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					                                            NACCHO
     Operational
      Definition
                                            of a
                            functional
                            local health
                            department




                            NACCHO
         NATIONAL
         ASSOCIATION OF
         COUNTY & CITY
         HEALTH OFFICIALS



                                                                           Public Health
                                                                          Prevent. Promote. Protect.
Operational Definition of a Functional Local Health Department • November 2005         1

November 2005
o p e r a t i o n a l          d e f i n i t i o n     o f   a
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G
         overnmental public health               Prevents, minimizes, and contains
         departments are responsible             adverse health effects from
         for creating and maintaining            communicable diseases, disease
conditions that keep people healthy.             outbreaks from unsafe food and
At the local level, the governmental             water, chronic diseases,
public health presence, or “local                environmental hazards, injuries,
health department,” can take many                and risky health behaviors.
forms.1 Furthermore, each                       Leads planning and response
community has a unique “public                  activities for public health
health system” comprising individuals           emergencies.
and public and private entities that
                                                Collaborates with other local
are engaged in activities that affect
                                                responders and with state and
the public’s health.
                                                federal agencies to intervene in
                                                other emergencies with public
Regardless of its governance or
                                                health significance (e.g., natural
structure, regardless of where specific
                                                disasters).
authorities are vested or where
particular services are delivered,               Implements health promotion
everyone, no matter where they live,             programs.
should reasonably expect the local              Engages the community to
health department to meet certain               address public health issues.
standards.2
                                                 Develops partnerships with public
                                                 and private healthcare providers
A FUNCTIONAL LOCAL HEALTH
                                                 and institutions, community-
DEPARTMENT:
                                                 based organizations, and other
                                                 government agencies (e.g.,
     Understands the specific health             housing authority, criminal
     issues confronting the                      justice, education) engaged in
     community, and how physical,                services that affect health to
     behavioral, environmental,                  collectively identify, alleviate, and
     social, and economic conditions             act on the sources of public
     affect them.                                health problems.
     Investigates health problems and           Coordinates the public health
     health threats.                            system’s efforts in an intentional,
                                                non-competitive, and non-
                                                duplicative manner.


NACCHO    NATIONAL
          ASSOCIATION OF
          COUNTY & CITY
          HEALTH OFFICIALS



 2
                                            NACCHO
    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
                                                  NOTES
                                                  1
                                                    For the purposes of this definition, a
    activities, evaluates performance
                                                  local health department may be locally
    and outcomes, and makes                       governed, part of a region or district, be
    adjustments as needed to                      an office or an administrative unit of the
                                                  state health department, or a hybrid of
    continually improve its                       these.
    effectiveness, enhance the                    2
                                                    See “Local Health Department
    community’s health status, and                Standards,” Pages 4 through 9, for further
                                                  description of the functions captured in
    meet the community’s                          this definition.
    expectations.




Operational Definition of a Functional Local Health Department • November 2005            3
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A
        ll local health departments        standards, LHDs employ strategies
        (LHDs),1 as governmental           that are evidence-based and informed
        entities, derive their authority   by best practices, and they operate
and responsibility from the state and      according to the highest level of
local laws that govern them.               professionalism and ethics to inspire
Accordingly, all LHDs exist for the        public confidence and trust.
common good and are responsible
for demonstrating strong leadership        A number of factors contribute to the
in the promotion of physical,              variability of how LHDs operate;
behavioral, environmental, social,         specifically capacity, authority,
and economic conditions that               resources, and composition of the
improve health and well-being;             local public health system:
prevent illness, disease, injury, and
premature death; and eliminate                 The LHD may have the capacity
health disparities.2 However, in the           to perform all of the functions on
absence of specific, consistent                its own; it may call upon the
standards regarding how LHDs fulfill           state to provide assistance for
this responsibility, the degree to             some functions; it may develop
which the public’s health is protected         arrangements with other
and improved varies widely from                organizations in the community
community to community.                        or with neighboring LHDs to
                                               perform some functions; or it may
These standards describe the                   control the means by which
responsibilities that every person,            other entities perform some
regardless of where they live, should          functions.
reasonably expect their LHD to fulfill.
They have been developed within                Government agencies other than
nationally recognized frameworks3              the LHD may have the authority
and with input from public health              to perform services that affect
professionals and elected officials4           public health.
from across the country. The
standards provide a framework by               Resources for public health may
which LHDs are accountable to the              be housed in a different agency.
state health department, the public
they serve, and the governing bodies           Each LHD jurisdiction is served by
(e.g., local boards of health, county          its own unique public health
commissioners, and mayors) to which            system: public and private health
they report. In meeting the                    care providers, businesses,
                                               community organizations,
NACCHO    NATIONAL                             academic institutions, and media
          ASSOCIATION OF
          COUNTY & CITY                        outlets that all contribute to the
          HEALTH OFFICIALS
                                               public’s health.
 4
                                            NACCHO
As a result of these differences, how       Currently, not all LHDs have the
LHDs meet the standards—whether             capacity to meet the standards. Many
they directly provide a service, broker     concerns have been raised regarding
particular capacities, or otherwise         the costs of developing the capacity,
ensure that the necessary work is           and the implications for LHDs that do
being done—will vary. Regardless of         not meet the standards. It is difficult
its specific capacity, authority, and       to anticipate costs, and it is equally
resources, and regardless of the            important to understand that
particular local public health system,      improvements in capacity can be
the LHD has a consistent                    made in the absence of new
responsibility to intentionally             resources. NACCHO is committed to
coordinate all public health activities     collecting and sharing models of
and lead efforts to meet the                LHDs and LHD arrangements to
standards.                                  demonstrate various means to
                                            enhance local governmental public
The standards are a guide to the            health capacity. Furthermore,
fundamental responsibilities of LHDs,       NACCHO is currently participating in
allowing for varied structural              a national dialogue on whether to
characteristics of LHDs (e.g.,              establish a voluntary national
governance, staffing patterns, size of      accreditation system for state and
the population served, etc.), and           local health departments,5 and is
recognizing that each LHD may have          supportive of such an effort.6 The
other duties unique to meeting the          results of this dialogue may generate
public health needs of the community        implications for LHDs not meeting the
it serves. Several states have              standards.
developed, or are in the process of
developing, state-specific standards        NACCHO urges LHDs to embrace
for LHDs, and the National Public           these standards both as a means of
Health Performance Standards                working with their state health
Program (NPHPSP) includes standards         departments, communities, and
for local public health systems.            governing bodies to develop a more
NACCHO analyses of several state            robust governmental public health
initiatives and the NPHPSP have             capacity, and as a means of holding
shown a high level of consistency           themselves uniformly accountable to
between these efforts and NACCHO’s          the public they serve.
nationally-developed standards.




Operational Definition of a Functional Local Health Department • November 2005   5
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1  Monitor health status and
   understand health issues facing         2   Protect people from health
                                               problems and health hazards.
   the community.
                                           a. Investigate health problems and
a. Obtain and maintain data that              environmental health hazards.
   provide information on the              b. Prevent, minimize, and contain
   community’s health (e.g., provider         adverse health events and
   immunization rates; hospital               conditions resulting from
   discharge data; environmental              communicable diseases; food-,
   health hazard, risk, and exposure          water-, and vector-borne outbreaks;
   data; community-specific data;             chronic diseases; environmental
   number of uninsured; and                   hazards; injuries; and health
   indicators of health disparities such      disparities.
   as high levels of poverty, lack of      c. Coordinate with other
   affordable housing, limited or no          governmental agencies that
   access to transportation, etc.).           investigate and respond to health
b. Develop relationships with local           problems, health disparities, or
   providers and others in the                environmental health hazards.
   community who have information          d. Lead public health emergency
   on reportable diseases and other           planning, exercises, and response
   conditions of public health interest       activities in the community in
   and facilitate information                 accordance with the National
   exchange.                                  Incident Management System, and
c. Conduct or contribute expertise to         coordinate with other local, state,
   periodic community health                  and federal agencies.
   assessments.                            e. Fully participate in planning,
d. Integrate data with health                 exercises, and response activities
   assessment and data collection             for other emergencies in the
   efforts conducted by others in the         community that have public health
   public health system.                      implications, within the context of
e. Analyze data to identify trends,           state and regional plans and in a
   health problems, environmental             manner consistent with the
   health hazards, and social and             community’s best public health
   economic conditions that adversely         interest.
   affect the public’s health.             f. Maintain access to laboratory and
                                              biostatistical expertise and capacity
                                              to help monitor community health
                                              status and diagnose and
                                              investigate public health problems
                                              and hazards.
 NACCHO    NATIONAL                        g. Maintain policies and technology
           ASSOCIATION OF
           COUNTY & CITY                      required for urgent
           HEALTH OFFICIALS
                                              communications and electronic
  6                                           data exchange.
                                               NACCHO
3   Give people information they
    need to make healthy choices.
                                                  health goals in partnership with
                                                  public and private organizations.
                                               d. Develop partnerships to generate
a. Develop relationships with the
                                                  interest in and support for
   media to convey information of
                                                  improved community health status,
   public health significance, correct
                                                  including new and emerging
   misinformation about public
                                                  public health issues.
   health issues, and serve as an
                                               e. Inform the community, governing
   essential resource.
                                                  bodies, and elected officials about
b. Exchange information and data
                                                  governmental public health
   with individuals, community
                                                  services that are being provided,
   groups, other agencies, and the
                                                  improvements being made in
   general public about physical,
                                                  those services, and priority health
   behavioral, environmental, social,
                                                  issues not yet being adequately
   economic, and other issues
                                                  addressed.
   affecting the public’s health.
c. Provide targeted, culturally-
   appropriate information to help
   individuals understand what
                                               5   Develop public health policies
                                                   and plans.

   decisions they can make to be               a. Serve as a primary resource to
   healthy.                                       governing bodies and
d. Provide health promotion                       policymakers to establish and
   programs to address identified                 maintain public health policies,
   health problems.                               practices, and capacity based on
                                                  current science and best practices.

4    Engage the community to
     identify and solve health
                                               b. Advocate for policies that lessen
                                                  health disparities and improve
     problems.                                    physical, behavioral, environmental,
                                                  social, and economic conditions in
a. Engage the local public health
                                                  the community that affect the
   system in an ongoing, strategic,
                                                  public’s health.
   community-driven, comprehensive
                                               c. Engage in LHD strategic planning
   planning process to identify,
                                                  to develop a vision, mission, and
   prioritize, and solve public health
                                                  guiding principles that reflect the
   problems; establish public health
                                                  community’s public health needs,
   goals; and evaluate success in
                                                  and to prioritize services and
   meeting the goals.
                                                  programs.
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

   Operational Definition of a Functional Local Health Department • November 2005   7
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6     Enforce public health laws and
      regulations.
                                              services, including preventive and
                                              health promotion services, in
                                              partnership with the community.
a. Review existing laws and
                                           c. Link individuals to available,
   regulations and work with
                                              accessible personal healthcare
   governing bodies and policy-
                                              providers (i.e., a medical home).
   makers to update them as needed.
b. Understand existing laws,
   ordinances, and regulations that
   protect the public’s health.
                                           8    Maintain a competent public
                                                health workforce.

                                           a. Recruit, train, develop, and retain a
c. Educate individuals and
                                              diverse staff.
   organizations on the meaning,
                                           b. Evaluate LHD staff members’ public
   purpose, and benefit of public
                                              health competencies,7 and address
   health laws, regulations, and
                                              deficiencies through continuing
   ordinances and how to comply.
                                              education, training, and leadership
d. Monitor, and analyze over time, the
                                              development activities.
   compliance of regulated
                                           c. Provide practice- and competency-
   organizations, entities, and
                                              based educational experiences for
   individuals.
                                              the future public health workforce,
e. Conduct enforcement activities.
                                              and provide expertise in
f. Coordinate notification of violations
                                              developing and teaching public
   among other governmental
                                              health curricula, through
   agencies that enforce laws and
                                              partnerships with academia.
   regulations that protect the public’s
                                           d. Promote the use of effective public
   health.
                                              health practices among other
                                              practitioners and agencies
7     Help people receive health
      services.                               engaged in public health
                                              interventions.
a. Engage the community to identify        e. Provide the public health workforce
   gaps in culturally-competent,              with adequate resources to do
   appropriate, and equitable                 their jobs.
   personal health services, including
   preventive and health promotion
   services, and develop strategies to     9    Evaluate and improve programs
                                                and interventions.
   close the gaps.                         a. Develop evaluation efforts to assess
b. Support and implement strategies           health outcomes to the extent
   to increase access to care and             possible.
   establish systems of personal health    b. Apply evidence-based criteria to
                                              evaluation activities where
 NACCHO     NATIONAL
            ASSOCIATION OF
                                              possible.
            COUNTY & CITY
            HEALTH OFFICIALS
                                           c. Evaluate the effectiveness and
                                              quality of all LHD programs and
  8
                                              NACCHO
   activities and use the information           NOTES
   to improve LHD performance and               1
                                                  For the purposes of these standards, an LHD
   community health outcomes.                   is defined as the governmental public health
d. Review the effectiveness of public           presence at the local level. It may be a locally
                                                governed health department, a branch of the
   health interventions provided by
                                                state health department, a state-created
   other practitioners and agencies
                                                district or region, a department governed by
   for prevention, containment, and/            and serving a multi-county area, or any other
   or remediation of problems                   arrangement that has governmental authority
   affecting the public’s health, and           and is responsible for public health functions
   provide expertise to those                   at the local level.
   interventions that need                      2
                                                  For the purposes of this document, “health
   improvement.                                 disparities” refer to differences in populations’
                                                health status that are avoidable and can be


10       Contribute to and apply the
         evidence base of public
                                                changed. These differences can result from
                                                social and/or economic conditions, as well as
                                                public policy. Examples include situations
         health.
                                                whereby hazardous waste sites are located in
a. When researchers approach the                poor communities, there is a lack of
   LHD to engage in research                    affordable housing, and there is limited or no
   activities that benefit the health of        access to transportation. These and other
                                                factors adversely affect population health.
   the community,
                                                3
    i. Identify appropriate                       The standards are framed around the Ten
         populations, geographic areas,         Essential Public Health Services, which have
                                                been reworded to more accurately reflect the
         and partners;
                                                specific LHD roles and responsibilities related
    ii. Work with them to actively
                                                to each category. In addition, these standards
         involve the community in all           are consistent with the National Public Health
         phases of research;                    Performance Standards Program (NPHPSP),
    iii. Provide data and expertise to          serving to specify the role of governmental
         support research; and,                 LHDs while the NPHPSP addresses the public
    iv. Facilitate their efforts to share       health system as a whole.
         research findings with the             4
                                                 This includes those from local health
         community, governing bodies,           departments, local boards of health, state
         and policymakers.                      health departments, and federal public health
b. Share results of research, program           agencies; as well as county commissioners,
                                                mayors, state legislators, and gubernatorial
   evaluations, and best practices
                                                health advisors.
   with other public health
                                                5
   practitioners and academics.                     www.exploringaccreditation.org
                                                6
c. Apply evidence-based programs                 NACCHO Resolution 04-06 further describes
   and best practices where possible.           NACCHO’s stance on accreditation.
                                                7
                                                 As defined by the Core Public Health
                                                Competencies developed by the Council on
                                                Linkages between Academia and Public
                                                Health Practice.

  Operational Definition of a Functional Local Health Department • November 2005              9
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P
         ublic health professionals and      WHAT ARE NACCHO’S
         the communities they serve          NEXT STEPS?
         deserve a common set of
                                             NACCHO’s first step is education and
expectations about local health              communication about the definition
departments (LHDs). More than 600            with LHDs, local boards of health,
governmental public health                   state health departments, federal
professionals and local and state            public health agenices, and local and
officials representing 30 different          state elected officials. Metrics will be
states contributed to this definition,       developed to allow LHDs to measure
which will be a living document.             their progress in achieving the
                                             standards.
By describing the functions of LHDs,
the definition will help citizens and        NACCHO will also gather examples of
                                             how LHDs use the definition. The
residents understand what they can
                                             Exploring Accreditation project will
reasonably expect from governmental
                                             examine the use of the standards as
public health in their communities.
                                             the basis for a voluntary national
The definition also will be useful to
                                             accreditation system for LHDs of all
elected officials, who need to               sizes and structures.
understand what LHDs do and how
to hold them accountable. And, the
definition will aid LHDs in obtaining        WHAT ACTION STEPS CAN
their fair share of resources.               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). We encourage
NACCHO    NATIONAL                           LHDs to download the fact sheets and
          ASSOCIATION OF
          COUNTY & CITY
          HEALTH OFFICIALS
                                             communications toolkit.

10
                                                 NACCHO
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                 For more information about this
submit examples online at:                            project, please contact
                                                      NACCHO at (202) 783-5550
     www.naccho.org/topics/                           and ask to speak with the
     infrastructure/                                  Operational Definition program
     operationaldefinition.cfm.                       manager, or e-mail
                                                      operationaldefinition@naccho.org.




    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.

Operational Definition of a Functional Local Health Department • November 2005              11
                            National Association of
                                County and City
                                 Health Officials
                             1100 17th Street, NW
                                  Second Floor
                            Washington, DC 20036
                            (202) 783-5550 Phone
                              (202) 783-1583 Fax
                                www.naccho.org




NACCHO   NATIONAL
         ASSOCIATION OF
         COUNTY & CITY
         HEALTH OFFICIALS



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