The structural relationship between state and local health agencies often defines local health departments' responsibilities and authority within communities. In states where local health departments provide a number of population and clinically-based services, the state health department may serve a minor role in assuring these services are delivered and providing resources for their delivery. In states where local health departments are limited in size and scope of public health activity, the state system is often the entity that provides health services at the local level through district offices or other local health units of the state structure. In both systems, health services and population-based programs can be successfully delivered to ensure the public's health. However, the type of state and local structure has implications for the way health partnerships are developed at the state and local level, and inform our thinking about how to transform effectively community public health systems.
Relationship Types Defined
As part of a nationwide study of public health infrastructure supported by The Robert Wood Johnson Foundation, the National Association of County and City Health Officials (NACCHO) asked state-local health department liaisons about the state and local health department structure in their state. (Note: The District of Columbia and Puerto Rico were referred to as "states" for the purpose of this study.) Liaisons were asked if their states fit into four broad categories originally defined by the Centers for Disease Control and Prevention (CDC) in a comprehensive state-by-state report titled the 1990 Profile of State and Territorial Public Health Systems. In "centralized" systems, the local health department is operated by the state health agency or board of health and functions under the state health agency's authority. In "decentralized" systems, local governments have "home-rule" or direct authority over local health agencies. Variations of these two general types include "mixed" systems in which state and local health services are provided by a combination of the state health agency, local government, boards of health or health departments in other jurisdictions. In "shared" systems, the local health department operates under the shared authority of the state health agency, the local government, and local boards of health. In NACCHO's study, an "other" category was created for the states of Hawaii and Rhode Island, two systems that reported having no local health department equivalents.
Decentralized Systems Are the Most Common
Most states reported that their state and local health structures were "decentralized" (50% or 26 states). In these systems, local governments operate under direct local control; for example, in the Commonwealth of Massachusetts over 350 cities and towns oversee community health issues through local boards of health that operate as local health units. Twenty-five percent (25% or 13 states) reported centralized systems, relationships in which the state health agency was the functional health unit at the local level. Examples of centralized systems can be found in the states of Florida, Vermont, and Nevada. Both the District of Columbia and Puerto Rico reported centralized systems.
While the centralized and decentralized categories form two broad types of state and local structures, there were states whose state and local health structures were "shared" or "mixed." For example, mixed systems were reported by Texas, New Hampshire, and Alaska.
Broad Categories Need to Be Refined
Several states reported exceptions to the broad categories they selected. This was especially the case in states with large cities that had municipal health departments, but the state agency provided services to the remaining population. Respondents noted that these variations did not change the overall state-local structure, but they did suggest that not all local jurisdictions in the state had the same structural relationship to the state health department. This variation is not well defined in the current four-category scheme, and suggests a need to further refine the structures listed. For example, in Louisiana it was noted that the City of New Orleans operates and has authority over their parish's health department. In Virginia, thirty-two (32) health departments are units of the state health agency and three local units operate autonomously under permission of that state's Assembly. Continued discussion between federal, state, and local health agencies and public health stakeholders will continue to elaborate these relationship types, updating them for use in future studies.
Implications for System Change
Continued research using this state-local structure typology and modifications to it will determine how these various structures impact the delivery of public health services and public health functions at the local level. The ways in which these structures influence funding allocations, program development, quality assurance, and community involvement in the local and state health systems also need to be addressed in future research. However, even these broad categories have broad implications for health systems change and community health partnerships. For example, in states with decentralized systems, there may be more opportunity for local groups to influence directly health system transformation within their jurisdictions, as "home-rule" systems often have set opportunities for community involvement that may lead to change. Transformation in states with centralized systems might be more far reaching since the entire state system is affected by changes and improvements to the system. Mixed and shared systems may in fact represent areas in which transformation in these state-local structures has begun as policy and decision making is shared between state and local health departments. They may also represent compromises in which systems change need to be more intensively pursued. The work of Turning Point sites will continue to inform these state-local structures, and provide a means for examining how transformation in health systems occurs at many different levels. Current research by Turning Point sites, NACCHO, and other public health partners will add to the growing understanding of how state and local health agencies work together to strengthen and improve community health across the country.
This report was prepared by Michael Fraser, MA, Program Manager at NACCHO. Keith Downing, Intern and Areana Quinones, Project Assistant at NACCHO were instrumental in helping complete the report. Funding was provided by a grant from The Robert Wood Johnson Foundation. Comments and suggestions regarding this article should be directed to Michael Fraser or Areana Quinones, NACCHO, (202) 783-5550.