Local Health Department Governance Classifications: Are They Even Important?

Local health departments are connected to and collaborate with their state health department and the government in numerous ways. In some jurisdictions, local health departments operate largely independently from the state; in others, they function as a local arm of the state or state health department; while in some cases, they are components of both. Understanding the structure of how the local health departments and state health departments are connected, including the authority and roles, is essential to understanding how local health departments operate, function, and deliver public health services to local communities. The National Association of County and City Health Officials (NACCHO) uses classifications for local health departments—local, shared, and state—that describes this relationship specifically for that local health department, in contrast to classifications used to describe the nature of all local health departments in the state collectively. Local indicates the local health department has authority based on local government; state indicates the local health department is a unit of the state health department with state-level authority; and shared indicates both a level of local and state government authority. The NACCHO, Association of State and Territorial Health Officials (ASTHO), and researchers have used a variety of characteristics that, when taken together, would help to classify governance, including entities for hiring or appointing local health department top executives, different activities that fall under local/state authority (eg, establishing fees and/or taxes), authority to issue public health orders, and financial/budgetary decision-making. This classification is in concert with the ASTHO that determines state governance structure.1 As national associations for governmental public health, both the ASTHO and NACCHO are invested in understanding state and local public health. While it can be confusing that the components of NACCHO and ASTHO’s definitions use some similar language, the ASTHO often refers to how public health is administered for the entire state, whereas the NACCHO’s “local,” “state,” and “shared” classification in most reporting describes the governance of the individual health department. For example, there are states that have locally governed local health departments as well as state-governed local health departments (such as in Virginia). In these cases, the NACCHO will describe local health departments within the state as having differing classifications individually. The NACCHO uses this classification of local health departments in a few ways. One of the key ways the NACCHO uses local governance classifications is to report on trends associated with this factor; the NACCHO does this for many of its national surveys. For example, in the 2022 National Profile of Local Health Departments, this governance structure was used to understand more detailed aspects of budgets, workforce, informatics, harassment, and more at local health departments.2 Given the importance of governance structures, the NACCHO Research has been considering ways to update this classification for each local health department as there is a possibility that these may change over time given changes to local health departments and state health departments. The initial effort to grasp aspects of where local and state authority and roles lie was done through a nationally representative survey of local health departments, the 2024 Forces of Change (FOC) survey.3 More details regarding methodology and results from 2024 FOC can be found at https://www.naccho.org/uploads/downloadable-resources/2024-Forces-of-Change-Survey-Report.pdf. Below are a few highlights from these data.3 Local Health Department Top Executives One in 4 local health departments reported that their top executive (ie, local health official, health officer) was a state employee. Regarding how local health department top executives were appointed or approved, this was often the responsibility of local government; 77% of local health departments reported their top executive was appointed locally by local government, and this decreased slightly to 69% for approval of top executive (Figure 1). FIGURE 1: Level of Government Responsible for Appointing and Approving Local Health Departments Top Executives Activities Related to Public Health Authority The 2024 FOC survey asked about 4 different activities and whether these fall under local government responsibility: making budgetary decisions affecting the local health department, establishing fees for local health department services, issuing public health orders, and establishing taxes/levies for public health. Over 8 in 10 local health departments reported local government authority for making budgetary decisions; around 7 in 10 reported local government authority for establishing fees or issuing public health orders; and just about 6 in 10 reported local government authority for establishing taxes/levies for public health (Figure 2). For those with taxes/levies under local authority, a large majority (87%) reported that the revenues received were directed to local government. This was similar for those with fees under local authority with 92% of these local health departments reporting revenues directed to local government. FIGURE 2: Key Activities and Whether They Are Local Government Responsibility Budgets Lastly, local health departments were asked how much of their budget was provided by the state public health agency. There was quite a bit of variability in these budgets. About 1 in 5 local health departments reported that less than 10% of their budget was provided by state health agencies; meanwhile, about 1 in 3 reported that 50% or more of their budget was provided by the state health agency (Figure 3). FIGURE 3: Percent of Local Health Department Budget Provided by State Questions in the 2024 FOC were asked initially as part of a broader effort to see how classifications from the early 2010s have changed; while NACCHO does make efforts to update these classifications ad hoc based on information from local health departments and state health departments, it would help to have some initial information on what local health department governance looks like in 2024, using similar criteria to the earlier efforts. Given this effort and initial data, across the next few years, NACCHO is planning to adjust items for future surveys and determine more systematic approaches to gathering this data beyond self-report, which was 1 major challenge to this initial pilot. There may be instances where NACCHO understands something to be objectively different than what was reported in these questions, and therefore, it raises the importance of having objective and verified data to update governance classifications or to revise governance classifications and definitions. NACCHO will continue updating the current classifications with advice and feedback from local health departments and state health departments in addition to any additional effort undertaken to understand and potentially revise these classifications. While it will be an effort that will take much time, funding, due diligence, and lots of input from partners and local health departments, it will help ensure that NACCHO has the best picture of how state health departments and each of their local health departments interact, operate, and function based on roles and authorities.