Tutorial Module 2: What is the Structure and Function of Government Public Health Agencies?

Among government agencies, the responsibility for the public health of the country is divided among the federal, state, and local entities. This module describes the different characteristics and roles of local, state, and federal public health agencies.

Local Public Health Agencies

Characteristics of Local Public Health Agencies (LPHA)

"According to the National Association of County and City Health Officials (NACCHO), a Local Public Health Agency (LPHA) is defined 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." As of 2000, there were 2,834 LPHAs that met this criteria. According to NACCHO data, over two-thirds of LPHAs serve jurisdictions with less than 50,000 people. Less than five percent serve jurisdictions with more than 500,000 people. Data from past studies indicate stability in the LPHA jurisdiction mix.(1)

NACCHO created five categories to describe the variation in LPHAs:

1. County: These are the most common type of LPHA and are responsible for only one county. The size of county-based LPHAs varies depending on the size of the county (i.e., a small rural county vs. Los Angeles County).

2. City: These LPHAs are responsible for a municipality, covering the geographic boundaries of a city. Examples include Kansas City, Missouri and New York City, New York.

3. City-County: In some cases, counties and cities jointly provide public health services. The city of Seattle and King County in Washington have a joint public health department. In these cases, health departments may have dual reporting requirements – both to city and county officials.

4. Town/Township: These LPHAs serve the geographic region of a township. The town of Manchester, Connecticut maintains its own health department.

5. Multi-county: LPHAs of this nature are responsible for multiple counties. In some cases, they operate much like County LPHAs, but with more than one county (e.g., local health districts in Virginia). In other types, such as regional LPHAs, the jurisdiction includes multiple counties, but reporting requirements may include reporting to several individual county boards of health.(2)

Exhibit 1 depicts the frequency of the different types of LPHAs.

Exhibit 1: LPHA Type

Source: National Association of County and City Health Officials (October 2001). LPHA Infrastructure, A Chartbook, pp. 9.

The size of LPHA staff varies. In NACCHO’s survey, LPHAs reported an average of 67 Full-Time Employee (FTE) staff, but only a median of 13. The largest of LPHAs can have thousands of employees, while those located in rural areas have skeleton staffs with the local health officers filling many roles. Staff are largely made up of administrative staff, environmental specialists, and public health nurses. Agencies also include physicians, epidemiologists, and public health laboratories.(3)

Administrative reporting relationships vary as widely as the types of LPHAs. According to NACCHO, over half of LPHA directors report to a local board of health. The division of the reporting relationships is located below in Exhibit 2.

Exhibit 2: LPHA Reporting Relationships

Source: National Association of County and City Health Officials (October 2001). LPHA Infrastructure, A Chartbook, pp. 10.

The degree of autonomy an LPHA has from the state in which it resides influences administrative reporting relationships. In Virginia, almost all LPHAs are state regional offices. They report directly to and receive direction from the state health department. In other states such as North Carolina, local health departments are autonomous.

The sources of funding and levels of expenditure are largely based on whether the LPHA is located in a Metropolitan Statistical Area (MSA) or not. According to the NACCHO, LPHAs in metropolitan areas maintained average annual expenditures of $8.9 million as opposed to $1.2 million for non-metropolitan areas. Metropolitan areas received the majority of funds from local sources, while non-metropolitan areas received equal proportions of funds from state and local sources.(4)

Despite the breadth of responsibility of LPHAs, many are lacking technology. In 2000, one-third of LPHAs serving populations of less than 25,000 did not have e-mail. Thirty percent of the same group did not have access to the Web.(5) Although these statistics have improved during the last two years, there are still considerable technology deficiencies in many LPHAs.

Roles of Local Government Public Health Agencies

LPHAs serve as the "front line" of public health agencies. While state and federal public health agencies perform a mix of direct services, oversight, and planning, LPHAs’ attention is focused on delivering services.(6) LPHAs provide a number of services within their area of jurisdiction. These activities include: adult and childhood immunizations, communicable disease control, lead poison prevention, community needs assessment, community outreach and education, environmental health services, epidemiology and surveillance programs, food safety, and restaurant inspections. A more comprehensive set of services is provided in multi-county/regional LPHAs than in smaller LPHAs due to resource constraints. For example, while smaller LPHAs may only focus on mandated population programs, such as disease surveillance, larger LPHAs may provide a broader continuum of care. Many LPHAs are choosing to outsource direct provision of services and concentrate on population based activities.(7) For example, some public health agencies are contracting with outside organizations to provide primary care, allowing more time for disease prevention and health promotion.

LPHAs are also responsible for conveying information to state and national levels. This information includes local needs and priorities, mandatory reporting, and the effects of programs and policies. Examples might include incidence of HIV/AIDS, the effects of a lead screening program, or the results of community needs assessment to examine public maternal and child health needs. With this information, state and federal agencies can examine large amounts of data and isolate important trends. Without this data transfer, many state and federal agencies would be without access to information critical to making policy decisions (See Modules 3 and 4 for more details on public health data and data use).

State Government Public Health Agencies

Characteristics of State Public Health Agencies

Every state in the country has an agency responsible for public health activities. However, how each agency operates and its location in the state government varies from state to state. In some cases, the state agency responsible for public health is an independent department. In other states, the public health agency is part of a larger, "umbrella" department that provides human services as well. In Maryland, the Department of Health and Mental Hygiene is in charge of public health and does not report to a higher department authority. In Texas, public health is also operated out of the Department of Health, which is overseen by the Texas Health and Human Services Commission. These departmental differences impact public health’s role at the state level and changes the access public health agencies have to different types of information. In either case, state public health agencies are usually headed by a medical professional (e.g., physician or nurse).(8)

There are three models for governance in a state public health agency:

1. Cabinet: the head of the state public health agency (e.g., the head of the Maryland Department of Health and Mental Hygiene is the Secretary) is appointed by and answers to the governor;

2. Board of Health: the state health director reports to an appointed board representing constituencies served by the department (e.g., Washington State); and

3. Umbrella: the public health agency is part of a larger state agency (e.g., the Texas Department of Health is part of the Texas Health and Human Services Commission). The public health agency director then reports to the head of the umbrella agency.(9)

Funding for state government public health agencies varies based on the type of governance model. In some cases, public health agencies receive direct appropriations from the state legislature. Agencies that are part of an umbrella organization will receive funding from a parent agency. Agencies also vary in how their money is spent. Some states have specific requirements for how funds are spent, while others provide more flexibility for agency heads to make spending decisions.

State government public health agencies are often responsible for management of federal government programs and funding streams at the state and local level, such as the Maternal and Child Health (MCH) block grant program (Title V Block Grant program funded by the Health Resources and Services Administration (HRSA) to states to administer to the underserved), the Women, Infants, Children (WIC) nutrition program (Special Supplemental Program administered by USDA), vital records, and most recently, bioterrorism and emergency preparedness.

In many cases, state government public health agencies have the ability to develop and enforce regulations, e.g., seatbelt laws, laws to protect the privacy of information, etc. (sometimes, state public health agencies are unable to develop certain regulations due to federal rules/laws). The creation of such regulations may be required by legislative statute or may be the prerogative of the agency director. The agency may be responsible for monitoring compliance with regulations and seeking action against those who are not in compliance.

Roles of State Government Public Health Agencies

State public health agencies fulfill three core functions: assessment, policy development, and assurance (see Module #1 for information on public health core functions).(10) To carry out the core functions, states agencies:

• Encourage, provide assistance, or require local governments and/or private providers to perform certain functions ;

• Provide certain services directly;

• Fund or channel funds from federal sources;

• Assist in the management and reporting requirements of state and/or federally funded programs; and

• Use authority to ensure that public health goals are met, including achieving Healthy People 2010 objectives.

From state to state, the specific activities for state government public health agencies vary. However, most state agencies are responsible for at least some of the following activities:

• Maternal and child health care;

• Nutrition;

• Vital records;

• Immunization;

• HIV/AIDS;

• Infectious disease surveillance;

• Prevention programs (e.g., adolescent school health, injury prevention and control, tobacco prevention and control);

• Environmental health;

• Public health informatics; and

• Preparedness policy.

Federal Public Health Agencies

Characteristics of Federal Public Health Agencies

The U.S. Department of Health and Human Services (DHHS) is responsible for the majority of the public health programs and initiatives conducted by the federal government. The Public Health Service is the lead agency within DHHS with regard to these activities. The Public Health Service is made up of the Office of Public Health and Science (including the Surgeon General) and nine operating divisions, all of which report to the Secretary of DHHS. The nine operation divisions are described in Exhibit 3 below. These offices are the primary contributors to federal government activities in public health.

Exhibit 3: Operating Divisions of the Office of Public Health and Science

In addition to the aforementioned operating divisions within the Office of Public Health and Science, other federal agencies contribute to public health. The Centers for Medicare and Medicaid Services (CMS) is responsible for operation of Medicare, Medicaid, and the State Children’s Health Insurance Program (S-CHIP). Through Medicare, Medicaid, and S-CHIP, CMS is involved with public health as a funder for these programs which are often administered in coordination with public health agencies.

The Environmental Protection Agency (EPA) is the federal agency responsible for many environmental programs and regulations. As a result, the EPA works closely with public health agencies and state environmental protection agencies to solve environmental health problems. The Social Security Administration (SSA) also plays important roles in public health, including disability determination and supporting electronic death registration systems. Finally, the U.S. Department of Agriculture (USDA) operates the Women, Infants, and Children (WIC) nutrition program.

Over time, these agencies, as well as others, have developed working relationships to achieve their overlapping public health goals. For example, many federal agencies participate in Healthy People 2010 to set objectives for the health of the nation. Many of these organizations are also working together to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Roles of Federal Public Health Agencies

The federal agencies and offices responsible for public health activities take on numerous roles, in some cases directly running programs, in part through grant making, and in others providing assistance to those local and state agencies working on the ground in many different ways.

• Policy Making: This function involves initiating, shaping, and implementing congressional and presidential decisions. In addition, DHHS also conducts policy making activities on its own. The privacy provisions created to comply with HIPAA are an example.

• Financing Public Health Activities: DHHS provides funding to state and local public health agencies through grants, contracts, and reimbursements. One of the sources is HRSA.

• Public Health Protection: In this role, DHHS assesses health risks and then sets and enforces standards and regulations to protect the public from those risks. The FDA regulates drugs in this way.

• Collecting and Disseminating Information: Agencies within DHHS are responsible for collecting data and maintaining data systems, setting standards, making data available for public use, and informing policy. For example, the National Center for Health Statistics (NCHS) fields several major national health surveys annually and supports the Vital Statistics Cooperation Program.

• Capacity Building for Public Health: In this role, DHHS works to ensure that the federal, state, and local pubic health agencies are equipped to carry-out their activities.

• Direct Management Services: The Indian Health Service provides direct medical care to Native Americans who are members of federally recognized Indian tribes.(21)

Internet References

The following are links to other sources of information regarding the structure and function of public health agencies.

• American College of Epidemiology (ACE)

• American Public Health Association

• Association for Professionals in Infection Control & Epidemiology (APIC)

• Association of Public Health Laboratories

• Association of State and Territorial Health Organizations

• Council of State and Territorial Epidemiologists

• Healthy People 2010 Public Health Infrastructure

• NACCHO - National Association of County and City Health Officials

• National Association of Local Boards of Health (NALBOH)

• Society for Epidemiologic Research (SER)

• Sample Public Health Tutorials (The Public Health Data Standards Consortium is not responsible for the quality of this information)

  • Role of the Local Public Health Department

  • Participants in Public Health

Endnotes

(1) National Association of County and City Health Officials (October 2001). LPHA Infrastructure, A Chartbook, pp. 9.
(2) National Association of County and City Health Officials (October 2001). LPHA Infrastructure, A Chartbook, pp. 8.
(3) National Association of County and City Health Officials (October 2001). LPHA Infrastructure, A Chartbook, pp. 2.
(4) Ibid.
(5) National Association of County and City Health Officials (April 2000). The Role of Local Public Health Agencies and the Health Alert Network Program in a National Surveillance System, pp 3.
(6) Fraser, Michael. State and Local Health Department Structures: Implications for Systems Change. Transformations in Public Health. Volume 1, Issue 4. pp. 1-2.
(7) National Association of County and City Health Officials (October 2001). LPHA Infrastructure, A Chartbook, pp. 18.
(8) Institute of Medicine (2002). The Future of the Public's Health in the 21st Century: The Governmental Public Health Infrastructure, pp. 111.
(9) Institute of Medicine (2002). The Future of the Public's Health in the 21st Century: The Governmental Public Health Infrastructure, pp. 112.
(10) Yasnoff, William A. and Centers for Disease Control and Prevention (July 16, 2002). Presentation to Computing Research Association.
(11) Agency for Healthcare Research and Quality (March 2001). AHRQ Profile [On-line], Available: http://www.ahrq.gov/about/profile.htm
(12) Agency for Toxic Substances and Disease Registry (January 30, 2003). About the Agency for Toxic Substances and Disease Registry [On-line], Available: http://www.atsdr.cdc.gov/about.html
(13) Centers for Disease Control and Prevention (November 2, 2002). About CDC [On-line], Available: http://www.cdc.gov/aboutcdc.htm
(14) National Center for Health Statistics (November 23, 2002). About NCHS [On-line], Available: http://www.cdc.gov/nchs/about.htm
(15) U.S. Food and Drug Administration (January 15, 2003). About the U.S. Food and Drug Administration [On-line], Available: http://www.fda.gov/opacom/hpview.html
(16) Health Resources and Services Administration (February 6, 2003). About HRSA [On-line], Available: http://www.hrsa.gov/about.htm
(17) Indian Health Service (October 16, 2002). Indian Health Service Fact Sheet [On-line], Available: http://www.ihs.gov/PublicInfo/PublicAffairs/Welcome_Info/ThisFacts.asp
(18) National Institutes of Health (January 28, 2003). About NIH [On-line], Available:http://www.nih.gov/about/
(19) Program Support Center (October 23, 2002). Mission and Location [On-line], Available :http://www.psc.gov/about/
(20) Substance Abuse and Mental Health Services Administration (August 26, 2002). About SAMHSA [On-line], Available: http://www.samhsa.gov/Menu/Level2_about.aspx
(21) Institute of Medicine (2002). The Future of the Public's Health in the 21st Century: The Governmental Public Health Infrastructure, pp. 113.