National Association of County and City Health Officials, November 15, 2005
OPERATIONAL DEFINITION OF A FUNCTIONAL LOCAL HEALTH DEPARTMENT
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. 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.
A FUNCTIONAL LOCAL HEALTH DEPARTMENT:
** 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 behaviors.
** Leads planning and response activities for public health emergencies.
** 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 interventions.
** 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.
LOCAL HEALTH DEPARTMENT STANDARDS, Part 1
All local health departments (LHDs), 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. 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 fulfill.
They have been developed within nationally recognized frameworks and with input from public health professionals and elected officials 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, and is supportive of such an effort. 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.
LOCAL HEALTH DEPARTMENT STANDARDS, Part 2
1. Monitor health status and understand health issues facing the community.
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 exchange.
c. Conduct or contribute expertise to periodic community health assessments.
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 agencies.
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 problems.
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 comply.
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 health.
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, 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 possible.
b. Apply evidence-based criteria to evaluation activities where possible.
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 research;
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.
WHAT ARE NACCHO'S NEXT STEPS?
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.
WHAT ACTION STEPS CAN YOU TAKE?
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: http://www.naccho.org/topics/infrastructure/operationaldefinit ion.cfm
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 email@example.com.
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 www.naccho.org
 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 these.
 See the section of this document titled, "Local Health Department Standards" for further description of the functions captured in this definition.
 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.
 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 health.
 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.
 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.
 NACCHO Resolution 04-06 further describes NACCHO's stance on accreditation.
 As defined by the Core Public Health Competencies developed by the Council on Linkages between Academia and Public Health Practice.