CDC Home
Safer, Healthier People
CDC HomeCDC SearchHealth Topics A-Z
 
  WONDER Home FAQ Help Contact Us Search  
 

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) 639-1943
FOREWORD

 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 System Supervisor
      District Secretary
      District Social Worker
      District Nutritionist
      District Programmatic Coordinators (WIC, STD, TB)

      E.  State-local Liaison

 Centralized Organizational Control, Informal Liaison Function

 The Office of Field Services serves as a liaison between agency
 field staff and the central office and support staff and provides
 technical assistance to field and program staff.  Office staff is
 comprised of a director, a field clerical advisor/consultant, a
 field nursing advisor/consultant, and a field administrative
 advisor/consultant.  The field clerical advisor represents field
 clerical staff, the field nursing advisor represents field
 nursing staff, and the field administrative advisor represents
 district administrators and coordinates monthly district staff
 meetings and certain conferences between central office and
 district staff.  The function of the Office of Field Services
 involves several activities:

      1.   Responding to requests for field visits to identify
           problem areas and/or make recommendations for problem
           solving.

      2.   Responding to requests by the program and support staff
           as representatives of the field staff.

      3.   Providing consultation to district staff on matters
           such as manpower, budgets, and management.

      4.   Identifying training needs of field staff and providing
           technical assistance to the Office of Staff
           Development.

      5.   Providing consultation to program staff regarding
           development and field implementation of services.

      6.   Providing field staff with pertinent and timely
           information that impacts operations, i.e., state
           legislative activities, central office activities, and
           policy development and implementation.

                7.   Conducting special assignments and projects at the
           request of the State Health Officer, Chief of Special
           Staff, District Health Officers, or District
           Administrators.

 The interaction between state and local public health agencies in
 Mississippi may be characterized as centralized organizational
 control.  Under this arrangement local health departments
 function directly under the state's authority.

      F.  Budget

 Total FY 1988 SHA expenditures were $105,899,000.  Total FY 1988
 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts          $55,247,000
        State Funds                           $19,533,000
        Local Funds                            $8,717,000
        Fees and Reimbursements               $22,382,000
        Other                                           0
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 Mississippi has 81 local health departments, consisting of 80
 county health departments and 1 multicounty health department.
 In some counties there are full-time branches of the main health
 department.  In addition to the county health departments and
 full-time branches, the SHA operates a statewide home health
 program through a series of 26 regional offices.  The entire
 health department system operates under the State Board of Health
 and the MSDH through the nine district offices to local health
 departments and full-time branches.

 State funds are provided to local health departments through a
 "Funds Allocation Formula."  Through this mechanism the monies
 are distributed on the basis of population, poverty level, and
 the level of utilization of health department services.

      B.  Services Provided

 The following information on services provided by local health
 departments in Mississippi is derived from a survey conducted by
 NACHO during 1989.  Sixty-four of the 81 local health departments
 in Mississippi 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              24   ( 37.5%)
            2.  Morbidity Data                          31   ( 48.4%)
            3.  Reportable Diseases                     64   (100.0%)
            4.  Vital Records and Statistics            20   ( 31.3%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        62   ( 96.9%)
            2.  Communicable Diseases                   64   (100.0%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement              9   ( 14.1%)
       B.  Health Planning                               8   ( 12.5%)
       C.  Priority Setting                             15   ( 23.4%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   62   ( 96.9%)
            2.  Health Facility Safety/Quality          40   ( 62.5%)
            3.  Rec. Facility Safety/Quality            34   ( 53.1%)
            4.  Other Facility Safety/Quality           30   ( 46.9%)

       B.  Licensing
            1.  Health Facilities                       13   ( 20.3%)
            2.  Other Facilities                        53   ( 82.8%)

       C.  Health Education                             50   ( 78.1%)

       D.  Environmental
            1.  Air Quality                             14   ( 21.9%)
            2.  Hazardous Waste Management              17   ( 26.6%)
            3.  Individual Water Supply Safety          58   ( 90.6%)
            4.  Noise Pollution                          2   (  3.1%)
            5.  Occupational Health and Safety           2   (  3.1%)
            6.  Public Water Supply Safety              60   ( 93.8%)
            7.  Radiation Control                       20   ( 31.3%)
            8.  Sewage Disposal Systems                 61   ( 95.3%)
            9.  Solid Waste Management                  29   ( 45.3%)
           10.  Vector and Animal Control               56   ( 87.5%)
           11.  Water Pollution                         45   ( 70.3%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             64   (100.0%)
            2.  Alcohol Abuse                            3   (  4.7%)
            3.  Child Health                            64   (100.0%)
            4.  Chronic Diseases                        64   (100.0%)
            5.  Dental Health                           17   ( 26.6%)
            6.  Drug Abuse                               3   (  4.7%)
            7.  Emergency Medical Service                4   (  6.3%)
            8.  Family Planning                         62   ( 96.9%)
            9.  Handicapped Children                    58   ( 90.6%)
           10.  Home Health Care                        61   ( 95.3%)
           11.  Hospitals                                -
           12.  Immunizations                           64   (100.0%)
           13.  Laboratory Services                     58   ( 90.6%)
           14.  Long-term Care Facilities                1   (  1.6%)
           15.  Mental Health                            5   (  7.8%)
           16.  Obstetrical Care                        52   ( 81.3%)
           17.  Prenatal Care                           63   ( 98.4%)
           18.  Primary Care                            31   ( 48.4%)
           19.  Sexually Transmitted Diseases           64   (100.0%)
           20.  Tuberculosis                            64   (100.0%)
           21.  WIC                                     64   (100.0%)

       C.  Local Health Officer

 M.D. Requirement, State Board of Health Appointment

 A competent physician may be appointed county health officer for
 each county by the State Board of Health or its executive
 officer.  It is the duty of the county health officer to
 administer programs and enforce the public health provisions of
 the Mississippi Code and the rules and regulations of the State
 Board of Health applicable to the county.  The health officer
 must report results of investigations to the board of supervisors
 and the State Board of Health.

      D.  Local Board of Health

 No Local Boards of Health

      E.  Staff

 The staffs of local health departments are made up of Federal,
 state, and locally funded positions, and contract employees.
 Some salaries are funded from general fees which are third party
 collections.  The state and locally funded employees are all
 considered to be state employees.  The number of staff for a
 local health department ranges from 4 to 58.

      F.  Budget

 Total FY 1988 LPHA expenditures were $30,043,000 *.  Total FY
 1988 United States LPHA expenditures were $3,987,948,000.

      Source of Funds
        Federal Grants and Contracts      $9,449,000
        State Funds                       $5,388,000
        Local Funds                       $8,717,000
        Fees and Reimbursements           $6,498,000
        Other Sources                              0
        Source Unknown                             0

 * This figure does not include the following expenditures paid
 from the State Central Office Budget for the benefit of local
 Public Health Agency clients:

      WIC Food (Mississippi has a warehouse distribution center
        rather than a voucher system)
      Drugs (oral contraceptives, hypertension, and
        hemophilia medications)
      Hospital Care (sterilizations and high-risk maternity
        deliveries)
      Children's Medical Program Expenditures
      Laboratory Services
2Mississippi State Department of Health, 1990

 State Health Officer
   District Offices (9)
     County Health Departments (82)
   State Health Officer's Staff
 Bureau of Health Services
      Children's Medical Services Division
      Reproduction Health Division
      Perinatal Services Division
      Children's Health Division
      Women, Infant and Children Division
      Chronic Illness Division
      Home Health Division

 Bureau of Preventive Health Services
      Communicable Disease Control Division

 Bureau of Environmental Health
      Sanitation Division
      Water Supply Division
      Safety and Health Division
      Radiological Health Division

 Bureau of Administrative Services
      Finance and Accounts Division
      Personnel Division

 Bureau of Information Resources
      Public Health Statistics Division
      Data Administration and Development Division
      Data Processing Division

 Bureau of Health Resources and Laboratories
      Public Health Laboratory Division
      Planning and Resource Development Division
      Licensure and Certification Division
      Child Care and Special Division Licensure
      Emergency Medical Services
2Types of Local Health Departments by Jurisdiction
                                   Mississippi, 1990

           Jurisdiction                        Co     M/Co

           Adams                               X
           Alcorn                              X
           Amite                               X
           Attala                              X
           Benton                              X
           Bolivar                             X
           Calhoun                             X
           Carroll                             X
           Chickasaw                           X
           Choctaw                             X
           Clairborne                          X
           Clarke                              X
           Clay                                X
           Coahoma                             X
           Copiah                              X
           Covington                           X
           De Soto                             X
           Forrest                             X
           Franklin                            X
           George                              X
           Greene                              X
           Grenada                             X
           Hancock                             X
           Harrison                            X
           Hines                               X
           Holmes                              X
           Humphreys                           X
           Issaquena                                  X
           Itawamba                            X
           Jackson                             X
           Jasper                              X
           Jefferson                           X
           Jefferson Davis                     X
           Jones                               X
           Kemper                              X
           Lafayette                           X
           Lamar                               X
           Lauderdale                          X
           Lawrence                            X
           Leake                               X
           Lee                                 X
           Leflore                             X
           Lincoln                             X
           Lowndes                             X
           Madison                             X
           Marion                              X
           Marshall                            X
           Monroe                              X
           Montgomery                          X
           Neshoba                             X
           Newton                              X
           Noxubee                             X
           Oktibbeha                           X
           Panola                              X
           Pearl River                         X
           Perry                               X
           Pike                                X
           Pontotoc                            X
           Prentiss                            X
           Quitman                             X
           Rankin                              X
           Scott                               X
           Sharkey                                    X
           Simpson                             X
           Smith                               X
           Stone                               X
           Sunflower                           X
           Tallahatchie                        X
           Tate                                X
           Tippah                              X
           Tishomingo                          X
           Tunica                              X
           Union                               X
           Walthall                            X
           Warren                              X
           Washington                          X
           Wayne                               X
           Webster                             X
           Wilkinson                           X
           Winston                             X
           Yazoo                               X
           Yolobusha                           X

           Co = County HD
           M/Co = Multicounty HD
1MISSOURI
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State      United States

 Population (1988)                  5,141,000        245,803,000
 Population Density (1988)                 74.6               69.4
   (per/sq.mi.)
 Number of Counties                       115              3,139
 Median Age (1987)                         32.4               31.7
 Percent Below Poverty Level (1985)        13.7               14.0
   (persons)
 Percent of Population Rural (1980)        32.0               26.0
 Percent of Population White (1980)        88.4               83.1
 Percent of Population Non-white (1980)    11.6               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 authority for counties in Missouri are
 established by the state constitution and statutes.

 Commission Form - (90) - The common structure of government is
 the commission consisting of three members with executive and
 legislative responsibility.  There is one presiding commissioner
 who is elected at large for a 4-year term and two associate
 commissioners elected from single-member districts for 2-year
 terms.  The constitution refers to the county government
 structure as County Court.  The name has been legally changed to
 commission but the constitution has not been amended.

 The constitution permits two alternate forms of county government
 in Missouri:  the Township Form and Home Rule Charter.

 Township Form - (23) - Counties which operate under this form are
 subdivided into 326 townships with each township electing four
 officials.

 Home Rule Charter - (2) - Counties with more than 85,000
 population may frame a county home rule charter.  These counties
 establish within the charter the specifics of their county

 Data for this state were updated November 1990. structure.
 Jackson and St. Louis Counties have adopted home rule
 charters.  Jackson has a nine-member board of legislators and
 St. Louis has a seven-member council.  Both counties use an
 elected county executive.  The authorizing legislation for
 charter government permits the consolidation of city and county
 governments, although none has chosen this option at the present
 time.  This legislation also designates St. Louis as a city and a
 county, thereby causing it to be considered an independent city.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The Missouri Department of Health (MDH), the SHA, is a
 free-standing, independent agency.  It was created in 1985 when
 the Division of Health, in the Department of Social Services, was
 elevated to a separate cabinet-level Department of Health.  The
 mission of the Department of Health remains basically unchanged
 from that of the first board of health 100 years ago.  Personnel
 of the Department of Health continue to be dedicated to the
 prevention of disease and the promotion of health for the
 citizens of the state.

 The following are some areas of responsibility for the SHA:

      State Public Health Authority
      State Agency for Children with Special Health Care Needs
      Certificate of Need Program
      Institutional Licensing Agency
      Institutional Certifying Authority for Federal Reimbursement
      State Institutions/Hospitals
      State Health Laboratory

      B.  Head of State Health Agency

 M.D. Requirement, Cabinet-level Appointment

 The Director of the MDH is appointed by the Governor, with advice
 and consent of the Senate.  As the chief executive officer, the
 Director is responsible for the managing the Department and the
 administering its programs and services.  The Director of Health
 is also the chief liaison officer of the Department of Health for
 joint efforts with other governmental agencies and with private
 organizations which conduct or sponsor programs that relate to
 public health in Missouri.  The Director's office also oversees
 public information, information systems, minority health, and
 personnel and training.

                C.  State Board of Health/Council

 Advisory

 The State Board of Health is made up of seven members appointed
 by the Governor with the advice and consent of the Senate.
 Statutes specify that three members must be physicians and
 surgeons licensed by the state, one member must be a dentist
 licensed by the state, and the other three members will be
 representatives of those persons, professions, and businesses
 which are regulated and supervised by the Department of Health
 and the State Board of Health.

 Duties and services of the Board of Health include the following:

      Advising the director of the MDH regarding the priorities,
      policies, and programs of the department;

      Reviewing all rules promulgated by MDH;

      Reviewing the budget of MDH; and

      Advising on administration of the State Hospital Subsidy
      Program, and administering the Medical and Osteopathic
      Student Loan Program, the Family Practice Residency Program,
      and the Student Nurse Loan Repayment Program.

      D.  Regional/District Health Offices

 MDH has divided the state into six geographical areas called
 districts.  Within these districts are six district and eight
 area (branch) offices which provide administrative and
 supervisory guidance to county and city health departments.
 Responsibilities of the district and area offices include the
 following:

      Assisting and guiding local health units in planning and
      carrying out public health programs;

      Providing technical assistance and consultation to county
      and city health units;

      Planning and conducting programs in areas without a local
      health unit or in areas with a local unit which lacks the
      personnel or expertise for a specific program; and

      Assisting county and city health units with preparation of
      budgets and other matters relating to the successful
      operation of the unit.

 The number of staff for the district offices ranges from 27 to
 43.  These staff generally include the following positions:

      District Administrator
      Community Health Nursing Consultants
      Sanitarians
      Children's Special Health Care Needs Staff
      Emergency Medical Technician
      Regulator for Bureau of Drugs and Narcotics
      Communicable Disease Coordinators
      Clerical Staff
      Health Educator
      Program Staff
      AIDS Prevention
      Sexually Transmitted Diseases
      Women, Infants and Children
      Immunization

      E.  State-local Liaison

 Decentralized Organizational Control, Formal Liaison Function

 The Division of Local Health and Institutional Services provides
 the liaison function between the SHA and local health units.  The
 Division plans, directs and evaluates the programs and operations
 of the Section of Local Health Services, Bureau of Community
 Health Nursing, Bureau of Primary Care, and the Missouri
 Rehabilitation Center located at Mt. Vernon, Missouri.  The
 services and programs offered by the Division are provided
 through the central office by district offices, where guidance
 for implementation of these programs takes place.  Services
 include consultation to local health agencies and evaluation of
 services provided by local agencies under contract with MDH.

 The MDH has established a Department of Health/Local Health
 Department "Partnership Council" for the following purpose:

      To facilitate the work of public health in Missouri, the MDH
      and local health departments (LHDs) will work in partnership
      to seek mutual objectives, understanding, and solutions to
      problems.

 Responsibilities of the Council include the following:

      1.   Joint MDH and local health department problem solving
           for issues involving LHDs

      2.   Setting agendas for quarterly LHD administrators'
           meetings

      3.   Reviewing proposed contract and program guidance
           changes
                4.   Establishing technical committees as necessary to
           assist in contract and program guideline change review

 The Council is composed of nine members nominated in the
 following manner and officially recognized by the Department
 Director as representing the interests of the metro and rural
 health officers:

      1.   The metro health officers nominate three
           representatives and assure that this representation is
           geographically balanced.

      2.   The rural health officers nominate one representative
           and one alternate from each of the MDH districts for a
           total of six representatives and six alternates.

      3.   The council elects a chair and vice chair from the
           membership.  One officer must be a metro health officer
           and one must be a rural health officer.

      4.   Staff support for the Partnership Council will be
           provided by the Division of Local Health and
           Institutional Services.  Council members serve 2-year
           terms.  Terms are staggered.

 The interaction between state and local public health agencies in
 Missouri may be characterized as decentralized organizational
 control.  Under this arrangement, local government directly
 operates health departments with or without a local board of
 health.

      F.  Budget

 Total FY 1988 Missouri SHA expenditures were $108,825,000.  Total
 FY 1988 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts          $47,211,000
        State Funds                           $50,292,000
        Local Funds                                     0
        Fees and Reimbursements               $11,322,000
        Other                                           0
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 There are 110 local health departments in Missouri.  These
 consist of 102 county, 4 city, 3 city-county, and 1 multicounty
 health departments.  Responsibilities of these local units
 include the following:
                Assess needs of the communities served and plan
                appropriate public health services;

      Enforce local codes and ordinances related to public health;

      Organize and conduct programs for the local area as needed;
      and

      Under contract, provide mandatory public health programs
      imposed upon the MDH by statute and provide other optional
      services consistent with local resources.

 Counties may choose by referendum to impose a local tax to
 support the local health department.  Upon passage of the
 referendum the county commission appoints an acting five-member
 board of trustees to oversee the health department.  At a special
 election, or the next scheduled election, regular trustees are
 elected to fill the positions.  In counties that do not have
 trustees, the county commission administers the local health
 department.

      B.  Services Provided

 The following information on services provided by local health
 departments in Missouri is derived from a survey conducted by
 NACHO during 1989.  One hundred and one of the 110 health
 departments in Missouri 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              23   ( 22.8%)
            2.  Morbidity Data                          47   ( 46.5%)
            3.  Reportable Diseases                     89   ( 88.1%)
            4.  Vital Records and Statistics            93   ( 92.1%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        61   ( 60.4%)
            2.  Communicable Diseases                  101   (100.0%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement             21   ( 20.8%)
       B.  Health Planning                              57   ( 56.4%)
       C.  Priority Setting                             40   ( 39.6%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   68   ( 67.3%)
            2.  Health Facility Safety/Quality          33   ( 32.7%)
            3.  Rec. Facility Safety/Quality            42   ( 41.6%)
            4.  Other Facility Safety/Quality           21   ( 20.8%)

       B.  Licensing
            1.  Health Facilities                        7   (  6.9%)
            2.  Other Facilities                        41   ( 40.6%)

       C.  Health Education                             74   ( 73.3%)

       D.  Environmental
            1.  Air Quality                             11   ( 10.9%)
            2.  Hazardous Waste Management              26   ( 25.7%)
            3.  Individual Water Supply Safety          77   ( 76.2%)
            4.  Noise Pollution                          9   (  8.9%)
            5.  Occupational Health and Safety          13   ( 12.9%)
            6.  Public Water Supply Safety              41   ( 40.6%)
            7.  Radiation Control                        8   (  7.9%)
            8.  Sewage Disposal Systems                 66   ( 65.3%)
            9.  Solid Waste Management                  26   ( 25.7%)
           10.  Vector and Animal Control               48   ( 47.5%)
           11.  Water Pollution                         33   ( 32.7%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             38   ( 37.6%)
            2.  Alcohol Abuse
            3.  Child Health                            96   ( 95.0%)
            4.  Chronic Diseases                        87   ( 86.1%)
            5.  Dental Health                           51   ( 50.5%)
            6.  Drug Abuse                               9   (  8.9%)
            7.  Emergency Medical Service                3   (  3.0%)
            8.  Family Planning                         58   ( 57.4%)
            9.  Handicapped Children                    26   ( 25.7%)
           10.  Home Health Care                        67   ( 66.3%)
           11.  Hospitals                                -
           12.  Immunizations                           99   ( 98.0%)
           13.  Laboratory Services                     26   ( 25.7%)
           14.  Long-term Care Facilities                1   (  1.0%)
           15.  Mental Health                            6   (  5.9%)
           16.  Obstetrical Care                         5   (  5.0%)
           17.  Prenatal Care                           46   ( 45.5%)
           18.  Primary Care                            12   ( 11.9%)
           19.  Sexually Transmitted Diseases           62   ( 61.4%)
           20.  Tuberculosis                            90   ( 89.1%)
           21.  WIC                                     90   ( 89.1%)

      C.  Local (County) Health Officer

 M.D. Required, County Commission Appointment

 Local health officers are required to be physicians.  They are
 appointed by the local governing body.  The health officer is
 responsible for managing the local health department and its
 programs.

 Most counties no longer appoint the traditional county health
 officer.  The actual "health officer," however, is the
 administrator of the health department.  This position does not
 require a physician.  In fact most rural county health
 departments do not employ a physician except to provide clinical
 services.

      D.  Local Board of Health

 Missouri has no local boards of health.  In 81 counties, 5-member
 boards of popularly elected trustees administer the local health
 department.  In other counties the county commissioners oversee
 the operation of the health 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 500.

      F.  Budget

 Total FY 1988 LPHA expenditures were $104,477,000 *.  Total FY
 1988 United States LPHA expenditures were $3,978,948,000.

      Source of Funds
        Federal Grants and Contracts     $37,741,000
        State Funds                       $7,145,000
        Local Funds                      $51,271,000
        Fees and Reimbursements           $8,320,000
        Other Sources                              0
        Source Unknown                             0

 The SHA reported that there were additional fees and
 reimbursements not retained by the local health department, but
 which reverted to the general revenues of the local or state
 government.
2Missouri Department of Health, 1990

 Governor
   Board of Health
   Missouri Health Facilities Review Committee
   State Cancer Commission
     Ellis Rachel State Cancer Center
 Director
 Deputy Director
 Local and State Partnership Council
 Certificate of Need Program
 Personnel and Training Office
 Information Systems Office
 Public Information Office
 Minority Health Office
 Governmental Affairs Office
 Executive Assistant
 Planning Assistant
 Chief Counsel
 Administration
      Internal Audit
      Bureau of General Services
      Bureau of Financial Services
      Bureau of Budget Services

 Environmental Health and Epidemiology
      State Public Health Lab
      Office of Epidemiology
      Bureau of Veterinary Public Health
      Bureau of AIDS Prevention
      Bureau of Environmental Epidemiology
      Section of Disease Prevention
      Bureau of Sexually Transmitted Diseases
      Bureau of Immunization
      Bureau of Communicable Disease Control
      Bureau of Tuberculosis Control
      Bureau of Radiological Health
      Bureau of Community Sanitation

 Local Health Institutional Services
      Missouri Rehabilitation Center
      Section of Local Health Services
        Local Health Agencies
      Bureau of Community Health Nursing
      Bureau of Primary Care

 Health Resources
      Office of Injury Control
      State Center for Health Statistics
      Bureau of Health Resources Statistics
      Bureau of Health Data Analysis
      Bureau of Health Services Statistics
                Bureau of Vital Records
      Bureau of Emergency Medical Services
      Bureau of Hospital Licensing & Certification
      Bureau of Narcotics and Dangerous Drugs
      Bureau of Home Health Licensing & Certification

 Maternal, Child, and Family Health
      Bureau of Dental Health
      Office of Medical Services
      Bureau of Special Health Care Needs
      Bureau of Perinatal and Child Health
      Section of Food and Nutrition Services
      Supplemental Food Program
      Bureau of Child and Adult Care Food Program

 Chronic Disease and Family Health
      Section of Food and Health Promotion
      Bureau of Health Promotion
      Bureau of Smoking, Tobacco, and Cancer
      Bureau of High Risk Intervention
2Types of Local Health Departments by Jurisdiction
                                     Missouri, 1990

           Jurisdiction          Co     C      C/Co   M/Co   N/Co

           Adair                 X
           Andrew                X
           Atchison              X
           Audrin                X
           Barry                 X
           Barton                X
           Bates                 X
           Benton                X
           Bollinger             X
           Butler                X
           Caldwell              X
           Callaway              X
           Camden                X
           Cape Girardeau        X
           Carroll               X
           Carter                X
           Cass                  X
           Cedar                                             X
           Charlton              X
           Christian             X
           Clark                 X
           Clay                  X
           Clinton               X
           Cole                  X
           Columbia-Boone                      X
           Cooper                X
           Crawford              X
           Dade                  X
           Dallas                X
           Daviess               X
           DeKalb                                     X
           Dent                  X
           Douglas               X
           Dunklin               X
           Franklin              X
           Gasconade             X
           Gentry                                     X
           Grundy                X
           Harrison              X
           Henry                 X
           Hickory               X
           Holt                                              X
           Howard                X
           Howell                                            X
           Independence                 X
           Iron                  X
           Jackson               X
           Jasper                       X
           Jefferson                    X
           Johnson                      X
           Joplin City                         X
           Kansas City                         X
           Knox                         X
           Laclede                      X
           Lafayette                    X
           Lawrence                     X
           Lewis                        X
           Lincoln                      X
           Linn                         X
           Livingston                   X
           Macon                        X
           Madison                      X
           Maries                                                   X
           Marion                       X
           McDonald                     X
           Mercer                       X
           Miller                       X
           Mississippi                  X
           Moniteau                     X
           Monroe                       X
           Montgomery                   X
           Morgan                       X
           New Madrid                   X
           Newton                       X
           Nodaway                      X
           Oregon                       X
           Osage                                                    X
           Ozark                        X
           Pemiscot                     X
           Perry                        X
           Pettis                       X
           Phelps                       X
           Pike                         X
           Platte                       X
           Polk                         X
           Pulaski                      X
           Putnam                       X
           Ralls                        X
           Randolph                     X
           Ray                          X
           Reynolds                     X
           Ripley                       X
           Saline                       X
           Schuyler                     X
           Scotland                     X
           Scott                        X
           Shannon                      X
           Shelby                       X
           Springfield-Greene                         X
           St. Charles                  X
           St. Clair                    X
           St. Francis                  X
           St. Joseph-Buchanan                        X
           St. Louis                    X
           St. Louis City                      X
           Ste Genevieve                X
           Stoddard                     X
           Stone                        X
           Sullivan                     X
           Taney                        X
           Texas                        X
           Vernon                       X
           Warren                                                   X
           Washington                   X
           Wayne                        X
           Webster                      X
           Worth                                             X
           Wright                       X

           Co = County HD
           C = City HD
           C/Co = City/County HD
           M/Co = Multicounty HD
           n/Co = No County HD
1MONTANA
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State      United States

 Population (1988)                    805,000        245,803,000
 Population Density (1988)                  5.5               69.4
   (per/sq.mi.)
 Number of Counties                        56              3,139
 Median Age (1987)                         31.3               31.7
 Percent Below Poverty Level (1985)        16.1               14.0
   (persons)
 Percent of Population Rural (1980)        47.0               26.0
 Percent of Population White (1980)        94.1               83.1
 Percent of Population Non-white (1980)     5.9               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 Montana counties are established
 by the state constitution and statutes.  Authority for home rule
 was established in the 1972 state constitution.  There are two
 categories of counties in Montana according to whether they have
 enacted Home Rule Charter or not.  Those that have enacted home
 rule are charter counties and those who do not may be considered
 general government power counties.

 Commission Form - (53) - The general government power counties
 have only the authority granted to them by the legislature.  They
 utilize the Commission Form of government with a three-member
 board of commissioners elected from single-member districts or at
 large.  The commission has all legislative and administrative
 responsibility for the county.

 Home Rule Charter - (3) - These counties have adopted a charter
 that is much like a constitution in that it establishes the
 power, rights, and responsibilities of a county.  Under a Home
 Rule Charter the counties may adopt any form of government except
 the Commission Form.  The three counties that have adopted a
 charter are Petroleum, Deer Lodge, and Silver Bow.  Deer Lodge
 and Petroleum have appointed county administrators, while Silver

 Data for this state were updated November 1990.

 Bow has an elected executive.  Additionally, Anaconda-Deer Lodge
 and Butte-Silver Bow have chosen to consolidate their city and
 county governments.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The Montana Department of Health and Environmental Sciences
 (MDHES), the SHA, is a free-standing, independent agency.  The
 mission of MDHES is to protect and promote the health of the
 people of Montana.  In doing so, the Department is charged with
 the ability to implement beneficial public health programs and
 enforce public health laws and regulations.  The Department also
 cooperates with local and private sources in determining
 Montana's health care needs, developing programs designed to help
 meet those needs, and continually evaluating current public
 health programs.

 Department activities are carried out at the statewide level or
 through local health programs.  Those activities include a
 variety of administrative and regulatory functions for approval,
 construction or purchase of certain medical facilities,
 inspection and certification of public health care facilities,
 inspection and regulation of hazardous materials in the
 environment, and administration of a number of Federally funded
 health services designed to prevent deterioration of preexisting
 health-related disorders.

 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
      Health Facility Licensing and Certifying Agency
      Food Establishment Licensing Agency
      Institutional Licensing Agency
      Institutional Certifying Authority for Federal Reimbursement

      B.  Head of State Health Agency

 No M.D. Requirement, Cabinet-level Appointment

 The Director of the Department of Health and Environmental
 Sciences is the head of the SHA.  The Office of the Director is
 responsible for overall management and program support for the
 Department, including coordination and provision of policy
 development and administration.  Additionally, the Director is
 responsible for carrying out policy developed with the Governor,
 carrying out provisions of relevant statutes passed into law by
 the legislature.  The Director is appointed by the Governor and
 confirmed by the Senate.

      C.  State Board of Health/Council

 Advisory and Policy-making

 The Board of Health and Environmental Sciences is a seven-member
 board appointed by the Governor.  The Board is composed of two
 licensed human health professionals, one doctor of veterinary
 medicine, and four members with active interest in public health
 and the welfare of the state.  The board is a quasi-judicial body
 that reviews actions on certain Department-issued licenses,
 permits and variances.  The Board is also authorized to adopt
 rules, regulations, and standards for relevant public health
 issues.  Two primary duties of the Board are to advise the
 Department in public health matters, and to hold hearings and
 take testimony in matters relating to the duties of the Board.
 The Board is also responsible for adopting, amending, and
 repealing rules for the administration, implementation, and
 enforcement of laws that deal with environmental protection and
 public health.

      D.  Regional/District Health Offices

 The state has not been divided down into administrative districts
 or regions.  A regional office in Billings, however, serves
 environmental health and licensing, certification, and
 construction program needs in eastern Montana.  This office is
 staffed by six individuals and functions as an extension of the
 central office.

      E.  State-local Liaison

 Decentralized Organizational Control, Informal Liaison Function

 The Department of Health and Environmental Sciences has
 historically designated the Administrator of the Health Services
 Division as liaison to the local health departments.  As liaison,
 the Administrator works with the Director of the Department in
 addressing concerns or matters having to do with all local public
 health agencies.

 The interaction between state and local public health agencies in
 Montana may be characterized as decentralized organizational
 control.  Under this arrangement the local government directly
 operates a health department and may or may not have a local
 board of health.

      F.  Budget

 Total FY 1988 Montana SHA expenditures were $27,404,084*.  Total
 FY 1988 United States SHA expenditures were $8,312,928,000.

 * Montana expenditure data were provided by SHA.
      Source of Funds
        Federal Grants and Contracts          $21,496,000
        State Funds                            $3,577,709
        Local Funds                                     0
        Fees and Reimbursements                $2,330,751
        Other                                           0
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 Montana has 49 local health departments that include 6
 city-county and 43 county health departments.  Seven counties do
 not have health departments and receive public health services
 from adjoining counties through a contractual arrangement.
 Counties with health departments often contract for additional
 public health services from a neighboring county.  Public health
 nurses and/or sanitarians who are based in one county may provide
 services to several nearby counties.

      B.  Services Provided

 The following information on services provided by local health
 departments in Montana is derived from a survey conducted by
 NACHO during 1989.  Twenty-six of the 49 local health departments
 in Montana 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               6   ( 23.1%)
            2.  Morbidity Data                           8   ( 30.8%)
            3.  Reportable Diseases                     22   ( 84.6%)
            4.  Vital Records and Statistics             8   ( 30.8%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                         8   ( 30.8%)
            2.  Communicable Diseases                   24   ( 92.3%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement             11   ( 42.3%)
       B.  Health Planning                              13   ( 50.0%)
       C.  Priority Setting                              9   ( 34.6%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   14   ( 53.8%)
            2.  Health Facility Safety/Quality          12   ( 46.2%)
            3.  Rec. Facility Safety/Quality            10   ( 38.5%)
            4.  Other Facility Safety/Quality            7   ( 26.9%)

       B.  Licensing
            1.  Health Facilities                        3   ( 11.5%)
            2.  Other Facilities                        14   ( 53.8%)

       C.  Health Education                             18   ( 69.2%)

       D.  Environmental
            1.  Air Quality                             11   ( 42.3%)
            2.  Hazardous Waste Management              13   ( 50.0%)
            3.  Individual Water Supply Safety          18   ( 69.2%)
            4.  Noise Pollution                          4   ( 15.4%)
            5.  Occupational Health and Safety           7   ( 26.9%)
            6.  Public Water Supply Safety              18   ( 69.2%)
            7.  Radiation Control                        3   ( 11.5%)
            8.  Sewage Disposal Systems                 17   ( 65.4%)
            9.  Solid Waste Management                  16   ( 61.5%)
           10.  Vector and Animal Control               13   ( 50.0)
           11.  Water Pollution                         17   ( 65.4%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             13   ( 50.0%)
            2.  Alcohol Abuse                            7   ( 26.9%)
            3.  Child Health                            23   ( 88.5%)
            4.  Chronic Diseases                        15   ( 57.7%)
            5.  Dental Health                            7   ( 26.9%)
            6.  Drug Abuse                               6   ( 23.1%)
            7.  Emergency Medical Service                7   ( 26.9%)
            8.  Family Planning                         14   ( 53.8%)
            9.  Handicapped Children                    15   ( 57.7%)
           10.  Home Health Care                        16   ( 61.5%)
           11.  Hospitals                                3   ( 11.5%)
           12.  Immunizations                           23   ( 88.5%)
           13.  Laboratory Services                      4   ( 15.4%)
           14.  Long-term Care Facilities                3   ( 11.5%)
           15.  Mental Health                            5   ( 19.2%)
           16.  Obstetrical Care                         3   ( 11.5%)
           17.  Prenatal Care                           14   ( 53.8%)
           18.  Primary Care                             5   ( 19.2%)
           19.  Sexually Transmitted Diseases           17   ( 65.4%)
           20.  Tuberculosis                            13   ( 50.0%)
           21.  WIC                                     20   ( 76.9%)

      C.  Local Health Officer

 No M.D. Requirement, Local Board of Health Appointment

 The local health officer must be a physician or a person with a
 master's degree in public health or equivalent and appropriate
 experience as determined by MDHES.  If the local board fails to
 appoint a health officer, MDHES can appoint one for the local
 jurisdiction.

 Local health officers, operating under the direction of the local
 board of health, have responsibility and authority to perform
 actions such as make inspections for sanitary conditions, impose
 and maintain quarantines, issue orders to remove filth, report
 communicable diseases to MDHES, file complaints with the
 appropriate court when rules and regulations of the local board
 are violated, make quarterly reports of his/her activities, and
 notify MDHES of changes in membership of the local board.

      D.  Local Board of Health

 Policy-making

 County boards of health consist of the county commissioners and
 two members appointed by the commissioners or five persons
 appointed by the commissioners.  The terms of office are 3 years,
 with the terms staggered.  City boards of health for first- and
 second-class cities consist of five persons appointed by the
 governing body.  Terms of office are staggered for a period of 3
 years.  By agreement, county commissioners and the governing body
 of a first- or second-class city can form a city-county board of
 health.  The board consists of one person appointed by the
 governing body of each participating city, one person appointed
 by the county commissioners, and additional persons appointed by
 the governing bodies of the entities involved.  Total membership
 is five persons with staggered terms of 3 years.  Two or more
 adjacent counties may unite to create a district board of
 health.  The governing body of each county and city included in
 the district appoints one member.  Additional members may be
 appointed by mutual agreement of the governing bodies.

 Local boards are responsible for appointing a local health
 officer, electing officers of the board, employing necessary
 staff, adopting bylaws to govern meetings, hold regular meetings,
 supervise the destruction and removal of all sources of filth
 which cause disease, guard against the introduction of
 communicable disease, and supervise inspections of public
 establishments for sanitary conditions.
                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 56.

      F.  Budget

 LPHA expenditure data are not available for Montana.
2Montana Department of Helath and Environmental Sciences, 1990

 Governor
 Director
 Deputy Director
 Health Services Division
      Health Planning Bureau
      Licensing, Certification and Construction Bureau
      Preventive Health Services Bureau
      Emergency Medical Services Bureau
      Family/Maternal and Child Health Bureau

 Environmental Sciences Division
      Air Quality Bureau
      Occupational Health Bureau
      Water Quality Bureau
      Food and Consumer Safety Bureau
      Solid and Hazardous Waste Bureau

 Centralized Services Division
      Support Services Bureau
      Chemistry Laboratory Bureau
      Records and Statistics Bureau
      Public Health Laboratory Bureau
2Types of Local Health Departments by Jurisdiction
                                     Montana, 1990

           Jurisdiction                 Co     C/Co   N/Co

           Beaverhead                   X
           Big Horn                     X
           Blaine                       X
           Broadwater                   X
           Carbon                       X
           Carter                                     X
           Cascade City-Co                     X
           Chouteau                     X
           Custer                       X
           Daniels                      X
           Dawson                       X
           Deer Lodge                   X
           Fallon                       X
           Fergus                       X
           Flathead City-Co                    X
           Gallatin                     X
           Garfield                     X
           Glacier                      X
           Golden Valley                X
           Granite                      X
           Hill                         X
           Jefferson                    X
           Judith Basin                               X
           Lake                         X
           Lewis & Clark                       X
           Liberty                      X
           Lincoln                      X
           Madison                      X
           McCone                       X
           Meagher                      X
           Mineral                      X
           Missoula-City Co                    X
           Mussel Shell                               X
           Park                         X
           Petroleum                                  X
           Phillips                     X
           Pondera                      X
           Powder River                 X
           Powell                                     X
           Prairie                      X
           Ravalli                      X
           Richland                     X
           Roosevelt                    X
           Rosebud                      X
           Sanders                      X
           Sheridan                     X
           Silver Bow-C Co                     X
           Stillwater                   X
           Sweet Grass                                X
           Teton                        X
           Toole                        X
           Treasure                     X
           Valley                       X
           Wheatland                    X
           Wibaux                       X
           Yellowstone C Co                    X

           Co = County HD
           C/Co = City/County HD
           N/Co = No County HD
1NEBRASKA
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State      United States

 Population (1988)                  1,602,000        245,803,000
 Population Density (1988)                 20.9               69.4
   (per/sq.mi.)
 Number of Counties                        93              3,139
 Median Age (1987)                         31.6               31.7
 Percent Below Poverty Level (1985)        14.8               14.0
   (persons)
 Percent of Population Rural (1980)        37.0               26.0
 Percent of Population White (1980)        94.9               83.1
 Percent of Population Non-white (1980)     5.1               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

 In Nebraska the state constitution and legislative acts provide
 the legal framework for county governments.  The counties exist
 to perform the state functions, and their actions are limited to
 the authority granted by the legislature.  County governments are
 either Commission or Township-Supervisor in form.

 Commission Form - (66) - Commissions with 3- or 5-member boards
 serve as the government for 66 counties.

 Township Supervisors - (27) - Township-Supervisors with 7-member
 boards function in the other 27 counties.  The supervisors and
 commissioners actually possess the same authority and
 responsibilities and differ in name only.  In both situations the
 boards function as the legislative and executive bodies for the
 county.  The primary difference between the two forms of
 government is the presence of township governments.  These are
 established by law and given authority to levy taxes to cover
 their expenses.

 Data for this state were updated October 1990.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The Department of Health, the SHA, is a free-standing,
 independent agency.  The mission of the Nebraska Department of
 Health is to prevent health problems before they occur; to assure
 Nebraska's health resources meet minimum acceptable standards,
 and to increase both the competence and accessibility of these
 health resources; and to collect, analyze, and report to the
 people of Nebraska accurate information about the status of their
 health and their health resources.

 The following are some areas of responsibility for the SHA:

      State Public Health Authority
      Institutional Licensing Agency
      Institutional Certifying Authority for Federal Reimbursement

      B.  Head of State Health Agency

 M.D. Requirement, Cabinet-level Appointment

 The Director of Health is the head of the SHA.  This position is
 appointed by the Governor and confirmed by the Legislature.  The
 Director must be a physician and is responsible for the
 administration of the Department of Health.

      C.  State Board of Health/Council

 Advisory and Policy-making

 The Nebraska Board of Health is made up of 15 members, 2 of which
 must be physicians, 1 member each from the dental, veterinary,
 civil engineering, pharmaceutical, nursing, optometry, podiatry,
 osteopathic, chiropractic, and physical therapy professions.  In
 addition two members represent the lay public.  Board members are
 appointed by the Governor and serve 3-year terms.

 The board serves in an advisory capacity to the Director and the
 Department and in a policy-setting capacity to the Bureau of
 Examining Boards.

      D.  Regional/District Health Offices

 Five regional offices are located in Scotts Bluff, North Platte,
 Kearney, Norfolk, and Omaha.  The service areas of these offices
 are not specified and actually vary from program to program.
 These offices are staffed by 5 to 15 which include positions such
 as the Regional Coordinator, nursing staff, environmental health
 personnel, a nutritionist, disease control personnel and clerks.

 The regional offices provide those services that are mandated by
 state statutes to the counties that do not have health
 departments and in some cases in counties that have health
 departments.  They also provide technical assistance to the local
 health departments.  The services provided by the offices vary
 from site to site with some offering only two or three services
 while others have a broader range.  The following is a list of
 services that different offices provide:

      Environmental Health
      Public Health Nursing
      Health Education/Promotion
      Dental Health
      Emergency Medical Services
      Health Facility Standards
      Home Health Care
      Communicable Disease Control
      Nutrition

      E.  State-local Liaison

 Decentralized Organizational Control, Formal Liaison Function

 The Director of the Bureau of Health Promotion and Disease
 Prevention is responsible for the state-local liaison function.
 As liaison the Director functions as a contact between state and
 local health agencies to provide technical assistance,
 consultation, and advise on budgets and programs.  To facilitate
 public health programs and activities, the NDH and local health
 departments formed the Department of Health/Local Health
 Department "Partnership Council."  This council works in
 partnership to seek mutual objectives, understandings, and
 solutions to problems.  Local health departments are represented
 by the Local Health Director's Group, which functions in an
 advisory capacity to the SHA.

 The interaction between state and local public health agencies in
 Nebraska can be characterized as decentralized organizational
 control.  Under this arrangement local government directly
 operates the local health department and has a local board of
 health.

      F.  Budget

 Total FY 1988 Nebraska SHA expenditures were $27,675,000.  Total
 FY 1988 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts          $18,215,000
        State Funds                            $5,186,000
        Local Funds                                     0
        Fees and Reimbursements                $3,881,000
        Other                                    $392,000
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 Nebraska has 18 local health departments.  These consist of 11
 county health departments, 2 city/county health departments, 1
 multicounty health department and 4 city health departments.  The
 multicounty unit is composed of five counties.

       B.  Services Provided

 The following information on services provided by local health
 departments in Nebraska is derived from a survey conducted by
 NACHO during 1989.  Fifteen of the 18 local health departments in
 Nebraska 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               4   ( 26.7%)
            2.  Morbidity Data                           4   ( 26.7%)
            3.  Reportable Diseases                      7   ( 46.7%)
            4.  Vital Records and Statistics             3   ( 20.0%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                         6   ( 40.0%)
            2.  Communicable Diseases                    9   ( 60.0%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement              6   ( 40.0%)
       B.  Health Planning                               9   ( 60.0%)
       C.  Priority Setting                              6   ( 40.0%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                    3   ( 20.0%)
            2.  Health Facility Safety/Quality           4   ( 26.7%)
            3.  Rec. Facility Safety/Quality             4   ( 26.7%)
            4.  Other Facility Safety/Quality            2   ( 13.3%)

       B.  Licensing
            1.  Health Facilities                        -
            2.  Other Facilities                         5   ( 33.3%)

       C.  Health Education                             12   ( 80.0%)

       D.  Environmental
            1.  Air Quality                              3   ( 20.0%)
            2.  Hazardous Waste Management               3   ( 20.0%)
            3.  Individual Water Supply Safety           8   ( 53.3%)
            4.  Noise Pollution                          1   (  6.7%)
            5.  Occupational Health and Safety           2   ( 13.3%)
            6.  Public Water Supply Safety               3   ( 20.0%)
            7.  Radiation Control                        1   (  6.7%)
            8.  Sewage Disposal Systems                  5   ( 33.3%)
            9.  Solid Waste Management                   5   ( 33.3%)
           10.  Vector and Animal Control                6   ( 40.0%)
           11.  Water Pollution                          5   ( 33.3%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling              5   ( 33.3%)
            2.  Alcohol Abuse                            1   (  6.7%)
            3.  Child Health                            11   ( 73.3%)
            4.  Chronic Diseases                        11   ( 73.3%)
            5.  Dental Health                            6   ( 40.0%)
            6.  Drug Abuse                               1   (  6.7%)
            7.  Emergency Medical Service                1   (  6.7%)
            8.  Family Planning                          2   ( 13.3%)
            9.  Handicapped Children                     2   ( 13.3%)
           10.  Home Health Care                        11   ( 73.3%)
           11.  Hospitals                                1   (  6.7%)
           12.  Immunizations                           12   ( 80.0%)
           13.  Laboratory Services                      3   ( 20.0%)
           14.  Long-term Care Facilities                -
           15.  Mental Health                            2   ( 13.3%)
           16.  Obstetrical Care                         1   (  6.7%)
           17.  Prenatal Care                            4   ( 26.7%)
           18.  Primary Care                             3   ( 20.0%)
           19.  Sexually Transmitted Diseases            3   ( 20.0%)
           20.  Tuberculosis                             3   ( 20.0%)
           21.  WIC                                      3   ( 20.0%)

      C.  Local Health Officer

 No M.D. Requirement, Board of Health Appointment

 The local health officer is the chief administrator of the local
 health department.  This position is appointed by the local board
 of health and approved by the county governing board.  Appointees
 must be either an M.D. or assisted by at least a part-time
 medical advisor.

                D.  Local Board of Health

 Policy-making

 Local boards of health are made up of nine members including a
 physician, a dentist, a county clerk or school superintendent, a
 county commissioner, and five public-spirited citizens.  The
 board is appointed by the county commissioners for a county board
 of health and appointed jointly by city council and county
 commissioners when the board of health is for city/county.

 State statute gives local boards of health overall responsibility
 for the operation of local health departments.

      E.  Staff

 The local jurisdiction is the employer of the staff of a local
 health department.  The number of staff employed by local health
 departments ranges from 1 to 90.

      F.  Budget

 Total FY 1988 LPHA expenditures were $8,690,000 *.  Total FY 1988
 United States LPHA expenditures were $3,978,948,000.

      Source of Funds
        Federal Grants and Contracts        $541,000
        State Funds                                0
        Local Funds*                      $8,000,000
        Fees and Reimbursements             $149,000
        Other Sources                              0
        Source Unknown                             0
2Nebraska Department of Health, 1990

 Director of Health
   Public Information
   Legal Services
   State Board of Health
 Assistant to the Director
 Deputy Director
 Bureau of Examining Boards
      Medical and Medical Support Professions
      Nursing and Specialized Medical Professions
      Rehabilitation Professions
      Behavioral and Social Services Professions
      Investigations and Enforcement

 Bureau of Health Facilities Standards
      Southeast Region
      Northeast Region
      Central Region
      Western Region
      Developmental Disabilities Facilities
      Licensing and Training

 Bureau of Environmental Health
      Asbestos Control Division
      Housing and Recreational Vehicles Division
      Drinking Water and Environmental Sanitation Division
      Radiological Health

 Bureau of Administrative Services
      Accounting
      Budget
      Personnel
      Western R/O

 Deputy Director
   Laboratory Services
   Epidemiology
 Bureau of Health Planning and Data Management
      Health Data Systems
      Health Policy and Planning
      Vital Statistics
      Section of Hospital and Medical Facilities

 Bureau of Family Health Services
      Maternal and Child Health
      Nutrition
      Developmental Disabilities Planning
      Dental Health
      Community Health Nursing

 Bureau of Health Promotion and Disease Prevention
      Health Promotion and Education
      Disease Control
      Emergency Medical Services
      Local Health Departments
      Chronic Disease
2Types of Local Health Departments by Jurisdiction
                                     Nebraska, 1990

           Jurisdiction                 Co     C      C/Co   M/Co   N/Co

           Adams                                                    X
           Antelope                                                 X
           Arthur                                            X
           Banner                                                   X
           Blaine                                                   X
           Boone                                                    X
           Box Butte                                                X
           Boyd                                                     X
           Brown                                                    X
           Buffalo                                                  X
           Burt                                                     X
           Butler                       X
           Cass                                                     X
           Cedar                                                    X
           Chase                                                    X
           Cherry                                                   X
           Cheyenne                                                 X
           Clay                                                     X
           Colfax                                                   X
           Cuming                                                   X
           Custer                                                   X
           Dakota                                                   X
           Dawes                        X
           Dawson                                                   X
           Deuel                                                    X
           Dixon                                                    X
           Dodge                                                    X
           Douglas                                                  X
           Dundy                        X
           Fillmore                                                 X
           Franklin                                                 X
           Frontier                                                 X
           Furnas                                                   X
           Gage                                                     X
           Garden                                                   X
           Garfield                                                 X
           Gosper                                                   X
           Grand Isle-Hall                            X
           Grant                                             X
           Greeley                                                  X
           Hamilton                                                 X
           Harlan                                                   X
           Hastings                            X
           Hayes                                                    X
           Hitchcock                                                X
           Hooker                                            X
           Howard                                                   X
           Jefferson                                                X
           Johnson                      X
           Kearney                             X
           Kearney                                           X      X
           Keith
           Keya Paha                                                X
           Kimball                                                  X
           Knox                                                     X
           Lincoln-Lancast                            X
           Logan                                                    X
           Loup                                                     X
           Madison                                                  X
           McPherson                                                X
           Merrick                      X
           Morrill                                                  X
           Nance                                                    X
           Nemaha                       X
           Norfolk                             X
           Nuckolls                                                 X
           Otoe                                                     X
           Pawnee                                                   X
           Perkins                                                  X
           Phelps                                                   X
           Pierce                                                   X
           Platte                                                   X
           Polk                         X
           Red Willow                   X
           Richardson                                               X
           Rock                                                     X
           Saline                                                   X
           Sarpy                                                    X
           Saunders                     X
           Scotts Bluff                 X
           Seward                                                   X
           Sheridan                                                 X
           Sherman                                                  X
           Sioux                                                    X
           Stanton                                                  X
           Thayer                                            X      X
           Thomas
           Thurston                                                 X
           Valley                                                   X
           Washington                                               X
           Wayne                                                    X
           Webster                                                  X
           Wheeler                                                  X
           York                                                     X

           Co = County HD C = City HD C/Co = City/County HD M/Co =Multico HD
1NEVADA
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State      United States

 Population (1988)                  1,054,000        245,803,000
 Population Density (1988)                  9.6               69.5
   (per/sq.mi.)
 Number of Counties                        17              3,139
 Median Age (1987)                         31.9               31.7
 Percent Below Poverty Level (1985)        14.4               14.0
   (persons)
 Percent of Population Rural (1980)        15.0               26.0
 Percent of Population White (1980)        87.5               83.1
 Percent of Population Non-white (1980)    12.5               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

 Nevada counties derive their authority from the state
 constitution, Nevada Revised Statutes and case law developed by
 state and Federal courts.

 Commission Form - (17) - All counties use the Commission Form of
 government, with boards of three, five, or seven-members.  The
 members are elected at large from single-member districts.
 Commissioners are permitted to appoint a county manager, and six
 counties have chosen to employ one.

      City-County Consolidation - (1) - City-county consolidations
      are permitted, and Carson City-Ormsby County have merged.
      This entity is considered an independent city by the U.S.
      Census Bureau.  A Commission Form of government with an
      appointed city manager is used.

 Data for this state were updated October 1990. II.  State Health Agency (SHA)
3II. State Health Agency (SHA)

      A.  General

 Component of Superagency

 The Nevada Health Division, the SHA, is a component of a
 superagency named the Department of Human Resources.  The mission
 of the State Health Division is to promote and protect the health
 of Nevadans and visitors to the state.

 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, Not Cabinet-level Appointment

 The administrator is the head of the SHA.  The administrator is
 appointed by the Director of the Department of Human Resources
 with consent of the Governor.  To qualify for appointment as
 administrator an individual must have had 2 years' experience, or
 the equivalent, as the administrator of:  (1) a full-time county
 or city health facility or department, or (2) a major health
 program at a state or national level.  The administrator is
 responsible for management of the SHA and its programs.

 The State Health Officer is a separate position with
 responsibility in the Department.  The State Health Officer is
 the senior medical public health advisor in the state.  The State
 Health Officer is appointed by the Director of the Department.
 To qualify, the State Health Officer must be a citizen of the
 United States, be certified or eligible for certification by the
 American Board of Preventive Medicine and be licensed or eligible
 for licensure, as a doctor of medicine to practice in Nevada.
 The State Health Officer shall enforce all laws and regulations
 pertaining to public health and investigate the causes of
 disease, epidemics, source of mortality, and nuisances affecting
 public health.

      C.  State Board of Health/Council

 Policy-making

 The Nevada Board of Health is composed of seven members,
 appointed by the Governor.  Two of the members must be physicians
 licensed to practice medicine for at least 5 years.  The State
 Board of Health is the supreme policy-making body for the State
 Health Department.

      D.  Regional/District Health Offices

 The health department does not divide the state into
 administrative districts or regions.  There are two locally
 administered district health departments (Washoe and Clark
 Counties) organized in accordance with applicable state statutes
 and local ordinances.

      E.  State-local Liaison

 Mixed Centralized and Decentralized Organizational Control,
 Informal Liaison Function

 There is no single office or individual who is responsible for
 the liaison between the SHA and local health units.
 Communications usually flow through the normal chain of command.

 The interaction between state and local public health agencies in
 Nevada may be characterized as mixed centralized and
 decentralized organizational control.  Under this arrangement
 local health services may be provided by the SHA in all rural
 jurisdictions and local governmental units, boards of health or
 health departments in other jurisdictions.

      F.  Budget

 Total FY 1988 Nevada SHA expenditures were $20,050,000.  Total FY
 1988 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts           $9,560,000
        State Funds                            $8,802,000
        Local Funds                                     0
        Fees and Reimbursements                $1,688,000
        Other                                    $877,000
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 There are 15 local health departments in Nevada.  These include
 two autonomous, full-service health districts located in Reno
 (Washoe County) and Las Vegas (Clark County) and 13 county
 entities where public health services are provided by field
 offices of the SHA.  These offices are administered, supervised,
 and funded by the SHA.  Esmeralda and Eureka counties, two of the
 smaller and more sparsely populated counties, do not have field
 offices but receive public health services from field offices in
 adjacent counties.

      B.  Services Provided

 The following information on services provided by local health
 districts is derived from a survey conducted by NACHO during
 1989.  Both of the full-service local health departments in
 Nevada responded to the survey.

 Services Provided by LPHAs                      Number of LPHAs

   I.  Assessment Activities
       A.  Data Collection/Analysis
            1.  Behavioral Risk Assessment              1
            2.  Morbidity Data                          2
            3.  Reportable Diseases                     2
            4.  Vital Records and Statistics            2

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        1
            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                   2
            2.  Health Facility Safety/Quality          1
            3.  Rec. Facility Safety/Quality            2
            4.  Other Facility Safety/Quality           1

       B.  Licensing
            1.  Health Facilities                       -
            2.  Other Facilities                        2

       C.  Health Education                             1

       D.  Environmental
            1.  Air Quality                             2
            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              2
            7.  Radiation Control                       -
            8.  Sewage Disposal Systems                 2
            9.  Solid Waste Management                  2
           10.  Vector and Animal Control               2
           11.  Water Pollution                         2

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             2
            2.  Alcohol Abuse                           -
            3.  Child Health                            2
            4.  Chronic Diseases                        1
            5.  Dental Health                           -
            6.  Drug Abuse                              1
            7.  Emergency Medical Service               2
            8.  Family Planning                         2
            9.  Handicapped Children                    1
           10.  Home Health Care                        2
           11.  Hospitals                               -
           12.  Immunizations                           2
           13.  Laboratory Services                     1
           14.  Long-term Care Facilities               -
           15.  Mental Health                           -
           16.  Obstetrical Care                        -
           17.  Prenatal Care                           1
           18.  Primary Care                            -
           19.  Sexually Transmitted Diseases           2
           20.  Tuberculosis                            2
           21.  WIC                                     2

       C.  Local Health Officer

 No M.D. Requirement, Local Governing Body Appointment

 Local health officers in the counties with autonomous health
 departments are not required to be physicians.  They are
 appointed by the local governing body.  The health officers are
 responsible for managing the local health departments and public
 health programs.

      D.  Local Board of Health

 Only the two autonomous health districts have boards of health.

      E.  Staff

 The staffs of the two autonomous local district health
 departments are employed and supervised by the local
 jurisdiction.  The number of employees for the department in
 Las Vegas is 190 and the one in Reno is 125.  The county units
 that are funded by the SHA are part of the State system and the
 staffs are state employees.

      F.  Budget

 Total FY 1988 LPHA expenditures were $14,728,000.  Total FY 1988
 United States LPHA expenditures were $3,978,948,000.

      Source of Funds
        Federal Grants and Contracts      $6,263,000
        State Funds                       $1,870,000
        Local Funds                       $3,414,000
        Fees and Reimbursements           $3,084,000
        Other Sources                        $97,000
        Source Unknown                             0

 The SHA reported that these figures include the total amount of
 additional monies expended by all local health departments.
2Nevada State Health Division, 1990

 Director Department of Human Resources
 State Health Officer
      Communicable Disease
      Laboratory
      Special Children's Clinic
      Epidemiology

 Administrator
      Administrative Services
      Personnel
      Financial Management

 State Board of Health
      Laboratory Advisory Board

 Bureau Regulatory Health
      Consumer Health Protection
      Radiological Material
      Low-Level Waste
      Health Facilities

 Administrative Services Officer
      Vital Statistics
      Cancer Registry
      Systems Analyst
      Emergency Medical Services
      Personnel
      Business Office

 Maternal and Child Health
      Metabolic Screening
      Health Education
      Genetic Services
      Children's Special Health Care
      Evaluations
      Medical Payments
      Primary Care

 Community Health Services
      Family Planning
      Nursing

 Women Infants and Children/Nutrition Program
2Types of Local Health Departments by Jurisdiction
                                      Nevada, 1990

           Jurisdiction                 Co     C      N/Co

           Carson City                         X
           Churchill                    X
           Clark                        X
           Douglas                      X
           Elko                         X
           Esmeralda                                  X
           Eureka                                     X
           Humboldt                     X
           Lander                       X
           Lincoln                      X
           Lyon                         X
           Mineral                      X
           Nye                          X
           Pershing                     X
           Storey                       X
           Washoe                       X
           White Pine                   X

           Co = County HD
           C = City HD
           N/Co = No County HD
1NEW HAMPSHIRE
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State      United States

 Population (1988)                  1,085,000        245,803,000
 Population Density (1988)                120.6               69.4
   (per/sq.mi.)
 Number of Counties                        10              3,139
 Median Age (1987                          31.9               31.7
 Percent Below Poverty Level (1985)         6.0               14.0
   (persons)
 Percent of Population Rural (1980)        48.0               26.0
 Percent of Population White (1980)        98.9               83.1
 Percent of Population Non-white) (1980)    1.1               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 function of county governments in New Hampshire
 are established by the state constitution and statutes.

 Commission Form - (10) - All county governments are based on the
 this form of government.  Each county uses two governing bodies,
 the board of commissioners and county delegation.  Both bodies
 are made up of three-member boards which are elected from
 single-member districts.  The county commissioners provide
 administrative and budgetary control over the county government,
 while the county delegation is responsible for appropriating
 necessary funds for the county to function.  Additionally,
 counties may appoint a county administrator.  All except one
 county has chosen this option.

 Home rule authority for New Hampshire counties exists, but no
 counties have exercised this option.  In another option, voters
 may petition for a charter commission to study and recommend a
 charter to meet the functional and structural needs of the
 county.  This procedure has not been used by any counties at the
 current time.

 For public health purposes and other governmental concerns, the
 primary units of government are city or town.

 Data for this state were updated January 1991. II.  State Health Agency (SHA)
3II. State Health Agency (SHA)

      A.  General

 Component of Superagency

 The State Division of Public Health Services is one of five
 divisions in the New Hampshire Department of Health and Human
 Services (NHDHHS) and is therefore a component of a superagency.
 The SHA has no relationship with the counties and they, except
 for the operation of county nursing homes, have no public health
 functions.

 The mission of the NHDHHS is to provide the opportunities and
 conditions necessary for people, individually and collectively,
 to achieve and/or maintain their health in a safe environment.

 The following are some areas of responsibility for the SHA:

      State Public Health Authority
      State Agency for Children with Special Health Care Needs
      State Professions Licensing Agency
      Institutional Licensing Agency

      B.  Head of State Health Agency

 M.D. Requirement, Not Cabinet-level Appointment

 The Division Director, who is required by state law to be a
 physician licensed or eligible for licensure in the state with at
 least 5 years' experience in public health, is responsible to the
 Department Commissioner who, in turn, is responsible to the
 Governor.

 The Director's staff is responsible for coordination and
 development of services, management oversight, planning, and
 policy establishment.  Crisis response and public information
 services are also the responsibility of the Director.

      C.  State Board of Health/Council

 There is no health council or board for the Division of Public
 Health Services.

      D.  Regional/District Health Offices

 The NHDHHS has not divided the state into administrative regions
 or districts.

       E.  State-local Liaison

 Mixed Centralized and Decentralized Organizational Control,
 Formal Liaison Function

 The Chief of the Bureau of Environmental Services has been
 designated by the SHA as the state-local liaison.  In this role
 the Chief acts as a focal point for communications between the
 state and local health departments.  This role developed because
 of the frequent communications that occur between the state and
 local health agencies in the important environmental area.  The
 legal coordinator for the SHA also has frequent communications
 with local health departments.

 The interaction between state and local public health agencies in
 New Hampshire 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 New Hampshire SHA expenditures were $23,024,000.
 Total FY 1988 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts          $12,075,000
        State Funds                            $9,416,000
        Local Funds                                     0
        Fees and Reimbursements                  $975,000
        Other                                    $557,000
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 New Hampshire has 13 local health departments, all of which are
 city health departments.  Only two of the health departments
 provide a wide range of services, but neither fulfill the
 complete roles usually ascribed to such entities.  Each city/town
 has a health officer, responsible under law for certain
 health-related issues, primarily in the public sanitation
 sector.  Each township is required to have a board of health.
 Cities, under state law, are "self-regulating."  This means that
 the state, for public health purposes, has no oversight or
 regulatory responsibilities.

      B.  Services Provided

 The following information on services provided by local health
 departments in New Hampshire is derived from a survey conducted
 by NACHO during 1989.  All 13 local health departments in New
 Hampshire 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              1   (  7.7%)
            2.  Morbidity Data                          1   (  7.7%)
            3.  Reportable Diseases                     7   ( 53.8%)
            4.  Vital Records and Statistics            3   ( 23.1%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        2   ( 15.4%)
            2.  Communicable Diseases                   6   ( 46.2%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement             12   ( 92.3%)
       B.  Health Planning                               3   ( 23.1%)
       C.  Priority Setting                              4   ( 30.8%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   10   ( 76.9%)
            2.  Health Facility Safety/Quality           5   ( 38.5%)
            3.  Rec. Facility Safety/Quality             8   ( 61.5%)
            4.  Other Facility Safety/Quality            7   ( 53.8%)

       B.  Licensing
            1.  Health Facilities                        3   ( 23.1%)
            2.  Other Facilities                        11   ( 84.6%)

       C.  Health Education                              5   ( 38.5%)

       D.  Environmental
            1.  Air Quality                              5   ( 38.5%)
            2.  Hazardous Waste Management               8   ( 61.5%)
            3.  Individual Water Supply Safety           8   ( 61.5%)
            4.  Noise Pollution                          5   ( 38.5%)
            5.  Occupational Health and Safety           7   ( 53.8%)
            6.  Public Water Supply Safety               8   ( 61.5%)
            7.  Radiation Control                        1   (  7.7%)
            8.  Sewage Disposal Systems                 12   ( 92.3%)
            9.  Solid Waste Management                   6   ( 46.2%)
           10.  Vector and Animal Control                9   ( 69.2%)
           11.  Water Pollution                         12   ( 92.3%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling              2   ( 15.4%)
            2.  Alcohol Abuse                            1   (  7.7%)
            3.  Child Health                             3   ( 23.1%)
            4.  Chronic Diseases                         1   (  7.7%)
            5.  Dental Health                            2   ( 15.4%)
            6.  Drug Abuse                               1   (  7.7%)
            7.  Emergency Medical Service                -
            8.  Family Planning                          -
            9.  Handicapped Children                     1   (  7.7%)
           10.  Home Health Care                         3   ( 23.1%)
           11.  Hospitals                                -
           12.  Immunizations                            4   ( 30.8%)
           13.  Laboratory Services                      -
           14.  Long-term Care Facilities                -
           15.  Mental Health                            -
           16.  Obstetrical Care                         -
           17.  Prenatal Care                            -
           18.  Primary Care                             1   (  7.7%)
           19.  Sexually Transmitted Diseases            2   ( 15.4%)
           20.  Tuberculosis                             2   ( 15.4%)
           21.  WIC                                      1   (  7.7%)

      C.  Local Health Officer

 No M.D. Requirement, Director of Division of Public Health
 Services Appointment

 Local town health officers are nominated by the Boards of
 Selectmen and are appointed by the Director of NHDHHS.  Few
 receive any salary and many are part-time with no public health
 services background.

 City health officers are usually better trained and most have
 some staff available to them.

      D.  Local Board of Health

 Policy-making

 By state law, towns (but not cities), may have a board of
 health.  In operation, such boards are the Board of Selectmen.
 They play no direct role in the delivery of public health
 services.

       E.  Staff

 The staffs of local health department are employed and supervised
 by the local jurisdiction.  The number of employees for a local
 health department ranges from 1 to 39.

      F.  Budget

 Total FY 1988 LPHA expenditures were $57,000.  Total FY 1988 LPHA
 expenditures were $3,978,948,000.

      Source of Funds
        Federal Grants and Contracts         $29,000
        State Funds                          $28,000
        Local Funds                                0
        Fees and Reimbursements                    0
        Other Sources                              0
        Source Unknown                             0

 These expenditures represent funds provided to two cities through
 contracts with the SHA.
2New Hampshire Division of Public Health Services, 1990

 Director
 Deputy Director
   Board of Nursing
   Health Services Planning and Review Board
 Office of Family and Community Health
      Bureau of Maternal and Child Health
      Bureau of Dental Health Services
      Bureau of Special Medical Services
      Bureau of WIC Nutrition Services

 Office of Health Promotion
      Bureau of Health Promotion
      Bureau of Emergency Medical Services
      Bureau of Child Care Standards and Licensing
      Bureau of Health Facilities Administration

 Office of Environmental Health and Hazard Assessment
      Bureau of Environmental Health
      Bureau of Radiological Health
      Bureau of Health Risk Assessment

 Office of Disease Prevention and Control
      Bureau of Disease Control
      Public Health Laboratories
2Types of Local Health Departments by Jurisdiction
                                  New Hampshire, 1990

           Jurisdiction                        C      N/Co

           Amherst                             X
           Belknap                                    X
           Berlin                              X
           Carroll                                    X
           Cheshire                                   X
           Claremont                           X
           Concord                             X
           Coos                                       X
           Dover                               X
           Grafton                                    X
           Hillsborough                               X
           Keene                               X
           Merrimack                                  X
           Nashua                              X
           Portsmouth                          X
           Rochester                           X
           Rockingham                                 X
           Salem                               X
           Somerworth                          X
           Stafford                                   X
           Sullivan                                   X

           C = City HD
           N/Co = No County HD
1NEW JERSEY
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State      United States

 Population (1988)                  7,721,000        245,803,000
 Population Density (1988)              1,033.9               69.4
   (per/sq.mi.)
 Number of Counties                        21              3,139
 Median Age (1987)                         34.1               31.7
 Percent Below Poverty Level (1985)         8.3               14.0
   (persons)
 Percent of Population Rural (1980)        11.0               26.0
 Percent of Population White (1980)        83.2               83.1
 Percent of Population Non-white (1980)    16.8               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 for county governments in New Jersey
 are established by the constitution and statutes.  Non-Charter
 and Optional Charter Status are two forms of county government
 that are permitted in New Jersey.

 Non-Charter Option - (15) - This form of government has
 legislative and administrative responsibilities that are under a
 three-, five-, seven-, or nine-member Board of Freeholders who
 are elected from single-member districts.  Thirteen of these
 counties have chosen to appoint an administrator to assist the
 board with administrative duties.

 Optional Charter Form - (6) - This form of government has been
 adopted by six counties.  Legislation authorizing the Charter
 Form of government provides for the separation of legislative and
 administrative powers within the counties.  Executive authority
 in these counties resides with an independently elected or
 appointed official.  Legislative responsibility is given to a
 Board of Freeholders made up of five, seven, or nine members who
 are elected from single-member districts, at large, or by a
 combination of methods.  Additionally, the Board of Freeholders

 Data for this state were updated November 1990. elects one member
 to serve as freeholder director for a 1-year term.  This individual
 has authority to appoint committees and boards and serves as a
 member of other county boards.  The two optional government structures
 listed below are being used by charter counties.

 County Executive Plan - (5) - This plan provides for a strong
 elected chief executive officer with veto power and authority for
 administration, budget, and appointments.

 Board President Plan - (1) - With this option the board appoints
 a county manager who has executive powers except for the power of
 veto.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The SHA is the New Jersey Department of Health (NJDH).  It is a
 free-standing, independent agency.  The current mission statement
 in the Department's 1990 planning document reads as follows:

 To execute legislative mandates, within the budget provided, to
 assure the health and well being of New Jersey's citizens.  The
 Department's mission is achieved through programs designed to:

      Collect vital statistics and other health data necessary to
      determine the prevalence and cause of disease.

      Prevent and control communicable and environmental diseases
      through detection, unique diagnostic laboratory services,
      immunization and other environmental health and public
      health services.

      Ensure public access to quality health care services
      provided at a reasonable cost.

 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

      B.  Head of State Health Agency

 M.D. Requirement, Cabinet-level Appointment

 The Commissioner of Health is the chief administrative officer of
 the NJDH.  The Commissioner is appointed by the Governor with
 advice and consent of the Senate, and serves at the pleasure of
 the Governor.  There is a requirement that the Commissioner be a
 licensed physician who is a graduate of a regularly chartered and
 legally constituted medical school or college.  The Commissioner
 must also have skill in sanitary science, and have at least 5
 years of full-time experience in an administrative or executive
 capacity in a public health agency or 10 years of full-time
 experience in community medical service.  Responsibility of the
 Commissioner includes the adoption of regulations governing the
 internal management of the Department; administering the work of
 the Department and laws under its jurisdiction; and enforcing
 those laws through legal proceedings.

      C.  State Board of Health/Council

 Policy-making

 New Jersey has an eight-member Public Health Council that is
 appointed by the Governor with the advice and consent of the
 State Senate.  The members are appointed with due regard for
 their knowledge and interest in public health.  Two members are
 to be licensed physicians and one member must be a licensed
 dentist.  The terms of office are 7 years, but the original
 appointments were made so that at least one member's term expires
 each year.  The chairman is elected by the members and serves in
 this capacity for 1 year or until a successor is elected.  The
 Council has the power, by majority vote of the members, to
 establish, amend, and repeal sanitary regulations that are
 necessary to preserve and improve the public health in the
 state.  Other duties of the Public Health Council include:
 requesting from the Commissioner any information concerning the
 work of the department that they consider necessary; consider any
 matter relating to the preservation and improvement of public
 health and advise the Commissioner on these matters; submit to
 the Commissioner any recommendations which it deems necessary for
 proper conduct of the department; study and investigate public
 health activities of the state and report to the Governor and
 legislature.

 There are a number of additional mandated boards, councils,
 commissions, authorities, and other bodies which relate to the
 NJDH, including these:  the Drug Utilization Review Council; the
 Health Care Administration Board; the Health Care Facilities
 Financing Authority; the Hospital Rate Setting Commission; and
 the Statewide Health Coordinating Council.  Appointments to these
 bodies are usually made by the Commissioner of Health or the
 Governor.  The members usually serve without compensation.

       D.  Regional/District Health Offices

 In 1984 the Office of Local Health and Regional Operations was
 consolidated into a centralized unit and renamed Local Health
 Development Services.  Presently all dealings with local health
 departments are through the central office.  A northern region
 health office does exist which houses immunization, refugee
 health, communicable disease, substance abuse programs, AIDS,
 health facility inspections, sexually transmitted diseases, and
 tuberculosis.  The regional office staff provide consultation
 support to the local health departments and do not provide direct
 patient services through the regional office.  Supervision for
 program staff located in the regional office comes directly from
 program chiefs in the central offices in Trenton.

      E.  State-local Liaison

 Decentralized Organizational Control, Formal Liaison Function

 The Local Health Development Unit is the Department's liaison
 with local health departments.  It has been structured to address
 the diverse needs of local health departments with special
 liaison positions to the activities mandated in minimum standards
 which are found in other divisions of the Department.  This unit
 serves as the primary communication point for local health
 departments and the NJDH.  Categorical funding for local health
 departments is provided through categorical programs.

 The interaction between state and local public health agencies in
 New Jersey may be characterized as decentralized organizational
 control.  Under this arrangement, local government directly
 operates health departments with or without a local board of
 health.

       F.  Budget

 Total FY 1988 SHA expenditures were $196,235,000.  Total FY 1988
 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts          $82,620,000
        State Funds                           $83,606,000
        Local Funds                                     0
        Fees and Reimbursements                $6,925,000
        Other                                 $23,085,000
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 There are 113 operating local health jurisdictions in New
 Jersey.  These jurisdictions include 15 county health
 departments, 19 city health departments, and 79 town/township
 health departments (6 of the township units represent multiple
 townships that have formed associations called Regional Health
 Commissions to provide public health services).  Under State
 statutes, local boards of health have the following options of
 delivery of services to meet minimum standards:  local health
 department; county health department; interlocal contract; or
 regional health commission.

      B.  Services Provided

 The following information on services provided by local health
 departments in New Jersey is derived from a survey conducted by
 NACHO during 1989.  One hundred and one of the 113 local health
 departments in New Jersey 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              49   ( 48.5%)
            2.  Morbidity Data                          66   ( 65.3%)
            3.  Reportable Diseases                     91   ( 90.1%)
            4.  Vital Records and Statistics            86   ( 85.1%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        82   ( 81.2%)
            2.  Communicable Diseases                   98   ( 97.0%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement             95   ( 94.1%)
       B.  Health Planning                              79   ( 78.2%)
       C.  Priority Setting                             76   ( 75.2%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   99   ( 98.0%)
            2.  Health Facility Safety/Quality          66   ( 65.3%)
            3.  Rec. Facility Safety/Quality            89   ( 88.1%)
            4.  Other Facility Safety/Quality           84   ( 83.2%)

       B.  Licensing
            1.  Health Facilities                       24   ( 23.8%)
            2.  Other Facilities                        88   ( 87.1%)

       C.  Health Education                             95   ( 94.1%)

       D.  Environmental
            1.  Air Quality                             86   ( 85.1%)
            2.  Hazardous Waste Management              86   ( 85.1%)
            3.  Individual Water Supply Safety          86   ( 85.1%)
            4.  Noise Pollution                         86   ( 85.1%)
            5.  Occupational Health and Safety          91   ( 90.1%)
            6.  Public Water Supply Safety              77   ( 76.2%)
            7.  Radiation Control                       48   ( 47.5%)
            8.  Sewage Disposal Systems                 85   ( 84.2%)
            9.  Solid Waste Management                  84   ( 83.2%)
           10.  Vector and Animal Control               99   ( 98.0%)
           11.  Water Pollution                         93   ( 92.1%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             23   ( 22.8%)
            2.  Alcohol Abuse                           34   ( 33.7%)
            3.  Child Health                            98   ( 97.0%)
            4.  Chronic Diseases                        92   ( 91.1%)
            5.  Dental Health                           42   ( 41.6%)
            6.  Drug Abuse                              31   ( 30.7%)
            7.  Emergency Medical Service               12   ( 11.9%)
            8.  Family Planning                         20   ( 19.8%)
            9.  Handicapped Children                    17   ( 16.8%)
           10.  Home Health Care                        42   ( 41.6%)
           11.  Hospitals                                6   (  5.9%)
           12.  Immunizations                          100   ( 99.0%)
           13.  Laboratory Services                     57   ( 56.4%)
           14.  Long-term Care Facilities                8   (  7.9%)
           15.  Mental Health                           17   ( 16.8%)
           16.  Obstetrical Care                        12   ( 11.9%)
           17.  Prenatal Care                           41   ( 40.6%)
           18.  Primary Care                            12   ( 11.9%)
           19.  Sexually Transmitted Diseases           70   ( 69.3%)
           20.  Tuberculosis                            75   ( 74.3%)
           21.  WIC                                     59   ( 58.4%)

      C.  Local Health Officer

 No M.D. Requirement, Local Governing Body Appointment

 State law mandates that each local health department be
 administered by a full-time licensed health officer.  Health
 officers are appointed by the governing bodies of the
 jurisdictions that employ them.  The health officer functions as
 the chief administrative officer of the board or authority, and
 is accountable to the board or authority.  The health officer, as
 authorized by the board or authority, is the responsible agent
 for all public health services and activities of the local health
 agency and shall:  direct and supervise all employees of the
 local health department; plan, manage and implement the
 programmatic components of the local health agency and prepare
 the budget; develop and maintain a system of evaluation for all
 public health services and activities of the local health
 department.  The health officer shall also maintain
 administrative relationships and communication with support
 services and community resources such as hospitals, emergency
 medical services providers, government agencies, voluntary
 organizations and other health care providers to promote
 inter-agency cooperation and effective allocation of health
 resources; enforce all public health laws, regulations, and
 ordinances and ensure appropriate disposition of all enforcement
 action; provide for open lines of communication within the
 organization; develop a referral directory and implement a
 referral log for health services provided by other agencies to
 community residents; oversee the completion of the Community
 Health Profile and the implementation of the Local Health Service
 Plan as requested by the NJDH; determine and define the health
 needs and priorities of the community based upon analyses and
 interpretation of health statistics and other pertinent
 information; and maintain proper records in accordance with the
 local health agency records' retention schedule as promulgated by
 the New Jersey Department of Education, Bureau of Archives and
 History.

       D.  Local Board of Health

 Policy-making

 In New Jersey every municipality is required and other
 jurisdictions are permitted to establish a board of health.  The
 boards are similar in some aspects such as the term of office,
 usually staggered and not to exceed 5 years, but other aspects of
 the boards vary with the jurisdiction.  The following are some of
 the variations:

 County Board of Health - The board of freeholders may serve or
 may appoint a board of health.  If a board of health is
 appointed, it will consist of at least five but no more than nine
 members.  Not more than two of the members will be members of the
 freeholders' board.

 Township Board of Health (townships under 20,000 population) -
 The board is made up of members of the township committee, the
 township assessor, the township clerk, and one physician
 appointed by the township board.

 Township Board of Health (townships over 20,000 population) - The
 board is composed of five to seven members appointed in the same
 manner as the township committee.

 Municipality Board of Health - The board is composed of five to
 seven members appointed by the governing body.

 Municipality Board of Health (Municipality over 80,000 population
 but not first class city) - The board is composed of 5 to 10
 members appointed by the mayor.

 First Class City Board of Health - The board contains 10 members
 appointed by the mayor.  Members must be citizens of the city.
 At least half of the members must be physicians and not more than
 one-half can be from the same political party.

 Local boards of health possess broad, general powers to enact
 ordinances and to make rules and regulations in the interest of
 protecting and improving public health.

      E.  Staff

 Local health department staffs are employed and supervised by the
 local jurisdiction.  The number of employees for local health
 departments ranges from 1 to 225.

      F.  Budget

 Total FY 1988 LPHA expenditures were $89,644,000.  Total FY 1988
 United States LPHA expenditures were $3,978,948,000.

      Source of Funds
        Federal Grants and Contracts     $10,842,000
        State Funds                      $15,989,000
        Local Funds                      $57,725,000
        Fees and Reimbursements                    0
        Other Sources                     $5,088,000
        Source Unknown                             0

 The SHA reported that these figures include the amount of
 additional local health department monies expended by all local
 health departments.
2New Jersey State Department of Health, 1990

 Commissioner of Health
 Chief of Staff
   Assistant Commissioner, Management and Administration
   Director, Office of Legal Services
   Director of Communications
   Director, Office of Governmental Relations
 Deputy Commissioner
      Assistant Commissioner, Epidemiology and Disease Control
      Assistant Commissioner, Occupational and Environmental
        Health
      Assistant Commissioner, Public Health and Environmental Labs

 Deputy
      Assistant Commissioner, Alcohol and Drug Abuse
      Assistant Commissioner, AIDS Prevention and Control
      Assistant Commissioner, Community Health Services

 Deputy Commissioner
      Assistant Commissioner, Health Facilities Evaluation and
        Licensing
      Assistant Commissioner, Health Planning and Resources
        Development
2Types of Local Health Departments by Jurisdiction
                                    New Jersey, 1990

           Jurisdiction                 Co     C      N/Co   T/T

           Atlantic                     X
           Atlantic                            X
           Belleville                                        X
           Bergen                       X
           Bergenfield                                       X
           Bernards                                          X
           Bloomfield                                        X
           Branchburg                                        X
           Bridgewater                                       X
           Burlington                   X
           Camden                       X
           Cape May                     X
           Clifton                                           X
           Closter                                           X
           Colts Neck                                        X
           Cranford                            X
           Cumberland                   X
           Denville                                          X
           Dover                                             X
           DuRidge Reg. Comm                                 X
           East Hanover                                      X
           East Orange                         X
           East Windsor                                      X
           Edison                                            X
           Elizabeth                           X
           Elmwood Park                                      X
           Englewood                           X
           Essex                                      X
           Ewing                                             X
           Fair Lawn                                         X
           Fairfield                                         X
           Fort Lee                                          X
           Franklin                                          X

           Freehold                                          X
           Gloucester                   X
           Hackensack                          X
           Hamilton                                          X
           Harrison                            X
           Hazlet                                            X
           Hillsborough                                      X
           Hoboken                             X
           Hopatcong                                         X
           Hudson                                     X
           Hunterdon                    X
           Jefferson                                         X
           Jersey City                         X
           Kearny                              X
           Kinnelon                                          X
           Lawrence                                          X
           Lincoln Park                                      X
           Linden                              X
           Livingston                                        X
           Long Beach                                        X
           Long Branch                                       X
           Madison Boro                                      X
           Manalapan                                         X
           Maplewood                                         X
           Matawan Boro                                      X
           Mercer                                     X
           Mid-Bergen Reg.                                   X
           Middle-Brook                                      X
           Middlesex                    X
           Middletown                                        X
           Millburn                                          X
           Monmouth                     X
           Monmouth Reg. Comm.                               X
           Montclair                                         X
           Montgomery                                        X
           Montville                                         X
           Morris                                     X
           Morristown                                        X
           Mt. Olive                                         X
           N.W. Bergen                                       X
           Newark                              X
           Ocean                        X
           Old Bridge                                        X
           Palisades Park                                    X
           Paramus                                           X
           Parsippany                                        X
           Passaic                      X
           Passaic                             X
           Patterson                           X
           Pequannock                                        X
           Piscataway                                        X
           Plainfield                          X
           Pompton                                           X
           Princeton                                         X
           Rahway                              X
           Ramsey                                            X
           Randolph                                          X
           Red Bank                            X
           Rockaway                                          X
           Roxbury                                           X
           Salem                        X
           Secaucus                            X
           Somerset                                   X
           Somerville                                        X
           South Brunswick                                   X
           South Orange                                      X
           South Plainfield                                  X
           Sparta                                            X
           Summit                              X
           Sussex                       X
           Teaneck                                           X
           Trenton                             X
           Union                                      X
           Union City                          X
           Vernon                                            X
           Vineland                            X
           Warren                       X
           Washington                                        X
           Washington                                        X
           Wayne                               X
           West Caldwell                                     X
           West Milford                                      X
           West Orange                                       X
           West Windsor                                      X
           Westfield                           X
           Woodbridge                                        X

           Co = County HD
           C = City HD
           N/Co = No County HD
           T/T = Town/Township HD
1NEW MEXICO
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State      United States

 Population (1988)                  1,507,000        245,803,000
 Population Density (1988)                 12.4               69.4
   (per/sq.mi.)
 Number of Counties                        33              3,139
 Median Age (1987)                         29.7               31.7
 Percent Below Poverty Level (1985)        18.5               14.0
   (persons)
 Percent of Population Rural (1980)        28.0               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)          12.6               12.5
   (25 years of age and over)

      B.  County Government Structure

 No Home Rule Authority

 The authority and framework for county governments in New Mexico
 are found in the state constitution and statutes.  Although the
 constitution provides for charter government, it applies only to
 1 county out of 33 through area limitations; therefore, the state
 has taken an official position as a non-home rule state.

 Commission Form - (33) - All counties except Los Alamos have this
 form of government, with three to five members elected at large
 from the districts in which they live.  Thirty-two of the 33
 counties have appointed administrators.

 Incorporated County - (1) - The state constitution establishes
 that any county with less than 144 square miles of area and more
 than 10,000 population may become an Incorporated County.  Los
 Alamos is the only Incorporated County in the state.  As an
 Incorporated County, Los Alamos is provided with a home rule
 charter which establishes the form of government, the officers,
 and responsibilities of the officers and officials.  The Los
 Alamos county government includes a seven-member council which is

 * These data were provided by the SHA.

 Data for this state were updated April 1991.
  elected at large and a strong administrator which is appointed.
 The restrictive nature of the home rule provision prohibits the
 eligibility of other counties.  City-county consolidations are
 permitted under state law, but none exists at present.
3II.  State Health Agency (SHA)

      A.  General

 Component of Superagency

 The Public Health Division of the Health Department is named as
 the SHA by the New Mexico Public Health Act.  The mission of the
 Public Health Division is to contribute to the achievement of the
 highest level of health possible for the people of New Mexico by
 promoting health, preventing disease, and minimizing the rate of
 death and disability from injuries and illnesses.

 The powers and authority of the Division are:

      1.   Receive grants, subsidies, donations, allotments or
           bequests offered to the state by the Federal
           government, individuals, or a foundation;

      2.   Supervise the health and hygiene of the people of the
           state;

      3.   Investigate, control and abate the causes of disease;

      4.   Establish, maintain and enforce isolation and
           quarantine;

      5.   Close public places and forbid gatherings of people
           when necessary for the protection of public health;

      6.   Establish programs and adopt regulations to prevent
           infant mortality, birth defects and morbidity;

      7.   Prescribe the duties of public health nurses and school
           nurses;

      8.   Maintain and enforce regulations for the licensure of
           health facilities;

      9.   Bring action in court for the enforcement of health
           laws and regulations and orders issued by the
           department;

      10.  Enter into agreements with other states to carry out
           the powers and duties of the department;

      11.  Cooperate and enter into contracts or agreements with
           the Federal government or any other person to carry out
           the powers and duties of the department;

      12.  Maintain and enforce regulations for the control of
           communicable diseases deemed to be dangerous to public
           health;

      13.  Maintain and enforce regulations for immunization
           against diseases deemed to be dangerous to the public
           health;

      14.  Maintain and enforce such rules and regulations as may
           be necessary to carry out provisions of the Public
           Health Act and to publish it;

      15.  Supervise state public health activities, operate a
           dental public health program, and operate state
           laboratories for the investigation of public health
           matters;

      16.  Sue and, with the consent of the legislature, be sued;

      17.  Regulate the practice of midwifery;

      18.  Administer legislation enacted pursuant to Title VI of
           the Public Health Act as amended and supplemented;

      19.  Inspect such premises or vehicles as necessary to
           ascertain the existence or nonexistence of conditions
           dangerous to public health or safety; and

      20.  Do all other things necessary to carry out its duties.

 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, Not Cabinet-level Appointment

 The Director of the Public Health Division is appointed by the
 Secretary of the Health Department and serves at the pleasure of
 the Secretary.  He/she is the chief administrator, expressing the
 goals of the state health agency to optimize the health of New
 Mexicans and focusing staff and financial resources so those
 goals and statutory responsibilities are met.  There is no M.D.
 requirement for this position.
                C.  State Board of Health/Council

 There is no State Board of Health or State Health Council in New
 Mexico.

      D.  Regional/District Health Offices

 The four health districts are administrative groupings of the 45
 field health offices.  All are state offices in the Field
 Operations Bureau.  The local field health offices report to the
 district; the district in turn reports to the Chief of Field
 Operations.  District offices are staffed with nurses,
 secretarial/clerical support staff, nurse practitioners,
 physicians, dentists, dental hygienists and assistants, health
 educators, nutritionists, administrators, disease prevention
 specialists, and social workers.  Each district has a District
 Health Officer, who has an M.D. degree.

      E.  State-local Liaison

 Centralized Organizational Control, Informal Liaison Function

 Local health offices are part of the SHA and do not have an
 individual or office that has specific responsibility for liaison
 functions.

 The interactions between state and local health agencies in New
 Mexico may be characterized as centralized organizational
 control.  Under this arrangement local health departments are
 operated by the SHA or a state board of health.

      F.  Budget

 Total FY 1988 New Mexico SHA expenditures were $48,849,548.
 Total FY 1988 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts          $31,970,548
        State Funds                           $16,432,100
        Local Funds                                     0
        Fees and Reimbursements                  $173,900
        Other                                    $273,000

 These figures exclude WIC and Commodity Supplemental Food
 Program.

 Child Care Food, Summer Food Service  $24,392,808
 WIC/Commodity Supplemental Food       $13,975,983
 Child Care Food/Summer Food           $10,480,757
3III.  Local Public Health Agencies (LPHAs)
                 A.  General

 New Mexico has 46 field health offices that provide public health
 services to local areas.  Although these units provide the same
 basic services as local public health agencies in other states,
 New Mexico does not consider them local health units because they
 are branches of the state health agency.  In addition to the 46
 units, Los Alamos County has a small locally funded office.  The
 Los Alamos office receives assistance from the SHA in the form of
 vaccines, birth control supplies, tuberculosis medications, and
 the like.

       B.  Services Provided

 The following information on services provided by local public
 health and environmental improvement offices in New Mexico is
 derived primarily from information provided by the Public Health
 Division Central Office.  Data for two items (indicated with an
 asterisk) are derived from a survey conducted by NACHO during
 1989.  Twenty-seven of the 46 local public health offices in New
 Mexico responded to the survey.  The Public Health Division
 provided information on all 46 local public health offices.
 Services provided by 70 percent of local public health offices in
 the state are underlined.

 Services Provided by LPHAs                      Number and Percent


   I.  Assessment Activities
       A.  Data Collection/Analysis
            1.  Behavioral Risk Assessment              46   (100.0%)
            2.  Morbidity Data                           -
            3.  Reportable Diseases                     46   (100.0%)
            4.  Vital Records and Statistics            16   ( 34.0%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                         -
            2.  Communicable Diseases                   46   (100.0%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement *            7   ( 25.9%)
       B.  Health Planning                              46   (100.0%)
       C.  Priority Setting                             46   (100.0%)

 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 *                      3   ( 11.1%)
            2.  Other Facilities                         -

       C.  Health Education                              46   (100.0%)

       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                -
           11.  Water Pollution                          -

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             46   (100.0%)
            2.  Alcohol Abuse                           46   (100.0%)
            3.  Child Health                            46   (100.0%)
            4.  Chronic Diseases                        46   (100.0%)
            5.  Dental Health                            -
            6.  Drug Abuse (education)                  46   (100.0%)
            7.  Emergency Medical Service                -
            8.  Family Planning                         44   ( 95.0%)
            9.  Handicapped Children                    46   (100.0%)
           10.  Home Health Care                         -
           11.  Hospitals                                -
           12.  Immunizations                           46   (100.0%)
           13.  Laboratory Services (limited)           46   (100.0%)
           14.  Long-term Care Facilities                -
           15.  Mental Health                            -
           16.  Obstetrical Care                         -
           17.  Prenatal Care                           22   ( 47.0%)
           18.  Primary Care                             -
           19.  Sexually Transmitted Diseases           46   (100.0%)
           20.  Tuberculosis                            46   (100.0%)
           21.  WIC                                     46   (100.0%)

 Environmental health problems are under the purview of the New
 Mexico Environment Department, which maintains a network of 22
 local offices throughout the state.  The Health Department and
 the Environment Department were until recently a part of the same
 agency.  Reportable diseases may be reported to district health
 officers, the Office of Epidemiology, or in the case of sexually
 transmitted diseases, directly to that program.  Vital records
 and statistics are kept by the central office.  Birth and death
 certificates are available through 16 field offices and the
 central office in Santa Fe.  All field health offices provide WIC
 nutrition services.
                C.  Local Health Officer

 M.D. Requirement, State Personnel System Appointment

 District Health Officers provide coverage for the field health
 offices in their districts.  They are employed through the
 regular state personnel system just as are all state health
 agency employees.  As part of community health promotion, health
 officers provide information on health issues to local, elected
 officials and maintain positive relationships with them.
 District Health Officers are, by state statute, responsible for
 the health of the public.  Besides providing direct patient
 services, they maintain standing orders, as well as provide
 quality assurance and supervision of clinicians.  Health officers
 are involved in the medical community, serving as liaison to
 other agencies, private physicians, and associations, enhancing
 awareness of public health and portraying health goals and
 messages to the public decision makers.  They are also an
 integral part of the planning and evaluation process and the
 district management team.

      D.  Local Board of Health

 New Mexico does not have local boards of health.

      E.  Staff

 The field health offices are staffed by state personnel employed
 by the Public Health Division.  The Division employs
 approximately 650 persons, about three-fourths of whom are based
 in field health offices.  Field office staff members are assisted
 by district staff who may travel throughout the state to consult
 or conduct presentations, training or disease investigation.

      F.  Budget

 Because local public health service units are part of the New
 Mexico Public Health Division, they do not consider them to be
 local health units.  Therefore, the budget information for these
 units is included in the budget of the SHA.  The counties do
 provide building space and offices.
2New Mexico Department of Health, 1990

 Governor
 Secretary
 Deputy Secretary
   Chief Medical Officer
   Office of Epidemiology
   Office of Planning and Evaluation
   Office of Internal Audit
   Office of Public Affairs
   Office of General Counsel
   Administrative Services Division
   Scientific Laboratory Division
 Public Health Division
 Developmental Disabilities Division
 Mental Health Division
 Behavioral Health Services Division
2Types of Local Health Departments by Jurisdiction
                                    New Mexico, 1990

           Jurisdiction                        Co     N/Co

           Bernalillo                                 X
           Catron                                     X
           Chaves                                     X
           Cibola                                     X
           Colfax                                     X
           Curry                                      X
           De Baca                                    X
           Dona Ana                                   X
           Eddy                                       X
           Grant                                      X
           Guadalupe                                  X
           Harding                                    X
           Hidalgo                                    X
           Lea                                        X
           Lincoln                                    X
           Los Alamos                          X
           Luna                                       X
           McKinley                                   X
           Mora                                       X
           Otero                                      X
           Quay                                       X
           Rio Arriba                                 X
           Roosevelt                                  X
           San Juan                                   X
           San Miguel                                 X
           Sandoval                                   X
           Santa Fe                                   X
           Sierra                                     X
           Socorro                                    X
           Taos                                       X
           Torrance                                   X
           Union                                      X
           Valencia                                   X

           Co = County HD
           N/Co = No County HD
1NEW YORK
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State    United States

 Population (1988)                 17,909,000      245,803,000
 Population Density (1988)                378.0             69.4
   (per/sq.mi.)
 Number of Counties                        62            3,139
 Median Age (1987)                         33.3             31.7
 Percent Below Poverty Level (1985)        15.8             14.0
   (persons)
 Percent of Population Rural (1980)        15.0             26.0
 Percent of Population White (1980)        79.5             83.1
 Percent of Population Non-White (1980)    20.5             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 for county governments in New York
 are established in the state constitution and statutes.  County
 governments fall into either Charter or Non-Charter status.  The
 legislative body of counties is known as Board of Supervisors,
 County Legislature, or Board of Representatives.  The boards
 range in number from 6 to 39 members and are elected at large,
 from single-member districts, or by a combination of methods.
 The votes of board members elected from single-member districts
 are weighed according to the population in the district.  All
 counties have the right to appoint a county administrator, but
 only charter counties can elect a county executive.

 Non-Charter Status - (38) - Seventeen of these counties have
 appointed County Administrators and two have hired County
 Managers.  The appointed administrator may function under the
 title of County Manager, County Administrator, or by some other
 title.

 Charter Status - (19) - Sixteen of these counties have elected
 County Executives, two have County Administrators, and one has a
 County Manager.

 Data for this state were updated January 1991. The five boroughs
 in New York City represent counties for certain purposes but do
 not have truly functional county governments.  The consolidation
 of the city and county governments in New York City is the only
 consolidation in the state.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The SHA, the New York Department of Health, is a free-standing,
 independent agency.  The Department of Health is established as
 an agency by the state constitution and the New York State Public
 Health Law.  The Department is charged with:  operating three
 health facilities; regulating specified types of health
 facilities; setting Medicaid and Blue Cross rates, and issuing
 facility certificates of need; developing public health
 initiatives in the fields of environment, community health,
 laboratories, and research; and functioning as liaison with local
 health units, including State Aid.

 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
      State Institutions/Hospitals

      B.  Head of State Health Agency

 M.D. Requirement, Cabinet-level Appointment

 The Commissioner is the head of the Department of Health, the
 SHA.  The Governor appoints the Commissioner with the consent of
 the State Senate.  The Commissioner must be a physician with at
 least 10 years' experience in the actual practice of his/her
 profession, and with skill and experience in public health duties
 and sanitary science.  Responsibility for managing the Department
 of Health rests with the Commissioner.

      C.  State Board of Health/Council

 Policy-making

 The Public Health Council is established by the Public Health
 Law.  Its members are appointed to 6-year terms of office by the
 Governor with consent of the Senate.  The Council is composed of
 15 members including the Commissioner of Health.  The functions
 of the Council are to assist in the public health rule-making
 process and to review the qualifications of those who wish to
 establish health facilities.

      D.  Regional/District Health Offices

 The state is divided into three public health regions, each with
 a regional office.  Within the regions are 10 district offices
 which provide direct environmental services to some of the
 smaller counties.  The regional offices assist local health
 departments.  District offices actually function as if they were
 a unit of local government, but direction is from the State
 Department of Health.

 The regional offices are staffed by approximately 75 to 150
 employees.  The Regional Director is the head of the regional
 office.  The staff includes administrative personnel, clerks,
 program consultants, and some service personnel such as sexually
 transmitted disease control personnel.

      E.  State-local Liaison

 Mixed Centralized and Decentralized Organizational Control,
 Formal Liaison Function

 The Director of Field Operations acts as liaison between the
 state and local public health agencies.  In this capacity, the
 Director serves as the primary focus of communications between
 the SHA and local public health agencies.  Additionally, the
 Director administers the program which provides State Aid to the
 local health departments.  This involves assuring that local
 health departments meet established standards for receiving State
 Aid.

 The interaction between state and local public health agencies in
 New York may be characterized as mixed centralized and
 decentralized 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 New York SHA expenditures were $695,766,000.  Total
 FY 1988 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts         $249,659,000
        State Funds                          $445,834,000
        Local Funds                                     0
        Fees and Reimbursements                  $273,000
        Other                                           0
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 New York has 59 local public health units including 58 county
 health departments and 1 city health department.  Thirty-six of
 the 59 units provide some level of "full public health
 services."  The remaining 23 units offer public health nursing
 services augmented by environmental services from the district
 offices.

 Local units are elements of local government.  As such, direction
 and primary financing are derived from the counties and cities.
 Substantial state funds flow to the local units, for which
 specified and negotiated services are provided.

       B.  Services Provided

 The following information on services provided by local health
 departments in New York is derived from a survey conducted by
 NACHO during 1989.  Fifty-seven of the 59 local health
 departments in New York 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              27   ( 47.4%)
            2.  Morbidity Data                          43   ( 75.4%)
            3.  Reportable Diseases                     54   ( 94.7%)
            4.  Vital Records and Statistics            41   ( 71.9%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        43   ( 75.4%)
            2.  Communicable Diseases                   56   ( 98.2%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement             36   ( 63.2%)
       B.  Health Planning                              47   ( 82.5)
       C.  Priority Setting                             46   ( 80.7%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   30   ( 52.6%)
            2.  Health Facility Safety/Quality          11   ( 19.3%)
            3.  Rec. Facility Safety/Quality            32   ( 56.1%)
            4.  Other Facility Safety/Quality           16   ( 28.1%)

       B.  Licensing
            1.  Health Facilities                        4   (  7.0%)
            2.  Other Facilities                        31   ( 54.4%)

       C.  Health Education                             47   ( 82.5%)

       D.  Environmental
            1.  Air Quality                             19   ( 33.3%)
            2.  Hazardous Waste Management              25   ( 43.9%)
            3.  Individual Water Supply Safety          38   ( 66.7%)
            4.  Noise Pollution                          9   ( 15.8%)
            5.  Occupational Health and Safety          14   ( 24.6%)
            6.  Public Water Supply Safety              36   ( 63.2%)
            7.  Radiation Control                       14   ( 24.6%)
            8.  Sewage Disposal Systems                 38   ( 66.7%)
            9.  Solid Waste Management                  21   ( 36.8%)
           10.  Vector and Animal Control               35   ( 61.4%)
           11.  Water Pollution                         28   ( 49.1%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             41   ( 71.9%)
            2.  Alcohol Abuse                            7   ( 12.3%)
            3.  Child Health                            54   ( 94.7%)
            4.  Chronic Diseases                        50   ( 87.7%)
            5.  Dental Health                           35   ( 61.4%)
            6.  Drug Abuse                               4   (  7.0%)
            7.  Emergency Medical Service               17   ( 29.8%)
            8.  Family Planning                         25   ( 43.9%)
            9.  Handicapped Children                    53   ( 93.0%)
           10.  Home Health Care                        54   ( 94.7%)
           11.  Hospitals                                -
           12.  Immunizations                           55   ( 96.5%)
           13.  Laboratory Services                     18   ( 31.6%)
           14.  Long-term Care Facilities               17   ( 29.8%)
           15.  Mental Health                            5   (  8.8%)
           16.  Obstetrical Care                         8   ( 14.0%)
           17.  Prenatal Care                           38   ( 66.7%)
           18.  Primary Care                            23   ( 40.4%)
           19.  Sexually Transmitted Diseases           52   ( 91.2%)
           20.  Tuberculosis                            56   ( 98.2%)
           21.  WIC                                     34   ( 59.6%)

       C.  Local Health Officer

 M.D. Requirement for Full-service Units, Local Governing Body
 Appointment

 There are two types of local health officers in New York State:
 one type serves the cities, towns, or villages in counties which
 do not operate full-service health departments; the other type is
 the Commissioner or Public Health Director who serves in counties
 with full-service health departments.  Health officers have
 responsibility for managing the local health department.  The
 health officers are appointed and supervised by the local
 governing boards.

      D.  Local Board of Health

 Policy-making

 Local boards of health are specified in the Public Health Law.
 Depending on circumstances, the board may be the local governing
 body or a separate entity.  In areas where the health department
 is not a full-service unit, the governing body functions as the
 board of health.  In full-service areas the governing body
 appoints a five-member board of health.  The boards help shape
 policy, but the governing body has emerged, with its fiscal
 controls, as the primary entity for the past 20 years.

      E.  Staff

 Staffs of local health departments are employed and supervised by
 the local health department.  The number of staff employed by a
 local health department ranges from 1 to 4,243.

      F.  Budget

 Total FY 1988 LPHA expenditures were $371,171,000.  Total FY 1988
 United States LPHA expenditures were $3,978,948,000.

      Source of Funds
        Federal Grants and Contracts     $12,585,000
        State Funds                      $82,258,000
        Local Funds                     $195,019,000
        Fees and Reimbursements          $81,309,000
        Other Sources                              0
        Source Unknown                             0
2New York State Department of Health, 1990

 At time of printing, State Health Agency undergoing
 reorganization
2Types of Local Health Departments by Jurisdiction
                                     New York, 1990

           Jurisdiction                        Co     C

           Albany                              X
           Allegany                            X
           Broome                              X
           Cattaraugus                         X
           Cayuga                              X
           Chautauqua                          X
           Chemung                             X
           Chenango                            X
           Clinton                             X
           Columbia                            X
           Cortland                            X
           Delaware                            X
           Dutchess                            X
           Erie                                X
           Essex                               X
           Franklin                            X
           Fulton                              X
           Genesee                             X
           Greene                              X
           Hamilton                            X
           Herkimer                            X
           Jefferson                           X
           Lewis                               X
           Livingston                          X
           Madison                             X
           Monroe                              X
           Montgomery                          X
           Nassau                              X
           New York City
           Niagara                             X
           Oneida                              X
           Onondaga                            X
           Ontario                             X
           Orange                              X
           Orleans                             X
           Oswego                              X
           Otsego                              X
           Putnam                              X
           Rensselaer                          X
           Rockland                            X
           Saratoga                            X
           Schenectady                         X
           Schoharie                           X
           Schuyler                            X
           Seneca                              X
           St. Lawrence                        X
           Steuben                                    X
           Suffolk                                    X
           Sullivan                                   X
           Tioga                                      X
           Tompkins                                   X
           Ulster                                     X
           Warren                                     X
           Washington                                 X
           Wayne                                      X
           Westchester                                X
           Wyoming                                    X
           Yates                                      X

           Co = County HD
           C  = City HD
1NORTH CAROLINA
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State      United States

 Population (1988)                  6,487,000        245,803,000
 Population Density (1988)                132.8               69.4
   (per/sq.mi.)
 Number of Counties                       100              3,139
 Median Age (1987)                         31.6               31.7
 Percent Below Poverty Level (1985)        15.2               14.0
   (persons)
 Percent of Population Rural (1980)        52.0               26.0
 Percent of Population White (1980)        75.8               83.1
 Percent of Population Non-white (1980)    24.2               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 powers and duties of county governments in North Carolina are
 established in the state constitution and statutes.

 Commission Form - (100) - Law defines the county governing body
 as a board of commissioners.  The board of commissioners,
 however, functions much like a council-manager system.  The board
 may contain any number of members but usually has from three to
 nine.  Five is the most common number of commissioners.  The
 commissioners are usually elected at large.  A growing trend,
 however, is for boards to be composed of a mixture of members
 elected at large and from single-member districts.

 The responsibilities of boards of commissioners fall into the
 following four major areas:  establishment of fiscal policy,
 including developing budget and determining property tax rates;
 regulation of private conduct, making ordinances, enforcing laws,
 establishing zoning and development regulations; general
 administration, implementation of all fiscal and personnel
 policies; and determination of what programs and services the
 county government will provide.  Statutes provide North Carolina
 with a variety of options as to the services they can provide.

 Data for this state were updated January 1991.
 Unlike most county governments in the United States, however,
 North Carolina counties do not have the authority or
 responsibility for roads.

 Because of the complexity of the responsibility of commissioners,
 98 of 100 counties have chosen to employ a county manager or
 administrator.  This individual is responsible to the board for
 administering all departments of the county government, except
 for the departments with separately elected heads.

 State laws permit city-county consolidations, but none has yet
 taken place.  The North Carolina Constitution and Statutes do not
 contain home rule authority for the counties.  Statutes do,
 however, give the counties considerable authority to manage their
 own affairs.
3II.  State Health Agency (SHA)

      A.  General

 Component of Superagency

 The Department of Environment, Health, and Natural Resources
 (DEHNR) is the newest department in North Carolina State
 government and has broad responsibility for the development of
 resources, policies and delivery of services that protect,
 promote and preserve North Carolina's natural resources, as well
 as public and private environmental health.  The department is
 organized into 25 major divisions, seven of which are charged
 with the administrative and statutory responsibility for carrying
 out public health programs in North Carolina.  These seven
 divisions and the Office of the State Health Director are
 considered the SHA.  DEHNR public health divisions are as
 follows:  Adult Health, Dental Health, Environmental Health,
 Epidemiology, Laboratory Services, Maternal and Child Health, and
 Post-Mortem Medicolegal Examination.  In addition to these
 divisions, housed within the State Health Director's Office are
 the Office of the Chief Nurse, Office of Health Education and
 Communications, Office of Local Health Services, and the
 Governor's Council on Physical Fitness and Health.

 The primary role of the seven health service divisions is to
 strengthen local health departments and to improve the health of
 the people of North Carolina.  The health divisions monitor
 public health achievements and performance and provide
 incentives, as well as assistance, to assure that no community
 falls below minimum standards.  Further, the divisions are
 responsible for studying, coordinating and enhancing health
 efforts involving or serving multiple communities and/or the
 state as a whole.  Finally, the public health divisions are
 themselves providers of statewide services not otherwise
 available.

 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

      B.  Head of State Health Agency

 M.D. Requirement, Not Cabinet-level Appointment

 The State Health Director is the head of the SHA.  The Director
 is appointed by the Secretary of DEHNR.  The position requires a
 physician licensed to practice medicine in North Carolina.  The
 Director is responsible for the oversight of DEHNR's seven public
 health divisions.  The Health Director serves as the department's
 Assistant Secretary for Health, performing duties and exercising
 authority assigned by the Secretary.  The scope of the delegated
 authority includes but is not limited to:

      1.   Exercising rule-making power granted to the
           Secretary of the department under General
           Statutes Chapter 130A.

      2.   Requiring local health departments to enforce
           rules of the Commission for Health Services
           pursuant to General Statutes 130A-4(b).

      3.   Abating public health nuisances and imminent
           hazards pursuant to General Statutes 130a-27.

      4.   Making final agency decisions in appeals
           concerning the interpretation and enforcement
           of provisions of General Statutes Chapter
           130A or rules adopted by the Commission for
           Health Services or the State Health Director,
           except that if the initial decision which is
           the subject matter of the appeal was made by
           the State Health Director, then the
           Secretary shall make the final agency
           decision.

      C.  State Board of Health/Council

 Policy-making

 The Commission for Health Services of DEHNR consists of 12
 members, 4 of whom are elected by the North Carolina Medical
 Society and 8 of whom are appointed by the Governor.  The
 Governor's appointments include a licensed pharmacist, a
 registered engineer experienced in sanitary engineering or soil
 science, a licensed dentist, a licensed veterinarian, a licensed
 optometrist, and a registered nurse.  Commission members are
 appointed for a term of 4 years.

 The Commission for Health Services has the authority and duty to
 adopt rules to protect and promote the public health.  The
 Commission is authorized to adopt rules necessary to implement
 the public health programs administered by DEHNR as provided in
 Chapter 130A North Carolina General Statutes.  The following is a
 partial list of public health issues which fall under the
 Commission's authority:

      Communicable disease control, including immunization
        requirements and control measures for AIDS and HIV
        infection
      Adolescent pregnancy prevention projects
      Sickle Cell Program
      Children's Special Health Service Program
      Home health services funds
      Restaurant sanitation standards
      Sewage collection, treatment, and disposal
      Standards for public water supply systems
      Hazardous waste management
      Solid waste management
      Mandated services for local health departments
      State Cancer Registry

      D.  Regional/District Health Offices

 To maintain a closer working relationship with health services
 providers, most DEHNR public health divisions staff seven
 regional offices.  From these offices, technical assistance is
 provided to local health departments, other health care
 providers, and local governmental units other than health
 departments.  Regional public health staff also monitor local
 health programs and, under certain circumstances, provide direct
 services.

 The administrative operations of the regional offices are
 overseen by regional managers.  Division staff located in the
 regional offices are supervised by division
 supervisors/coordinators or program representatives in the
 central office in Raleigh.

      E.  State-local Liaison

 Shared Organizational Control, Formal Liaison Function

 All local health directors in the state belong to the non-profit
 Local Health Director's Association.  The Association serves as a
 bridge between local and state public health policy-makers.  The
 Association president appoints local health directors to standing
 and special committees to serve as liaison to the public health
 divisions.  Each committee is charged to review and advise the
 health divisions about policies affecting the delivery of public
 health programs in local communities.

 The interaction between state and local public health agencies in
 North Carolina 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 North Carolina SHA expenditures were $178,155,000.
 Total FY 1988 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts          $78,155,000
        State Funds                           $80,041,000
        Local Funds                                     0
        Fees and Reimbursements                         0
        Other                                 $20,677,000
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 North Carolina has 87 local health departments, consisting of 80
 county and 7 multicounty health departments, which provide public
 health services to all 100 counties.

      B.  Services Provided

 The following information on services provided by local health
 departments in North Carolina is derived from a survey conducted
 by NACHO during 1989.  Sixty-nine of the 87 local health
 departments in North Carolina 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              46   ( 66.7%)
            2.  Morbidity Data                          54   ( 78.3%)
            3.  Reportable Diseases                     69   (100.0%)
            4.  Vital Records and Statistics            69   (100.0%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        48   ( 69.6%)
            2.  Communicable Diseases                   68   ( 98.6%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement             39   ( 56.5%)
       B.  Health Planning                              56   ( 81.2%)
       C.  Priority Setting                             51   ( 73.9%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   62   ( 89.9%)
            2.  Health Facility Safety/Quality          53   ( 76.8%)
            3.  Rec. Facility Safety/Quality            26   ( 37.7%)
            4.  Other Facility Safety/Quality           18   ( 26.1%)

       B.  Licensing
            1.  Health Facilities                       19   ( 27.5%)
            2.  Other Facilities                        51   ( 73.9%)

       C.  Health Education                             64   ( 92.8%)

       D.  Environmental
            1.  Air Quality                             12   ( 17.4%)
            2.  Hazardous Waste Management              21   ( 30.4%)
            3.  Individual Water Supply Safety          65   ( 94.2%)
            4.  Noise Pollution                          7   ( 10.1%)
            5.  Occupational Health and Safety          15   ( 21.7%)
            6.  Public Water Supply Safety              36   ( 52.2%)
            7.  Radiation Control                        6   (  8.7%)
            8.  Sewage Disposal Systems                 67   ( 97.1%)
            9.  Solid Waste Management                  36   ( 52.2%)
           10.  Vector and Animal Control               55   ( 79.7%)
           11.  Water Pollution                         45   ( 65.2%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             69   (100.0%)
            2.  Alcohol Abuse                            6   (  8.7%)
            3.  Child Health                            69   (100.0%)
            4.  Chronic Diseases                        61   ( 88.4%)
            5.  Dental Health                           62   ( 89.9%)
            6.  Drug Abuse                              11   ( 15.9%)
            7.  Emergency Medical Service                1   (  1.4%)
            8.  Family Planning                         65   ( 94.2%)
            9.  Handicapped Children                    46   ( 66.7%)
           10.  Home Health Care                        48   ( 69.6%)
           11.  Hospitals                                3   (  4.3%)
           12.  Immunizations                           69   (100.0%)
           13.  Laboratory Services                     64   ( 92.8%)
           14.  Long-term Care Facilities                4   (  5.8%)
           15.  Mental Health                            1   (  1.4%)
           16.  Obstetrical Care                        37   ( 53.6%)
           17.  Prenatal Care                           66   ( 95.7%)
           18.  Primary Care                            24   ( 34.8%)
           19.  Sexually Transmitted Diseases           68   ( 98.6%)
           20.  Tuberculosis                            69   (100.0%)
           21.  WIC                                     66   ( 95.7%)

      C.  Local Health Officer

 No M.D. Requirement, Local Board of Health Appointment

 The local health director is the administrative head of the local
 health department.  The local board of health, after consulting
 with appropriate county board or board of commissioners, can
 appoint a local health director.  Equal emphasis is placed on
 education and experience in determining the qualifications of a
 local health director, but he/she shall not be required to be a
 physician.

 As the administrative head of the local health department, the
 local health director performs the public health duties
 prescribed by and under the supervision of the local board of
 health.  The local health director serves as secretary to the
 board of health, is the administrative head of the health
 department carrying out programs at the direction of the board,
 and is financially responsible both to the board of health and
 the county commissioners.  The local health director is given
 the following powers and duties pursuant to General Statutes
 Chapter 130A:

      To administer programs as directed by the local board of
      health.

      To enforce the rules of the local board of health.

      To investigate the causes of infectious, communicable and
      other diseases.

      To exercise quarantine authority and isolation and to
      promote the benefits of good health.

      To advise local officials concerning public health matters.

      To enforce the immunization requirements.

      To examine and investigate cases of venereal disease.

      To examine and investigate cases of tuberculosis.

      To examine, investigate and control rabies.

      To abate public health nuisances and imminent hazards.

      To employ and dismiss employees of the local health
      department.

      To enter contracts, in accordance with the Local Government
      Finance Act, General Statutes Chapter 159, on behalf of the
      local health department.

      D.  Local Board of Health

 Policy-making

 The local board of health is the policy-making, rule-making and
 adjudicatory body for the county (local) health department.  The
 members of the local board of health are appointed by the county
 commissioners.  All boards are composed of 11 members.  The
 composition of a local board must reasonably reflect the
 population makeup of the county and must include:  one physician
 licensed to practice medicine in the state, one licensed dentist,
 one licensed optometrist, one licensed veterinarian, one
 registered nurse, a licensed pharmacist, one professional
 engineer, one county commissioner, and three representing the
 general public.  If, however, one of the designated professionals
 has only one person residing in the county, the county
 commissioners shall have the option of appointing a member of the
 general public.  The term of office for board members is 3
 years.  No member may serve more than three consecutive 3-year
 terms unless the member is the only person residing in the county
 who represents one of the professions designated.  Local boards
 of health in North Carolina have the responsibility to protect
 and promote the public health.  Thus, local boards have the
 authority to adopt rules necessary for that purpose.  The local
 board may adopt a more stringent rule in an area regulated by the
 Commission for Health Services or the Environmental Management
 Commission where, in the opinion of the board, a more stringent
 rule is required to protect the public health; otherwise, the
 rules of the Commission for Health Services or the Environmental
 Management Commission shall prevail over the rules of the local
 board of health.  The local board may not adopt rules concerning
 the grading and permitting of food and lodging facilities.  The
 local board may, however, adopt rules concerning sanitary sewage
 collection, treatment and disposal systems, which are not
 designed to discharge effluent to the land surface or surface
 waters and which are not public or community systems.

 The local board of health may, in its rules, adopt by reference
 any code, standard, rule or regulation which has been adopted by
 any agency of North Carolina, another state, any agency of the
 United States, or by a generally recognized association.

 The local board may impose a fee for services to be rendered by a
 local health department, except where the imposition of a fee is
 prohibited by statute or where an employee of the local health
 department is performing the service as an agent of the state.

 The relationship between the local board of health, health
 director and county government is one of cooperation and
 collaboration.  The local board of health is the legal
 representative of the community's various public health services
 rendered by the health department.  The county commissioners are
 authorized to appropriate funds from property tax levies and to
 allocate other revenues whose utilization is not otherwise
 restricted by law for the local health department's use.  A
 capital reserve fund can be established by commissioners to buy,
 erect, repair or alter public health facilities.  A local health
 department's director and the local board of health ultimately
 are responsible for organizing and administering the health
 department's activities.

      E.  Staff

 The staff of local health departments are employed and supervised
 by the local jurisdiction.  The number of staff employed by local
 health departments ranges from 6 to 318.

      F.  Budget

 Total FY 1988 LPHA Expenditures were $158,517,000.  Total FY 1988
 United States LPHA expenditures were $3,978,948,000.

      Source of Funds
        Federal Grants and Contracts     $22,416,000
        State Funds                      $28,331,000
        Local Funds                     $107,770,000
        Fees and Reimbursements                    0
        Other Sources                              0
        Source Unknown                             0
2North Carolina Department of Environment, Health,
       and Natural Resources, 1990

 Secretary
   Budget Officer
   General Counsel
   Personnel Director
   Wildlife Resources
   Administrative Assistant
 Deputy Secretary, Environment and Natural Resources
   Albemarle/Pamlico
   Governmental Waste Management Environmental Education
   Highway Environment Evaluation
 Deputy Secretary, Health and Administration
   Legislative Affairs
   Public Affairs
   Regional Managers
     Asheville
     Fayetteville
     Mooresville
     Raleigh
     Washington
     Wilmington
     Winston-Salem
 Assistant Secretary, Environment Protection
      Coastal Management
      Environmental Management
      Solid Waste Management
      Land Resources
      Office of Waste Reduction
      Radiation Protection
      Water Resources

 Assistant Secretary, Natural Resources
      Forest Resources
      Marine Fisheries
      Parks and Recreation
      Soil and Water Conservation
      Special Projects
      Zoological Park

 Assistant Secretary Health and State Health Director
      Deputy State Health Director
        Adult Health
        Dental Health
        Environmental Health
        Epidemiology
        Maternal-Child Health

      Assistant State Health Director
        Health Education
        Laboratory Services
        Local Health Services
        Post Mortem Medicolegal Examination

      Governor's Council on Physical Fitness and Health

      Public Health Nursing

 Assistant Secretary Administration
      Computer Systems
      Fiscal Management
      General Services
      Office of General Counsel
      Office of Personnel
      Planning and Assessment
      Statistics and Information
2Types of Local Health Departments by Jurisdiction
                                  North Carolina, 1990

           Jurisdiction                        Co     M/Co

           Alamance                            X
           Alexander                           X
           Alleghany                                  X
           Anson                               X
           Ashe                                       X
           Avery                                      X
           Beaufort                            X
           Bertie                              X
           Bladen                              X
           Brunswick                           X
           Buncombe                            X
           Burke                               X
           Cabarrus                            X
           Caldwell                            X
           Camden                                     X
           Carteret                            X
           Caswell                             X
           Catawba                             X
           Chatham                             X
           Cherokee                            X
           Chowan                                     X
           Clay                                X
           Cleveland                           X
           Columbus                            X
           Craven                              X
           Cumberland                          X
           Currituck                           X
           Dare                                X
           Davidson                            X
           Davie                               X
           Duplin                              X
           Durham                              X
           Edgecombe                           X
           Forsyth                             X
           Franklin                            X
           Gaston                              X
           Gates                                      X
           Graham                              X
           Granville                                  X
           Greene                              X
           Guilford                            X
           Halifax                             X
           Harnett                             X
           Haywood                             X
           Henderson                           X
           Hertford                                   X
           Hoke                                X
           Hyde                                X
           Iredell                             X
           Jackson                             X
           Johnston                            X
           Jones                               X
           Lee                                 X
           Lenoir                              X
           Lincoln                             X
           Macon                               X
           Madison                             X
           Martin                                     X
           McDowell                                   X
           Mecklenburg                         X
           Mitchell                                   X
           Montgomery                          X
           Moore                               X
           Nash                                X
           New Hanover                         X
           North Hampton                       X
           Onslow                              X
           Orange                              X
           Pamlico                             X
           Pasquotank                                 X
           Pender                              X
           Perquimans                                 X
           Person                              X
           Pitt                                X
           Polk                                       X
           Randolph                            X
           Richmond                            X
           Robeson                             X
           Rockingham                          X
           Rowan                               X
           Rutherford                                 X
           Sampson                             X
           Scotland                            X
           Stanly                              X
           Stokes                              X
           Surry                               X
           Swain                               X
           Transylvania                        X
           Tyrrell                                    X
           Union                               X
           Vance                                      X
           Wake                                X
           Warren                              X
           Washington                                 X
           Wautauga                                   X
           Wayne                               X
           Wilkes                              X
           Wilson                              X
           Yadkin                              X
           Yancy                                      X

           Co = County HD
           M/Co = Multicounty HD
1NORTH DAKOTA
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State      United States

 Population (1988)                    667,000        245,803,000
 Population Density (1988)                  9.6               69.4
   (per/sq.mi.)
 Number of Counties                        53              3,139
 Median Age (1987)                         30.3               31.7
 Percent Below Poverty Level (1985)        15.9               14.0
   (persons)
 Percent of Population Rural (1980)        51.0               26.0
 Percent of Population White (1980)        95.8               83.1
 Percent of Population Non-white (1980)     4.2               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 provide the authority and
 structure for counties in North Dakota.  The Commission Form
 serves as the basis for county governments in the state.

 Commission Form - (53) - Boards of commissioners consist of three
 or five members and are elected from single-member districts.
 Three options from the pure commission form of government is
 available to counties.

      Home Rule Charter - (1) - Walsh County has chosen this
      option. Under this option the board of commissioners has
      expanded authority in the areas of county elections,
      financial and fiscal affairs, penalties for violation of
      ordinances, resolutions and regulations, and expansion of
      taxation.

 Data for this state were updated April 1991.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The SHA is the North Dakota Department of Health and Consolidated
 Laboratories (NDDHCL), a free-standing, independent agency.  In
 carrying out its public health responsibilities, the Department:

      inspects and licenses health facilities, hotels,
      motels, boardinghouses, and food establishments;
      certifies hospitals, nursing homes, home health
      agencies, laboratories, and other health facilities for
      Medicare and Medicaid certification; registers and
      preserves vital records; trains and licenses emergency
      health services; provides education and preventive
      health service to mothers, infants, and children,
      including family planning and nutrition service;
      develops dental health education and tooth decay
      prevention service; coordinates and promotes local
      public health service; provides communicable and
      chronic disease control programs; provides health
      education and promotion activities; coordinates a
      uniform program of public health nursing including home
      health care; provides consultative, advisory, and
      enforcement service on all phases of environmental
      health encompassing water supply, water and air
      pollution control, environmental health and
      recreational facilities, solid waste disposal,
      radiation control, and noise and hazardous waste
      control; provides forensic analysis services; and
      registers and analyzes agricultural and petroleum
      products.

 The mission statement for NDDHCL reads as follows:

      We, as public employees, are dedicated to the goal of
      assuring that North Dakota is a healthy place to live and to
      the belief that each person should have an equal opportunity
      to enjoy good health.  To accomplish this mission, we are
      committed to the protection of healthy lifestyles,
      protection and enhancement of the environment, and provision
      of quality health care services for the people of North
      Dakota.

 The following are some broad areas of responsibility for the SHA:

      State Public Health Authority
      Lead Environmental Agency in the State
      State Health Planning and Development Agency
      Health Professions Licensing Agency
                Institutional Licensing Agency
      Institutional Certifying Authority for Federal Reimbursement

      B.  Head of State Health Agency

 M.D. Requirement, Cabinet-level Appointment

 The State Health Officer, the administrative head of the SHA, is
 appointed by the Governor for a term of 4 years.  The individual
 must be a physician who has graduated from a regular school of
 medicine of a class A standing, has experience in public health,
 and be licensed to practice medicine in the state.
 Responsibilities of the State Health Officer include:  enforcing
 regulations of the public health council; developing and
 coordinating local health services; allocating health funds
 subject to approval of the health council; collecting and
 distributing health education materials; maintaining a central
 health laboratory; establishing services for medical hospitals,
 such as licensing and consultation on construction planning; and
 enforcing minimum standards of performance for local departments
 of health; collecting and tabulating vital health statistics.

      C.  State Board of Health/Council

 Policy-making

 The health council is composed of 15 members appointed by the
 Governor for 3-year terms.  Two members are appointed from a list
 of names recommended by the State Hospital Association, two
 members from the State Medical Association, one member from the
 State Dental Association, one member from the State Optometric
 Association, one member from the State Nurses' Association, and
 one member from the State Pharmaceutical Association.  The other
 seven members are consumers of health care services and not
 employed in the health care field.  These members represent
 business, agriculture, organized labor, and senior citizens.
 Acting in an advisory capacity to the council are the State
 Health Officer, the Attorney General, the Director of
 Institutions, the State Fire Marshal, the Executive Secretary of
 the State Board of Nursing, the Executive Director of the
 Department of Human Services, and the Executive Director of the
 Indian Affairs Commission.

 The council establishes standards, rules, and regulations for the
 maintenance of public health, including sanitation and disease
 control; develops, establishes, and enforces basic standards for
 hospitals and related medical institutions; holds hearing related
 to licensing of medical facilities; and directs the State Health
 Officer to do all things required in the proper performance of
 the various responsibilities placed upon the NDDHCL.

       D.  Regional/District Health Offices

 The state is not divided into administrative regions or
 districts.

       E.  State-local Liaison

 Decentralized Organizational Control, Informal Liaison Function

 The coordination of local health services is performed by the
 Division of Public Health Services.  In this role the Division
 serves as primary point of contact between the SHA and the local
 health departments.  They act as consultants, provide
 administrative services, provide some continuing education, and
 conduct some research for local health departments.

 The interaction between state and local public health agencies in
 North Dakota may be characterized as decentralized organizational
 control.  Under this arrangement local boards of health directly
 operate health departments.

       F.  Budget

 Total FY 1988 SHA expenditures were $17,487,000.  Total FY 1988
 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts          $11,733,000
        State Funds                            $5,252,000
        Local Funds                                     0
        Fees and Reimbursements                  $196,000
        Other                                    $305,000
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 North Dakota has 22 local health departments consisting of 7
 multicounty, 4 city/county, and 11 county health departments.
 Local health departments are autonomous from the SHA.

       B.  Services Provided

 The following information on services provided by local health
 departments in North Dakota is derived from a survey conducted by
 NACHO during 1989.  Nineteen of the 21 local health departments
 existing in North Dakota at the time of the survey 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

   I.  Assessment Activities
       A.  Data Collection/Analysis
            1.  Behavioral Risk Assessment               5   ( 26.3%)
            2.  Morbidity Data                           3   ( 15.8%)
            3.  Reportable Diseases                     16   ( 84.2%)
            4.  Vital Records and Statistics             3   ( 15.8%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                         7   ( 36.8%)
            2.  Communicable Diseases                   16   ( 84.2%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement              5   ( 26.3%)
       B.  Health Planning                              12   ( 63.2%)
       C.  Priority Setting                             10   ( 52.6%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                    5   ( 26.3%)
            2.  Health Facility Safety/Quality           3   ( 15.8%)
            3.  Rec. Facility Safety/Quality             5   ( 26.3%)
            4.  Other Facility Safety/Quality            3   ( 15.8%)

       B.  Licensing
            1.  Health Facilities                        -
            2.  Other Facilities                         3   ( 15.8%)

       C.  Health Education                             15   ( 78.9%)

       D.  Environmental
            1.  Air Quality                              4   ( 21.1%)
            2.  Hazardous Waste Management               7   ( 36.8%)
            3.  Individual Water Supply Safety          10   ( 52.6%)
            4.  Noise Pollution                          2   ( 10.5%)
            5.  Occupational Health and Safety           2   ( 10.5%)
            6.  Public Water Supply Safety              11   ( 57.9%)
            7.  Radiation Control                        2   ( 10.5%)
            8.  Sewage Disposal Systems                  9   ( 47.4%)
            9.  Solid Waste Management                   8   ( 42.1%)
           10.  Vector and Animal Control               11   ( 57.9%)
           11.  Water Pollution                         10   ( 52.6%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             10   ( 52.6%)
            2.  Alcohol Abuse                            2   ( 10.5%)
            3.  Child Health                            18   ( 94.7%)
            4.  Chronic Diseases                        15   ( 78.9%)
            5.  Dental Health                            5   ( 26.3%)
            6.  Drug Abuse                               4   ( 21.1%)
            7.  Emergency Medical Service                1   (  5.3%)
            8.  Family Planning                          7   ( 36.8%)
            9.  Handicapped Children                     4   ( 21.1%)
           10.  Home Health Care                        13   ( 68.4%)
           11.  Hospitals                                -
           12.  Immunizations                           19   (100.0%)
           13.  Laboratory Services                      4   ( 21.1%)
           14.  Long-term Care Facilities                -
           15.  Mental Health                            5   ( 26.3%)
           16.  Obstetrical Care                         3   ( 15.8%)
           17.  Prenatal Care                            7   ( 36.8%)
           18.  Primary Care                             3   ( 15.8%)
           19.  Sexually Transmitted Diseases            9   ( 47.4%)
           20.  Tuberculosis                            15   ( 78.9%)
           21.  WIC                                     14   ( 73.7%)

      C.  Local Health Officer

 M.D. Requirement, Local Board of Health Appointment

 The county board of health appoints a county health officer for a
 term of 5 years.  The health officer must be a physician licensed
 to practice medicine in the state.  It is not necessary for the
 health officer to be a resident of the county at the time of
 appointment.  The county health officer is employed and
 supervised by the county board of health.

 The power and responsibilities of the county health officer
 include the following:

      1.   Exercise the powers of the county board of health under
           the supervision of such board and of the NDDHCL
           throughout the county outside the corporate limits of
           cities.

      2.   Make sanitary inspections of such places as deemed
           advisable when it is believed there is probability that
           a health-threatening condition exists within the
           jurisdiction, and take such action as deemed necessary
           for the protection of the public health.

      3.   Investigate, subject to the supervisory control of the
           NDDHCL, public water and ice supplies which are
           suspected of being contaminated, and cause them to be
           condemned when it is necessary.

      4.   Enforce cleanliness in schools, and inspect
           overcrowded, poorly ventilated, and unsanitary or
           unsafe schoolhouses and, when necessary, report cases
           of unsanitary or unsafe school buildings to the county
           board of health for investigation.

      5.   Enforce all laws, rules, and regulations relating to
           the preservation of the life and health of the people
           of the county.

      6.   Keeps record of all proceedings of the county board of
           health and of official acts by the health officer.

      D.   Local Board of Health

 Policy-making

 County boards of health consist of five members appointed by the
 county commission.  The five members include one physician, one
 dentist, one business or professional person, one farmer, and one
 county commissioner.  The terms of office are 5 years with
 appointments, timed so that one member's term expires each year.
 The board cannot be composed of all male or all female members.

 In cities with a Council Form of government the board of health
 consists of four alderman appointed by the mayor at the first
 meeting of the city council in April each year, the city
 engineer, and the city health officer.

 In cities with a Commission Form of government the city
 commissioners may appoint a board of health or serve as the board
 of health.  If the commission serves as the board of health, the
 city physician is the executive officer of the board of health.
 An appointed board of health is under the supervision of the
 NDDHLC.  This board consists of five members, including one
 physician, one dentist, one business or professional person, one
 city commissioner, and one other person appointed by the mayor,
 subject to confirmation by the city commission.

 District, county, and city boards of health are subject to the
 supervisory control of the NDDHCL and the State Health Officer.
 They have the following powers and duties within their
 jurisdictions:

      1.   To employ persons as may be necessary to carry into
           effect the regulations established by it and the
           provisions of the title.

      2.   To inquire into all nuisances, sources of filth, and
           causes of sickness, and make regulations regarding the
           same as necessary for the public health and safety.

      3.   To adopt such quarantine and sanitary measures as are
           necessary when an infectious or contagious disease
           exists in its jurisdiction, but quarantine measures
           must be in compliance with other statutes.

      4.   To enter into and examine at any time all buildings,
           lots and places of any description within its
           jurisdiction for the purpose of ascertaining if the
           conditions may affect public health.

      5.   To make rules in district health units and county
           health departments and to recommend to city councils or
           city commissioners, as the case may be, ordinances for
           the protection of public health and safety.

      6.   To keep records and make reports as may be required by
           the NDDHCL.

      7.   To prepare a budget for the next fiscal year at the
           time and in the manner in which a county budget is
           adopted.  The budget must be submitted to the county
           commissioners for approval.  In the case of a city, the
           budget must be submitted to the governing body of the
           city for approval.

 County Boards of health, subject to the supervisory control of
 the NDDHCL and the State Health Officer, have the following
 additional powers:

      1.   To supervise all matters relating to the preservation
           of the life and health of the people of the county,
           including the supervision of public water supplies and
           sewage systems.

      2.   To isolate, kill, or remove any animal affected with a
           contagious or infectious disease when such animal is a
           menace to the health of human beings.

      3.   To make and enforce orders in local matters when an
           emergency exists, or when the local board of health has
           neglected or refused to act with promptness or
           efficiency, or when the local board has not been
           established.

      E.  Staff

 Local staffs are employed and supervised by the jurisdiction for
 which they serve.  The number of employees for local health
 departments ranges from 1 to 34.

      F.  Budget

 Total FY 1988 LPHA expenditures were $9,739,000.  Total FY 1988
 United States LPHA expenditures were $3,978,948,000.

      Source of Funds
        Federal Grants and Contracts      $4,216,000
        State Funds                         $525,000
        Local Funds                       $3,333,000
        Fees and Reimbursements           $1,333,000
        Other Sources                       $332,000
        Source Unknown                             0
2North Dakota State Department of Health, 1990

 Governor
 State Health Council
 State Health Officer
 Health Services Branch
 Preventive Health Section
      Community Health Nursing
      Disease Control
      Maternal and Child Health
      Health Education and Promotion

 Health Resources Section
      Emergency Health Services
      Health Facilities
      Health Resource Analysis

 Environmental Health
      Environmental Engineering
      Waste Management
      Water Supply and Pollution Control
2Types of Local Health Departments by Jurisdiction
                                   North Dakota, 1990

           Jurisdiction                 Co     C/Co   M/Co   N/Co

           Adams
           Benson
           Billings
           Bismark-Burleig                     X
           Bottineau
           Bowman
           Burke
           Cavalier
           Dickey                                            X
           Divide
           Dunn
           Eddy
           Emmons                       X
           Fargo-Cass Co                       X
           Foster                       X
           Golden Valley
           Grand Forks C/C                     X
           Grant
           Griggs
           Hettinger
           Kidder                       X
           La Moure                                          X
           Logan
           McHenry
           McKenzie
           McLean
           Mcintosh                     X
           Mercer
           Morton
           Mountrail
           Nelson
           Oliver
           Pembina                      X
           Pierce
           Ramsey
           Ransom                       X
           Renville
           Richland                     X
           Rolette                                           X
           Sargent                      X
           Sheridan
           Slope
           Stark
           Steele                       X
           Stutsman
           Towner                                            X
           Traill                       X
           Valley-Barnes C                     X
           Walsh                        X
           Ward                                       X
           Wells                                             X
           Williams                                   X

           Co = County HD
           C/Co = City/County HD
           M/Co = Multicounty HD
           N/Co = No county HD
1OHIO
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State      United States

 Population (1988)                 10,855,000        245,803,000
 Population Density (1988)                264.7               69.4
   (per/sq.mi.)
 Number of Counties                        88              3,139
 Median Age (1987)                         31.9               31.7
 Percent Below Poverty Level (1985)        12.8               14.0
   (persons)
 Percent of Population Rural (1980)        27.0               26.0
 Percent of Population White (1980)        88.9               83.1
 Percent of Population Non-white (1980)    11.1               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 authority for county government in Ohio are
 established by the state constitution and revised code.  All
 counties operate under a Commission Form of government unless
 voters choose an optional form.

 Commission Form - (86) - All except one county operates with a
 county commission.  The commission is made up of a three-member
 board that is elected at large, from single-member districts, or
 by a combination of methods.  Twenty-two counties have appointed
 county administrators to assist the board with administrative
 responsibilities.

 Home Rule Charter - (1) - Summit County citizens adopted a home
 rule charter in 1979.  Under this charter they have a county
 executive who is elected at large.  Their legislative board
 consists of 11 members, 8 of whom are elected from single-member
 districts and 3 elected at large.  All counties can adopt a
 charter by a simple majority vote, but only Summit has chosen to
 move in this direction.

 Data for this state were updated November 1990.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The name of the SHA is the Ohio Department of Health (ODH).  It
 is a free-standing, independent agency.  The ODH shall protect
 and improve the health of all Ohio citizens by preventing
 disease, disability and premature death, securing a healthy
 environment and assuring that health providers meet state and
 Federal requirements.  The ODH shall emphasize health promotion,
 disease prevention, health education, and provide accountable
 leadership on universal health concerns while assuring that all
 Ohio citizens have access to quality affordable health 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

 M.D. Requirement, Cabinet-level Appointment

 The Director of Health is appointed by the Governor with advice
 and consent of the Senate.  The Director must be a physician
 licensed to practice medicine in the state and have had
 experience in pursuing some phase of medical practice and
 additional experience in public health administration.

 The Director of Health is responsible for performing all duties
 that are incident to the position of chief executive officer.
 These duties include administering the laws relating to health
 and sanitation and the regulations of the health department;
 preparing sanitary and public health regulations for
 consideration by the public health council and submitting the
 council recommendations for new legislation; and attending
 meetings of the public health council.

      C. State Board of Health/Council

 Advisory

 The Public Health Council is composed of seven members, appointed
 by the Governor, including at least three physicians licensed to
 practice medicine in the state.

 The Public Health Council has the following duties and
 responsibilities:
                Adopt, amend, or rescind sanitary rules to be of general
      application throughout the state.

      Take evidence in appeals from the decision of the Director
      of Health in matters coming before the Director for official
      action.

      Conduct hearings in cases where the law requires the
      Department to hold hearings and make decisions based on the
      evidence presented at the hearings.

      Prescribe by rule the number of functions of divisions and
      bureaus and the qualifications of the chiefs of divisions
      and bureaus within the department.

      Enact and amend bylaws in relation to its meetings and the
      transaction of business.

      Consider any matter relating to the preservation and
      improvement of public health and advise the Director on the
      matter with any recommendations it considers wise.

      D.  Regional/District Health Offices

 ODH has divided the state into four geographical areas called
 districts.  Each of the districts has an office which assists the
 local health departments with their programs by providing
 technical assistance and consultation.  They are also responsible
 for coordinating a peer review process utilizing staff from the
 local agencies to conduct quality assurance reviews of other
 local health department staffs.  District employees are hired and
 supervised at the state level.  There are no patient services
 from the district offices.  The following is a list of programs
 representative of the district office advisory and administrative
 staff:

      Communicable Diseases
      Immunizations
      Crippled Children Program
      MCH/WIC
      Dental
      Sexually Transmitted Diseases
      Occupational Health
      Nutrition
      Environmental Health

      E.  State-local Liaison

 Shared Organizational Control, Formal Liaison Function

 The Bureau of Local Health Departments fulfills the state-local
 liaison function for the SHA.  In this role its serves as the
 primary focus for communications between the SHA and the local
 health departments.

 The interaction between state and local public health agencies in
 Ohio 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 Ohio SHA expenditures were $182,966,000.  Total FY
 1988 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts         $114,355,000
        State Funds                           $40,469,000
        Local Funds                                     0
        Fees and Reimbursements               $27,992,000
        Other                                    $151,000
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 There are currently 153 LPHAs in Ohio which include 25 county, 63
 city-county, and 65 city health departments.  Ohio uses the word
 "district" to denote all local health departments (county, city
 or combined district).  LPHAs receive money from the state on a
 competitive basis according to their need.  The state determines
 how this money is to be spent.

      B.  Services Provided

 The following information on services provided by local health
 departments in Ohio is derived from a survey conducted by NACHO
 during 1989.  One hundred and forty-nine of the 153 local health
 departments in Ohio 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              46   ( 30.9%)
            2.  Morbidity Data                          81   ( 54.4%)
            3.  Reportable Diseases                    133   ( 89.3%)
            4.  Vital Records and Statistics           130   ( 87.2%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        90   ( 60.4%)
            2.  Communicable Diseases                  137   ( 91.9%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement            116   ( 77.9%)
       B.  Health Planning                              88   ( 59.1%)
       C.  Priority Setting                             82   ( 55.0%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   118   ( 79.2%)
            2.  Health Facility Safety/Quality           94   ( 63.1%)
            3.  Rec. Facility Safety/Quality            121   ( 81.2%)
            4.  Other Facility Safety/Quality            49   ( 32.9%)

       B.  Licensing
            1.  Health Facilities                        61   ( 40.9%)
            2.  Other Facilities                        141   ( 94.6%)

       C.  Health Education                             122   ( 81.9%)

       D.  Environmental
            1.  Air Quality                              36   ( 24.2%)
            2.  Hazardous Waste Management               70   ( 47.0%)
            3.  Individual Water Supply Safety          114   ( 76.5%)
            4.  Noise Pollution                          17   ( 11.4%)
            5.  Occupational Health and Safety           33   ( 22.1%)
            6.  Public Water Supply Safety               78   ( 52.3%)
            7.  Radiation Control                        31   ( 20.8%)
            8.  Sewage Disposal Systems                 118   ( 79.2%)
            9.  Solid Waste Management                  116   ( 77.9%)
           10.  Vector and Animal Control               139   ( 93.3%)
           11.  Water Pollution                          91   ( 61.1%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             30   ( 20.1%)
            2.  Alcohol Abuse                           26   ( 17.4%)
            3.  Child Health                           127   ( 85.2%)
            4.  Chronic Diseases                        95   ( 63.8%)
            5.  Dental Health                           48   ( 32.2%)
            6.  Drug Abuse                              30   ( 20.1%)
            7.  Emergency Medical Service               11   (  7.4%)
            8.  Family Planning                         47   ( 31.5%)
            9.  Handicapped Children                   113   ( 75.8%)
           10.  Home Health Care                        70   ( 47.0%)
           11.  Hospitals                               12   (  8.1%)
           12.  Immunizations                          141   ( 94.6%)
           13.  Laboratory Services                     52   ( 34.9%)
           14.  Long-term Care Facilities                5   (  3.4%)
           15.  Mental Health                           11   (  7.4%)
           16.  Obstetrical Care                        21   ( 14.1%)
           17.  Prenatal Care                           63   ( 42.3%)
           18.  Primary Care                            42   ( 28.2%)
           19.  Sexually Transmitted Diseases          102   ( 68.5%)
           20.  Tuberculosis                           104   ( 69.8%)
           21.  WIC                                     82   ( 55.0%)

      C.  Local Health Officer

 No M.D. Requirement, District Board of Health Appointment

 Local health officers in Ohio are called Commissioners of
 Health.  They are appointed by the district board of health to
 terms not to exceed 5 years.  Commissioners must be a licensed
 physician, a licensed dentist, a licensed veterinarian,
 chiropractor, podiatrist, or the holder of a master's degree in
 public health, or related health field as determined by the board
 of health.  The commissioner serves as the secretary and chief
 executive officer of the board of health.  Commissioners are
 responsible for carrying out all orders of the board of health
 and for enforcing all sanitary laws and regulations in the
 district.  If the commissioner is not a physician, the board is
 responsible for employing a medical director to provide adequate
 medical direction.

      D.  Local Board of Health

 Advisory

 In Ohio the state is divided into health districts.  Cities
 constitute city districts, and the townships and villages in each
 county are combined into what is known as general health
 districts.  In these districts the board of health consists of
 five members who are appointed by the district advisory council.
 The law stipulates that one member of the board must be a
 physician and that appointments will be made with due regard to
 equal representation of all parts of the district.  The board
 members are appointed for 5-year terms of office.  Original
 appointments to the board were made in such a way to ensure that
 the term of office of one member expires each year.  In city
 health districts the legislative authority of the city is
 authorized to establish a board of health.  The board consists of
 five members appointed by the mayor and confirmed by the
 legislative authority.  The term of office is 5 years.  As with
 the general health districts, the original appointments were made
 so that one member's term of office expires each year.  Two or
 more health districts, city or general districts, may combine to
 form one combined health district.  This district can establish a
 board of health with the number of members, terms of office and
 method of appointment established in the contract between the
 jurisdictions that are combining.

 Each board of health is responsible for the administration and
 management of the local health department in a manner that should
 ensure that the local health department plans, organizes,
 manages, and coordinates health needs of the population in an
 effective manner.  Boards of health have specific responsibility
 to study and record the prevalence of disease and provide for
 prompt diagnosis and control of communicable diseases.  Boards
 may also provide the following:  medical and dental supervision
 of school children; free treatment for venereal diseases;
 inspection of schools, public institutions, jails, workhouses,
 children's homes, infirmaries, county homes, and other
 charitable, benevolent and correctional institutions; inspection
 of dairies, stores, restaurants, hotels and other places where
 food is manufactured, handled, stored, or sold; inspection and
 abatement of nuisances to public health; and taking such steps as
 necessary to protect the public and prevent disease.

      E.  Staff

 LPHA staffs are employed and supervised at the local level.  The
 number of staff for a local health department ranges from 4 to
 315.

      F.  Budget

 Total FY 1988 expenditures were $147,948,000.  Total FY 1988
 United States LPHA were $3,978,948,000.

      Source of Funds
        Federal Grants and Contracts     $32,642,000
        State Funds                       $3,551,000
        Local Funds                      $73,900,000
        Fees and Reimbursements          $36,931,000
        Other Sources                              0
        Source Unknown                      $924,000

 The SHA reported that these figures include the total amount of
 additional local health department monies expended by all local
 health departments in the state.
2Ohio Department of Health, 1990

 Public Health Council
 Board of Examiners of Nursing Home Administrators
 Hearing Aid Dealers and Fitters Licensing Board
 Chief of Staff
   Minority Affairs and Compliance
   Health Policy and Analysis
   Personnel Services
   Health Resources
   Internal Audit Unit
   Legislative Affairs
   Legal Services
   Budget Policy
   Public Affairs
 Assistant Director
 Employee Assistance Program
 Division of Preventive Medicine
      Bureau of Communicable Diseases
      Bureau of Chronic Diseases
      Bureau of Occupational Health
      Bureau of Health Promotion and Education
      Bureau of Epidemiology and Toxicology

 Division of Environmental Health
      Bureau of Technical Environmental Health
      Bureau of Local Environmental Health Services
      Bureau of State Environmental Health Services

 Division of Administrative Services
      Bureau of Data Services
      Bureau of Purchasing Management Services
      Bureau of District and Facilities Management
      Bureau of Fiscal Management
      Bureau of Vital Statistics

 Division of Maternal and Child Health
      Bureau for Children with Medical Handicaps
      Bureau of Maternal and Child Health
      Bureau of Dental Health
      Bureau of Women, Infants and Children

 Division of Medical Services
      Bureau of Adult Care Facilities and Rest Homes
      Bureau of Enforcement
      Bureau of Medicare and Medical Certification

 Division of Supportive Services
      Bureau of Local Health Departments
      Bureau of Nursing
      Bureau of Public Health Laboratories
      Bureau of Nutrition
      Migrant Breast Center
      Bureau of Employee Health
2Types of Local Health Departments by Jurisdiction
                                       Ohio, 1990

           Jurisdiction                 Co     C      C/Co

           Adams                        X
           Akron                               X
           Allen                                      X
           Alliance                            X
           Ashland                      X
           Ashland                             X
           Ashtabula                           X
           Ashtabula                                  X
           Athens                                     X
           Auglaize                                   X
           Barberton                           X
           Bellaire                            X
           Bellevue                            X
           Belmont                                    X
           Belpre                              X
           Bexley                              X
           Brown                        X
           Bryan                               X
           Bucyrus                             X
           Butler                                     X
           Campbell                            X
           Canton                              X
           Carroll                      X
           Champaign                                  X
           Cincinnati                          X
           Clark                        X
           Clermont                                   X
           Cleveland                           X
           Cleveland Hts                       X
           Clinton                                    X
           Columbiana                   X
           Columbus                            X
           Conneaut                            X
           Coshocton                    X
           Coshocton                           X
           Crawford                                   X
           Cuyahoga                                   X
           Defiance                                   X
           Delaware                                   X
           Drake                                      X
           East Cleveland                      X
           East Liverpool                      X
           East Palestine                      X
           Elyria                              X
           Erie                                       X
           Fairfield                    X
           Fayette                                    X
           Findlay                             X
           Franklin                                   X
           Fulton                                     X
           Galion                              X
           Gallia                       X
           Gallipolis                          X
           Geauga                       X
           Giard                               X
           Grandview Hts                       X
           Greene                                     X
           Guernsey                                   X
           Hamilton                            X
           Hamilton                                   X
           Hancock                      X
           Hardin                                     X
           Harrison                     X
           Henry                                      X
           Highland                                   X
           Hocking                                    X
           Holmes                       X
           Huron                                      X
           Indian Hill                         X
           Ironton                             X
           Jackson                                    X
           Jefferson                    X
           Kent                                X
           Knox                                       X
           Lake                                       X
           Lakewood                            X
           Lancaster                           X
           Lawrence                     X
           Licking                                    X
           Logan                                      X
           Lorain                              X
           Lorain                                     X
           Lucas                                      X
           Madison                                    X
           Mahoning                                   X
           Marietta                            X
           Marion                       X
           Marion                              X
           Martins Ferry                       X
           Massillon                           X
           Medina                       X
           Meigs                        X
           Mercer                                     X
           Miami                                      X
           Middletown                          X
           Mingo Junction                      X
           Monroe                       X
           Montgomery                                 X
           Morgan                       X
           Morrow                                     X
           Muskingum                                  X
           New Carlisle                        X
           New Philadelphia                    X
           Newark                              X
           Niles                               X
           Noble                        X
           Norwood                             X
           Oakwood                             X
           Ottawa                                     X
           Paulding                     X
           Perry                                      X
           Pickaway                                   X
           Pike                                       X
           Piqua                               X
           Portage                                    X
           Portsmouth                          X
           Preble                                     X
           Putnam                       X
           Ravenna                             X
           Reading                             X
           Richland                                   X
           Ross                                       X
           Salem                               X
           Sandusky                                   X
           Scioto                       X
           Seneca                                     X
           Shaker Hts                          X
           Sharonville                         X
           Shelby                              X
           Shelby                                     X
           Springdale                          X
           Springfield                         X
           St. Bernard                         X
           Stark                                      X
           Struthers                           X
           Stubenville                         X
           Summit                                     X
           Toledo                              X
           Toronto                             X
           Troy                                X
           Trumbull                                   X
           Tuscarawas                                 X
           Union                                      X
           Upper Arlington                     X
           Van Wert                                   X
           Vinton                       X
           Warren                              X
           Warren                                     X
           Washington                   X
           Wayne                                      X
           Wellsville                          X
           Williams                                   X
           Wood                                       X
           Wyandot                                    X
           Youngstown                          X

           Co = County HD
           C = City HD
           C/Co = City/County HD
1OKLAHOMA
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State     United States

 Population (1988)                  3,242,000       245,803,000
 Population Density (1988)                 47.2              69.4
   (per/sq.mi.)
 Number of Counties                        77             3,139
 Median Age                                31.3              31.7
 Percent Below Poverty Level (1985)        16.1              14.0
   (persons)
 Percent of Population Rural (1980)        33.0              26.0
 Percent of Population White (1980)        85.9              83.1
 Percent of Population Non-white (1980)    14.1              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 Oklahoma Constitution and Statutes provide authority and
 establish the framework for county governments.

 Commission Form - (77) - All counties use this form of government
 and have three-member boards.  Each commissioner is elected from
 one of the equally populated districts that make up the counties.
 The boards of commissioners serve as the administrative and
 executive bodies for the counties.

 The counties are administrative arms of the state, with services
 and responsibilities established by the state.  There is no
 authority for home rule, charters or other alternative forms of
 county governments.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The Oklahoma State Department of Health, the SHA, is a
 free-standing, independent agency.  The mission of the SHA is to

 Data for this state were updated October 1990. promote health and
 prevent disease among the citizens of Oklahoma.

 The following are some areas of responsibility for the SHA:

      State Public Health Authority
      Lead Environmental Agency in State
      State Professions Licensing Agency (for plumbers,
        electricians and professional counselors)
      Institutional Licensing Agency
      Institutional Certifying Authority for Federal Reimbursement

      B.  Head of State Health Agency

 M.D. Requirement, Not Cabinet-level Appointment

 The Commissioner of Health is the Chief Executive Officer of the
 SHA.  The Commissioner is appointed by the State Board of Health
 and serves at their pleasure.  Duties of the Commissioner include
 general supervision of health and appointing authority of the
 agency in hiring staff.  The Commissioner also investigates,
 inspects and enforces the Public Health Code, rules, and
 regulations of the Board of Health; and serves as official chief
 health officer of the state.

      C.  State Board of Health/Council

 Policy-making

 The State Board of Health is composed of nine members appointed
 by the Governor and confirmed by the Senate for 9-year terms of
 office.  They represent geographic regions of the state.  At
 least four members must be licensed physicians and members of the
 Oklahoma State Medical Association.  One member must be a
 psychiatrist and represent the state "at large." Responsibilities
 of the Board include adopting rules, regulations, and standards;
 accepting and dispersing grants, allotments, gifts, and
 appropriations; and establishing the organizational lines of the
 agency necessary to carry out the provisions of the Public Health
 Code.

       D.  Regional/District Health Offices

 The only regions or districts that exist are informal in nature
 and subject to constant change.  There are no regional offices.

      E.  State-local Liaison

 Mixed Centralized and Decentralized Organizational Control,
 Informal Liaison Function

 County health agencies which are not city-county health agencies
 are under the Deputy Commissioner for Local Health and local
 boards of health.  Regional administrators serve as liaison and
 managers.  City-county health agencies are decentralized but
 follow the State Board of Health rules and standards.

 The interaction between state and local public health agencies in
 Oklahoma may be characterized as mixed centralized and
 decentralized organizational control.  Mandated local health
 services may be provided by the SHA in some jurisdictions.

      F.  Budget

 Total FY 1988 SHA expenditures were $89,781,789*.  Total FY 1988
 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts          $34,225,887
        State Funds                           $33,389,014
        Local Funds                           $14,235,314
        Fees and Reimbursements                $7,931,574
        Other                                           0
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 There are 69 local health departments in Oklahoma.  Sixty-seven
 are county health departments and two are city-county health
 departments.

 Oklahoma counties are entitled to services required by statute;
 however, only those counties which elect to support a
 comprehensive local health department (those that provide a wide
 range of services), with up to 2.5 mills on property or funds
 from the county treasury, have complete services.  To date, 69 of
 the 77 counties have comprehensive health departments.  The
 remaining eight counties have no health departments but do have
 county superintendents of health, appointed by the Commissioner
 of Health.  Any public health services available to these
 counties are provided by neighboring counties or the SHA.

 * These data were provided by the SHA.  They exclude WIC Federal
 funds and Tulsa and Oklahoma city-county health departments.
 Every county with a comprehensive local health department has a
 local medical director appointed by the Commissioner.  The local
 administrators, who manage the day-to-day activities of the
 department, are responsible for a regional function covering
 multiple counties (average three).  Except for "autonomous"
 counties (Oklahoma and Tulsa), the authority is centralized in
 the SHA.

 Counties with more than 225,000 population are considered
 "autonomous" counties and have free-standing health departments
 that are semi-autonomous from the SHA.  Oklahoma and Tulsa
 counties fall into this category.

      B.  Services Provided

 The following information on services provided by local health
 departments in Oklahoma was obtained from the SHA.

 Services Provided by LPHAs                           Number and Percent

   I.  Assessment Activities
       A.  Data Collection/Analysis
            1.  Behavioral Risk Assessment               -
            2.  Morbidity Data                           -
            3.  Reportable Diseases                     69 (100.0%)
            4.  Vital Records and Statistics            69 (100.0%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        69 (100.0%)
            2.  Communicable Diseases                   69 (100.0%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement             69 (100.0%)
       B.  Health Planning                               -
       C.  Priority Setting                             69 (100.0%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   69 (100.0%)
            2.  Health Facility Safety/Quality          69 (100.0%)
            3.  Rec. Facility Safety/Quality            69 (100.0%)
            4.  Other Facility Safety/Quality            -

       B.  Licensing
            1.  Health Facilities                        -
            2.  Other Facilities                         -

       C.  Health Education                             69 (100.0%)

       D.  Environmental
            1.  Air Quality                              -
            2.  Hazardous Waste Management               -
            3.  Individual Water Supply Safety          69 (100.0%)
            4.  Noise Pollution                          -
            5.  Occupational Health and Safety           -
            6.  Public Water Supply Safety              69 (100.0%)
            7.  Radiation Control                        -
            8.  Sewage Disposal Systems                 69 (100.0%)
            9.  Solid Waste Management                  69 (100.0%)
           10.  Vector and Animal Control               69 (100.0%)
           11.  Water Pollution                          -

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             69 (100.0%)
            2.  Alcohol Abuse                            -
            3.  Child Health                            69 (100.0%)
            4.  Chronic Diseases                        69 (100.0%)
            5.  Dental Health                            -
            6.  Drug Abuse                               -
            7.  Emergency Medical Service                -
            8.  Family Planning                         69 (100.0%)
            9.  Handicapped Children                     -
           10.  Home Health Care                         -
           11.  Hospitals                                -
           12.  Immunizations                           69 (100.0%)

           13.  Laboratory Services                      -
           14.  Long-term Care Facilities                -
           15.  Mental Health                            -
           16.  Obstetrical Care                         -
           17.  Prenatal Care                           69 (100.0%)
           18.  Primary Care                            69 (100.0%)
           19.  Sexually Transmitted Diseases           69 (100.0%)
           20.  Tuberculosis                            69 (100.0%)
           21.  WIC                                     69 (100.0%)

       C.  Local Health Officer

 M.D. Requirement, Commissioner Appointment

 Local health officers, roughly synonymous with Medical Directors,
 are appointed and supervised by the Commissioner of Health.
 Their duties are to abolish nuisances, control disease, prevent
 the spread of disease, enforce health regulations, and perform
 other duties and functions as may be required by the
 Commissioner.  If the local health officer serves less than full
 time (and they all do except in the "autonomous" counties), the
 Commissioner may delegate nonmedical administrative duties to
 another employee of the county, the administrative director.  The
 local health officer relates primarily to staff, while the
 administrative director deals directly with the local board, the
 county government and the state.

      D.  Local Board of Health

 Policy-making

 The local board of health in all counties except "autonomous"
 counties consists of five members.  Board members are appointed
 by a variety of different people.  Two members are appointed by
 the Commissioner of Health.  One member who must be a school
 administrator is appointed by the county judge.  County
 commissioners appoint two members, one of whom is a medical
 person and another person who serves at the pleasure of the
 county commissioners and is usually a county commissioner.  All
 members serve 4-year terms, except for the latter appointment
 which has no specific term of office.  The two "autonomous"
 counties have 9-member boards and are autonomous from the SHA
 except that they must follow the rules and regulations of the
 State Board of Health and the qualifications of the members must
 be approved by the Commissioner of Health.  The local board must
 meet at least twice a year.  The duties of the board include
 calling for the election of a local health department;
 responsibility for maintaining a local health department;
 responsibility for preparing and submitting to the County Excise
 Board a request for local funds to operate the department; and
 advising the SHA of health matters.  Local boards may also adopt
 regulations that are subject to approval by the Commissioner and
 consistent with the state law and State Board of Health
 regulations.

       E.  Staff

 Local staffs are considered to be state employees, although the
 actual salary may come from a combination of many sources.  All
 personnel actions are approved by the Commissioner of Health.
 Candidates for employment at local health departments are
 interviewed by local staff with central office oversight.
 Although in "autonomous" counties the staff is employed and
 supervised by the local management, these counties do use the job
 specifications that the state has established.  The number of
 employees for local health departments ranges from 6 to 185.

      F.  Budget

 Total FY 1988 LPHA expenditures were $49,125,000.  Total FY 1988
 United States LPHA expenditures were $3,978,948,000.

      Source of Funds
        Federal Grants and Contracts      $8,028,000
        State Funds                      $17,373,000
        Local Funds                      $21,494,000
        Fees and Reimbursements           $2,172,000
        Other Sources                        $58,000
        Source Unknown                             0
 The SHA reported that these figures include the total of
 additional local health department monies expended by all local
 health departments.
2Oklahoma State Department of Health, 1990

 State Board of Health
 Commissioner of Health
 Health Planning Services
 Personal Health Services
      Deputy Commissioner
      Chronic Disease Service
      Dental Service
      Epidemiology Services
      Health Education and Information Service
      Laboratory Service
      Maternal and Child Health Services
      Nutrition/WIC Service

 Local Health Services
      Deputy Commissioner
      Medical Consultant
      Local Health Administration
      Child Guidance Services
      Nursing Services
      Professional Counselors' Licensing

 Administrative Services
      Deputy Commissioner and State Registrar
      Central Services Division
      Fiscal Service
      Personnel Services
      Vital Records

 Special Health Services
      Deputy Commissioner
      Long-Term Care Services
      Medical Facilities Service
      Eldercare Services
      Certificate of Need Division

 Environmental Health Services
      Deputy Commissioner
      Air Quality Service
      Food Protection Service
      General Environmental Services
      Occupational Licensing Service
      Radiation and Special Hazards Service
      State Environmental Laboratory Service
      Waste Management Service
      Water Quality Service
2Types of Local Health Departments by Jurisdiction
                                     Oklahoma, 1990

           Jurisdiction                        Co     C/Co   N/Co

           Adair                               X
           Alfalfa                                           X
           Beaver
           Beckham                             X
           Blaine                              X
           Bryan                               X
           Caddo                               X
           Canadian                            X
           Carter                              X
           Cherokee                            X
           Choctaw                             X
           Cimarron                                          X
           Cleveland                           X
           Coal                                X
           Comanche                            X
           Cotton                              X
           Craig                               X
           Creek                               X
           Custer                              X
           Delaware                            X
           Dewey                                             X
           Ellis                                             X
           Garfield                            X
           Garvin                              X
           Grady                               X
           Grant                               X
           Greer                               X
           Harmon                              X
           Harper                                            X
           Haskell                             X
           Hughes                              X
           Jackson                             X
           Jefferson                           X
           Johnston                            X
           Kay                                 X
           Kingfisher                          X
           Kiowa                               X
           Latimer                             X
           LeFlore                             X
           Lincoln                             X
           Logan                               X
           Love                                X
           Major                               X
           Marshall                            X
           Mayes                               X
           McClain                             X
           McCurtain                           X
           McIntosh                            X
           Murray                              X
           Muskogee                            X
           Noble                               X
           Nowata                                            X
           Okfuskee                            X
           Oklahoma City C                            X
           Okmulgee                            X
           Osage                               X
           Ottawa                              X
           Pawnee                              X
           Payne                               X
           Pittsburg                           X
           Pontotoc                            X
           Pottawatomie                        X
           Pushmataha                          X
           Roger Mills                                       X
           Rogers                              X
           Seminole                            X
           Stephens                            X
           Swquoyah                            X
           Texas                               X
           Tillman                             X
           Tulsa City Co                              X
           Wagoner                             X
           Washata                                           X
           Washington                          X
           Woods                               X
           Woodward                            X

           Co = County HD
           C/Co = City/County HD
           N/Co = No County HD
1OREGON
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State    United States

 Population (1988) *                2,741,000      245,803,000
 Population Density (1988) *               28.5             69.4
   (per/sq.mi.)
 Number of Counties                        36            3,139
 Median Age (1987)                         32.6             31.7
 Percent Below Poverty Level (1985)        11.9             14.0
   (persons)
 Percent of Population Rural (1980)        32.0             26.0
 Percent of Population White (1980)        94.6             83.1
 Percent of Population Non-white (1980)     5.4             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 Oregon are
 established in the state constitution and statutes.  Oregon
 counties operate either under General Law or Home Rule Charters.

 General Law - (29) - These counties have governments that operate
 under provision of General Law.  Fifteen of these have a
 commission and 13 functions with a county court system made up of
 a county judge and 2 commissioners.  The judge has administrative
 responsibilities for the county functions, as well as juvenile
 court and probate responsibilities.  Five of the General Law
 counties have appointed a county administrator to assist the
 board.

 Home Rule Charters - (7) - Home rule provisions in the
 constitution permit counties to adopt, amend, or repeal
 charters.  The legislative body is made up of three- or
 five-member boards of commissioners who are elected at large,
 from single-member districts or by a combination of methods.
 Five charter counties have appointed an administrative officer.
 Multnomah County has a board chair who is elected at large and
 has administrative responsibility.

 * These data were provided by the SHA.

 Data for this state were updated November 1990.
3II.  State Health Agency (SHA)

      A.  General

 Component of Superagency

 The Health Division is the SHA in Oregon.  It is a component of a
 superagency called the Department of Human Resources.  Functions
 of the Health Division are, for the most part, supportive to
 county and regional health departments.  Local health agencies
 have primary obligation for the direct delivery of public health
 services to Oregon's population.  The Division's broad mission is
 to protect, preserve, and promote the health of all Oregonians.
 Its main functions include:  monitoring the health of the public;
 monitoring the activities of businesses whose practices may
 affect the health of all citizens through licensing/certification
 or a permit system; establishing standards and priorities for
 public health services by working with local health departments
 that provide the majority of direct public health services;
 providing health information to a wide variety of individuals and
 health providers for the purposes of health planning, treatment,
 services development, and evaluation.

 The following are some areas of responsibility for the SHA:

      State Public Health Authority
      Institutional Licensing Agency
      Institutional Certifying Authority for Federal Reimbursement
      State Institutions/Hospitals

      B.  Head of State Health Agency

 No M.D. Requirement, Not Cabinet-level Appointment

 The Administrator of the Health Division is head of the SHA.
 This official is appointed by the Director of the Department of
 Human Resources.  If the Administrator is a physician, he may
 also be the State Public Health Officer.  If the Administrator is
 a non-physician, however, he/she appoints the State Health
 Officer who also serves as Deputy Administrator of the Health
 Division and is responsible for the medical and paramedical
 aspects of health programs.

      C.  State Board of Health/Council

 Advisory

 Oregon has a Public Health Advisory Board which consists of 15
 members appointed by the Governor for 4-year terms.  The board
 serves as an advisory body to the Assistant Director for Health
 by reviewing statewide health issues and participating in public
 health policy development.

 D.  Regional/District Health Offices

 The Health Division has no regional or district offices.

      E.  State-local Liaison

 Decentralized Organizational Control, No Formal Liaison Function

 There is not an individual or office that has responsibility for
 liaison between the SHA and local health departments.  However,
 there are organizations that provide this function.  The
 Conference of Local Health Officials, which is authorized by
 statute, consists of all local health officers, public health
 administrators, nursing directors, and supervising sanitarians.
 The Conference executive committee, with the chairperson, advises
 the assistant director for health on implementing Oregon's public
 health laws and the rules of the Health Division.  In addition,
 the Public Health Management Council, an unofficial group of
 local public health administrators, advises the assistant
 director for health on state and local health program direction
 and administration.

 The interaction between state and local public health agencies in
 Oregon may be characterized as decentralized organizational
 control.  Under this arrangement local governments directly
 operate health departments with or without a local board of
 health.

      F.  Budget

 Total FY 1988 SHA expenditures were $39,106,000*.  Total FY 1988
 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants                        $25,174,000*
        State Funds                            $8,491,000
        Local Funds                                     0
        Fees and Reimbursements                         0
        Other                                  $5,441,000*

 * These data were provided by the SHA.
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 Oregon has 34 local public health departments.  These consist of
 33 county health departments and 1 multicounty health department
 (regional health department) that covers 2 rural counties (Wasco
 and Sherman).  In two counties (Columbia, Wheeler) the local
 government contracts with private health clinics to perform as
 the health department.  One county (Gilliam) has no health
 department.

 While the Health Division is responsible for overseeing the
 expenditures of Federal and state public health funds, the
 relationship between local health departments and the SHA is
 mainly one of consultation and periodic performance review.
 Funding called State Support for Public Health is provided to
 local health departments if they have services in the following
 mandated areas:  communicable disease control; parent and child
 health (including family planning); health information and
 referral; vital statistics; and environmental health.  The
 current level of funding is 55 cents per capita.  Counties which
 provide only part of the required services receive funding
 proportional to the services they provide.

      B.  Services Provided

 The following information on services provided by local health
 departments in Oregon is derived from a survey conducted by NACHO
 during 1989.  Thirty-three of the 35 local health departments in
 Oregon 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   ( 24.2%)
            2.  Morbidity Data                          23   ( 69.7%)
            3.  Reportable Diseases                     33   (100.0%)
            4.  Vital Records and Statistics            31   ( 93.9%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                         9   ( 27.3%)
            2.  Communicable Diseases                   32   ( 97.0%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement             19   ( 57.6%)
       B.  Health Planning                              27   ( 81.8%)
       C.  Priority Setting                             22   ( 66.7%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   16   ( 48.5%)
            2.  Health Facility Safety/Quality           7   ( 21.2%)
            3.  Rec. Facility Safety/Quality            14   ( 42.4%)
            4.  Other Facility Safety/Quality            6   ( 18.2%)

       B.  Licensing
            1.  Health Facilities                        1   (  3.0%)
            2.  Other Facilities                        19   ( 57.6%)

       C.  Health Education                             26   ( 78.8%)

       D.  Environmental
            1.  Air Quality                             11   ( 33.3%)
            2.  Hazardous Waste Management              17   ( 51.5%)
            3.  Individual Water Supply Safety          20   ( 60.6%)
            4.  Noise Pollution                          4   ( 12.1%)
            5.  Occupational Health and Safety           2   (  6.1%)
            6.  Public Water Supply Safety              18   ( 54.5%)
            7.  Radiation Control                        4   ( 12.1%)
            8.  Sewage Disposal Systems                 15   ( 45.5%)
            9.  Solid Waste Management                  15   ( 45.5%)
           10.  Vector and Animal Control               16   ( 48.5%)
           11.  Water Pollution                         15   ( 45.5%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             33   (100.0%)
            2.  Alcohol Abuse                            7   ( 21.2%)
            3.  Child Health                            28   ( 84.8%)
            4.  Chronic Diseases                        14   ( 42.4%)
            5.  Dental Health                            8   ( 24.2%)
            6.  Drug Abuse                               8   ( 24.2%)
            7.  Emergency Medical Service                7   ( 21.2%)
            8.  Family Planning                         31   ( 93.9%)
            9.  Handicapped Children                    11   ( 33.3%)
           10.  Home Health Care                         4   ( 12.1%)
           11.  Hospitals                                -
           12.  Immunizations                           33   (100.0%)
           13.  Laboratory Services                     20   ( 60.6%)
           14.  Long-term Care Facilities                -
           15.  Mental Health                            9   ( 27.3%)
           16.  Obstetrical Care                         5   ( 15.2%)
           17.  Prenatal Care                           29   ( 87.9%)
           18.  Primary Care                            10   ( 30.3%)
           19.  Sexually Transmitted Diseases           32   ( 97.0%)
           20.  Tuberculosis                            33   (100.0%)
           21.  WIC                                     29   ( 87.9%)

 Because the statute does not spell out the elements of the
 required environmental health services, and because the licensing
 fees collected are not sufficient to support the program, some
 rural counties do not provide any environmental health services
 beyond nuisance follow-up services.  In these counties the Health
 Division provides minimal services to assure safe public food and
 water supplies.

      C.  Local Health Officer

 M.D. or D.O. Requirement, Local Governing Body Appointment

 Each county is required by statute to have a licensed medical
 doctor as the local health officer.  The Conference of Local
 Health Officials developed model standards for health officer
 responsibilities and qualifications.  The health officer must be
 licensed in Oregon as a medical doctor or doctor of osteopathy,
 have 2 years of practice as a licensed physician, and have
 training and/or experience in epidemiology or public health.
 Duties for the health officer include the following:  provide
 medical direction for clinical activities, including developing
 and signing standing orders and protocols; provide consultation
 on medical issues to health department personnel; act as liaison
 between local health department and local medical community; may
 provide direct clinical service; promote public health in the
 community; and represent the agency to community groups, other
 agencies, and the media.  The scope of health officer services
 varies widely, usually in relation to the size of the county
 health department.  Rural counties receive very limited health
 officer time--in some cases only 1-2 hours per week.  There are
 three full-time health officers in Oregon, and one of these is
 also the administrator of a health department.

      D.  Local Board of Health

 Policy-making

 In most counties the Board of Commissioners declared themselves
 the local board of health, in addition to being the statutory
 local health authority.  This eliminated the administrative and
 budgetary confusion created by having two bodies legally
 responsible for public health matters in the county.  The few
 boards of health that continue to exist as separate entities are
 advisory only and relate primarily to the public health
 administrator.

      E.  Staff

 The staffs of local health departments are employed and
 supervised by the local jurisdiction.  The number of full-time
 employees for local health departments ranges from 1 to 388.

      F.  Budget

 Total FY 1988 LPHA expenditures were $34,265,494*.  Total FY 1988
 United States LPHA expenditures were $3,978,948,000.

      Source of Funds
        Federal Grants and Contracts,
          State Funds                       $11,796,152*
        Local Funds, Fees and
          Reimbursements                    $21,243,031*
        Other Sources                        $1,226,314*
        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

 * These data were provided by the SHA.
2Oregon State Health Division, 1990

 Administrator
   Executive Assistant
   Oregon Health 2000
 Deputy Administrator/State Health Officer
 Administrative Services
      Licensing Boards
      Fiscal Services
      Information Systems
      Personnel
      Purchasing/Services
      State Medical Examiner

 Environmental Health
      Drinking Water Systems
      Emergency Medical Services and Injury Prevention
      Environmental Services and Consultation
      Health Care Survey Section
      Radiation Control

 Epidemiology and Health Statistics
      Center for Health Statistics
      Communicable Diseases
      Non-Communicable Diseases
      Sexually Transmitted Diseases

 Health Services
      Family Planning/Adolescent Health
      Field Services
      Maternal/Child Dental Health
      Immunizations
      Women, Infants and Children
      Minority Health

 Public Health Laboratory
      General Microbiology
      Laboratory Support
      Newborn Screening
      Quality Assurance and Consultation
      Virology/Immunology
2Types of Local Health Departments by Jurisdiction
                                      Oregon, 1990

           Jurisdiction                        Co     M/Co   N/Co

           Baker                               X
           Benton                              X
           Clackamas                           X
           Clatsop                             X
           Columbia                            X
           Coos                                X
           Crook                               X
           Curry                               X
           Deschutes                           X
           Douglas                             X
           Gilliam                                           X
           Grant                               X
           Harney                              X
           Hood River                          X
           Jackson                             X
           Jefferson                           X
           Josephine                           X
           Klamath                             X
           Lake                                X
           Lane                                X
           Lincoln                             X
           Linn                                X
           Malheur                             X
           Marion                              X
           Morrow                              X
           Multomah                            X
           Polk                                X
           Sherman                                    X
           Tillamook                           X
           Umatilla                            X
           Union                               X
           Wallowa                             X
           Wasco                                      X
           Washington                          X
           Wheeler                             X
           Yamhill                             X

           Co = County HD
           M/Co = Multicounty HD
           N/Co = No County HD
1PENNSYLVANIA
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State    United States

 Population (1988)                 12,002,000      245,803,000
 Population Density (1988)                267.4             69.4
   (per/sq.mi.)
 Number of Counties                        67            3,139
 Median Age (1987)                         33.8             31.7
 Percent Below Poverty Level (1985)        10.5             14.0
   (persons)
 Percent of Population Rural (1980)        31.0             26.0
 Percent of Population White (1980)        89.8             83.1
 Percent of Population Non-white (1980)    10.2             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 Pennsylvania Constitution and Statutes provide a basis for
 the structure and function of county governments in the
 commonwealth.  The counties may select one of three variations in
 government structure.  The choices are Commission, Home Rule
 Charter, and Optional County Plan.

 Commission Form - (61) - These counties have three-member boards,
 elected at large, which are delegated executive, administrative
 and legislative powers.  Four of the commission counties have
 appointed an administrator.  In some counties the chief clerk has
 been given responsibility for many administrative duties.
 Several counties have restructured the chief clerk position to
 increase the responsibility and make the position similar to that
 of an administrator, but with fewer responsibilities.

 Home Rule Charter - (6) - In 1972 the legislature enacted
 provisions for Home Rule Charters and the Optional County Plan.
 Adoption of home rule can begin with action by the county
 commission or by a citizens' referendum.

 Optional County Plan - (0) - At the present time, no counties
 have adopted the Optional County Plan.

 Data for this state were updated October 1990.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The SHA is an independent, free-standing agency known as the
 Pennsylvania Department of Health (PDH).  Department functions
 are divided among the following five Deputy Secretaries:  Deputy
 Secretary for Public Health Programs; Deputy Secretary for Drug
 and Alcohol Programs; Deputy Secretary for Administration; Deputy
 Secretary for Community Health; and Deputy Secretary for Planning
 and Quality Assurance.  The mission of the PDH is to develop an
 effective public health system which promotes the optimal health
 of Pennsylvania's citizens and reduces their need for medical
 care by the following means:

      Assisting citizens to adopt healthful behaviors
      Eliminating preventable illnesses
      Reducing the severity of illness and disability
      Facilitating access to high quality health care in the
        appropriate setting
      Identifying and eliminating health hazards

 The following are some broad 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

 Some other areas of responsibility for the SHA include
 communicable and non-communicable disease investigation and
 control, statewide implementation of maternal and child health
 programs, and state agency for drug and alcoholism programs.

      B.  Head of State Health Agency

 M.D. Requirement, Cabinet-level Appointment

 The head of the PDH is the Secretary of Health.  The Secretary is
 a cabinet-level officer appointed by the Governor.  Requirements
 are an M.D. degree and at least 10 years' experience.  The
 Secretary's duties are to protect the health of the people of the
 state, and to determine and deploy the most efficient and
 practical means for the preventing and suppressing disease.
      C.  State Board of Health/Council

 Advisory

 PDH has an Advisory Health Board which consists of the Secretary
 of Health, who serves as chair, and 12 other members, including
 at least 5 licensed physicians, 1 licensed dentist, 1 licensed
 pharmacist, 1 licensed RN, 1 engineer registered with the
 commonwealth, and 3 other individuals.  The board is appointed by
 the Governor and has the following duties and responsibilities:
 advise the Secretary of Health; make rules and regulations deemed
 necessary for disease prevention, health protection, and for
 efficient operation of the Department; prescribe minimum health
 activities and minimum standards of performance of health
 services for counties or other political subdivisions.

      D.  Regional/District Health Offices

 The PDH has the authority, with approval of the Governor, to
 divide the commonwealth into health districts and to appoint a
 health officer for each district.  The District Health Officer
 reports to the Deputy Secretary for Community Health and is
 responsible for implementing delegated programs and activities.
 The commonwealth is divided into 6 health service districts, for
 operating the 62 state health centers in those counties that do
 not operate their own health agency.  The following list
 represents the organization and the principal positions for the
 district health offices:

      District Executive Director

      Health Educator

      Nursing Services
         District Nurse Administrator
         Community Health Nurse Supervisors
         Diabetes Facilitator

      Program Services
         District Epidemiology Program Services Supervisor
         Chronic Disease Representative(s)
         Tuberculosis Representative
         Immunization Representative
         Sexually Transmitted Disease Representative(s)

      Consultant Services
         District Medical Director
         Dental Hygienist
         Environmental Health Specialist
         Nutritionist
         Physical Therapist

                Administrative Services
         Administrative Officer
         District Office Secretaries

      E.  State-local Liaison

 Mixed Centralized and Decentralized Organizational Control,
 Formal Liaison Function

 The Deputy Secretary for Community Health serves as the liaison
 between the SHA and local health agencies.  In this capacity the
 Deputy Secretary serves as a primary communication point between
 local health and the SHA.  Communications and discussions between
 district directors, city and county health departments, and the
 SHA are facilitated through meetings organized by the Deputy
 Secretary to discuss policy, standards, and operations.
 Additionally, the Deputy Secretary appoints committees and
 workgroups from the local health officials to deal with important
 issues facing the public health community.

 The Deputy Secretary for Community Health directly supervises the
 six district offices and the 62 state health centers, wherein the
 state assumes major responsibility for public health functions.
 In the remaining counties, county health departments assume this
 role under enabling legislation.  The Deputy Secretary for
 Community Health establishes required program standards, monitors
 program activities and approves funding to qualifying agencies.

 The interaction between state and local public health agencies in
 Pennsylvania may be characterized as mixed centralized and
 decentralized organizational control.  Under this arrangement
 public health services in Pennsylvania may be provided by the SHA
 in some jurisdictions and by local government units, boards of
 health, or health departments in other jurisdictions.

      F.  Budget

 Total FY 1988 SHA expenditures were $265,948,000.  Total FY 1988
 United States SHA expenditures were $8,312,928,000.

       Source of Funds
         Federal Grants and Contracts         $119,659,000
         State Funds                          $142,231,000
         Local Funds                                     0
         Fees and Reimbursements                $4,058,000
         Other                                           0
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 There are 70 LPHAs in Pennsylvania which provide a wide range of
 services.  These LPHAs fall into two different groups.  The first
 of these groups is known as local health departments.  These
 health units are semi-autonomous from the state and serve
 counties, cities, and city/county jurisdictions.  Currently there
 are eight of these units.  They consist of one city-county, three
 city, and four county health departments.  An additional county
 health department is scheduled to begin operation in 1991, when
 Montgomery County begins functioning.  These health departments
 must meet established standards and provide certain mandated
 services.  Upon meeting established requirements, the local
 health departments are eligible for financial support from the
 state in the form of matching funds.  They can receive up to
 $4.50 per capita for health and an additional $1.50 per capita
 for environmental health.

 The second type of LPHA is the State Health Center System.  Each
 county in the state that is not served by a local health
 department is served by a unit of the State Health Center
 System.  There are 62 service units in the State Health Center
 System.  This system is funded entirely by the state and staffed
 and administered by state employees.  These units are divided
 into six administrative districts.

 A third type of LPHA exists in the state, which is made up of
 boards of health and health officers from boroughs, townships and
 cities.  The 240 units in this category do not receive funds from
 the state and are generally autonomous from the PDH in their
 operation and services.  They have a limited number of staff and
 services.

      B.  Services Provided

 The following information on services provided by local health
 departments in Pennsylvania is derived from a survey conducted by
 NACHO during 1989.  Since only 7 of the 68 health departments in
 Pennsylvania responded to the 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               4   ( 57.1%)
            2.  Morbidity Data                           6   ( 85.7%)
            3.  Reportable Diseases                      7   (100.0%)
            4.  Vital Records and Statistics             2   ( 28.6%)
       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                         6   ( 85.7%)
            2.  Communicable Diseases                    7   (100.0%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement              7   (100.0%)
       B.  Health Planning                               7   (100.0%)
       C.  Priority Setting                              6   ( 85.7%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                    7   (100.0%)
            2.  Health Facility Safety/Quality           6   ( 85.7%)
            3.  Rec. Facility Safety/Quality             6   ( 85.7%)
            4.  Other Facility Safety/Quality            3   ( 42.9%)

       B.  Licensing
            1.  Health Facilities                        2   ( 28.6%)
            2.  Other Facilities                         7   (100.0%)

       C.  Health Education                              7   (100.0%)

       D.  Environmental
            1.  Air Quality                              3   ( 42.9%)
            2.  Hazardous Waste Management               4   ( 57.1%)
            3.  Individual Water Supply Safety           5   ( 71.4%)
            4.  Noise Pollution                          2   ( 28.6%)
            5.  Occupational Health and Safety           1   ( 14.3%)
            6.  Public Water Supply Safety               4   ( 57.1%)
            7.  Radiation Control                        3   ( 42.9%)
            8.  Sewage Disposal Systems                  5   ( 71.4%)
            9.  Solid Waste Management                   5   ( 71.4%)
           10.  Vector and Animal Control                7   (100.0%)
           11.  Water Pollution                          5   ( 71.4%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling              7   (100.0%)
            2.  Alcohol Abuse                            2   ( 28.6%)
            3.  Child Health                             7   (100.0%)
            4.  Chronic Diseases                         7   (100.0%)
            5.  Dental Health                            2   ( 28.6%)
            6.  Drug Abuse                               2   ( 28.6%)
            7.  Emergency Medical Service                3   ( 42.9%)
            8.  Family Planning                          1   ( 14.3%)
            9.  Handicapped Children                     3   ( 42.9%)
           10.  Home Health Care                         2   ( 28.6%)
           11.  Hospitals                                -
           12.  Immunizations                            7   (100.0%)
           13.  Laboratory Services                      4   ( 57.1%)
           14.  Long-term Care Facilities                1   ( 14.3%)
           15.  Mental Health                            1   ( 14.3%)
           16.  Obstetrical Care                         1   ( 14.3%)
           17.  Prenatal Care                            3   ( 42.9%)
           18.  Primary Care                             1   ( 14.3%)
           19.  Sexually Transmitted Diseases            7   (100.0%)
           20.  Tuberculosis                             7   (100.0%)
           21.  WIC                                      4   ( 57.1%)

 The cities, boroughs, and townships which have boards of health
 and health officers usually provide a limited range of services
 to their jurisdictions.  Most of the services provided include
 food protection, health education, disease reporting, and
 investigation of public health complaints.

       C.  Local Health Officer

 No M.D. Requirement, Local Governing Body Appointment

 A variety of health codes require the appointment of local boards
 of health and health officers or sanitary officers at the level
 of cities, townships and boroughs.  Currently there are 242 local
 health officers/sanitary officers in Pennsylvania.

       D.  Local Board of Health

 Policy-making

 Local boards of health for cities, townships, and boroughs are
 established by several different laws, some of which specify
 that the council will serve as the board of health if one is not
 appointed.  The boards of health consist of five members, with
 one or two specified to be physicians if any reside in the
 jurisdiction.

       E.  Staff

 The semi-autonomous local health departments employ and supervise
 their own staffs.  The State Health Center System staffs are
 employed and supervised by the state.  The number of employees
 for either of these types of units ranges from 20 to 1,614.
 Boroughs, townships, and cities which have boards of health and
 health officers generally have a very limited staff, but the
 exact numbers are not known.

       F.  Budget

 Total FY 1988 LPHA expenditures were $65,878,000.  Total FY 1988
 United States LPHA expenditures were $3,978,948,000.
        Source of Funds
         Federal Grants and Contracts      $5,044,000
         State Funds                      $24,930,000
         Local Funds                                0
         Fees and Reimbursements                    0
         Other Sources                              0
         Source Unknown                   $35,903,000

 The SHA reported that these figures include the total amount of
 additional local health department monies expended by all local
 health departments.
2Pennsylvania Department of Health, 1990

 Secretary of Health
 Deputy Secretary for Public Health Programs
      Bureau of HIV/AIDS
      Bureau of Special Public Health Services
      Bureau of Epidemiology and Disease Prevention
      Bureau of Maternal and Child Preventive Programs

 Deputy Secretary for Administration
      State Health Data Center
      Bureau of Financial Management
      Bureau of Personnel
      Bureau of Administrative Services

 Deputy Secretary for Planning and Quality Assurance
      Bureau of Laboratories
      Bureau of Planning
      Bureau of Health Financing and Program Development
      Bureau of Quality Assurance

 Deputy Secretary for Drug and Alcohol Programs
      Bureau of Program Services
      Bureau of Community Services

 Deputy Secretary for Community Health
      Southeastern District
      South Central District
      Southwestern District
      Northeastern District
      North Central District
      Northwestern District
      Local Health Departments
        Allegheny
        Allentown
        Bethlehem
        Bucks
        Chester
        Erie
        Philadelphia
        York
2Types of Local Health Departments by Jurisdiction
                                   Pennsylvania, 1990

           Jurisdiction                        Co     C      C/Co

           Adams                               X
           Allegheny                           X
           Allentown                                  X
           Armstrong                           X
           Beaver                              X
           Bedford                             X
           Berks                               X
           Bethlehem                                  X
           Blair                               X
           Bradford                            X
           Bucks                               X
           Butler                              X
           Cambria                             X
           Cameron                             X
           Carbon                              X
           Centre                              X
           Chester                             X
           Clarion                             X
           Clearfield                          X
           Clinton                             X
           Columbia                            X
           Crawford                            X
           Cumberland                          X
           Dauphin                             X
           Delaware                            X
           Elk                                 X
           Erie                                X
           Fayette                             X
           Forest                              X
           Franklin                            X
           Fulton                              X
           Greene                              X
           Huntingdon                          X
           Indiana                             X
           Jefferson                           X
           Juniata                             X
           Lackawanna                          X
           Lancaster                           X
           Lawrence                            X
           Lebanon                             X
           Lehigh                              X
           Luzerne                             X
           Lycoming                            X
           McKean                              X
           Mercer                              X
           Mifflin                             X
           Monroe                              X
           Montgomery                          X
           Montour                             X
           Northampton                         X
           Northumberland                      X
           Perry                               X
           Philadelphia                                      X
           Pike                                X
           Potter                              X
           Schuylkill                          X
           Snyder                              X
           Somerset                            X
           Sullivan                            X
           Susquehanna                         X
           Tioga                               X
           Union                               X
           Venango                             X
           Warren                              X
           Washington                          X
           Wayne                               X
           Westmoreland                        X
           Wyoming                             X
           York                                X
           York City                                  X

           Co = County HD
           C = City HD
           C/Co = City/County HD
1RHODE ISLAND
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State     United States

 Population (1988)                    993,000       245,803,000
 Population Density (1988)                941.2              69.4
   (per/sq.mi.)
 Number of Counties                         5             3,139
 Median Age (1987)                         33.2              31.7
 Percent Below Poverty Level (1985)         9.0              14.0
   (persons)
 Percent of Population Rural (1980)        13.0              26.0
 Percent of Population White (1980)        94.7              83.1
 Percent of Population Non-white (1980)     5.3              16.9
 Median Years of Education (1980)          12.3              12.5
   (25 years of age and over)

      B.  County Government Structure

 There are no functioning county governments in Rhode Island.
 Local government consists of 39 cities and towns represented in
 the State Legislature by 50 Senators and 100 Representatives.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The Rhode Island Department of Health (RIDH) is a free-standing
 independent agency that serves as the SHA.  The primary mission
 of the Department is to promote the health of the population and
 to prevent disease through lifestyle change, environmental
 protection, and health care delivery.

 Public health services in Rhode Island are for the most part
 delivered on a contractual mechanism.  The SHA contracts with
 community health centers, visiting nursing associations, and
 hospital outpatient departments for the provision of services.  A
 few services, such as STD services, are delivered directly by the
 SHA.

 Data for this state were updated October 1990.
 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
      State Professions' Licensing Agency
      Institutional Licensing Agency
      Institutional Certifying Authority for Federal Reimbursement

      B.  Head of State Health Agency

 M.D. Requirement, Cabinet-level Appointment

 The Director of Health is the head of the SHA.  This individual
 must be a physician graduated from an acceptable medical college
 and must have a minimum of 1 year of graduate instruction in
 public health administration, or board certification in a medical
 specialty, and a minimum of 5 years' full-time experience in
 health administration.  The Governor appoints, with Senate
 approval, the Director of Health for a 5-year term.

      C.  State Board of Health/Council

 Advisory

 Rhode Island has no State Board of Health.  However, there are
 numerous advisory councils associated with the RIDH for specific
 issues or programs.  There are two types of councils:  standing
 committees have a legislative base and are program oriented; ad
 hoc committees have no legal mandate and are appointed to address
 issues and problems as needed.  Both types of committees are
 formed and appointed in a variety of ways including appointment
 by the Governor, program directors, and the Director of Health.
 They both serve as conduits for input into health department
 activity by outside sources.

      D.  Regional/District Health Offices

 There are no regional or district public health offices in Rhode
 Island.

      E.  State-local Liaison

 Since there are no local public health departments in Rhode
 Island, there is no state-local liaison.

      F.  Budget

 Total FY 1988 Rhode Island SHA expenditures were $35,643,138.
 Total FY 1988 United States SHA expenditures were $8,312,928,000.

 These data were provided by the SHA.
                 Source of Funds
         Federal Grants and Contracts          $13,076,420
         State Funds                           $21,118,078
         Local Funds                                     0
         Fees and Reimbursements                         0
         Other                                  $1,948,631
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 There are no local public health agencies in Rhode Island.  All
 public health services are provided by the State Department of
 Health.

       B.  Services Provided

 There are no local public health agencies to provide services.

       C.  Local Health Officer

 There are no local health officers in Rhode Island.

       D.  Local Board of Health

 There are no local boards of health in Rhode Island.

       E.  Staff

 There are no local public health department staffs.

       F.  Budget

 There is no budget for local public health agencies.
2Rhode Island Department of Health, 1990

 Director of Health
   Office of Medical Examiner
 Associate Director Environmental Health
      Environmental Health Risk Assessment
      Food Protection
      Drinking Water Quality
      Occupational and Radiological Health
      Health Laboratories

 Associate Director Health Services Regulation
      Facilities Regulation
      Professional Regulation
      Drug Control
      Medical Licensure and Discipline
      Health Systems Development

 Medical Director Family Health
      Primary Care
      Dental Health
      Children with Special Health Care Needs
      Nutrition
      Women, Infants and Children (WIC)

 Medical Director Disease Control
      Communicable Disease
      Sexually Transmitted Disease/AIDS
      Chronic Disease
      Vital Records
      Health Promotion
2Types of Local Health Departments by Jurisdiction
                                   Rhode Island, 1990

                  Rhode Island does not have local health departments
1SOUTH CAROLINA
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State      United States

 Population (1988)                  3,469,000        245,803,000
 Population Density (1988)                114.9               69.4
   (per/sq.mi.)
 Number of Counties                        46              3,139
 Median Age (1987)                         30.1               31.7
 Percent Below Poverty Level (1985)        15.2               14.0
   (persons)
 Percent of Population Rural (1980)        46.0               26.0
 Percent of Population White (1980)        68.8               83.1
 Percent of Population Non-white (1980)    31.2               16.9
 Median Years of Education (1980)          12.1               12.5
   (25 years of age and over)

      B.  County Government Structure

 Home Rule Authority

 Authority for the operation of county governments in South
 Carolina is provided in the state constitution and statutes.  A
 Home Rule Act was passed in 1975 which gave counties the option
 of four different forms of governments.

 Council Form - (0) - This option delegates all legislative and
 executive authority to the council, which may be elected at large
 or from single-member districts.

 Council-supervisor - (8) - This option authorizes a supervisor
 who is elected separately from the council and serves as the
 chief executive officer for the county.

 Council-administrator or council-manager - (38) - These options
 are quite similar in function.  Under these forms of government
 the council is permitted to appoint a manager or administrator to
 carry out the policy and administrative functions.

 Home Rule Authority - In 1975 the South Carolina Constitution was
 amended to give additional power to county governments.  Even
 with these laws the counties still have somewhat restricted
 authority.  They are limited to levying property taxes and
 business license taxes.  Since they are athorized to raise taxes
 for a wider variety of services, many counties have increased
 services beyond those traditionally provided.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The South Carolina Department of Health and Environmental Control
 (SCDHEC) is the SHA.  It is a free-standing, independent agency.
 The mission of SCDHEC is to protect the public's health and
 environment.  As the principal advisor to the state on public
 health, the Department has the responsibility and authority to
 prevent, abate, and control pollution and health problems.

 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

      B.  Head of State Health Agency

 No M.D. Requirement, Not Cabinet-level Appointment

 The Commissioner is the chief executive officer of the
 Department.  The Commissioner is appointed by the Board of Health
 and Environmental Control and serves at the pleasure of the
 Board.  There is no specific tenure for the Commissioner.

 Responsibilities of the Commissioner include enforcing
 environmental quality and health regulations for which the
 Department has responsibility, advocating the availability of
 public health services, and assuring that good quality public
 health services are available.

      C.  State Board of Health/Council

 Policy-making

 The State Board of Health and Environmental Control is made up of
 seven members who are appointed by the Governor with advice and
 consent of the Senate.  A Board member is appointed from each of
 the six Congressional districts and one member at large.  The
 term of office is 4 years.

 The Board makes policy, approves the budget, approves
 Department-sponsored legislation and acts as an adjudicatory body
 for appeals of Department regulatory decisions.  The Board hires
 and reviews the performance of the Commissioner.  The Board
 chooses its own officers on an annual basis.

      D.  Regional/District Health Offices

 The 46 counties of South Carolina are divided into 15 public
 health districts and 12 environmental control districts.  Health
 districts are comprised of two to six counties, with a health
 department in each county.  The district administration and
 district core management staffs are all headed by a district
 health officer who reports to the Deputy Commissioner for Health
 Services.

 Each health district provides personal and environmental health
 services to the residents of the district.  Each health district
 has a vital records registrar to record vital events in the
 district's counties.  County health departments are linked
 directly to the district office; the district office is linked
 directly to the central office.  Health service delivery planning
 is done centrally with local input, allowing latitude for
 districts and counties to adapt the plan to fit local
 situations.  Funds are budgeted centrally with district input.
 Reporting to state and Federal funding sources is a
 responsibility of the central office but depends on accurate and
 timely local reporting of activities.

      E.  State-local Liaison

 Centralized Organizational Control, Formal Liaison Function

 The state-local liaison is the Deputy Commissioner for Health
 Services.  The Deputy Commissioner supervises the district health
 officers, as well as the bureau directors and discipline offices
 (nursing, nutrition, health education, social work, and
 dentistry), in the central office.  Therefore, this
 organizational position is pivotal to making the central office
 responsive to local needs and to setting priorities for activity
 and budgetary support.

 The interaction between state and local public health agencies in
 South Carolina 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 a state board of health.

      F.  Budget

 Total FY 1988 South Carolina SHA expenditures were $181,958,000.
 Total FY 1988 United States SHA expenditures were $8,312,928,000.
       Source of Funds
         Federal Grants and Contracts          $68,482,000
         State Funds                           $77,380,000
         Local Funds                            $2,891,000
         Fees and Reimbursements               $33,205,000
         Other                                           0
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 There is a county health center in each of the 46 counties.  In
 addition, there may be other sites within a county where
 clinic-based health services are provided.  Each county health
 department is part of a district structure.  There are two to six
 counties in a district.  Management of health services is
 provided through the district office.  The district health
 director provides direction and oversight for all activities
 within the district.  The director may or may not be a public
 health physician.  The district administrator is responsible for
 fiscal management, budget preparation and oversight, and
 personnel procedure compliance.  The district nursing director
 oversees all nursing services.  The district environmental health
 director is responsible for all environmental health programs in
 the district's counties.  At the district office are specialized
 discipline staff such as social workers, health educators, and
 nutritionists who provide services to the residents of all
 counties in a district.  In most districts is a director for the
 specific disciplines who is generally part of the district
 management staff.

 District offices are linked directly to the central office since
 the district health director reports directly to the Deputy
 Commissioner for Health Services.

      B.  Services Provided

 The following information on services provided by local health
 departments in South Carolina is derived from a survey conducted
 by NACHO during 1989.  Fourteen of the 46 local health
 departments in South Carolina 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               8   ( 57.1%)
            2.  Morbidity Data                          10   ( 71.4%)
            3.  Reportable Diseases                     12   ( 85.7%)
            4.  Vital Records and Statistics            13   ( 92.9%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        10   ( 71.4%)
            2.  Communicable Diseases                   14   (100.0%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement              4   ( 28.6%)
       B.  Health Planning                              10   ( 71.4%)
       C.  Priority Setting                              9   ( 64.3%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   13   ( 92.9%)
            2.  Health Facility Safety/Quality           7   ( 50.0%)
            3.  Rec. Facility Safety/Quality             6   ( 42.9%)
            4.  Other Facility Safety/Quality            5   ( 35.7%)

       B.  Licensing
            1.  Health Facilities                        -
            2.  Other Facilities                        12   ( 85.7%)

       C.  Health Education                             13   ( 92.9%)

       D.  Environmental
            1.  Air Quality                              5   ( 35.7%)
            2.  Hazardous Waste Management               6   ( 42.9%)
            3.  Individual Water Supply Safety          12   ( 85.7%)
            4.  Noise Pollution                          5   ( 35.7%)
            5.  Occupational Health and Safety           7   ( 50.0%)
            6.  Public Water Supply Safety               6   ( 42.9%)
            7.  Radiation Control                        5   ( 35.7%)
            8.  Sewage Disposal Systems                 14   (100.0%)
            9.  Solid Waste Management                   7   ( 50.0%)
           10.  Vector and Animal Control               14   (100.0%)
           11.  Water Pollution                          8   ( 57.1%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             14   (100.0%)
            2.  Alcohol Abuse                            1   (  7.1%)
            3.  Child Health                            14   (100.0%)
            4.  Chronic Diseases                        12   ( 85.7%)
            5.  Dental Health                            9   ( 64.3%)
            6.  Drug Abuse                               4   ( 28.6%)
            7.  Emergency Medical Service                2   ( 14.3%)
            8.  Family Planning                         14   (100.0%)
            9.  Handicapped Children                    13   ( 92.9%)
           10.  Home Health Care                        14   (100.0%)
           11.  Hospitals                                -
           12.  Immunizations                           14   (100.0%)
           13.  Laboratory Services                     11   ( 78.6%)
           14.  Long-term Care Facilities                1   (  7.1%)
           15.  Mental Health                            1   (  7.1%)
           16.  Obstetrical Care                         8   ( 57.1%)
           17.  Prenatal Care                           13   ( 92.9%)
           18.  Primary Care                             6   ( 42.9%)
           19.  Sexually Transmitted Diseases           14   (100.0%)
           20.  Tuberculosis                            14   (100.0%)
           21.  WIC                                     14   (100.0%)

       C.  Local Health Officer

 No M.D. Requirement, Assistant Commissioner Appointment

 The district health director serves as the local health officer
 for each of the counties in the district, except for one county
 which has a private physician as part-time county health
 officer.  Responsibilities of this position include the direction
 and oversight of all public health activities within the
 district.

      D.  Local Board of Health

 Advisory

 A few counties have boards of health but they are advisory in
 function.  Members may be appointed by the county governing body,
 the local legislative delegation, or may represent the local
 medical community.  Additionally, there are several district
 advisory boards of health.

      E.  Staff

 All Department staffs, whether located in the state's central
 office, in the districts, or county health departments, are
 considered state employees.  They are all subject to uniform
 policies, procedures, and benefits.  The number of staff for a
 local health department ranges from 10 to 255.

      F.  Budget

 Total FY 1988 LPHA expenditures were $76,890,000.  Total FY 1988
 United States LPHA expenditures were $3,978,948,000.

       Source of Funds
         Federal Grants and Contracts     $17,192,000
         State Funds                      $34,038,000
         Local Funds                       $2,891,000
         Fees and Reimbursements          $22,769,000
         Other Sources                              0
         Source Unknown                             0
2South Carolina Department of Health and Environmentsl Control, 199

 Board of Health and Environmental Control
 Commissioner
 Office of General Counsel
 Office of External Affairs
 Office of Assessment and Quality
 Office of Planning and Policy Development
 Office of Internal Audits
 Office of Minority Health
 Assistant to the Commissioner
 Special Medical Consultant
   Vital Records and Public Health Statistics
   Drug Control
 Deputy Commissioner for Health Regulation
 Assistant Deputy Commissioner
      Health Facilities and Services Development
      Health Facilities Regulations
      Bureau of Certification

 Deputy Commissioner for Administrative Services
      Budgets
      Business Management
      Information Resource Management
      Personnel Services

 Deputy Commissioner for Environmental Quality Control
      Assistant Deputy Commissioner
      Air Quality Control
      Analytical and Biological Services
      Solid and Hazardous Waste Management
      Drinking Water Protection
      Water Supply and Special Programs
      District Services
        Appalachia I
        Appalachia II
        Appalachia III
        Catawba
        Low Country
        Lower Savannah
        Midlands
        Pee Dee
        Trident
        Upper Savannah
        Waccamaw
        Wateree
      Program Management
      Radiological Health

 Deputy Commissioner for Health Services
      District Health Directors
        Appalachia I
        Appalachia II
        Appalachia III
        Catawba
        Low Country
        Lower Savannah
        Edisto
        East Midlands
        West Midlands
        Pee Dee I
        Pee Dee II
        Trident
        Upper Savannah
        Waccamaw
        Wateree
      Environmental Health
      Preventive Health Services
      Maternal and Child Health
      Laboratories
      Health Promotion
      Home Health and Long-Term Care
2Types of Local Health Departments by Jurisdiction
                                  South Carolina, 1990

           Jurisdiction                      Co

           Abbeville                         X
           Aiken                             X
           Allendale                         X
           Anderson                          X
           Bamberg                           X
           Barnwell                          X
           Beaufort                          X
           Berkeley                          X
           Calhoun                           X
           Charleston                        X
           Cherokee                          X
           Chester                           X
           Chesterfield                      X
           Clarendon                         X
           Colleton                          X
           Darlington                        X
           Dillon                            X
           Dorchester                        X
           Edgefield                         X
           Fairfield                         X
           Florence                          X
           Georgetown                        X
           Greenville                        X
           Greenwood                         X
           Hampton                           X
           Horry                             X
           Jasper                            X
           Kershaw                           X
           Lancaster                         X
           Laurens                           X
           Lee                               X
           Lexington                         X
           Marion                            X
           Marlboro                          X
           McCormick                         X
           Newberry                          X
           Oconee                            X
           Orangeburg                        X
           Pickens                           X
           Richland                          X
           Saluda                            X
           Spartanburg                       X
           Sumter                            X
           Union                             X
           Williamsburg                      X
           York                              X
                 Co = County HD
1SOUTH DAKOTA
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State    United States

 Population (1988)                    713,000      245,803,000
 Population Density (1988)                  9.4             69.4
   (per/sq.mi.)
 Number of Counties                        66            3,139
 Median Age (1987)                         31.0             31.7
 Percent Below Poverty Level (1985)        17.3             14.0
   (persons)
 Percent of Population Rural (1980)        54.0             26.0
 Percent of Population White (1980)        92.6             83.1
 Percent of Population Non-white (1980)     7.4             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 South Dakota Constitution and Statutes establish the
 structure of county governments and provide them with authority
 to operate.

 Commission Form - (66) - County Commission is the form of
 government used throughout the state.  The commissions are made
 of three- to five-member boards who are usually elected from
 single-member districts; however, 14 counties elect the
 commissioners at large.

      Home Rule Charter - (2) - Counties are permitted by the
      constitution to approve or amend a charter by public
      referendum.  The adoption of a home rule charter provides
      counties with authority to function in any area that is not
      prohibited by the state constitution or statutes.  Todd and
      Shannon currently are the only counties that have adopted
      home rule charters.

      City-County Consolidation - (1) - A simplified method of
      consolidation for city-counties or county-county is also
      permitted.  The consolidation of Washabaugh County into
      Jackson County in 1979 is the only consolidation that has
      taken place.

 Data for this state were updated December 1990.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The South Dakota Department of Health, the SHA, is a
 free-standing, independent agency.  The mission of the agency is
 promoting health and disease prevention to protect the health of
 South Dakotans.

 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 Secretary of Health, the head of the SHA, is a cabinet-level
 officer appointed by the Governor and confirmed by the
 legislature.  The Secretary is responsible for ensuring the
 following functions:

      1.   Promoting and protecting the health of the public by
           preventing and controlling communicable diseases

      2.   Providing a delivery system for public health services
           for the elderly, families, adolescents, mothers and
           children (including but not limited to community health
           nursing, maternal and child health programs, nutrition
           services and children's comprehensive health care)

      3.   Certifying medical facilities and insuring the sanitary
           condition of certain public establishments

      4.   Maintaining a vital records system

      5.   Performing necessary health planning to assure access
           to quality health care services

      6.   Providing public health laboratory support services

      C.  State Board of Health/Council

 No State Board of Health

      D.  Regional/District Health Offices

 The state does not have formal regions or districts.  Individual
 programs informally subdivide the state into geographical regions
 for operational and manpower distribution purposes to assure
 adequate coverage and appropriate delivery of public health
 services.  These regions, however, are informally established,
 and vary from program to program.

      E.  State-local Liaison

 Mixed Centralized and Decentralized Organizational Control,
 Informal Liaison Function

 No single individual or office has responsibility for the
 state-local liaison function.  Communication between the SHA and
 local areas often takes place at the program level.

 The interaction between state and local public health agencies in
 South Dakota 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 South Dakota SHA expenditures were $20,688,000.
 Total FY 1988 United States SHA expenditures were $8,312,928,000.

       Source of Funds
         Federal Grants and Contracts          $13,971,000
         State Funds                            $3,831,000
         Local Funds                                     0
         Fees and Reimbursements                $2,785,000
         Other                                    $101,000
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 South Dakota has seven local health departments, consisting of
 three county and four city health departments.  Any public health
 services that exist in the other areas are provided by the SHA.
 Sanitarians, usually covering multiple county areas, provide food
 protection and other services to these areas.  In addition,
 public health nurses provide basic public health care in most
 counties.
      B.  Services Provided

 The following information on services provided by local health
 departments in South Dakota is derived from a survey conducted by
 NACHO during 1989.  Six of the seven local health departments in
 South Dakota 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               1   ( 16.7%)
            2.  Morbidity Data                           1   ( 16.7%)
            3.  Reportable Diseases                      2   ( 33.3%)
            4.  Vital Records and Statistics             1   ( 16.7%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                         2   ( 33.3%)
            2.  Communicable Diseases                    3   ( 50.0%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement              2   ( 33.3%)
       B.  Health Planning                               1   ( 16.7%)
       C.  Priority Setting                              1   ( 16.7%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                    1   ( 16.7%)
            2.  Health Facility Safety/Quality           1   ( 16.7%)
            3.  Rec. Facility Safety/Quality             2   ( 33.3%)
            4.  Other Facility Safety/Quality            1   ( 16.7%)

       B.  Licensing
            1.  Health Facilities                        1   ( 16.7%)
            2.  Other Facilities                         5   ( 83.3%)

       C.  Health Education                              1   ( 16.7%)

       D.  Environmental
            1.  Air Quality                              1   ( 16.7%)
            2.  Hazardous Waste Management               1   ( 16.7%)
            3.  Individual Water Supply Safety           1   ( 16.7%)
            4.  Noise Pollution                          1   ( 16.7%)
            5.  Occupational Health and Safety           1   ( 16.7%)
            6.  Public Water Supply Safety               5   ( 83.3%)
            7.  Radiation Control                        -
            8.  Sewage Disposal Systems                  3   ( 50.0%)
            9.  Solid Waste Management                   3   ( 50.0%)
           10.  Vector and Animal Control               5   ( 83.3%)
           11.  Water Pollution                          2   ( 33.3%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling              2   ( 33.3%)
            2.  Alcohol Abuse                            1   ( 16.7%)
            3.  Child Health                             2   ( 33.3%)
            4.  Chronic Diseases                         1   ( 16.7%)
            5.  Dental Health                            -
            6.  Drug Abuse                               -
            7.  Emergency Medical Service                -
            8.  Family Planning                          2   ( 33.3%)
            9.  Handicapped Children                     1   ( 16.7%)
           10.  Home Health Care                         1   ( 16.7%)
           11.  Hospitals                                -
           12.  Immunizations                            2   ( 33.3%)
           13.  Laboratory Services                      2   ( 33.3%)
           14.  Long-term Care Facilities                -
           15.  Mental Health                            -
           16.  Obstetrical Care                         -
           17.  Prenatal Care                            -
           18.  Primary Care                             1   ( 16.7%)
           19.  Sexually Transmitted Diseases            2   ( 33.3%)
           20.  Tuberculosis                             1   ( 16.7%)
           21.  WIC                                      2   ( 33.3%)

       C.  Local Health Officer

 M.D. Requirement, Local Board of Health or Governing Body
 Appointment

 Local health officers are required to be physicians.  They are
 appointed by the local board of health or the local governing
 body if no board of health exists.  Their responsibilities
 include administering the local health department, enforcing
 state public health laws and rules and regulations, and enforcing
 local public health regulations and ordinances.

      D.  Local Board of Health

 Policy-making

 Local boards of health may be for cities, counties or multiple
 jurisdictional areas.  City boards of health consist of 21
 members appointed by the governing body.  The members represent a
 broad mix of health professionals, business leaders, and
 industrial representatives.  County boards of health are composed
 of seven members appointed by the county governing body.  Members
 include one county commissioner, a physician, and five
 individuals selected from the county electorate.  The boards are
 responsible for establishing local health regulations and
 recommending health issues to the local governing body for their
 enactment as ordinances.  Although the statutes authorize the
 appointment of boards of health, many areas of South Dakota do
 not have them.

      E.  Staff

 The staffs of local health departments are employed and
 supervised by the local jurisdictions.  The number of employees
 for a local health department ranges from 1 to 42.

      F.  Budget

 Total 1988 LPHA expenditures were not available.
2South Dakota State Department of Health, 1990

 Secretary of Health
 Office of Rural Health
   USD School of Medicine
 Office of Medical Services
 Executive Assistant
 Legal Counsel
 Support Services
 Center for Health Policy and Statistics
 Laboratory Services
 Division of Public Health
      Licensure and Certification
      Communicable Disease

 Division of Health Services
      Community Health Service
      Maternal and Child Health
      West River Community Health Center, Rapid City
      Health Education/Promotion
2Types of Local Health Departments by Jurisdiction
                                   South Dakota, 1990

           Jurisdiction                        Co     C      N/Co

           Aberdeen                                   X
           Aurora                                            X
           Beadle                                            X
           Bennett                                           X
           Bon Homme                                         X
           Brookings                                  X
           Brookings                                         X
           Brown                               X
           Brule                                             X
           Buffalo                                           X
           Butte                                             X
           Campbell                                          X
           Charles Mix                                       X
           Clark                                             X
           Clay                                              X
           Codington                                         X
           Corson                                            X
           Custer                                            X
           Davison                                           X
           Day                                               X
           Deuel                                             X
           Dewey                                             X
           Douglas                                           X
           Edmunds                                           X
           Fall River                                        X
           Faulk                                             X
           Grant                                             X
           Gregory                                           X
           Haakon                                            X
           Hamlin                                            X
           Hand                                              X
           Hanson                                            X
           Harding                                           X
           Hughes                                            X
           Huron                                      X
           Hutchinson                                        X
           Hyde                                              X
           Jackson                                           X
           Jerauld                                           X
           Jones                                             X
           Kingsbury                                         X
           Lake                                              X
           Lawrence                            X
           Lincoln                                           X
           Lyman                                             X
           Marshall                                          X
           McCook                                            X
           McPherson                                         X
           Meade                                             X
           Mellette                                          X
           Miner                                             X
           Minnehaha                                         X
           Moody                                             X
           Pennington                          X
           Perkins                                           X
           Potter                                            X
           Roberts                                           X
           Sanborn                                           X
           Shannon                                           X
           Sioux Falls                                X
           Spink                                             X
           Stanley                                           X
           Sully                                             X
           Todd                                              X
           Tripp                                             X
           Turner                                            X
           Union                                             X
           Walworth                                          X
           Yankton                                           X
           Ziebach                                           X

           Co = County HD
           C = City HD
           N/Co = No County HD
1TENNESSEE
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State    United States

 Population (1988)                  4,895,000      245,803,000
 Population Density (1988)                118.9             69.4
   (per/sq.mi.)
 Number of Counties                        95            3,139
 Median Age (1987)                         32.0             31.7
 Percent Below Poverty Level (1985)        18.1             14.0
   (persons)
 Percent of Population Rural (1980)        40.0             26.0
 Percent of Population White (1980)        83.5             83.1
 Percent of Population Non-white (1980)    16.5             16.9
 Median Years of Education (1980)          12.2             12.5
   (25 years of age and over)

      B.  County Government Structure

 Home Rule Authority

 All 95 Tennessee counties derive their powers from the state
 constitution and statutes.  They establish the legal framework
 for county governments and list the duties and powers of the
 governing bodies.  There are four different structures of
 government to choose from:  Commission, County Charter,
 City-County Consolidation, and County Manager Status.  To date,
 no counties have chosen the County Manager Status.

 Commission Form - (92) - The commission consists of a board of 9
 to 25 county commissioners, which are elected from single-member
 districts.  They serve as the county legislative body.  They have
 a county executive who is elected at large and serves as the
 administrative head of the county.

 County Charter - (1) - Shelby County is Tennessee's only charter
 county.  The county charter separates the county's legislative,
 executive, and judicial functions, as in all of Tennessee's
 counties.  A stronger elected executive, who possesses veto
 powers over commission ordinances and resolutions, is a major
 result of the charter.  A commission remains as the legislative
 body of the county and has the authority to adopt county
 ordinances.

 Data for this state were updated January 1991.
 City-county Consolidation - (2) - The state's two existing
 city-county consolidations are Nashville-Davidson County and
 Lynchburg-Moore County.  Both use a metro council as the
 legislative body and a metro executive with executive and
 administrative authority and limited veto power over metro
 council ordinances and resolutions.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The SHA in Tennessee is called the Tennessee Department of Health
 and Environment (TDHE).  It is a free-standing, independent
 agency that consists of four bureaus (see attached table of
 organization).  The SHA establishes goals and objectives for the
 state and broad guidelines for implementation by regional
 offices.  State funds are distributed to local health departments
 by at least two mechanisms.  One involves "Aid to Local Health
 Departments," whereby funds are deposited into an individual
 account for each county.  This account includes funds derived
 from fees and reimbursements, local appropriations, and other
 sources, and is used in the operation of the health departments.
 Resources may also be routed to local health departments through
 the regional offices.

 The following is a list of some areas of responsibility for the
 SHA:

      State Public Health Authority
      Medicaid Single State Agency
      Lead Environmental Agency in State
      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

      B.  Head of State Health Agency

 No M.D. Requirement, Cabinet-level Appointment

 The head of the SHA is the Commissioner of Health and
 Environment.  The Commissioner is a cabinet-level appointee who
 reports directly to the Governor.  The Commissioner is not
 required to be a physician.

 When the Commissioner is not a physician, a Chief Medical Officer
 is appointed.  This individual is selected from a group of three
 candidates who are submitted by the Tennessee Medical
 Association.  The Governor and the Commissioner of the TDHE
 select the Chief Medical Officer.  The Chief Medical Officer
 serves primarily as an advisor to the Commissioner.

      C.  State Board of Health/Council

 Advisory

 A State Public Health Council consists of 12 members appointed by
 the Governor and serves in an advisory capacity to the
 Commissioner.  The six physician members of the council are
 recommended by the Tennessee Medical Society and two appointed
 from each grand division of the state.

      D.  Regional/District Health Offices

 The state is divided into 10 administrative regions (see attached
 map), 6 of which are metro regions (Shelby County Region,
 Jackson/Madison County Region, Davidson County Region, Hamilton
 County Region, Knox County Region, and Sullivan County Region)
 and 4 of which are rural regions (West Tennessee Region, Middle
 Tennessee Region, Central Region, and East Tennessee Region).
 The metro regions are single-county regions in which regional
 functions are performed by county health department staff.  Metro
 regions have more autonomy than rural regions because a greater
 share of their budget is derived locally.  Each region has a
 regional office that is staffed by state, contract, or by county
 employees in the case of some metro regions.  The regional
 offices are responsible for addressing goals and objectives that
 are established by the state.  To accomplish this, the regions
 assess the specific needs of the counties in the region and
 assist the counties in providing services to meet the needs.
 They provide resources to counties in the form of technical
 assistance or positions funded by the region.  Regions have the
 option of pursuing additional funding through grants or other
 mechanisms that may be available.  Additionally, the regional
 office is responsible for supervising local staffs in the
 region.  The following are some of the principal positions
 included in the approximately 30-member staffs that comprise
 regional offices:

       Regional Director
       Regional Medical Director
       Regional Nursing Director
       Regional Environmental Health Director
       Regional Communicable Disease Director
       Regional Accountant
       Procurement Officer
       Personnel Officer
       Quality Assurance Director
       Systems Support -- Computer Specialist
                 Local Health Coordinator -- Liaison between local health
         departments and the regional office
       Clerical Consultant

 All the regions have community health agencies that consist of
 local people appointed by the Governor to oversee health policy
 for the region and to develop health care programs to ensure
 access to primary care centers and to private health care
 providers.  To assist with providing primary health care in rural
 areas, the Health Access Act was enacted.  This Act serves to
 promote recruitment of medical practitioners in medically
 underserved rural areas and also provides financial incentives to
 physicians who are willing to contract to work for specified
 periods in these areas.

       E.  State-Local Liaison

 Mixed Centralized and Decentralized Organizational Control,
 Informal Liaison Function

 The state does not have a formal state and local liaison office
 or function at the state level.  Communications flow through the
 chain of command.

 The interaction of state and local public health agencies in
 Tennessee may be characterized as a mixed centralized and
 decentralized organizational control.  Under this arrangement,
 local health services may be provided by the SHA in some
 jurisdictions or by local health departments in other
 jurisdictions.

       F.  Budget

 Total FY 1988 SHA expenditures (SHA expenditures listed for
 Tennessee consist of the expenditures for only one bureau, the
 Bureau of Health Services) were $178,597,000.  Total FY 1988
 United States SHA expenditures were $8,312,928,000.

        Source of Funds
          Federal Grants and Contracts      $73,514,000
          State Funds                       $77,966,000
          Local Funds                        $5,310,000
          Fees and Reimbursements           $19,466,000
          Other                              $2,341,000
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 Tennessee has 94 county health departments and one city-county
 health department.  Tremendous variation exists in the size of
 these agencies and the level of services provided.  The number of
 employees ranges from 3 to 679 and budgets range from $74,500 to
 $17,432,765.

       B.  Services Provided

 The following information on services provided by local health
 departments in Tennessee is derived from a survey conducted by
 NACHO during 1989.  Seventy-one of the 95 local health
 departments in Tennessee 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   ( 33.8%)
            2.  Morbidity Data                          45   ( 63.4%)
            3.  Reportable Diseases                     59   ( 83.1%)
            4.  Vital Records and Statistics            71   (100.0%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        39   ( 54.9%)
            2.  Communicable Diseases                   71   (100.0%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement             18   ( 25.4%)
       B.  Health Planning                              30   ( 42.3%)
       C.  Priority Setting                             25   ( 35.2%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   49   ( 69.0%)
            2.  Health Facility Safety/Quality          28   ( 39.4%)
            3.  Rec. Facility Safety/Quality            33   ( 46.5%)
            4.  Other Facility Safety/Quality           11   ( 15.5%)

       B.  Licensing
            1.  Health Facilities                       12   ( 16.9%)
            2.  Other Facilities                        30   ( 42.3%)

       C.  Health Education                             48   ( 67.6%)

       D.  Environmental
            1.  Air Quality                             34   ( 47.9%)
            2.  Hazardous Waste Management              32   ( 45.1%)
            3.  Individual Water Supply Safety          64   ( 90.1%)
            4.  Noise Pollution                          3   (  4.2%)
            5.  Occupational Health and Safety           7   (  9.9%)
            6.  Public Water Supply Safety              52   ( 73.2%)
            7.  Radiation Control                       22   ( 31.0%)
            8.  Sewage Disposal Systems                 65   ( 91.5%)
            9.  Solid Waste Management                  53   ( 74.6%)
           10.  Vector and Animal Control               46   ( 64.8%)
           11.  Water Pollution                         39   ( 54.9%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             50   ( 70.4%)
            2.  Alcohol Abuse                            5   (  7.0%)
            3.  Child Health                            69   ( 97.2%)
            4.  Chronic Diseases                        51   ( 71.8%)
            5.  Dental Health                           50   ( 70.4%)
            6.  Drug Abuse                               7   (  9.9%)
            7.  Emergency Medical Service                9   ( 12.7%)
            8.  Family Planning                         66   ( 93.0%)
            9.  Handicapped Children                    59   ( 83.1%)
           10.  Home Health Care                        43   ( 60.6%)
           11.  Hospitals                                -
           12.  Immunizations                           70   ( 98.6%)
           13.  Laboratory Services                     45   ( 63.4%)
           14.  Long-term Care Facilities                -
           15.  Mental Health                            -
           16.  Obstetrical Care                         1   (  1.4%)
           17.  Prenatal Care                           52   ( 73.2%)
           18.  Primary Care                            30   ( 42.3%)
           19.  Sexually Transmitted Diseases           69   ( 97.2%)
           20.  Tuberculosis                            69   ( 97.2%)
           21.  WIC                                     70   ( 98.6%)

       C.  Local Health Officer

 M.D. Requirement, Commission Appointment

 County health officers are appointed by the county commission but
 are usually supervised and evaluated by the regional office.  An
 exception occurs in metro regions where the health officer is
 nominated and evaluated by the board of health.  Even in this
 case, appointing authority remains with the county
 commission/metro council.  In many small counties the regional
 medical director serves as the health officer for some or all
 counties in the region and is appointed by the commission in each
 county.

       D.  Local Board of Health

 Policy-making
 The existence and composition of county boards of health are
 provided for by state law.  A county legislative body may
 establish a board of health that consists of up to 11 members.
 The board includes the county executive, two physicians nominated
 by the county medical society, one dentist nominated by the
 county dental society, one registered nurse nominated by the
 county nurses association, a pharmacist nominated by the county
 pharmaceutical society, the county superintendent of education,
 and the county health director and county health officer who
 serve as ex officio members.  The county legislative body may
 appoint a doctor of veterinary medicine and a citizen
 representative to the board.  The county legislative body may
 directly appoint any member when a nomination is not made in a
 timely manner.  The board serves a term of 4 years.  Statutes
 specify that the boards of health have the following powers and
 duties:

      1.   To govern the policies of full-time county health
           departments.

      2.   Through the county health director and/or county health
           officer, to enforce rules and regulations.

      3.   To adopt rules and regulations as may be necessary or
           appropriate to protect the general health and safety of
           the citizens of the county.

      4.   To require an annual budget be prepared and to
           present the budget to the county legislative body.

      E.  Staff

 County health department staff may be state employees, county
 employees, and/or contract employees.  The medical director
 and/or administrator is supervised by the regional office.
 Front-line supervision for other positions is usually performed
 by local health department personnel.

      F.  Budget

 Total FY 1988 LPHA expenditures were $61,755,000.  Total FY 1988
 United States LPHA expenditures were $3,978,948,000.

        Source of Funds
          Federal Grants and Contracts     $6,188,000
          State Funds                     $13,102,000
          Local Funds                     $27,068,000
          Fees and Reimbursements         $14,531,000
          Other Sources                      $867,000
2Tennessee Department of Health and Environment, 1990

 Governor
 Public Health Council
 Commissioner
 Deputy Commissioner
   Internal Audit
 Laboratory Services
 Research and Development
 Personnel
 General Counsel
 Administrative Services
 Bureau of Health Services
      Health Assessment
      Primary Care/Indigent Care
      Physician Placement
      Program Services
      Health Promotion/Disease Control
      Communicable Disease Control
      AIDS
      Community Health
      Maternal and Child Health
      Regional Offices
      Local Health Departments

 Bureau of Medicaid
      Medical Support
      Staff Support
      Systems Operations
      Policy Planning
      Regional Offices

 Bureau of Environment
      Air Pollution Control
      Radiological Health
      Food & General Sanitation
      Solid/Hazardous Waste
      Superfund
      Construction Grants & Loans
      Ground Water Protection
      Water Pollution Control
      Water Supply
      Field Offices

 Bureau of Manpower and Facilities
      Emergency Medical Services
      Health-Related Boards
      Health Care Facilities
      Field Offices
2Types of Local Health Departments by Jurisdiction
                                    Tennessee, 1990

           Jurisdiction                        Co     C/Co

           Anderson                            X
           Bedford                             X
           Benton                              X
           Bledsoe                             X
           Blount                              X
           Bradley                             X
           Campbell                            X
           Cannon                              X
           Carroll                             X
           Carter                              X
           Cheatham                            X
           Chester                             X
           Claiborne                           X
           Clay                                X
           Cocke                               X
           Coffee                              X
           Crockett                            X
           Cumberland                          X
           Davidson                                   X
           De Kalb                             X
           Decatur                             X
           Dickson                             X
           Dyer                                X
           Fayette                             X
           Fentress                            X
           Franklin                            X
           Gibson                              X
           Giles                               X
           Grainger                            X
           Greene                              X
           Grundy                              X
           Hamblen                             X
           Hamilton                            X
           Hancock                             X
           Hardeman                            X
           Hardin                              X
           Hawkins                             X
           Haywood                             X
           Henderson                           X
           Henry                               X
           Hickman                             X
           Houston                             X
           Humphreys                           X
           Jackson                             X
           Jefferson                           X
           Johnson                             X
           Knox                                X
           Lake                                X
           Lauderdale                          X
           Lawrence                            X
           Lewis                               X
           Lincoln                             X
           Loudon                              X
           Macon                               X
           Madison                             X
           Marion                              X
           Marshall                            X
           Maury                               X
           McMinn                              X
           McNairy                             X
           Meigs                               X
           Monroe                              X
           Montgomery                          X
           Moore                               X
           Morgan                              X
           Obion                               X
           Overton                             X
           Perry                               X
           Pickett                             X
           Polk                                X
           Putnam                              X
           Rhea                                X
           Roane                               X
           Robertson                           X
           Rutherford                          X
           Scott                               X
           Sequatchie                          X
           Sevier                              X
           Shelby                              X
           Smith                               X
           Stewart                             X
           Sullivan                            X
           Sumner                              X
           Tipton                              X
           Trousdale                           X
           Unicoi                              X
           Union                               X
           Van Buren                           X
           Warren                              X
           Washington                          X
           Wayne                               X
           Weakley                             X
           White                               X
           Williamson                          X
           Wilson                              X

           Co = County HD    C/Co = City/County HD
1TEXAS
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State    United States

 Population (1988)                 16,837,000      245,803,000
 Population Density (1988)                 64.2             69.4
   (per/sq.mi.)
 Number of Counties                       254            3,139
 Median Age (1987)                         29.6             31.7
 Percent Below Poverty Level (1985)        15.9             14.0
   (persons)
 Percent of Population Rural (1980)        20.0             26.0
 Percent of Population White (1980)        78.7             83.1
 Percent of Population Non-white (1980)    21.3             16.9
 Median Years of Education (1980)          12.4             12.5
   (25 years of age and over)

      B.  County Government Structure

 No Home Rule Authority

 The framework and authority for county governments in Texas are
 contained in the state constitution and statutes.

 Commissioners Court - (254) - The court made up of a county judge
 and four commissioners is the general form of county
 governments.  All 254 counties have exactly the same form of
 government, except for urban counties which may have more
 commissioners.  The commissioners are elected from individual
 commissioner precincts, and the judge is elected at large.

 Counties in Texas have limited authority and serve as an
 administrative element of the state.  The power delegated to
 counties is limited and granted for specific functions.  No
 provisions exist for home rule authority, charter, or other
 governmental structures.

 Data for this state were revised November 1990.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The Texas Department of Health (TDH), a free-standing,
 independent agency, is the SHA and is charged with protecting and
 promoting the health and well-being of the people of Texas.  The
 department's responsibilities include:

      Personal health promotion, maintenance and treatment
        services
      Infectious disease control and prevention services
      Environmental and consumer health protection services
      Laboratory services
      Health facility architectural plan review
      Public health education and information services
      Administrative 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
      Institutional Certifying Authority for Federal Reimbursement

      B.  Head of State Health Agency

 M.D. Requirement, Not Cabinet-level Appointment

 The Commissioner is the head of the SHA and the state's chief
 health officer.  The Commissioner, under the supervision of the
 State Board of Health, administers and enforces the health laws
 of the state.  Along with the staff, the Commissioner oversees
 the day-to-day administration of the Department's policies and
 programs.  The Commissioner is selected by the Texas Board of
 Health and serves at the will of the board.  By law, the
 Commissioner must be licensed to practice medicine in the state.

      C.  State Board of Health/Council

 Policy-making

 The 18 members of the State Board of Health are appointed by the
 Governor with the advice and consent of the senate.  Except for
 the public members, each must be licensed under the laws of the
 state and must have at least 5 years' experience in Texas in the
 area of specialization.  Board composition includes:

                Six physicians, one of whom specializes in the treatment of
        disabled children
      Two hospital administrators
      One dentist
      One registered nurse
      One veterinarian
      One pharmacist
      One nursing home administrator
      One optometrist
      One professional civil engineer who has specialized in the
        practice of sanitary engineering
      One chiropractor
      Two public members

 Board members serve staggered 6-year terms, with the terms of six
 members expiring February 1 of each odd-numbered year.  No later
 than September 1 of each odd-numbered year, the Governor
 designates one board member as chairman and one member as
 vice-chairman.  The board may appoint advisory committees to
 assist in performing its duties.  The board has general
 supervision and control over all matters relating to the health
 and well-being of Texas residents.

      D.  Regional/District Health Offices

 The state of Texas is divided into eight public health regions.
 These regions follow county and council of government boundaries
 and are functionally representative of the distinct geographical
 areas and demographic population groups within the state.  A
 physician director and staff for each state health department
 program are assigned to each public health region.  Within the
 eight regions are 18 regional offices.  The primary purpose of
 the public health regional offices is to provide public health
 services in the areas of the state not covered by local health
 departments.  These services include direct clinical services and
 regulatory services.  In addition, the public health regions
 serve as reference and resource centers for the local health
 departments in the respective regions.

 The staff for regions usually range from 200 to 400 employees.
 The following positions are typical of those found in regional
 offices:

      Regional Medical Director
      Assistant Regional Director for Administration
      Regional Nursing Director
      Chief Regional Engineer
      Program Managers
        Immunization
        Tuberculosis
        Sexually Transmitted Diseases
        WIC
                Clinical Nurses
      Clerical Staff
      Health Education/Promotion
      Volunteer Coordinator

 The public health regional offices are supported by state and
 Federal funds and are accountable to the SHA.

      E.  State-local Liaison

 Mixed Centralized and Decentralized Organizational Control,
 Formal Liaison Function

 The Associateship for Community and Rural Health at the THD
 serves as the state-local liaison.  All correspondence from the
 SHA to the local health departments is coordinated through the
 Associateship.  All grants, contracts, budget and activity
 reporting as well as policies and procedures are coordinated
 through the Associateship.  This Associateship also provides
 orientation and continuing education for local public health
 professionals.

 The interaction between state and local public health agencies in
 Texas 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 Texas SHA expenditures were $362,715,000.  Total FY
 1988 United States SHA expenditures were $8,312,928,000.

       Source of Funds
         Federal Grants and Contracts         $182,388,000
         State Funds                          $163,058,000
         Local Funds                                     0
         Fees and Reimbursements                $9,667,000
         Other                                  $7,601,000
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 Texas has 71 state-participating local health departments
 including 33 county, 27 city-county, 8 city, and 3 multicounty
 health departments.  The total count varies from this because
 counties with multiple cities that have merged their health
 departments are called districts.  The local units receive state
 funds in the form of contracts for services provided and
 generally provide a broad range of public health services.

 There is also a category of local health entities that provide
 public health services and are classified as Non-participating
 Units.  These units are small and usually provide only a limited
 range of services, such as environmental health.  They do not
 receive any state funds.  The exact number and location of these
 units are not available.

 The state provides public health services to local areas that do
 not have a local health department.  These services are provided
 through the regional offices.

      B.  Services Provided

 The following information on services provided by local health
 departments in Texas is derived from a survey conducted by NACHO
 during 1989.  Sixty-eight of the 71 local health departments in
 Texas 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              22   ( 32.4%)
            2.  Morbidity Data                          25   ( 36.8%)
            3.  Reportable Diseases                     59   ( 86.8%)
            4.  Vital Records and Statistics            23   ( 33.8%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        31   ( 45.6%)
            2.  Communicable Diseases                   61   ( 89.7%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement             48   ( 70.6%)
       B.  Health Planning                              37   ( 54.4%)
       C.  Priority Setting                             35   ( 51.5%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   48   ( 70.6%)
            2.  Health Facility Safety/Quality          40   ( 58.8%)
            3.  Rec. Facility Safety/Quality            32   ( 47.1%)
            4.  Other Facility Safety/Quality           23   ( 33.8%)

       B.  Licensing
            1.  Health Facilities                       19   ( 27.9%)
            2.  Other Facilities                        51   ( 75.0%)

       C.  Health Education                             45   ( 66.2%)

       D.  Environmental
            1.  Air Quality                             22   ( 32.4%)
            2.  Hazardous Waste Management              31   ( 45.6%)
            3.  Individual Water Supply Safety          55   ( 80.9%)
            4.  Noise Pollution                          8   ( 11.8%)
            5.  Occupational Health and Safety          13   ( 19.1%)
            6.  Public Water Supply Safety              44   ( 64.7%)
            7.  Radiation Control                        7   ( 10.3%)
            8.  Sewage Disposal Systems                 57   ( 83.8%)
            9.  Solid Waste Management                  31   ( 45.6%)
           10.  Vector and Animal Control               49   ( 72.1%)
           11.  Water Pollution                         40   ( 58.8%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             47   ( 69.1%)
            2.  Alcohol Abuse                            6   (  8.8%)
            3.  Child Health                            58   ( 85.3%)
            4.  Chronic Diseases                        41   ( 60.3%)
            5.  Dental Health                           31   ( 45.6%)
            6.  Drug Abuse                               4   (  5.9%)
            7.  Emergency Medical Service                7   ( 10.3%)
            8.  Family Planning                         36   ( 52.9%)
            9.  Handicapped Children                    23   ( 33.8%)
           10.  Home Health Care                         8   ( 11.8%)
           11.  Hospitals                                3   (  4.4%)
           12.  Immunizations                           65   ( 95.6%)
           13.  Laboratory Services                     40   ( 58.8%)
           14.  Long-term Care Facilities                4   (  5.9%)
           15.  Mental Health                            -
           16.  Obstetrical Care                        15   ( 22.1%)
           17.  Prenatal Care                           45   ( 66.2%)
           18.  Primary Care                            19   ( 27.9%)
           19.  Sexually Transmitted Diseases           56   ( 82.4%)
           20.  Tuberculosis                            61   ( 89.7%)
           21.  WIC                                     42   ( 61.8%)

      C.  Local Health Officer

 M.D. Requirement, Local Governing Body Appointment

 The local health authority is a physician licensed to practice
 medicine in Texas and is appointed by the official executive body
 of a county, city, or combination of cities and counties to
 provide necessary health-related advice and to enforce laws which
 protect the health of the people of that jurisdiction.  Such
 duties include but are not limited to assisting the Texas Board
 of Health in the enforcement of proper rules, regulations,
 requirements, and ordinances of local quarantine, inspection,
 disease prevention and suppression, birth and death statistics,
 general sanitation, contagious infections and dangerous epidemic
 diseases, and disaster planning in the health authority's
 jurisdiction.

 The Local Public Health Reorganization Act, however, is
 permissive; if the respective governing body chooses not to
 appoint a health authority, the Texas Board of Health or its
 designee may appoint a public health regional director to perform
 the duties of a health authority.  In a county or a city served
 by a local health department, if the director of the local health
 department is a physician licensed to practice medicine in Texas,
 the director must be formally appointed the health authority for
 that jurisdiction.  In counties not served by local health
 departments or those with non-physician directors, the physician
 serving as health authority is usually engaged full-time in the
 private practice of medicine and may or may not be remunerated
 for performing the health authority duties.

 The physician appointed to serve as health authority of a city,
 county or district must serve the executive body of the local
 jurisdiction and also the Texas Board of Health.  The health
 authority may consult with the Regional Director for guidance or
 technical assistance in performing the duties set forth in  the
 Act.

      D.  Local Board of Health

 Advisory

 The Local Public Health Reorganization Act allows for creation of
 a local advisory or administrative public health board.  An
 "advisory public health board" shall advise members and the
 directors on matters of public health.  An "administrative public
 health board" shall have the authority to adopt substantive and
 procedural rules which are necessary and appropriate to promote
 and preserve the health and safety of the public within its
 jurisdiction, provided that no rule adopted shall be in conflict
 with the laws of the state or the ordinances of any member
 municipality or county.  Again, the law is permissive and gives
 the respective executive body discretion in appointing a local
 public health board.  Current data on which local health
 departments have local public health boards are not available.

      E.  Staff

 The staffs of local health departments consist of local, state,
 and contract employees.  These individuals are supervised by the
 local jurisdiction.  The number of employees for a local health
 department ranges from 1 to 1,033.
      F.  Budget

 Total FY 1988 LPHA expenditures were $197,417,000*.  In Fy 1988
 United States LPHA expenditures were $3,978,948,000.

       Source of Funds
         Federal Grants and Contracts     $18,814,000*
         State Funds                      $20,903,000
         Local Funds                     $124,844,000*
         Fees and Reimbursements              $51,000
         Other Sources                       $698,000*
         Source Unknown                   $32,107,000*

 * The SHA reported that these figures were estimated.
2Texas Department of Health, 1990

 Governor
 Board of Health
 Commissioner of Health
   Office of General Counsel
   Office of the Board of Health
   Internal Audit
 Deputy Commissioner
   Public Health Promotion Division
   Bureau of State Health Data and Policy Analysis
 Assistant Deputy Commissioner for Administration
      Bureau of Personnel Management
      Bureau of Automated Data Services
      Bureau of Support Services

 Associate Commissioner for Special Health Services
      Bureau of Long-Term Care
      Bureau of Vital Statistics
      Bureau of Licensing and Certification

 Associate Commissioner for Family Health Services
      Bureau of Maternal and Child Health
      Bureau of Women, Infants and Children's Nutrition
      Bureau of Chronically Ill and Disabled Children's Services

 Associate Commissioner for Disease Prevention
      Bureau of Disease Control and Epidemiology
      Bureau of HIV and STD Control Protection
      Bureau of Dental and Chronic Disease Prevention
      Bureau of Laboratories

 Associate Commissioner for Environmental and Consumer Health
   Protection
      Bureau of Radiation Control
      Bureau of Consumer Health Protection
      Bureau of Environmental Health
      Bureau of Solid Waste Management
      Bureau of Veterinary Public Health

 Associate Commissioner for Community and Rural Health
      Bureau of Community Health Services and Administration
      Bureau of Emergency Management
      Public Health Regions
2Types of Local Health Departments by Jurisdiction
                                      Texas, 1990

           Jurisdiction                 Co     C      C/Co   M/Co   N/Co

           Abilene-Taylor                             X
           Anderson                                                 X
           Andrews City Co                            X
           Angelina City C                            X
           Aransas                                                  X
           Archer                                                   X
           Armstrong                                                X
           Atascosa                     X                           X
           Austin-Travis C                            X
           Baily                                                    X
           Bandera                      X
           Bastrop                                                  X
           Baylor                                                   X
           Beaumont                            X
           Bee                                                      X
           Bell Dist                                  X
           Big Spring-Howa                            X
           Blanco                                                   X
           Borden                                                   X
           Bosque                                                   X
           Brazoria                     X
           Brazos                       X
           Brewster                                                 X
           Briscoe                                                  X
           Brooks                                                   X
           Brownwood-Brown                            X
           Burleson                                                 X
           Burnett                                                  X
           Caldwell                                                 X
           Calhoun                      X
           Callahan                                                 X
           Cameron                      X
           Camp                                                     X
           Carson                                                   X
           Cass                         X
           Castro                                                   X
           Cherokee                     X
           Childress                                                X
           Clay                                                     X
           Cochran                                                  X
           Coke                                                     X
           Coleman                                                  X
           Collin                       X
           Collingsworth                                            X
           Colorado                                                 X
           Comal                                                    X
           Comanche                                                 X
           Concho                                                   X
           Cooke                                                    X
           Corpus Christi-                            X
           Corsicana-Navar                            X
           Coryell                                                  X
           Cottle                                                   X
           Crane                                                    X
           Crockett                                                 X
           Crosby                                                   X
           Cuero-Dewitt                               X
           Culberson                                                X
           Dallam                                                   X
           Dallas                       X
           Dallas                              X
           Dawson                                                   X
           Deaf Smith                                               X
           Del Rio-Val Ver                            X
           Delta                                                    X
           Denton                       X
           Dickens                                                  X
           Dimmit                       X
           Donley                                                   X
           Duval                                                    X
           Eastland                                                 X
           Ector                        X
           Edwards                                                  X
           El Paso City Co                            X
           Ellis                                                    X
           Erath                                                    X
           Falls                                                    X
           Fannin                                                   X
           Fayette                                                  X
           Fisher                                                   X
           Floyd                                                    X
           Foard                                                    X
           Fort Bend                    X
           Fort Worth                          X
           Franklin                                                 X
           Freestone                                                X
           Frio                                                     X
           Gaines                                            X
           Galveston                    X
           Garza                                                    X
           Gillespie                                                X
           Glasscock                                                X
           Gollad                                                   X
           Gonzales                                                 X
           Gray                                                     X
           Grayson                      X
           Greenville-Hunt                            X
           Gregg                                                    X
           Grimes                                                   X
           Guadalupe                                                X
           Hall                                                     X
           Hamilton                                                 X
           Hansford                                                 X
           Hardeman                                                 X
           Hardin                       X
           Harris                       X
           Hartley                                                  X
           Haskell                                                  X
           Hemphill                                                 X
           Henderson                                                X
           Hidalgo                                                  X
           Hill                                                     X
           Hockley                                           X
           Hood                                                     X
           Hopkins                                                  X
           Houston                                                  X
           Houston                             X
           Hudspeth                                                 X
           Hutchinson                                               X
           Irion                                                    X
           Jack                                                     X
           Jackson                      X
           Jasper                                            X
           Jeff Davis                                               X
           Jefferson                    X
           Jim Hogg                                                 X
           Jim Wells                                                X
           Johnson                                                  X
           Jones                                                    X
           Karnes                                                   X
           Kaufman                                                  X
           Kendall                                                  X
           Kenedy                                                   X
           Kent                                                     X
           Kerr                                                     X
           Kimble                                                   X
           King                                                     X
           Kinney                                                   X
           Kleberg                                                  X
           Knox                                                     X
           LaSalle                                                  X
           Lamb                                                     X
           Lampasas                                                 X
           Lavaca                                                   X
           Lee                                                      X
           Leon                                                     X
           Liberty                                                  X
           Limestone                                                X
           Lipscomb                                                 X
           Live Oak                     X
           Llano                                                    X
           Loredo                                                   X
           Loving                                                   X
           Lubbock                             X
           Lubbock                                                  X
           Lynn                                                     X
           Madison                                                  X
           Marion                                                   X
           Marshall-Harris                            X
           Martin                                                   X
           Mason                                                    X
           Matagorda                    X
           Maverick                     X
           McCulloch                                                X
           McMullen                                                 X
           Medina                       X
           Menard                                                   X
           Midland                             X
           Midland                                                  X
           Milam                        X
           Mills                                                    X
           Mitchell                                                 X
           Montague                                                 X
           Montgomery                   X
           Moore                                                    X
           Morris                                                   X
           Motley                                                   X
           Nacogdoches                                              X
           Navarro                      X
           Newton                                            X
           Ochiltree                                                X
           Oldham                                                   X
           Orange                       X
           Palo Pinto                                               X
           Panola                                                   X
           Paris- Lamar Co                            X
           Parker                                                   X
           Parmer                                                   X
           Pecos                                                    X
           Plainview-Hale                             X
           Polk                                                     X
           Port Arthur                         X
           Potter                                            X
           Presidio                                                 X
           Rains                                                    X
           Randall                                           X
           Reagan                                                   X
           Real                                                     X
           Red River                                                X
           Reeves                                                   X
           Refugio                                                  X
           Roberts                                                  X
           Robertson                                                X
           Rockwall                                                 X
           Runnels                                                  X
           Rusk                                                     X
           Sabine                                                   X
           San Angelo-Tom                             X
           San Angustine                                            X
           San Antonio-Bex                            X
           San Jacinto                  X
           San Marcos-Hays                            X
           San Patricio                 X
           San Saba                                                 X
           Schleicher                                               X
           Scurry                       X
           Shelby                                                   X
           Sherman                                                  X
           Skackelford                                              X
           Somervell                                                X
           Starr                                                    X
           Stephens                                                 X
           Sterling                                                 X
           Stonewall                                                X
           Sutton                                                   X
           Sweetwater-Nola                            X
           Swisher                                                  X
           Tarrant                      X
           Terrell                                                  X
           Terry                                             X
           Texarkana-Bowie                            X
           Throckmorton                                             X
           Titus                                                    X
           Trinity                                                  X
           Tyler                                                    X
           Tyler-Smith Co                             X
           Upshur                                                   X
           Upton                                                    X
           Uvalde City Co                             X
           Van Zandt                                                X
           Victoria                     X
           Waco McLennan C                            X
           Walker                                                   X
           Waller                                                   X
           Ward                                                     X
           Washington                                               X
           Webb                                                     X
           Wharton                                                  X
           Wheeler                                                  X
           Wichita Falls C                            X
           Wilbarger                                                X
           Willacy                                                  X
           Williamson Dist                            X
           Wilson                       X
           Winkler                                                  X
           Wise                                                     X
           Wood                         X
           Yoakum                                            X
           Young                                                    X
           Zapata                                                   X
           Zavala                       X
1UTAH
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State    United States

 Population (1988)                  1,690,000      245,803,000
 Population Density (1988)                 20.9             69.4
   (per/sq.mi.)
 Number of Counties                        29            3,139
 Median Age (1987)                         25.5             31.7
 Percent Below Poverty Level (1985)        11.1             14.0
   (persons)
 Percent of Population Rural (1980)        16.0             26.0
 Percent of Population White (1980)        94.6             83.1
 Percent of Population Non-white (1980)     5.4             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 structure and authority for county governments are
 established by the Utah Constitution and Code.

 Commission Form - (28) - At the present time, all counties except
 Cache use this form of government.  With the Commission Form,
 counties use three-member boards of commissioners who are elected
 from single-member districts, at large, or a combination.  They
 serve as the administrative and legislative bodies for the
 county.

 General County Plan - (1) - Cache County functions under the
 General County Plan which provides for a county council that is
 the governing body.  An elected executive is mandated under this
 plan.

 Many other options as to the form of county government and their
 management plans are available to Utah counties, but none has
 been adopted at the present time.

 Data for this state were updated November 1990.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The Utah Department of Health (UDH), the SHA, is a free-standing,
 independent agency.  Its mission is (1) to protect the public's
 health through preventing illness, injury, disability, and
 premature death; assuring access to affordable, quality health
 care; and promoting healthy lifestyles; and (2) to protect the
 environment through preventing or reducing pollution to
 environmentally safe levels.

 The following are some areas of responsibility for the SHA:

      State Public Health Agency
      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

 M.D. Requirement, Cabinet-level Appointment

 The chief administrative officer of the UDH, the Executive
 Director, is appointed by the Governor with the advice and
 consent of the Senate.  The Executive Director serves at the
 pleasure of the Governor.  The Executive Director is required to
 be a physician who is licensed to practice medicine and surgery
 in the state.  In addition, the candidate is required to have 1
 year's graduate work in a recognized school of public health or
 its equivalent and have at least 5 years' professional full-time
 experience, of which at least 3 must have been in public health
 administration.

 The Executive Director has the following powers and
 responsibilities:  to enforce state laws and rules established by
 the Department; to amend, modify, or rescind committee rules; to
 order abatement of public health hazards; to organize the
 Department; to accept Federal aid; to accept funds and gifts; and
 to prescribe rules for administration and government of the
 Department.

 * The Governor has proposed a new Department of Environmental
 Quality.

      C.  State Board of Health/Council

 Advisory

 Utah has a seven-member Health Advisory Council which is
 appointed by the Governor with the advice and consent of the
 Senate.  The membership must be broadly representative of the
 public interest and will be selected with due regard to their
 interest in or knowledge of public health, environmental health,
 health planning, health care financing or health care delivery
 systems.  The Council must include health professionals, but the
 majority of the membership must be non-health professionals.  No
 more than four persons can be from the same political party, and
 consideration for membership must take into account balance in
 terms of geography, sex, and ethnicity.  Council members are
 appointed to 4-year staggered terms.

 The Council is responsible for advising the Department on any
 subject deemed to be appropriate by the Council except that the
 Council cannot become involved in administrative matters.  The
 Council is directed to advise the Department as requested by the
 executive director.  Quarterly Council meetings are required, and
 additional meetings may be held if considered necessary by the
 chairman.

      D.  Regional/District Health Offices

 The UDH has not divided the state into administrative regions or
 districts.

      E.  State-local Liaison

 Decentralized Organizational Control, Formal Liaison Function

 The UDH has designated the Office of Local and Rural Health
 Systems as its liaison unit for general, non-programmatic
 communications with local health departments.  The Office
 provides a variety of technical assistance ranging from needs
 assessment to facilitating the purchase of liability insurance to
 quality assurance.  It administers $1,416,674 in Federal and
 state funds as block grant contracts to local health
 departments.  It advocates for local health departments within
 the UDH, and among policy makers such as state legislators.  The
 Office arranges two UDH meetings with local health departments
 each year, in addition to providing considerable support for
 quarterly meetings of the Utah Association of Local Health
 Officers, the Local Community Health Nursing Directors
 Association, and the Conference of Local Environmental Health
 Administrators.  It also maintains a limited amount of data on
 each local health department, such as financial expenditures and
 services provided.

 The interaction of state and local public health agencies in Utah
 may be characterized as decentralized organizational control.
 Under this arrangement, local governments are responsible for
 creating health departments with appointed local boards of
 health.

      F.  Budget

 Total FY 1988 SHA expenditures were $58,012,000.  Total FY 1988
 United States SHA expenditures were $8,312,928,000.

       Source of Funds
         Federal Grants and Contracts          $37,315,000
         State Funds                           $15,194,000
         Local Funds                                     0
         Fees and Reimbursements                $5,481,000
         Other                                     $23,000
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 Utah has 12 local health departments, 6 of which are city/county
 (single county) and 6 multicounty (district).  Local health
 departments are legally separate and autonomous from the UDH.
 The UDH has over 200 contracts each year with the local health
 departments to support their provision of public health
 services.  Some of the contracts are categorical for specific
 programs while others are block grants.  Matching local funds
 (currently at 40 percent rate) are required for eligibility for
 these funds.  The local health departments must also meet minimum
 standards of performance that are promulgated by the UDH.

      B.  Services Provided

 The following information on services provided by local health
 departments in Utah is derived from a survey conducted by NACHO
 during 1989.  Eleven of the 12 local health departments in Utah
 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               6   ( 54.5%)
            2.  Morbidity Data                           5   ( 45.5%)
            3.  Reportable Diseases                      6   ( 54.5%)
            4.  Vital Records and Statistics             7   ( 63.6%)
       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                         8   ( 72.7%)
            2.  Communicable Diseases                    9   ( 81.8%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement              8   ( 72.7%)
       B.  Health Planning                              10   ( 90.9%)
       C.  Priority Setting                             11   (100.0%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   10   ( 90.9%)
            2.  Health Facility Safety/Quality           7   ( 63.6%)
            3.  Rec. Facility Safety/Quality            11   (100.0%)
            4.  Other Facility Safety/Quality            5   ( 45.5%)

       B.  Licensing
            1.  Health Facilities                        1   (  9.1%)
            2.  Other Facilities                         9   ( 81.8%)

       C.  Health Education                             11   (100.0%)

       D.  Environmental
            1.  Air Quality                              9   ( 81.8%)
            2.  Hazardous Waste Management               6   ( 54.5%)
            3.  Individual Water Supply Safety          11   (100.0%)
            4.  Noise Pollution                          2   ( 18.2%)
            5.  Occupational Health and Safety           2   ( 18.2%)
            6.  Public Water Supply Safety              11   (100.0%)
            7.  Radiation Control                        5   ( 45.5%)
            8.  Sewage Disposal Systems                 10   ( 90.9%)
            9.  Solid Waste Management                   9   ( 81.8%)
           10.  Vector and Animal Control               10   ( 90.9%)
           11.  Water Pollution                         11   (100.0%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling              8   ( 72.7%)
            2.  Alcohol Abuse                            1   (  9.1%)
            3.  Child Health                            11   (100.0%)
            4.  Chronic Diseases                        11   (100.0%)
            5.  Dental Health                           10   ( 90.9%)
            6.  Drug Abuse                               2   ( 18.2%)
            7.  Emergency Medical Service                5   ( 45.5%)
            8.  Family Planning                          9   ( 81.8%)
            9.  Handicapped Children                     8   ( 72.7%)
           10.  Home Health Care                         2   ( 18.2%)
           11.  Hospitals                                -
           12.  Immunizations                           11   (100.0%)
           13.  Laboratory Services                      6   ( 54.5%)
           14.  Long-term Care Facilities                -
           15.  Mental Health                            1   (  9.1%)
           16.  Obstetrical Care                         2   ( 18.2%)
           17.  Prenatal Care                           11   (100.0%)
           18.  Primary Care                             5   ( 45.5%)
           19.  Sexually Transmitted Diseases           11   (100.0%)
           20.  Tuberculosis                             9   ( 81.8%)
           21.  WIC                                     11   (100.0%)

      C.  Local Health Officer

 M.D. Requirement When Population over 100,000, Local Board of
 Health Appointment

 The local health officer is appointed by the local board of
 health.  Local health officers are required to be medical doctors
 unless the population of the jurisdiction is under 100,000.  The
 role of the local health officer for each of the 12 local health
 departments is to provide overall direction for the local public
 health programs.  Supervision of the local health officer is
 performed by the local board of health.

      D.  Local Board of Health

 Policy-making

 The local board of health is appointed by the county
 commissioners and sometimes municipal officials.  One or more of
 the county commissioners usually serve on these boards.  The
 health officer may serve as secretary to the board.  The number
 of members must be at least five, but the maximum number is not
 specified in the law.  The function of the local board of health
 is to provide policy direction to the local health department.

      E.  Staff

 The staffs of local health departments are employed by the local
 health officer.  The number of staff for individual local health
 departments ranges from 4 to 220.

      F.  Budget

 Total FY 1988 LPHA expenditures were $33,447,000.  Total FY 1988
 United States LPHA expenditures were $3,978,948,000.

      Source of Funds
        Federal Grants and Contracts     $14,204,000
        State Funds                       $1,800,000
        Local Funds                       $8,500,000
        Fees and Reimbursements           $8,430,000
        Other Sources                              0
        Source Unknown                             0

 The SHA reported that these figures include the total amount of
 additional local health department monies expended by all local
 health departments.
2Utah Department of Health, 1990

 Governor
 Executive Director
   Health Advisory Council
     Ethnic Minority Health Commission
 Public Information
 Governmental and Community Allocations
 Local and Rural Health Systems
   Rural/Health Advisory Commission
 Division of Health Care Financing
      Facility Manager
      Policy and Planning
      Financial Services
      Medicaid and Mgmt. Info. System Operations
      Utah Medical Assistance Program Planning
      Manager Health Care

 Division of Environmental Health
      Solid and Hazardous Waste
        Solid and Hazardous Waste Comm.
      Drinking & Water Sanitation
        Safe Drinking Water Comm.
      Radiation Control
        Radiation Technical Advisory Comm.
      Water Pollution Control
        Water Pollution Control Comm.
      Air Quality
        Air Quality Comm.

 Office of the Medical Examiner
   Medical Examiner Advisory Comm.

 Deputy Director
   Assistant Director Financial Services
     Finance
     Financial Audit
     General Services
   Assistant Director Administrative Services
     Organizational Development and Evaluation
     Vital Records and Health Statistics
     Budget
     Human Resource Management
     EDP and Systems
 State Health Laboratory
      Environmental Chemistry and Toxicology
      Laboratory Improvement
      Microbiology

 Division of Community Health Services
      Epidemiology
        AIDS Advisory Comm.
      Health Facility Licensure
        Health Facility Comm.
      Chronic Disease
      Health Promotion and Risk Reduction
      Emergency Medical Services
        Emergency Medical Services Comm.

 Division of Family Health Service
      Child Health
      Dental Health
      Children's Special Health Services
        Interagency Coordinating Council for Infants and Toddlers
      Communicative Disorders
      Maternal and Infant Health
      WIC Services
        WIC Advisory Council
2Types of Local Health Departments by Jurisdiction
                                       Utah, 1990

           Jurisdiction                        C/Co   M/Co

           Beaver                                     X
           Bountiful-Davis Co                  X
           Box Elder                                  X
           Cache                                      X
           Carbon                                     X
           Daggett                                    X
           Duchesne                                   X
           Emory                                      X
           Garfield                                   X
           Grand                                      X
           Heber-Wasatch Co                    X
           Iron                                       X
           Juab                                       X
           Kane                                       X
           Millard                                    X
           Morgan                                     X
           Park City-Summit Co                 X
           Piute                                      X
           Provo-Utah Co                       X
           Rich                                       X
           Salt Lake C/Co                      X
           San Juan                                   X
           Sanpete                                    X
           Sevier                                     X
           Tooele C/Co                         X
           Uintah                                     X
           Washington                                 X
           Wayne                                      X
           Weber                                      X

           C/Co = City/County HD
           M/Co = Multicounty HD
1VERMONT
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State    United States

 Population (1988)                    557,000      245,803,000
 Population Density (1988)                 60.1             69.4
   (per/sq.mi.)
 Number of Counties                        14            3,139
 Median Age (1987)                         31.1             31.7
 Percent Below Poverty Level (1985)         9.2             14.0
   (persons)
 Percent of Population Rural (1980)        66.0             26.0
 Percent of Population White (1980)        99.1             83.1
 Percent of Population Non-white (1980)      .9             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

 The Vermont Constitution and Statutes empower and establish the
 legal framework for counties.  Counties operate under a County
 Court System.  The officers of this form of government consist of
 a Superior Judge who is appointed by the Governor and assistant
 judges of the Superior Court who are elected at large.  The
 assistant judges provide the principal management function for
 the county.

 State statutes require counties to provide and own a courthouse
 to be used only as chambers for a justice of the Supreme Court
 and for the Superior Judge and Superior Court.  It is also
 available to the probate court and district court.

 Counties are granted authority to acquire and own land, condemn
 land, assess taxes to support legitimate functions, and collect
 rent on leased property.

 There are no provisions in Vermont for home rule authority,
 county administrators, or optional forms of government.

 Data for this state were updated January 1991.
3II.  State Health Agency (SHA)

      A.  General

 Component of Superagency

 The SHA is the Vermont Department of Health (VDH), which is a
 component of a superagency called the Agency of Human Services.
 The purpose of the agency is to provide services to citizens and
 communities throughout the state to prevent illness and control
 or eliminate hazards to the public.

 The following are some specific program areas for which the SHA
 has responsibility:

      Title V (Maternal and Child Health) - all of it
      WIC
      Title X
      Nutrition (surveillance, nutrition education/training, and
        grant consultation)
      Early Periodic Screening, Diagnosis and Testing (outreach,
        education, and case management only)
      Refugee Health
      Emergency Medical Services
      Epidemiology (communicable disease, immunizations, chronic
        disease, and health promotion)
      Environmental Health
      Dental Health
      Chief Medical Examiner
      Public Health Statistics and Vital Records (includes
        hospital discharge data) - policy, planning, and
        evaluation
      Laboratory
      Occupational and Radiological Health

 The following are broad areas of responsibility for the SHA:

      State Public Health Authority
      Title V including Children With Special Health Care Needs
      Institutional Licensing Agency
      Institutional Certifying Authority for Federal Reimbursement

      B.  Head of State Health Agency

 M.D. Requirement, Cabinet-level Appointment

 The Commissioner of Health, the head of the SHA, is appointed by
 the Secretary of the Agency for Human Services and by statutory
 requirement must be a physician.

 The responsibilities of the Commissioner include the delegation
 of power and assignment of duties as appropriate.  The
 Commissioner is also responsible for conducting investigations
 when information indicates possible public health hazards and may
 determine when a public health risk or hazard is a state or local
 problem.

      C.  State Board of Health/Council

 Advisory

 Vermont has a seven-member State Board of Health appointed by the
 Governor.  The board is composed of three physicians, one
 dentist, and three lay persons.  The members are appointed for a
 term of 6 years.  The board functions in an advisory capacity to
 the Commissioner.

      D.  Regional/District Health Offices

 Vermont has not divided the state into solely administrative
 districts or regions.  The 12 districts that exist are both
 administrative and service delivery units for the VDH.

      E.  State-local Liaison

 Centralized Organizational Control, Formal Liaison Function

 The Director of the Division of Local Health is the focus of
 communications between the SHA and the district offices.  The
 Director is also in the chain of command with line authority over
 the district offices.

 The interaction between state and local health agencies in
 Vermont 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 a state board of health.

      F.  Budget

 Total FY 1988 SHA expenditures were $21,655,000.  Total FY 1988
 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts          $12,378,000
        State Funds                            $8,785,000
        Local Funds                                     0
        Fees and Reimbursements                  $304,000
        Other                                    $197,000
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 Vermont has no autonomous local health departments.  The local
 units are part of the SHA.  The 12 district offices provide
 services to local areas and perform many of the same basic
 functions as local health departments in other states.  The
 districts are composed of several towns (multitown areas) units
 and have no relationship to county governments.

      B.  Services Provided

 The following are services provided by all 12 of the districts
 (information provided by VDH).  Services provided by at least 70
 percent of the health departments in the state are underlined.

 Services Provided by LPHAs                       Number and Percent

   I.  Assessment Activities
       A.  Data Collection/Analysis
            1.  Behavioral Risk Assessment              12   (100.0%)
            2.  Morbidity Data                          12   (100.0%)
            3.  Reportable Diseases                     12   (100.0%)
            4.  Vital Records and Statistics             -

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                         -
            2.  Communicable Diseases                   12   (100.0%)

  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                   12   (100.0%)
            2.  Health Facility Safety/Quality           -
            3.  Rec. Facility Safety/Quality             -
            4.  Other Facility Safety/Quality           12   (100.0%)

       B.  Licensing
            1.  Health Facilities                        -
            2.  Other Facilities                        12   (100.0%)

       C.  Health Education                             12   (100.0%)

       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              12    (100.0%)
            7.  Radiation Control                        -
            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              -
            2.  Alcohol Abuse                            -
            3.  Child Health                            12   (100.0%)
            4.  Chronic Diseases                        12   (100.0%)
            5.  Dental Health                            -
            6.  Drug Abuse                               -
            7.  Emergency Medical Service                -
            8.  Family Planning                         12   (100.0%)
            9.  Handicapped Children                    12   (100.0%)
           10.  Home Health Care                         -
           11.  Hospitals                                -
           12.  Immunizations                           12   (100.0%)
           13.  Laboratory Services                      -
           14.  Long-term Care Facilities                -
           15.  Mental Health                            -
           16.  Obstetrical Care                         -
           17.  Prenatal Care *                         12   (100.0%)
           18.  Primary Care                             -
           19.  Sexually Transmitted Diseases            -
           20.  Tuberculosis                             -
           21.  WIC                                     12   (100.0)

       C.  Local Health Officer

 No M.D. Requirement, Board of Health Appointment

 State law in Vermont designates the health officer as the town
 official who is responsible for public health problems in their
 town.  Health officers have the power of the Vermont Commissioner
 of Health in their town(s) of jurisdiction.  A health officer is
 an agent of the VDH and has authority to enforce any state health
 regulations in his/her town.  The health officer relates to the
 VDH district office for technical assistance, support, and
 training.  The health officer will also relate to the VDH central
 office consultants, depending on the issue.

 * Public health nursing and nutritional counseling
      D.  Local Board of Health

 Policy-making

 Each of the 251 towns in Vermont has it own local board of health
 which is usually the town Board of Selectpersons.  The board of
 health is responsible for appointing the town health officer.

      E.  Staff

 All personnel are either employed or contracted by the state.
 The district units have on average 12 employees in each unit.  A
 typical region would have a District Manager, four nurses, a
 nutritionist, two health educators, two to three clerks, one
 dental hygienist, and one sanitarian.

      F.  Budget

 There are no local sources of funding.
2Vermont Department of Health, 1990

 Commissioner
 Emergency Medical Services Division
 Epidemiology Health Promotion and Chronic Disease Division
 Administration Division
 Public Health Policy and Analysis Division
 Dental Division
 Occupational and Radiological Health Division
 Chief Medical Examiner Division
 Environmental Health Division
 Programs for Children with Special Health Needs Division
 Public Health Laboratory Division
 Local Health
      Chief of Operations
      District Manager (12)
      Local Health District Staff
2Types of Local Health Departments by Jurisdiction
                                     Vermont, 1990

           Jurisdiction                               N/Co   M/T

           Addison                                    X
           Barre                                             X
           Bennington                                 X
           Bennington                                        X
           Brattleboro                                       X
           Burlington                                        X
           Caledonia                                  X
           Chittenden                                 X
           Essex                                      X
           Franklin                                   X
           Grand Isle                                 X
           Lamoille                                   X
           Middlebury                                        X
           Morrisville                                       X
           Newport                                           X
           Orange                                     X
           Orleans                                    X
           Rutland                                    X
           Rutland                                           X
           Springfield                                       X
           St. Albans                                        X
           St. Johnsbury                                     X
           Washington                                 X
           White River Junctio                               X
           Windham                                    X
           Windsor                                    X

           N/Co = No County HD
           M/T = Multitownship HD
1VIRGINIA
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State      United States

 Population (1988)                  6,015,000        245,803,000
 Population Density (1988)                151.5               69.4
   (per/sq.mi.)
 Number of Counties *                      95              3,139
 Median Age (1987)                         31.8               31.7
 Percent Below Poverty Level (1985)        10.0               14.0
   (persons)
 Percent of Population Rural (1980)        34.0               26.0
 Percent of Population White (1980)        79.1               83.1
 Percent of Population Non-White (1980)    20.9               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 authority for county governments in Virginia
 are established by the state constitution and code.  Counties may
 choose one of six different forms of government:  Traditional,
 County Board, County Executive, County Manager, Urban County
 Manager, and Urban County Executive.

 Traditional Form - (85) - This form has a board made up of 3 to
 11 supervisors who are elected from single-member districts, at
 large, or by a combination of methods.  Eighty-two of these
 counties have a board-appointed administrator.  In the other two
 counties the board serves as the legislative and administrative
 body.

 County Administrator Form - (3) - This form is used in Carroll,
 Russell, and Scott Counties where the board appoints a county
 administrator who also serves as the county purchasing agent.

 County Executive Plan - (2) - In Albemarle and Prince William
 Counties which use this plan, the county executive is appointed

 * Virginia has 95 counties and 41 independent cities, which total
 136 separate areas.

 Data for this state were updated January 1991. by the board and
 responsible for administering all affairs under the board's control.

 County Manager Form - (1) - Henrico County operates with this
 plan and uses a board that appoints a county manager.

 Urban County Executive Form - (1) - The Urban County Executive
 Form is patterned after the County Executive but expands the
 board's authority in certain areas and permits the board to
 appoint an executive officer.

 Urban County Manager Form - (1) - This form operates with a
 board-appointed county manager who is quite similar to the County
 Executive, except that the position has more authority to appoint
 employees in administrative services.

 Charter Form - (2) - Chesterfield and Roanoke counties operate
 under the Traditional Form of government and also have a county
 charter.  Although they have a charter, there is no home rule
 authority, and most local decisions require approval by the
 General Assembly.  These counties operate with boards of
 supervisors and appointed administrators.

 City-county Consolidation - (5) - The following city-county
 consolidations are known as cities:  Hampton-Elizabeth
 City-County is known as the City of Hampton; Virginia
 Beach-Princess Anne County is known as the City of Virginia
 Beach; South Norfolk-Norfolk County is known as the City of
 Chesapeake; Warwick City-Newport News County is known as the City
 of Newport News; and Suffolk-Nansemond County is known as the
 City of Suffolk.  In addition to these consolidations, all cities
 of the first class make up a type of government known as
 independent cities, of which Virginia has 41.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The State Health Agency is the Virginia Department of Health
 (VDH).  It is a free-standing, independent agency (see attached
 table of organization).  The Code of Virginia states, "the State
 Board of Health and the State Health Commissioner, assisted by
 the State Department of Health, shall administer and provide a
 comprehensive program of preventive, curative, restorative and
 environmental health services, educate the citizens in health and
 environmental matters, develop and implement health resource
 plans, collect and preserve vital records and health statistics,
 assist in research, and abate hazards and nuisances to the health
 and to the environment, both emergency and otherwise, and thereby
 improve the quality of life in the commonwealth."

 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 Health Planning and Development Agency

      B.  Head of State Health Agency

 M.D. Requirement, Cabinet-level Appointment

 The Commissioner of Health, the head of the SHA, is appointed by
 the Governor and confirmed by each house of the General
 Assembly.  The Commissioner must be a physician licensed to
 practice medicine in this state, be certified by the American
 Board of Preventive Medicine, experienced in public health
 duties, sanitary science and environmental health, and otherwise
 qualified to execute the duties incumbent on him/her by law.

      C.  State Board of Health/Council

 Policy-making

 The State Board of Health consists of 11 residents of Virginia
 appointed by the Governor for terms of 4 years each.  Two members
 of the Board are members of the Medical Society of Virginia, one
 member is a member of the Virginia Pharmaceutical Association,
 one member is a member of the State Dental Association, one
 member is a member of the Virginia Nurses' Association, one
 member is a member of the Virginia Veterinary Association, one
 member is a representative of local government, one member is a
 representative of the hospital industry, one member is a
 representative of the nursing home industry, and two members are
 consumers with expertise in health care policy, analysis, and
 financing.  A vacancy, other than expiration of term, is filled
 by the Governor for the unexpired term.  The responsibility of
 the board includes:  making policy, promulgating regulations for
 operation of the department's program; licensing of certain
 health professions and facilities; protecting environmental
 health standards.

      D.  Regional/District Health Offices

 The state is divided into four regions each directed by a
 physician (see attached map).  The regions are further divided
 into 36 districts, each directed by a physician.  Each locality,
 cities and counties, is served by a local health department.
 The following positions are common to regional offices:
                Director
      Administrator
      Sanitarian
      Nurse Manager
      Nutritionist
      Program Representatives
        STD
        AIDS
        Immunization
        TB
        WIC
      Secretary
      Several Clerks

 The regional staff usually function as consultants, providing
 support to the health departments in the region.  They may be
 involved in program evaluation but not usually in evaluating or
 supervising the performance of staff.  The Regional Director is
 responsible for supervising and evaluating the performance of the
 district medical directors in the region.

       E.  State-local Liaison

 Centralized Organizational Control, Formal Liaison Function

 The Deputy Commissioner for Community Health Services functions
 as the state-local liaison.  He is responsible for the day-to-day
 operations of the regional, district and local health
 departments.  Information flows up and down this chain of
 command.

 The state and LPHA interaction in Virginia may be characterized
 as centralized organizational control.  Under this system, local
 health departments function directly under the state's authority
 and are operated by the SHA or a state board of health.

       F.  Budget

 Total FY 1988 SHA expenditures were $206,196,000.  Total FY 1988
 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts          $55,085,000
        State Funds                           $88,562,000
        Local Funds                           $40,847,000
        Fees and Reimbursements               $21,702,000
        Other                                           0
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 Virginia has 119 local health departments.  These local health
 departments consist of 13 city/county departments, 24 city health
 departments, and 82 county health departments.   Within these
 local departments are 56 satellite clinic offices for a total of
 175 clinic sites.  The governing body of any city/county enters
 into a contractual agreement with the Board of Health for
 operating the local health department.  Each local health
 department is funded cooperatively by the state and local
 funding, with shares determined by the revenue capacity of the
 locality.  The contract specifies the services to be provided, in
 addition to the services required by law, and also other
 provisions as the board and governing body of the city/county may
 agree upon.  Local health departments are supported by a
 cooperative budget, which, including local match dollars and fee
 revenue, totals $104,665,622 ($17.82 per capita).

       B.  Services Provided

 The following information on services provided by local health
 departments in Virginia is derived from a survey conducted by
 NACHO during 1989.  Fifty-seven of the 119 local health
 departments in Virginia responded to the survey.  Services
 provided by 70 percent of health departments in the state are
 underlined.

 Services Provided by LPHAs                           Number and Percent

   I.  Assessment Activities
       A.  Data Collection/Analysis
            1.  Behavioral Risk Assessment              22   ( 38.6%)
            2.  Morbidity Data                          26   ( 45.6%)
            3.  Reportable Diseases                     56   ( 98.2%)
            4.  Vital Records and Statistics            56   ( 98.2%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        41   ( 71.9%)
            2.  Communicable Diseases                   56   ( 98.2%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement             32   ( 56.1%)
       B.  Health Planning                              29   ( 50.9%)
       C.  Priority Setting                             27   ( 47.4%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   54   ( 94.7%)
            2.  Health Facility Safety/Quality          24   ( 42.1%)
            3.  Rec. Facility Safety/Quality            28   ( 49.1%)
            4.  Other Facility Safety/Quality           21   ( 36.8%)

       B.  Licensing
            1.  Health Facilities                        5   (  8.8%)
            2.  Other Facilities                        47   ( 82.5%)

       C.  Health Education                             45   ( 78.9%)

       D.  Environmental
            1.  Air Quality                              6   ( 10.5%)
            2.  Hazardous Waste Management              13   ( 22.8%)
            3.  Individual Water Supply Safety          52   ( 91.2%)
            4.  Noise Pollution                          7   ( 12.3%)
            5.  Occupational Health and Safety          10   ( 17.5%)
            6.  Public Water Supply Safety              35   ( 61.4%)
            7.  Radiation Control                        4   (  7.0%)
            8.  Sewage Disposal Systems                 54   ( 94.7%)
            9.  Solid Waste Management                  17   ( 29.8%)
           10.  Vector and Animal Control               44   ( 77.2%)
           11.  Water Pollution                         32   ( 56.1%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             56   ( 98.2%)
            2.  Alcohol Abuse                            2   (  3.5%)
            3.  Child Health                            55   ( 96.5%)
            4.  Chronic Diseases                        53   ( 93.0%)
            5.  Dental Health                           44   ( 77.2%)
            6.  Drug Abuse                               2   (  3.5%)
            7.  Emergency Medical Service                1   (  1.8%)
            8.  Family Planning                         55   ( 96.5%)
            9.  Handicapped Children                    45   ( 78.9%)
           10.  Home Health Care                        52   ( 91.2%)
           11.  Hospitals                                2   (  3.5%)
           12.  Immunizations                           57   (100.0%)
           13.  Laboratory Services                     27   ( 47.4%)
           14.  Long-term Care Facilities                4   (  7.0%)
           15.  Mental Health                            1   (  1.8%)
           16.  Obstetrical Care                        23   ( 40.4%)
           17.  Prenatal Care                           57   (100.0%)
           18.  Primary Care                            16   ( 28.1%)
           19.  Sexually Transmitted Diseases           56   ( 98.2%)
           20.  Tuberculosis                            57   (100.0%)
           21.  WIC                                     57   (100.0%)

       C.  Local Health Officer

 M.D. Requirement, Commonwealth Appointment

 All districts are headed by a local health director.  Each
 director is a physician licensed to practice medicine in
 Virginia.  The Virginia recruitment and hiring process is used to
 fill these local health director positions.  Interviewing and
 hiring are done at the regional level and are subject to approval
 of the local governing body.  The director is responsible for
 carrying out services which are required by law and other
 provisions mandated by the State Board of Health or by the local
 governing body.

       D.  Local Board of Health

 Virginia does not mandate local boards of health.  All local
 health departments are units of the VDH and are governed by the
 State Board of Health.  Some localities have advisory boards.

       E.  Staff

 All employees of local health departments are employees of VDH,
 with the exception of Arlington County which is operating a
 locally administered health department as a pilot project
 authorized by the General Assembly.  In some instances the
 locality may be the employer, but the employee is under the
 supervision of the local health department.  The positions are
 funded through the contractual agreement or Federal grants and
 contracts.  The number of full-time employees for an individual
 local health department ranges from 2 to 500.

       F.  Budget

 Total FY 1988 LPHA expenditures were $110,084,000.  Total FY 1988
 United States LPHA expenditures were $3,978,948,000.

      Source of Funds
        Federal Grants and Contracts     $ 9,873,000
        State Funds                      $48,498,000
        Local Funds                      $36,364,000
        Fees and Reimbursements          $15,349,000
        Other Sources                              0
        Source Unknown                             0

 The SHA reported that these figures include the total amount of
 additional local health department monies expended by all local
 health departments.
2Virginia Department of Health, 1990

 Commissioner of Health
 Deputy Commissioner for Health Care Services
      Director Office of Family Health Services
                Division of M.C.H.
                Division of Family Planning
                Division of Children's Special Services
                Division of P.H. Nutrition
                Division of Dental Health

      Director Office of Epidemiology
                Division of Communicable Disease Control
                Division of Health Hazards Control
                Division of Survey and Investigation

      Director Office of Health Education and Information
                Division of Health Education
                Division of Information Services
                Division of Chronic Disease Control

 Deputy Commissioner for Community Health Services
      Director Northern Region
      Director Southwest Region
      Director Central Region
      Director Eastern Region
      Nursing Director
      Director Sanitation Services
      Office of Water Programs
                Division of Water Supply Engineering
                Division of Wastewater Engineering
                Division of Shellfish Sanitation

 Deputy Commissioner for Administration
      Director Office of Human Resource Management
                Division of Compensation and Class.
                Division of Policy, Benefits and Operations
                Division of Employment Services
                Division of E.E.O.
                Division of Organizational Development and Training

      Director Office of Finance and General Services
                Division of Purchasing and General Services
                Division of Budget Services
                Division of Information Resources
                Division of Home Health Services
                Division of Vital Records
                Division of Accounting

      Director Office Planning and Reg. Services
                Division of Resources Development
                Division of Licensing and Certification
                Division of E.M.S.
                Division of Health Planning
2Types of Local Health Departments by Jurisdiction
                                     Virginia, 1990

           Jurisdiction                        Co     C      C/Co

           Accomack                            X
           Alexandria                                 X
           Amelia                              X
           Amherst                             X
           Appomattox                          X
           Arlington                           X
           Bath                                X
           Bedford                             X
           Bedford                                    X
           Bland                               X
           Botetourt                           X
           Bristol                                    X
           Brunswick                           X
           Buchanan                            X
           Buckingham                          X
           Buena Vista                                X
           Campbell                            X
           Caroline                            X
           Carroll                             X
           Charles City                        X
           Charlotte                           X
           Charlottsville-Albe                               X
           Chesapeake                                 X
           Chesterfield                        X
           Clarke                              X
           Clifton Forge                              X
           Colonial Height                            X
           Covington                                  X
           Covington-Alleghany                               X
           Craig                               X
           Culpeper                            X
           Cumberland                          X
           Danville                                   X
           Dickenson                           X
           Dinwiddie                           X
           Emproia-Greensville                               X
           Essex                               X
           Fairfax                             X
           Fairfax                                    X
           Falls Church                               X
           Fauquier                            X
           Floyd                               X
           Fluvanna                            X
           Franklin                            X
           Franklin                                   X
           Fredericksburg                             X
           Front R.-Warren                                   X
           Galax                                      X
           Giles                               X
           Gloucester                          X
           Goochland                           X
           Grayson                             X
           Greene                              X
           Hampton                                    X
           Hanover                             X
           Harrisburg-Rockingh                               X
           Henrico                             X
           Highland                            X
           Hopewell                                   X
           Isle of Wight                       X
           James City                          X
           King George                         X
           King William                        X
           King and Queen                      X
           Lancaster                           X
           Lee                                 X
           Lexington                                  X
           Lexington-Rockbridg                               X
           Loudoun                             X
           Louisia                             X
           Lunenburg                           X
           Lynchburg                                  X
           Madison                             X
           Manassas                                   X
           Manassas Park                              X
           Martinsville-Henry                                X
           Mathews                             X
           Mecklinburg                         X
           Montgomery                          X
           Nelson                              X
           New Kent                            X
           Newport News                               X
           Norfolk                                    X
           Northampton                         X
           Northumberland                      X
           Norton-Wise Co                                    X
           Nottoway                            X
           Orange                              X
           Page                                X
           Patrick                             X
           Petersburg                                 X
           Pittsylvania                        X
           Poquoson                                   X
           Poquoson-York Co                                  X
           Portsmouth                                 X
           Powhatan                            X
           Prince Edward                       X
           Prince William                      X
           Pulaski                             X
           Radford                                    X
           Rappahannock                        X
           Richmond                            X
           Richmond                                   X
           Roanoke                                    X
           Roanoke City/Co                                   X
           Rockingham                          X
           Russell                             X
           S. Boston-Halifax                                 X
           Salem                                      X
           Scott                               X
           Shenandoah                          X
           Smyth                               X
           Southampton                         X
           Spotsylvania                        X
           Stafford                            X
           Staunton                                   X
           Staunton-Augusta                                  X
           Suffolk                                    X
           Surry                               X
           Sussex                              X
           Tazewell                            X
           Virginia Beach                             X
           Washington                          X
           Waynesboro                                 X
           Westmoreland                        X
           Williamsburg                               X
           Winchester                                 X
           Winnchester-Freder                                X
           Wythe                               X
           York                                X

           Co = County HD
           C/Co = City/County HD
           C = City HD
1WASHINGTON
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State      United States

 Population (1988)                  4,648,000        245,803,000
 Population Density (1988)                 69.9               69.4
   (per/sq.mi.)
 Number of Counties                        39              3,139
 Median Age (1987)                         31.9               31.7
 Percent Below Poverty Level (1985)        12.0               14.0
   (persons)
 Percent of Population Rural (1980)        27.0               26.0
 Percent of Population White (1980)        91.5               83.1
 Percent of Population Non-white (1980)     8.5               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 function of the county government in Washington
 are established by the state constitution and statutes.  Counties
 can choose between two structural options for their governments:
 Commission and Home Rule Charter.

 Commission Form - (34) - These counties have three-member
 commissioner boards which are elected from single-member
 districts.  The boards serve as the legislative and executive
 bodies for the counties.  Within the group of counties that
 employ the Commission Form of government, 13 use an appointed
 administrator to carry out the polices established by the board.

 Home Rule Charter - (5) - Four of these counties function with a
 council and an elected executive.  One Home Rule Charter county
 (Clallam) has a commission and an appointed administrator.

 Data for this state were updated March 1991.
3II.  State Health Agency (SHA)

      A.  General

 Free-standing, Independent

 The Division of Health was a component of the superagency (the
 Washington Department of Social and Health Services) from 1970
 until 1989, when an independent Department of Health was
 re-established.  The Department of Health is the state agency
 which helps Washingtonians live healthier lives by:

      Empowering individuals and communities to make informed
        health choices

      Assuring access to quality prevention and illness care

      Protecting people from environmental threats to health

      Advocating sound, cost-effective health policies

 The following are some areas of responsibility for the SHA:

      State Public Health Authority
      Institutional Licensing Agency (except nursing homes)
      Institutional Certifying Authority for Federal Reimbursement
        (except nursing homes)
      Health Professions Licensing Agency
      State Agency for Children with Special Health Care Needs

      B.  Head of State Health Agency

 No M.D. Requirement, Cabinet-level Appointment

 The Secretary of the Department of Health is the administrative
 head of the SHA.  Appointed by the Governor and confirmed by the
 Senate, the Secretary is not required to have an M.D. degree.
 The State Health Officer, who is appointed by the Secretary, does
 require an M.D. degree.  To fulfill the responsibilities and
 duties of the office, the Secretary shall:

      1.   Exercise all the powers and perform all the duties
           prescribed by law with respect to public health and
           vital statistics.

      2.   Investigate and study factors relating to the
           preservation, promotion, and improvement of the health
           of the people, the causes of morbidity and mortality,
           and effects of the environment and other conditions
           upon the public health for such action as the board
           determines is necessary.

      3.   Strictly enforce all laws for the protection of the
           public health and the improvement of sanitary
           conditions in the state, and all rules, regulations,
           and orders of the State Board of Health.

      4.   Enforce the public health laws of the state and the
           rules and regulations promulgated by the Department or
           the board of health in local matters, when in its
           opinion an emergency exists and the local board of
           health has failed to act with sufficient promptness or
           efficiency, or is unable, for reasons beyond its
           control, to act, or when no local board has been
           established.

      5.   Investigate outbreaks and epidemics of disease that may
           occur and advise local health officers as to measures
           to be taken to prevent and control the same.

      6.   Exercise general supervision over the work of local
           health departments and establish uniform reporting
           systems by local health officers to the State
           Department of Health.

      7.   Have the same authority as local health officers,
           except that the Secretary shall not exercise such
           authority unless the local health officer fails or is
           unable to do so, or when in an emergency the safety of
           the public health demands it.

      8.   Cause to be made, from time to time, personal health
           and sanitation inspections at state-owned or contracted
           institutions and facilities to determine compliance
           with sanitary and health care standards as adopted by
           the department, and require the governing authorities
           thereof to take such action as will conserve the health
           of all persons connected therewith, and report the
           findings to the Governor.

      9.   Take such measures as the Secretary deems necessary to
           promote the public health, to establish or participate
           in the establishment of health educational or training
           activities, and to provide funds for and to authorize
           the attendance and participation in such activities of
           employees of the state or local health department and
           other individuals engaged in programs related to or
           part of the public health programs of the local health
           departments or State Health Department.  The Secretary
           is also authorized to accept any funds from the Federal
           government or any public or private agency made
           available for health education training purposes and to
           conform with such requirements as are necessary to
           receive such funds.
      10.  Establish and maintain laboratory facilities and
           services as necessary to carry out the responsibilities
           of the Department.

       C.  State Board of Health/Council

 Policy-making

 The Washington Board of Health is a 10-member body, appointed by
 the Governor, made up of the Secretary of the Department, 4
 persons experienced in matters of health and sanitation, 1 person
 who is an elected city official who is a member of a local health
 board, 1 local health officer, and 2 persons representing the
 consumers of health care.

       D.  Regional/District Health Offices

 The SHA has not divided the state into geographical regions or
 districts.

       E.  State-local Liaison

 Decentralized Organizational Control, Formal Liaison Function

 The Office of Local Health Support Services has responsibility
 for the state-local liaison.  In support of the Department's
 mission, the Office of Local Health Support Services facilitates
 the formal partnership link between the Washington Department of
 Health and the public health community in Washington State.  The
 objectives of the Office are to facilitate communication and
 coordination between the Department of Health and local
 government, to increase capacity of local public health agencies
 to develop and implement effective public health programs.  The
 Office has the following roles/functions:

      1.   Represent the Secretary/State Health Officer to outside
           agencies and organization.

      2.   Act as liaison and resource to program managers and
           local public health agency managers.

      3.   Provide management services and consultation to local
           public health agencies.

      4.   Manage consolidated contract with local public health
           agencies.

 The interaction between state and local public health agencies in
 Washington may be characterized as decentralized organizational
 control.  Under this arrangement local government directly
 operates local health departments with a local board of health.
 Responsibilities are defined by state statute and State Board of
 Health regulations.

       F.  Budget

 Total FY 1988 Washington SHA expenditures were $25,987,000*.
 Total FY 1988 United States SHA expenditures were $8,312,928,000.


      Source of Funds
        Federal Grants and Contracts          $4,674,000
        State Funds                           $6,890,000
        Local Funds                             $151,000
        Fees and Reimbursements                        0
        Other                                          0
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 Washington has 32 local health departments, consisting of 25
 county, 5 multicounty, and 2 city-county health departments.

       B.  Services Provided

 The following information on services provided by local health
 departments in Washington is derived from a survey conducted by
 NACHO during 1989.  All 32 local health departments in Washington
 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              10   ( 31.3%)
            2.  Morbidity Data                          15   ( 46.9%)
            3.  Reportable Diseases                     30   ( 93.8%)
            4.  Vital Records and Statistics            32   (100.0%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        10   ( 31.3%)
            2.  Communicable Diseases                   32   (100.0%)

 * These data exclude most funds expended on maternal and child
 health because these programs were in another part of the
 superagency.

  II.  Policy Development
       A.  Health Code Dev. and Enforcement             22   ( 68.8%)
       B.  Health Planning                              23   ( 71.9%)
       C.  Priority Setting                             23   ( 71.9%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   28   ( 87.5%)
            2.  Health Facility Safety/Quality           6   ( 18.8%)
            3.  Rec. Facility Safety/Quality            22   ( 68.8%)
            4.  Other Facility Safety/Quality            9   ( 28.1%)

       B.  Licensing
            1.  Health Facilities                        2   (  6.3%)
            2.  Other Facilities                        28   ( 87.5%)

       C.  Health Education                             25   ( 78.1%)

       D.  Environmental
            1.  Air Quality                              6   ( 18.8%)
            2.  Hazardous Waste Management              25   ( 78.1%)
            3.  Individual Water Supply Safety          30   ( 93.8%)
            4.  Noise Pollution                          6   ( 18.8%)
            5.  Occupational Health and Safety           5   ( 15.6%)
            6.  Public Water Supply Safety              30   ( 93.8%)
            7.  Radiation Control                        3   (  9.4%)
            8.  Sewage Disposal Systems                 31   ( 96.9%)
            9.  Solid Waste Management                  30   ( 93.8%)
           10.  Vector and Animal Control               28   ( 87.5%)
           11.  Water Pollution                         26   ( 81.3%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             31   ( 96.9%)
            2.  Alcohol Abuse                            6   ( 18.8%)
            3.  Child Health                            32   (100.0%)
            4.  Chronic Diseases                        19   ( 59.4%)
            5.  Dental Health                           20   ( 62.5%)
            6.  Drug Abuse                               6   ( 18.8%)
            7.  Emergency Medical Service                4   ( 12.5%)
            8.  Family Planning                         15   ( 46.9%)
            9.  Handicapped Children                    29   ( 90.6%)
           10.  Home Health Care                         5   ( 15.6%)
           11.  Hospitals                                -
           12.  Immunizations                           32   (100.0%)
           13.  Laboratory Services                     19   ( 59.4%)
           14.  Long-term Care Facilities                -
           15.  Mental Health                            3   (  9.4%)
           16.  Obstetrical Care                         3   (  9.4%)
           17.  Prenatal Care                           24   ( 75.0%)
           18.  Primary Care                             8   ( 25.0%)
           19.  Sexually Transmitted Diseases           29   ( 90.6%)
           20.  Tuberculosis                            32   (100.0%)
           21.  WIC                                     25   ( 78.1%)

      C.  Local Health Officer

 M.D. Requirement, Local Board of Health Appointment

 Local health officers are appointed by the local board of health
 and are required to be an M.D.  They have the power and duty to
 enforce state statutes, state rules, and local rules passed by
 the local board of health.

      D.  Local Board of Health

 Policy-making

 County commissioners constitute the local board of health for
 county health departments.  District (multicounty) boards are
 composed of representatives from county commissioners, city, and
 town governments within the jurisdiction.  These boards enforce
 state statutes, enact and enforce local rules, approve health
 budget, and supervise the local health department.

      E.  Staff

 All of the staffs of local health departments are county
 employees, except for King County which has a mixture of county
 and Seattle City employees.  The number of individuals employed
 by a local health department ranges from 1 to 960.

      F.  Budget

 Total FY 1988 LPHA expenditures were $87,001,000**.  Total FY
 1988 United States LPHA expenditures were $3,978,948,000.

      Source of Funds
        Federal Grants and Contracts     $14,007,000
        State Funds                      $10,126,000
        Local Funds                      $42,852,000
        Fees and Reimbursements          $17,778,000
        Other Sources                     $2,238,000
        Source Unknown                             0

 The SHA reported that these figures include the total amount of
 additional monies expended by all local health departments.

 ** These data were provided by the SHA.
2Wahington State Department of Health, 1990

 Secretary
 Deputy Secretary
   Board of Health
   Health Officer
     Local Health Support Services
   Attorney General Office Health Division
   Legal and Constituency Affairs/Media Relations
 Division of Health Information--Assistant Secretary
      Epidemiology
      Health Policy Support
      Hospital Data System
      Center for Health Statistics
      Birth Defects

 Division of Parent and Child Health--Assistant Secretary
      Women, Infants and Children (WIC)
      Maternal/Infant Health, Newborn Screening and Genetics
      Operation Support
      Family Planning
      Children with Special Health Care Needs
      Child and Adolescent Health

 Division of Health Promotion and Disease Prevention--
   Assistant Secretary
      Primary Health Care Services
      Injury Prevention Operations
      Health Education and Promotion
      Rural Health Systems Project
      Heart Disease and Cancer
      Kidney Disease and Diabetes
      Parent and Child Health
      Prevention/Education
      Operations/Client Services
      EPI-Surveillance
      Sexually Transmitted Disease
      Immunization/Tuberculosis Services

 Division of Environmental Health--Assistant Secretary
      Drinking Water
      Radiation Protection
      Shellfish
      Local Environmental Health Support
      Toxic Substances
      Program Services

 Division of Licensing and Certification--Assistant Secretary
      Facility Licensing and Certification Division
      Professional Licensing Services Division
      Fac. Development and Accom. Licensing
      Licensing Policy and Budget
      EMS/Trauma

 Division of Laboratories--Assistant Secretary
      Virology and Serology
      Radiation Chemistry
      Laboratory Resource and Development
      Public Health Microbiology Lab
      Environmental Chemistry
      Bacterial/Quality Assurance
      Newborn Screening
      Genetics Laboratory

 Division of Management Services Assistant Secretary
      Comptroller's Officer
      Contracts/Rules
      Information Services
      Administrative Services
      Personnel
2Types of Local Health Departments by Jurisdiction
                                    Washington, 1990

           Jurisdiction                        Co     C/Co   M/Co

           Adams                               X
           Asotin                              X
           Benton                                            X
           Chelan                                            X
           Clallam                             X
           Clark                                             X
           Columbia                            X
           Cowlitz                                           X
           Douglas                                           X
           Ferry                                             X
           Franklin                                          X
           Garfield                            X
           Grant                               X
           Grays Harbor                        X
           Island                              X
           Jefferson                           X
           Kitsap                              X
           Kittitas                            X
           Klickitat                                         X
           Lewis                               X
           Lincoln                             X
           Mason                               X
           Okanogan                            X
           Pacific                             X
           Pend Oreille                                      X
           San Juan Island                     X
           Seattle-King Co                            X
           Skagit                              X
           Skamania                                          X
           Snohomish                           X
           Spokane                             X
           Stevens                                           X
           Tacoma-Pierce C                            X
           Thurston                            X
           Wahkiakum                                         X
           Walla Walla                         X
           Whatcom                             X
           Whitman                             X
           Yakima                              X

           Co = County HD
           C/Co = City/County HD
           M/Co = Multicounty HD
1WEST VIRGINIA
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State     United States

 Population (1988)                  1,877,000       245,803,000
 Population Density (1988)                 77.8              69.4
   (per/sq.mi.)
 Number of Counties                        55             3,139
 Median Age (1987)                         32.4              31.7
 Percent Below Poverty Level (1985)        22.3              14.0
   (persons)
 Percent of Population Rural (1980)        64.0              26.0
 Percent of Population White (1980)        96.2              83.1
 Percent of Population Non-white (1980)     3.8              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 West Virginia Constitution establishes the structure and
 provides authority for operating county governments.

 Commission Form - (55) - The commissions are made up of three
 members, except one county which has a five-member board.  The
 commissioners are elected at large with staggered 6-year terms.
 Twenty-three counties have the position for appointed
 administrators.

 Although counties do not have authority to adopt home rule or
 charter provisions, they can apply to the legislature for
 permission to alter the county commission.  The form of county
 government can also be changed with permission of the legislature
 and approval by the voters.

 Data for this state were updated January 1991.
3II.  State Health Agency (SHA)

      A.  General

 Component of Superagency

 The Bureau of Public Health, the SHA, is a component of the
 superagency known as the Department of Health and Human
 Resources.  The mission of the Department is to organize and
 manage resources to develop and implement a continuum of
 health services so that they are primarily dedicated to the
 statewide support and enhancement of public health, environmental
 health, and behavioral health services, which are community
 responsive, therapeutically appropriate, and prevention oriented.

 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 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, Not Cabinet-level Appointment

 The Director of the Bureau of Health is the State Health
 Officer.  This individual speaks for public health in the state.
 Various statutes give the Director authority to approve the
 appointment of county health officers, decide public health
 goals, develop policies, direct the disbursement of funds, and is
 otherwise the leader from whom all direction flows.  This
 position is appointed by the Secretary of Health and Human
 Services.

      C.  State Board of Health/Council

 Policy-making

 The 16-member State Board of Health is appointed by the Governor,
 with the advice and consent of the Senate.  Three members of the
 board shall be physicians or surgeons with a doctor of medicine
 degree, one member shall be an osteopathic physician, one shall
 be a dentist, one shall be a registered nurse, one shall be a
 pharmacist, three shall be from mental health disciplines, one
 shall be an administrator of a licensed hospital, one shall be an
 optometrist, one shall be a chiropractor, and three shall be
 representative citizens.  All appointments are for 5-year terms.

 The Board reviews actions brought before it when the law dictates
 that it has final approval.  Some such actions include final
 approval of policies, rules, regulations, and fees before they
 are implemented.  The composition and functions of the Board of
 Health are currently being reviewed, and changes are forthcoming.

      D.  Regional/District Health Offices

 The state has no designated regional/district health offices, but
 it is divided into eight public health management districts for
 the more efficient delivery of community health services.  The
 geographic delineation of the districts was determined by various
 factors including community interest and homogeneity, natural
 boundaries, patterns of communication and transportation, and
 uniformity of social and economic problems.

      E.  State-local Liaison

 Shared Organizational Control, Formal Liaison Function

 The Division of Local Health has been given responsibility for
 formal liaison functions between the state and local health.
 Although communications from the top down are usually transmitted
 to the locals through this office, the locals may contact anyone
 or any office at the state level.  Field nurses currently have a
 major role in state-local liaison, but future plans call for a
 centrally located group of public health specialists to perform
 this function.

 The interaction between state and local public health agencies in
 West Virginia 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 West Virginia SHA expenditures were $159,720,000.
 Total FY 1988 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts          $32,762,000
        State Funds                           $99,724,000
        Local Funds                                     0
        Fees and Reimbursements                $2,639,000
        Other                                 $24,595,000
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 West Virginia has 49 local public health agencies, including 40
 county health departments (one of which has contracted with a
 private provider for certain mandated services), 7 city-county
 health departments, and 2 multicounty health departments.  One of
 the multicounty units consists of two counties and the other has
 six counties.

 All of the local health departments relate to the state by having
 the same personnel merit system for employees, reporting diseases
 to the epidemiology section, working with regional health
 advisory groups, and sending in monthly and yearly expenditure
 reports.  Annually all counties send to the Director, Bureau of
 Public Health, through the Division of Local Health, their
 projected budget and program plans for the next fiscal year for
 approval.  State aid funds are distributed by formula, and every
 local agency depends on that distribution for financial support.

      B.  Services Provided

 The following information on services provided by local health
 departments in West Virginia is derived from a survey conducted
 by NACHO during 1989.  Thirty-six of the 49 local health
 departments in West Virginia responded to the survey.  Services
 provided by at least 70 percent of health departments in the
 state that responded to the survey are underlined.

 Services Provided by LPHAs                    Number and Percent


   I.  Assessment Activities
       A.  Data Collection/Analysis
            1.  Behavioral Risk Assessment              11   ( 30.6%)
            2.  Morbidity Data                           9   ( 25.0%)
            3.  Reportable Diseases                     22   ( 61.1%)
            4.  Vital Records and Statistics             8   ( 22.2%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        24   ( 66.7%)
            2.  Communicable Diseases                   35   ( 97.2%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement             22   ( 61.1%)
       B.  Health Planning                              20   ( 55.6%)
       C.  Priority Setting                             14   ( 38.9%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   35   ( 97.2%)
            2.  Health Facility Safety/Quality          27   ( 75.0%)
            3.  Rec. Facility Safety/Quality            29   ( 80.6%)
            4.  Other Facility Safety/Quality           16   ( 44.4%)

       B.  Licensing
            1.  Health Facilities                       14   ( 38.9%)
            2.  Other Facilities                        30   ( 83.3%)

       C.  Health Education                             29   ( 80.6%)

       D.  Environmental
            1.  Air Quality                             18   ( 50.0%)
            2.  Hazardous Waste Management              17   ( 47.2%)
            3.  Individual Water Supply Safety          36   (100.0%)
            4.  Noise Pollution                          4   ( 11.1%)
            5.  Occupational Health and Safety           8   ( 22.2%)
            6.  Public Water Supply Safety              34   ( 94.4%)
            7.  Radiation Control                        7   ( 19.4%)
            8.  Sewage Disposal Systems                 34   ( 94.4%)
            9.  Solid Waste Management                  19   ( 52.8%)
           10.  Vector and Animal Control               29   ( 80.6%)
           11.  Water Pollution                         25   ( 69.4%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             19   ( 52.8%)
            2.  Alcohol Abuse                            2   (  5.6%)
            3.  Child Health                            28   ( 77.8%)
            4.  Chronic Diseases                        19   ( 52.8%)
            5.  Dental Health                           14   ( 38.9%)
            6.  Drug Abuse                               3   (  8.3%)
            7.  Emergency Medical Service                3   (  8.3%)
            8.  Family Planning                         34   ( 94.4%)
            9.  Handicapped Children                     8   ( 22.2%)
           10.  Home Health Care                        12   ( 33.3%)
           11.  Hospitals                                -
           12.  Immunizations                           36   (100.0%)
           13.  Laboratory Services                     13   ( 36.1%)
           14.  Long-term Care Facilities                3   (  8.3%)
           15.  Mental Health                            2   (  5.6%)
           16.  Obstetrical Care                         7   ( 19.4%)
           17.  Prenatal Care                           12   ( 33.3%)
           18.  Primary Care                             7   ( 19.4%)
           19.  Sexually Transmitted Diseases           34   ( 94.4%)
           20.  Tuberculosis                            34   ( 94.4%)
           21.  WIC                                     11   ( 30.6%)

       C.  Local Health Officer

 M.D. Requirement, Local Board of Health Appointment

 A county or municipal board of health has the authority to
 appoint a health officer to serve for an indefinite term at the
 pleasure of the appointing board of health.  The health officer
 must be a physician licensed or eligible for licensure in the
 state.  The salary will be determined by the appointing board and
 will be paid from the county or municipal treasury.

 Under the supervision of the appointing board, a local health
 officer is responsible for administering all state public health
 laws, rules, regulations, and orders that are applicable to the
 county or municipality.  The health officer serves as secretary
 to the local board of health and attends all meetings but does
 not vote.  The health officer is responsible for supervising and
 directing the activities of the county or municipal health
 services, employees and facilities, except that the duties do not
 include the rendering of medical or surgical services on an
 individual basis to wards of the county or municipality or to
 inmates of any public institution operated or maintained by the
 county commission or municipality.  The county health officer or
 a designated representative determines when corrections have been
 made sufficient to warrant removal of any restrictions or
 limitations placed by a health department employee.  The local
 health officer has responsibility to report to the State Director
 of Health a weekly report, in a manner specified by the Director,
 those diseases or conditions for which a report is required.

      D.  Local Board of Health

 Policy-making

 Local boards of health are composed of five members appointed by
 the county or municipal governing body.  In any county or
 municipality where the board of education contributes funds to
 the county or municipality, the board of education may nominate
 one member of the local board of health.  All members of the
 board of health must be citizens and residents of the county or
 municipality they are appointed to represent.  No more than three
 of the members can belong to the same political party, nor more
 than two of the members can be residents of the same magisterial
 district or municipal ward, nor more than two members can be
 personally and individually licensed in, engaged in, or actively
 participating in the same business, profession, or occupation.

 All members of the board are appointed for terms of 5 years, with
 the terms staggered so that the term of one member expires each
 year.  The salary of members is established by the governing body
 of the county or municipality but is not to exceed $10 per
 meeting.  Reimbursement is authorized for actual expenses for
 necessary travel and other expenses incurred in the performance
 of duties as a member of the board.

 County or municipal boards of health are required to direct,
 supervise, and control all matters relating to the general health
 and sanitation of their respective counties or municipalities.
 They are given the same power as the State Board of Health, or
 Director, as far as the powers are applicable to the county or
 municipality.  The boards of health have the power and authority
 to adopt, promulgate, and amend rules and regulations, consistent
 with the laws of the state and the rules and regulations of the
 State Board of Health, as may be necessary and proper for the
 protection of the general health of the municipality or county
 and the prevention of the introduction, propagation, and spread
 of disease.

 It is the duty of local boards of health to protect the general
 health and supervise and control the sanitation of their
 respective counties and municipalities, to enforce the laws of
 the state pertaining to public health and the rules and
 regulations of the State Board of Health, insofar as they are
 applicable to the counties or municipalities.  They are also
 required to perform other duties in relation to public health as
 may be prescribed by order of the county commission or ordinances
 in municipalities as long as they are consistent with the laws,
 rules, and regulations of the State Board of Health.  All local
 boards of health receiving state or Federal funds for health
 purposes must first receive approval by the Director of the State
 Bureau of Health for their general plans of operation for health
 purposes.

      E.  Staff

 The staffs of local health departments are employed and managed
 by the local jurisdiction but are also part of the State Merit
 System.  The number of employees for a local health department
 ranges from 2 to 80.

      F.  Budget

 Total FY 1988 LPHA expenditures were $19,472,000.  Total FY 1988
 United States LPHA expenditures were $3,978,948,000.

      Source of Funds
        Federal Grants and Contract          $98,000*
        State Funds                       $6,528,000
        Local Funds                       $4,124,000*
        Fees and Reimbursements           $5,824,000*
        Other Sources                     $2,898,000*
        Source Unknown                             0

 *The SHA reported that these figures were estimated.  The SHA
 reported that the expenditures shown include the total amount of
 additional monies expended by all local health departments.
2West Virginia Department of Health and Human Resources, 1990

 Secretary of Health and Human Resources
 Regulatory Agencies
 Legal Services
 Public Information
 Inspector General
 Administration and Finance
 Public Health
      Community Health
        Emergency Medical Services
        Maternal and Child Health
        Dental Services
        Local Health
        Primary Care
        Nutritional Services
      Environmental Health
      Epidemiology and Health Promotion
      Laboratory

 Community Support
      Behavioral Health
      Social Services
      Long-Term Care
      Commission on Aging
      Veterans' Affairs
      Women's Commission

 Income Assistance
      Medical Services
      Income Maintenance
      Child Advocacy
      Work and Training

 Employment Security
      Employment Services

 Worker's Compensation
2Types of Local Health Departments by Jurisdiction
                                  West Virginia, 1990

           Jurisdiction                        Co     C/Co   M/Co

           Barbour                             X
           Berkeley                            X
           Boone                               X
           Braxton                             X
           Brooke                              X
           Buchannan-Upshur Co                        X
           Calhoun                                           X
           Charleston-Kana Co                         X
           Clarksburg-Harr Co                         X
           Clay                                X
           Doddridge                           X
           Elkins-Randolph Co                         X
           Fairmont-Marion Co                         X
           Fayette                             X
           Gilmer                              X
           Grant                               X
           Greenbrier                          X
           Hampshire                           X
           Hancock                             X
           Hardy                               X
           Huntington-Cabe Co                         X
           Jackson                             X
           Jefferson                           X
           Lewis                               X
           Lincoln                             X
           Logan                               X
           Marshall                            X
           Mason                               X
           McDowell                            X
           Mercer                              X
           Mineral                             X
           Mingo                               X
           Monongalia                          X
           Monroe                              X
           Morgan                              X
           Nicholas                            X
           Pendleton                           X
           Pleasants                                         X
           Pocahontas                          X
           Preston                             X
           Putnam                              X
           Raleigh                             X
           Ritchie                                           X
           Roane                                             X
           Summers                             X
           Taylor                              X
           Tucker                              X
           Tyler                                             X
           Wayne                               X
           Webster                             X
           Wetzel                                            X
           Wheeling-Ohio Co                           X
           Wirt                                              X
           Wood                                              X
           Wyoming                             X

           Co = County HD
           C/Co = City/County HD
           M/Co = Multicounty HD
1WISCONSIN
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State   United States

 Population (1988)                  4,855,000     245,803,000
 Population Density (1988)                 89.2            69.4
   (per/sq.mi.)
 Number of Counties                        72           3,139
 Median Age (1987)                         31.4            31.7
 Percent Below Poverty Level (1985)        11.6            14.0
   (persons)
 Percent of Population Rural (1980)        36.0            26.0
 Percent of Population White (1980)        94.4            83.1
 Percent of Population Non-white (1980)     5.6            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 state constitution and statutes establish and empower the
 county governments of Wisconsin.

 Commission Form - (72) - The counties function under a Commission
 Form of government which is made up of three-member Boards of
 Supervisors who are elected from single-member districts.
 Districts are permitted to elect two Supervisors if their
 population is twice that for other districts in the county.
 Counties may choose from the following structural options:

      County Executive - (8) - They may elect a strong county
      executive with veto power over the Board of Supervisors.
      Eight counties have chosen this option.

      County Administrator - (9) - Counties may also choose to
      have a County Administrator.  This position is appointed by
      the Board of Supervisors and serves as the chief
      administrative officer of the county.  Currently, nine
      counties have appointed a County Administrator.

 Data for this state were updated November 1990.      Administrative
      Coordinator - (55) - Fifty-five counties
      operate with an Administrative Coordinator.  The
      Administrative Coordinator is an elected or appointed
      official who is appointed to serve in this capacity.  The
      responsibility of this position includes coordinating all
      administrative and management functions of the county that
      are not under the authority of other boards or elected
      officials.

 Still another choice involves the utilization of a county
 coordinator position.  This position administers all management
 functions of the county not vested in boards or other elected
 officials.  Currently no counties have chosen this option.

 Counties have been granted authority for administrative and
 organizational home rule.  Even with this authority the power of
 the counties is limited, but their flexibility in carrying out
 functions is increased.  No counties in Wisconsin have opted for
 consolidation of city and county governments.
3II.  State Health Agency (SHA)

      A.  General

 Component of Superagency

 The SHA is the Wisconsin Division of Health.  It is a component
 of a superagency called the Department of Health and Social
 Services.  The mission of the Division of Health is to administer
 programs to promote and protect public health, regulate the
 quality of health care facilities and services, and assure that
 state residents have access to health care.

 Major responsibilities for the Department include:

      1.   Administer the Medical Assistance Program.

      2.   Survey hospitals, nursing homes, and other health care
           facilities for compliance with state standards.

      3.   Maintain vital records plus compile data on health
           status and utilization of health care facilities.

      4.   Conduct communicable disease surveillance and
           epidemiology.

      5.   Conduct environmental health programs, including
           facility sanitation, occupational safety and health
           consultation, and radiological surveillance.

      6.   Administer the Maternal and Child Health and Preventive
           bloc grants, WIC, and other Federally funded prevention
           and intervention programs.

 The following are some broad areas of responsibility for the SHA:

      State Public Health Authority
      Medicaid Single State Agency
      Institutional Licensing Agency
      Institutional Certifying Authority for Federal Reimbursement

      B.  Head of State Health Agency

 No M.D. Requirement, Not Cabinet-level Appointment

 The Administrator for the Division of Health serves as the State
 Health Officer and administrative head of the unit.  The
 Administrator is appointed by the Secretary of the Department of
 Health and Social Services.  The statutes indicate that the
 Secretary can assign the Administrator any duties related to the
 Secretary or the Department of Health and Social Services.  The
 State Health Officer may appoint such advising and examining
 bodies as provided by law.

      C.  State Board of Health/Council

 Wisconsin does not have a state board of health or health
 council.

      D.  Regional/District Health Offices

 Wisconsin has five regional offices which provide consultations
 and technical assistance to the local health units in their
 jurisdiction.  Regional staffs implement a number of programs
 which are centrally administered, plus assist local health
 agencies on issues related to public health that may go beyond
 the programmatic scope of the division's central office.  They do
 not, however, provide direct patient services.  They also serve a
 liaison function between the central office and local agencies.
 The number of staff in the regional offices ranges from 12 to
 16.  The following types of employees are typically found in
 regional offices:

      Regional Director
      Nutritionists
      Immunization Program Advisor
      Public Health Educators
      Public Health Sanitarians
      Public Health Nurses
      Clerical Personnel      E.  State-local Liaison

 Decentralized Organizational Control, Informal Liaison Function

 The regional offices might be considered the state-local liaisons
 for many purposes, but this activity is not limited to one
 individual or entity within the Division of Health.  On occasion,
 local and central office staffs deal with each other directly.
 The central office recognizes that a special partnership exists
 between the state and local health agencies because of the shared
 mission.  Due to this partnership the Division of Health staff is
 strongly encouraged to engage in cooperative interaction with
 local agency staff.

 The interaction between state and local public health agencies in
 Wisconsin may be characterized as decentralized organizational
 control.  Under this arrangement local government directly
 operates health departments with or without a local board of
 health.

      F.  Budget

 Total FY 1988 Wisconsin SHA expenditures were $75,585,000*.
 Total FY 1988 United States SHA expenditures were $8,312,928,000.

      Source of Funds
        Federal Grants and Contracts          $46,562,000
        State Funds                           $25,441,000
        Local Funds                                     0
        Fees and Reimbursements                $3,582,000
        Other                                           0
3III.  Local Public Health Agencies (LPHAs)

       A.  General

 Wisconsin has 107 local public health agencies, ranging in size
 from those with a single nurse to full-service health
 departments.  They consist of 69 county, 37 city or village
 health departments, and 1 city-county health department.  For the
 most part, they are locally administered, locally funded, and
 responsible to local governmental authorities.

 * These expenditure data exclude state and Federal
 funding for Medical Assistance Program.
       B.  Services Provided

 The following information on services provided by local health
 departments in Wisconsin is derived from a survey conducted by
 NACHO during 1989.  Eighty-two of the 107 local health
 departments in Wisconsin 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              33   ( 40.2%)
            2.  Morbidity Data                          35   ( 42.7%)
            3.  Reportable Diseases **                 107   (100.0%)
            4.  Vital Records and Statistics            31   ( 37.8%)

       B.  Epidemiology/Surveillance
            1.  Chronic Diseases                        43   ( 52.4%)
            2.  Communicable Diseases**                107   (100.0%)

  II.  Policy Development
       A.  Health Code Dev. and Enforcement             53   ( 64.6%)
       B.  Health Planning                              57   ( 69.5%)
       C.  Priority Setting                             60   ( 73.2%)

 III.  Assurance Activities
       A.  Inspection
            1.  Food and Milk Control                   30   ( 36.6%)
            2.  Health Facility Safety/Quality          17   ( 20.7%)
            3.  Rec. Facility Safety/Quality            28   ( 34.1%)
            4.  Other Facility Safety/Quality           21   ( 25.6%)

       B.  Licensing
            1.  Health Facilities                        4   (  4.9%)
            2.  Other Facilities                        34   ( 41.5%)

       C.  Health Education                             68   ( 82.9%)

       D.  Environmental
            1.  Air Quality                             20   ( 24.4%)

 ** The SHA reported that all public health agencies are required
 to collect and submit data on reportable disease, and to conduct
 epidemiology and surveillance of selected communicable diseases.
 Although the NACHO survey indicated less than 100 percent
 involvement, all agencies do provide these services.
            2.  Hazardous Waste Management              23   ( 28.0%)
            3.  Individual Water Supply Safety          42   ( 51.2%)
            4.  Noise Pollution                         20   ( 24.4%)
                 5.  Occupational Health and Safety     16   ( 19.5%)
            6.  Public Water Supply Safety              25   ( 30.5%)
            7.  Radiation Control                       18   ( 22.0%)
            8.  Sewage Disposal Systems                 19   ( 23.2%)
            9.  Solid Waste Management                  19   ( 23.2%)
           10.  Vector and Animal Control               53   ( 64.6%)
           11.  Water Pollution                         27   ( 32.9%)

       E.  Personal Health Services
            1.  AIDS Testing and Counseling             37   ( 45.1%)
            2.  Alcohol Abuse                           14   ( 17.1%)
            3.  Child Health                            75   ( 91.5%)
            4.  Chronic Diseases                        71   ( 86.6%)
            5.  Dental Health                           24   ( 29.3%)
            6.  Drug Abuse                              14   ( 17.1%)
            7.  Emergency Medical Service                8   (  9.8%)
            8.  Family Planning                         23   ( 28.0%)
            9.  Handicapped Children                    42   ( 51.2%)
           10.  Home Health Care                        44   ( 53.7%)
           11.  Hospitals                                -
           12.  Immunizations                           80   ( 97.6%)
           13.  Laboratory Services                     27   ( 32.9%)
           14.  Long-term Care Facilities                1   (  1.2%)
           15.  Mental Health                           11   ( 13.4%)
           16.  Obstetrical Care                         5   (  6.1%)
           17.  Prenatal Care                           31   ( 37.8%)
           18.  Primary Care                            10   ( 12.2%)
           19.  Sexually Transmitted Diseases           67   ( 81.7%)
           20.  Tuberculosis                            67   ( 81.7%)
           21.  WIC                                     54   ( 65.9%)

      C.  Local Health Officer

 No M.D. Required, Local Board of Health or Governing Body
 Appointment

 Local health officers are not required to be physicians.  They
 are appointed by the local board of health or the local governing
 body.  The responsibilities of the local health officer are to
 provide rules and regulations as necessary to preserve health,
 prevent spread of communicable diseases, cause removal of any
 objects detrimental to health, enforce state public health laws
 and regulations, and supervise the staff of the health
 department.  They are also required to enforce the rules and
 regulations of the local board of health.
       D.  Local Board of Health

 Policy-making

 Counties in Wisconsin may have boards of health, county health
 committees or county health commissions.  These bodies consist of
 five to eight members usually appointed by the chairperson of the
 local governing body.  The jurisdiction of the local board
 depends on the size of the county and whether the county has a
 single county board of health.  If there is not a single county
 board of health, there may be a county health commission or
 committee appointed to have jurisdiction over areas of the county
 that do not have city or village boards of health.

 Local boards of health generally have responsibility for securing
 the staffs of the local health department, overseeing the
 operation of the local health department, and protecting the
 health of the citizens within their jurisdiction.

       E.  Staff

 The staffs of local health departments are employed and
 supervised by the local governmental agency.  The number of staff
 for a local health department ranges from 1 to 365.

       F.  Budget

 Total FY 1988 LPHA expenditures were $13,342,000***.  Total FY
 1988 LPHA expenditures were $3,978,948,000.

       Source of Funds
         Federal Grants and Contracts     $10,788,000
         State Funds                       $2,554,000
         Local Funds                                0
         Fees and Reimbursements                    0
         Other Sources                              0
         Source Unknown                             0

 *** Local government funding, which constitutes approximately 69
 percent of local agency budgets, is not included in this figure.
2Wisconsin Division of Health, 1990

 Secretary Health and Social Services
 Administrator Division of Health
 Regions
      Northeastern
      Northern
      Southeastern/Milwaukee
      Southern
      Western

 Office of Health Care Information
 Center for Health Statistics
 Bureau of Health Care Financing
 Bureau of Quality Compliance
 Bureau of Community Health and Prevention
 Bureau of Environmental Health
 Office of Management and Policy
2Types of Local Health Departments by Jurisdiction
                                    Wisconsin, 1990

           Jurisdiction                 Co     C      C/Co   N/Co   T/T

           Adams                        X
           Appleton                            X
           Ashland                      X
           Barron                       X
           Bayfield                     X
           Beloit                              X
           Brown                        X
           Brown Deer                          X
           Buffalo                      X
           Burlington                                               X
           Burnett                      X
           Caledonia                           X
           Calumet                      X
           Chippewa                     X
           Clark                        X
           Columbia                     X
           Crawford                     X
           Cuddahy                             X
           Dane                         X
           De Pere                             X
           Dodge                        X
           Door                         X
           Douglas                      X
           Dover                                                    X
           Dunn                         X
           Eau Claire C Co                            X
           Elmwood Park                        X
           Florence                     X
           Fond Du Lac                  X
           Forest                       X
           Franklin                            X
           Glendale                            X
           Grant                        X
           Green                        X
           Green Bay                           X
           Green Lake                   X
           Greendale                           X
           Greenfield                          X
           Hales Corners                       X
           Iowa                         X
           Iron                         X
           Jackson                      X
           Jefferson                    X
           Juneau                       X
           Kenosa                              X
           Kewaunee                     X
           Konosha                      X
           La Crosse                    X
           Lafayette                    X
           Langlade                     X
           Lincoln                      X
           Madison                             X
           Manitowoc                    X
           Manitowoc                           X
           Marathon                     X
           Marinette                    X
           Marquette                    X
           Menasha                             X
           Milwaukee                           X
           Milwaukee                                         X
           Monominee                    X
           Monroe                       X
           Mount Pleasant                                           X
           Neenah                              X
           Nonway                                                   X
           North Bay                           X
           Oak Creek                           X
           Oconto                       X
           Oneida                       X
           Oshkosh                             X
           Outgamie                     X
           Ozaukee                      X
           Pepin                        X
           Pierce                       X
           Polk                         X
           Portage                      X
           Price                        X
           Racine                                            X
           Racine                              X
           Raymond                                                  X
           Richland                     X
           Rock                         X
           Rusk                         X
           Sauk                         X
           Sawyer                       X
           Shawano                      X
           Sheboygan                    X
           Shorewood                           X
           South Milwaukee                     X
           St. Croix                    X
           St. Francis                         X
           Sturtevant                          X
           Taylor                       X
           Trempealeau                  X
           Union Grove                         X
           Vernon                       X
           Vilas                        X
           Walworth                     X
           Washburn                     X
           Washington                   X
           Waterford                           X
           Watertown                           X
           Waukesha                     X
           Waupaca                      X
           Waushara                     X
           Wauwatosa                           X
           West Allis                          X
           Whitefish Bay                       X
           Winnebago                    X
           Wood                         X
           Yorkville                           X

           Co = County HD
           C = City HD
           C/Co = City/County HD
           N/Co = No County HD
           T/T = Town/Township HD
1WYOMING
2Public Health System Profile
3I.  General State Information

      A.  Selected Sociodemographic Indicators

                                        State      United States

 Population (1988)                    479,000        245,803,000
 Population Density (1988)                  4.9               69.4
   (per/sq.mi.)
 Number of Counties                        23              3,139
 Median Age