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Scientific Data Documentation
Profile Of State And Territorial Public Health System, 1991
ACKNOWLEDGEMENTS Public Health Practice Program Office Division of Public Health Systems October 1991 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Centers for Disease Control This document is in the public domain and may be freely copied or reprinted. Copies of this document are available from CDC. We invite your suggestions and comments on the utility of this publication and ways of improving it. Comments and/or suggestions should be directed to: Edward H. Vaughn Health Systems Analyst Public Health Practice Program Office Centers for Disease Control Atlanta, Georgia 30333 Telephone (404) 639-1943FOREWORD On behalf of the Centers for Disease Control (CDC) and the Public Health Practice Program Office (PHPPO), we are pleased to present the Profile of State and Territorial Public Health Systems: United States, 1990. This publication is a first effort to describe how public health services are organized and delivered in each state and territory. Major components of the public health system in each jurisdiction are described, and the relationships between these components are explored. The cooperation of state and territorial public health officials was invaluable to completing this project. State officials provided much of the information used in the document and made many suggestions for improvement. Several local public health officials also provided information and assistance. In Healthy People 2000: National Health Promotion and Disease Prevention Objectives (1), an ambitious far-reaching objective is proposed: "By the Year 2000, increase to at least 90 percent the proportion of people who are served by a local health department that is effectively carrying out the core functions of public health." To monitor progress toward that objective, we are developing a unique surveillance system designed to assess the status of the public health system at the state and local levels. We have developed these profiles, in part, to assist in this process. Further, we also anticipate that state and local public health officials will find these profiles useful in many ways. For example, they could be used as a starting point for research on the public health system, to compare and/or contrast elements of the system, and as a source for models of organizational structure and function. Finally, CDC personnel and those of other Federal health agencies should find these profiles useful as they work with state and local agencies. For example, CDC, through its Epidemic Intelligence Service (EIS) program, provides assistance in epidemiologic investigations. EIS officers performing such investigations could benefit by familiarizing themselves with the appropriate profile. Similarly, CDC Public Health Advisors assigned to work in state and local agencies could review their state's profile as part of their orientation process. We invite your comments on other uses of these profiles and ways to improve this document in future years. Edward L. Baker, M.D., M.P.H. Director Public Health Practice Program Office Centers for Disease Control SUMMARY Introduction To achieve National Health Promotion and Disease Prevention Objective 8.14, a new surveillance system will be needed that can measure and evaluate the status of public health practice in state and local systems in the United States. As stated in Objective 8.14, by the Year 2000, the nation needs to "increase to at least 90 percent the proportion of people who are served by a local health department that is effectively carrying out the core functions of public health" (1). The design of such a surveillance system requires an understanding of how public health systems in the United States currently are organized, and how state and local components interact. This information is not routinely collected and summarized, nor easily available. Also, public health systems in the United States change so often that the available information soon becomes out of date. The purpose of this book is to offer a descriptive profile of how public health systems in the United States are organized at state and local levels, and how state and local components interact, based on existing information available between 1989 and 1990. Specifics are included on all 50 states, the District of Columbia, and the 8 territories of the United States. Methods In 1989 and 1990, we collected existing pamphlets, brochures, publications, reports, or other printed materials prepared by state and territorial public health systems on selected topics (e.g., the organization of the State Health Agency (SHA); the head of the SHA; the state board of health or council; regional or district health offices; and state-local relationships). For SHAs with a Local Health Liaison Official (LHLO) (a SHA staff member with responsibility for coordinating with the local health departments in the state), we asked the LHLO to provide this information. For SHAs with no LHLO, we identified other appropriate public health officials and requested that they provide similar information. We simultaneously compiled information from other existing data sources. For example, we obtained information on demographics by state from the 1980 national census, and budget information from the Public Health Foundation (2). To identify local public health agencies (LPHAs), we used the following definition: an administrative and service unit of local or state government, concerned with health, employing at least one full-time person, and carrying some responsibility for health of a jurisdiction smaller than the state. This definition was previously used in a national survey of LPHAs by C. Arden Miller (3). We asked SHA representatives to use the Miller definition in reviewing information about LPHAs in their state (e.g., the number of LPHAs; types of geographic jurisdictions for LPHAs; and the number of LPHAs with local boards of health and local health officers). For determining staff and services in LPHAs, we analyzed data from a survey of LPHAs conducted by the National Association of County Health Officials (NACHO) and the Centers for Disease Control (CDC) (4). For these tabulations, we used the NACHO definition of an LPHA: "an administrative and service unit of local or state government concerned with health and carrying some responsibility for the health of a jurisdiction smaller than a state" (4). The NACHO definition is less restrictive than the Miller definition (i.e., the NACHO definition does not require that an LPHA have a "full-time person"). We developed draft documents for each state and territory and returned them to the SHA for review and verification.Results Selected Sociodemographic Indicators Program requirements for public health agencies may differ depending on the characteristics of the population to be served. The demographics of the population vary considerably in different jurisdictions. For example, the 1988 state populations ranged from a low of about 0.5 million in Alaska to a high of about 28 million people in California. The 1988 population density ranged from a low of about 1 per square mile in Alaska to a high of about 1,000 per square mile in New Jersey. The proportion of the population categorized as rural in states in 1980 ranged from a low of 9 percent in California to a high of 66 percent in Vermont. The percent of the population categorized as non-white in states in 1980 ranged from a low of about 1 percent in Vermont to a high of 67 percent in Hawaii. The median age of the population in states in 1987 ranged from a low of about 26 years in Utah to a high of 36 years in Florida. Public health agencies often are health care providers for the most needy portions of the population. The percent of the population in a state below the poverty level in 1985 ranged from a low of about 6 percent in New Hampshire to a high of about 25 percent in Mississippi. Educational levels are another important consideration in delivery of public health services. In 1980, median years of education in state populations ranged from a low of 12.1 years (Kentucky, South Carolina) to a high of 12.8 years (Alaska, Colorado, Utah). County Government Structure The local government structure directly influences LPHA activities and services. County governments are the most common type of local government structure within which LPHAs operate. The relationship between county governments and LPHAs varies within and betwen states. Geographic jurisdictions of LPHAs are as follows: a county in 72 percent (2,067/2,876) of LPHAs; town/township in 11 percent (325/2,876); city in 7 percent (212/2,876); city-county in 6 percent (158/2,876); and multi- county in 4 percent (114/2,876). County government authority is granted by state constitutions or statutes. Thirty-two (64%) states and the District of Columbia permit home rule authority, or local adoption of a home rule option. This option provides counties with an opportunity to enact a "local constitution" which gives the county additional authority and powers (e.g., to levy taxes for LPHA services and activities). About 70 percent of counties have a county commission form of government structure. The commission consists of an elected board, ranging from 2 to over 100 members. The commission has legislative powers that may include passing ordinances and adopting budgets, and administrative powers that may include supervising some or all departments and appointing administrative employees. A hallmark of the commission form of government is that "county commissioners" share administrative responsibility with several independently elected "row officers" such as the county clerk, auditor and recorder, assessor, treasurer, prosecuting attorney, sheriff, and coroner. About 20 percent of counties have a county administrator. The county administrator position is usually appointed by and accountable to the governing board or legislative body. Other titles given this position include chief administrative officer, appointed administrator, administrator, and county manager. About 5 percent of counties have an elected executive. Similar to the position of a mayor, the executive is elected at large and is responsible for working with the county legislative body. Elected executives have veto power over the legislative body. State Health Agencies (SHAs) All 50 states, the District of Columbia, and 8 territories have SHAs responsible for the administration of public health services within their jurisdictions. SHAs usually are organized as one of two models: as a freestanding, independent agency responsible directly to the governor or the board of health, or as a component of a superagency. The SHA is an independent government agency in 31 (62%) states, and a component of a state government superagency in 19 (38%) states and the District of Columbia. Of the seven territories for which information is available, SHAs are independent agencies in six territories and a component of a superagency in one territory. Depending on how activities in a state are organized, public health responsibilities and authority may not be located in the SHA. For example, only 4 SHAs (8%) are the state mental health authority, and only 15 (29%) SHAs are the lead environmental agency for the state (Table S-1). In The Future of Public Health, the Institute of Medicine recommended that each state have a health department that has responsibility for all primarily health-related functions, such as Medicaid, mental health and substance abuse, environmental responsibilities requiring health expertise, health planning, and regulation of health facilities and professions (5). Head of State Health Agency The position of the official who appoints the head of the SHA affects this individual's level of authority and access to key decision makers in state government. The head of the SHA is appointed by the governor to a cabinet-level position in 32 (64%) states; the head of the superagency in which the SHA resides in 14 (28%); and the state board of health in 4 (8%) (Mississippi, Oklahoma, South Carolina, and Texas). The head of the SHA is appointed by the Mayor of the District of Columbia. The head of the SHA is appointed by the governor in the four territories for which this information is available. The head of the SHA is required to have an M.D. degree in 23 (46%) states and the District of Columbia. Of the four territories for which this information is available, two territories require that the head of the SHA have an M.D. degree, and two territories do not. State Board or Councils of Health State boards or councils of health are used for citizen input into the operation of the SHA by 40 (80%) states. These boards or councils function in a policy-making capacity in 21 (42%) states, in an advisory capacity in 17 (34%), and in both capacities in 2 (4%). Regional or District Health Offices A SHA may organize its jurisdiction into regions or districts to provide closer administrative or technical support to Local Public Health Agencies (LPHAs). Administrative regions or districts are used in 28 (56%) states. The number of regions or districts per SHA ranges from a low of 2 (Massachusetts, New Jersey) to a high of 19 (Georgia). Three of the territories also are divided into administrative regions or districts. State-local Liaison The organizational relationships between local public health agencies (LPHAs) and the SHA fall into four broad categories, ranging from one where LPHAs are semi-independent of the SHA to one where LPHAs are sub-units of the SHA. Map S-1 shows variation of state-local relationships by state. State-local relationships are decentralized in 16 (32%) states (local governments directly operate LPHAs); mixed centralized and decentralized in 16 (32%) (local health services may be provided by the SHA, local governmental units, boards of health, or health departments in other jurisdictions); centralized in 10 (20%) (LPHAs function directly under the state's authority and are operated by the SHA or board of health); and shared in 7 (14%) (LPHAs are under the authority of the SHA, as well as the local government and board of health). Budget Total expenditures for public health by states are difficult to compare and interpret because SHA organization and responsibilities differ, and SHA programs vary in importance and content. Total SHA expenditures in fiscal year 1988 ranged from a low of $14 million (Wyoming) to a high of $793 million (California). The total SHA expenditures for public health in that year were less than $100 million in 25 (50%) states; from $100 to 199 million in 15 (30%) states and the District of Columbia; from $200 to 299 million in 4 (8%); from $300 to 399 million in 3 (6%); and more than $400 million dollars in 3 (6%) (California, Maryland, and New York). Local Public Health Agencies (LPHAs) Using the Miller definition of an LPHA (except for Alaska and Hawaii where the SHA requested that some local administrative/service units not be classified as LPHAs), representatives of SHAs reported 2,876 LPHAs. In the 1989 NACHO survey, a total of 2,932 LPHAs were identified (using the less restrictive NACHO definition) (4), a difference of only 2 percent (56/2,932) more LPHAs. In the 1989 NACHO survey, 2,269 (77%) of LPHAs returned completed questionnaires. Forty-two percent of these LPHAs served less than 25,000 population, and an additional 23 percent served less than 50,000 population (4). Services Provided Activities in assessment, policy development, and assurance reported by the respondent LPHAs in the 1989 NACHO survey are summarized Tables S-2, S-3, and S-4. The percentage of LPHAs reporting activity in specific functions generally increased as the size of the population served by the jurisdiction increased. Immunizations, reportable diseases, child health, and tuberculosis control activities were reported by almost all (80% or more) of LPHAs. At least half the LPHAs reported activities in the following areas: health education; sexually transmitted diseases; Women, Infants, and Children (WIC) program; family planning; prenatal care; acquired immunodeficiency syndrome (AIDS) testing and counseling; chronic diseases; and home health care. From 35 percent to 49 percent of LHDs provided services to handicapped children and laboratory and dental services. Less than 25 percent provided services in the following categories: occupational safety and health, primary care, obstetrical care, drug and alcohol use, mental health, emergency medical services, long-term facilities, and hospitals. Local Board of Health Local boards of health are used in 38 (76%) states to provide local input into or control of the operation of LPHAs. Local boards have policy-making responsibilities in 28 (56%) states, advisory responsibilities in 5 (10%), both advisory and policy-making responsibilities in 3 (6%), and different responsibilities in different geographic areas in 2 (4%). None of the territories reported having local boards of health. Local Health Officer A local health officer (or equivalent official) is assigned responsibility to provide LPHA leadership in 48 (96%) states. Minnesota and Rhode Island have no local health officers. Local health officers are appointed by the local board of health in 19 (38%) states, by the local governmental authority in 16 (32%), by the head of the SHA in 9 (18%), by the State Board of Health in 2 (4%), by the Deputy Commissioner for Health in 1 (2%), and by the state merit system in 1 (2%). Local health officers are required to have an M.D. degree in 22 (44%) states. An additional 3 (6%) states require M.D. degrees in some LPHAs. Staff LPHA staff are employed by the LPHA in 31 (62%) states, by the SHA in 9 (18%), and by combinations of SHA and LPHA in 9 (18%). The number of employees per LPHA ranges from 1 to 26,000. Additional details on the characteristics of LPHA staff are available from the 1989 NACHO questionnaire survey (4). Forty- six percent of 2,137 respondent LPHAs report a staff size of 9 or fewer full-time employees. Typically, the majority of LPHAs serving jurisdictions with less than 25,000 population report employing a clerical or secretarial employee (89%); a registered nurse (83%); and an engineer/sanitarian (65%). In addition to these, the majority of LPHAs serving jurisdictions with 25,000 to 49,999 population also report employing a physician (65%). In addition to these staff, the majority of LPHAs serving jurisdictions with 50,000 to 99,999 population also report employing a health educator (54%) and nutritionist/dietitian (67%). Budget Total expenditures for public health in LPHAs are difficult to compare and interpret for reasons similar to those limiting comparison of SHA expenditures (i.e., LPHA organization and responsibilities may differ, and LPHA programs can vary in importance and content). Total LPHA expenditures for fiscal year 1988 by state ranged from a low of $57,000 (New Hampshire) to a high of $439 million (California). The total LPHA expenditures by state in that year were less than $100 million in 30 (71%) of the 42 states which reported local health department expenditures; from $100 to 199 million in 7 (17%); from $200 to 299 million in 3 (7%); and more than $300 million in 2 (5%) (California and New York).Discussion and Conclusion This book provides a descriptive profile of how public health systems in the United States are organized at the state and local levels, and how state and local components interact, based on information available in 1989 and 1990. Several general patterns are apparent from the profiles. For example, the public health system typically involves the following units of organization: SHAs (100% of states); state administrative regions or districts (56% of states); and counties (72% of states). The SHA usually is an independent government agency (62% of states). LPHAs commonly are operated directly by local government (32% of states) or by a mixture of local and state government (32% of states). Citizen input into the public health system occurs at the state level through state boards or councils of health (80% of states), and at the local level through local boards of health (76% of states). Although SHAs and LPHAs typically have physicians on staff or access to input from physicians, top administrative leadership positions tend to be filled by non- physicians, with only 46% of states requiring the head of the SHA or the LPHA to have a medical degree. In addition, the size of the population served in a jurisdiction is an important factor related to the organization and nature of public health agencies. The number and nature of LPHA activities, and the number and level of specialization of staff, generally increase as the size of the population served by the jurisdiction increases. In 1945, Emerson recommended that LPHAs should serve populations of no less than 50,000 (6). Many experts have debated the merits of this. Additional studies would appear worthwhile, since the majority (65%) of LPHAs in the 1989 study by NACHO report that they served jurisdictions with less than 50,000 population. To monitor progress towards achieving Healthy People 2000 Objective 8.14, the nation must develop a surveillance system that can measure and evaluate the status of public health practice in state and local systems in the United States. Surveillance information will be needed in three broad areas: 1) the geographic boundaries of LPHA jurisdictions; 2) simple descriptive information regarding public health agencies and the populations which they serve (e.g., budgets, workforce, services, demographic information, and organizational structure); and 3) information to describe how effectively LPHAs perform the core functions of public health in their jurisdiction (assessment, policy development, and assurance). CDC has identified 10 organizational practices or processes that must be carried out by a component of the public health system in each locality. These 10 practices or processes are summarized in Table S-5. The profiles in this book represent a first step toward developing a surveillance system for Objective 8.14. The profiles provide information related to the first and second areas of surveillance (i.e., geographic boundaries and simple descriptive information). Much more will be needed. For example, the profiles do not include any information on the 10 practices or processes, nor has any attempt been made to measure or evaluate the effectiveness of LPHAs. At least four challenges remain for future surveillance efforts: The first challenge will be to operationally define the elements of each of the 10 practices or processes for surveillance purposes, and then to develop indicators and validate those indicators as measures of the practices. The second challenge will be the changes that tend to occur in the organization of public health agencies. For example, during the 6 months that elapsed while draft profiles were being circulated to SHAs for review, five states modified their SHA structure. Frequent updates will be needed to keep information current. The third challenge will be the diversity that exists in the organization and activities of SHAs and LPHAs. For example, one LPHA may have an epidemiologist as a staff member, while another LPHA may obtain assistance from an epidemiologist with the SHA. Similarly, environmental health may be the responsibility of one SHA, but not another. As a result of differences in organizational structure and activities, different agencies may need to be evaluated independently (i.e., while comparisons over time within a SHA may be possible, comparisons between different SHAs may not be possible). An area where research is definitely needed is whether a system of classification (or typology) of SHAs and LPHAs might be possible, which would facilitate surveillance, comparison, and evaluation of effectiveness. For example, while comparison of a large LPHA with a small LPHA may be analogous to a comparison of "apples and eggs," comparison of a small LPHA with another small LPHA might be meaningful. The fourth challenge for future surveillance efforts will be to identify the most useful data for describing and monitoring local public health practice in the United States. The hope is that as greater experience is gained, a small number of measures will begin to be identified that will allow monitoring of trends over time in a standardized fashion, facilitate comparisons between and among communities, identify problem areas that managers need to investigate further, and help managers decide how to best use resources.Table S-1 Responsibilities of State Health Agencies (SHAs) in 50 States and the District of Columbia, 1990. SHAs (N=51) Responsibilities n ( %) State Public Health Authority 51 (100) Institutional Licensing Agency 41 ( 80) Institutional Certifying Authority for Federal Reimbursement 40 ( 78) State Agency for Children with Special Health Care Needs 39 ( 77) State Health Planning and Development Agency 22 ( 43) State Institutions/Hospitals 16 ( 31) Lead Environmental Agency in the State 15 ( 29) State Professions Licensing Agency 10 ( 20) Medicaid Single State Agency 5 ( 10) State Mental Health Authority 4 ( 8) SOURCE: Characteristics of State and Local Health Agencies 1988 (7).Table S-2 Assessment and Policy Development: Activities Reported by 2,269 Local Public Health Agencies (LPHAs), 1990. LPHAs Reporting Activities Activities n ( %) Assessment A. Data Collection/Analysis 1. Reportable Diseases 1,978 ( 87) 2. Vital Records and Statistics 1,440 ( 64) 3. Morbidity Data 1,114 ( 49) 4. Behavioral Risk Assessment 752 ( 33) B. Epidemiology/Surveillance 1. Communicable Diseases 2,072 ( 91) 2. Chronic Diseases 1,235 ( 54) Policy Development A. Health Code Development and Enforcement 1,330 ( 59) B. Health Planning 1,299 ( 57) C. Priority Setting 1,166 ( 51) SOURCE: National Association of County Health Officials 1990 (4).Table S-3 Assurance: Inspection, Licensing, Health Education, and Environmental Activities Reported by 2,269 Local Public Health Agencies (LPHAs), 1990. LPHAs Reporting Activities Activities n ( %) Inspection 1. Food and Milk Control 1,639 ( 72) 2. Recreational Facility Safety/Quality 1,233 ( 54) 3. Health Facility Safety/Quality 1,063 ( 47) 4. Other Facility Safety/Quality 722 ( 32) Licensing 1. Other Facilities 1,621 ( 71) 2. Health Facilities 489 ( 22) Health Education 1,679 ( 74) Environmental 1. Sewage Disposal Systems 1,785 ( 79) 2. Individual Water Supply Safety 1,742 ( 77) 3. Vector and Animal Control 1,582 ( 70) 4. Water Pollution 1,353 ( 60) 5. Public Water Supply Safety 1,311 ( 58) 6. Solid Waste Management 1,252 ( 55) 7. Hazardous Waste Management 1,048 ( 46) 8. Air Quality 739 ( 33) 9. Occupational Health and Safety 526 ( 23) 10. Radiation Control 472 ( 21) 11. Noise Pollution 458 ( 20) SOURCE: National Association of County Health Officials 1990 (4).Table S-4 Assurance of Personal Health Services: Activities Reported by 2,269 Local Public Health Agencies (LPHAs), 1990. LPHAs Reporting Activities Activities n ( %) Personal Health Services 1. Immunizations 2,089 ( 92) 2. Child Health 1,903 ( 84) 3. Tuberculosis 1,826 ( 81) 4. Sexually Transmitted Diseases 1,650 ( 73) 5. Chronic Diseases 1,570 ( 69) 6. WIC 1,564 ( 69) 7. Family Planning 1,347 ( 59) 8. Prenatal Care 1,339 ( 59) 9. AIDS Testing and Counseling 1,294 ( 57) 10. Home Health Care 1,139 ( 50) 11. Handicapped Children 1,062 ( 47) 12. Laboratory Services 983 ( 43) 13. Dental Health 851 ( 38) 14. Primary Care 501 ( 22) 15. Obstetrical Care 459 ( 20) 16. Drug Abuse 389 ( 17) 17. Alcohol Abuse 351 ( 16) 18. Mental Health 319 ( 14) 19. Emergency Medical Service 293 ( 13) 20. Long-term Care Facilities 143 ( 6) 21. Hospitals 64 ( 3) SOURCE: National Association of County Health Officials 1990 (4).Table S-5 Ten Organizational Practices or Processes That Must Be Carried Out by a Component of the Public Health System in Each Locality. ASSESSMENT 1. ASSESS the health needs of the community. 2. INVESTIGATE the occurrence of health effects and health hazards in the community. 3. ANALYZE the determinants of identified health needs. POLICY DEVELOPMENT 4. ADVOCATE FOR PUBLIC HEALTH, BUILD CONSTITUENCIES and identify resources in the community. 5. SET PRIORITIES among health needs. 6. DEVELOP PLANS and policies to address priority health needs. ASSURANCE 7. MANAGE resources and develop organizational structure. 8. IMPLEMENT programs. 9. EVALUATE programs and provide quality assurance. 10. INFORM and EDUCATE the public.GUIDE FOR USING THE PROFILE Suggested Uses This book is intended for use by Federal, state, and local public health officials as a reference on the public health system in each state and territory. Federal health officials who are working with state and local health departments can use this book to familiarize themselves with a state or territory. For example, Epidemic Intelligence Service (EIS) Officers or other Federal assignees could use this book to review the public health system before working in a state. The book also enables Federal, state, or local health officials to compare or contrast the public health system in different states or territories. It is a handy source of information on the structure of public health agencies and the interrelationships between the components of these agencies. The book can also be used as a starting point for future research on the public health system. General Format The outline that follows is used throughout the book, with only minor variations, to describe the major components of the public health system in each state or territory and the relationships between the components. For territories, however, an additional section in the outline entitled, "Location, Geography and People," is added. Under each item in the outline is a brief description of the type of information that will be presented for each state or territory. The states and the District of Columbia are presented in alphabetical order followed by the territories in alphabetical order. Rhode Island and Delaware state that they have no local health departments. Hawaii and New Mexico report only a single, autonomous local health department in each state: the city of Honolulu for the former and Los Alamos County for the latter. With the exception of the two small autonomous units in Hawaii and New Mexico, these states classify their systems as completely centralized. With the exception of Rhode Island, which delivers or arranges all public health services from a centralized state health agency, they do, however, deliver services from district offices at the local level. We have included these state-controlled service units in Delaware under the local health department section, while at the same time recognizing that the state does not consider these "local health departments." Hawaii and New Mexico requested that their local service units not be categorized as local health departments.State Public Health System Profile Selected Sociodemographic Indicators State United States Population (1988) 245,803,000 Population Density (1988) 69.4 (per/sq.mi.) Number of Counties 3,139 Median Age (1987) 31.7 Percent Below Poverty Level (1985) 14.0 (persons) Percent of Population Rural (1980) 26.0 Percent of Population White (1980) 83.1 Percent of Population Non-white (1980) 16.9 Median Years of Education (1980) 12.5 (25 Years of age and over) The sources of these data for sociodemographic indicators are Current Population Reports, County Population Estimates: July 1, 1988, 1987, 1986 (8), The State Policy Data Book 1988 (9), State and Metropolitan Area Data Book 1986 (10), Census of Population (11), and Census of Population (12). County Government Structure Home Rule or No Home Rule Authority - This section indicates whether the state and counties have home rule. It also describes the structure and function of county governments in each state. The role and responsibility of key players, such as elected executives or administrators, are described. The roles are described because these players are often quite involved in delivering public health services at the local level. Their involvement may include the budget process and/or policy-making when the governing body serves as the local board of health. Each paragraph discussing a different form of government begins with the form underlined and the number of counties using that form enclosed in parentheses, i.e., Commission Form (25). The adoption of home rule by states and counties is noted as it relates to the ability to levy taxes for specific purposes and as an indicator of an individual county's capacity for self-government. Home Rule Authority - A grant of authority from the state to counties through statutes or constitutions allows local self-determination. Home rule is not a form of government but an authority to effect change in the areas of structure, function, and fiscal powers. Charter Reform is a tool used by the counties to achieve greater levels of home rule authority. It is the mechanism used to form charter commissions for achieving county reform. This is accomplished through state constitutional amendment or legislative measures that ultimately serve as a broader tool for home rule authority. The following are the most common forms of local government: Commission Form - This is the most traditional and widely used form of county government. Under the Commission Form an elected board of from 2 to over 100 has legislative powers, such as passing ordinances, adopting budgets, and also administrative powers such as supervising some or all departments and appointing some administrative employees. A hallmark of the Commission Form is that "county commissioners" share administrative responsibility with several independently elected "row officers" who frequently include a county clerk, auditor and recorder, assessor, treasurer, prosecuting attorney, sheriff, and coroner. County Administrator - This position is usually appointed by and accountable to the governing board or legislative body. Other titles given this position are chief administrative officer, appointed administrator, administrator, and county manager. Elected Executive - Similar to the position of a mayor, this position is elected at large and is responsible for working with the county legislative body. Elected executives are strong, partially due to their veto power over the legislative body. Other forms of county government less frequently seen in the descriptive profiles will be briefly described by individual state. The source of these data for states is County Government Structure: A State By State Report, 1989 (13). The source of information on the government structure of territories is The Europa World Year Book, 1990 (14). The sources of information on the location, geography and people of the territories are The Europa World Year Book, 1990 (14), Evaluation of Federal Support to Health Systems of the Pacific Insular Jurisdictions of the U.S., 1984 (15), and A Reevaluation of Health Services in U.S.-Associated Pacific Island Jurisdictions, 1989 (16). State Health Agency (SHA) General Free-standing, Independent or Component of Superagency - The SHA is categorized as a free-standing, independent agency or a component of a superagency. This section contains information about the SHA, such as its name, mission statement, and some areas of responsibility. The responsibilities are taken from a list that includes the following areas: State Public Health Authority Medicaid Single State Agency Lead Environmental Agency in the State State Mental Health Authority State Agency for Children with Special Health Care Needs State Health Planning and Development Agency State Professions Licensing Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals The source of these data on the responsibilities of SHAs is Characteristics of State and Local Health Agencies, 1988 (7). Head of State Health Agency M.D. Requirement, Cabinet-level Appointment - This section indicates if an M.D. is required for the head of the SHA and whether the position is a cabinet-level office. It identifies the head of the SHA and includes information about the position such as the title, method of appointment, and responsibilities. State Board of Health/Council Advisory or Policy-making - This section describes the State Board of Health/Council as advisory or policy-making in nature. The composition, method of appointment, roles, and responsibilities of the boards and/or councils are discussed. Regional/District Health Offices Here is indicated whether the state has been administratively divided into districts or regions using the terms designated by the particular state, i.e., "management areas," "public health areas," etc. The location of the regional/district offices and the area served by these offices are illustrated on a state map. The structure and types of programs administered are included, as well as line of authority to state and local levels. State-local Liaison Type of Organizational Control, Formal or Informal Liaison Function - In this section the relationship between the SHA and local public health agencies is characterized as one of the following types: Centralized Organizational Control - local health departments function directly under the state's authority and are operated by an SHA or a board of health. Decentralized Organizational Control - local governments directly operate local health departments with or without a board of health. Mixed Centralized and Decentralized Organizational Control - local health services may be provided by the SHA, local governmental units, boards of health, or health departments in other jurisdictions. Shared Organizational Control - local health departments are under the authority of the SHA, as well as the local government and board of health. Also included in this section is a discussion of the state-local liaison function, including authority and responsibility. The source of these data on the relationship between state and local health departments is Characteristics of State and Local Health Agencies, 1988 (7). Budget The total FY 1988 SHA expenditures, by source of funds, are compared with total FY 1988 United States SHA expenditures. The source of these data is Public Health Agencies 1990: An Inventory of Programs and Block Grant Expenditures (2). Local Public Health Agencies (LPHAs) General This section describes local health departments and classifies them according to the administrative/service areas within their jurisdictions. This classification scheme includes city, city-county, county, multicounty, township/town, multitownship, and borough jurisdictions. A map is included to illustrate local public health jurisdictions in each state and territory. When more than one city and/or township/town health department exists in the same county, the symbol on the map designating the type of unit will be followed by the number of units in parentheses. To identify the number and types of local public health agencies (LPHAs), we used the following definition developed by C. Arden Miller: an administrative and service unit of local or state government, concerned with health, employing at least one full-time person, and carrying some responsibility for health of a jurisdiction smaller than the state (3). We also utilized data on services provided and staff employed by LPHAs which were obtained from a survey conducted by the National Association of County Health Officials and the Centers for Disease Control (unpublished survey results, 1989). For these tabulations we used the NACHO definition of an LPHA: "an administrative and service unit of local or state government concerned with health and carrying out some responsibility for the health of a jurisdiction smaller than a state" (4). The NACHO definition is less restrictive than the Miller definition (i.e., the NACHO definition does not require that an LPHA have a "full-time person"). Services Provided Public health services provided by LPHAs in each state are included. The data on services provided by LPHAs are derived, unless stated otherwise, from a survey of LPHAs that was conducted by the National Association of County Health Officials and Centers for Disease Control (unpublished survey results, 1989). The percent of LPHAs reporting is calculated by dividing the total number of LPHAs responding to the survey in each state by the number of LPHAs reporting they provide the particular service. The services that are provided by 70 percent of LPHAs are underlined. The percent of units reporting will not be given for states with five or fewer respondents. The service information is provided in three major categories: assessment activities, assurance activities, and policy development. The data are presented in column format displayed as follows: Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 9 ( 23.1%) 2. Morbidity Data 25 ( 64.1%) 3. Reportable Diseases 33 ( 84.6%) 4. Vital Records and Statistics 36 ( 92.3%) B. Epidemiology/Surveillance 1. Chronic Diseases 21 ( 53.8%) 2. Communicable Diseases 38 ( 97.4%) II. Policy Development A. Health Code Dev. and Enforcement 24 ( 61.5%) B. Health Planning 13 ( 33.3%) C. Priority Setting 21 ( 53.8%) III. Assurance Activities A. Inspection 1. Food and Milk Control 37 ( 94.9%) 2. Health Facility Safety/Quality 20 ( 51.3%) 3. Rec. Facility Safety/Quality 16 ( 41.0%) 4. Other Facility Safety/Quality 11 ( 28.2%) B. Licensing 1. Health Facilities 7 ( 17.9%) 2. Other Facilities 34 ( 87.2%) C. Health Education 27 ( 69.2%) D. Environmental 1. Air Quality 6 ( 15.4%) 2. Hazardous Waste Management 11 ( 28.2%) 3. Individual Water Supply Safety 34 ( 87.2%) 4. Noise Pollution 3 ( 7.7%) 5. Occupational Health and Safety 4 ( 10.3%) 6. Public Water Supply Safety 20 ( 51.3%) 7. Radiation Control 7 ( 17.9%) 8. Sewage Disposal Systems 39 (100.0%) 9. Solid Waste Management 34 ( 87.2%) 10. Vector and Animal Control 38 ( 97.4%) 11. Water Pollution 17 ( 43.6%) E. Personal Health Services 1. AIDS Testing and Counseling 39 (100.0%) 2. Alcohol Abuse 2 ( 5.1%) 3. Child Health 38 ( 97.4%) 4. Chronic Diseases 28 ( 71.8%) 5. Dental Health 12 ( 30.8%) 6. Drug Abuse 2 ( 5.1%) 7. Emergency Medical Service 1 ( 2.6%) 8. Family Planning 39 (100.0%) 9. Handicapped Children 3 ( 7.7%) 10. Home Health Care 38 ( 97.4%) 11. Hospitals 1 ( 2.6%) 12. Immunizations 39 (100.0%) 13. Laboratory Services 19 ( 48.7%) 14. Long-term Care Facilities 10 ( 25.6%) 15. Mental Health 2 ( 5.1%) 16. Obstetrical Care 19 ( 48.7%) 17. Prenatal Care 36 ( 92.3%) 18. Primary Care 22 ( 56.4%) 19. Sexually Transmitted Diseases 38 ( 97.4%) 20. Tuberculosis 39 (100.0%) 21. WIC 38 ( 97.4%) Local Health Officer M.D. Requirement, Appointment - This section shows if an M.D. requirement exists and how the health officer is appointed. The authority and responsibilities that this position holds are described. Local Board of Health Advisory or Policy-making - This section is used to indicate whether the local board of health has advisory or policy-making responsibility. The existence, composition, terms of office, and responsibilities of local boards of health are discussed. Staff This section contains a discussion of the staff of LPHAs. Included is information about the employer of the staff, supervision, and a range of staff size. The sources of these data on the range of staff size are the National Association of County Health Officials and the Centers for Disease Control (unpublished survey results, 1989). Budget The total FY 1988 LPHA expenditures for each state and the United States are provided. The source of funds is also provided. The source of these data is Public Health Agencies 1990: An Inventory of Programs and Block Grant Expenditures (2). Following this outline will be a table of organization for the SHA and a map of the state depicting the type and number of local health departments, administrative regions/districts if they exist, and the location of regional/district offices.ALABAMA Public Health System Profile I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 4,103,000 245,803,000 Population Density (1988) 80.8 69.4 (per/sq.mi.) Number of Counties 67 3,139 Median Age (1987) 31.0 31.7 Percent Below Poverty Level (1985) 20.6 14.0 (persons) Percent of Population Rural (1980) 40.0 26.0 Percent of Population White (1980) 73.8 83.1 Percent of Population Non-white (1980) 26.2 16.9 Median Years of Education (1980) 12.2 12.5 (25 years of age and over) B. County Government Structure No Home Rule Authority The source of power for Alabama counties is state statutes, which establish the legal framework of county government and delineate the authority and duties of the governing bodies. Commission Form - (67) - This form is the basis of all county governments in the state and is made up of three to seven members usually elected from districts. About one-third of the counties elect a probate judge, at large, who serves as the chair of the commission. As chairman and presiding officer the judge is responsible for recording proceedings of the commission, issuing all necessary orders, administering finances, and generally maintaining county authority. The chair is permitted to vote only in tie-breaking situations. Other counties have a chair that is elected from the commission with duties and authority that are similar to those that general law confers on probate judges who serve as chairs of county commissions. Counties that have this arrangement have adopted it through local legislation. Finally, there are 31 other counties that have appointed administrators which assist the commission in daily administration of the county. Data for this state were updated February 1991.II. State Health Agency (SHA) A. General Free-standing, Independent The Alabama Department of Public Health, the SHA, is a free-standing, independent agency. The mission of the SHA is to serve the people in Alabama by assuring conditions in which they can be healthy. The SHA, under the direction of the State Board of Health, has the following general responsibilities: 1. To exercise general control over the enforcement of the laws relating to public health. 2. To investigate the causes, modes of propagation, and means of prevention of diseases. 3. To investigate the influence of localities and employment on the health of the people. 4. To inspect all schools, hospitals, asylums, jails, theaters, opera houses, courthouses, churches, public halls, prisons, stockades where convicts are kept, markets, dairies, milk depots, slaughter pens or houses, railroad depots, railroad cars, street railroad cars, lines of railroads and street railroads, industrial and manufacturing establishments, offices, stores, banks, club houses, hotels, rooming houses, residences and other similar places. Whenever insanitary conditions in any of these places, institutions or establishments or conditions prejudicial to health, or likely to become so, are found, proper steps are taken by the proper authorities to have such conditions corrected or abated. The following are some specific areas of responsibility for the SHA: State Public Health Authority Institutional Licensing Authority Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency M.D. Requirement, Not Cabinet-level Appointment The State Health Officer is appointed by and functions under the direction of the State Committee of Public Health. Statutes require this individual to be a physician. The State Health Officer acts as the executive officer of the Department of Public Health on behalf of the Committee, when the Committee is not in session. The State Health Officer also exercises general supervision over county boards of health and county health officers. It is the responsibility of the Health Officer to keep abreast of all diseases which may be in danger of invading the state, and to take prompt measures to prevent such invasions and keep the Governor and the Legislature informed as to health conditions prevailing in the state, especially as to outbreaks of any notifiable diseases; and submit to the Governor and Legislature recommendations for controlling the outbreaks. C. State Board of Health/Council Policy-making The Medical Association of the state of Alabama serves as the State Board of Health. There is also a State Committee of Public Health which is composed of 12 members of the Board of Censors of the Medical Association and the chairmen of 4 councils: 1) Council of Dental Health; 2) Council on Animal and Environmental Health; 3) Council on the Prevention of Disease and Medical Care; and 4) Council on Health Costs, Administration, and Organization. Physician members of the Committee are selected by the State Board of Health, one from each congressional district in the state and the remainder from the state-at-large. The "State Board of Health" is the same as the "State Committee of Public Health" except when the State Board of Health is actually in session. The State Committee of Public Health possesses all of the prerogatives, powers, and duties prescribed by law for the State Board of Health. The State Board of Health may, by a three-fifths vote, alter or amend any action of the State Committee of Public Health, but only when the board is in session. The duty of the four councils is to provide public health information, evaluation of data, research, advice and recommendation to the State Committee of Public Health and perform other functions requested by the Committee. D. Regional/District Health Offices Alabama is divided into nine administrative regions called Public Health Areas (see attached map). Area offices are commonly staffed by individuals who fill the following positions: Assistant State Health Officer Clinicians Area Disease Coordinator Area Health Educator Coordinator Area Nutrition Coordinator Area Social Worker Coordinator Area Nursing Director Area Environmental Director Area Administrator Assistant Area Administrator Area Clerical Director Area Office Clerks Most of the staffs of the area offices are in the chain of command and involved in the supervision of the local health department staffs. The Assistant State Health Officers supervise the county and area health officers within their geographic area of responsibility. In some counties the Assistant State Health Officer for the Area will be appointed as the county health officer, while in other areas the county will appoint someone else as county health officer. Alabama also has four district health departments. The district health departments are Northwest Alabama Regional Health Department (Colbert, Franklin, and Lauderdale counties), Tri-county District Health Department (Cullman, Lawrence, and Limestone counties), West Alabama District Health Department (Bibb, Greene, Lamar, Pickens, and Tuscaloosa counties), and Gulf Coast District Health Department (Baldwin, Conecuh, and Escambia counties). These are historical, multicounty units which function as units for some issues, such as funding, but generally the counties in these districts have administrative functions which are similar to other counties under the supervision of the area office. While these units still exist, the current focus is on the Public Health Areas rather than district health departments. E. State-local Liaison Shared Organizational Control, Informal Liaison Function The liaison function between the SHA and local health agencies is accomplished through the formal chain of command that extends from the SHA to Public Health Areas and to local health departments. The interaction between state and local public health agencies in Alabama may be characterized as shared organizational control. Under this arrangement local health departments are under the authority of the state as well as the local government and board of health. F. Budget Total FY 1988 SHA expenditures were $90,564,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $52,550,000 State Funds $34,906,000 Local Funds 0 Fees and Reimbursements $2,383,000 Other $726,000 III. Local Public Health Agencies (LPHAs) A. General The 67 county health departments in Alabama function as the LPHAs in the state. They are staffed by State Merit System employees. While general supervision and direction comes from the state, there is also input from the local board of health. Budgets are developed for each county and presented to the State Health Officer for approval. These budgets are made up of a mixture of local and state funds. State-appropriated funds are allocated to the counties according to need. B. Services Provided The following information on services provided by local health departments in Alabama is derived from a survey conducted by NACHO during 1989. Thirty-nine of the 67 local health departments in Alabama responded to the survey. Services provided by 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 9 ( 23.1%) 2. Morbidity Data 25 ( 64.1%) 3. Reportable Diseases 33 ( 84.6%) 4. Vital Records and Statistics 36 ( 92.3%) B. Epidemiology/Surveillance 1. Chronic Diseases 21 ( 53.8%) 2. Communicable Diseases 38 ( 97.4%) II. Policy Development A. Health Code Dev. and Enforcement 24 ( 61.5%) B. Health Planning 13 ( 33.3%) C. Priority Setting 21 ( 53.8%) III. Assurance Activities A. Inspection 1. Food and Milk Control 37 ( 94.9%) 2. Health Facility Safety/Quality 20 ( 51.3%) 3. Rec. Facility Safety/Quality 16 ( 41.0%) 4. Other Facility Safety/Quality 11 ( 28.2%) B. Licensing 1. Health Facilities 7 ( 17.9%) 2. Other Facilities 34 ( 87.2%) C. Health Education 27 ( 69.2%) D. Environmental 1. Air Quality 6 ( 15.4%) 2. Hazardous Waste Management 11 ( 28.2%) 3. Individual Water Supply Safety 34 ( 87.2%) 4. Noise Pollution 3 ( 7.7%) 5. Occupational Health and Safety 4 ( 10.3%) 6. Public Water Supply Safety 20 ( 51.3%) 7. Radiation Control 7 ( 17.9%) 8. Sewage Disposal Systems 39 (100.0%) 9. Solid Waste Management 34 ( 87.2%) 10. Vector and Animal Control 38 ( 97.4%) 11. Water Pollution 17 ( 43.6%) E. Personal Health Services 1. AIDS Testing and Counseling 39 (100.0%) 2. Alcohol Abuse 2 ( 5.1%) 3. Child Health 38 ( 97.4%) 4. Chronic Diseases 28 ( 71.8%) 5. Dental Health 12 ( 30.8%) 6. Drug Abuse 2 ( 5.1%) 7. Emergency Medical Service 1 ( 2.6%) 8. Family Planning 39 (100.0%) 9. Handicapped Children 3 ( 7.7%) 10. Home Health Care 38 ( 97.4%) 11. Hospitals 1 ( 2.6%) 12. Immunizations 39 (100.0%) 13. Laboratory Services 19 ( 48.7%) 14. Long-term Care Facilities 10 ( 25.6%) 15. Mental Health 2 ( 5.1%) 16. Obstetrical Care 19 ( 48.7%) 17. Prenatal Care 36 ( 92.3%) 18. Primary Care 22 ( 56.4%) 19. Sexually Transmitted Diseases 38 ( 97.4%) 20. Tuberculosis 39 (100.0%) 21. WIC 38 ( 97.4%) C. Local Health Officer M.D. Requirement, County Board of Health Appointment The county health officer is elected by the county board of health subject to the approval of the State Committee of Public Health. The local health officer, under the direction of the State Health Officer and the county board of health, has sole direction of all sanitary and public health work within the county and incorporated municipalities. D. Local Board of Health Policy-making The boards of censors of county medical societies, in affiliation with the Medical Association of the state of Alabama and organized in accordance with the provisions of its constitution, are constituted county boards of health of their respective counties under the supervision of the State Board of Health. The duties of the county boards of health subject to the supervision and control of the State Board of Health are as follows: 1. To supervise the enforcement of the health laws of the state, including all ordinances or rules and regulations of municipalities or of county boards of health or of the State Board of Health, and to supervise the enforcement of the law for collection of vital and mortuary statistics and to adopt and promulgate, if necessary, rules and regulations for administering the health laws of the state and rules and regulations of the State Board of Health, which rules and regulations of the county boards of health have the force and effect of law and are executed and enforced by the same bodies, officials, agents and employees as in the case of health laws. 2. To investigate, through county health officers or quarantine officers, cases or outbreaks of any notifiable diseases and to enforce such measures for the prevention or extermination of said diseases as are authorized by law. 3. To investigate, through county health officers or quarantine officers, all nuisances to public health and, through said officers, to take proper steps for the abatement of such nuisances. 4. To exercise, through county health officers or quarantine officers, special supervision over the sanitary conditions of schools, hospitals, asylums, jails, theaters, opera houses, courthouses, churches, public halls, prisons, markets, dairies, milk depots, slaughter pens or houses, railroad depots, railroad cars, dining cars, street railroad cars, lines of railroads and street railroads, airports, industrial and manufacturing establishments, offices, stores, banks, club houses, hotels, rooming houses, residences and the sources of supply, tanks, reservoirs, pumping stations and avenues of conveyance of drinking water and other institutions and places of like character and, whenever unsanitary conditions are found, to use all legal means to have the same abated. E. Staff Staffs of local health departments belong to the State Merit System. They may be employed locally and paid with funds from a variety of sources, but they are technically state employees. The number of full-time employees for local health departments ranges from 7 to 694. F. Budget Total FY 1988 LPHA expenditures were $52,557,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts 0 State Funds $8,101,000 Local Funds $13,999,000 Fees and Reimbursements $29,639,000 Other Sources 0 Source Unknown $818,000 2Alabama Department Of Public Health, 1990 State Government State Board of Health State Committee of Public Health State Health Officer General Counsel Staff Assistant for Legislative Affairs State Assistant for Capital Expansion Staff Assistant for Professional Services Public Health Nursing Office of Administrative Services Office of Health Promotion and Information Office of Internal Audit Office of Management Services Bureau of Clinical Laboratories Division of Administrative Support Services Division of Microbiology Division of Microbacteriology/Mycology Division of Scientific Services Division of Serology Birmingham Division Decatur Division Dothan Division Mobile Division Bureau of Environmental and Health Service Standards Division of Environmental Health Division of Licensure and Certification Public Health Areas County Health Departments Bureau of Disease Control and Rehabilitative Services Division of Disease Control Division of Epidemiology Division of Long-Term Care and Rehabilitation Division of AIDS Prevention and Control Bureau of Family Health Services Division of Family Planning Division of Maternity Services Division of Child Health Division of WIC Dental Health Section Division of Family Planning Bureau of Vital Statistics Division of Record Preservation and Certification Services Division of Record Services Division of Registration Services Division of Statistical Analysis Services 2Types of Local Health Departments by Jurisdiction Alabama, 1990 Jurisdiction Co Autauga X Baldwin X Barbour X Bibb X Blount X Bullock X Butler X Calhoun X Chactaw X Chambers X Cherokee X Chilton X Clark X Clay X Cleburne X Coffee X Colbert X Conecuh X Coosa X Covington X Crenshaw X Cullman X Dale X Dallas X De Kalb X Elmore X Escambia X Etowah X Fayette X Franklin X Geneva X Greene X Hale X Henry X Houston X Jackson X Jefferson X Lamar X Lauderdale X Lawrence X Lee X Limestone X Lowndes X Macon X Madison X Marengo X Marion X Marshall X Mobile X Monroe X Montgomery X Morgan X Perry X Pickens X Pike X Randolph X Russell X Shelby X St. Clair X Sumter X Talladega X Tallapoosa X Tuscaloosa X Walker X Washington X Wilcox X Winston X Co = County HD 1ALASKA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 524,000 245,803,000 Population Density (1988) 0.9 68.8 (per/sq.mi.) Number of Counties 0 3,139 Median Age (1987) 28.4 31.7 Percent Below Poverty Level (1985) 8.8 14.0 (persons) Percent of Population Rural (1980) 36.0 26.0 Percent of Population White (1980) 77.1 83.1 Percent of Population Non-white (1980) 22.9 16.9 Median Years of Education (1980) 12.8 12.5 (25 years of age and over) B. Local Government Structure Home Rule Authority The organization of local government in Alaska is governed by the state constitution and statutes. Cities and boroughs are legal entities (municipalities) which perform both regulatory and proprietary functions. Alaska has three types of general law boroughs and two types of general law cities. In addition, both boroughs and cities may also adopt charters providing for home rule. General law cities may adopt charters providing for home rule. General law cities and boroughs can perform only those functions permitted by law, while home rule cities and boroughs can perform functions that are not prohibited by law or charter. Unified home rule municipalities are entities composed of an organized borough and all the cities within the geographic limits of that borough. Alaska currently has 14 organized boroughs that include about 40 percent of the state's land mass and 85 percent of the population. The remainder of the state consists of a single unorganized borough. Data for this state were updated February 1991. 3II. State Health Agency (SHA) A. General Component of Superagency The Division of Health, the SHA, is a component of the superagency, the Department of Health and Social Services (DHSS). The Department is under the direction of a Commissioner who is appointed by the Governor and is a member of his cabinet. The Division of Public Health exists to prevent disease and premature mortality through promotion of positive health practices and to minimize disability and the need for institutionalization through the early detection of disease and appropriate intervention. Programs are directed from the central office in Juneau and supervisory offices in Juneau, Anchorage, Fairbanks, and Bethel. Activities of the Division run the gamut from genetic screening to training of emergency medical services personnel. The Division's programs are both directly operated by state employees and by grants and contracts with non-profit entities. The following are some areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs B. Head of State Health Agency No M.D. Requirement, Commissioner Appointment The Director of the Division of Public Health is the head of the SHA. This official is appointed by the Commissioner of Health and Social Services and is not required to be a physician. The Director's responsibilities include overall policy and operational direction of the Division. C. State Board of Health/Council Alaska does not have a State Board or Council of Health. D. Regional/District Health Offices Public health nursing programs have regional offices in Anchorage, Bethel, and Juneau. No single regional official or office has jurisdiction over all public health programs within the geographic limits of the region. Although local governmental units generally can choose to provide public health services, most have not done so because of small populations and tax bases and the high cost of providing such services. E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Informal Liaison Function No single individual or office has responsibility for state-local liaison functions. Communications between these levels usually follow the chain of command. The interaction between state and local public health agencies in Alaska may be characterized as mixed centralized and decentralized organizational control. Under this arrangement local health services may be provided by the SHA in some jurisdictions and by local governmental units or by non-profit agencies which receive grants from the SHA to provide specific services. F. Budget Total FY 1988 Alaska SHA expenditures were $29,403,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $5,377,000 State Funds $23,733,000 Local Funds 0 Fees and Reimbursements $292,000 Other 0 3III. Local Public Health Agencies (LPHAs) A. General Alaska has two LPHAs: the North Slope Borough and the Anchorage Municipal Health Department. These units receive financial assistance from the state for specified public health activities. In addition, some public health services, often in the realm of personal health services, are provided by the Regional Native Health Corporations. The state provides grant funds for these services in response to specific grant applications. In the case of two such corporations, the state grants include funds for public health nursing services. For both local governmentally sponsored and corporation sponsored systems, the state continues to provide certain direct services such as epidemiology. In areas that are not served by local health departments, the state provides direct health services through the Section of Nursing in the Division of Public Health. The Section of Nursing supports 21 health centers which are staffed by public health nurses and itinerate public health nurses. The staff of these centers consist of state employees who are under state direction and who report within the state chain of command. While these health centers probably meet the Miller definition for local health departments, the state prefers not to include them in this category. In Alaska has evolved a unique system of health care which provides services to the state's ethnically diverse and geographically scattered population. This system is composed of the State Division of Public Health, the Indian Health Service (IHS), Native Regional Health Corporations, and private physicians. Public health nursing supports 21 health centers. The public health nurse network, which currently consists of 100 nurses, provides the first line of primary care by delivering services to over 200 communities. The U.S. Public Health Service plays an important role in the state's health care system. The IHS operates a system of eight service units. Each service unit's field hospital or clinic serves as the activity hub for health centers. Although public health nursing and IHS serve many of the same people, a general agreement regarding responsibilities avoids service duplication. Under powers granted in the Alaska Native Claims Settlement Act of 1971, Native corporations have established regional health authorities. Each of the 12 regional health corporations have assumed administrative responsibility for the village-based community health aides (CHAs). The CHAs work in village health clinics and are guided by radio and/or telephone communications with IHS physicians. CHAs comprise a significant portion of the rural primary health care network. To prevent service duplication of effort, public health nursing, the IHS, and the Native Regional Health Corporations work to coordinate services at three levels. DHSS program managers, IHS service unit administrators, and the regional health authorities consult with each other on long-range planning. Public health nurses, IHS medical staff and CHA program coordinators meet at regular intervals to coordinate efforts. Moreover, when public health nurses and IHS physicians visit a village, they join the CHAs in a team effort to deliver necessary services. B. Services Provided The following information on services provided by local health departments in Alaska is derived from a survey conducted by NACHO during 1989. Both local health departments in Alaska responded to the survey. Services Provided by LPHAs Number of LPHAs I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment - 2. Morbidity Data - 3. Reportable Diseases 1 4. Vital Records and Statistics 1 B. Epidemiology/Surveillance 1. Chronic Diseases - 2. Communicable Diseases 2 II. Policy Development A. Health Code Dev. and Enforcement 2 B. Health Planning 2 C. Priority Setting 2 III. Assurance Activities A. Inspection 1. Food and Milk Control 1 2. Health Facility Safety/Quality 1 3. Rec. Facility Safety/Quality 2 4. Other Facility Safety/Quality 2 B. Licensing 1. Health Facilities - 2. Other Facilities 1 C. Health Education 2 D. Environmental 1. Air Quality 1 2. Hazardous Waste Management 2 3. Individual Water Supply Safety 2 4. Noise Pollution 1 5. Occupational Health and Safety - 6. Public Water Supply Safety 1 7. Radiation Control - 8. Sewage Disposal Systems 2 9. Solid Waste Management 1 10. Vector and Animal Control 2 11. Water Pollution 2 E. Personal Health Services 1. AIDS Testing and Counseling 2 2. Alcohol Abuse 2 3. Child Health 2 4. Chronic Diseases 1 5. Dental Health 2 6. Drug Abuse 1 7. Emergency Medical Service 1 8. Family Planning 2 9. Handicapped Children 1 10. Home Health Care 1 11. Hospitals 1 12. Immunizations 2 13. Laboratory Services 1 14. Long-term Care Facilities - 15. Mental Health 1 16. Obstetrical Care 1 17. Prenatal Care 1 18. Primary Care 1 19. Sexually Transmitted Diseases 2 20. Tuberculosis 2 21. WIC 2 C. Local Health Officer The Municipality of Anchorage is the only area in Alaska with a local health officer. The health officer is appointed by the local governing body and is not required to be a physician. Responsibility of the health officer includes overall management of the department and its programs. D. Local Board of Health Some communities have formal or informal health councils or boards with membership drawn from the general population and representative of voluntary and official agencies. E. Staff The staffs of local health departments range in size from 120 to 200. The staff of the Municipality of Anchorage Health Department and the North Slope Borough Health Department are employed and supervised by the local jurisdiction. F. Budget Total FY 1988 LPHA expenditures were $1,388,000*. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts 0 State Funds $1,388,000 Local Funds 0 Fees and Reimbursements 0 Other Sources 0 Source Unknown 0 * These data include only state funds that were given to the 2Alaska Department Of Health And Social Services, 1990 Commissioner, Department of Health and Social Services Director, Division of Public Health Family Health Section Early Prevention Program Infant Learning Program Handicapped Children's Program Communicable Disease Unit Genetics Services Maternal and Adolescent Health Unit WIC Nutrition Services Nursing Section Bethel Nursing Northern Region Nursing Southeast Region Nursing Southcentral Region Nursing Contract Services Home Health EPSDT Record Patient Management System Emergency Medical Services Section Statewide Coordination and Administration Training/Licensing Injury Prevention Education Epidemiology Section Disease Reporting, Survey and Investigation Chronic Diseases Data Processing and Statistical Analysis Infectious Diseases Administrative Support Occupational Health/Environmental Risk Assessment/Injury Prevention Laboratory Section Public Health Lab-Juneau Public Health Lab-Anchorage Public Health Lab-Fairbanks Radiological Health Vital Statistics Records Research Training 2Types of Local Health Departments by Jurisdiction Alaska, 1990 Jurisdiction Bu C Anchorage X North Slope X Bu = Burrough HD C = City HD 1ARIZONA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 3,487,000 245,803,000 Population Density (1988) 30.7 69.4 (per/sq.mi.) Number of Counties 15 3,139 Median Age (1987) 31.0 31.7 Percent Below Poverty Level (1985) 10.7 14.0 (persons) Percent of Population Rural (1980) 16.0 26.0 Percent of Population White (1980) 82.4 83.1 Percent of Population Non-white (1980) 17.6 16.9 Median Years of Education (1980) 12.7 12.5 (25 years of age and over) B. County Government Structure No Home Rule Authority The Arizona Constitution and Statutes establish and empower the county governments. They also give the legislature responsibility for establishing the mission for counties. Commission Form - (15) - All 15 county governments are based on the Commission Form. The commissions are made up generally of three-member Boards of Supervisors. Five counties have chosen to increase the number of supervisors on their boards from three to five. The Boards of Supervisors and other elected county officials fulfill the executive function for counties since there are no elected executive officers. All 15 counties appoint an administrator to handle the administrative responsibilities of the counties, even though this position is not supported by the constitution or statutes. Arizona counties are administrative arms of the state and do not have any authority that is not granted them by the constitution and statutes. They have no authority to adopt home rule provisions or charters. Data for this state were updated December 1990. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Arizona Department of Health Services (ADHS), the SHA, is a free-standing, independent agency. Its mission is to protect and improve the health status of residents by identifying health issues and developing interventions to prevent disease, disability, and premature death. The following are some areas of responsibility for the SHA: State Public Health Authority State Mental Health Authority State Agency for Children with Special Health Care Needs State Health Planning and Development Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Director of ADHS is appointed by and responsible to the Governor. The Director is responsible for formulating policies, plans, and programs to effectuate the mission and purpose of the Department. Requirements for office include administrative experience and an educational background that prepares the Director for the administrative responsibilities assigned to the position. C. State Board of Health/Council There is no State Board of Health. D. Regional/District Health Offices Although the state is not divided into districts or regions, ADHS does have two satellite offices located in Flagstaff and Tucson. The staffs in these offices are employees of the ADHS. Typical positions in these offices are for purposes of monitoring, i.e., certification and licensure surveyors. E. State-local Liaison Decentralized Organizational Control, Formal Liaison Function The Office of Local Health Services has the responsibility for state-local liaison activities. Major functions that fall within the liaison role are communication, coordination, and representing the local health department perspective to the SHA. Other activities include generalized public health consultation, technical assistance, facilitation, and education. The interaction between state and local public health agencies in Arizona may be characterized as decentralized organizational control. Under this arrangement, local government directly operates a health department with or without a board of health. F. Budget Total FY 1988 Arizona SHA expenditures (data provided by SHA) were $170,276,332. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $40,676,564 State Funds $112,655,609 Local Funds 0 Fees and Reimbursements $3,976,483 Other $15,622,651 3III. Local Public Health Agencies (LPHAs) A. General Arizona has 15 LPHAs that exist in the form of county health departments. Local health departments are each independent and separate from the ADHS. The local health agency selectively accepts delegation and agrees to perform the functions, conferred in accordance with standards of performance established by the Director of the ADHS. In summary, the local health department is the direct service extension of the ADHS to insure mandatory services are provided at the local level. State funds are provided to local health departments mainly in the form of contracts for services; however, some funds are available through grant mechanisms. B. Services Provided The following information on services provided by local health departments in Arizona is derived from a survey conducted by NACHO during 1989. All 15 of the local health departments in Arizona responded to the survey. Services provided by 70 percent of the local health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 6 ( 40.0%) 2. Morbidity Data 4 ( 26.7%) 3. Reportable Diseases 15 (100.0%) 4. Vital Records and Statistics 5 ( 33.3%) B. Epidemiology/Surveillance 1. Chronic Diseases 7 ( 46.7%) 2. Communicable Diseases 15 (100.0%) II. Policy Development A. Health Code Dev. and Enforcement 12 ( 80.0%) B. Health Planning 11 ( 73.3%) C. Priority Setting 12 ( 80.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 13 ( 86.7%) 2. Health Facility Safety/Quality 9 ( 60.0%) 3. Rec. Facility Safety/Quality 12 ( 80.0%) 4. Other Facility Safety/Quality 9 ( 60.0%) B. Licensing 1. Health Facilities 2 ( 13.3%) 2. Other Facilities 13 ( 86.7%) C. Health Education 13 ( 86.7%) D. Environmental 1. Air Quality 4 ( 26.7%) 2. Hazardous Waste Management 5 ( 33.3%) 3. Individual Water Supply Safety 9 ( 60.0%) 4. Noise Pollution 1 ( 6.7%) 5. Occupational Health and Safety 2 ( 13.3%) 6. Public Water Supply Safety 10 ( 66.7%) 7. Radiation Control 3 ( 20.0%) 8. Sewage Disposal Systems 14 ( 93.3) 9. Solid Waste Management 9 ( 60.0%) 10. Vector and Animal Control 13 ( 86.7%) 11. Water Pollution 8 ( 53.3%) E. Personal Health Services 1. AIDS Testing and Counseling 13 ( 86.7%) 2. Alcohol Abuse - 3. Child Health 11 ( 73.3%) 4. Chronic Diseases 8 ( 53.3%) 5. Dental Health 2 ( 13.3%) 6. Drug Abuse - 7. Emergency Medical Service 1 ( 6.7%) 8. Family Planning 13 ( 86.7%) 9. Handicapped Children 4 ( 26.7%) 10. Home Health Care 7 ( 46.7%) 11. Hospitals - 12. Immunizations 14 ( 93.3%) 13. Laboratory Services 6 ( 40.0%) 14. Long-term Care Facilities 1 ( 6.7%) 15. Mental Health 2 ( 13.3%) 16. Obstetrical Care 1 ( 6.7%) 17. Prenatal Care 7 ( 46.7%) 18. Primary Care 2 ( 13.3%) 19. Sexually Transmitted Diseases 15 (100.0%) 20. Tuberculosis 15 (100.0%) 21. WIC 12 ( 80.0%) C. Local Health Officer No M.D. Requirement, Board of Supervisors Appointment The local health officer is appointed by the County Board of Supervisors. Each county establishes individual requirements, experience, and education for the health officer. Authority and responsibilities of local health officers include: providing full-time public health services; employing qualified personnel and utilizing local, state, Federal, and other funds, or any combination of funds to provide services at the local level in conformity with the rules, regulations and policies of the State Health Department. D. Local Board of Health Advisory The size of the board of health of each county is dependent upon the number of supervisory districts. The board must include a member of the board of supervisors, a licensed physician, and citizen members. The term served by each member is 4 years. The local health department director serves as an ex officio member. The board acts in an advisory capacity to the Board of Supervisors and the local health department. E. Staff Staffs of the local health departments are employed and supervised by the local health jurisdiction. Some local staff are part of the State Merit System, but most belong to local systems. Authority of the staff is determined at the local level in accordance with policy, rules, and regulations set at the state level. The number of employees of local health departments ranges from 7 to 500. F. Budget Total FY 1988 LPHA Expenditures (data provided by SHA) were $220,556,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $6,077,000 State Funds 5,010,000 Local Funds $86,681,000 Fees and Reimbursements $101,901,000 Other Sources $2,571,000 Source Unknown $19,000,000 The SHA reported that there were additional fees and reimbursements not retained by the local health departments, but which reverted to the general revenues of the local or state government. The SHA also reported that these figures include the total amount of additional local health department monies expended by all local health departments. 2Arizona Department Of Health Services, 1990 Governor Director Disease Control Research Commission Deputy Director Division of Disease Prevention Services Chronic Disease Epidemiology Infectious Disease Services Health Education Risk Assessments and Investigations Division of Laboratory Services Chemistry Lab Certification Microbiology Regional Labs Division of Family Health Services Children's Rehabilitation Services Dental Health Maternal and Child Health Nutrition Division of Emergency Medical Services and Health Care Facility Emergency Medical Services Child Day Care Licensing Health Facilities Licensure Health Economics and Facility Development Director/Departmental Support Services Affirmative Action Planning and Health Status Monitoring Local and Border Health Public Information Operations Division of Behavioral Health Services Arizona State Hospital South Arizona Mental Health Clinic Community Behavioral Health Chronically Mentally Ill Behavioral Health Licensure 2Types of Local Health Departments by Jurisdiction Arizona, 1990 Jurisdiction Co Apache X Cochise X Coconino X Gila X Graham X Greenlee X La Paz X Maricopa X Mohave X Navajo X Pima X Pinal X Santa Cruz X Yavapai X Yuma X Co = County HD 1ARKANSAS 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 2,395,000 245,803,000 Population Density (1988) 46.0 69.4 (per/sq.mi.) Number of Counties 75 3,139 Median Age (1987) 32.2 31.7 Percent Below Poverty Level (1985) 22.9 14.0 (persons) Percent of Population Rural (1980) 48.0 26.0 Percent of Population White (1980) 82.7 83.1 Percent of Population Non-white (1980) 17.3 16.9 Median Years of Education (1980) 12.2 12.5 (25 years of age and over) B. County Government Structure No Home Rule Authority Arkansas counties receive their structure and authority from what is known as the County Government Code. This Code is actually a part of the constitution that was amended in 1975 (Amendment 55) and Act 742 that was passed in 1977. Quorum Court Form - (75) - Under this type of government the legislative body is made up of 9 to 15 justices of the peace who are elected from single-member districts. A county judge who is elected at large serves as chairman of the legislative body and administers the affairs of the government. Home Rule - While it is not called home rule, Chapter 37 of the County Government Code gives county governments authority that is similar to home rule. It provides counties with options to establish different governmental organizations and structures, such as consolidations. Also, the constitution empowers Quorum Courts to enact any legislation that is not prohibited by the constitution or state statutes. Data for this state were updated October 1990. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Arkansas Department of Health (ADH) is a free-standing, independent agency. The agency's mission is to promote and protect the public health and well-being of the citizens of Arkansas. Efforts are directed in the areas of direct provision of preventive, environmental, and personal health care services; certification and monitoring of certain health facilities, systems, and providers; and serving as a catalyst to improve the state's health care system and environmental quality. The following are some areas of responsibility for the SHA: State Public Health Authority State Professions Licensing Authority Institutional Licensing Authority Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency M.D. Requirement, Cabinet-level Appointment The head of the SHA is the Director of the ADH. This office is a cabinet-level appointment that is made by the Governor. The Director is required to be a physician and also serves as Secretary of the State Board of Health. The role of the Director is to oversee the general operations of the agency and to promote public health in Arkansas. C. State Board of Health/Council Policy-making The State Board of Health is a policy-making body made up of 21 members, appointed by the Governor. The Governor selects the members from lists of names submitted by organizations, such as the State Medical Society, that are represented on the Board. The following professions or groups are represented on the Board: seven licensed medical doctors; one licensed, registered dentist; one registered, professional engineer; one licensed, professional nurse; one licensed pharmacist; one licensed veterinarian; one registered sanitarian; one hospital administrator; one licensed, registered optometrist; one licensed chiropractor; one restaurant operator; one consumer representative; one licensed doctor of podiatric medicine; one member of the Arkansas Public Health Association; and one member over 60 who is not actively engaged in or retired from any occupation, profession, or industry to be regulated by the State Board of Health. D. Regional/District Health Offices The ADH has divided the state into 10 management areas, each with an area office. These area offices are responsible for the day-to-day administrative oversight of the local health units and for the oversight of programs, operations, and professional standards in the health units. The administrative structure of the area office consists of an area manager and his/her core team. The core team includes a nursing supervisor, sanitarian supervisor, and a records and clerical supervisor. E. State-local Liaison Centralized Organizational Control, Formal Liaison Function The Bureau of Community Health Services is ADH's liaison with the area offices and local health units. The Bureau has line authority over the area offices and local health units (field operations). The Bureau provides direction and general supervision to the area offices which, in turn, provide the same to local health units. The interaction between state and local public health agencies in Arkansas may be characterized as centralized organizational control. Under this arrangement, local health departments function directly under the state's authority and are operated by the SHA or State Board of Health. F. Budget Total FY 1988 SHA expenditures were $67,265,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $29,150,000 State Funds $26,101,000 Local Funds 0 Fees and Reimbursements $10,694,000 Other $1,321,000 3III. Local Public Health Agencies (LPHAs) A. General Ninety-seven LPHAs, called local health units in Arkansas, provide various services throughout the state. The basic administrative/service jurisdiction is the county. Several counties, however, have more than one local health unit. B. Services Provided The following information on services provided by local health departments in Arkansas is derived from a survey conducted by NACHO during 1989. Fifty of the 97 local health departments in Arkansas responded to the survey. The services provided by 70 percent of the local health units in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 14 ( 28.0%) 2. Morbidity Data 19 ( 38.0%) 3. Reportable Diseases 45 ( 90.0%) 4. Vital Records and Statistics 46 ( 92.0%) B. Epidemiology/Surveillance 1. Chronic Diseases 29 ( 58.0%) 2. Communicable Diseases 49 ( 98.0%) II. Policy Development A. Health Code Dev. and Enforcement 13 ( 26.0%) B. Health Planning 24 ( 48.0%) C. Priority Setting 19 ( 38.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 46 ( 92.0%) 2. Health Facility Safety/Quality 22 ( 44.0%) 3. Rec. Facility Safety/Quality 34 ( 68.0%) 4. Other Facility Safety/Quality 9 ( 18.0%) B. Licensing 1. Health Facilities 3 ( 6.0%) 2. Other Facilities 27 ( 54.0%) C. Health Education 34 ( 68.0%) D. Environmental 1. Air Quality 6 ( 12.0%) 2. Hazardous Waste Management 15 ( 30.0%) 3. Individual Water Supply Safety 42 ( 84.0%) 4. Noise Pollution 2 ( 4.0%) 5. Occupational Health and Safety 4 ( 8.0%) 6. Public Water Supply Safety 27 ( 54.0%) 7. Radiation Control 9 ( 18.0%) 8. Sewage Disposal Systems 44 ( 88.0%) 9. Solid Waste Management 16 ( 32.0%) 10. Vector and Animal Control 37 ( 74.0%) 11. Water Pollution 22 ( 44.0%) E. Personal Health Services 1. AIDS Testing and Counseling 43 ( 86.0%) 2. Alcohol Abuse 1 ( 2.0%) 3. Child Health 50 (100.0%) 4. Chronic Diseases 37 ( 74.0%) 5. Dental Health 10 ( 20.0%) 6. Drug Abuse 3 ( 6.0%) 7. Emergency Medical Service 4 ( 8.0%) 8. Family Planning 48 ( 96.0%) 9. Handicapped Children 9 ( 18.0%) 10. Home Health Care 46 ( 92.0%) 11. Hospitals 1 ( 2.0%) 12. Immunizations 50 (100.0%) 13. Laboratory Services 21 ( 42.0%) 14. Long-term Care Facilities 1 ( 2.0%) 15. Mental Health 2 ( 4.0%) 16. Obstetrical Care 15 ( 30.0%) 17. Prenatal Care 42 ( 84.0%) 18. Primary Care 5 ( 10.0%) 19. Sexually Transmitted Diseases 49 ( 98.0%) 20. Tuberculosis 50 (100.0%) 21. WIC 50 (100.0%) C. Local Health Officer M.D. Requirement, State Board of Health Appointment Arkansas law created the position of county health officer and describes the duties. The statute requires the State Board of Health to appoint a county health officer for each county. The appointment is subject to the approval of the county judge. The State Board of Health appoints the county health officers for 2-year terms, but has very limited interaction with them. The county health officer is directed by the Local Health Unit Administrator, the Director of ADH, and the State Board of Health. The county health officer was used more in the past during quarantines, but because quarantines are now rare, the health officer is much less active. Specific duties set by statute and by the health department for a county health officer include the following: Requirements Set by ADH 1. Maintain interest and knowledge of health unit activities and of county's health needs; represent needs to those in power; serve as an advocate for the health unit in the community and as a liaison between health unit and peers (medical society), State Board of Health, state medical officer and political leadership. 2. Uphold and observe ADH standards, policies, and procedures. 3. Have a role in planning, coordinating, and approving community services; serve on health advisory board. 4. Assist and act as medical consultant in handling epidemics; report contagious diseases to the ADH in an effort to prevent communicable disease. 5. Maintain good rapport and regular contact with health unit staff. 6. Be available for consultation in event of public disaster or emergency. Requirements Set by Statute 1. Caring for prisoners in county jails. 2. Caring for inmates of county poor farms and hospitals. 3. County quarantine. 4. Assist the ADH and State Board of Health in the following: a. Matters of local quarantine b. Inspection for sanitary purposes c. Prevention and suppression of disease d. General sanitation e. Vital statistics f. Submission of reports to the Board of Health where required D. Local Board of Health There are no local boards of health in Arkansas. E. Staff The staffs of the area offices and local health units are employed by ADH. The number of employees in a local health unit ranges from 2 to 65. F. Budget Since Arkansas does not consider the local service units to be local health departments, expenditure data are not available. 2Arkansas Department Of Health, 1990 Director Deputy Director Deputy Director Health Promotion and Services Bureau of Administrative Support Services Division of Data Processing Division of Financial Management Division of Maintenance Division of Personnel Management Office of Legal Services Division of Central Supply and Services Bureau of Public Health Program Section of Maternal and Child Health Division of Infant and Child Health Division of Perinatal Health Division of Reproduction Health Office of Hearing, Speech and Vision Division of WIC Section of In-Home Service Division of Home Health Division of Personal Care Office of Home Care Office of Hospice Office of Independence Plan Office of Blood Alcohol Office of Dental Health Section of Health Maintenance Division of AIDS/STD Division of Communicable Disease and Immunization Division of Tuberculosis Division of Chronic Diseases and Disabilities Prevention Bureau of Community Health Services 10 Area Offices (with Support Teams) 97 Local Health Units Office of Policies and Procedures Office of Quality Assurance Division of Epidemiology Office of Epizootic Diseases Bureau of Health Resources Division of Health Education and Promotion Division of Medical Social Services Division of Nursing Services Division of Nutrition Services Division of Pharmacy and Drug Control Division of Records and Clerical Section of Health Facilities Services and Systems Division of Vital Records Center for Health Statistics Bureau of Environmental Health Services Division of Engineering Division of Radiation Control and Emergency Management Division of Public Health Laboratories Division of Sanitarian Services Division of Plumbing and Natural Gas Control 2Types of Local Health Departments by Jurisdiction Arkansas, 1990 Jurisdiction Co Arkansas X Ashley X Baxter X Benton X Boone X Bradley X Calhoun X Carroll X Chicot X Clark X Clay X Cleborne X Cleveland X Columbia X Conway X Craighead X Crawford X Crittenden X Cross X Dallas X Desha X Drew X Faulkner X Franklin X Fulton X Garland X Grant X Greene X Hemstead X Hot Spring X Howard X Independence X Izard X Jackson X Jefferson X Johnson X Lafayette X Lawrence X Lee X Lincoln X Little River X Logan X Lonoke X Madison X Marion X Miller X Mississippi X Monroe X Montgomery X Nevada X Newton X Ocachita X Perry X Phillips X Pike X Poinsett X Polk X Pope X Prairie X Pulaski X Randolph X Saline X Scott X Searcy X Sebastian X Sevier X Sharp X St. Francis X Stone X Union X Van Buren X Washington X White X Woodruff X Yell X Co = County HD 1CALIFORNIA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 28,314,000 245,803,000 Population Density (1988) 181.1 69.4 (per/sq.mi.) Number of Counties 58 3,139 Median Age (1987) 31.3 31.7 Percent Below Poverty Level (1985) 13.6 14.0 (persons) Percent of Population Rural (1980) 9.0 26.0 Percent of Population White (1980) 76.2 83.1 Percent of Population Non-white (1980) 23.8 16.9 Median Years of Education (1980) 12.7 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority County governments in California are given two options under the state constitution: General Law or Charter status. General Law - (46) - Authority for the operation of General Law counties is found in Article XI of the California Constitution and Law found in the Government Code. Charter - (12) - Charter counties operate under the authority of the Charter. A charter may be proposed by a County Board of Supervisors or by a Charter Commission. Commission Form - (7) - Both General Law and Charter governments have several options they can chose as to the structure of their governments. They can operate under a "pure" Commission with a Board of Supervisors which serves as the legislative and executive bodies for the county. County Administrator - (50) - Fifty counties have appointed County Administrators. Elected Executive - (1) - San Francisco is the only county operating with an elected executive (mayor). This option is open only to Charter counties. San Francisco is also the only Data for this state were updated October 1990. city-county consolidation. Another unique feature of this government is the presence of two executive officers. The mayor is elected at large and the chief administrative officer is appointed. The legislative body for the county is made up of an 11-member Board of Supervisors. 3II. State Health Agency (SHA) A. General Component of Superagency The Department of Health Services is a component of the superagency called the California Health and Welfare Agency. The mission of the Department is to protect the health of all Californians. The goals set to accomplish this mission are to: promote an environment that will contribute to human health and well-being; assure the availability to equal access to comprehensive health services; emphasize prevention-oriented health care programs; promote the development of knowledge concerning the causes and cures of illness and the means of delivering health services to the public; assure economic expenditure of public funds to serve those with the greatest need. These goals are carried out through the following 11 programs: Preventive Medical Services Toxic Substance Control Environmental Health AIDS Family Health Services Laboratory Services Rural and Community Health Medical Care Services Licensing and Certification Audits and Investigations Special Projects The following are some areas of responsibility for the SHA: State Public Health Authority Medicaid Single State Agency Lead Environmental Agency in the State State Agency for Children with Special Health Care Needs Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The head of the SHA is the Director of Health Services. This individual is appointed by the Governor and approved by the legislature. There is no M.D. requirement. The responsibilities are to administer the activities of the Department of Health. C. State Board of Health/Council No State Board of Health There is no state board of health. Several advisory groups, however, have been formed that have no mandated authority (the California Conference of Local Health Officers is an example). D. Regional/District Health Offices California is not regionalized nor does it have district health offices in relationship to the Department of Health Services. The state does have field offices which are solely an administrative arm of the state to provide a closer administrative structure for the purpose of authorizing treatment and fielding provider problems. No patient or health services are provided from these offices. E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Formal Liaison Function The Chief of the County Health Services Branch, Division of Rural and Community Health Services, is designated as the state-local liaison. In addition there is support from the Office of External Affairs which is responsible for organizing the Conference of Local Health Officers. These two organizational units also are responsible for the dissemination of information and issues surrounding local health departments. The interaction between state and local public health agencies in California may be characterized as mixed centralized and decentralized organizational control. Under this arrangement, local health services in the state may be provided by the SHA in some jurisdictions and by local governmental units in others. F. Budget Total FY 1988 California SHA expenditures (excluding Medi-Cal and so forth) were $792,670,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $259,746,000 State Funds $531,076,000 Local Funds 0 Fees and Reimbursements 0 Other $1,848,000 3III. Local Public Health Agencies (LPHAs) A. General There are 61 local public health agencies in California. These consist of 58 county and 3 city health departments (see map). There are 12 contract counties which, due to their small population, are supplied with public health nurses and sanitarians by the state. The county is responsible for the building and health officer. These offices usually consist of a staff of two to four. All local health departments receive funds from a local tax base. The state then subsidizes this by matching county costs for public health on a dollar for dollar basis, up to a maximum amount. This includes inpatient and outpatient services since California's counties are considered providers of last resort. B. Services Provided The following information on services provided by local health departments in California is derived from a survey conducted by NACHO during 1989. Fifty-two of the 61 local health departments responded to the survey. Services provided by 70 percent of the local health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 15 ( 28.8%) 2. Morbidity Data 40 ( 76.9%) 3. Reportable Diseases 49 ( 94.2%) 4. Vital Records and Statistics 46 ( 88.5%) B. Epidemiology/Surveillance 1. Chronic Diseases 26 ( 50.0%) 2. Communicable Diseases 50 ( 96.2%) II. Policy Development A. Health Code Dev. and Enforcement 34 ( 65.4%) B. Health Planning 38 ( 73.1%) C. Priority Setting 36 ( 69.2%) III. Assurance Activities A. Inspection 1. Food and Milk Control 35 ( 67.3%) 2. Health Facility Safety/Quality 24 ( 46.2%) 3. Rec. Facility Safety/Quality 35 ( 67.3%) 4. Other Facility Safety/Quality 21 ( 40.4%) B. Licensing 1. Health Facilities 9 ( 17.3%) 2. Other Facilities 37 ( 71.2%) C. Health Education 43 ( 82.7%) D. Environmental 1. Air Quality 2. Hazardous Waste Management 41 ( 78.8%) 3. Individual Water Supply Safety 39 ( 75.0%) 4. Noise Pollution 18 ( 34.6%) 5. Occupational Health and Safety 23 ( 44.2%) 6. Public Water Supply Safety 42 ( 80.8%) 7. Radiation Control 16 ( 30.8%) 8. Sewage Disposal Systems 41 ( 78.8%) 9. Solid Waste Management 40 ( 76.9%) 10. Vector and Animal Control 38 ( 73.1%) 11. Water Pollution 40 ( 76.9%) E. Personal Health Services 1. AIDS Testing and Counseling 49 ( 94.2%) 2. Alcohol Abuse 24 ( 46.2%) 3. Child Health 50 ( 96.2%) 4. Chronic Diseases 43 ( 82.7%) 5. Dental Health 25 ( 48.1%) 6. Drug Abuse 24 ( 46.2%) 7. Emergency Medical Service 41 ( 78.8%) 8. Family Planning 44 ( 84.6%) 9. Handicapped Children 43 ( 82.7%) 10. Home Health Care 15 ( 28.8%) 11. Hospitals 9 ( 17.3%) 12. Immunizations 51 ( 98.1%) 13. Laboratory Services 42 ( 80.8%) 14. Long-term Care Facilities 7 ( 13.5%) 15. Mental Health 17 ( 32.7%) 16. Obstetrical Care 16 ( 30.8%) 17. Prenatal Care 28 ( 53.8%) 18. Primary Care 18 ( 34.6%) 19. Sexually Transmitted Diseases 51 ( 98.1%) 20. Tuberculosis 50 ( 96.2%) 21. WIC 38 ( 73.1%) C. Local Health Officer M.D. Requirement, Board of Supervisors' Appointment The local health officer is appointed by the county board of supervisors. He/she must be an M.D. Responsibilities include hiring, firing, and supervising the staff. D. Local Board of Health Some counties have boards but the state does not require them. The authority of the boards also varies. E. Staff There is a full range of laboratory, clinical, and field staffs. Office staff size ranges from 2 to 2,600, with the average being from 50 to 100. They are all under local administration, except for the nurses and sanitarians who work in public health contract counties as stated previously. F. Budget Total FY 1988 LPHA expenditures were $439,343,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $179,517,000 State Funds $259,772,000 Local Funds 0 Fees and Reimbursements 0 Other Sources 0 Source Unknown 0 The SHA reported that there were additional fees and reimbursements not reported by local health departments, but which reverted to the general revenues of the local or state government. 2Calfornia Department Of Health Services, 1990 Secretary of Health and Welfare Chief Deputy Director Office of Civil Rights Office of Legal Services External Affairs Office of Quality Improvement Public Health Deputy Director Assistant Deputy Director Office of AIDS Environmental Health Family Health Division Division of Laboratories Preventive Medical Services Division Rural and Community Health Division Chief Deputy Director Director of Health Services Assistant Director 2Types of Local Health Departments by Jurisdiction California, 1990 Jurisdiction Co C Alameda X Alpine X Amador X Berkeley X Butte X Calavaras X Colusa X Contra Costa X Del Norte X El Dorado X Fresno X Glenn X Humboldt X Imperial X Inyo X Kern X Kings X Lake X Lassen X Long Beach X Los Angeles X Madera X Marin X Mariposa X Mendocino X Merced X Modoc X Mono X Monterey X Napa X Nevada X Orange X Pasadena X Placer X Plumas X Riverside X Sacramento X San Benito X San Bernardino X San Diego X San Francisco X San Joaquine X San Luis Obispo X San Mateo X Santa Barbara X Santa Clara X Santa Cruz X Shasta X Sierra X Siskiyou X Solano X Sonoma X Stanislaus X Sutter X Tehama X Trinity X Tulare X Tuolumne X Ventura X Yolo X Yuba X Co = County HD C = City HD 1COLORADO 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) * 3,300,000 245,803,000 Population Density (1988) 31.9 69.4 (per/sq.mi.) Number of Counties 63 3,139 Median Age (1987) 30.8 31.7 Percent Below Poverty Level (1985) 10.3 14.0 (persons) Percent of Population Rural (1980) 19.0 26.0 Percent of Population White (1980) 89.0 83.1 Percent of Population Non-white (1980) 11.0 16.9 Median Years of Education (1980) 12.8 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The Colorado Constitution, Colorado Revised Statutes, and case law developed in state and Federal courts serve as the basis for the structure and function of county governments. Most counties have boards of commissioners that serve as the legislative and administrative bodies. The counties for the most part have three-member boards with the option for five-member boards. The boards are elected at large but have district residency requirements. Several options for the structure and function of county governments are available in Colorado. City-county Consolidation - (1) - This form is authorized and has been selected by Denver city-county. Home Rule Charters - (2) - These are available and have been selected by two counties. Home rule authority in Colorado provides little additional authority, but it does allow counties to provide some additional services. * These data were provided by the SHA. Data for this state were updated October 1990. Appointed Administrator - (45) - Still another option that is available to counties is the possibility of appointing an administrator. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Colorado Department of Health (CDH), the SHA, is an independent, free-standing agency. Major functions of the Department are managed under the Office of Health and Environmental Protection, Office of Administration and Support, Office of Health Care and Prevention. CDH is dedicated to protecting and improving the health and environment of the people of Colorado; to prevent disease, disability, and premature death; to protect and improve the quality of Colorado's air, land and water; to promote public policies and individual lifestyles which maintain and improve personal and environmental health; and to provide health services to Coloradans with special needs. The following are some areas of responsibility for the SHA: State Public Health Authority Lead Environmental Agency in the State State Agency for Children with Special Health Care Needs State Health Planning and Development Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Executive Director is the head of the CDH. The position is a cabinet-level appointment that is made by the Governor and requires an M.P.H. or equivalent degree. Responsibilities and powers of the Executive Director include the following: serving as secretary to the State Board of Health; appointing authority for all SHA staff; formulating policy for public health; and serving as chief executive officer for the Department. C. State Board of Health/Council Policy-making The State Board of Health is composed of nine members appointed by the Governor. One member is appointed from each of the six congressional districts, with consent of the Senate, and the remaining positions are appointed from the state-at-large. No more than five members can be from the same political party, and no business or professional group may constitute a majority. The law also requires that one member be a county commissioner. The board adopts rules and regulations to carry out public health laws and functions in an advisory capacity to the Executive Director of the CDH. D. Regional/District Health Offices Although CDH has not divided the state into administrative regions or districts, two regional offices are located in Pueblo and Grand Junction. These offices are extensions of the central office and exist to make the services of the central office more assessable to the local health departments. E. State-local Liaison Decentralized Organizational Control, Formal Liaison Function The Local Health Services Director administers financial support for and maintains close liaison with local health departments to develop and implement state public health policy and to resolve local and statewide issues. Departmental technical staffs work with their local counterparts to assure the public access to essential health services. The interaction between state and local public health agencies in Colorado may be characterized as decentralized organizational control. Under this arrangement local government directly operates health departments with a local board of health. F. Budget Total FY 1988 Colorado SHA expenditures were $109,099,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $71,980,000 State Funds $23,590,000 Local Funds 0 Fees and Reimbursements $8,083,000 Other $5,447,000 3III. Local Public Health Agencies (LPHAs) A. General Colorado has 52 local health departments, consisting of four multicounty health departments (called regional and district health departments in Colorado) and 48 county health departments. Colorado counts 10 county health departments and the regional and district health departments as full-fledged health departments. These local health departments provide services to 23 counties and 90 percent of the state's population. Thirty-eight counties use county nursing services and county sanitarian and environmentalist services to provide public health services and function as the local health department. The county commissioners serve as the board of health. Thirty-eight counties have county nursing services. The nurses offer basic public health care such as immunizations, communicable and chronic disease control, maternal and child health, home care of the sick, preventive assessments of children and elderly. The CDH, through the Community Nursing Section, provides training, technical assistance, and supervision to these nurses. Additionally, the Department assists the local areas by reimbursing for a portion of the nurse's salary. Fifteen boards of county commissioners and the city of Vail employ public health sanitarians to provide public health services. Three additional counties purchase the services of sanitarians from nearby counties. The sanitarians work under contract with the Consumer Protection Division and perform inspections of restaurants, grocery stores, motels, child care centers, schools and summer camps. They also provide services mandated by local laws and regulations and provide advice to local elected officials on matters related to environmental health issues. The Department reimburses local governments for part of the sanitarians' salaries. One county (Hinsdale) with a population of about 400 does not have a health department. B. Services Provided The following information on services provided by local health departments in Colorado is derived from a survey conducted by NACHO during 1989. Thirty-six of the 54 local health departments in Colorado responded to the survey. Services provided by 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 8 ( 22.2%) 2. Morbidity Data 15 ( 41.7%) 3. Reportable Diseases 27 ( 75.0%) 4. Vital Records and Statistics 14 ( 38.9%) B. Epidemiology/Surveillance 1. Chronic Diseases 14 ( 38.9%) 2. Communicable Diseases 31 ( 86.1%) II. Policy Development A. Health Code Dev. and Enforcement 12 ( 33.3%) B. Health Planning 22 ( 61.1%) C. Priority Setting 20 ( 55.6%) III. Assurance Activities A. Inspection 1. Food and Milk Control 19 ( 52.8%) 2. Health Facility Safety/Quality 13 ( 36.1%) 3. Rec. Facility Safety/Quality 16 ( 44.4%) 4. Other Facility Safety/Quality 20 ( 55.6%) B. Licensing 1. Health Facilities 4 ( 11.1%) 2. Other Facilities 21 ( 58.3%) C. Health Education 25 ( 69.4%) D. Environmental 1. Air Quality 18 ( 50.0%) 2. Hazardous Waste Management 17 ( 47.2%) 3. Individual Water Supply Safety 22 ( 61.1%) 4. Noise Pollution 8 ( 22.2%) 5. Occupational Health and Safety 10 ( 27.8%) 6. Public Water Supply Safety 15 ( 41.7%) 7. Radiation Control 9 ( 25.0%) 8. Sewage Disposal Systems 20 ( 55.6%) 9. Solid Waste Management 15 ( 41.7%) 10. Vector and Animal Control 21 ( 58.3%) 11. Water Pollution 19 ( 52.8%) E. Personal Health Services 1. AIDS Testing and Counseling 20 ( 55.6%) 2. Alcohol Abuse 6 ( 16.7%) 3. Child Health 28 ( 77.8%) 4. Chronic Diseases 23 ( 63.9%) 5. Dental Health 8 ( 22.2%) 6. Drug Abuse 6 ( 16.7%) 7. Emergency Medical Service 6 ( 16.7%) 8. Family Planning 21 ( 58.3%) 9. Handicapped Children 28 ( 77.8%) 10. Home Health Care 18 ( 50.0%) 11. Hospitals 2 ( 5.6%) 12. Immunizations 29 ( 80.6%) 13. Laboratory Services 15 ( 41.7%) 14. Long-term Care Facilities 5 ( 13.9%) 15. Mental Health 2 ( 5.6%) 16. Obstetrical Care 6 ( 16.7%) 17. Prenatal Care 27 ( 75.0%) 18. Primary Care 6 ( 16.7%) 19. Sexually Transmitted Diseases 21 ( 58.3%) 20. Tuberculosis 22 ( 61.1%) 21. WIC 28 ( 77.8%) C. Local Health Officer No M.D. Requirement, Local Governing Body Appointment Local health officers are appointed by the local governing body. They must have an M.P.H. degree or equivalent and, when not an M.D., must appoint a medical advisor. The candidate must have had experience in the management or supervision of a public health program or its equivalent. The titles for local health officers in Colorado are Public Health Administrator I and II. A Public Health Administrator I can serve a local health department in a jurisdiction under 100,000 population and a Public Health Administrator II serves jurisdictions that are over 100,000 population. The administrators are responsible for managing full-time health departments. This includes the direction and supervision of all programs and activities; interpretation and administration of their purposes; enforcement of public health laws, rules, and regulations; provision of or arrangement for medical services in public health clinics and school health programs. D. Local Board of Health Policy-making Full service departments have boards of health appointed by county commissioners. Boards are policy setting bodies. They also appoint health officers who serve at the pleasure of the board. In the 40 counties without full service departments, the commission serves as the board. E. Staff The staffs of local health departments are employed and supervised by the local jurisdiction. The number of employees for local health departments ranges from 1 to 200. F. Budget Total FY 1988 LPHA expenditures were $27,897,000. Total FY 1988 United States LPHA expenditures were $ 3,978,948,000. SHA funds are distributed to local health agencies on a per capita basis. In counties that have no local health departments, the state pays 20 percent of the public health nurses' salaries and 40 percent of the sanitarians' salaries. Source of Funds Federal Grants and Contracts $425,000 State Funds $3,969,000 Local Funds $18,476,000 Fees and Reimbursements $1,155,000 Other Sources $3,873,000 Source Unknown 0 The SHA reported that there were additional fees and reimbursements not retained by local health departments, but which reverted to the general revenues of the local or state government. The SHA also reported that these figures include the total of additional local health department monies expended by all local health departments. 2Colorado Department of Health, 1990 Governor Colorado Department of Health State Board of Health Executive Director Office of External Affairs Public Relations Governmental Liaison Local Health Services Office of Health and Environmental Protection Rocky Flats Program Unit Air Pollution Control Division Technical Services Stationary Sources Mobile Sources Water Quality Control Division Field Support Permits and Enforcement Ground Water and Standards Drinking Water Disease Control and Environmental Epidemiology Division Communicable Disease Control Environmental Epidemiology STD/AIDS Hazardous Waste Management Division Hazardous Waste Control Section Solid Waste and Incident Management Section Remedial Programs Section Consumer Protection Division Field Services Technical Assistance Radiation Control Division X-Ray Regulation and Inspection Uranium and Special Projects Environmental Surveillance Radioactive Materials Licensure and Inspection Office of Administration and Support Administrative Services Division Business Management Human Resources Data Services Support Services Emergency Medical Services Division Laboratory Division Microbiology Chemistry Toxicology Newborn Screening Health Facilities Division Administrative Services Program Development Evaluation Long-Term Care Hospital Medicare Residential Investigations Office of Health Care and Prevention Health Statistics & Vital Records Division Certification Health Statistics Data Management Alcohol and Drug Abuse Division Prevention/Intervention Treatment Services Administrative Support/Planning and Evaluation Prevention Programs Division Chronic Disease Control Injury Prevention Colorado Action for Healthy People Family and Comm. Health Services Division Family Health Services Childrens' Health Services Migrant Health Dental Health Nutrition Services Community Services Medical Affairs and Special Programs Cooperative Agreement/Primary Care 2Types of Local Health Departments by Jurisdiction Colorado, 1990 Jurisdiction Co M/Co N/Co Adams X Alamosa X Arapahoe X Archuletta X Baca X Bent X Boulder X Chaffee X Cheyenne X Clear Creek X Conejos X Costilla X Crowley X Custer X Delta X Denver X Dolores X Douglas X Eagle X El Paso X Elbert X Fremont X Garfield X Gilpin X Grand X Gunnison X Hinsdale X Huerfano X Jackson X Jefferson X Kiowa X Kit Carson X La Plata X Lake X Larimer X Lincoln X Logan X Los Animas X Mesa X Mineral X Moffat X Montezuma X Montrose X Otero X Ourey X Park X Phillips X Pitkin X Prowers X Pueblo X Rio Blanco X Rio Grande X Routt X Saguache X San Juan X San Miguel X Sedgwick X Summit X Teller X Washington X Weld X Yuma X Co = County HD M/Co= Multicounty HD N/Co =No County HD 1CONNECTICUT 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 3,233,000 245,803,000 Population Density (1988) 663.6 69.4 (per/sq.mi.) Number of Counties 8 3,139 Median Age (1987) 33.9 31.7 Percent Below Poverty Level (1985) 7.6 14.0 (persons) Percent of Population Rural (1980) 21.0 26.0 Percent of Population White (1980) 90.1 83.1 Percent of Population Non-white (1980) 9.9 16.9 Median Years of Education (1980) 12.6 12.5 (25 years of age and over) B. County Government Structure Connecticut has no functioning county governments. Counties are used for geographic designation only. 3II. State Health Agency (SHA) A. General Free-standing, Independent Agency The Connecticut Department of Health Services (CDHS), the SHA, is a free-standing, independent agency. The mission of CDHS is to become the best state health department in the nation. In doing so, the CDHS will promote and enhance the public's health by employing the most efficient and practical means to prevent and suppress disease. The following are some areas of responsibility for the SHA: State Public Health Authority Lead Environmental Agency in the State State Agency for Children with Special Health Care Needs Data for this state were updated February 1991. State Health Planning and Development Agency State Professions Licensing Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement The Department encourages the development and expansion of full-time local health services by subsidizing the cost of such services to local communities. Grants-in-aid are made to all departments and districts with full-time health officers. To be eligible for funding, the local health departments must comply with funding regulations in the public health code. B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment As the chief executive officer of the CDHS, the Commissioner is appointed by the Governor for a term of office concurrent with the gubernatorial term and required to have M.D./M.P.H or M.P.H. degrees. It is the duty of the Commissioner of CDHS to use the most efficient and practical means for prevention and suppression of disease, and administer the health laws and the public health code. The Commissioner is also responsible for the overall operation and administration of CDHS. C. State Board of Health/Council No State Board of Health Although Connecticut has no State Board or Council of Health, it does have a statewide advisory committee on public health. The advisory committee is composed of 25 members who are health care professionals, providers, and consumers. D. Regional/District Health Offices CDHS has two regional offices located in Norwich and Bridgeport which are extensions of the central office and have only managerial functions. The offices do not have specific geographic areas of service. E. State-local Liaison Decentralized Organizational Control, Formal Liaison Function The Office of Local Health Administration has responsibility for state-local liaison. This function began in the fall of 1989 when CDHS began a major local health initiative to focus on the needs of local health officers, their departments, and districts in the state by establishing an Office of Local Health Administration. An objective of this office is to enhance communication between the Department and other state agencies with local health officers through periodic forums, resource materials, advisory groups, and other mechanisms. The interaction between state and local public health agencies in Connecticut may be characterized as decentralized organizational control. Under this arrangement local governments directly operate health departments with or without local boards of health. F. Budget Total FY 1988 Connecticut SHA expenditures were $72,983,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $35,225,000 State Funds $37,758,000 Local Funds 0 Fees and Reimbursements 0 Other 0 3III. Local Public Health Agencies (LPHAs) A. General Connecticut has 49 local health departments, consisting of full and part-time local health departments and district health departments. The districts consist of towns, cities, and boroughs which have voted to combine their health services into a district health department. Currently there are 13 districts, 28 full-time, and 8 part-time health departments. The designation of full- or part-time depends on the presence or absence of a full-time health officer. There are 70 other jurisdictions in Connecticut which have health services but do not have at least one full-time position. B. Services Provided The following information on services provided by local health departments in Connecticut is derived from a survey conducted by NACHO during 1989. Seventy of the local health jurisdictions in Connecticut responded to the survey. These respondents include several service units known as part-time health departments, which do not meet our definition of a local health department. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 14 ( 20.0%) 2. Morbidity Data 24 ( 34.3%) 3. Reportable Diseases 63 ( 90.0%) 4. Vital Records and Statistics 18 ( 25.7%) B. Epidemiology/Surveillance 1. Chronic Diseases 22 ( 31.4%) 2. Communicable Diseases 61 ( 87.1%) II. Policy Development A. Health Code Dev. and Enforcement 58 ( 82.9%) B. Health Planning 35 ( 50.0%) C. Priority Setting 30 ( 42.9%) III. Assurance Activities A. Inspection 1. Food and Milk Control 58 ( 82.9%) 2. Health Facility Safety/Quality 32 ( 45.7%) 3. Rec. Facility Safety/Quality 46 ( 65.7%) 4. Other Facility Safety/Quality 32 ( 45.7%) B. Licensing 1. Health Facilities 17 ( 24.3%) 2. Other Facilities 61 ( 87.1%) C. Health Education 43 ( 61.4%) D. Environmental 1. Air Quality 26 ( 37.1%) 2. Hazardous Waste Management 43 ( 61.4%) 3. Individual Water Supply Safety 57 ( 81.4%) 4. Noise Pollution 25 ( 35.7%) 5. Occupational Health and Safety 23 ( 32.9%) 6. Public Water Supply Safety 34 ( 48.6%) 7. Radiation Control 20 ( 28.6%) 8. Sewage Disposal Systems 66 ( 94.3%) 9. Solid Waste Management 31 ( 44.3%) 10. Vector and Animal Control 42 ( 60.0%) 11. Water Pollution 61 ( 87.1%) E. Personal Health Services 1. AIDS Testing and Counseling 18 ( 25.7%) 2. Alcohol Abuse 8 ( 11.4%) 3. Child Health 34 ( 48.6%) 4. Chronic Diseases 22 ( 31.4%) 5. Dental Health 15 ( 21.4%) 6. Drug Abuse 11 ( 15.7%) 7. Emergency Medical Service 16 ( 22.9%) 8. Family Planning 8 ( 11.4%) 9. Handicapped Children 8 ( 11.4%) 10. Home Health Care 15 ( 21.4%) 11. Hospitals - 12. Immunizations 53 ( 75.7%) 13. Laboratory Services 11 ( 15.7%) 14. Long-term Care Facilities 5 ( 7.1%) 15. Mental Health 11 ( 15.7%) 16. Obstetrical Care 4 ( 5.7%) 17. Prenatal Care 8 ( 11.4%) 18. Primary Care 5 ( 7.1%) 19. Sexually Transmitted Diseases 33 ( 47.1%) 20. Tuberculosis 32 ( 45.7%) 21. WIC 18 ( 25.7%) C. Local Health Officer No M.D. Requirement, Local Governing Body Appointment Local health officers are hired by the municipality or health district and approved by the Commissioner of CDHS. Local health officers are not required to be physicians. They are, however, required to have a graduate degree in public health as a result of at least 1 year's training that has included at least 60 hours in local health administration. The health officers are responsible for all duties assigned by the local board of health as well as those required by statutes and the public health code. D. Local Board of Health Policy-making District boards of health represent districts that are formed when a group of local jurisdictions (towns, cities, and boroughs) vote to form district departments of health. Each town, city, and borough which voted to become part of the district may appoint one member to the board. Jurisdictions with populations of more than 10,000 are entitled to an additional representative for each 10,000 population, with a limit of five representatives. The members are appointed by the governing bodies of the respective jurisdictions to terms of 3 years. The terms are staggered so that approximately one-third of the terms expire each year. The board is responsible for managing the affairs of the district health department. Some towns and municipalities have boards of health that function in an advisory capacity to the local governing body. The board members are appointed by the local governing body. The number of members vary greatly for these boards. E. Staff The staffs of the local health departments are employed and supervised by the local jurisdiction. The number of staff employed by local health departments ranges from 1 to 140. F. Budget Total FY 1988 LPHA expenditures were $29,957,000*. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $2,696,000 State Funds $5,748,000 Local Funds $21,513,000* Fees and Reimbursements 0 Other Sources 0 Source Unknown 0 * The SHA reported that these figures were estimated. 2Connecticut Department of Health Services, 1990 Advisory Committee Commissioner Commission on Long-Term Care Commission on Hospitals and Health Care Center for Chronic Disease Urban/Rural Health Executive Secretary Center for Governmental Relations Center for Communications Internal/External Deputy Commissioner Bureau of Health Promotion Environmental Epidemiology and Occupational Health Environmental Health Services Infectious Disease Epidemiology Local Health Administration Health Surveillance and Planning Bureau of Community Health Child/Adolescent Health Division Community Health Systems Division Family/Reproductive Health Division Executive Assistant Executive Assistant Executive Assistant Deputy Commissioner Bureau of Health System Regulation Community Nursing and Home Health Emergency Medical Services Hospitals and Medical Care Medical Quality Assurance Regulations Administrative Services Affirmative Action Data Processing Personnel Services Program Monitoring and Fiscal Review Bureau of Laboratory Services Biological Sciences Environmental Chemistry Laboratory Standards Organic Chemistry Toxicology and Criminology 2Types of Local Health Departments by Jurisdiction Connecticut, 1990 Jurisdiction N/Co T/T M/T Avon X Bethel X Bloomfield X Brigdeport X Bristol-Burlington X Chesprocott Dist. X Clinton X Danbury X Durham X East Hartford X East Shore Dist. X Fairfield X Fairfield X Farmington X Farmington Valley X Glastonbury X Greenwich X Groton X Hartford X Hartford X Litchfield X Manchester X Meriden X Middlesex X Middletown X Milford X Naugatuck Valley X New Britain X New Fairfield X New Haven X New Haven X New London X New Milford X New Tolland X Newtown X North Central Dist. X Northeast Dist X Norwalk X Old Lyme X Pomeraug Dist. X Quinnipiack Valley X Southington X Stafford Dist. X Stamford X Stratford X Tolland X Tolland X Torrington Area X Uncas Region Dist. X Wallingford X Waterbury X West Hartford X West Haven X Weston-Westport X Windham X Windsor X N/Co = No county HD T/T = Town/Township HD M = Multitownship HD 1DELAWARE 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 660,000 245,803,000 Population Density (1988) 341.6 69.4 (per/sq.mi.) Number of Counties 3 3,139 Median Age (1987) 31.6 31.7 Percent Below Poverty Level (1985) 11.4 14.0 (persons) Percent of Population Rural (1980) 29.0 26.0 Percent of Population White (1980) 82.1 83.1 Percent of Population Non-white (1980) 17.9 16.9 Median Years of Education (1980) 12.5 12.5 (25 years of age and over) B. County Government Structure No Home Rule Authority The state constitution and statutes establish the authority and structural framework for the three counties of Delaware. Council Form - (2) - New Castle and Sussex counties use the Council Form of government with only slight variations between them. They both have a six-member council elected from districts. New Castle has a seventh member who is elected from the county at large. New Castle also has an elected executive officer and an appointed administrative officer who is responsible to the executive officer. Sussex county appoints a county administrator to fulfill the administrative functions of the county. Levy Court System - (1) - Kent county operates under a Levy Court System which has five Levy Court Commissioners and an appointed county administrator. Data for this state were updated December 1990. 3II. State Health Agency (SHA) A. General Component of Superagency The Delaware Division of Public Health, the SHA, is a component of a superagency called the Department of Health and Social Services (DHSS). For the well-being of Delaware families and communities, the Division of Public Health provides leadership and fosters partnerships to promote healthy lifestyles, prevent disease, disability and premature death, protect human health from environmental hazards, and provide or assure access to health care for vulnerable populations in need. The following are some areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals B. Head of State Health Agency M.D. Requirement, Not Cabinet-level Appointment The Director of the Division of Public Health is the head of the SHA. The Director is appointed by the Secretary of the Department of Health and Social Services with the Governor's approval and serves at the will of the administration. Law requires that the Director be a physician, preferably with an M.P.H. and at least 5 years of increasing administrative responsibility. The Director is the chief administrative officer of the Division and a member of the State Board of Health, where the regulatory and enforcement authority is derived. Membership in several committees and task forces result from both appointment and law. These include: 1. Authority on Radiation Control 2. Controlled Substance Abuse Committee 3. Delaware Emergency Medical Services Advisory Committee 4. Title XIX Medical Advisory Committee 5. Developmental Disabilities Advisory Committee Direct supervision of two deputies and the Directors of the State Laboratory, Offices of Narcotics and Dangerous Drugs, Health Facilities Standards and Licensing Office, and Office of Emergency Medical Services are part of the Director's responsibilities. C. State Board of Health/Council Policy-Making The State Board of Health consists of two members, the Secretary of DHSS and the Director of the Division of Public Health. The Secretary of DHSS serves as Chair, and the Director acts as the secretary of the board, responsible for the agenda, minutes, and preparation of agenda items. D. Regional/District Health Offices The SHA does not divide the state into administrative regions or districts. E. State-local Liaison Centralized Organizational Control, No Liaison Function The local service units are elements of the SHA so there is no need for a liaison function. Delaware is a state that has achieved the highest level of centralization. All of the service units are elements of the SHA and function without any local funds or input. The interaction between state and local public health agencies in Delaware may be characterized as centralized organizational control. Under this arrangement local health departments function directly under the state's authority and are operated by the SHA or State Board of Health. F. Budget Total FY 1988 Delaware SHA expenditures were $52,806,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $7,916,000 State Funds $43,613,000 Local Funds $49,000 Fees and Reimbursements $563,000 Other $666,000 3III. Local Public Health Agencies (LPHAs) A. General Delaware does not consider the three service units to be local health departments. The SHA, however, has a branch office located in each county to provide public health services in that jurisdiction. We recognize that these units are part of the SHA and receive no local funding or input, but they are providing public health services in local jurisdictions. B. Services Provided The following information on services provided by local health departments in Delaware is derived from a list of state-mandated services that are carried out by the three regional offices. Since Delaware does not consider the regional offices to be local health departments, they did not respond to the NACHO survey of local health departments. Services Provided by LPHAs Number of LPHAs I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 3 2. Morbidity Data - 3. Reportable Diseases 3 4. Vital Records and Statistics 3 B. Epidemiology/Surveillance 1. Chronic Diseases 3 2. Communicable Diseases 3 II. Policy Development A. Health Code Dev. and Enforcement - B. Health Planning - C. Priority Setting - III. Assurance Activities A. Inspection 1. Food and Milk Control 3 2. Health Facility Safety/Quality - 3. Rec. Facility Safety/Quality - 4. Other Facility Safety/Quality - B. Licensing 1. Health Facilities - 2. Other Facilities - C. Health Education - D. Environmental 1. Air Quality - 2. Hazardous Waste Management - 3. Individual Water Supply Safety 3 4. Noise Pollution - 5. Occupational Health and Safety - 6. Public Water Supply Safety 3 7. Radiation Control 3 8. Sewage Disposal Systems - 9. Solid Waste Management - 10. Vector and Animal Control - 11. Water Pollution - E. Personal Health Services 1. AIDS Testing and Counseling 3 2. Alcohol Abuse - 3. Child Health 3 4. Chronic Diseases - 5. Dental Health - 6. Drug Abuse - 7. Emergency Medical Service - 8. Family Planning 3 9. Handicapped Children 3 10. Home Health Care - 11. Hospitals - 12. Immunizations 3 13. Laboratory Services - 14. Long-term Care Facilities - 15. Mental Health - 16. Obstetrical Care - 17. Prenatal Care 3 18. Primary Care - 19. Sexually Transmitted Diseases 3 20. Tuberculosis 3 21. WIC 3 C. Local Health Officer No M.D. Requirement, State Merit System Appointment Assistant State Health Officers are in charge of each of the three local health units. They may be physicians but are not required to be. They are responsible for enforcing public health regulations in their county and supervising activities in their area, including contracting for the local services. These Assistant State Health Officers are State Merit System employees and are appointed through the standard process for hiring state employees. Their responsibilities resemble those of the State Director except for formulating budget and proposing legislation. D. Local Board of Health There are no local boards of health in Delaware. E. Staff The staffs for the local service units are employees of the SHA and part of the State Merit System. The number of employees in the local service units range from 40 to 100. F. Budget Funding for providing local public health services in Delaware is handled entirely by the SHA without the input of any local funds. 2Delaware Division of Public Health, 1990 Governor Department of Health and Social Services Board of Health Office of the Secretary Division of Aging Division of Alcohol, Drug Abuse and Mental Health Division of Business Administration and General Services Division of Child Support Enforcement Division of Medical Examiner Division of Public Health Director Long-Term Care Section Community Health Section Office of Narcotics and Dangerous Drugs Office of Emergency Medical Services Office of Health Facilities Standards and Licensing Laboratory Division of Mental Retardation Division of Social Services Division of State Services Centers Division of Visually Impaired Division of Planning and Research Evaluation 2Types of Local Health Departments by Jurisdiction Delaware, 1990 Jurisdiction Co Kent X New Castle X Sussex X Co = County HD 1DISTRICT OF COLUMBIA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 617,000 245,803,000 Population Density (1988) 9,793.7 69.4 (per/sq.mi.) Number of Counties 0 3139 Median Age (1987) 32.9 31.7 Percent Below Poverty Level (1979) 18.6 12.4 (persons) Percent of Population Rural (1980) 0.0 26.0 Percent of Population White (1980) 26.9 83.1 Percent of Population Non-white (1980) 73.1 16.9 Median Years of Education (1980) 12.7 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The government of the District of Columbia is unique among local governments in the United States in that it functions as a state, a county, a city, a school district and special districts combined. Home Rule Charter - The District of Columbia is also different from other local governments because it was chartered by Congress. In 1973 Congress passed the District of Columbia Self-Government Reorganization Act, which is commonly called home rule. With the Home Rule Charter, Congress retained the authority to review legislation passed by the District of Columbia Council and to control policy through the appropriation process. The tax base for the District of Columbia is different because the charter restricts the ability of the government to tax. It prohibits non-resident income tax and property tax on 56 percent of the land. Each year the Federal government makes a payment to the District government to compensate for costs incurred in delivering services to the Federal establishment, for revenue lost to the District because of the presence of the Federal government and for the Federal restrictions on the District tax authority. The Federal payment, which began when the District was established as the Nation's capital in 1800, is determined each year by the President and Congress through the Data for the District of Columbia were updated February 1991. legislative process. Despite the intended purpose of the Federal payment, it has not kept pace with the revenue lost due to Federal restrictions on the District's taxing authority. Council Form - The District of Columbia Council, which is the legislative body, is composed of a 13-member board including a Council Chairman. Terms of office for the Council members are 4 years. Eight Council members are elected from each of eight wards, with four others and the Council Chairman elected at-large. Only two of the at-large members may be from the same political party (excluding the Chairman). Terms of office are staggered so that the terms of six members expire and 2 years later terms of the other six members plus the Chairman expire. The Chairman is the chief executive for the Council, conducting all meetings and signing all legislation on behalf of this body. This official is responsible for referring all bills to the appropriate committee and transmitting all approved bills to the Mayor for signature and to the Congress. The Chairman nominates council officers, Chairman pro tempore, committee chairmanships, committee members, and others such as auditor and representatives for independent boards. The Executive Officer of the District of Columbia government is the Mayor. The District has a non-voting delegate to the U.S. House of Representatives. This delegate is elected by popular vote every 2 years. 3II. State Health Agency (SHA) A. General Component of Superagency The Commission of Public Health is the SHA for the District of Columbia. The Commission has SHA responsibility, including providing local health services. It is a component of a superagency called the Department of Human Services. The mission of the Commission of Public Health is to assure equitable access to comprehensive, high quality public health services to all residents and visitors and to monitor and improve their health status. The following is a list of areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs Emergency Medical Services State Agency (included by SHA) Local Public Health Responsibility Responsibility for Institutions/Hospitals (public long-term care only) B. Head of State Health Agency M.D. Requirement, Mayoral Appointment The Commissioner of Public Health, the title for director of the SHA, is appointed by the Mayor. The Office of Commissioner is responsible for the formulation, implementation and evaluation of health care services delivered to both residents and visitors. The Commissioner has responsibility to manage in an effective and efficient manner and to provide the public with preventive and treatment programs that will help the sick and reduce suffering. C. State Board of Health/Council The District of Columbia does not have a Council or Board of Health. D. Regional/District Health Offices The Commission of Public Health in the Department of Human Services functions as both the state and local public health agency (LPHA) for the District. The Commission provides public health services through a network of 25 public health care clinics. The clinics provide a range of specialized and primary health services on an outpatient basis. The clinics are not uniform in services provided or in staffing patterns. Individual clinics tend to specialize in specific areas of service such as control of sexually transmitted diseases, tuberculosis, drug abuse, or ambulatory care. The following is a list of services provided by the Commission of Public Health: Services Provided by LPHA Number of LPHA Reporting I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 1 2. Morbidity Data 1 3. Reportable Diseases 1 4. Vital Records and Statistics - B. Epidemiology/Surveillance 1. Chronic Diseases 1 2. Communicable Diseases 1 II. Policy Development A. Health Code Dev. and Enforcement - B. Health Planning 1 C. Priority Setting 1 III. Assurance Activities A. Inspection 1. Food and Milk Control - 2. Health Facility Safety/Quality - 3. Rec. Facility Safety/Quality - 4. Other Facility Safety/Quality - B. Licensing 1. Health Facilities - 2. Other Facilities - C. Health Education 1 D. Environmental 1. Air Quality - 2. Hazardous Waste Management - 3. Individual Water Supply Safety - 4. Noise Pollution - 5. Occupational Health and Safety - 6. Public Water Supply Safety - 7. Radiation Control - 8. Sewage Disposal Systems - 9. Solid Waste Management - 10. Vector and Animal Control 1 11. Water Pollution - E. Personal Health Services 1. AIDS Testing and Counseling 1 2. Alcohol Abuse 1 3. Child Health 1 4. Chronic Diseases 1 5. Dental Health 1 6. Drug Abuse 1 7. Emergency Medical Service 1 8. Family Planning 1 9. Handicapped Children 1 10. Home Health Care 1 11. Hospitals (long term care) 1 12. Immunizations 1 13. Laboratory Services 1 14. Long-term Care Facilities 1 15. Mental Health - 16. Obstetrical Care 1 17. Prenatal Care 1 18. Primary Care 1 19. Sexually Transmitted Diseases 1 20. Tuberculosis 1 21. WIC 1 E. State-Local Liaison The District of Columbia performs the functions of both state and local government. Hence, there is no need for a liaison function. F. Budget Total 1987 District of Columbia SHA expenditures were $194,329,000. Total 1987 United States SHA expenditures were $8,148,511,000. Source of Funds Federal Grants and Contracts $37,074,000 State Funds $155,114,000 Local Funds 0 Fees and Reimbursements $2,140,000 Other 0 2District of Columbia Comission of Public Health, 1990 Commissioner Deputy Commissioner Office of Management and Budget Office of Health Care Access Office of Chief Medical Examiner Alcohol and Drug Abuse Services Office of Emergency Health and Medical Services Ambulatory Health Care Office of Medical Affairs for Social Services Long-Term Care Office of Health Planning and Development Preventive Health Services Bureau of Sexually Transmitted Disease Control Bureau of Laboratories Bureau of Epidemiology and Disease Control Bureau of Cancer Control Bureau of Tuberculosis Control Office of AIDS Activities Office of Dental Health Office of Maternal and Child Health Office of Nutrition 2Types of Local Health Departments by Jurisdiction District of Columbia, 1990 Jurisdiction C N/Co District X C = City HD 1FLORIDA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) * 12,503,800 245,803,000 Population Density (1988) * 230.8 69.4 (per/sq.mi.) Number of Counties 67 3,139 Median Age (1987) 36.0 31.7 Percent Below Poverty Level (1985) 13.4 14.0 (persons) Percent of Population Rural (1980) 16.0 26.0 Percent of Population White (1980) 84.0 83.1 Percent of Population Non-white (1980) 16.0 16.9 Median Years of Education (1980) 12.5 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority Florida counties derive their power from the state constitution and state statutes. The general form of county government is a five-member board of commissioners that is elected at large. Exceptions to this rule are Volusia and Jacksonville-Duval which have county councils and Hillsborough and Dade which have seven- and nine-member county commissions. Dade also has a county mayor. County governments in Florida fall into either Charter or non-Charter status. Both Charter and non-Charter counties have the legal option of utilizing a county administrator position to perform administrative affairs of the board. At the present time 40 counties have chosen to utilize some form of appointed county administrator. Charter Form - (12) - In charter governments the commission retains legislative and policy-making roles, but executive functions may be delegated to an appointed or elected official. The counties may utilize a County Manager, a County Chairman-Administrator, or a County Executive to fulfill the executive function. * These data were provided by the SHA. Data for this state were updated October 1990. Non-Charter Form - (55) - Counties utilizing this form of government have many of the same powers granted to charter counties. Non-Charter counties, however, do not have the option of changing the structure or the manner of selection for the governing body and county officers. 3II. State Health Agency (SHA) A. General Component of Superagency The Department of Health and Rehabilitative Services (HRS) is responsible for the provision of state-supported public health services in Florida. The purpose of HRS is to integrate the delivery of all health, social, and rehabilitative services offered by the state. As a result, HRS is the primary provider of public assistance services. Public health activities represent only a fraction of the Department's overall activities. The Department is headed by a Secretary appointed by the Governor and confirmed by the Senate. The Secretary is served by five Deputy Secretaries responsible for the major organizational units that comprise the Department (see attached table of organization). The following are some of the areas of responsibility for the SHA: State Public Health Authority State Institutions/Hospitals Environmental health activities are divided between HRS and the Department of Environmental Regulation. B. Head of State Health Agency No M.D. Requirement, Not Cabinet-level Appointment The Deputy Secretary for Health is the State Health Officer. The State Health Officer is appointed by and serves at the pleasure of the Secretary of HRS. The State Health Officer must be a licensed physician or hold a master's degree or doctorate in public health from an accredited university, and must have specialized training and experience in public health service and administration. The State Health Officer is responsible for defining the mission and setting the policy direction for the state public health system, directing and coordinating the activities of four assistant health officers, providing leadership to public health staffs, conveying the public health mission and program to the public and the legislature, ensuring coordination and interaction between the public health system and related programs within HRS and the external community, and providing medical supervision to the HRS county public health units. The State Health Officer provides policy guidance for public health unit staff, but does not have line authority over employees in the public health units. The State Health Officer directs the State Health Office. C. State Board of Health/Council Advisory Florida has two state health councils. However, neither is a board of health in the traditional sense. Both are strictly advisory. They are the Advisory Council on Health and the Statewide Health Council. The Advisory Council on Health serves in an advisory capacity to the State Health Officer. It is composed of 11 members who are appointed by the Secretary of HRS in consultation with the State Health Officer. Members of this council must include three physicians; the Secretary of the Department of Environmental Regulation; the Dean of the College of Public Health at the University of South Florida; a dentist; a registered nurse; a veterinarian; an individual with professional expertise in environmental health; and a consumer or representative of an advocacy group. In addition to advising the State Health Officer on general policies affecting public health in the state, the Council recommends programs to carry out the purposes of the Department. The second council, the Statewide Health Council, advises the Governor, Legislature, and Department on state health policy issues, health planning activities, and regulation programs. The Statewide Health Council is composed of the chairman of the 11 local health councils, 2 individuals appointed by the Speaker of the House of Representatives, and 2 individuals appointed by the President of the Senate. Much of the Statewide Health Council's work involves collating the information and planning materials gathered by 11 local health planning councils. However, the Statewide Health Council also reviews district health plans for consistency with the state health goals and policies, prepares a state report on the adequacy, appropriateness, and effectiveness of state funds distributed to meet the needs of the medically indigent, and assists the local health councils in developing an analysis of service and facility needs of persons with AIDS-related illnesses. D. Regional/District Health Offices HRS service areas in Florida are divided into 11 districts. Each district is headed by a District Administrator. The District Administrator is appointed by the Secretary and is directly responsible to the Deputy Secretary for Operations. The District Administrator has line authority over all Department programs assigned to the district. The Deputy District Administrator for Health and district administrators in each district have direct supervisory authority over the public health unit directors and administrators. Although staffing levels in the different district offices vary, district staff with responsibility for public health activities generally include the following: District Administrator Deputy Assistant Administrator for Health Environmental Health Consultant Nursing Consultant Human Services Program Manager(s) Human Services Program Analysts E. State-local Liaison Centralized Organizational Control, Informal Liaison Function State-local liaison activities are primarily handled by District Administrators and County Public Health Unit Directors and Administrators. There are no positions allocated for purely liaison purposes. The majority of day-to-day contact between state public health officials and local officials is handled by the county public health unit directors and administrators. The interaction between state-local public health agencies in Florida may be characterized as centralized organizational control. Under this arrangement, local health departments function directly under the state's authority and are operated by the SHA. F. Budget Total FY 1988 SHA expenditures were $366,796,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $98,553,000 State Funds $198,694,000 Local Funds $29,358,000 Fees and Reimbursements $38,439,000 Other $1,752,000 3III. Local Public Health Agencies (LPHAs) A. General There are 67 county health departments in Florida. HRS enters into contracts with the 67 counties in Florida to identify funding for the services that will be provided by the public health units. All contracts are negotiated and approved by the appropriate local governing bodies and the appropriate district administrators on behalf of the Department. The county public health units are part of the Department of Health and Rehabilitative Services. County health unit employees are HRS employees. B. Services Provided The following information on services provided by local health departments in Florida is derived from a survey conducted by NACHO during 1989. Sixty-three of the 67 local health departments in Florida responded to the survey. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 26 ( 41.3%) 2. Morbidity Data 40 ( 63.5%) 3. Reportable Diseases 62 ( 98.4%) 4. Vital Records and Statistics 62 ( 98.4%) B. Epidemiology/Surveillance 1. Chronic Diseases 48 ( 76.2%) 2. Communicable Diseases 62 ( 98.4%) II. Policy Development A. Health Code Dev. and Enforcement 36 ( 57.1%) B. Health Planning 45 ( 71.4%) C. Priority Setting 42 ( 66.7%) III. Assurance Activities A. Inspection 1. Food and Milk Control 51 ( 81.0%) 2. Health Facility Safety/Quality 46 ( 73.0%) 3. Rec. Facility Safety/Quality 38 ( 60.3%) 4. Other Facility Safety/Quality 25 ( 39.7%) B. Licensing 1. Health Facilities 20 ( 31.7%) 2. Other Facilities 47 ( 74.6%) C. Health Education 52 ( 82.5%) D. Environmental 1. Air Quality 16 ( 25.4%) 2. Hazardous Waste Management 48 ( 76.2%) 3. Individual Water Supply Safety 59 ( 93.7%) 4. Noise Pollution 12 ( 19.0%) 5. Occupational Health and Safety 23 ( 36.5%) 6. Public Water Supply Safety 55 ( 87.3%) 7. Radiation Control 30 ( 47.6%) 8. Sewage Disposal Systems 60 ( 95.2%) 9. Solid Waste Management 40 ( 63.5%) 10. Vector and Animal Control 59 ( 93.7%) 11. Water Pollution 44 ( 69.8%) E. Personal Health Services 1. AIDS Testing and Counseling 63 (100.0%) 2. Alcohol Abuse 7 ( 11.1%) 3. Child Health 63 (100.0%) 4. Chronic Diseases 59 ( 93.7%) 5. Dental Health 32 ( 50.8%) 6. Drug Abuse 11 ( 17.5%) 7. Emergency Medical Service 6 ( 9.5%) 8. Family Planning 63 (100.0%) 9. Handicapped Children 15 ( 23.8%) 10. Home Health Care 26 ( 41.3%) 11. Hospitals 2 ( 3.2%) 12. Immunizations 63 (100.0%) 13. Laboratory Services 45 ( 71.4%) 14. Long-term Care Facilities 7 ( 11.1%) 15. Mental Health 2 ( 3.2%) 16. Obstetrical Care 37 ( 58.7%) 17. Prenatal Care 61 ( 96.8%) 18. Primary Care 62 ( 98.4%) 19. Sexually Transmitted Diseases 63 (100.0%) 20. Tuberculosis 62 ( 98.4%) 21. WIC 62 ( 98.4%) C. Local Health Officer M.D. or D.O. Requirement, Secretary Appointment County public health units are headed by a Director or Administrator. The Director is a doctor of medicine or osteopathy who is trained in public health administration and appointed by the Secretary of HRS after consultation with the State Health Officer, the District Administrator, and after concurrence of the Board of County Commissioners. The Administrator is trained in public health administration, but is not a physician. Administrators are appointed in the same fashion as directors. Directors and Administrators are HRS employees. D. Local Board of Health Florida does not have local boards of health. E. Staff The county public health unit employees are HRS employees. They are supervised, with the exceptions of the unit directors and administrators, by the supervisory staff in the unit. Unit directors and administrators are supervised by the district administrators and deputy administrators. The number of employees for public health units ranges from 4 to 680. F. Budget Total FY 1988 LPHA expenditures were $216,402,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $19,105,000 State Funds $146,531,000 Local Funds $29,358,000 Fees and Reimbursements $21,407,000 Other Sources 0 Source Unknown 0 The SHA reported that these figures include the total amount of additional monies expended by all local health departments. 2Florida Department of Health and Rehabilitative Services, 1990 Secretary Deputy Secretary for Administrative Services Deputy Secretary for Programs Deputy Secretary for Health Assistant Deputy Program and Financial Assessment Director of Quality Assurance and Public Health Nursing Assistant Health Officer for Disease Control and AIDS Prevention Assistant Health Officer for Family Health Services Assistant Health Officer for Technical Health Services Assistant Health Officer for Environmental Health Deputy Secretary for Operations District Administrator Deputy District Administrator for Health HRS County Public Health Units Deputy Secretary for Management Systems 2Types of Local Health Departments by Jurisdiction Florida, 1990 Jurisdiction Co Alachua X Baker X Bay X Bradford X Brevard X Broward X Calhoun X Charlotte X Citrus X Clay X Collier X Columbia X Dade X De Soto X Dixie X Duval X Escambia X Flagler X Franklin X Gadsden X Gilchrist X Glades X Gulf X Hamilton X Hardee X Hendry X Hernando X Highlands X Hillsborough X Holmes X Indian River X Jackson X Jefferson X Lafayette X Lake X Lee X Leon X Levy X Liberty X Madison X Manatee X Marion X Martin X Monroe X Nassau X OKaloosa X Okeechobee X Orange X Osceola X Palm Beach X Pasco X Pinellas X Polk X Putnam X Santa Rosa X Sarasota X Seminole X St. Johns X St. Lucie X Sumter X Suwannee X Taylor X Union X Volusia X Wakulla X Walton X Washington X Co = County HD 1GEORGIA 2Georgia Divison of Public Health, 1990 3I. General State Information A. Selected Socio-Demographic Indicators State United States Population (1988) 6,342,000 245,803,000 Population Density (1988) * 107.7 69.4 (per/sq.mi.) Number of Counties 159 3,139 Median Age (1987) * 30.6 31.7 Percent Below Poverty Level (1985) * 16.6 14.0 (persons) Percent of Population Rural (1980) * 37.6 26.0 Percent of Population White (1980) * 72.8 83.1 Percent of Population Non-white (1980) * 27.2 16.9 Median Years of Education (1980) 12.2 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority Georgia counties operate under powers granted to them by the Georgia Constitution and Statutes. Commission Form - (159) - The county government is based on the Commission Form and is usually made up of three- to nine-member boards. However, 22 counties have only one commissioner. Sixty-one counties appoint an administrative manager who is responsible for the daily administration of the county government. Home Rule - (39) - The power of county governments in Georgia is limited to that conferred on them by law or implied in the granting of other authority. In 1965 the state constitution was amended under home rule legislation giving counties legislative authority to pass ordinances, regulations, and resolutions on subjects that were not otherwise restricted by the state constitution or other laws. City-County Consolidation - (1) - Although the state constitution permits cities and counties to consolidate their * These date were provided by the SHA. Data for this state were updated October 1990. governments, only Columbus-Muscogee have chosen to do so. This consolidated government functions with an elected mayor and 10 councilmen. County governments do not have charters in Georgia. Instead, legislative acts function in the same way and establish boards of commissioners, their terms of office, salaries, powers, and duties. 3II. State Health Agency (SHA) A. General Component of Superagency The SHA in Georgia is called the Division of Public Health. It is a component of a superagency that is called the Georgia Department of Human Resources (GDHR). The mission of the GDHR is to assist Georgians in achieving their highest levels of health, development, independence, and self sufficiency. The following are some areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs B. Head of State Health Agency M.D. Required, Not Cabinet-level Appointment The head of the SHA is the Director of the Division of Public Health. This position is appointed by the Commissioner of the Department of Human Resources. There is a legal requirement that the Director be a physician. The Director has responsibility for the management and administration of the Division of Health. C. State Board of Health/Council Policy-making Georgia has a Board of Human Resources rather than a State Board of Health or Health Council. It is composed of 15 members, but not more than two, from each congressional district in the state. The members are appointed by the Governor and confirmed by the Senate for staggered 5-year terms. Seven members of the board must be professionally engaged in rendering health services, and at least five of those seven must be licensed to practice medicine in Georgia. The Board establishes the general policy to be followed by the agency. It also appoints the commissioner for the department, subject to approval of the Governor. The Commissioner of the GDHR is required by law to be the chief administrative officer of the Board and subject to the policy established by the Board. D. Regional/District Health Offices State law permits the establishment of administrative multicounty districts with the consent of the county governments and boards of health of the counties involved. Nineteen administrative areas (known as districts) currently exist in Georgia. The districts range in size from 1 to 16 counties. Each district has a health director who is appointed by the Commissioner and approved by the boards of health of the concerned counties. The District Health Director serves all of the counties in common and has all of the powers and duties as the director of a single county board of health. The district offices are staffed with the following employees: District Health Director District Administrator District Community Epidemiologist District Chief of Nursing District Program Manager District Environmental Chief District Program Heads District Typists and Clerks District offices are in the "lead" county of the district, which is usually the largest county in population. The district office is usually housed separately from a county health department. Staff from the district office are involved in the direct provision of services, but the services are usually provided at a county health department rather than the district office. E. State-local Liaison Shared Organizational Control, Informal Liaison Function The state does not have a single individual or office that has responsibility for the interface between the SHA and local health agencies. The Director of the Division of Public Health, however, has four individuals who function as regional coordinators, relating to counties and regions within their geographic areas of responsibility. The interaction between state and local public health agencies in Georgia may be characterized as shared organizational control. Under this arrangement, local health departments are under the authority of the board of health and certain indirect authority from the state which is provided contractually. F. Budget Total FY 1988 Georgia SHA expenditures were $198,845,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $81,008,000 State Funds $116,710,000 Local Funds 0 Fees and Reimbursements $788,000 Other $339,000 3III. Local Public Health Agencies (LPHAs) A. General Each of the 159 counties in Georgia has a county health department which functions as the LPHA. B. Services Provided The following information on services provided by local health departments in Georgia is derived from a survey conducted by NACHO during 1989. One Hundred and fourteen of the 159 local health departments responded to the survey. Services provided by 70 percent of the local health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 55 ( 48.2%) 2. Morbidity Data 86 ( 75.4%) 3. Reportable Diseases 107 ( 93.9%) 4. Vital Records and Statistics 56 ( 49.1%) B. Epidemiology/Surveillance 1. Chronic Diseases 57 ( 50.0%) 2. Communicable Diseases 106 ( 93.0%) II. Policy Development A. Health Code Dev. and Enforcement 55 ( 48.2%) B. Health Planning 71 ( 62.3%) C. Priority Setting 59 ( 51.8%) III. Assurance Activities A. Inspection 1. Food and Milk Control 72 ( 63.2%) 2. Health Facility Safety/Quality 64 ( 56.1%) 3. Rec. Facility Safety/Quality 61 ( 53.5%) 4. Other Facility Safety/Quality 13 ( 11.4%) B. Licensing 1. Health Facilities 39 ( 34.2%) 2. Other Facilities 90 ( 78.9%) C. Health Education 89 ( 78.1%) D. Environmental 1. Air Quality 23 ( 20.2%) 2. Hazardous Waste Management 26 ( 22.8%) 3. Individual Water Supply Safety 97 ( 85.1%) 4. Noise Pollution 10 ( 8.8%) 5. Occupational Health and Safety 39 ( 34.2%) 6. Public Water Supply Safety 52 ( 45.6%) 7. Radiation Control 14 ( 12.3%) 8. Sewage Disposal Systems 89 ( 78.1%) 9. Solid Waste Management 31 ( 27.2%) 10. Vector and Animal Control 64 ( 56.1%) 11. Water Pollution 37 ( 32.5%) E. Personal Health Services 1. AIDS Testing and Counseling 112 ( 98.2%) 2. Alcohol Abuse 51 ( 44.7%) 3. Child Health 112 ( 98.2%) 4. Chronic Diseases 88 ( 77.2%) 5. Dental Health 70 ( 61.4%) 6. Drug Abuse 50 ( 43.9%) 7. Emergency Medical Service 28 ( 24.6%) 8. Family Planning 114 (100.0%) 9. Handicapped Children 74 ( 64.9%) 10. Home Health Care 31 ( 27.2%) 11. Hospitals 7 ( 6.1%) 12. Immunizations 114 (100.0%) 13. Laboratory Services 82 ( 71.9%) 14. Long-term Care Facilities 8 ( 7.0%) 15. Mental Health 56 ( 49.1%) 16. Obstetrical Care 34 ( 29.8%) 17. Prenatal Care 110 ( 96.5%) 18. Primary Care 16 ( 14.0%) 19. Sexually Transmitted Diseases 113 ( 99.1%) 20. Tuberculosis 111 ( 97.4%) 21. WIC 113 ( 99.1%) C. Local Health Officer (District Health Director) M.D. Requirement, Commissioner of Department of Human Resources Appointment The District Health Director usually serves as the county health officer for each of the counties in the district. He/she is appointed by the Commissioner of the Department of Human Resources with the consent of the county boards of health in the district. In fact, the boards of health in each county subsequently appoint the district health director to the position of county medical director. The district health officer is required to provide those services mandated by the SHA, but he/she has the authority to provide other services. The limiting factor is the availability of local funds to support additional services. The Director is subject to the policies and directives of the county board of health and the policies and directives of the Division of Public Health. The Director is required to devote his/her entire time to service and to the health districts and to be vigilant in procuring compliance with its rules and regulations and with Georgia health laws and rules and regulations that have application within the county and district. The Director is also directed to make reports to the county board of health and to the Division of Public Health as required. D. Local Board of Health Policy-making State law provides for the creation of county boards of health, their membership, powers and responsibilities. Each board of health is specified by law to be composed of the following seven members: 1. The Chief Executive Officer of the governing authority of the county. 2. The county superintendent of schools. 3. A practicing physician (a nurse or dentist if no physician is available). 4. A consumer to represent mental health, mental retardation, and substance abuse services. 5. A consumer or nurse who is interested in promoting public health. 6. A consumer who represents the county's needy, underprivileged, or elderly. 7. The Chief Executive Officer of the governing authority of the largest municipality in the county. In counties with a population between 250,000 and 400,000, the board may appoint the superintendent of the county's largest municipal school system as an ex officio member. The county boards of health are empowered by state statutes to perform the following functions: 1. Establish and adopt bylaws for its own governance. 2. Exercise responsibility and authority in all matters within the county pertaining to health unless the responsibility is designated to another agency. 3. Take such steps as may be necessary to prevent and suppress disease and conditions deleterious to health and determine compliance with health laws and rules, regulations, and standards. 4. Adopt and enforce rules and regulations appropriate to its functions and powers. 5. Receive and administer all grants, gifts, moneys, and donations for purposes of health. 6. Make contracts and establish fees for the provision of mental health and other public health services by county boards of health. 7. Contract with the Department of Human Resources or other agencies for assistance in the performance of its functions and the exercise of its powers and for supplying services which are within its purview to perform. Counties with more than 550,000 population may create boards of health by ordinance. The board of health in these counties is very similar in structure (seven members) and functions by operating under state law. The board of health is directed to appoint a director who is a licensed physician to serve as its chief executive officer. The director, with approval of the board, may designate aides and assistants. E. Staff The county health department staffs are employees of the county board of health, but under the State Merit and Retirement Systems. Additionally, they are not considered to be county employees, but rather board of health employees. The funds for staff salaries may come from all sources available such as fees, grants-in-aid, county money, and state money. Employees are not categorized according to the source of funds for their salaries and are generally unaware of the source. The number of employees for local health departments ranges from 2 to 698. F. Budget Total FY 1988 Georgia LPHA expenditures were $91,371,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $5,307,000 State Funds $44,987,000 Local Funds $25,110,000 Fees and Reimbursements $11,175,000 Other Sources $4,794,000 Source Unknown 0 2Georgia Division of Public Health, 1990 Director Office of Epidemiology Employees' Health Service Administrative Services Section Planning and Evaluation Library Fiscal Management Personnel Vital Records and Health Statistics Research and Special Studies Emergency Health Section Field Services Research and Evaluation Training Administrative Services Environmental Health Section Environmental Services Special Services Occupational Health Family Health Services Section Immunization Program Women's Health Office of Dental Health Office of Medicine Office of Nursing Office of Nutrition Children's Medical Services Office of Pharmacy Children and Adolescent Health WIC Community Health Section Field Laboratory Services Administrative Support Services Micro-Immunology Services Chemistry Services Sexually Transmitted Disease Adult Health Genetic Screening Tuberculosis Control Primary Health Care Section Appalachia Resource Development Coastal Plains District/Unit Health Directors County Health Departments County Boards of Health 2Types of Local Health Departments by Jurisdiction Georgia, 1990 Jurisdiction Co Appling X Atkinson X Bacon X Baker X Baldwin X Banks X Barrow X Bartow X Beckley X Ben Hill X Berrien X Bibb X Brantley X Brooks X Bryan X Bulloch X Burke X Butts X Calhoun X Camden X Carroll X Catoosa X Chandler X Charlton X Chatham X Chattahoochee X Chattoga X Cherokee X Clarke X Clay X Clayton X Clinch X Cobb X Coffee X Columbia X Cook X Coweta X Crawford X Crisp X Dade X Dawson X De Kalb X Decatur X Dodge X Dooly X Dougherty X Douglas X Early X Echols X Effingham X Elbert X Emanuel X Evans X Fannin X Fayette X Floyd X Forsyth X Franklin X Fulton X Gilmer X Glascock X Glynn X Gordon X Grady X Greene X Gwinnett X Habersham X Hall X Hancock X Haralson X Harris X Hart X Heard X Henry X Irwin X Jackson X Jasper X Jeff Davis X Jefferson X Jenkins X Johnson X Jones X Lamar X Lanier X Laurens X Lee X Liberty X Lincoln X Long X Lowndes X Lumpkin X Macon X Madison X Marion X McDuffie X McIntosh X Meriwether X Miller X Mitchell X Monroe X Montgomery X Morgan X Murray X Muscogee X Newton X Oconee X Oglethorpe X Paulding X Peach X Pickens X Pierce X Pike X Polk X Pulaski X Putnam X Quitman X Rabin X Randolph X Richmond X Rockdale X Schley X Screven X Seminole X Spalding X Stephens X Stewart X Sumter X Talbot X Taliaferro X Tattanall X Taylor X Telfair X Terrel X Thomas X Tift X Toombs X Towns X Treutlen X Troup X Turner X Twiggs X Union X Upson X Walker X Walton X Ware X Warren X Washington X Wayne X Webster X Wheeler X White X Whitefield X Wilcox X Wilkerson X Wilkes X Worth X Colquitt X Houston X Co = County HD 1HAWAII 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 1,098,000 245,803,000 Population Density (1988) 170.9 69.4 (per/sq.mi.) Number of Counties 4 3,139 Median Age (1987) 30.9 31.7 Percent Below Poverty Level (1985) 10.7 14.0 (persons) Percent of Population Rural (1980) 13.0 26.0 Percent of Population White (1980) 33.0 83.1 Percent of Population Non-white (1980) 67.0 16.9 Median Years of Education (1980) 12.7 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The structure and authority for county governments in Hawaii are established by the state constitution. Charter Form - (4) - All of the counties have this form of government. The governing body for the counties is the council, the members of which are elected at-large, except for Honolulu city-county which elects them from districts. Three counties are served by nine-member councils, and one is served by a seven-member council. While the legislative function of county government is served by the council, the executive function is served by a mayor. City-County Consolidation - (1) - The state constitution permits the consolidation of city and county governments. At the present time, only Honolulu city-county has merged. Home rule authority is also provided for in the constitution. The constitution states that each county shall have power to develop and adopt a charter for its own self-government within limits established by law. One county, Kalawao, is administratively associated with the County of Maui and does not have full county status. Data for this state were updated December 1990 3II. State Health Agency (SHA) A. General Free-standing, Independent The Hawaii Department of Health (HDH), the SHA, is a free-standing, independent agency. The mission of the Department is to provide leadership to monitor, protect, and enhance the health of all people in Hawaii. The following are some areas of responsibility for the SHA: State Public Health Authority Lead Environmental Agency in the State State Mental Health Authority State Agency for Children with Special Health Care Needs State Health Planning and Development Agency (attached to the HDH for administrative purposes) Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Director is the head of the HDH. The Director, under the general direction of the Governor and with the advice of the Board of Health, plans, directs, and administers statewide activities designed to protect, preserve and improve the physical and mental well-being of the people of the state of Hawaii. The Governor appoints the Director and the Senate confirms the appointment. C. State Board of Health/Council Advisory The State Board of Health is composed of 11 members appointed by the Governor with confirmation by the Senate. Terms of office are 4 years and not to exceed two terms. One member is appointed from each of the counties, including Kalawao, and six members are appointed at-large. The Director of the Department of Human Services serves as an ex officio member. The Board functions to provide advice to the Director on matters within the jurisdiction of the Department to hold hearings for the Department at the request of the Director and to undertake special projects at the request of the Director. D. Regional/District Health Offices The central health office is located on the island of Oahu and district health offices are on Kauai, Maui and Hawaii. The district offices administer and coordinate the delivery of public health services. Services for some programs are delivered directly through the district offices, but services for other programs are provided by private providers through contracts. E. State-local Liaison Centralized Organizational Control, Informal Liaison Function Since the service-providing units, the district health offices, are part of the HDH, there is no need for a formal liaison between the state and local units. Communications between the different levels take place through the normal chain of command. The interaction between state and local public health agencies in Hawaii may be characterized as centralized organizational control. Under this arrangement local health departments function directly under the state's authority and are operated the HDH or State Board of Health. F. Budget Total FY 1988 Hawaii SHA expenditures were $218,116,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $19,099,000 State Funds $110,419,000 Local Funds 0 Fees and Reimbursements $88,033,000 Other $567,000 3III. Local Public Health Agencies (LPHAs) A. General The Honolulu City Health Department is the only local health department in Hawaii. Three district health offices are located on the islands of Kauai, Maui, and Hawaii. The central office on Oahu functions as a district office. The district offices provide public health services to local areas and perform the same basic function as local health departments in other states. However, Hawaii does not consider these district units to be local health departments. B. Services Provided The following are services provided by the district health offices in Hawaii. Information on all three district health departments was provided by the HDH. Honolulu City Health Department provides physical examinations for city employees and runs the ambulance service on Oahu under contract with the state. Services provided by the Honolulu City Health Department are not included in the following list: Services Provided by LPHAs Number of LPHAs I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment - 2. Morbidity Data - 3. Reportable Diseases - 4. Vital Records and Statistics 3 B. Epidemiology/Surveillance 1. Chronic Diseases - 2. Communicable Diseases 3 II. Policy Development A. Health Code Dev. and Enforcement - B. Health Planning - C. Priority Setting - III. Assurance Activities A. Inspection 1. Food and Milk Control 3 2. Health Facility Safety/Quality 3 3. Rec. Facility Safety/Quality 3 4. Other Facility Safety/Quality 3 B. Licensing 1. Health Facilities - 2. Other Facilities 3 C. Health Education 3 D. Environmental 1. Air Quality 3 2. Hazardous Waste Management 3 3. Individual Water Supply Safety 3 4. Noise Pollution - 5. Occupational Health and Safety - 6. Public Water Supply Safety 3 7. Radiation Control - 8. Sewage Disposal Systems 3 9. Solid Waste Management 3 10. Vector and Animal Control 3 11. Water Pollution 3 E. Personal Health Services 1. AIDS Testing and Counseling 3 2. Alcohol Abuse 3 3. Child Health 3 4. Chronic Diseases - 5. Dental Health 3 6. Drug Abuse 3 7. Emergency Medical Service - 8. Family Planning 3 9. Handicapped Children 3 10. Home Health Care 1 11. Hospitals - 12. Immunizations 3 13. Laboratory Services 3 14. Long-term Care Facilities - 15. Mental Health 3 16. Obstetrical Care - 17. Prenatal Care 3 18. Primary Care 3 19. Sexually Transmitted Diseases 3 20. Tuberculosis 3 21. WIC 3 C. Local Health Officer M.D. Requirement, State Health Director Appointment The District Health Services Administrator is equivalent to the local health officer and is appointed by the State Director of Health. This position requires an M.D. degree. The District Health Services Administrator is responsible for managing the district health office and its programs. D. Local Board of Health There are no local boards of health in Hawaii. E. Staff The staffs of the district health offices are employees of the HDH and part of the State Civil Service System. F. Budget Total FY 1988 LPHA expenditures were $7,028,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts 0 State Funds $6,582,000 Local Funds $445,000 Fees and Reimbursements 0 Other Sources 0 Source Unknown 0 The SHA reported that these figures include the total amount of additional local health department monies spent by the Honolulu City Health Department. 2Hawaii Department of Health, 1990 Director of Health Administrative Services Office Personnel Office Health Information Systems Office Office of Affirmative Action District Health Office Hawaii District Health Office Maui District Health Office Kauai Personal Health Services Administration Family Health Services Administration Developmental Disabilities Division Community Health Nursing Division Office of Elder Health Environmental Health Administration Environmental Health Services Division Environmental Management Division Hazardous Evaluation and Emergency Response Office Environmental Planning Office Environmental Resources Office Community Hospital Administration Community Hospital Division Health Promotion and Disease Prevention Administration Health Prevention and Education Division Communicable Disease Division Dental Health Division Office of Refugee Immigrant Health Behavioral Health Services Administration Adult Mental Health Division Alcohol and Drug Abuse Division Children and Adolescent Mental Health Division Health Resources Administration State Laboratory Division Health Quality Assurance Division Office of Health Status Monitoring Office of Hawaiian Health Office of Planning, Policy and Program Development 2Types of Local Health Departments by Jurisdiction Hawaii, 1990 Jurisdiction C N/Co Hawaii X Honolulu X Honolulu X Kalawao X Kauai X Maui X C = City HD N/Co = No county HD 1IDAHO 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 1,003,000 245,803,000 Population Density (1988) 12.2 69.4 (per/sq.mi.) Number of Counties 44 3,139 Median Age (1987) 29.8 31.7 Percent Below Poverty Level (1985) 16.0 14.0 (persons) Percent of Population Rural (1980) 46.0 26.0 Percent of Population White (1980) 95.5 83.1 Percent of Population Non-white (1980) 4.5 16.9 Median Years of Education (1980) 12.6 12.5 (25 years of age and over) B. County Government Structure No Home Rule Authority County governments in Idaho are empowered by the state constitution which provides the legal framework for the county government, establishes the authority of county officials and their terms of office, lists the function that counties perform, creates limits on county indebtedness, and contains detailed provisions on county boundaries. Commission Form - (44) - Three-member county commissions are the governing bodies of the counties. The boards of commissioners exercise both legislative and executive powers. They are elected at large but must meet district residency requirements. Counties in Idaho function as units of the state government by administering elections, enforcing state laws, and performing other functions required by the state. They also function as units of local government in meeting needs of citizens by providing standard services at the local level. Data for this state were updated October 1990. 3II. State Health Agency (SHA) A. General Component of Superagency The SHA in Idaho is the Department of Health and Welfare, with primary health-related responsibility delegated to the Division of Health. The information provided is restricted to the Division of Health. The mission of the Division of Health is to effectively and efficiently mobilize and manage appropriate resources for the protection and improvement of the health of the citizens of Idaho. The following are some areas of responsibility for the Department of Health and Welfare: State Public Health Authority State Agency for Children with Special Health Care Needs Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement The following are some areas of responsibility for the Division of Health: Preventive Medicine Maternal and Child Health Emergency Medical Services Health Policy Vital Statistics State Laboratories Epidemiology Services B. Head of State Health Agency No M.D. Requirement, Not Cabinet Level Appointment The Administrator for the Division of Health is the head of the SHA. The Administrator is appointed by the Director of the Department of Health and Welfare with concurrence of the State Board of Health and Welfare. The Administrator reports to the Director. It is the responsibility of this person to administer the numerous programs of the Division of Health in a manner that most efficiently protects the citizens of the state from communicable disease, substance abuse, improperly administered health facilities, accidents, and aggravated conditions due to lack of early diagnosis. C. State Board of Health/Council Policy-making Idaho has a Board of Health and Welfare which consists of seven members who are appointed by the Governor with the charge to formulate rules and regulations for the Department of Health and Welfare and to advise its directors. The members are chosen with regard for their knowledge and interest in environmental protection and health. D. Regional/District Health Offices The state is subdivided into seven administrative regions. The regions have offices which function as extensions of the central office. They provide direct services to their jurisdictions in the areas of mental health, food stamps, and Medicaid. E. State-Local Liaison Decentralized Organizational Control, Informal Liaison Function The district health departments are autonomously governed by local boards of health. The relationship between the Division of Health and the district health departments is basically a contractual arrangement wherein the Bureaus of Preventive Medicine and Maternal and Child Health contract with the districts to provide program services. The interaction between state and local public health agencies in Idaho may be characterized as decentralized organizational control. Under this arrangement local governments directly operate health departments with a local board of health. F. Budget Total FY 1988 Idaho SHA expenditures were $21,005,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $14,195,000 State Funds $6,809,000 Local Funds 0 Fees and Reimbursements 0 Other 0 3III. Local Public Health Agencies (LPHAs) A. General During the 1970's, Idaho passed legislation to provide for fairly uniform public health services for every county in the state through seven multicounty health departments which are called district health departments. Each district is autonomously governed by a local board of health. These agencies are answerable to the public through the county commissioners and district boards of health. The districts receive state money in the form of contracts for services. B. Services Provided The following information on services provided by local health departments in Idaho is derived from a survey conducted by NACHO during 1989. All seven of the local health departments in Idaho responded to the survey. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 3 ( 42.9%) 2. Morbidity Data 4 ( 57.1%) 3. Reportable Diseases 7 (100.0%) 4. Vital Records and Statistics 6 ( 85.7%) B. Epidemiology/Surveillance 1. Chronic Diseases 6 ( 85.7%) 2. Communicable Diseases 7 (100.0%) II. Policy Development A. Health Code Dev. and Enforcement 5 ( 71.4%) B. Health Planning 6 ( 85.7%) C. Priority Setting 6 ( 85.7%) III. Assurance Activities A. Inspection 1. Food and Milk Control 7 (100.0%) 2. Health Facility Safety/Quality - 3. Rec. Facility Safety/Quality 6 ( 85.7%) 4. Other Facility Safety/Quality 3 ( 42.9%) B. Licensing 1. Health Facilities - 2. Other Facilities 6 ( 85.7%) C. Health Education D. Environmental 1. Air Quality 2 ( 28.6%) 2. Hazardous Waste Management 5 ( 71.4%) 3. Individual Water Supply Safety 7 (100.0%) 4. Noise Pollution 1 ( 14.3%) 5. Occupational Health and Safety - 6. Public Water Supply Safety 5 ( 71.4%) 7. Radiation Control 2 ( 28.6%) 8. Sewage Disposal Systems 6 ( 85.7%) 9. Solid Waste Management 7 (100.0%) 10. Vector and Animal Control 7 (100.0%) 11. Water Pollution 6 ( 85.7%) E. Personal Health Services 1. AIDS Testing and Counseling 7 (100.0%) 2. Alcohol Abuse 1 ( 14.3%) 3. Child Health 7 (100.0%) 4. Chronic Diseases 6 ( 85.7%) 5. Dental Health 7 (100.0%) 6. Drug Abuse - 7. Emergency Medical Service - 8. Family Planning 7 (100.0%) 9. Handicapped Children 7 (100.0%) 10. Home Health Care 3 ( 42.9%) 11. Hospitals - 12. Immunizations 7 (100.0%) 13. Laboratory Services 4 ( 57.1%) 14. Long-term Care Facilities - 15. Mental Health - 16. Obstetrical Care 2 ( 28.6%) 17. Prenatal Care 7 (100.0%) 18. Primary Care 1 ( 14.3%) 19. Sexually Transmitted Diseases 7 (100.0%) 20. Tuberculosis 7 (100.0%) 21. WIC 7 (100.0%) C. Local Health Officer No M.D. Requirement, Local Board of Health Appointment The District Health Director is appointed by the District Board of Health. Although there is no M.D. requirement, each district must have a doctor of medicine licensed in Idaho as a staff member or as a regular consultant. The Director is responsible for administration of the health department. D. Local Board of Health Policy-making District boards of health are appointed by the boards of county commissioners within each district. The duties and responsibilities of the boards include both advisory and policy making. E. Staff District health department staffs are employed and supervised by the jurisdiction which they serve. The number of employees for district health departments in Idaho ranges from 45 to 104. F. Budget Total FY 1988 LPHA Expenditures were $3,174,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $3,174,000 State Funds 0 Local Funds 0 Fees and Reimbursements 0 Other Sources 0 Source Unknown 0 2Idaho Department Of Health and Welfare, 1990 Division of Health Office of Epidemiological Services Office of Policy and Resource Development Emergency Medical Service Bureau Southwest/South Central Region East Region North Region/Central Region EMGE Project Training Bureau of Laboratories Virology/Serology Chemistry Genetics Lab Improvement Microbiology Inorganic Organic Center for Health Statistics Vital Records Health Statistics Maternal and Child Health Bureau Children's Special Health Program Improved Pregnancy Family Planning WIC Dental Health Nutrition Preventive Medicine Bureau AIDS/STD Environmental Health Immunization Food Protection Film Library Health Promotion/Disease Prevention 2Types of Local Health Departments by Jurisdiction Idaho, 1990 Jurisdiction M/Co Ada X Adams X Bannock X Bear Lake X Benewah X Bingham X Blaine X Boise X Bonner X Bonneville X Boundary X Butte X Camas X Canyon X Caribou X Cassia X Clark X Clearwater X Custer X Elmore X Franklin X Fremont X Gem X Gooding X Idaho X Jefferson X Jerome X Kootenai X Latah X Lemhi X Lewis X Lincoln X Madison X Minidoka X Nez Perce X Oneida X Owyhee X Payette X Power X Soshone X Teton X Twin Falls X Valley X Washington X M/Co = Multicounty HD 1ILLINOIS 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 11,615,000 243,915,000 Population Density (1988) 208.7 69.4 (per/sq.mi.) Number of Counties 102 3,139 Median Age (1987) * 32.0 31.7 Percent Below Poverty Level (1985) 15.6 14.0 (persons) Percent of Population Rural (1980) * 16.7 26.0 Percent of Population White (1980) * 83.6 83.1 Percent of Population Non-white (1980) * 16.4 16.9 Median Years of Education (1980) 12.5 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The state constitution and statutes establish the structure and authority for county governments in Illinois. County Board Form - (85) - This form has 5 to 29 board members elected from districts. Commission Form - (17) - In this form are three commissioners elected from the county at large. Elected Executive Form - (1) - Under the Illinois Constitution, counties may adopt home rule authority. The home rule authority comes through the adoption of an Elected County Executive Form of government. Home rule counties are entitled to exercise any power or perform any function related to government affairs. However, the General Assembly may deny or limit any power granted to local governments. Cook county is the only county that has adopted home rule. Non-home rule counties have only the general powers granted to them by law. They elect an executive officer from the board or commission. * These data were provided by the SHA. The following are four variations from which counties can choose in regard to an executive officer: Elected Executive Plan -(1) - Although this plan is part of the home rule packet, counties can adopt the elected executive portion of the plan and reject the home rule elements. This option establishes a separate legislative and executive branch. At the present time, only Will county has adopted this plan. Appointed County Administrator Plan - (12) - Under this plan the appointed administrator has responsibility for administration and coordination. County Board President Plan - (2) - DuPage and St. Clair utilize this plan and grant the president general administrative responsibility for the affairs of the county. County Manager Plan - (0) - This option has not been used at the present time, but it gives administrative authority to a professional administrator appointed and supervised by the board. 3II. State Health Agency (SHA) A. General Free-standing, Independent The SHA in Illinois, the Department of Public Health (IDPH), is a free-standing, independent agency. The mission of the Department is to fulfill society's interest in assuring conditions in which people can be healthy. The Department has authority to promulgate rules and regulations setting minimum program and performance standards for local health departments, while prescribing minimum qualifications for professional, technical and administrative staff of local health departments. Other responsibilities include the approval of counties seeking to form multicounty health departments and the determination of classifications for local health departments. The IDPH contains five administrative units, with staff located in two co-centralized offices in Springfield and Chicago, eight regional offices and three public health laboratories. The following are some areas of responsibility for the SHA: State Public Health Authority State Health Policy and Planning Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency M.D. Requirement, Cabinet-level Appointment The Director of the IDPH, appointed by the Governor, must be either a person licensed to practice medicine and surgery in this state, having had at least 5 years' practical experience in the practice of medicine and surgery, have administrative knowledge of and experience in public health or a person with the general knowledge of and administrative experience in public health. C. State Board of Health/Council Advisory The State Board of Public Health Advisors is an advisory committee composed of nine members, one of whom is a senior citizen, appointed by the Governor. The Governor will appoint four members who will be physicians (licensed to practice medicine in all branches); one member who is a local public health administrator; one member who is a dentist licensed to practice dentistry and who has been active in public health; one member who is a registered professional nurse (licensed) and who has been active in public health; one member who is a member of the statewide Health Coordinating Council, who represents a professional group; and one member who is a public health sanitarian or sanitary engineer. D. Regional/District Health Offices The IDPH operates eight regional offices located in Chicago, Rockford, Peoria, Springfield, Edwardsville, Marion, Champaign, and West Chicago. Each of the regional offices operates under the direction of a Regional Health Officer (RHO) and is responsible for a specified geographic area of the state. The general duties of the Regional Health Officer are as follows: Under the direction of the IDPH Associate Director, Office of Program Administrative Support, to coordinate, monitor and evaluate the effectiveness of programs. To be the focal point for regional activities by requiring all Governor's office, legislative, press, consumer or interest group inquiries be handled through the RHO. To be responsible for conflict resolution within the regional office; however, if a resolution cannot be accomplished, the RHO shall initiate and participate in discussion with the central office to ensure resolution. To coordinate regional activities as they affect local health agencies. To develop grants and contracts for services in consultation with the regional program supervisor or division chiefs. The following are some of the principal positions that are included in the 30- to 35-member staffs of regional offices: Regional Health Officer Communicable Disease Coordinator Immunization Coordinator MCH Nurse Coordinator Long-term Care Nurse Regional Engineer Swimming Pool Inspector Plumbing Inspector Food Inspector Environmental Health Inspector Architect Clerical Staff E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Formal Liaison Function The local liaison unit within IDPH is the Division of Local Health Administration (DLHA). Organizationally it is one division within the Office of Program and Administrative Support. The overall mission of DLHA is to maintain and improve communication with local health departments (LHDs). The division serves as the state health department contact point for LHDs; promotes the development of LHDs; promulgates program standards and minimum qualifications for LHDs; provides oversight to the evaluation of LHD basic public health services; distributes formula grant funds to LHDs; provides consultation and technical assistance to LHDs; offers training to LHD personnel; assists LHDs with personnel recruitment; processes evaluation of LHD personnel; updates and distributes LHD directories; provides information to LHDs regarding legislation, rules or policies that may affect them; provides orientation to newly appointed LHD administrators; consults or meets with LHD administrators, boards of health and other local officials on local health issues; participates in planning retreats for boards of health; participates on various committees comprised of Department personnel and LHD administrators on issues of common interest; staffs Project Health; maintains electronic communication with LHDs in emergency and non-emergency situations; provides environmental health liaison and training for LHDs; and provides nursing liaison and training for LHDs. The interaction between state and local public health agencies in Illinois may be characterized as mixed centralized and decentralized organizational control. Under this arrangement, local health services may be provided by the SHA in some jurisdictions and by local governmental units, boards of health, or health departments in others. F. Budget Total FY 1988 SHA expenditures were $189,333,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $101,659,000 State Funds $86,119,000 Local Funds 0 Fees and Reimbursements $1,510,000 Other $44,000 3III. Local Public Health Agencies (LPHAs) A. General There are 81 local health departments covering 85 counties and 94 percent of the Illinois population. Five city, 3 township (known as districts in Illinois), 6 multicounty units (serving 17 counties), 1 city-county, and 66 county health departments make up the 81 local health departments. In Illinois, local governments are the primary source of support for local public health services; whether these services exist or not is decided by the people in local political units. Counties may establish a health department by resolution of the county board or by referendum vote. Resolution health departments can be established by a majority of the county board. Upon passage of the resolution, the chairman of the county board appoints a board of health. The primary funding source for resolution health departments comes from the general fund of the county government. Referendum health departments have a tax base established in the referendum to provide local support. The structure and function of the two types of health departments is the same, only the source of local funds is different. The IDPH provides Basic Health Service Grant funds through a formula distribution to both resolution and referendum health departments. No matching local funds are required for receiving these funds. During the health department's first 3 years of development, a Development Grant in the range of $17,500-$27,500 (depending on population size) is available each year. After the third year of operation, resolution and referendum health departments are expected to have implemented the 10 required programs. Due to autonomy of local health departments in Illinois, the IDPH cannot mandate a specific role for them. Through the Department's standard setting and funding roles, however, attempts have been made to encourage the following activities for local health departments: 1. Provide a local operation sufficient to meet local public health needs. 2. Develop and maintain local fiscal support. 3. Maintain and continue to upgrade all required programs. 4. Develop and maintain all recommended and optional programs which are appropriate to the needs and priorities of the area served. 5. Provide consultation to the state agency through service on various Departmental task forces designed to review standards and other mutual problems. 6. Endeavor to enhance local programs through contracts or merger with adjacent departments. The IDPH divides local health departments into four primary types: 1. Developmental: A local health department which has been in operation less than 3 full years and has not been approved for the five core programs. 2. Unaccredited: A local health department which has been in operation more than 3 full years and has not been approved for all five core programs. 3. Accredited: A local health department which is approved for the five core programs but currently is not approved for at least one of the five non-core programs. 4. Certified: A local health department which is currently approved for all 10 of the required programs. B. Services Provided The following information on services provided by local health departments in Illinois is derived from a survey conducted by NACHO during 1989. Sixty-eight of the 81 local health departments in Illinois responded to the survey. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 32 ( 47.1%) 2. Morbidity Data 44 ( 64.7%) 3. Reportable Diseases 66 ( 97.1%) 4. Vital Records and Statistics 40 ( 58.8%) B. Epidemiology/Surveillance 1. Chronic Diseases 58 ( 85.3%) 2. Communicable Diseases 68 (100.0%) II. Policy Development A. Health Code Dev. and Enforcement 54 ( 79.4%) B. Health Planning 52 ( 76.5%) C. Priority Setting 49 ( 72.1%) III. Assurance Activities A. Inspection 1. Food and Milk Control 62 ( 91.2%) 2. Health Facility Safety/Quality 18 ( 26.5%) 3. Rec. Facility Safety/Quality 11 ( 16.2%) 4. Other Facility Safety/Quality 11 ( 16.2%) B. Licensing 1. Health Facilities 6 ( 8.8%) 2. Other Facilities 55 ( 80.9%) C. Health Education 59 ( 86.8%) D. Environmental 1. Air Quality 4 ( 5.9%) 2. Hazardous Waste Management 21 ( 30.9%) 3. Individual Water Supply Safety 60 ( 88.2%) 4. Noise Pollution 6 ( 8.8%) 5. Occupational Health and Safety 5 ( 7.4%) 6. Public Water Supply Safety 21 ( 30.9%) 7. Radiation Control 6 ( 8.8%) 8. Sewage Disposal Systems 63 ( 92.6%) 9. Solid Waste Management 58 ( 85.3%) 10. Vector and Animal Control 42 ( 61.8%) 11. Water Pollution 37 ( 54.4%) E. Personal Health Services 1. AIDS Testing and Counseling 50 ( 73.5%) 2. Alcohol Abuse 16 ( 23.5%) 3. Child Health 65 ( 95.6%) 4. Chronic Diseases 67 ( 98.5%) 5. Dental Health 22 ( 32.4%) 6. Drug Abuse 14 ( 20.6%) 7. Emergency Medical Service 5 ( 7.4%) 8. Family Planning 48 ( 70.6%) 9. Handicapped Children 12 ( 17.6%) 10. Home Health Care 40 ( 58.8%) 11. Hospitals 1 ( 1.5%) 12. Immunizations 67 ( 98.5%) 13. Laboratory Services 25 ( 36.8%) 14. Long-term Care Facilities 5 ( 7.4%) 15. Mental Health 15 ( 22.1%) 16. Obstetrical Care 6 ( 8.8%) 17. Prenatal Care 54 ( 79.4%) 18. Primary Care 14 ( 20.6%) 19. Sexually Transmitted Diseases 65 ( 95.6%) 20. Tuberculosis 58 ( 85.3%) 21. WIC 65 ( 95.6%) C. Local Health Officer M.D. Requirement for Medical Health Officer, Local Board of Health Appointment Two job titles in Illinois are equivalent to the title of local health officer: Public Health Administrator and Medical Health Officer. The primary duties for the Public Health Administrator are as follows: planning, organizing, and directing the work of all staff while establishing operational methods and procedures; assisting in policy development while recommending the establishment and revision of rules and regulations; preparing statistical, financial and special reports while holding periodic conferences with subordinates; directing staff services and developing data, budget estimates, and requests; directing the department personnel program; supervising purchasing and storekeeping activities; performing public standards development, research and planning programs; writing, assigning, and reviewing correspondence; interpreting statistics, regulations and rules while adapting methods and procedures to change legal and policy conditions. Requirements for the Public Health Administrator are a master's degree in public health or public administration and 2 years of full-time administrative experience in public health; or graduation from a 4-year college with a broad educational background and 4 years of full-time experience, of which at least 2 years must be in public health. Medical Health Officer has identical distinguishing work features to the Public Health Administrator; however, the minimum requirements for each job title differ. This position requires completion of courses in an approved medical school or completion of courses approved by the Education Council for Foreign Medical Graduates supplemented by 1 year of internship or its equivalent; a license to practice medicine in Illinois; a master's degree in public health or equivalent experience in a health field; a certification in public health by the American Board of Preventive Medicine or board certification in a related specialty is desirable; and a year of full-time experience in public health administration. D. Local Board of Health Policy-making County boards of health consist of eight members appointed by the president or chairman of the county board. Membership, as defined under Illinois Statutes, requires "at least two members of each county board of health shall be physicians licensed in Illinois to practice medicine in all of its branches, at least one member shall be a dentist licensed in Illinois and one member shall be chosen from the county board of supervisors or commissioners as the case may be." Public health districts and municipalities may also establish a board of health. In counties not under township organization, the county commissioners are the board of health for each district in the county. Districts in counties under township organization that consist of a single town have the supervisor, assessor and town clerk as members of the board. When a district consists of two or more adjacent towns, the supervisors of the towns in conjunction with the chairman of the county board make up the board of health. In municipalities with Commission Form of government, the Mayor, with the approval of the corporate authorities, appoints the board of five directors, two of whom must be physicians. E. Staff Local health department staffs are employed and supervised by the local jurisdiction. The number of employees for a local health department ranges from 2 to 2,100. F. Budget Total FY 1988 LPHA expenditures were $197,791,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $33,786,000 State Funds $45,547,000 Local Funds $66,263,000 Fees and Reimbursements $17,401,000 Other Sources $12,563,000 Source Unknown $22,232,000 2Illinois Department of Public Health, 1990 Director Board of Public Health Advisors Medical Determinations Board Assistant Director Center for Rural Health Office of Health Policy and Planning Division of Facilities Development Division of Health Statistics and Policy Development Division of Legal Services Division of Governmental Affairs Division of Audits Division of Communications Equal Employment Opportunity Officer Public Health Deputy Director Office of Program and Administrative Support Employee Services and Benefits Unit/Word Processing Center Training Center Regional Operations Division of Local Health Administration Division of Personnel and Labor Relations Division of General Services Division of Financial Services Division of Vital Records Division of Data Processing Office of Health Services Assistant Associate Director Center for Health Promotion Division of Family Health Division of Chronic Diseases Division of Dental Health Division of Alcohol and Substance Abuse Testing Division of Health Assessment and Screening Office of Health Care Regulation Division of Administrative and Technical Support Bureau of Long-Term Care Division of LTC Quality Assurance Division of LTC Field Operations Division of LTC Information and Research Division of Health Care Facilities and Programs Division of Emergency Medical Services and Highway Safety Office of Health Protection Assistant Associate Director Emergency Officer Division of Infectious Diseases Division of Food, Drugs and Dairies Division of Environmental Health Division of Epidemiologic Studies Division of Laboratories 2Types of Local Health Departments by Jurisdiction Illinois, 1990 Jurisdiction Co C C/Co M/Co N/Co T/T Adams X Alexander X Bond X Boone X Brown X Bureau X Calhoun X Carroll X Cass X Champaign X Champaign-Urbana X Chicago X Christian X Clark X Clay X Clinton X Coles X Cook X Crawford X Cumberland X De Kalb X Dewitt X Douglas X Du Page X East Side District X Edgar X Edwards X Effingham X Evanston X Fayette X Ford X Franklin X Fulton X Gallatin X Greene X Grundy X Hamilton X Hancock X Hardin Henderson X X Henry X Iroquois X Jackson X Jasper X Jefferson X Jersey X Jo Daviess X Johnson X Kane X Kankakee X Kendall X Knox X La Salle X Lake X Lawrence X Lee X Livingston X Logan X Macon X Macoupin X Madison X Marion X Marshall X Mason X Massac X McDonough X McHenery X McLean X Menard X Mercer X Monroe X Montgomery X Morgan X Oak Park X Ogle X Peoria City/Co X Perry X Piatt X Pike X Pope X Pulaski X Putnam X Randolph X Richland X Rock Island X Saline X Sangamon X Schuyler X Scott X Shelby X Skokie X Springfield X St. Clair X Stark X Stephenson X Stickney Township X Tazwell X Union X Vermillion X Wabash X Warren X Washington X Wayne X White X Whiteside X Will X Williamson X Winnebago X Woodford X Co = County HD C = City HD C/Co = City/County HD M/Co = Multicounty HD N/Co = No County HD T/T = Town/Township HD 1INDIANA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 5,556,000 245,803,000 Population Density (1988) 154.6 69.4 (per/sq.mi.) Number of Counties 92 3,139 Median Age (1987) 31.3 31.7 Percent Below Poverty Level (1985) 12.0 14.0 (persons) Percent of Population Rural (1980) 36.0 26.0 Percent of Population White (1980) 91.2 83.1 Percent of Population Non-white (1980) 8.8 16.9 Median Years of Education (1980) 12.4 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The structure and function of counties in Indiana are established by the state constitution and Title 36 of the Indiana Code. Commission Form - (92) - The Commission Form of government is used by the counties in Indiana. Most county governments in Indiana have two governing bodies, a board of commissioners and a county council. The boards of commissioners are made up of three members elected at large with residency requirements in existing districts. They serve as the executive and legislative bodies of county governments. The county councils serve as the fiscal bodies of the governments and are usually made up of seven members. Four council members are elected from single-member districts and three members are elected at large. Additionally, two counties have appointed administrators to handle the administrative duties of the county. Counties in Indiana have home rule authority as granted in Title 36 of the Indiana Code. The section of code relating to home rule specifies that counties have the powers granted by law and other powers necessary or desirable to conduct county affairs. Data for this state were updated February 1991. In 1969, the Indiana General Assembly passed a law facilitating the consolidation of Marion County and Indianapolis. This unified government consists of a 29-member city-county council and a mayor. Twenty-five members of the council are elected from single-member districts and four are elected at large. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Indiana State Board of Health (ISBH), the SHA, is a free-standing, independent agency. The following are some areas of responsibility for the SHA: State Public Health Authority State Health Planning and Development Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement Special State Institutions such as School for Blind B. Head of State Health Agency M.D. Requirement, Cabinet-level Appointment The State Health Commissioner serves as the Chief Executive Officer of the Department and as Secretary for the Executive Board of the State Board of Health. The Commissioner is appointed by and serves at the pleasure of the Governor. As Chief Executive Officer, the Commissioner is responsible for overall management of the SHA and its programs. C. State Board of Health/Council Policy-making The Executive Board of the State Board of Health is composed of 11 members appointed by the Governor. The members of the Board elect a Chairman from among its membership. The Executive Board is responsible for making policy for the State Board of Health and approving appointments made by the Commissioner. D. Regional/District Health Offices The ISBH has not divided the state into regions or districts. E. State-local Liaison Decentralized Organizational Control, Formal Liaison Function The primary mission of the staff members of the State Board of Health is to function as consultants to local health department staff within the state. In addition staff members of the Division of Local Support are assigned on a geographical basis to work directly with local health department staff and to provide both technical and management consultative services. Interaction between state and local public health agencies in Indiana may be characterized as decentralized organizational control. Under this arrangement local governments directly operate health departments with or without a board of health. F. Budget Total FY 1988 Indiana SHA expenditures were $106,237,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $48,357,000 State Funds $57,881,000 Local Funds 0 Fees and Reimbursements 0 Other 0 3III. Local Public Health Agencies (LPHAs) A. General Indiana has 96 local health departments, composed of 1 multicounty, 5 city, and 90 county health departments. According to state law, the ISBH is the "superior agency" to each of the local health departments. In this capacity the ISBH is charged with the responsibility of approving the appointment of local health officers and overseeing the programs and activities of the local health departments. B. Services Provided The following information on services provided by local health departments in Indiana is derived from a survey conducted by NACHO during 1989. Ninety-four of the 95 local health departments in Indiana responded to the survey. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 13 ( 13.8%) 2. Morbidity Data 38 ( 40.4%) 3. Reportable Diseases 71 ( 75.5%) 4. Vital Records and Statistics 89 ( 94.7%) B. Epidemiology/Surveillance 1. Chronic Diseases 38 ( 40.4%) 2. Communicable Diseases 85 ( 90.4%) II. Policy Development A. Health Code Dev. and Enforcement 51 ( 54.3%) B. Health Planning 49 ( 52.1%) C. Priority Setting 21 ( 22.3%) III. Assurance Activities A. Inspection 1. Food and Milk Control 67 ( 71.3%) 2. Health Facility Safety/Quality 21 ( 22.3%) 3. Rec. Facility Safety/Quality 30 ( 31.9%) 4. Other Facility Safety/Quality 8 ( 8.5%) B. Licensing 1. Health Facilities 6 ( 6.4%) 2. Other Facilities 63 ( 67.0%) C. Health Education 56 ( 59.6%) D. Environmental 1. Air Quality 41 ( 43.6%) 2. Hazardous Waste Management 50 ( 53.2%) 3. Individual Water Supply Safety 76 ( 80.9%) 4. Noise Pollution 9 ( 9.6%) 5. Occupational Health and Safety 12 ( 12.8%) 6. Public Water Supply Safety 51 ( 54.3%) 7. Radiation Control 17 ( 18.1%) 8. Sewage Disposal Systems 87 ( 92.6%) 9. Solid Waste Management 61 ( 64.9%) 10. Vector and Animal Control 76 ( 80.9%) 11. Water Pollution 65 ( 69.1%) E. Personal Health Services 1. AIDS Testing and Counseling 22 ( 23.4%) 2. Alcohol Abuse 3 ( 3.2%) 3. Child Health 61 ( 64.9%) 4. Chronic Diseases 50 ( 53.2%) 5. Dental Health 9 ( 9.6%) 6. Drug Abuse 6 ( 6.4%) 7. Emergency Medical Service 4 ( 4.3%) 8. Family Planning 16 ( 17.0%) 9. Handicapped Children 53 ( 56.4%) 10. Home Health Care 45 ( 47.9%) 11. Hospitals 2 ( 2.1%) 12. Immunizations 89 ( 94.7%) 13. Laboratory Services 17 ( 18.1%) 14. Long-term Care Facilities 1 ( 1.1%) 15. Mental Health 4 ( 4.3%) 16. Obstetrical Care 11 ( 11.7%) 17. Prenatal Care 29 ( 30.9%) 18. Primary Care 5 ( 5.3%) 19. Sexually Transmitted Diseases 26 ( 27.7%) 20. Tuberculosis 75 ( 79.8%) 21. WIC 30 ( 31.9%) C. Local Health Officer M.D. or D.O. Requirement, Local Board of Health Appointment The role of the local health officer is to serve as chief executive officer for the local health department and carry out the policies and programs as determined by the local board. Local health officers are appointed to 4-year terms by members of the local board of health. D. Local Board of Health Policy-making The board of a county health department is composed of seven members--no more than four of whom may be from the same political party. The members of the board are appointed by their respective city or county executives for a 4-year term. The authority for this organization and function lies in state statutes. The local board is responsible for the appointment of a health officer. The local health officer and the local board of health work with the county commissioners in establishing annual budgets which are submitted to the county councils for approval. Those health departments which are based within the city structure follow a similar process with the city officials. The board of health for multicounty health departments is composed of four members from each county represented in the department. E. Staff The staffs of local health departments are employed and supervised by the local jurisdiction. The number of staff for a local health department ranges from 1 to 550. F. Budget Total FY 1988 LPHA expenditures were $41,920,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $5,416,000 State Funds $2,805,0000 Local Funds $28,281,000 Fees and Reimbursements $5,058,000 Other Sources $360,000 Source Unknown 0 The SHA reported that there were additional fees and reimbursements not retained by the local health departments, but which reverted to the general revenues of the local or state government. 2Indiana State Board of Health, 1990 State Health Commissioner Office of External Affairs Office of Legal Affairs Executive Assistant Executive Assistant Executive Assistant Office of Assistant Commissioner for Health Support Services Bureau of Laboratories Environmental Laboratories Division Disease Control Laboratories Division Laboratory Support Division Consumer Health Lab Division Bureau of Administrative Services Management Information Services Division Human Resources Division Finance Division Bureau of Institutional Services Internal Support Services Division Indiana Veterans' Home Indiana School for the Blind Indiana School for the Deaf Soldiers' and Sailors' Children's Home Silvercrest Children's Development Center Office of Assistant Commissioner for Health Maintenance Bureau of Disease Intervention Acute Disease Division Chronic Disease Division Acquired Disease Division Bureau of Family Health Services Nutrition Division MCH Division Child Specialty Services Division Bureau of Local Health Services Dental Health Local Support Services Division Industrial Hygiene and Radiologic Health Division Sanitary Engineering Division Office of Assistant Commissioner for Health Marketing Bureau of Quality Assurance Health Facilities Division Acute Care Services Division Child Care Facilities Division Bureau of Policy Development Public Health Research Division Public Health Statistics Division Division of Health Planning Bureau of Health Promotion Health Education Division Graphic Arts Division Bureau of Consumer Protection Wholesale Consumer Affairs Division Retail Consumer Affairs Division Food Animal Affairs Division 2Types of Local Health Departments by Jurisdiction Indiana, 1990 Jurisdiction Co C M/Co Adams X Allen X Bartholomew X Benton X Blackford X Boone X Brown X Carroll X Cass X Clark X Clay X Clinton X Crawford X Daviess X De Kalb X Dearborn X Decatur X Delaware X Dubois X East Chicago X Elkhart X Fayette X Floyd X Fountain X Franklin X Fulton X Gary X Gibson X Grant X Greene X Hamilton X Hammond X Hancock X Harrison X Hendricks X Henry X Howard X Huntington X Jackson X Jasper X Jay X Jefferson X Jennings X Johnson X Knox X Kosciusko X La Porte X Lafayette X Lagrange X Lake X Lawrence X Madison X Marion X Marshall X Martin X Miami X Monroe X Montgomery X Morgan X Newton X Noble X Ohio X Orange X Owen X Parke X Perry X Pike X Porter X Posey X Pulaski X Putnam X Randolph X Ripley X Rush X Scott X Shelby X Spencer X St. Joseph X Starke X Steuben X Sullivan X Switzerland X Tippecanoe X Tipton X Union X Vanderburgh X Vermillion X Vigo X Wabash X Warren X Warrick X Washington X Wayne X Wells X West Lafayette X White X Whitley X Co = County HD C = City HD M/Co = Multicounty HD 1IOWA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 2,834,000 245,803,000 Population Density (1988) 50.6 69.4 (per/sq.mi.) Number of Counties 99 3,139 Median Age (1987) 32.0 31.7 Percent Below Poverty Level (1985) 8.0 14.0 (persons) Percent of Population Rural (1980) 41.0 26.0 Percent of Population White (1980) 97.4 83.1 Percent of Population Non-white (1980) 2.6 16.9 Median Years of Education (1980) 12.5 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The structure and authority of county governments in Iowa are established by the state constitution and statutes. Commission Form - (99) - All 99 counties in Iowa operate under a County Commission Form of government. The board is made up of three or five members called county supervisors. They are elected from single-member districts and have residency requirements. Two counties, Scott and Polk, have appointed administrators. Iowa counties have had constitutional home rule since 1979. Under home rule, counties have been able to pass legislation without permission from the state. The constitution, under home rule provisions, permits the consolidation of counties or city-counties. These jurisdictions are granted authority to establish their governments and perform governmental functions but not to levy tax unless specifically authorized by the General Assembly. A new county government law became effective in 1988. It provides five new, optional governmental structures and a Data for this state were updated October 1990. mechanism for establishing a charter commission. The five options are as follows: 1. Board-elected Executive - a strong elected executive with veto power over the board. 2. Board-manager - an elected board with an appointed manager. 3. Charter - Specific charter proposed by a charter commission county may have an elected or appointed administrative officer. 4. City-county Consolidation - a city-county consolidation is conferred with all of the powers granted to cities or counties. 5. County-county Consolidation - permits the consolidation of contiguous counties upon approval of the voters in the affected areas. Counties have not yet adopted any of these new options. 3II. State Health Agency (SHA) A. General Free-standing, Independent The SHA is a free-standing, independent agency named the Iowa Department of Public Health (IDPH). The IDPH exists to promote, protect, and ensure the health and well-being of Iowans, and to provide for access, quality and affordability of services. The Department promotes health and prevents disease by the following: Conducting research, planning and evaluating as a basis for initiating and revising programs and policies. Assuring compliance with public health laws through regulation and enforcement. Administering state and Federal statutory requirements and programs through direct and contracted services. Promoting and supporting health and well-being through education and consultation. The Department is responsible for substance abuse prevention, health planning, vital records, health professional licensure, communicable disease control, radiation control, emergency medical services, maternal and child health, nutrition, dental health, birth defects/genetics counseling, health promotion, public health nursing, homemaker-home health aide, and a few environmental programs. The following are some broad areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs (through contract with the University of Iowa) State Health Planning and Development Agency State Health Professions Licensing Agency B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Director of Health is the chief administrative officer of the Department. The Director is a cabinet-level officer appointed by the Governor and confirmed by the Senate. The Director is responsible for directing and administering the programs and services of the Department. The duties of the Director include: recommendations to the state board of health; the adoption of rules for the implementation of statutes; service as Secretary of the State Board of Health; the establishment of the administrative organization; and other actions to administer and direct the Department's programs. C. State Board of Health/Council Policy-making The Board of Health is made up of nine members. Five members are to be learned in the health professions and four are to represent the general public. The members are appointed by the Governor for 3-year terms. They approve all Department rules before they become effective, establish policies for the performance of the Department, and advise the Department, the Governor, and the Legislature on public health matters. D. Regional/District Health Offices The Department does not have regional/district offices. Specific programs have field staffs with assigned territories, but these staffs are housed in the central office, in a local health department, or some other individual arrangement. E. State-local Liaison Decentralized Organizational Control, Formal Liaison Function The state-local liaison function is currently being performed by a nurse consultant in the Division of Family and Community Health. The interaction between state and local public health agencies in Iowa may be characterized as decentralized organizational control. Under this arrangement local governments directly operate health departments. F. Budget Total FY 1988 Iowa SHA expenditures were $58,273,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $30,538,000 State Funds $27,510,000 Local Funds 0 Fees and Reimbursements $73,000 Other $152,000 3III. Local Public Health Agencies (LPHAs) A. General Iowa has 99 local health departments. These consist of 93 county units, 5 city units and 1 city-county unit (the city-county unit is designated as a district by Iowa). Iowa uses the term "boards of health" rather than health departments. Boards of health that employ at least one full-time employee are referred to as a health department in this document. Nine boards employ only a nurse and 16 boards employ only an environmentalist. All other boards have more than one employee. The SHA provides the funds to the local areas to support public health nursing services and homemaker-home health aide services. These funds may go through the local board of health, board of supervisors, or other governmental or non-profit organization. B. Services Provided The following information on services provided by local health departments in Iowa is derived from a survey conducted by NACHO during 1989. Since only 9 of the 99 Iowa counties participated in this survey, the results may not be representative of the total state. Services provided by 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 1 ( 11.1%) 2. Morbidity Data 5 ( 55.6%) 3. Reportable Diseases 6 ( 66.7%) 4. Vital Records and Statistics 2 ( 22.2%) B. Epidemiology/Surveillance 1. Chronic Diseases 3 ( 33.3%) 2. Communicable Diseases 8 ( 88.9%) II. Policy Development A. Health Code Dev. and Enforcement 4 ( 44.4%) B. Health Planning 7 ( 77.8%) C. Priority Setting 6 ( 66.7%) III. Assurance Activities A. Inspection 1. Food and Milk Control 7 ( 77.8%) 2. Health Facility Safety/Quality 2 ( 22.2%) 3. Rec. Facility Safety/Quality 1 ( 11.1%) 4. Other Facility Safety/Quality 2 ( 22.2%) B. Licensing 1. Health Facilities - 2. Other Facilities 8 ( 88.9%) C. Health Education 6 ( 66.7%) D. Environmental 1. Air Quality 7 ( 77.8%) 2. Hazardous Waste Management 5 ( 55.6%) 3. Individual Water Supply Safety 6 ( 66.7%) 4. Noise Pollution 5 ( 55.6%) 5. Occupational Health and Safety 1 ( 11.1%) 6. Public Water Supply Safety 3 ( 33.3%) 7. Radiation Control 1 ( 11.1%) 8. Sewage Disposal Systems 7 ( 77.8%) 9. Solid Waste Management 4 ( 44.4%) 10. Vector and Animal Control 8 ( 88.9%) 11. Water Pollution 8 ( 88.9%) E. Personal Health Services 1. AIDS Testing and Counseling 9 (100.0%) 2. Alcohol Abuse - 3. Child Health 4 ( 44.4%) 4. Chronic Diseases 4 ( 44.4%) 5. Dental Health 1 ( 11.1%) 6. Drug Abuse - 7. Emergency Medical Service 2 ( 22.2%) 8. Family Planning 2 ( 22.2%) 9. Handicapped Children 1 ( 11.1%) 10. Home Health Care 6 ( 66.7%) 11. Hospitals - 12. Immunizations 8 ( 88.9%) 13. Laboratory Services 3 ( 33.3%) 14. Long-term Care Facilities - 15. Mental Health - 16. Obstetrical Care - 17. Prenatal Care 2 ( 22.2%) 18. Primary Care - 19. Sexually Transmitted Diseases 8 ( 88.9%) 20. Tuberculosis 7 ( 77.8%) 21. WIC 3 ( 33.3%) C. Local Health Officer No M.D. Requirement, Board of Health Appointment The primary authority in local public health resides with the local boards of health. The boards delegate responsibility to their employees. This can include the formal naming of a health officer for certain functions but this is not routinely done. If named, the health officer would only have authority through the local board of health. D. Local Board of Health Policy-making Each county must have a board of health unless they are part of a district health department. Cities with populations over 25,000 may have a board of health and 5 cities have chosen to do so. Local boards of health may apply to create district boards of health. The boards are consist of five volunteer members (one of which must be a physician) appointed by the board of supervisors or city council. These boards are planning and policy-making boards, and their rules must be approved by the board of supervisors before they take effect. Funds for the local boards of health must be appropriated by the board of supervisors. E. Staff The staffs are employees of the local boards of health. The number of employees for a local health department ranges from 5 to 84. F. Budget Total FY 1988 LPHA expenditures were $23,494,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contract $990,000 State Funds $4,266,000 Local Funds $7,080,000 Fees and Reimbursements $760,000 Other Sources $1,254,000 Source Unknown $682,000 The SHA reported that there were additional fees and reimbursements not retained by the LPHA, but which reverted to the general revenues of the local or state government. The SHA also reported that these figures include the total amount of additional local health department monies expended by all local health departments. 2Iowa Department of Public Health, 1990 Governor State Board of Health Substance Abuse Commission Health Facilities Council Professional Licensing Boards Director of Public Health Health Data Commission Health Advisory Committee and Councils Division of Substance Abuse Bureau of Prevention and Training Bureau of Licensure Division of Central Administration Bureau of Accounting/Finance Bureau of Information Management Bureau of Communications Bureau of Vital Records Bureau of Professional Licensure Division of Disease Prevention Bureau of Radiological Health Bureau of Health Engineering/Consumer Safety Bureau of Veterinarian P.H. Environmental Epidemiology Bureau of Compliance/Health Care Services Bureau of Disease Assessment Bureau of Epidemiology Office of Health Planning Planning Office of Rural Health Health Data Commission Primary Care Certificate of Need Division of Family and Community Health Bureau of Maternal and Child Health Bureau of Nutrition Bureau of Dental Health Bureau of Birth Defects/Genetics Complex Bureau of Public Health Nursing Bureau of Homemaker/Home Health Aide Bureau of Support Services Well Elderly Clinics 2Types of Local Health Departments by Jurisdiction Iowa, 1990 Jurisdiction Co C C/Co N/Co Adair X Adams X Allamakee X Ames X Appanoose X Audubon X Benton X Blackhawk X Boone X Bremer X Buchanan X Buena Vista X Butler X Calhoun X Carroll X Cass X Cedar X Cerro Gordo X Cherokee X Chicksaw X Clarke X Clay X Clayton X Clinton X Council Bluffs X Crawford X Dallas X Davis X Decatur X Delaware X Des Moines X Des Moines X Dickenson X Dubuque X Dubuque X Emmet X Fayette X Floyd X Franklin X Fremont X Greene X Grundy X Gutherie X Hamilton X Hancock X Hardin X Harrison X Henry X Howard X Humboldt X Ida X Iowa X Jackson X Jasper X Jefferson X Johnson X Jones X Keokuk X Kossuth X Lee X Linn X Louisa X Lucas X Lyon X Madison X Mahaska X Marion X Marshall X Mills X Mitchell X Monona X Monroe X Montgomery X Muscatine X O'Brien X Osceola X Ottumwa X Page X Palo Alto X Plymouth X Pocohontas X Polk X Pottawattamie X Poweshiek X Ringgold X Sac X Scott X Shelby X Sioux X Siouxland Dist X Story X Tama X Taylor X Union X Van Buren X Wapello X Warren X Washington X Wayne X Webster X Winnebago X Winneshiek X Worth X Wright X Co = County HD C = City HD C/Co = City/County HD N/Co = No County HD 1KANSAS 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 2,496,000 245,803,000 Population Density (1988) 30.5 69.4 (per/sq.mi.) Number of Counties 105 3,139 Median Age (1987) 31.7 31.7 Percent Below Poverty Level (1985) 13.8 14.0 (persons) Percent of Population Rural (1980) 33.0 26.0 Percent of Population White (1980) 91.7 83.1 Percent of Population Non-white (1980) 8.3 16.9 Median Years of Education (1980) 12.6 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority County governments in Kansas are established and empowered by the state constitution. Commission Form - (105) - All counties in the state use this form of government. The commissions are made up of three- or five-member boards that are elected from single-member districts. Seven counties utilize an appointed administrator for their administrative functions. Authority for home rule was established in 1974. This legislation gives counties authority to conduct business and perform legislative and administrative functions that are considered appropriate and not otherwise prohibited by statutes. The data for this state were updated September 1990. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Kansas Department of Health and Environment (KDHE) is the official SHA. It is a free-standing, independent agency. The mission of the KDHE is to protect and maintain the health of Kansans and the quality of the environment through information, education, prevention, and regulation. The Division of Health, one of the major units within KDHE, is responsible for protecting and promoting the health of Kansans through a variety of public health service delivery and regulatory programs. The Division's role is to assure services through funding assistance to local agencies; establishing policy and procedures; technical assistance; and program consultation, planning, implementation, and continuation. The following are some areas of responsibility for the SHA: State Public Health Authority Lead Environmental Agency in the State State Agency for Children with Special Health Care Needs Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Secretary of KDHE, entrusted with broad powers to ensure public health and a safe environment, directs the management of the Department in the provision of services to the citizens of Kansas. The Secretary, a member of the Governor's Cabinet, sets agency policy and assigns staff to carry out regulatory enforcement and public health tasks. The Secretary is not required to be a physician. The Director of Health, the State Health Officer, is appointed by the Secretary KDHE. The Director is the state's chief public health medical official and is responsible for the management of the Division of Health. The Director is required to be a physician. Specifically, the Director of Health is charged with the responsibility of maintaining surveillance of indicators of disease and disability, and overseeing and assisting in the provision of public health services to the citizens of Kansas. C. State Board of Health/Council Advisory The Advisory Commission on Health and Environment is a 13-member body which advises the Secretary, KDHE, on public health and environmental issues. Members serve as a sounding board for departmental initiatives. The Governor appoints individuals to represent a cross-section of the health and environmental interests. D. Regional/District Health Offices Six district offices are located in cities throughout the state, but the state has not been divided into geographic regions. The district offices serve as an extension of the central office programs in Topeka, providing consultation and technical assistance to local health departments, enabling the agency to maintain closer ties to citizens and local health departments in more remote geographic areas, and permitting the agency to respond more quickly and appropriately to problems or requests. Program field staffs are assigned to each district office. Management responsibilities, including provision of support services for field staffs, are carried out in each district office by a District Office Manager and administrative support staff. District Office Managers are supervised by staff from the Office of the Secretary in Topeka. E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Formal Liaison Function The Office of Local Health serves as the liaison with local health departments. Community consultants, which are a part of the central office but physically are located in KDHE district offices, serve as the Division of Health's field staff and liaison to local health departments. The consultants deliver state-level administrative leadership, consultation, and support services to local health units, and assist program consultants in monitoring quality and standards-of-care given by local agencies. The office administers the Aid-to-Counties Program; this provides local health departments and other eligible community agencies with state and Federal funding of public health services at the local level. The state aid is provided through a formula which requires an equal match of local tax funds. The office also maintains a Continuing Education for Nursing Providership Agreement with the Kansas State Board of Nursing. The Office of Rural Health serves as a focal point in the effort to maintain rural health care services. It exists to facilitate and coordinate locally generated ideas to improve the availability of a variety of rural health services. The office draws on the resources, program activities, and staffing of the Division to ensure that Department activities are responsive to rural health needs. The interaction between state and local health agencies in Kansas may be characterized as mixed centralized and decentralized organizational control. Under this arrangement, local health services in the state may be provided by the SHA in some jurisdictions and by local governmental units, boards of health, or health departments in other jurisdictions. F. Budget Total FY 1988 SHA expenditures were $46,945,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $28,923,000 State Funds $17,148,000 Local Funds 0 Fees and Reimbursements $546,000 Other $328,000 3III. Local Public Health Agencies (LPHAs) A. General There are 97 local health departments in Kansas. Local health departments exist in 104 of 105 counties in Kansas. Three multicounty agencies provide service to 10 counties, 12 counties are served by city/county health departments, and the other 82 counties are served by county health departments. Two of the counties, Stevens and Nemaha, provide health services through contract with a county hospital and a private provider, respectively. Within the 82 counties there are several informal "program sharing" arrangements whereby one county health department may contract with KDHE to provide service for a number of surrounding, usually contiguous, counties. B. Services Provided The following information on services provided by local health departments in Kansas is derived from a survey conducted by NACHO during 1989. Eighty-one of 97 local health departments in Kansas responded to the survey. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 21 ( 25.9%) 2. Morbidity Data 12 ( 14.8%) 3. Reportable Diseases 62 ( 76.5%) 4. Vital Records and Statistics 14 ( 17.3%) B. Epidemiology/Surveillance 1. Chronic Diseases 36 ( 44.4%) 2. Communicable Diseases 68 ( 84.0%) II. Policy Development A. Health Code Dev. and Enforcement 24 ( 29.6%) B. Health Planning 32 ( 39.5%) C. Priority Setting 17 ( 21.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 8 ( 9.9%) 2. Health Facility Safety/Quality 21 ( 25.9%) 3. Rec. Facility Safety/Quality 10 ( 12.3%) 4. Other Facility Safety/Quality 8 ( 9.9%) B. Licensing 1. Health Facilities 30 ( 37.0%) 2. Other Facilities 22 ( 27.2%) C. Health Education 61 ( 75.3%) D. Environmental 1. Air Quality 8 ( 9.9%) 2. Hazardous Waste Management 14 ( 17.3%) 3. Individual Water Supply Safety 36 ( 44.4%) 4. Noise Pollution 1 ( 1.2%) 5. Occupational Health and Safety 5 ( 6.2%) 6. Public Water Supply Safety 20 ( 24.7%) 7. Radiation Control 5 ( 6.2%) 8. Sewage Disposal Systems 29 ( 35.8%) 9. Solid Waste Management 16 ( 19.8%) 10. Vector and Animal Control 22 ( 27.2%) 11. Water Pollution 24 ( 29.6%) E. Personal Health Services 1. AIDS Testing and Counseling 40 ( 49.4%) 2. Alcohol Abuse 7 ( 8.6%) 3. Child Health 73 ( 90.1%) 4. Chronic Diseases 51 ( 63.0%) 5. Dental Health 13 ( 16.0%) 6. Drug Abuse 8 ( 9.9%) 7. Emergency Medical Service 2 ( 2.5%) 8. Family Planning 58 ( 71.6%) 9. Handicapped Children 33 ( 40.7%) 10. Home Health Care 47 ( 58.0%) 11. Hospitals 1 ( 1.2%) 12. Immunizations 79 ( 97.5%) 13. Laboratory Services 32 ( 39.5%) 14. Long-term Care Facilities 13 ( 16.0%) 15. Mental Health 4 ( 4.9%) 16. Obstetrical Care 7 ( 8.6%) 17. Prenatal Care 37 ( 45.7%) 18. Primary Care 12 ( 14.8%) 19. Sexually Transmitted Diseases 41 ( 50.6%) 20. Tuberculosis 53 ( 65.4%) 21. WIC 67 ( 82.7%) C. Local Health Officer M.D. Requirement in Jurisdictions over 100,000 Population, County Board of Health Appointment The local health officer is appointed by the county board of health. In counties or multicounty units with less than 100,000 population the board may appoint a qualified local health administrator (generally a nurse) as the local health officer, if a person licensed to practice medicine, surgery, or dentistry is designated as medical consultant to the administrator. Counties with more than 100,000 population must appoint a health officer who has been licensed to practice medicine and surgery, with preference being given to persons who have training in public health. The local health officer in each county is responsible for keeping accurate records of all the transactions of the department, and for receiving and distributing all forms from the Secretary of KDHE. In addition, the health officer is responsible for having an annual sanitary inspection made of each school building and grounds within the county, and investigating, reporting, and taking measures to prevent the spread of infectious, contagious, or communicable disease. The health officer is also responsible for performing such other duties as may be required by the county, joint board of health, or the Secretary. D. Local Board of Health Policy-making Boards of county commissioners act as county boards of health for their respective counties. The board of county commissioners in any county having a population of less than 15,000 may contract with the governing body of any hospital located in the county for the provision of services to the county board of health. E. Staff The staffs of local health departments are employed and supervised by the local jurisdiction. The number of employees for a local health department ranges from 1 to 183. In 15 health departments there is only 1 nurse on staff. There are 76 health departments that do not employ a sanitarian. F. Budget Total FY 1988 LPHA expenditures were $23,821,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $6,010,000 State Funds $2,190,000 Local Funds 0 Fees and Reimbursements $186,000 Other Sources 0 Source Unknown $15,435,000 2Kansas Department of Health and Environment, 1990 Governor Department of Health and Environment Advisory Commission on Health and Environment Task Forces, Boards Assistant Secretary and General Counsel Executive Manager Legal Services General Services Personnel Services Health and Environmental Laboratory Analytical Chemistry Microbiology Laboratories Laboratory Information and Reporting Office Laboratory Improvement Program Office Division of Environment Bureau of Environmental Remediation Bureau of Air and Waste Management Bureau of Water Bureau of Environmental Quality Surface Mining Section Division of Health Assistant Director for Medical Services Office of Local and Rural Health Systems Bureau of Environmental Health Services Bureau of Disease Control Bureau of Adult and Child Care Bureau of Family Health Office of Chronic Disease and Health Promotion Division of Information Systems Office of Communication Services Office of Vital Statistics Office of Public Information Services Office of Health and Environmental Education District Offices (answer to all of the above). 2Types of Local Health Departments by Jurisdiction Kansas, 1990 Jurisdiction Co C/Co M/Co N/Co Allen X Anderson X Atchinson X Barber X Barton X Bourbon X Brown X Butler X Chase X Chatauqua X Cherokee X Cheyenne X City-Cowley Co X Clark X Clay X Cloud X Coffee X Commanche X Crawford X Dickinson X Doniphan X Edwards X Elk X Ellis X Ellsworth X Emporia-Lyon Co X Finney X Ford X Franklin X Gove X Graham X Grant X Gray X Greeley X Greenwood X Hamilton X Harper X Harvey X Haskell X Hodgeman X Hutchinson-Reno Co X Jackson X Jefferson X Jewell X Johnson X Junction C.-Geary X Kansas C-Wyandotte X Kearny X Kingmen X Kiowa X Labette X Lane X Lawrence-Douglas Co X Levenworth X Liberal-Seward Co X Lincoln X Linn X Logan X Manhattan-Riley Co X Marion X Marshall X McPherson X Meade X Miami X Mitchell X Montgomery X Morris X Morton X Nemaha X Neosho X Ness X Norton X Oberlin-Decatur Co X Osage X Osborne X Ottowa X Pawnee X Phillips X Pottawatomie X Pratt X Rawlings X Republic X Rice X Rooks X Rush X Russell X Salina-Saline Co X Scott X Sheridan X Sherman X Smith X Stafford X Stanton X Stevens X Sumner X Thomas X Topeka-Shawnee Co X Trego X Wabaunsee X Wallace X Washington X Wichita X Wichita-Sedwick Co X Wilson X Woodson X Co = County HD C/Co = City/County HD M/Co = Multicounty HD N/Co = No County HD 1KENTUCKY 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 3,726,000 245,803,000 Population Density (1988) 93.9 69.4 (per/sq.mi.) Number of Counties 120 3,139 Median Age (1987) 31.1 31.7 Percent Below Poverty Level (1985) 19.4 14.0 (persons) Percent of Population Rural (1980) 49.0 26.0 Percent of Population White (1980) 92.3 83.1 Percent of Population Non-white (1980) 7.7 16.9 Median Years of Education (1980) 12.1 12.5 (25 years of age and over) B. County Government Structure No Home Rule Authority Kentucky counties receive their authority to exist and function from the state constitution and statutes. County governments are based on the Fiscal Court System. Under this system the counties are given the choice of Magistrate or Commission status. Magistrate Variety - (106) - This form consists of a County Judge/Executive and three to eight justices of the peace who are elected from separate districts. The County Judge serves as the executive officer for the county and presiding officer of the Fiscal Court. The justices of the peace have duties and authority that relate only to the Fiscal Court. Commission Form - (13) - The Commission Form of government under the Fiscal Court System consists of county judge/executive and three commissioners elected at large. The authority of the commissioners is related to the fiscal court. Urban-County Form - (1) - The state constitution does not provide for charter, consolidated city-county or other structural forms of government. In 1970, however, the General Assembly passed a Data for this state were updated October 1990. law authorizing an Urban-County government form. The merger provided for in this law produces an entity that is neither a city nor a county but has the authority and characteristics of a city or county. Lexington-Fayette chose this form of government. Additionally, Louisville-Jefferson developed a limited consolidation under which there is an agreement on sharing taxes, annexation, and specific services. Home Rule Authority - The Fiscal Court depends on authority delegated to it by the General Assembly under Kentucky Revised Statutes. The home rule provision that was amended in 1978, however, granted the counties more authority so they could operate more efficiently while still operating under some constraints. Under these acts counties may pass ordinances, issue regulations, levy taxes, issue bonds, and appropriate funds. 3II. State Health Agency (SHA) A. General Component of Superagency The Department of Health Services is the SHA for Kentucky. It is a component of a superagency called the Cabinet for Human Resources. The mission of the SHA is to protect and promote the health of the citizens of Kentucky. The following are some areas of responsibility for the SHA: State Public Health Authority State Health Planning and Development Agency B. Head of State Health Agency M.D. Requirement, Not Cabinet-level Appointment The Department for Health Services is headed by a Commissioner. The Commissioner is appointed by the Secretary of the Cabinet for Human Resources with the approval of the Governor. The Commissioner must be a licensed physician with training and experience in the administration and management of public health. The Commissioner is responsible for advising the head of major organizational units on policies and programs relating to all matters of public health and on any actions necessary to safeguard the health of the citizens of Kentucky. The Commissioner serves as the chief medical officer of Kentucky. The Commissioner exercises authority over the Department for Health Services under the direction of the Secretary of the Cabinet for Human Resources and is responsible only for what is delegated by the Secretary. C. State Board of Health/Council Advisory The Council for Health Services is a citizen advisory body which provides advice to the Citizens' Commission for Human Resources (a citizen advisory body to the Cabinet for Human Resources), the Secretary for Human Resources, the Commissioner for Health Services, and other officials of the commonwealth on policy matters concerning the delivery of health services. The Council for Health Services is composed of no more than 19 citizen members appointed by the Governor. Members are chosen to broadly represent public interest groups concerned with health services, recipients of health services provided by the state, minority groups, and the general public. The Governor appoints the Chairman of the Council who also serves as a voting member of the Citizens' Commission for Human Resources. The Secretary for Human Resources and the Commissioner for Health Services are non-voting ex officio members of the Council and the Commissioner is staff director and secretary to the Council. The Council meets quarterly or on the call of the Secretary of Human Resources or the Commissioner for Health Services. D. Regional/District Health Offices The Department of Health Services has not divided the state into administrative regions or districts. There are district health departments, but these are counties that have combined their health departments to make one service unit. The only membership restriction is that counties within a district health department must be within the same governmental Area Development District (ADD). E. State-local Liaison Shared Organizational Control, Informal Liaison Function The Department for Health Services, Cabinet for Human Resources, does not employ state-local liaisons as such. Rather, the Department's program, professional, and support staffs provide direct technical assistance to local health departments via telephone consultations, written communications, and on-site consultations. The Department does employ regional nurse consultants in the Home Health Program and program/field representatives in the sexually transmitted diseases (STD) immunization, women, infants, and children (WIC) and environmental health programs. The function of these staffs is to relay the program-specific priorities of Federal and state agencies and to provide readily available, on-site assistance and supervision to local health department staff. In turn, the "regional" field staff can relate local concerns and the local perspective to state program staff. The interaction between state and local public health agencies in Kentucky may be characterized as shared organizational control. Under this arrangement local health departments are under the authority of the SHA, as well as the local government and board of health. F. Budget Total FY 1988 Kentucky SHA expenditures were $110,232,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $63,620,000 State Funds $44,404,000 Local Funds 0 Fees and Reimbursements $2,135,000 Other $73,000 3III. Local Public Health Agencies (LPHAs) A. General There are 52 local health departments in Kentucky. Seventeen of these are district (multicounty health departments), 33 are single-county health departments, and 2 are city-county health departments. The districts contain five health departments that were city-county units before their merger into the districts. The two city-county health departments consist of Jefferson County which has a city of the 1st class (Louisville) and Fayette County\Lexington City which has an Urban County Form of government. The Cabinet for Human Resources determines the areas in which district (multicounty) health departments may be established. The fiscal court for each of the counties must approve the formation of the district by a simple majority vote. Each county included in the district will be responsible for providing its share of the expense of creating, establishing, operating, and maintaining the department. B. Services Provided The following information on services provided by local health departments in Kentucky is derived from a survey conducted by NACHO during 1989. Forty-four of the 52 local health departments in Kentucky responded to the survey. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 15 ( 34.1%) 2. Morbidity Data 30 ( 68.2%) 3. Reportable Diseases 43 ( 97.7%) 4. Vital Records and Statistics 43 ( 97.7%) B. Epidemiology/Surveillance 1. Chronic Diseases 34 ( 77.3%) 2. Communicable Diseases 42 ( 95.5%) II. Policy Development A. Health Code Dev. and Enforcement 23 ( 52.3%) B. Health Planning 31 ( 70.5%) C. Priority Setting 28 ( 63.6%) III. Assurance Activities A. Inspection 1. Food and Milk Control 40 ( 90.9%) 2. Health Facility Safety/Quality 26 ( 59.1%) 3. Rec. Facility Safety/Quality 34 ( 77.3%) 4. Other Facility Safety/Quality 16 ( 36.4%) B. Licensing 1. Health Facilities 6 ( 13.6%) 2. Other Facilities 37 ( 84.1%) C. Health Education 35 ( 79.5%) D. Environmental 1. Air Quality 4 ( 9.1%) 2. Hazardous Waste Management 11 ( 25.0%) 3. Individual Water Supply Safety 38 ( 86.4%) 4. Noise Pollution 2 ( 4.5%) 5. Occupational Health and Safety 4 ( 9.1%) 6. Public Water Supply Safety 29 ( 65.9%) 7. Radiation Control 15 ( 34.1%) 8. Sewage Disposal Systems 40 ( 90.9%) 9. Solid Waste Management 17 ( 38.6%) 10. Vector and Animal Control 35 ( 79.5%) 11. Water Pollution 22 ( 40.0%) E. Personal Health Services 1. AIDS Testing and Counseling 36 ( 81.8%) 2. Alcohol Abuse 3 ( 6.8%) 3. Child Health 44 (100.0%) 4. Chronic Diseases 37 ( 84.1%) 5. Dental Health 25 ( 56.8%) 6. Drug Abuse 6 ( 13.6%) 7. Emergency Medical Service 1 ( 2.3%) 8. Family Planning 44 (100.0%) 9. Handicapped Children 19 ( 43.2%) 10. Home Health Care 19 ( 43.2%) 11. Hospitals - 12. Immunizations 44 (100.0%) 13. Laboratory Services 32 ( 72.7%) 14. Long-term Care Facilities - 15. Mental Health - 16. Obstetrical Care 21 ( 47.7%) 17. Prenatal Care 43 ( 97.7%) 18. Primary Care 5 ( 11.4%) 19. Sexually Transmitted Diseases 44 (100.0%) 20. Tuberculosis 44 (100.0%) 21. WIC 44 (100.0%) C. Local Health Officer M.D. Requirement, Local Board of Health Appointment County and district boards of health have authority to appoint a health officer. The appointments are subject to the approval of the Cabinet for Human Resources. The health officer is subject to Merit System provisions and holds office at the pleasure of both the board of health and the Cabinet for Human Resources. The health officer of a county or district health department is directed to devote his entire time to the duties of his office and not be engaged in the private practice of medicine, serve as the secretary to the county board of health and keep minutes of the proceedings, and be the chief administrative officer of the county health department. A local health officer may serve as health officer for more than one county if the local boards of health and the Cabinet for Human Resources approve. D. Local Board of Health Policy-making County boards of health consist of nine members, except for the five city-county boards of health which consist of seven members. On the county boards of health, seven members are appointed by the Cabinet for Human Resources; one member is appointed by the Fiscal Court; and the County Judge/Executive is a member by virtue of his office. On the city-county boards of health, the seven-member board is composed of the mayor or city manager; the County Judge/Executive; and five appointed members which include one dentist, one nurse, and three physicians. In the event that qualified persons are not available to fill specific positions on the board, the Secretary of the Cabinet for Human Resources may appoint a resident lay person knowledgeable in consumer affairs to fill each vacancy. District boards of health, except for districts which serve a county containing a city of the first class or an urban-county government, are composed of the one county judge/executive or his designee from each county in the district and one additional member per county per 15,000 population. The fiscal court of each county submits names to the Secretary of the Cabinet for Human Resources, who makes the appointments. Nominations to the Secretary are to include two nominations from each of the following groups: fiscal court of each county; county board of health for each county; county medical society; county dental society; district nursing association; and veterinarians from the county, when available. The district boards are composed of the following: at least 25 percent doctors of medicine or osteopathy licensed in Kentucky; at least one licensed, registered nurse; one dentist; and one veterinarian, when available. The remaining members of the board will be concerned community leaders residing within the county they are to represent. The term of office for district boards of health is 2 years, with the terms staggered so that half of the members are appointed each year. Responsibilities for county, city-county, and district boards of health include the following: appoint a health officer and establish his salary; hold regular meetings at least once every 3 months; adopt rules and regulations necessary to protect the health of the people; act in a general advisory capacity to the health officer on all matters relating to the local department of health; hear and decide appeals from rulings, decisions, and actions of the local health department or health officer; perform all other functions necessary to carry out the provisions of law and the rules and regulations that have been adopted. E. Staff The staffs of local health departments are employed and supervised by the local jurisdiction. The number of employees for a local health department ranges from 5 to 289. F. Budget Total FY 1988 LPHA expenditures were $78,678,000. Total FY 1988 LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $15,759,000 State Funds $18,215,000 Local Funds $20,983,000 Fees and Reimbursements $23,721,000 Other Sources 0 Source Unknown 0 2Kentucky Department for Health Services, 1990 Commissioner Division of Administration and Financial Management Budget and Fiscal Planning Branch Administrative Branch Local Fiscal Systems Branch Division of Vital Records and Health Development Health Data Branch Vital Statistics Branch Community Health Development Branch Division of Disability Determination Claims Adjudication Branch (A) Claims Adjudication Branch (B) Operations Support Branch Medical Services Branch Hearings Branch Administrative Support Branch Lexington Branch Louisville Branch Division of Epidemiology Health Promotion Branch Communicable Disease Branch Surveillance and Investigation Branch Chronic Disease Branch Division of Community Safety Product Safety Branch Radiation Control Branch Drug Control Branch EMS Branch Milk Control Branch Division of Laboratory Services Chemistry Branch Microbiology Branch Technical and Administrative Services Branch Division of Local Health Environmental Sanitation Branch Food Branch Information and Support Branch Local Health Personnel Merit System Branch Local Program Support Branch Division of Maternal and Child Health Nutrition Services Branch Central Support Branch Maternal and Family Planning Services Branch 2Types of Local Health Departments by Jurisdiction Kentucky, 1990 Jurisdiction Co C/Co M/Co Adair X Allen X Anderson X Ballard X Barren X Bath X Bell X Boone X Bourbon X Boyd X Boyle X Bracken X Breathitt X Breckinridge X Bullitt X Butler X Caldwell X Calloway X Campbell X Carroll X Carslile X Carter X Casey X Christian X Clark X Clay X Clinton X Crittenden X Cumberland X Daviess X Edmondson X Elliott X Estill X Fleming X Floyd X Franklin X Fulton X Gallatin X Garrard X Grant X Graves X Grayson X Green X Greenup X Hancock X Hardin X Harlan X Harrison X Hart X Henderson X Henry X Hickman X Hopkins X Jackson X Jessamine X Johnson X Kenton X Knott X Larue X Laurel X Lawrence X Lee X Leslie X Letcher X Lewis X Lexington-Fayette X Lincoln X Livingston X Logan X Louisville-Jefferso X Lyon X Madison X Magoffin X Marion X Marshall X Martin X Mason X McCracken X McCreary X McLean X Meade X Menifee X Mercer X Metcalfe X Monroe X Montgomery X Morgan X Muhlenberg X Nelson X Nicholas X Ohio X Oldham X Owen X Owsley X Pendleton X Perry X Pike X Powell X Pulaski X Robertson X Rockcastle X Rowan X Russell X Scott X Shelby X Simpson X Spencer X Taylor X Todd X Trigg X Trimble X Union X Warren X Washington X Wayne X Webster X Whitley X Wolfe X Woodford X Co = County HD C = City HD C/Co = City/County HD M/Co = Multicounty HD 1LOUISIANA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 4,408,000 245,803,000 Population Density (1988) 99.0 69.4 (per/sq.mi.) Number of Counties 64 3,139 Median Age (1987) 29.1 31.7 Percent Below Poverty Level (1985) 18.1 14.0 (persons) Percent of Population Rural (1980) 31.0 26.0 Percent of Population White (1980) 69.2 83.1 Percent of Population Non-white (1980) 30.8 16.9 Median Years of Education (1980) 12.2 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The state constitution and statutes provide the structure and authority for county equivalents, called parishes, to operate in Louisiana. Parishes may choose any of three variations in structure for their governments: Commission, Police Jury System, or Parish Home Rule Charter. Police Jury System - (50) - In this system the governing body, the Police Jury, has both legislative and administrative authority. The Jury is made up of 5 to 15 members who are elected from single-member districts. The exact number of members is determined by historical and population factors. The administrative structure varies widely in parishes with Police Jury. They have the authority to appoint a manager or administrator position. Sixteen parishes have appointed an administrator. Parish Home Rule Charter - (14) - Home rule parishes may use a President-Council plan involving the election of a full-time chief executive, elected at large. Thirteen of the 14 home rule parishes elect an executive. The other parish uses a Council-Administrator who is appointed by the board and is Data for this state were updated November 1990. responsible for administrative functions. Consolidation of parish and city governments is authorized under home rule charters and has been implemented in three metropolitan areas: the City of Baton Rouge and East Baton Rouge Parish, the City of New Orleans and Orleans Parish, and the City of Houma and Terrebonne Parish. 3II. State Health Agency (SHA) A. General Component of Superagency The SHA is the Office of Public Health (OPH). It is a component of a superagency called the Department of Health and Hospitals. The mission of the SHA is to protect and enhance the health of the people of Louisiana and to help create the conditions in which all can enjoy the best of health. The following are some areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs State Maternal and Child Health Agency State Title 10/Family Planning Agency State Safe-drinking Water Program Agency B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The OPH is administered by an Assistant Secretary appointed by the Secretary of the Department of Health and Hospitals (DHH) in accordance with the provisions of law. It is not a requirement for the Director of the OPH to be a physician. When he/she is not a physician, the designation of State Health Officer falls upon a person meeting the requirements stated below: "The State Health Officer shall be a licensed and practicing physician in the state of Louisiana and continue to be so qualified during his term of office. He shall be a full-time employee of the DHH. The Secretary of DHH may designate any department employee, including himself, as State Health Officer." The State Health Officer is responsible at all times for taking all of the necessary steps to execute the sanitary laws of the state and to carry out the rules, ordinances, and regulations that are contained in the state sanitary code. He/she may issue warrants only to arrest or prevent epidemics or abate any imminent menace to the public health. All other actions are governed by the administrative enforcement procedures contained in the State Sanitary Code. C. State Board of Health/Council Currently the state of Louisiana does not have a State Board or Council of Health. D. Regional/District Health Offices The OPH has divided the state into nine administrative regions (see attached map). The health regions function as administrative units in the field. They coordinate health activities, administrative, programmatic, and professional supervision, and are a direct link for parish health units and the central office. All but two of the parish health units act under the supervision and direction of the regional offices of the OPH of the Department of Health and Hospitals. Five of the largest parishes in the OPH system have physician health directors. The other 57 have a chief nurse, chief sanitarian, and chief clerk who answers to their counterparts at the regional office. None of them have administrative authority over the entire parish health unit, and there is no administrator or administrative assistant. Two of the 64 parishes, Orleans and Plaquemines, have local health departments that answer to the parish, not to OPH. Despite this difference in management structure, these two local health departments maintain excellent working relationships with the Office of Public Health. The regional offices are staffed with 15 to 50 employees. Each region has a Regional Administrator, Assistant Administrator, Regional Public Health Nurse, Regional Sanitarian, clerical support staff and program consultants. Programs administered by regional offices include maternal and child health, family planning, nutrition, genetic diseases, social services, handicapped children, adult health, disease control, laboratory services and regulatory services such as water and sewage, sanitary services, and oyster water monitoring. E. State-local Liaison Centralized Organizational Control, Informal Liaison Function The liaison between state and local public health units is accomplished through the normal chain of command. The interaction between state and 62 of the 64 local public health agencies in Louisiana may be characterized as centralized organizational control. The other two are decentralized. Under this arrangement local health services in the state are provided by the SHA in most jurisdictions and by local government in two jurisdictions. F. Budget Total FY 1988 Louisiana SHA expenditures were $116,726,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $71,560,000 State Funds $28,051,000 Local Funds $6,845,000 Fees and Reimbursements $10,243,000 Other 24,000 3III. Local Public Health Agencies (LPHAs) A. General There is a health unit in each of the 64 parishes. Sixty-two of these are parish health units, which are units of the OPH. The other two are independent, local health departments located in Orleans and Plaquemines Parishes. The Orleans Parish unit is a city-parish (county) unit and Plaquemines is a parish (county) unit. The state does not consider the parish health units they administer to be local health departments. However, they are included in our count of local health departments because they meet our definition of a local health department. B. Services Provided The following information on services provided by local health departments in Louisiana is derived from a survey conducted by NACHO during 1989. Twenty-five of the 64 local health departments in Louisiana responded to the survey. Services provided by 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 7 ( 28.0%) 2. Morbidity Data 18 ( 72.0%) 3. Reportable Diseases 25 (100.0%) 4. Vital Records and Statistics 25 (100.0%) B. Epidemiology/Surveillance 1. Chronic Diseases * - 2. Communicable Diseases 25 (100.0%) II. Policy Development A. Health Code Dev. and Enforcement 13 ( 52.0%) B. Health Planning 15 ( 60.0%) C. Priority Setting 12 ( 48.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 20 ( 80.0%) 2. Health Facility Safety/Quality 18 ( 72.0%) 3. Rec. Facility Safety/Quality 13 ( 52.0%) 4. Other Facility Safety/Quality 13 ( 52.0%) B. Licensing 1. Health Facilities * - 2. Other Facilities 17 ( 68.0%) C. Health Education 17 ( 68.0%) D. Environmental 1. Air Quality 2 ( 8.0%) 2. Hazardous Waste Management 7 ( 28.0%) 3. Individual Water Supply Safety 24 ( 96.0%) 4. Noise Pollution 3 ( 12.0%) 5. Occupational Health and Safety * - 6. Public Water Supply Safety 24 ( 96.0%) 7. Radiation Control * - 8. Sewage Disposal Systems 25 (100.0%) 9. Solid Waste Management 16 ( 64.0%) 10. Vector and Animal Control 19 ( 76.0%) 11. Water Pollution 17 ( 68.0%) E. Personal Health Services 1. AIDS Testing and Counseling 19 ( 76.0%) 2. Alcohol Abuse * - 3. Child Health 25 (100.0%) 4. Chronic Diseases * - 5. Dental Health 10 ( 40.0%) 6. Drug Abuse * - 7. Emergency Medical Service * - 8. Family Planning 25 (100.0%) 9. Handicapped Children 21 ( 84.0%) 10. Home Health Care * - 11. Hospitals - 12. Immunizations 25 (100.0%) 13. Laboratory Services 20 ( 80.0%) 14. Long-term Care Facilities - 15. Mental Health * - 16. Obstetrical Care 10 ( 40.0%) 17. Prenatal Care 23 ( 92.0%) 18. Primary Care 4 ( 16.0%) 19. Sexually Transmitted Diseases 24 ( 96.0%) 20. Tuberculosis 25 (100.0%) 21. WIC 25 (100.0%) * The SHA provided additional information indicating that these particular activities are not performed by any local health departments in Louisiana. C. Local Health Officer No M.D. Requirement, State Health Officer Appointment Local health departments may have local health officers. These health officers are appointed by the State Health Officer after consultation with the parish governing authority and with the approval of the Secretary of the Department of Health and Hospitals. The parish health officer is a full-time licensed physician, if possible, and if a physician is not available, the parish health officer is a full-time employee experienced in the administration and enforcement of public health programs. The health officer must live in the parish in which appointed unless service to more than one parish is provided. These officers are responsible for administering the local health department, including all of its programs and functions. D. Local Board of Health With the exception of Orleans Parish there are no local boards of health in Louisiana. Informal advisory committees are present in 42 of the 62 parishes run by OPH. E. Staff The staffs of local health departments except Orleans and Plaquemines Parishes are state employees. Orleans Parish staff are local employees and part of the City of New Orleans Merit System. Plaquemines Parish staff are employees of that parish merit system. Administrative supervision of parish health units is performed by regional staff. The number of employees for a local health department ranges from 2 to 300. F. Budget Total FY 1988 LPHA expenditures were $685,000 **. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $548,000 State Funds $103,000 Local Funds $32,000 Fees and Reimbursements 2,000 Other Sources 0 Source Unknown 0 ** These data include only money provided to the City of New Orleans and Plaquemines Parish in the form of contracts for services. The SHA reported that there were additional fees and reimbursements not retained by the local health departments, but which reverted to the general revenues of the local or state government. 2Louisiana Department of Health and Hospitals, 1990 Secretary Undersecretary Deputy Secretary Assistant Secretary Office of Public Health Deputy Assistant Secretary - Programs Division of Family Health Services Maternal and Child Health Section Family Planning Section Nutrition Section Genetic Diseases Section Social Services Section Handicapped Children's Services Section Division of Disease Control Tuberculosis Control Section Sexually Transmitted Diseases Section Health Promotion Section Epidemiology Section Immunization Section Division of Environmental Health Services Engineering Services Section Sanitarian Services Section Division of Laboratories Amite Milk Lab Section Lake Charles Regional Lab Section Alexandria Regional Lab Section Shreveport Regional Lab Section Monroe Regional Lab Section Lafayette Regional Lab Section Central Lab Section Chemistry Section Microbiology Section Virology-Immunology Section Biochemistry Section Quality Assurance Section Radiation Section Deputy Assistant Secretary - Administration Division of Local Health Services Region I Region II Region III Region IV Region V Region VI Region VII Region VIII Region X Division of Records and Statistics Public Health Statistics Section Vital Records Section Tumor Registry Section LA Cancer and Lung Trust Fund Board Section Division of Administrative Services Pharmacy Section Policy, Planning and Evaluation Section Human Resources Section Data Processing Section Operations and Support Section Administrative Services Section 2Types of Local Health Departments by Jurisdiction Louisiana, 1990 Jurisdiction Co C/Co Acadia X Allen X Ascension X Assumption X Avoyelles X Beauregard X Bienville X Bossier X Caddo X Calcasieu X Caldwell X Cameron X Catahoula X Claiborne X Concordia X De Soto X E. Baton Rouge X East Carroll X East Feliciana X Evangeline X Franklin X Grant X Iberia X Iberville X Jackson X Jefferson X Jefferson Davis X La Salle X Lafayette X Lafourche X Lincoln X Livingston X Madison X Morehouse X Natchitoches X New Orleans X Ouachita X Plaquemines X Pointe Coupee X Rapides X Red River X Richland X Sabine X St. Bernard X St. Charles X St. Helena X St. James X St. John Baptis X St. Landry X St. Martin X St. Mary X St. Tammany X Tangipahoa X Tensas X Terrebonne X Union X Vermilion X Vernon X W. Baton Rouge X Washington X Webster X West Carroll X West Feliciana X Winn X Co = County HD C/Co = City/County HD 1MAINE 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 1,206,000 245,803,000 Population Density (1988) 38.9 69.4 (per/sq.mi.) Number of Counties 16 3,139 Median Age (1987) 32.4 31.7 Percent Below Poverty Level (1985) 11.9 14.0 (persons) Percent of Population Rural (1980) 53.0 26.0 Percent of Population White (1980) 98.7 83.1 Percent of Population Non-white (1980) 1.3 16.9 Median Years of Education (1980) 12.5 12.5 (25 years of age and over) B. County Government Structure No Home Rule Authority The structure of authority of county governments in Maine is determined by statutes enacted by the legislature. Commission Form - (16) - This form of government is used by all counties in Maine. The commissions are composed of three-member boards elected from single-member districts. Counties can appoint an administrator to perform administrative functions in the county. Two counties currently have appointed administrators. There are no provisions for home rule authority. The commission, however, may determine if a charter should be adopted or amended. Voters can also petition for the establishment of a charter by submitting petitions with signatures that represent 10 percent of the vote in the last gubernatorial election. At the present, no counties operate under a charter. Data for this state were updated April 1991. 3II. State Health Agency (SHA) A. General Component of Superagency The Bureau of Health, the SHA, is a component of a superagency called the Department of Human Services. The mission of the Bureau of Health is to preserve, protect, and promote the health and well-being of the population through the organization and delivery of services designed to reduce the risk of disease by: (1) modifying physiological and behavioral characteristics of population groups; (2) controlling environmental hazards to human health; and (3) promoting health/wellness through education, counseling and access to health services. The following are some broad areas of responsibility for the SHA: State Public Health Authority Lead Environmental Agency in the State State Agency for Children with Special Health Care Needs State Health Planning and Development Agency Institutional Licensing Agency These are some additional areas of responsibility for the SHA: Wastewater and Plumbing Radiological Health Drinking Water Regulations Maternal and Child Health Immunizations Epidemiology Disease Control AIDS Sexually Transmitted Diseases Tuberculosis B. Head of State Health Agency No M.D. Requirement, Not Cabinet-level Appointment The head of the SHA is the Director of the Bureau of Health. The Commissioner of the Department of Human Services appoints the Director. The Director of the Bureau functions as the state's Health Officer. In addition to overseeing the Bureau's programs, the Director is instrumental in furthering cooperative relationships with the medical and public health communities in the state and in the Nation. The director represents the Bureau of Health's interests through active participation in the work of numerous state boards, committees, and organizations, and at the national level, represents Maine through membership in the Association of State and Territorial Health Officers. C. State Board of Health/Counil Maine does not have a State Board of Health or State Council of Health. D. Regional/District Health Offices The SHA has not divided the state into administrative regions or districts. E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Informal Liaison Function Responsibility for liaison between the SHA and local public health/community health agencies has not been assigned to any particular office or individual. Liaison activities are handled informally by individual agencies, programs and offices. The interaction between state and local public health agencies in Maine may be characterized as mixed centralized and decentralized organizational control. Under this arrangement local health services may be provided by the SHA in some jurisdictions and by local governmental units, boards of health, or health departments in other jurisdictions. F. Budget Total FY 1988 Maine SHA expenditures were $25,736,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $15,002,000 State Funds $8,869,000 Local Funds 0 Fees and Reimbursements $1,865,000 Other 0 3III. Local Public Health Agencies (LPHAs) A. General The eight local health departments in Maine consist of three city health departments (located in the cities of Bangor, Lewiston, and Portland) and five Department of Human Service regions (one county and four multicounty units). The city health departments are autonomous units, and the public health nursing services are elements of the SHA that provide public health services to local areas. B. Services Provided The following information on services provided by local health departments in Maine is derived from a survey conducted by NACHO during 1989. Five of the eight local health departments in Maine responded to the survey. Services Provided by LPHAs Number of LPHAs I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment - 2. Morbidity Data - 3. Reportable Diseases 3 4. Vital Records and Statistics 1 B. Epidemiology/Surveillance 1. Chronic Diseases - 2. Communicable Diseases 3 II. Policy Development A. Health Code Dev. and Enforcement 1 B. Health Planning 1 C. Priority Setting 1 III. Assurance Activities A. Inspection 1. Food and Milk Control 1 2. Health Facility Safety/Quality 2 3. Rec. Facility Safety/Quality 1 4. Other Facility Safety/Quality 1 B. Licensing 1. Health Facilities 2 2. Other Facilities 2 C. Health Education 2 D. Environmental 1. Air Quality 1 2. Hazardous Waste Management 1 3. Individual Water Supply Safety 1 4. Noise Pollution 1 5. Occupational Health and Safety 1 6. Public Water Supply Safety 1 7. Radiation Control 1 8. Sewage Disposal Systems 2 9. Solid Waste Management 1 10. Vector and Animal Control 1 11. Water Pollution 1 E. Personal Health Services 1. AIDS Testing and Counseling 1 2. Alcohol Abuse - 3. Child Health 2 4. Chronic Diseases - 5. Dental Health 1 6. Drug Abuse - 7. Emergency Medical Service 1 8. Family Planning 1 9. Handicapped Children - 10. Home Health Care 1 11. Hospitals - 12. Immunizations 3 13. Laboratory Services 1 14. Long-term Care Facilities - 15. Mental Health - 16. Obstetrical Care 1 17. Prenatal Care 2 18. Primary Care 1 19. Sexually Transmitted Diseases 1 20. Tuberculosis 2 21. WIC - C. Local Health Officer No M.D. Requirement, Local Governing Body Appointment Each municipality in Maine is required to appoint a health officer. Maine has approximately 325 local health officers. A listing is maintained by the Bureau of Health. Over one-third of them have a medical/health/public health background (doctors, nurses, physician assistants, and emergency medical technicians). These people are considered a valuable resource for the state and, to date, have not been used to their full potential. There is presently no structural statewide organization for health officers. D. Local Board of Health Information on local boards of health is not available. E. Staff Autonomous local health departments employ and supervise their staffs. The staffs of Public Health Nursing Services are employed and supervised by the SHA. The number of employees for a local service unit ranges from 1 to 30. F. Budget Total FY 1988 LPHA expenditures are not available. 2Maine Department of Human Services, 1990 Department of Human Services Advisory Comm. on Radioactive Waste Human Services Council Maine AFDC Coordinating Committee Certificate of Need Advisory Committee Office of Attorney General Office of Public and Legislative Affairs Environmental Health Advisory Committee Alcohol and Drug Abuse Plan Committee Advisory Committee on Radiation Bureau of Health Division of Health Engineering Radiological Emergency Prep. Committee Scientific Advisory Panel Division of Disease Control Maine-Dental Health Council Emergency Medical Services Board Division of Health Promotion and Education Bureau of Medical Services Comm. to Advise D.H.S. on AIDS Division of Maternal and Child Health Public Health Laboratory Office of Dental Health Division of Public Health Nursing Office of Emergency Medical Services Maine Medical Lab Commission Advisory Board for Water Treatment Plant Operations Bureau of Medical Services Office of Vital Statistics Office of Mgmt. and Budget Division of Regional Administration Office of Programs Bureau of Income Maintenance Bureau of Maine's Elderly Bureau of Social Services Bureau of Rehabilitation Division of Deafness Division of Eye Care Office of Alcohol & Drug Abuse Prevention 2Types of Local Health Departments by Jurisdiction Maine, 1990 Jurisdiction Co C M/Co Androscoggin X Aroostook X Bangor X Cumberland X Franklin X Hancock X Kennebec X Knox X Lewiston X Lincoln X Oxford X Penobscot X Piscataquis X Portland X Sagadahoc X Somerset X Waldo X Washington X York X Co = County HD C = City HD M/Co = Multicounty HD 1MARYLAND 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 4,622,000 245,803,000 Population Density (1988) 469.9 69.4 (per/sq.mi.) Number of Counties 24 3,139 Median Age (1987) * 32.5 31.7 Percent Below Poverty Level (1985) 8.7 14.0 (persons) Percent of Population Rural (1980) 20.0 26.0 Percent of Population White (1980) 74.9 83.1 Percent of Population Non-white (1980) 25.1 16.9 Median Years of Education (1980) 12.5 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The structure of county government in Maryland is established by the state constitution and is either Commission, Code Home Rule, or Charter Home Rule. The governing bodies are elected from single-member districts, at large, or by a combination of the methods. Commission Form - (11) - These counties have not adopted a level of home rule. They have a board of commissioners made up of five members with administrative and legislative responsibility. Seven of the commission counties have appointed administrators. Maryland has provided counties with home rule authority under two structures: code home rule and charter home rule. Under both of these options the state has delegated some legislative authority for local matters to the counties. The primary difference in the two structures is the method by which they are adopted and changed. All home rule counties can use either commission, elected executive-council, or council-manager as the structure of their governmental body. *These data were provided by the SHA. Data for this state were updated November 1990. Code Home Rule - (4) - In these counties the governmental board makes structural changes in the county government by enacting laws. These counties operate with a board of county commissioners, and each has an appointed county administrator. Charter Home Rule - (8) - In these counties the governmental body is required to submit any proposed amendments of the charter to the voters for approval. Six of these counties have a county council with an elected executive, and two counties use the Council-manager Form. Independent City - (1) - Baltimore City is an independent city which operates as a county with an elected executive/mayor. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Maryland Department of Health and Mental Hygiene (MDHMH), the SHA, is a free-standing, independent agency. The mission of public health services in Maryland is to prevent and reduce the consequences of illness and disability on individuals and society and to assure a dynamic system of prevention, intervention, and rehabilitation services. The following are some areas of responsibility for the SHA: State Public Health Authority State Mental Health Authority State Agency for Children with Special Health Care Needs State Health Planning and Development Agency State Professions Licensing Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Secretary of MDHMH is the head of the SHA. This official is appointed by the Governor with advice and consent of the Senate. The Secretary is responsible directly to the Governor and serves at the pleasure of the Governor. The Secretary has responsibility for advising the Governor on all matters assigned to the Department and is responsible for carrying out the Governor's policies on these matters. Full responsibility for operation of the Department, including the establishment of guidelines and procedures to promote the orderly and efficient administration of the Department, rests with the Secretary. C. State Board of Health/Council Advisory Maryland has a board entitled the Board of Review of the Department. This board is composed of seven members appointed by the Governor with advice and consent of the Senate. At least four of the members must come from the general public and the other three must have knowledge and experience in at least one of the fields under the jurisdiction of the Department. The term of office for members is 3 years. The terms of members are staggered so that no more than three members' terms will expire on any given year. The Board is responsible for making recommendations to the Secretary on the operation and administration of the Department as the Board considers necessary or desirable. If an advisory board for the department is not created, the Board will advise the Secretary on any departmental matter that the Secretary submits to the Board. Unless otherwise provided for in policy or law, the Board will hear and determine appeals from decisions involving the Secretary or any unit of the Department. D. Regional/District Health Offices The state is not generally divided into administrative districts or regions. The local service units are organized along county lines, and the services are provided at the county level. Some individual programs such as Mental Hygiene and WIC, however, have established administrative regions. E. State-Local Liaison Shared Organizational Control, Formal Liaison Function The Office of Local and Family Health Administration is responsible for the liaison function between local health agencies and the MDHMH. In this role the office serves as a primary focus of communications between the state and local health agencies. Some functions of this office include the management of monthly local health officers' roundtable meetings, assisting local areas in recruiting health officers, and participation in meetings of the Association of Local Health Officers when invited and upon request. The interaction between state and local public health agencies in Maryland may be characterized as shared organizational control. Under this arrangement local health departments are under the authority of the SHA, as well as the local government and board of health. F. Budget Total FY 1988 Maryland SHA expenditures were $732,553,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $63,006,000 State Funds $590,872,000 Local Funds $32,079 Fees and Reimbursements 0 Other $46,597,000 3III. Local Public Health Agencies (LPHAs) A. General There are 24 local health jurisdictions in Maryland. Twenty-three of these are county health departments, and one is a city health department (Baltimore City). The state supports local health services through a mechanism called Case Formula. This formula provides money to local health departments on an approximate 50/50 percent matching basis. The exact percentage of the match is based on the population and the equalized property tax in each county. B. Services Provided The following information on services provided by local health departments in Maryland is derived from a survey conducted by NACHO during 1989. All 24 of the local health departments in Maryland responded to the survey. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities 1. Behavioral Risk Assessment 16 ( 66.7%) 2. Morbidity Data 20 ( 83.3%) 3. Reportable Diseases 23 ( 95.8%) 4. Vital Records and Statistics 22 ( 91.7%) B. Epidemiology/Surveillance 1. Chronic Diseases 12 ( 50.0%) 2. Communicable Diseases 24 (100.0%) II. Policy Development A. Health Code Dev. and Enforcement 18 ( 75.0%) B. Health Planning 21 ( 87.5%) C. Priority Setting 18 ( 75.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 21 ( 87.5%) 2. Health Facility Safety/Quality 15 ( 62.5%) 3. Rec. Facility Safety/Quality 18 ( 75.0%) 4. Other Facility Safety/Quality 12 ( 50.0%) B. Licensing 1. Health Facilities 9 ( 37.5%) 2. Other Facilities 23 ( 95.8%) C. Health Education 23 ( 95.8%) D. Environmental 1. Air Quality 19 ( 79.2%) 2. Hazardous Waste Management 16 ( 66.7%) 3. Individual Water Supply Safety 22 ( 91.7%) 4. Noise Pollution 15 ( 62.5%) 5. Occupational Health and Safety 5 ( 20.8%) 6. Public Water Supply Safety 19 ( 79.2%) 7. Radiation Control 8 ( 33.3%) 8. Sewage Disposal Systems 22 ( 91.7%) 9. Solid Waste Management 14 ( 58.3%) 10. Vector and Animal Control 20 ( 83.3%) 11. Water Pollution 18 ( 75.0%) E. Personal Health Services 1. AIDS Testing and Counseling 24 (100.0%) 2. Alcohol Abuse 22 ( 91.7%) 3. Child Health 24 (100.0%) 4. Chronic Diseases 22 ( 91.7%) 5. Dental Health 16 ( 66.7%) 6. Drug Abuse 23 ( 95.8%) 7. Emergency Medical Service 5 ( 20.8%) 8. Family Planning 24 (100.0%) 9. Handicapped Children 21 ( 87.5%) 10. Home Health Care 19 ( 79.2%) 11. Hospitals - 12. Immunizations 24 (100.0%) 13. Laboratory Services 13 ( 54.2%) 14. Long-term Care Facilities 3 ( 12.5%) 15. Mental Health 23 ( 95.8%) 16. Obstetrical Care 12 ( 50.0%) 17. Prenatal Care 22 ( 91.7%) 18. Primary Care 6 ( 25.0%) 19. Sexually Transmitted Diseases 24 (100.0%) 20. Tuberculosis 24 (100.0%) 21. WIC 22 ( 91.7%) C. Local Health Officer No M.D. Requirement, Secretary Appointment County health officers are nominated by the county governing body and are appointed by the Secretary of MDHMH. The local health officer is the chief executive officer of the local health department. Health officers are required to have a master's degree in public health and at least 2 years' work in the field of public health, or at least 5 years' work in the field of public health. The following are powers and duties of county health officers: 1. The health officer for a county is the Executive Officer and Secretary of the county board of health. 2. The health officer for a county has responsibility for appointing the staff of the county health department. 3. A health officer may obtain samples of food and drugs for analysis. 4. A county health officer, under the direction of the Secretary, will enforce the state health laws and the policies, rules, and regulations that the Secretary adopts. 5. The health officer will have an office at an accessible place in the county. 6. Except for particular situations specified by law, the county health officer will, under the direction of the county board of health, enforce the rules and regulations that the county board adopts. 7. The county health officer will enforce in each municipality or special taxing district in the county the rules and regulations that the county board of health adopts, unless the municipality or district has a charter provision or ordinance that specifies otherwise. 8. A health officer will perform any investigation or other duties or function directed by the Secretary or the county board of health and submit appropriate reports to them. D. Local Board of Health Policy-making In general, the county governing body functions as the board of health for the county. In a code county or charter county the governing body has the option of appointing a board of health or serving that function themselves. Responsibilities of the local boards of health are to meet each May and October, to coordinate its activities with the Department, to report to the Department on the sanitary conditions of the county whenever the Board considers it important and necessary, and to adopt and enforce rules and regulations on any nuisance or cause of disease in the county. E. Staff In three jurisdictions the local staff is employed by the county. In 21 jurisdictions the staff is employed by the state. However, in all jurisdictions, except Baltimore City, the health officer is a state employee. The number of employees for an individual local health department ranges from 49 to 706. F. Budget Total FY 1988 LPHA expenditures were $99,542,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $2,424,000 State Funds $41,575,000 Local Funds $32,079,000 Fees and Reimbursements 0 Other Sources $23,463,000 Source Unknown 0 2Maryland Department of Health and Mental Hygiene, 1990 Governor Secretary Deputy Secretary for Operations Deputy Secretary for Public Health Services Office of Health Program Support/Special Projects Local Health Administration AIDS Administration Alcohol and Drug Abuse Administration Community Health Surveillance and Laboratory Administration Developmental Disabilities Administration Family Health Administration Mental Hygiene Administration Deputy Secretary for Health Care Policy, Finance and Regulation 2Types of Local Health Departments by Jurisdiction Maryland, 1990 Jurisdiction Co C Allegany X Anne Arundel X Baltimore X Baltimore City X Calvert X Caroline X Carroll X Cecil X Charles X Dorchester X Frederick X Garrett X Harford X Howard X Kent X Montgomery X Prince Georges X Queen Annes X Somerset X St. Marys X Talbot X Washington X Wicomico X Worchester X Co = County HD 1MASSACHUSETTS 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 5,890,000 245,803,000 Population Density (1988) 752.8 69.4 (per/sq.mi.) Number of Counties 14 3,139 Median Age (1987) 33.0 31.7 Percent Below Poverty Level (1985) 9.3 14.0 (persons) Percent of Population Rural (1980) 16.0 26.0 Percent of Population White (1980) 93.5 83.1 Percent of Population Non-White (1980) 6.5 16.9 Median Years of Education (1980) 12.6 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The structure and authority for counties in Massachusetts are provided by the state constitution and statutes. Commission Form - (10) - Ten of the 14 counties in Massachusetts have 3-member county commissions, treasurers, and county advisory boards made up of locally elected officials. The primary function of counties under this framework is the administration of jails, houses of correction, court houses, and registries of deeds. Home Rule Charter - (2) - In 1985 Massachusetts enacted provisions of home rule authority which provided the counties with greater legislative authority. Home Rule Charters were adopted in Hampshire and Barnstable counties. Hampshire County adopted a charter plan which has a government body with 26 commissioners elected to 2-year terms from 26 towns in the county and an appointed administrator. The vote of each commissioner is weighted according to the population of the town from which he/she is elected. Barnstable County has a 3-member executive body elected at large, a 15-member legislative assembly elected by district, and an appointed administrator. The vote of the assembly members is weighted according to the population of their respective districts. Data for this state were updated February 1991. City/County Consolidation - (2) - These consolidations are Boston and Suffolk County and Nantucket and Nantucket County. Both governments operate with an elected executive. 3II. State Health Agency (SHA) A. General Component of Superagency The Massachusetts Department of Public Health (MDPH), the SHA, is a component of a superagency known as the Executive Office of Human Services. MDPH is one of 11 departments within the Secretariat of Human Services. The MDPH includes the following bureaus: Communicable Disease Control; Laboratory and Environmental Sciences, Environmental Monitoring and Regulation; Parent; Child and Adolescent Health; Health Statistics Research and Evaluation; Community Health Programs; Health Care Systems; Public Health Hospitals; and Substance Abuse. Initiatives of MDPH include the following: strengthen efforts to fight AIDS and substance abuse; promote better adolescent health; reduce infant deaths; decrease environmental health hazards; reduce health risks for the poor; improve health care for the elderly; assure high quality, accessible health care for all citizens; and maximize the use of MDPH resources. The following are some broad areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Commissioner is head of the Department of Public Health. This officer is appointed by the Governor and responsible to the Secretary of Human Services. The Commissioner sits on the Public Health Council, the final decision-making body for the state public health policies. C. State Board of Health/Council Policy-making Massachusetts has a State Public Health Council which consists of eight members and the Commissioner who serves as chairman. Three of the appointed members must be providers of health services, of whom two must be physicians. The five remaining members must not be providers of health care. Three of these must be selected from a list of candidates submitted by the Secretary of Elder Affairs. The term of office is 6 years. Members are appointed by the Governor with advice and consent of the Senate. The Council is responsible for approving public health policy for the operation of the health department and its programs. D. Regional/District Health Offices MDPH has two regional units which serve local health departments and boards--one in western Massachusetts and the other in the Boston central office. They provide consultation and technical assistance, planning and coordination, inspection and code enforcement, and continuing education and training. Overall, staff in the two regional offices represent the following MDPH programs: community sanitation, childhood lead poisoning prevention, radon control, AIDS, communicable diseases, prenatal outreach, high-risk infant and early childhood intervention, school nursing and case management for children with special health care needs. E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Informal Liaison Function MDPH has not designated one office or individual the responsibility for liaison between the SHA and local health agencies. Specific programs communicate directly with the local boards of health. Staff units in the two regional offices, which are extensions of the central office, function as liaisons for information and referral. The interaction between state and local public health agencies in Massachusetts may be characterized as mixed centralized and decentralized organizational control. Under this arrangement local health services may be provided by the SHA in some jurisdictions and by local governmental units, boards of health, or health departments in other jurisdictions. F. Budget Total FY 1988 Massachusetts SHA expenditures were $281,759,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $61,555,000 State Funds $220,204,000 Local Funds 0 Fees and Reimbursements 0 Other 0 3III. Local Public Health Agencies (LPHAs) A. General Massachusetts has 351 cities and towns, each with their own local board of health. Although the commonwealth has no direct authority over these health units, it does have authority by regulation and mandate to determine their functions and activities. The local units range from offices staffed only with volunteer, part-time board members or part-time staff, to full-fledged health departments. While information on the specifics of local staffing is limited, estimates are that Massachusetts has approximately 183 local units which have at least one full-time employee and thereby meet our definition of a local health department. Seven of these represent multitown jurisdictions (intermunicipal health districts) which enable member towns to share staff and other resources. Massachusetts has one county health department (Barnstable). B. Services Provided The following information on services provided by local health departments in Massachusetts is derived from a survey conducted by NACHO during 1989. Two hundred and thirty-nine of the 359 local boards of health in Massachusetts responded to the survey. Services provided by at least 70 percent of the boards of health in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 17 ( 7.1%) 2. Morbidity Data 70 ( 29.3%) 3. Reportable Diseases 172 ( 72.0%) 4. Vital Records and Statistics 82 ( 34.3%) B. Epidemiology/Surveillance 1. Chronic Diseases 48 ( 20.1%) 2. Communicable Diseases 174 ( 72.8%) II. Policy Development A. Health Code Dev. and Enforcement 198 ( 82.8%) B. Health Planning 87 ( 36.4%) C. Priority Setting 70 ( 29.3%) III. Assurance Activities A. Inspection 1. Food and Milk Control 201 ( 84.1%) 2. Health Facility Safety/Quality 125 ( 52.3%) 3. Rec. Facility Safety/Quality 154 ( 64.4%) 4. Other Facility Safety/Quality 83 ( 34.7%) B. Licensing 1. Health Facilities 89 ( 37.2%) 2. Other Facilities 215 ( 90.0%) C. Health Education 103 ( 43.1%) D. Environmental 1. Air Quality 100 ( 41.8%) 2. Hazardous Waste Management 155 ( 64.9%) 3. Individual Water Supply Safety 150 ( 62.8%) 4. Noise Pollution 87 ( 36.4%) 5. Occupational Health and Safety 57 ( 23.8%) 6. Public Water Supply Safety 117 ( 49.0%) 7. Radiation Control 40 ( 16.7%) 8. Sewage Disposal Systems 204 ( 85.4%) 9. Solid Waste Management 166 ( 69.5) 10. Vector and Animal Control 133 ( 55.6%) 11. Water Pollution 163 ( 68.2%) E. Personal Health Services 1. AIDS Testing and Counseling 18 ( 7.5%) 2. Alcohol Abuse 16 ( 6.7%) 3. Child Health 76 ( 31.8%) 4. Chronic Diseases 50 ( 20.9%) 5. Dental Health 34 ( 14.2%) 6. Drug Abuse 24 ( 10.0%) 7. Emergency Medical Service 17 ( 7.1%) 8. Family Planning 11 ( 4.6%) 9. Handicapped Children 13 ( 5.4%) 10. Home Health Care 73 ( 30.5%) 11. Hospitals 6 ( 2.5%) 12. Immunizations 139 ( 58.2%) 13. Laboratory Services 25 ( 10.5%) 14. Long-term Care Facilities 10 ( 4.2%) 15. Mental Health 27 ( 11.3%) 16. Obstetrical Care 6 ( 2.5%) 17. Prenatal Care 23 ( 9.6%) 18. Primary Care 11 ( 4.6%) 19. Sexually Transmitted Diseases 29 ( 12.1%) 20. Tuberculosis 96 ( 40.2%) 21. WIC 12 ( 5.0%) C. Local Health Officer No M.D. Requirement, Local Government Body Appointment Approximately 75 percent of Massachusetts towns and cities hire health agents; in 45 percent, the agents are full-time, in 30 percent part-time. The local health officer may or may not supervise staff. Except for the larger communities, local health officers are hired by local boards of health, or the mayor (with council approval), depending on the form of local government. The local board of health usually develops a contract with its health officer. Local personnel policies and employee benefits generally apply. He/she is involved in direct health protection activities, which include inspections for permits and licenses, responding to emergencies and complaints and reviewing plans for facilities siting. Areas of responsibility include food service, retail food, swimming pools, and beaches, private wells, septic systems, recreational camps for children, solid waste transfer, and housing and nuisance complaints. He/she also maintains public records, keeps local board of health members informed and organizes their regular meetings, hearings, and public education campaigns. There is no involvement of county government, except in Barnstable County, where county-level staff coordinate activities with additional staff hired by the local health boards. MDPH regional office staffs in western Massachusetts, as well as Boston, provide consultation and training for local health officers and board members on code enforcement and other health-related programs such as cancer reduction and AIDS education. Outside western Massachusetts, these functions are performed solely by MDPH staff in Boston. The State Department of Environmental Protection carries out similar functions for program areas under its jurisdiction, including subsurface sewage and solid waste disposal. D. Local Board of Health Policy-making The local board of health was established by state legislation. If a town does not choose to elect or have its Board of Selectmen appoint a board of health, the Board of Selectmen act as the Board of Health. Terms of office are generally staggered--1, 2 and 3 years. Most boards have three members; some have five. Local health boards may appoint agents to act in their behalf to handle code enforcement matters; however, final responsibility rests with the board, which must conduct all its business at regular or special public meetings, posted in advance. Functions include: enforcement of the state sanitary and environmental codes mentioned above, and handling of public emergencies, nuisance problems and facilities siting. The local board of health has extensive authority to enact local regulations, to act in emergencies or to abate public health nuisances, and to review and make decisions regarding definitive housing subdivisions plans. Most are involved in vector control programs, many conduct lead paint inspections and approximately one-third manage solid waste disposal facilities and programs. E. Staff Local staffs are all employed by the local boards of health or health departments. Some 3-year state seed grants have been available for newly created, multitown health districts to encourage smaller towns to obtain shared professional expertise. The District boards, which employ the staff, contain equal representation from their constituent towns, which still maintain their individual health boards. No county or state unit employs local public health staff. F. Budget Total FY 1988 LPHA expenditures were $2,396,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $1,529,000 State Funds $868,000 Local Funds 0 Fees and Reimbursements 0 Other Sources 0 Source Unknown 0 2Massachusetts Department of Public Health, 1990 Commissioner's Office Planning and Policy Government Relations General Counsel Management and Resources Administration Finance AIDS Office Communicable Disease Center Laboratory and Environmental Sciences Environmental Monitoring and Regulation Parent, Child and Adolescent Health Health Statistics, Research and Evaluation Community Health Programs Health Care Systems Public Health Hospitals Substance Abuse 2Types of Local Health Departments by Jurisdiction Massachusetts, 1990 Jurisdiction Co C N/Co T/T M/T Abington X Achusnet X Acton X Agawam X Amesbury X Amhurst X Andover X Arlington X Athol X Attleboro X Auburn X Avon X Barnstable X Barnstable X Bedford X Bellingham X Belmont X Berkshire X Beverly X Billerica X Blackstone X Boston X Bourne X Boxford-Topsfield X Braintree X Bridgewater X Bristol X Brocton X Brookline X Burlington X Cambridge X Canton X Charlton X Chelmsford X Chelsea X Chicopee X Clinton X Cohasset X Concord X Danvers X Dartmouth X Dedham X Dighton X Dracut X Dudley X Dukes X E. Franklin Co. X Easton X Essex X Essex X Everett X Fall River X Falmouth X Fitchburg X Foothills X Foxborough X Framington X Franklin X Franklin X Freetown X Gardner X Georgetown X Glouchester X Greenfield X Hamilton X Hampden X Hampden X Hampshire X Hanover X Harwich X Haverhill X Hingham X Holbrook X Holden X Holliston X Holyoke X Hopkinton X Hudson X Hull X Ipswich X Kingston X Lakeville X Lawrence X Leominster X Lexington X Longmeadow X Lowell X Ludlow X Lynn X Lynnfield X Malden X Manchester X Mansfield X Marblehead X Marion X Marlborough X Marshfield X Mashpee X Mattapoisett X Maynard X Medford X Medway X Melrose X Methuen X Middleborough X Middlesex X Middleton X Milford X Milton X Nahant X Nantucket X Nantucket X Nashoba Association X Natick X New Bedford X Newburyport X Newton X Norfolk X North Adams X North Andover X North Attleboro X North Reading X Northampton X Northborough X Norwell X Norwood X Orange X Orleans X Oxford X Paxton X Peabody X Pembroke X Pepperell X Pittsfield X Plymouth X Plymouth X Provincetown X Quabbin District X Quincy X Randolph X Raynham X Reading X Rehoboth X Revere X Rockland X Rockport X Rowe X Salem X Saugus X Scituate X Seekonk X Sharon X Sheffield X Sherborn X Shrewsbury X Somerset X Somerville X Southborough X Southbridge X Spencer X Springfield X Sterling X Stoneham X Stoughton X Stow X Sudbury X Suffolk X Swampscott X Swansea X Taunton X Tewksbury X Tri-town District X Tyngsborough X Wakefield X Walpole X Waltham X Wareham X Watertown X Wayland X Welfleet X Wellesley-Needham X West Newbury X West Springfield X Westborough X Westfield X Westport X Westwood X Weymouth X Whitman X Williamstown X Wilmington X Winchendon X Winthrop X Woburn X Worcester X Worchester X Co = County HD C = City HD T/T = Town/Township HD N/Co = No County HD M/T = Multitownship HD 1MICHIGAN 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 9,240,000 245,803,000 Population Density (1988) 162.2 69.4 (per/sq.mi.) Number of Counties 83 3,139 Median Age (1987) 31.1 31.7 Percent Below Poverty Level (1985) 14.5 14.0 (persons) Percent of Population Rural (1980) 29.0 26.0 Percent of Population White (1980) 85.0 83.1 Percent of Population Non-white (1980) 15.0 16.9 Median Years of Education (1980) 12.5 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The structure and authority of county governments in Michigan are determined by the state constitution, state statutes and court cases. Three forms of government are available to Michigan counties: Commission, Charter, and United Forms. Commission Form - (80) - Commissions are used by 80 counties. The boards of commissioners are made up of 5 to 35 members, determined by population, and elected from single-member districts. State law permits commission counties to hire other employees that they consider necessary. Under this provision 31 counties have appointed an administrator and 18 have hired a fiscal controller. Charter Form - (1) - One county has adopted the Charter Form of government. The Charter has home rule provisions which permit the county to elect an executive officer. Under the Charter the board of commissioners become primarily a legislative body with administrative functions transferred to the executive. United Form - (2) - The United Form is currently being used by two counties: Oakland and Bay. This type of government provides more local options than the Commission but fewer than the Charter. While it allows counties to elect an executive officer Data for this state were updated December 1990. or appoint a manager, both counties have chosen elected executives. The executive is elected to 4-year terms and is stronger than an appointed manager because of veto power. 3II. State Health Agency (SHA) A. General Free-standing, Independent The State Health Agency is an independent, free-standing agency known as the Michigan Department of Public Health (MDPH). The mission of the Department is to continually and diligently endeavor to prevent disease, prolong life, and promote the public health through organized programs, including prevention and control of environmental hazards; prevention and control of diseases; prevention and control of health problems of particularly vulnerable population groups; development of health care facilities and agencies and health services delivery systems; and regulation of health care facilities and agencies and health services delivery systems to the extent provided by law. Major department functions are divided among the following four bureaus and two centers: Center for Environmental Health Sciences; Bureau of Environmental and Occupational Health; Bureau of Community Health Services; Center for Health Promotion; Bureau of Health Facilities; and Bureau of Laboratory and Epidemiological Services. The following are some areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The head of the SHA is the State Health Director, who is a cabinet-level officer appointed by the Governor. Under state law if the state health director is not a physician, the Director must designate a physician as the chief medical executive of the department. The Director, with the approval of the Governor, may establish the internal organization of the department and is responsible for all internal administrative procedures. C. State Board of Health/Council Advisory Michigan has the Public Health Advisory Council that consists of 16 members who are appointed by the Governor. The Council is to represent consumers and providers of health and to be representative of the population as to sex, race, and ethnicity and will include representatives of the local governing body. The term of office is 4 years. As the name indicates, the duties of this Council involve advising and consulting with the Director on public health programs and policy. D. Regional/District Health Offices The Bureau of Community Services has divided the state into three administrative regions: Northern region, Eastern region, and Western region. Each of the regions has a regional office, located in Lansing. Through the regional offices the bureau provides advice, policy direction, and technical support to local agencies charged with the delivery of health services. Also, they develop comprehensive plans, execute performance contracts with local agencies, and monitor and evaluate local agency performance. The typical regional office staff consists of 15 to 20 persons led by an administrative head, the Regional Chief. Under the Regional Chief are two sections, the Operations Section and the Program Section, which are supervised by section chiefs. The Operations Section is staffed by administrative types of personnel. The Program Section is staffed primarily by individuals who are program consultants. E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Formal Liaison Function The function of state-local liaison has evolved from a separate office within the Department, with some oversight responsibilities, to a single position reporting to the Director. It is this individual's responsibility to see that the Department's programs with local public health departments are coordinated, to act as an ombudsman for local health department concerns, and to represent the Director in dealing with local issues. The interaction between state and local public health agencies in Michigan may be characterized as mixed centralized and decentralized organizational control. Under this arrangement local health services may be provided by the SHA in some jurisdictions and by local governmental units, boards of health, or health departments in other jurisdictions. F. Budget Total FY 1988 Michigan SHA expenditures were $306,640,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $126,208,000 State Funds $142,265,000 Local Funds $414,000 Fees and Reimbursements $32,085,000 Other $4,896,000 3III. Local Public Health Agencies (LPHAs) A. General Michigan has 50 local health departments, consisting of 35 county health departments, 14 multicounty health departments (known as districts) and 1 city health department. These local departments can be organized in any of the four following ways: single county units; district health departments comprised of two or more counties; city health departments in cities with 750,000 or more population; or associated health departments in which two or more local governing entities may contract for employment of personnel or the consolidation of functions of their local health departments. Eight of these units are currently associated units. Each county maintaining an approved county health department is entitled to participate in cost sharing by the state. Other state and Federal funds are also available to local health departments through MDPH in the form of general and categorical appropriations made by the State Legislature and Congress to meet specific needs or health problems. B. Services Provided The following information on services provided by local health departments in Michigan is derived from a survey conducted by NACHO during 1989. Forty-seven of 50 local health departments in Michigan responded to the survey. Services provided by 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 24 ( 51.1%) 2. Morbidity Data 28 ( 59.6%) 3. Reportable Diseases 45 ( 95.7%) 4. Vital Records and Statistics 23 ( 48.9%) B. Epidemiology/Surveillance 1. Chronic Diseases 28 ( 59.6%) 2. Communicable Diseases 46 ( 97.9%) II. Policy Development A. Health Code Dev. and Enforcement 43 ( 91.5%) B. Health Planning 28 ( 59.6%) C. Priority Setting 31 ( 66.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 31 ( 66.0%) 2. Health Facility Safety/Quality 20 ( 42.6%) 3. Rec. Facility Safety/Quality 37 ( 78.7%) 4. Other Facility Safety/Quality 9 ( 19.1%) B. Licensing 1. Health Facilities 4 ( 8.5%) 2. Other Facilities 44 ( 93.6%) C. Health Education 35 ( 74.5%) D. Environmental 1. Air Quality 15 ( 31.9%) 2. Hazardous Waste Management 29 ( 61.7%) 3. Individual Water Supply Safety 45 ( 95.7%) 4. Noise Pollution 5 ( 10.6%) 5. Occupational Health and Safety 10 ( 21.3%) 6. Public Water Supply Safety 42 ( 89.4%) 7. Radiation Control 14 ( 29.8%) 8. Sewage Disposal Systems 43 ( 91.5%) 9. Solid Waste Management 32 ( 68.1%) 10. Vector and Animal Control 41 ( 87.2%) 11. Water Pollution 40 ( 85.1%) E. Personal Health Services 1. AIDS Testing and Counseling 45 ( 95.7%) 2. Alcohol Abuse 12 ( 25.5%) 3. Child Health 47 (100.0%) 4. Chronic Diseases 37 ( 78.7%) 5. Dental Health 13 ( 27.7%) 6. Drug Abuse 14 ( 29.8%) 7. Emergency Medical Service 11 ( 23.4%) 8. Family Planning 44 ( 93.6%) 9. Handicapped Children 42 ( 89.4%) 10. Home Health Care 24 ( 51.1%) 11. Hospitals - 12. Immunizations 47 (100.0%) 13. Laboratory Services 16 ( 34.0%) 14. Long-term Care Facilities 7 ( 14.9%) 15. Mental Health 2 ( 4.3%) 16. Obstetrical Care 14 ( 29.8%) 17. Prenatal Care 39 ( 83.0%) 18. Primary Care 7 ( 14.9%) 19. Sexually Transmitted Diseases 46 ( 97.9%) 20. Tuberculosis 47 (100.0%) 21. WIC 39 ( 83.0%) C. Local Health Officer No M.D. Requirement, Board of Health or Governing Body Appointment State law requires that each local public health department have a full-time local health officer. This officer may be a medical health officer or an administrative health officer. The medical health officer must be a licensed physician while the administrative health officer has no such requirement. If the health officer is not a physician, a medical director must be employed who is responsible to the health officer for medical decisions. The health officer functions as the administrative officer of the board of health and as the director of the department. In single county health departments, the board of health usually selects and refers the preferred candidate to the local governing entity with the recommendation for appointment. In districts the board of health selects and appoints the health officer. D. Local Board of Health Policy-making County governments are authorized by state law to appoint a board of health. Cities with 750,000 or more population also have this authority. State law provides for formation of district boards of health when district health departments are created. The district board of health is composed of two members from each county board of commissioners, or two members appointed by the mayor in the case of a city. A county or city may have more representatives with consent of the local governing bodies. The major responsibility of the local board of health is to learn as much as possible about health problems of the community and to participate actively in finding solutions for these problems. Other duties of the local boards of health include the following: approve the health department programs; interpret health department programs; approve the budget; approve expenditures; and adopt regulation for approval by the local governing body. E. Staff All local public health departments have as a minimum the following staff members: medical or administrative health officer, medical director (if an administrative health officer is employed), administrator, public health nurses, environmental health staff, office manager, bookkeepers, clerks, health educators, vision and hearing technicians, accountants, laboratory technicians, dentists, physical therapists, and home health aids. The number of staff for a local health department ranges from 9 to 911. The staff are employed and supervised by the jurisdiction that they serve. F. Budget Total FY 1988 LPHA expenditures were $287,078,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $41,347,000 State Funds $77,990,000 Local Funds $112,338,000 Fees and Reimbursements $47,388,000 Other Sources $8,014,000 Source Unknown 0 The SHA reported that these figures include the total amount of additional monies expended by all local health departments. 2Michigan Department of Public Health, 1990 State Health Director Public Health Advisory Council Office of Substance Abuse Services Chief Medical Executive Food and Nutrition Commission Deputy Directors Affirmative Action Office of Budget and Finance Office of Personnel Office of General Services Office of Management Information Systems Office of State Registrar and Center for Health Statistics Office of the Director Publications and Media Services Legislative Liaisons Federal Liaison Center for Environmental Health Sciences Bureau of Environmental and Occupational Health Bureau of Community Services 50 Local Health Departments Center for Health Promotion Bureau of Health Facilities Bureau of Laboratory and Epidemiological Services 2Types of Local Health Departments by Jurisdiction Michigan, 1990 Jurisdiction Co M/Co Alcona X Alger X Allegan X Alpena X Antrim X Arenac X Baraga X Barry X Bay X Benzie X Berrien X Branch X Calhoun X Cass X Charlevoix X Cheboygan X Chippewa X Clare X Clinton X Crawford X Delta X Dickinson X Eaton X Emmet X Genesee X Gladwin X Gogebic X Grand Traverse X Gratiot X Hillsdale X Houghton X Huron X Ingham X Iona X Iron X Isabella X Jackson X Kalamazoo X Kalkaska X Kent X Keweenaw X Lake X Lapeer X Leeanau X Lenawee X Livingston X Losco X Luce X Mackinac X Macomb X Manistee X Marquette X Mason X Mecosta X Midland X Minominee X Missaukee X Monroe X Montcalm X Montmorency X Muskegon X Newaygo X Oakland X Oceana X Ogemaw X Ontonagon X Osceola X Oscoda X Otsego X Ottawa X Presque Isle X Roscommon X Saginaw X Sanilac X Scoolcraft X Shiawassee X St. Clair X St. Joseph X Tuscola X Van Buren X Washtenaw X Wayne X Wexford X Co = County HD M/Co = Multicounty HD 1MINNESOTA 2Public Helath System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 4,307,000 245,803,000 Population Density (1988) 54.1 69.4 (per/sq.mi.) Number of Counties 87 3,139 Median Age (1987) 31.5 31.7 Percent Below Poverty Level (1985) 12.6 14.0 (persons) Percent of Population Rural (1980) 33.0 26.0 Percent of Population White (1980) 96.6 83.1 Percent of Population Non-white (1980) 3.4 16.9 Median Years of Education (1980) 12.6 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The state constitution and statutes provide authority and structure for county governments in Minnesota. Commission Form - (87) - Commission is the basic structure for county governments. The boards are made up of three, five, seven, or nine members who are elected from single-member districts. Minnesota counties may choose one or more options from the following five choices: 1. Elected Executive Plan 2. County Manager Plan 3. At-large Chair Plan 4. County Administrator Plan 5. Auditor-Administrator Plan APPOINTED ADMINISTRATORS - (30) - This is an appointed position with full administrative powers. Data for this state were updated November 1990. AUDITOR-ADMINISTRATOR PLAN - (12) - This involves the election of an auditor who serves primarily in a fiscal capacity but also has some administrative responsibilities. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Minnesota Department of Health (MDH), the SHA, is a free-standing, independent agency. The mission of MDH is to protect, maintain, and improve the health of citizens of the state through the development and maintenance of an organized system of programs and services carried out by both state and local government with the cooperation of non-governmental entities. The following are some areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Commissioner of Health is the Chief Executive Officer for the SHA. The Commissioner is appointed by the Governor with the consent of the Senate. There is no requirement for the Commissioner to be a physician. Selection is to be based on ability and experience in matters of public health. Responsibilities of the position include the administration of the SHA and its offices, establishing standards for community health boards, and assisting in the development, administration, and implementation of community health services. C. State Board of Health/Council Advisory Minnesota does not have a State Board of Health or Health Council. However, it does have an advisory committee called the State Community Health Services Advisory Committee. The Committee is composed of representatives from each of the 48 local community health boards. The State Committee is required by law to meet at least four times a year and provide advice, consultation, and recommendations to the Commissioner regarding the development, maintenance, funding and evaluation of community health services (CHS). The Department relies on the State CHS Advisory Committee for assistance in making policy and technical decisions related to the CHS subsidy program and to local public health in general. D. Regional/District Health Offices MDH has seven district offices. The geographic area that these district offices serve varies from program to program depending on the service and the population served. In fact district maps are different for almost every program. The district offices are staffed with MDH employees. The following is a list of staff that is housed in a district: District Representative District Clerk Typist District Epidemiologist Community Environmental Services Consultant Environmental Field Services Sanitarian/Supervisor Emergency Medical Services Consultant Health Facility Evaluator Unit Supervisor Health Facility Evaluator Administrative Specialist Health Facility Evaluator Laboratory Specialist Health Facility Evaluator Nurse Consultant Health Facility Evaluator Sanitarian Specialist Mothers and Children Program Consultant Public Health Nurse Consultant Quality Assurance and Review Registered Nurse Senior Quality Assurance and Review Social Worker Senior Services for Children with Handicaps Nurse Consultant Services for Children with Handicaps Social Worker Vision and Hearing Consultant Women, Infants and Children Program Consultant Water Supply and Engineering Engineer/Sanitarian/Supervisor E. State-local Liaison Shared Organizational Control, Formal Liaison Function The Local Public Health Act of 1987 (MN stay. 145A) was enacted to develop and maintain an integrated system of community health services under local administration and within a system of state guidelines and standards. The mission of Community Health Services is to bring people to protect and promote the health of the general population within a community health service area. This is accomplished by the prevention of disease, injury, disability, and preventable death through the promotion of effective coordination and use of community resources, and by extending health services into the community. The Community Health Services Division of MDH serves as the entity with responsibility for state-local liaison activities. In this role the Division assists the State CHS Advisory Committee by coordinating, facilitating, and providing staff support for the committee. The District Representatives that are assigned to the district offices work for the Division. They are responsible for maintaining the regional offices and assisting the community health boards with administrative questions. The Division also assigns public health nursing consultants to the regional offices to provide technical assistance to the 48 community health boards on matters relating to programs. Other program specialists are in the regional offices to provide assistance to the community health boards. The interaction between state and local public health agencies in Minnesota may be characterized as shared organizational control. Under this arrangement local health departments are under the authority of the SHA as well as the local government and board of health. F. Budget Total FY 1988 Minnesota SHA expenditures were $87,454,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $49,983,000 State Funds $35,675,000 Local Funds 0 Fees and Reimbursements $1,748,000 Other $48,000 3III. Local Public Health Agencies (LPHAs) A. General In Minnesota all 87 counties are served by 48 local health entities. These entities consist of 20 county health departments, 23 multicounty units and 5 city health departments. The SHA provides funds to eligible local boards of health through a formula established in 1987. This formula is a base allocation of funds equal to or above the 1985 appropriation plus a per capita allocation of that amount above the 1985 base. The local match required is now a dollar of local effort for each dollar of state subsidy. B. Services Provided The following information on services provided by local health departments in Minnesota is derived from a survey conducted by NACHO during 1989. Forty-six of the 48 local health departments in Minnesota responded to the survey. Services provided by 70 percent of the local health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 26 ( 56.5%) 2. Morbidity Data 18 ( 39.1%) 3. Reportable Diseases 32 ( 69.6%) 4. Vital Records and Statistics 13 ( 28.3%) B. Epidemiology/Surveillance 1. Chronic Diseases 20 ( 43.5%) 2. Communicable Diseases 30 ( 65.2%) II. Policy Development A. Health Code Dev. and Enforcement 24 ( 52.2%) B. Health Planning 39 ( 84.8%) C. Priority Setting 40 ( 87.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 14 ( 30.4%) 2. Health Facility Safety/Quality 7 ( 15.2%) 3. Rec. Facility Safety/Quality 18 ( 39.1%) 4. Other Facility Safety/Quality 5 ( 10.9%) B. Licensing 1. Health Facilities 3 ( 6.5%) 2. Other Facilities 20 ( 43.5%) C. Health Education 35 ( 76.1%) D. Environmental 1. Air Quality 12 ( 26.1%) 2. Hazardous Waste Management 12 ( 26.1%) 3. Individual Water Supply Safety 30 ( 65.2%) 4. Noise Pollution 9 ( 19.6%) 5. Occupational Health and Safety 5 ( 10.9%) 6. Public Water Supply Safety 16 ( 34.8%) 7. Radiation Control 3 ( 6.5%) 8. Sewage Disposal Systems 22 ( 47.8%) 9. Solid Waste Management 18 ( 39.1%) 10. Vector and Animal Control 25 ( 54.3%) 11. Water Pollution 23 ( 50.0%) E. Personal Health Services 1. AIDS Testing and Counseling 16 ( 34.8%) 2. Alcohol Abuse 8 ( 17.4%) 3. Child Health 44 ( 95.7%) 4. Chronic Diseases 43 ( 93.5%) 5. Dental Health 10 ( 21.7%) 6. Drug Abuse 3 ( 6.5%) 7. Emergency Medical Service 26 ( 56.5%) 8. Family Planning 34 ( 73.9%) 9. Handicapped Children 37 ( 80.4%) 10. Home Health Care 43 ( 93.5%) 11. Hospitals - 12. Immunizations 44 ( 95.7%) 13. Laboratory Services 10 ( 21.7%) 14. Long-term Care Facilities 2 ( 4.3%) 15. Mental Health 13 ( 28.3%) 16. Obstetrical Care 4 ( 8.7%) 17. Prenatal Care 39 ( 84.8%) 18. Primary Care 15 ( 32.6%) 19. Sexually Transmitted Diseases 23 ( 50.0%) 20. Tuberculosis 29 ( 63.0%) 21. WIC 37 ( 80.4%) C. Local Health Officer No Local Health Officer There are no local health officers in Minnesota. The local board of health is required to appoint an "agent" to act on the board's behalf, but this agent functions as an administrator rather than a health officer. D. Local Board of Health Policy-making The governing body of a city or county is responsible for assuming the duties of a board of health or appointing and empowering a community health board. One political jurisdiction may request a neighboring jurisdiction to undertake the responsibilities of a board of health. Two or more contiguous counties or city and county combinations may establish a joint board of health (joint powers board). The board consists of at least five members appointed by the local governing body(ies). They are required to meet at least twice a year. A county or multicounty board of health has responsibility and power of a board of health for the entire jurisdiction unless a city board of health is present within the jurisdiction. The board, under supervision of the Commission, enforces laws, regulations and ordinances within its jurisdiction and areas of responsibility. A community health board has the powers and duties of a board of health, as well as the general responsibility for development and maintenance of an integrated system of community health services. There are currently 48 community health boards in Minnesota. These boards were initiated to develop and maintain an integrated system of community health services under local administration and within a system of state guidelines and standards. Boards of health may qualify as community health boards if they meet specific requirements established by law. The following are some of the requirements: meets requirements specified in sections 145A.09 to 145A.13 of the Local Public Health Act and is eligible for community health subsidy under section 145A.13; the board must include within its jurisdiction a population of 30,000 or more or be composed of three or more contiguous counties; and a city which meets requirements of law and is eligible for a community health subsidy. Within a year of the approval of a community health plan by the commissioner, all other boards of health within the jurisdiction are generally required to cease to exist. Some exceptions include: a joint powers agreement; a delegation agreement; or a jurisdiction which includes a city with 300,000 or more population. Local community health boards are required to meet at least three times a year to assist in the process of community assessment, priority setting, program planning and budgeting, and other functions related to community health services activities. They are also required to submit formal plans every 2 years, submit annual activity reports and to meet other eligibility requirements established in statute and rule. E. Staff Local health department staffs are employed and supervised by the jurisdiction that they serve. The number of employees for a local health department ranges from 1 to 200. F. Budget Total FY 1988 LPHA expenditures were $128,537,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $13,230,000 State Funds $16,500,000 Local Funds $40,944,000 Fees and Reimbursements $51,132,000 Other Sources 0 Source Unknown $6,731,000 The SHA reported that these figures include the total amount of additional local health department monies expended by all local health departments. 2Minnesota Department of Health, 1990 Governor Commissioner of Health Assistant to Commissioner Health Law Executive Budget Officer Office of Health Facility Complaints Bureau of Administration Health Information and General Services Deputy Commissioner Office of Legal and Policy Affairs Bureau of Health Delivery Systems Community Health Services Health Resources Health Systems Development Maternal and Child Health Bureau of Health Protection Disease Prevention and Control Environmental Health Health Promotion and Education Public Health Laboratory 2Types of Local Health Departments by Jurisdiction Minnesota, 1990 Jurisdiction Co C M/Co Aitkin X Anoka X Becker X Beltrami X Benton X Big Stone X Bloomington X Blue Earth X Brown X Carlton X Carver X Cass X Chippewa X Chisago X Clay X Clearwater X Cook X Cottonwood X Crow Wing X Dakota X Dodge X Douglas X Edina X Faribault X Fillmore X Freeborn X Goodhue X Grant X Hennepin X Houston X Hubbard X Isanti X Itasca X Jackson X Kanabec X Kandiyohi X Kittson X Koochiching X Lac qui Parle X Lake X Le Sueur X Lincoln X Lyon X Mahonomen X Marshall X Martin X McLeod X Meeker X Mille Lacs X Minneapolis X Morrison X Mower X Murray X Nicollet X Nobles X Norman X Olmstead X Otter Tail X Pennington X Pine X Pipestone X Polk X Pope X Ramsey X Red Lake X Redwood X Renville X Rice X Richfield X Rock X Roseau X Scott X Sherburne X Sibley X St Louis X St. Paul X Stearns X Steele X Stevens X Swift X Todd X Traverse X Wabasha X Wadena X Waseca X Washington X Watonwan X Wilkin X Winona X Co = County HD C = City HD M/Co = Multicounty HD 1MISSISSIPPI 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) * 2,748,786 245,803,000 Population Density (1988) * 57.5 69.4 (per/sq.mi.) Number of Counties 82 3,139 Median Age (1987) 29.1 31.7 Percent Below Poverty Level (1985) 25.1 14.0 (persons) Percent of Population Rural (1980) * 52.7 26.0 Percent of Population White (1980) 64.1 83.1 Percent of Population Non-white (1980) 35.9 16.9 Median years of Education (1980) 12.2 12.5 (25 Years of age and over) B. County Government Structure Home Rule Authority Counties are empowered by the state constitution and the Mississippi Code. Commission Form - (82) - County governments utilize a five-member Board of Supervisors, based on the Commission Form of government. The supervisors, who are the governing body, are elected from single-member districts. Within this form of government are two different organizational structures, the Unit System and the Beat System. Unit System - (47) - The five supervisors elected from single-member districts serve as the governing body. It differs in that administrative functions are placed under the authority of a county road manager who is appointed by the board of supervisors. This system includes more centralization in the area of policy, administrative, and budgetary affairs. Fourteen of these counties also have appointed county administrators. Beat System - (35) - Supervisors in this system have general authority over the whole county and limited responsibility Data for this state were updated November 1990. for managing roads and bridges in their individual districts. Two of these counties have appointed county administrators. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Mississippi State Department of Health (MSDH) is a free-standing, independent agency. The mission of the MSDH is to achieve the best possible health status for the citizens of Mississippi. This mission incorporates the following goals of public health: 1. To prevent or control diseases in the most cost-effective manner possible. 2. To provide protection for the public from threats to health and safety from several sources: unsanitary conditions related to food, drinking water, and sewage, unnecessary exposure to radiation, and unsafe and unhealthy conditions in health care facilities, child care facilities and the workplace. 3. To promote public policy and individual lifestyles which will improve the health status of all citizens. 4. To assure access to essential health services for the state's most vulnerable populations: low income women, infants and children, the elderly, and the disabled. The following are some areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs State Health Planning and Development Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency M.D. Requirement, Not Cabinet-level Appointment The State Health Officer is the Executive Officer for the SHA and has all authority and responsibility incumbent on the position by law. The State Health Officer is appointed by the State Board of Health for a term of 6 years. The appointee must be a physician with a graduate degree in public health or be a physician who, in the opinion of the Board, is fitted and equipped to execute the duties incumbent on the position by law. The State Health Officer may not engage in the private practice of medicine. This position has the authority of the board when it is not in session and is subject to the rules and regulations established by the State Board of Health. C. State Board of Health/Council Policy-making The State Board of Health consists of 13 members appointed by the Governor and confirmed by the Senate. Terms of office are 6 years and are staggered so that expirations are spread out. The members must be engaged professionally in rendering health services or be consumers of health services and have no financial conflict of interest. The members must also be knowledgeable in at least one of the matters of jurisdiction of the board. The following are some areas of responsibility for the State Board of Health: 1. To organize the SHA into bureaus and divisions that are considered necessary and to assign appropriate functions as required by law. 2. To provide general supervision of the health interest of the people of the state and to exercise the right, powers, and duties of those acts which it is authorized by law to enforce. 3. To establish programs to promote the public health, to be administered by the State Department of Health. 4. To make and publish all reasonable rules and regulations necessary to enable it to discharge its duties and powers and to carry out the purposes and objectives of its creation. D. Regional/District Health Offices The SHA has subdivided the state into nine public health districts. Each district has an office which has direct line authority over the local health departments within its jurisdiction. They also provide support and consultative services. The offices are staffed by 15 to 25 employees. The staffs usually include the following positions: District Health Officer District Administrator District Supervisor Nurse District Environmentalist District Office