National Association of County and City Health Officials  [Printer-friendly version]
November 15, 2005


Governmental public health departments are responsible for creating
and maintaining conditions that keep people healthy. At the local
level, the governmental public health presence, or "local health
department (LHD)," can take many forms.[1] Furthermore, each community
has a unique "public health system" comprising individuals and public
and private entities that are engaged in activities that affect the
public's health.

Regardless of its governance or structure, regardless of where
specific authorities are vested or where particular services are
delivered, everyone, no matter where they live, should reasonably
expect the local health department to meet certain standards.[2]


** Understands the specific health issues confronting the community,
and how physical, behavioral, environmental, social, and economic
conditions affect them.

** Investigates health problems and health threats.

** Prevents, minimizes, and contains adverse health effects from
communicable diseases, disease outbreaks from unsafe food and water,
chronic diseases, environmental hazards, injuries, and risky health

** Leads planning and response activities for public health

** Collaborates with other local responders and with state and federal
agencies to intervene in other emergencies with public health
significance (e.g., natural disasters).

** Implements health promotion programs.

** Engages the community to address public health issues.

** Develops partnerships with public and private healthcare providers
and institutions, community-based organizations, and other government
agencies (e.g., housing authority, criminal justice, education)
engaged in services that affect health to collectively identify,
alleviate, and act on the sources of public health problems.

** Coordinates the public health system's efforts in an intentional,
non-competitive, and non-duplicative manner.

** Addresses health disparities.

** Serves as an essential resource for local governing bodies and
policymakers on up-to-date public health laws and policies.

** Provides science-based, timely, and culturally competent health
information and health alerts to the media and to the community.
Provides its expertise to others who treat or address issues of public
health significance.

** Ensures compliance with public health laws and ordinances, using
enforcement authority when appropriate.

** Employs well-trained staff members who have the necessary resources
to implement best practices and evidence-based programs and

** Facilitates research efforts, when approached by researchers, that
benefit the community.

** Uses and contributes to the evidence base of public health.

** Strategically plans its services and activities, evaluates
performance and outcomes, and makes adjustments as needed to
continually improve its effectiveness, enhance the community's health
status, and meet the community's expectations.


All local health departments (LHDs),[3] as governmental entities,
derive their authority and responsibility from the state and local
laws that govern them. Accordingly, all LHDs exist for the common good
and are responsible for demonstrating strong leadership in the
promotion of physical, behavioral, environmental, social, and economic
conditions that improve health and well-being; prevent illness,
disease, injury, and premature death; and eliminate health
disparities.[4] However, in the absence of specific, consistent
standards regarding how LHDs fulfill this responsibility, the degree
to which the public's health is protected and improved varies widely
from community to community.

These standards describe the responsibilities that every person,
regardless of where they live, should reasonably expect their LHD to

They have been developed within nationally recognized frameworks[5]
and with input from public health professionals and elected
officials[6] from across the country. The standards provide a
framework by which LHDs are accountable to the state health
department, the public they serve, and the governing bodies (e.g.,
local boards of health, county commissioners, and mayors) to which
they report. In meeting the standards, LHDs employ strategies that are
evidence-based and informed by best practices, and they operate
according to the highest level of professionalism and ethics to
inspire public confidence and trust.

A number of factors contribute to the variability of how LHDs operate;
specifically capacity, authority, resources, and composition of the
local public health system:

** The LHD may have the capacity to perform all of the functions on
its own; it may call upon the state to provide assistance for some
functions; it may develop arrangements with other organizations in the
community or with neighboring LHDs to perform some functions; or it
may control the means by which other entities perform some functions.

** Government agencies other than the LHD may have the authority to
perform services that affect public health.

** Resources for public health may be housed in a different agency.

** Each LHD jurisdiction is served by its own unique public health
system: public and private health care providers, businesses,
community organizations, academic institutions, and media outlets that
all contribute to the public's health.

As a result of these differences, how LHDs meet the standards --
whether they directly provide a service, broker particular capacities,
or otherwise ensure that the necessary work is being done -- will
vary. Regardless of its specific capacity, authority, and resources,
and regardless of the particular local public health system, the LHD
has a consistent responsibility to intentionally coordinate all public
health activities and lead efforts to meet the standards.

The standards are a guide to the fundamental responsibilities of LHDs,
allowing for varied structural characteristics of LHDs (e.g.,
governance, staffing patterns, size of the population served, etc.),
and recognizing that each LHD may have other duties unique to meeting
the public health needs of the community it serves. Several states
have developed, or are in the process of developing, state-specific
standards for LHDs, and the National Public Health Performance
Standards Program (NPHPSP) includes standards for local public health
systems. NACCHO analyses of several state initiatives and the NPHPSP
have shown a high level of consistency between these efforts and
NACCHO's nationally developed standards.

Currently, not all LHDs have the capacity to meet the standards. Many
concerns have been raised regarding the costs of developing the
capacity, and the implications for LHDs that do not meet the
standards. It is difficult to anticipate costs, and it is equally
important to understand that improvements in capacity can be made in
the absence of new resources. NACCHO is committed to collecting and
sharing models of LHDs and LHD arrangements to demonstrate various
means to enhance local governmental public health capacity.
Furthermore, NACCHO is currently participating in a national dialogue
on whether to establish a voluntary national accreditation system for
state and local health departments,[7] and is supportive of such an
effort.[8] The results of this dialogue may generate implications for
LHDs not meeting the standards.

NACCHO urges LHDs to embrace these standards both as a means of
working with their state health departments, communities, and
governing bodies to develop a more robust governmental public health
capacity, and as a means of holding themselves uniformly accountable
to the public they serve.


1. Monitor health status and understand health issues facing the

a. Obtain and maintain data that provide information on the
community's health (e.g., provider immunization rates; hospital
discharge data; environmental health hazard, risk, and exposure data;
community-specific data; number of uninsured; and indicators of health
disparities such as high levels of poverty, lack of affordable
housing, limited or no access to transportation, etc.).

b. Develop relationships with local providers and others in the
community who have information on reportable diseases and other
conditions of public health interest and facilitate information

c. Conduct or contribute expertise to periodic community health

d. Integrate data with health assessment and data collection efforts
conducted by others in the public health system.

e. Analyze data to identify trends, health problems, environmental
health hazards, and social and economic conditions that adversely
affect the public's health.

2. Protect people from health problems and health hazards.

a. Investigate health problems and environmental health hazards.

b. Prevent, minimize, and contain adverse health events and conditions
resulting from communicable diseases; food-, water-, and vector-borne
outbreaks; chronic diseases; environmental hazards; injuries; and
health disparities.

c. Coordinate with other governmental agencies that investigate and
respond to health problems, health disparities, or environmental
health hazards.

d. Lead public health emergency planning, exercises, and response
activities in the community in accordance with the National Incident
Management System, and coordinate with other local, state, and federal

e. Fully participate in planning, exercises, and response activities
for other emergencies in the community that have public health
implications, within the context of state and regional plans and in a
manner consistent with the community's best public health interest.

Maintain access to laboratory and biostatistical expertise and
capacity to help monitor community health status and diagnose and
investigate public health problems and hazards.

Maintain policies and technology required for urgent communications
and electronic data exchange.

3. Give people information they need to make healthy choices.

a. Develop relationships with the media to convey information of
public health significance, correct misinformation about public health
issues, and serve as an essential resource.

b. Exchange information and data with individuals, community groups,
other agencies, and the general public about physical, behavioral,
environmental, social, economic, and other issues affecting the
public's health.

c. Provide targeted, culturally appropriate information to help
individuals understand what decisions they can make to be healthy.

d. Provide health promotion programs to address identified health

4. Engage the community to identify and solve health problems.

a. Engage the local public health system in an ongoing, strategic,
community-driven, comprehensive planning process to identify,
prioritize, and solve public health problems; establish public health
goals; and evaluate success in meeting the goals.

b. Promote the community's understanding of, and advocacy for,
policies and activities that will improve the public's health.

c. Support, implement, and evaluate strategies that address public
health goals in partnership with public and private organizations.

d. Develop partnerships to generate interest in and support for
improved community health status, including new and emerging public
health issues.

e. Inform the community, governing bodies, and elected officials about
governmental public health services that are being provided,
improvements being made in those services, and priority health issues
not yet being adequately addressed.

5. Develop public health policies and plans.

a. Serve as a primary resource to governing bodies and policymakers to
establish and maintain public health policies, practices, and capacity
based on current science and best practices.

b. Advocate for policies that lessen health disparities and improve
physical, behavioral, environmental, social, and economic conditions
in the community that affect the public's health.

c. Engage in LHD strategic planning to develop a vision, mission, and
guiding principles that reflect the community's public health needs,
and to prioritize services and programs.

6. Enforce public health laws and regulations.

a. Review existing laws and regulations and work with governing bodies
and policy-makers to update them as needed.

b. Understand existing laws, ordinances, and regulations that protect
the public's health.

c. Educate individuals and organizations on the meaning, purpose, and
benefit of public health laws, regulations, and ordinances and how to

d. Monitor, and analyze over time, the compliance of regulated
organizations, entities, and individuals.

e. Conduct enforcement activities.

f. Coordinate notification of violations among other governmental
agencies that enforce laws and regulations that protect the public's

7. Help people receive health services.

a. Engage the community to identify gaps in culturally competent,
appropriate, and equitable personal health services, including
preventive and health promotion services, and develop strategies to
close the gaps.

b. Support and implement strategies to increase access to care and
establish systems of personal health services, including preventive
and health promotion services, in partnership with the community.

c. Link individuals to available, accessible personal healthcare
providers (i.e., a medical home).

8. Maintain a competent public health workforce.

a. Recruit, train, develop, and retain a diverse staff.

b. Evaluate LHD staff members' public health competencies,[9] and
address deficiencies through continuing education, training, and
leadership development activities.

c. Provide practice- and competency-based educational experiences for
the future public health workforce, and provide expertise in
developing and teaching public health curricula, through partnerships
with academia.

d. Promote the use of effective public health practices among other
practitioners and agencies engaged in public health interventions.

e. Provide the public health workforce with adequate resources to do
their jobs.

9. Evaluate and improve programs and interventions.

a. Develop evaluation efforts to assess health outcomes to the extent

b. Apply evidence-based criteria to evaluation activities where

c. Evaluate the effectiveness and quality of all LHD programs and
activities and use the information to improve LHD performance and
community health outcomes.

d. Review the effectiveness of public health interventions provided by
other practitioners and agencies for prevention, containment, and/ or
remediation of problems affecting the public's health, and provide
expertise to those interventions that need improvement.

10. Contribute to and apply the evidence base of public health.

a. When researchers approach the LHD to engage in research activities
that benefit the health of the community,

i. Identify appropriate populations, geographic areas, and partners;

ii. Work with them to actively involve the community in all phases of

iii. Provide data and expertise to support research; and,

iv. Facilitate their efforts to share research findings with the
community, governing bodies, and policymakers.

b. Share results of research, program evaluations, and best practices
with other public health practitioners and academics.

c. Apply evidence-based programs and best practices where possible.


Public health professionals and the communities they serve deserve a
common set of expectations about local health departments (LHDs). More
than 600 governmental public health professionals and local and state
officials representing 30 different states contributed to this
definition, which will be a living document.

By describing the functions of LHDs, the definition will help citizens
and residents understand what they can reasonably expect from
governmental public health in their communities. The definition also
will be useful to elected officials, who need to understand what LHDs
do and how to hold them accountable. And, the definition will aid LHDs
in obtaining their fair share of resources.


NACCHO's first step is education and communication about the
definition with LHDs, local boards of health, state health
departments, federal public health agenices, and local and state
elected officials. Metrics will be developed to allow LHDs to measure
their progress in achieving the standards.

NACCHO will also gather examples of how LHDs use the definition. The
Exploring Accreditation project will examine the use of the standards
as the basis for a voluntary national accreditation system for LHDs of
all sizes and structures.


LHDs can use the definition and standards to assess local efforts,
measure performance, expand functions, enhance activities, and
communicate about the role of local public health to their governing
bodies, elected officials, and community.

NACCHO has developed a set of three fact sheets describing the role of
local public health and a communications toolkit as part of this
project. Both the toolkit and the fact sheets are available on
NACCHO's Web site (see the following column). NACCHO encourages LHDs
to download and use the fact sheets and communications toolkit.

Finally, your experiences with the definition will inform and help
shape the implementation phase of this effort. Please submit examples
of how LHDs have met the definition (particularly those involving the
development of shared capacity and/ or resources), applied the tools
in the communications toolkit, or otherwise used the definition or
related materials.


You can find additional materials and submit examples online at:

For more information about this project, please contact NACCHO at
(202) 783-5550 and ask to speak with the Operational Definition
program manager, or e-mail

NACCHO thanks the following organizations for their contributions to
the development of the operational definition: the Association of
State and Territorial Health Officials, the Association of State and
Territorial Local Health Liaison Officials, the Centers for Disease
Control and Prevention, the Health Resources and Services
Administration, the National Association of Counties, the National
Association of Local Boards of Health, the National Conference of
State Legislatures, the National Governors Association, the National
League of Cities, and the U.S. Conference of Mayors.

Funding for this project was provided by the Robert Wood Johnson
Foundation and the Centers for Disease Control and Prevention (under
cooperative agreement U50/CCU302718). The contents of this document
are solely the responsibility of the authors and do not necessarily
represent the official views of the sponsors.

National Association of County and City Health Officials, 1100 17th
Street, NW, Second Floor, Washington, DC 20036; phone: (202) 783-5550;
Fax: (202) 783-1583


[1] For the purposes of this definition, a local health department may
be locally governed, part of a region or district, be an office or an
administrative unit of the state health department, or a hybrid of

[2] See the section of this document titled, "Local Health Department
Standards" for further description of the functions captured in this

[3] For the purposes of these standards, an LHD is defined as the
governmental public health presence at the local level. It may be a
locally governed health department, a branch of the state health
department, a state-created district or region, a department governed
by and serving a multi-county area, or any other arrangement that has
governmental authority and is responsible for public health functions
at the local level.

[4] For the purposes of this document, "health disparities" refer to
differences in populations' health status that are avoidable and can
be changed. These differences can result from social and/or economic
conditions, as well as public policy. Examples include situations
whereby hazardous waste sites are located in poor communities, there
is a lack of affordable housing, and there is limited or no access to
transportation. These and other factors adversely affect population

[5] The standards are framed around the Ten Essential Public Health
Services, which have been reworded to more accurately reflect the
specific LHD roles and responsibilities related to each category. In
addition, these standards are consistent with the National Public
Health Performance Standards Program (NPHPSP), serving to specify the
role of governmental LHDs while the NPHPSP addresses the local public
health system as a whole.

[6] Input came from local health departments, local boards of health,
state health departments, and federal public health agencies; as well
as county commissioners, mayors, state legislators, and gubernatorial
health advisors.


[8] NACCHO Resolution 04-06 further describes NACCHO's stance on

[9] As defined by the Core Public Health Competencies developed by
the Council on Linkages between Academia and Public Health Practice.