Definition of a Functional Health Department, NACCHO, 2006

NACCHO• Addresses health disparities.• Serves as an essential resource forlocal governing bodies andpolicymakers on up-to-datepublic health laws and policies.• Provides science-based, timely,and culturally competent healthinformation and health alerts tothe media and to the community.• Provides its expertise to otherswho treat or address issues ofpublic health significance.• Ensures compliance with publichealth laws and ordinances,using enforcement authoritywhen appropriate.• Employs well-trained staffmembers who have the necessaryresources to implement bestpractices and evidence-basedprograms and interventions.• Facilitates research efforts, whenapproached by researchers, thatbenefit the community.• Uses and contributes to theevidence base of public health.• Strategically plans its services andactivities, evaluates performanceand outcomes, and makesadjustments as needed tocontinually improve itseffectiveness, enhance thecommunity’s health status, andmeet the community’sexpectations.NOTES1For the purposes of this definition, alocal health department may be locallygoverned, part of a region or district, bean office or an administrative unit of thestate health department, or a hybrid ofthese.2See “Local Health DepartmentStandards,” Pages 4 through 9, for furtherdescription of the functions captured inthis definition.Operational Definition of a Functional Local Health Department • November 20053

l o c a l h e a l t h d e p a r t m e n tstandardsAll local health departments(LHDs), 1 as governmentalentities, derive their authorityand responsibility from the state andlocal laws that govern them.Accordingly, all LHDs exist for thecommon good and are responsiblefor demonstrating strong leadershipin the promotion of physical,behavioral, environmental, social,and economic conditions thatimprove health and well-being;prevent illness, disease, injury, andpremature death; and eliminatehealth disparities. 2 However, in theabsence of specific, consistentstandards regarding how LHDs fulfillthis responsibility, the degree towhich the public’s health is protectedand improved varies widely fromcommunity to community.These standards describe theresponsibilities that every person,regardless of where they live, shouldreasonably expect their LHD to fulfill.They have been developed withinnationally recognized frameworks 3and with input from public healthprofessionals and elected officials 4from across the country. Thestandards provide a framework bywhich LHDs are accountable to thestate health department, the publicthey serve, and the governing bodies(e.g., local boards of health, countycommissioners, and mayors) to whichthey report. In meeting theNACCHO4NATIONALASSOCIATION OFCOUNTY & CITYHEALTH OFFICIALSstandards, LHDs employ strategiesthat are evidence-based and informedby best practices, and they operateaccording to the highest level ofprofessionalism and ethics to inspirepublic confidence and trust.A number of factors contribute to thevariability of how LHDs operate;specifically capacity, authority,resources, and composition of thelocal public health system:•••The LHD may have the capacityto perform all of the functions onits own; it may call upon thestate to provide assistance forsome functions; it may developarrangements with otherorganizations in the communityor with neighboring LHDs toperform some functions; or it maycontrol the means by whichother entities perform somefunctions.Government agencies other thanthe LHD may have the authorityto perform services that affectpublic health.Resources for public health maybe housed in a different agency.• Each LHD jurisdiction is served byits own unique public healthsystem: public and private healthcare providers, businesses,community organizations,academic institutions, and mediaoutlets that all contribute to thepublic’s health.

NACCHOAs a result of these differences, howLHDs meet the standards—whetherthey directly provide a service, brokerparticular capacities, or otherwiseensure that the necessary work isbeing done—will vary. Regardless ofits specific capacity, authority, andresources, and regardless of theparticular local public health system,the LHD has a consistentresponsibility to intentionallycoordinate all public health activitiesand lead efforts to meet thestandards.The standards are a guide to thefundamental responsibilities of LHDs,allowing for varied structuralcharacteristics of LHDs (e.g.,governance, staffing patterns, size ofthe population served, etc.), andrecognizing that each LHD may haveother duties unique to meeting thepublic health needs of the communityit serves. Several states havedeveloped, or are in the process ofdeveloping, state-specific standardsfor LHDs, and the National PublicHealth Performance StandardsProgram (NPHPSP) includes standardsfor local public health systems.NACCHO analyses of several stateinitiatives and the NPHPSP haveshown a high level of consistencybetween these efforts and NACCHO’snationally developed standards.Currently, not all LHDs have thecapacity to meet the standards. Manyconcerns have been raised regardingthe costs of developing the capacity,and the implications for LHDs that donot meet the standards. It is difficultto anticipate costs, and it is equallyimportant to understand thatimprovements in capacity can bemade in the absence of newresources. NACCHO is committed tocollecting and sharing models ofLHDs and LHD arrangements todemonstrate various means toenhance local governmental publichealth capacity. Furthermore,NACCHO is currently participating ina national dialogue on whether toestablish a voluntary nationalaccreditation system for state andlocal health departments, 5 and issupportive of such an effort. 6 Theresults of this dialogue may generateimplications for LHDs not meeting thestandards.NACCHO urges LHDs to embracethese standards both as a means ofworking with their state healthdepartments, communities, andgoverning bodies to develop a morerobust governmental public healthcapacity, and as a means of holdingthemselves uniformly accountable tothe public they serve.Operational Definition of a Functional Local Health Department • November 20055

l o c a l h e a l t h d e p a r t m e n tstandards1Monitor health status andunderstand health issues facingthe community.a. Obtain and maintain data thatprovide information on thecommunity’s health (e.g., providerimmunization rates; hospitaldischarge data; environmentalhealth hazard, risk, and exposuredata; community-specific data;number of uninsured; andindicators of health disparities suchas high levels of poverty, lack ofaffordable housing, limited or noaccess to transportation, etc.).b. Develop relationships with localproviders and others in thecommunity who have informationon reportable diseases and otherconditions of public health interestand facilitate informationexchange.c. Conduct or contribute expertise toperiodic community healthassessments.d. Integrate data with healthassessment and data collectionefforts conducted by others in thepublic health system.e. Analyze data to identify trends,health problems, environmentalhealth hazards, and social andeconomic conditions that adverselyaffect the public’s health.NACCHO6NATIONALASSOCIATION OFCOUNTY & CITYHEALTH OFFICIALS2Protect people from healthproblems and health hazards.a. Investigate health problems andenvironmental health hazards.b. Prevent, minimize, and containadverse health events andconditions resulting fromcommunicable diseases; food-,water-, and vector-borne outbreaks;chronic diseases; environmentalhazards; injuries; and healthdisparities.c. Coordinate with othergovernmental agencies thatinvestigate and respond to healthproblems, health disparities, orenvironmental health hazards.d. Lead public health emergencyplanning, exercises, and responseactivities in the community inaccordance with the NationalIncident Management System, andcoordinate with other local, state,and federal agencies.e. Fully participate in planning,exercises, and response activitiesfor other emergencies in thecommunity that have public healthimplications, within the context ofstate and regional plans and in amanner consistent with thecommunity’s best public healthinterest.f. Maintain access to laboratory andbiostatistical expertise and capacityto help monitor community healthstatus and diagnose andinvestigate public health problemsand hazards.g. Maintain policies and technologyrequired for urgentcommunications and electronicdata exchange.

NACCHO3Give people information theyneed to make healthy choices.a. Develop relationships with themedia to convey information ofpublic health significance, correctmisinformation about publichealth issues, and serve as anessential resource.b. Exchange information and datawith individuals, communitygroups, other agencies, and thegeneral public about physical,behavioral, environmental, social,economic, and other issuesaffecting the public’s health.c. Provide targeted, culturallyappropriate information to helpindividuals understand whatdecisions they can make to behealthy.d. Provide health promotionprograms to address identifiedhealth problems.4Engage the community toidentify and solve healthproblems.a. Engage the local public healthsystem in an ongoing, strategic,community-driven, comprehensiveplanning process to identify,prioritize, and solve public healthproblems; establish public healthgoals; and evaluate success inmeeting the goals.b. Promote the community’sunderstanding of, and advocacyfor, policies and activities that willimprove the public’s health.c. Support, implement, and evaluatestrategies that address publichealth goals in partnership withpublic and private organizations.d. Develop partnerships to generateinterest in and support forimproved community health status,including new and emergingpublic health issues.e. Inform the community, governingbodies, and elected officials aboutgovernmental public healthservices that are being provided,improvements being made inthose services, and priority healthissues not yet being adequatelyaddressed.5Develop public health policiesand plans.a. Serve as a primary resource togoverning bodies andpolicymakers to establish andmaintain public health policies,practices, and capacity based oncurrent science and best practices.b. Advocate for policies that lessenhealth disparities and improvephysical, behavioral, environmental,social, and economic conditions inthe community that affect thepublic’s health.c. Engage in LHD strategic planningto develop a vision, mission, andguiding principles that reflect thecommunity’s public health needs,and to prioritize services andprograms.Operational Definition of a Functional Local Health Department • November 20057

l o c a l h e a l t h d e p a r t m e n tstandards6a. Review existing laws andregulations and work withgoverning bodies and policymakersto update them as needed.b. Understand existing laws,ordinances, and regulations thatprotect the public’s health.c. Educate individuals andorganizations on the meaning,purpose, and benefit of publichealth laws, regulations, andordinances and how to comply.d. Monitor, and analyze over time, thecompliance of regulatedorganizations, entities, andindividuals.e. Conduct enforcement activities.f. Coordinate notification of violationsamong other governmentalagencies that enforce laws andregulations that protect the public’shealth.7NACCHO8Enforce public health laws andregulations.Help people receive healthservices.a. Engage the community to identifygaps in culturally competent,appropriate, and equitablepersonal health services, includingpreventive and health promotionservices, and develop strategies toclose the gaps.b. Support and implement strategiesto increase access to care andestablish systems of personal healthNATIONALASSOCIATION OFCOUNTY & CITYHEALTH OFFICIALSservices, including preventive andhealth promotion services, inpartnership with the community.c. Link individuals to available,accessible personal healthcareproviders (i.e., a medical home).8Maintain a competent publichealth workforce.a. Recruit, train, develop, and retain adiverse staff.b. Evaluate LHD staff members’ publichealth competencies, 7 and addressdeficiencies through continuingeducation, training, and leadershipdevelopment activities.c. Provide practice- and competencybasededucational experiences forthe future public health workforce,and provide expertise indeveloping and teaching publichealth curricula, throughpartnerships with academia.d. Promote the use of effective publichealth practices among otherpractitioners and agenciesengaged in public healthinterventions.e. Provide the public health workforcewith adequate resources to dotheir jobs.9Evaluateand improve programsand interventions.a. Develop evaluation efforts to assesshealth outcomes to the extentpossible.b. Apply evidence-based criteria toevaluation activities wherepossible.c. Evaluate the effectiveness andquality of all LHD programs and

NACCHOactivities and use the information toimprove LHD performance andcommunity health outcomes.d. Review the effectiveness of publichealth interventions provided byother practitioners and agenciesfor prevention, containment, and/or remediation of problemsaffecting the public’s health, andprovide expertise to thoseinterventions that needimprovement.10Contribute to and apply theevidence base of publichealth.a. When researchers approach theLHD to engage in researchactivities that benefit the health ofthe community,i. Identify appropriatepopulations, geographic areas,and partners;ii. Work with them to activelyinvolve the community in allphases of research;iii. Provide data and expertise tosupport research; and,iv. Facilitate their efforts to shareresearch findings with thecommunity, governing bodies,and policymakers.b. Share results of research, programevaluations, and best practiceswith other public healthpractitioners and academics.c. Apply evidence-based programsand best practices where possible.NOTES1For the purposes of these standards, anLHD is defined as the governmental publichealth presence at the local level. It may bea locally governed health department, abranch of the state health department, astate-created district or region, a departmentgoverned by and serving a multi-countyarea, or any other arrangement that hasgovernmental authority and is responsiblefor public health functions at the local level.2For the purposes of this document,“health disparities” refer to differences inpopulations’ health status that are avoidableand can be changed. These differencescan result from social and/or economicconditions, as well as public policy.Examples include situations wherebyhazardous waste sites are located in poorcommunities, there is a lack of affordablehousing, and there is limited or no accessto transportation. These and other factorsadversely affect population health.3The standards are framed around the TenEssential Public Health Services, which havebeen reworded to more accurately reflectthe specific LHD roles and responsibilitiesrelated to each category. In addition, thesestandards are consistent with the NationalPublic Health Performance StandardsProgram (NPHPSP), serving to specify therole of governmental LHDs while theNPHPSP addresses the local public healthsystem as a whole.4Input came from local healthdepartments, local boards of health, statehealth departments, and federal publichealth agencies; as well as countycommissioners, mayors, state legislators,and gubernatorial health advisors.5www.exploringaccreditation.org6NACCHO Resolution 04-06 furtherdescribes NACCHO’s stance onaccreditation.7As defined by the Core Public HealthCompetencies developed by the Council onLinkages between Academia and PublicHealth Practice.Operational Definition of a Functional Local Health Department • November 2005 9

o p e r a t i o n a l d e f i n i t i o n o f af u n c t i o n a l l o c a l h e a l t h d e p a r t m e n tPublic health professionals andthe communities they servedeserve a common set ofexpectations about local healthdepartments (LHDs). More than 600governmental public healthprofessionals and local and stateofficials representing 30 differentstates contributed to this definition,which will be a living document.By describing the functions of LHDs,the definition will help citizens andresidents understand what they canreasonably expect from governmentalpublic health in their communities.The definition also will be useful toelected officials, who need tounderstand what LHDs do and howto hold them accountable. And, thedefinition will aid LHDs in obtainingtheir fair share of resources.WHAT ARE NACCHO’SNEXT STEPS?NACCHO’s first step is education andcommunication about the definitionwith LHDs, local boards of health,state health departments, federalpublic health agenices, and local andstate elected officials. Metrics will bedeveloped to allow LHDs to measuretheir progress in achieving thestandards.NACCHO will also gather examples ofhow LHDs use the definition. TheExploring Accreditation project willexamine the use of the standards asthe basis for a voluntary nationalaccreditation system for LHDs of allsizes and structures.WHAT ACTION STEPS CANYOU TAKE?LHDs can use the definition andstandards to assess local efforts,measure performance, expandfunctions, enhance activities, andcommunicate about the role of localpublic health to their governingbodies, elected officials, andcommunity.NACCHONATIONALASSOCIATION OFCOUNTY & CITYHEALTH OFFICIALSNACCHO has developed a set of threefact sheets describing the role of localpublic health and a communicationstoolkit as part of this project. Boththe toolkit and the fact sheets areavailable on NACCHO’s Web site (seethe following column). NACCHOencourages LHDs to download and use thefact sheets and communications toolkit.10

NACCHOFinally, your experiences with thedefinition will inform and help shapethe implementation phase of thiseffort. Please submit examples ofhow LHDs have met the definition(particularly those involving thedevelopment of shared capacity and/or resources), applied the tools in thecommunications toolkit, or otherwiseused the definition or relatedmaterials.You can find additional materials andsubmit examples online at:www.naccho.org/topics/infrastructure/operationaldefinition.cfm.For more information about thisproject, please contactNACCHO at (202) 783-5550and ask to speak with theOperational Definition programmanager, or e-mailoperationaldefinition@naccho.org.NACCHO thanks the following organizations for their contributions to the developmentof the operational definition: the Association of State and Territorial Health Officials,the Association of State and Territorial Local Health Liaison Officials, the Centers forDisease Control and Prevention, the Health Resources and Services Administration, theNational Association of Counties, the National Association of Local Boards of Health,the National Conference of State Legislatures, the National Governors Association, theNational League of Cities, and the U.S. Conference of Mayors.Funding for this project was provided bythe Robert Wood Johnson Foundation andthe Centers for Disease Control andPrevention (under cooperative agreementU50/CCU302718). The contents of thisdocument are solely the responsibility ofthe authors and do not necessarilyrepresent the official views of the sponsors.Operational Definition of a Functional Local Health Department • November 200511

National Association ofCounty and CityHealth Officials1100 17th Street, NWSecond FloorWashington, DC 20036(202) 783-5550 Phone(202) 783-1583 Faxwww.naccho.orgNACCHO12NATIONALASSOCIATION OFCOUNTY & CITYHEALTH OFFICIALS