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Assessment Protocol for Excellence in Public Health (APEXPH)

U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Public Health Practice Program Office, National Association of County Health Officials (ADDITIONAL COPIES MAY BE OBTAINED FROM NATIONAL ASSOCIATION OF COUNTY HEALTH OFFICIALS, ADDRESS IS AT THE END OF THIS DOCUMENT)

Publication date: 03/01/1991

Table of Contents

A collaborative project of

Executive Summary



The Role of a Local Health Department
The APEXPH Process
How APEXPH Was Developed
About the Process
Overview of the Process: APEXPH is a three part process.
Resources Needed


A collaborative project of

  1. The American Public Health Association
  2. The Association of Schools of Public Health
  3. The Association of State and Territorial Health Officials
  4. The Centers for Disease Control
  5. The National Association of County Health Officials
  6. The United States Conference of Local Health Officers
Funded through a Cooperative Agreement between the Centers for Disease Control and the National Association of County Health Officials, March 1991. Additional copies of this publication may be obtained from National Association of County Health Officials 440 First Street, N.W. Washington, D.C. 20001

Executive Summary

The APEXPH workbook is offered to local health departments as a means of enhancing their organizational capacity and strengthening their leadership role in their communities. It is intended for voluntary use by a local health department. A strong local health department will better enable a community to achieve locally relevant goals.

The workbook guides health department officials in two principal areas of activity: (1) assessing and improving the organizational capacity of the department, and (2) working with the local community to assess and improve the health status of the citizens. It has three main parts.

Part I, Organizational Capacity Assessment, helps a health department director and an internal assessment team focus on improving organizational performance. Included are indicators which focus on authority to operate, community assessment, policy development, and major administrative areas. This part of the workbook assists health departments in creating an organizational action plan, including setting priorities for correcting perceived weaknesses. When the Organizational Capacity Assessment is made an ongoing process, it should result in progressive improvement in the performance of a health department.

Part II, The Community Process, strengthens the partnership between a local health department and its community in addressing the community's major public health problems and building a healthier community. It guides the formation of a community advisory committee, which identifies health problems requiring priority attention and then sets health status goals and programmatic objectives. The aim is to mobilize community resources in pursuit of locally relevant public health objectives. It will lay the groundwork for local adoption of the Healthy People 2000(1) objectives and other appropritate national or state objectives.

Part III, Completing the Cycle, describes activities that are necessary to ensure that the plans developed for Parts I and II are effectively carried out and accomplish the desired results. These activities include policy development, assurance, monitoring, and evaluation.


APEXPH began in July 1987 as a cooperative project of the American Public Health Association (APHA), the Association of Schools of Public Health (ASPH), the Association of State and Territorial Health Officials (ASTHO), the Centers for Disease Control (CDC), the National Association of County Health Officials (NACHO), and the United States Conference of Local Health Officers (USCLHO). A fourteen-member Steering Committee, made up of representatives of the participating associations, provided guidance on policy. A Work Group of representatives of ASTHO, CDC, NACHO and USCLHO prepared this workbook. CDC, NACHO, and USCLHO staff provided research and logistical support. Special thanks are extended to the staff of the many local health authorities who assisted in the development of APEXPH through their voluntary participation in peer review boards, pilot testing, and demonstration activities.


During the past twenty years, increasing attention has been drawn to the fact that we, as a nation, have not applied all that we know to prevent disease, disability, environmental health risks, and premature death. This concern has been the subject of a number of national reports, the most prominent of which have been the following:

  • Healthy People (HEW, 1979)
  • Model Standards for Community Preventive Health Services (HEW, 1979)
  • Promoting Health/Preventing Disease: Objectives for the Nation (HHS,1981)
  • Model Standards: A Guide for Community Preventive Health Services (APHA, 1985)
  • Report of the Presidential Commission on the Human Immunodeficiency Virus Epidemic (The Presidential Commission . . . , 1988)
  • The Future of Public Health (IOM, 1988)
  • Healthy People 2000: National Health Promotion and Disease Prevention Objectives (HHS, 1991).
  • Healthy Communities 2000: Model Standards (APHA, March 1991 proposed publication date)
These reports provide a starting point for addressing public health in the 1990's. They identify a wide range of problems for which strategies and interventions exist to significantly improve community health status. They recognize the need for public and private collaboration; they emphasize the importance of community participation, local leadership, and strong intergovernmental relations; and they assert the need to plan and evaluate public health efforts on the basis of objective statistical data.

Three of these reports directly address the role of the local health authority. The Preamble to the 1979 Model Standards introduced the concept of "a governmental presence (for health) at the local level." The 1985 Model Standards restated that concept. According to those publications, government at the local level has the responsibility for ensuring that health problems are monitored and that services to correct those problems are available. The Future of Public Health (IOM, 1988) further describes the role of a local health department and identifies the three "core functions" of a local health authority as assessment, policy development, and assurance. These reports define a health planning and leadership role for a local health authority that is fundamental to the protection of the community's health. These reports also assert that a community is best served when its health authority assumes a leadership role for public health. This workbook, Assessment Protocol for Excellence in Public Health (APEXPH), has been designed to help local health authorities take on this role. It will guide a local health authority in voluntarily assessing and improving its capacity to lead its community toward improved health.


Public health is what we, as a society, do collectively to assure the conditions in which people can be healthy. The Future of Public Health, Institute of Medicine, 1988.

If we, as a society, are to improve the conditions that affect the health of all of us, we must begin in local communities, dealing with local conditions. Local health departments have a responsibility to take a key role in this effort. They should lead their communities in an examination of local health problems and in the development of plans to overcome those problems. This workbook provides a process by which a local health department can assume this leadership role and work with its community towards a common goal of improved health for its citizens.

The Role of a Local Health Department

Administering a public health department is a demanding responsibility. Rarely is there time to step back from daily concerns and assess the capacity, results, and overall direction of the department, or analyze the opportunities that lie in the future. Rarely is there time for a health department to involve its community in its planning processes, or to lead the society it serves in a collective effort to assure a healthy future for all its people. But, for a health department to fulfill its larger responsibility to its community, it must periodically take time for these activities.

The leadership role of a local health department will be substantially strengthened by periodic self-assessment and adherence to the following principles:

  • Because government has a basic duty to assure the public's health, health departments must lead their communities in assessing health problems, setting appropriate policies, and assuring that health problems are effectively addressed.
  • Because leadership comes with accountability, health departments must set and meet standards of competence and practice that are perceived by their communities as relevant to the protection and promotion of the public health.
  • Because public health problems require hard choices, health departments must be willing to take risks and shape their programs according to the public health needs of the community.
  • Because public health problems demand coordinated, authoritative responses, state and local health departments must find ways to work in partnership and to strengthen each other's resources and authority.
  • Because scientific knowledge should be used in setting public health priorities, health departments should provide their communities with such information and should help them in using it to develop community-based health plans.
  • Because public health problems are multi-dimensional, health departments must seek creative solutions from a wide range of community resources.
  • Because improvements in the public's health require active community ownership and commitment, health departments must work in partnership with community agencies, community leaders, interest groups, and representatives of high risk population groups.
The Assessment Protocol for Excellence in Public Health (APEXPH) provides a method by which a local health department can take action to assume the leadership role defined above.

The APEXPH Process

How APEXPH Was Developed

APEXPH began in July 1987 as a cooperative project of the American Public Health Association (APHA), the Association of Schools of Public Health (ASPH), the Association of State and Territorial Health Officials (ASTHO), the Centers for Disease Control (CDC), the National Association of County Health Officials (NACHO), and the United States Conference of Local Health Officers (USCLHO). The two major groups that were instrumental in the development of the APEXPH workbook were the APEXPH Work Group and the APEXPH Steering Committee. The Work Group, consisting of representatives of ASTHO, CDC, NACHO, and USCLHO, was responsible for the initial development and review of all workbook materials and for subsequent revisions of those materials. The Steering Committee, consisting of representatives of all the cooperating organizations, provided overall direction and policy guidance to the project and was responsible for the review and ratification of all workbook materials.

Once the Work Group and Steering Committee were satisfied that the workbook was ready for more extensive review, Peer Reviewers from selected local health departments reviewed the workbook for content, relevance, readability, and format. Based on their comments, further revisions were made, after which ten local health departments were selected as Pilot Sites. Personnel in those health departments reviewed the entire draft and used Part I, the Organizational Capacity Assessment, to develop Organizational Action Plans. They also tested the data collection component of The Community Process portion of the workbook. These ten pilot tests were completed in July of 1989; based on their results, additional workbook revisions were made.

Following those revisions, thirteen local health departments served as Demonstration Sites in a field test of the workbook. The Demonstration Sites were selected to include large, medium, and small health departments, using the National Profile of Local Health Departments, a comprehensive national database developed by NACHO. Participants at the Demonstration Sites reported that the APEXPH process was valuable and should benefit local health departments of all sizes. Based on recommendations from the Demonstration Sites, final revisions were made.

About the Process

APEXPH is a voluntary process for organizational and community self- assessment, planned improvements, and continuing evaluation and reassessment. It is not intended as a protocol for the evaluation of a local health department by an outside reviewer, such as a state or federal department. It should be most valuable when it is adapted to local circumstances and needs and when it is integrated into the ongoing operations of the health department.

Flexibility is one of the primary features of the APEXPH process. For example, it can involve a large number of staff in a highly structured process or very few people in a less formal approach; either can lead to greater teamwork and improved strategic planning. Examples of documents that were developed by several demonstration sites using earlier drafts of this workbook are provided in Sections I-C and II-C. These demonstrate that the APEXPH process as described in this workbook can be implemented to suit the needs of a particular health department and community.

APEXPH is fundamentally different from other assessment and evaluation protocols in the following ways:

  • It is a true self-assessment and can be completed by its users in a form and manner designed to meet their needs.
  • It leads to a practical plan of action.
  • It focuses on a health department's administrative capacity, basic structure and role in its community, and on the community's actual and perceived problems, rather than on technical performance in specific programs or compliance with a set of objective standards.
  • It provides an opportunity for a local health department to assess its relationships with local government agencies and with community, state and federal health agencies.
  • It can assist in determining how to strengthen these relationships and how to obtain needed support.
  • It provides a protocol through which a health department, by working with the community to assess health needs, set priorities, and develop policy, and assuring that health needs are met, will become recognized within the community as having a major role in the health of its citizens.
  • It can easily be adapted to fit local situations and resources.

Overview of the Process: APEXPH is a three part process.

Part I, Organizational Capacity Assessment

Calls for an internal review of a local health department. It provides for an assessment of a health department's basic administrative capacity and of its capacity to undertake Part II. It is conducted by the health department director and a team of key staff members.

Part II, The Community Process

Is intended to be a more public endeavor, involving key members of a community as well as department staff in assessing the health of the community and identifying the role of the health department in relation to community strengths and health problems. It provides for the use of both objective health data and the community's perceptions of community health problems.

Part III, Completing the Cycle

Integrates the plans developed during the Organizational Capacity Assessment and The Community Process into the ongoing activities of a health department and the community it serves. It discusses policy development, assurance, monitoring, and evaluation of plans developed in conducting Parts I and II.


A first step in planning a self-assessment is assuring that the health department has the authority to undertake the assessment and to act on its results. This may not require any special action for some health departments; others may need to gain the formal approval of their policy boards before proceeding.

Before undertaking either Part I or II, the director and senior management of a health department should review the entire document. Neither the Organizational Capacity Assessment nor The Community Process should be initiated without a clear understanding of the commitment and resources they require and of their possible risks and benefits. Particularly important is the ability to collect and analyze the data needed in Part II, as well as a long-term commitment of time and resources.

Because of its potential for bringing about change, the decision to implement the APEXPH process should be made with the understanding and consent of those who hold a stake in the outcome. The consent of stakeholders does not always have to be formal, but it is essential. Some potential stakeholders are described in both Parts I and II.

Directors of local health departments may vary in the degree to which they choose to involve their communities in self-assessment, planning, policy development, assurance, monitoring, and evaluation called for by the APEXPH process. Although APEXPH does encourage health officials to involve their communities in all of these areas because of the community support which may result, the process can be modified. For example, the Community Health Committee, formed in Part II, may be more limited in size or composition than the workbook recommends. Similarly, the scope of the community health plan developed by the Community Health Committee can be more limited than the text suggests. Such adaptations can make an initial APEXPH implementation more suitable to local circumstances.

Resources Needed

Users caution that the staff time required should not be underestimated. Organizational Capacity Assessment requires collecting and analyzing data, scheduling and conducting meetings, and ensuring adequate communication among all participants.

Typically, resources needed for The Community Process are substantially greater than those needed for the Organizational Capacity Assessment. Ideally, a health department should be able to establish and staff a Community Health Committee, and should have (1) the communication resources to maintain a highly public process, (2) access to appropriate health status data, and (3) staff who can analyze these data and prepare basic information for a Community Health Committee.

Again, it is recommended that a health department director review the entire process at the outset to get a full understanding of the time and resources needed to complete APEXPH satisfactorily. A resource bibliography in Appendix G lists references that may be helpful to workbook users in preparing to conduct the APEXPH process and for answering questions that may arise during implementation.


The APEXPH process often produces recommendations for change in services and for improvements in functioning. Implementation of these recommendations may require funding and/or cooperation by other organizations.

The annual budget process is a convenient way to pace the APEXPH process and use the results. During the budget process, key stakeholders come together to discuss priorities, options, and plans for the coming year. This is true for health departments and for other governmental, voluntary, and private agencies whose cooperation may be needed to implement recommendations that come out of the APEXPH process. Approaching these other agencies at the proper point in their budget process can be effective in gaining their cooperation on programs of mutual interest.

The director of a local health department can also use the results of APEXPH to strengthen the partnership with the state health department. The APEXPH process can pinpoint ways to improve communication and to collaborate on activities of mutual interest.


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