local and state agencies began placing increased emphasis on population-level services in the mid-1990s. In many instances, this resulted in contracts or other arrangements with private-sector providers to provide personal health services for disenfranchised populations. In place of direct service delivery, local and state health departments increasingly conducted community assessments, developed local and state priorities and plans, participated in the development of healthy communities, and addressed such issues as community violence prevention, injury prevention, and safer sex practices. In some locales, "public health" has been redefined to mean "that which the community does collectively to protect and improve the health of its residents." In such communities, the role of the state and local health departments is principally to provide financial and technical resources, and to convene and guide local process.
PERFORMANCE MEASUREMENT AND ACCREDITATION
The 1990s heralded a call for increased accountability of governmental agencies, and for greater emphasis on outcomes. Florida developed performance standards, and several other states developed standards as a component of statewide accreditation. Illinois, in conjunction with its IPLAN program, also developed a certification system for local health departments.
In the late 1990s, the CDC, in partnership with NACCHO, the Association of State and Territorial Health Officials, the National Association of Local Boards of Health, the Public Health Foundation, and the American Public Health Association, conducted an effort to develop national performance standards for local and state public health systems and for standards related to governance. The National Public Health Performance Standards Program (NPHPSP), is based on three principles:(1) public health must be accountable to its constituencies; (2) public health professionals need a system for ensuring that the provision of essential public health services meets a defined level of quality; and (3) the public health decision-making process must be based on strong scientific evidence. The standards use the essential services as categories of services. By early 2000 this program was still in its infancy, and the standards were being tested in several states. The objective was to implement the program nationally on a voluntary basis early in the first decade of the twenty-first century.
By the end of the twentieth century, public health leaders were having serious discussions about the need for accreditation of state and local health departments. Some pointed out that public health is the last health arena with no accreditation available, and that some form of accreditation is needed to assure quality and accountability. Others expressed concerns about the feasibility of accreditation, given the huge diversity in organizational capacity and jurisdictional structures. It is clear that the discussions will continue, and that the NPHPSP will likely serve as the basis for an accreditation system, should one evolve.
Many people have decried the lack of a certification program for public health workers, particularly in light of the small percentage of the workforce that has had formal training in public health. While some of the specific professions comprising the public health workforce have their own licensure or certification (e.g., MDs, RNs, registered sanitarians), none necessarily assure or contribute to overarching public health competency. Efforts to explore the potential for this type of certification were beginning in January 2000.
Thomas L. Milne
Carol K. Brown
(see also: Accreditation of Local and State Health Departments; Community Health; Director of Health; Essential Public Health Services; Mobilizing for Action through Planning and Partnerships; National Association of County and City Health Officials; National Association of Local Boards of Health; Official U.S. Health Agencies )
Core Public Health Functions Steering Committee (1994). Public Health in America. Washington, DC: Office of Disease Prevention and Health Promotion, USDHHS.
Institute of Medicine, Committee on the Future of Public Health (1998) The Future of Public Health. Washington, DC: National Academy Press.
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