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Scientific Data Documentation
Profile Of State And Territorial Public Health System, 1991ACKNOWLEDGEMENTS Public Health Practice Program Office Division of Public Health Systems October 1991 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Centers for Disease Control This document is in the public domain and may be freely copied or reprinted. Copies of this document are available from CDC. We invite your suggestions and comments on the utility of this publication and ways of improving it. Comments and/or suggestions should be directed to: Edward H. Vaughn Health Systems Analyst Public Health Practice Program Office Centers for Disease Control Atlanta, Georgia 30333 Telephone (404) 639-1943FOREWORD On behalf of the Centers for Disease Control (CDC) and the Public Health Practice Program Office (PHPPO), we are pleased to present the Profile of State and Territorial Public Health Systems: United States, 1990. This publication is a first effort to describe how public health services are organized and delivered in each state and territory. Major components of the public health system in each jurisdiction are described, and the relationships between these components are explored. The cooperation of state and territorial public health officials was invaluable to completing this project. State officials provided much of the information used in the document and made many suggestions for improvement. Several local public health officials also provided information and assistance. In Healthy People 2000: National Health Promotion and Disease Prevention Objectives (1), an ambitious far-reaching objective is proposed: "By the Year 2000, increase to at least 90 percent the proportion of people who are served by a local health department that is effectively carrying out the core functions of public health." To monitor progress toward that objective, we are developing a unique surveillance system designed to assess the status of the public health system at the state and local levels. We have developed these profiles, in part, to assist in this process. Further, we also anticipate that state and local public health officials will find these profiles useful in many ways. For example, they could be used as a starting point for research on the public health system, to compare and/or contrast elements of the system, and as a source for models of organizational structure and function. Finally, CDC personnel and those of other Federal health agencies should find these profiles useful as they work with state and local agencies. For example, CDC, through its Epidemic Intelligence Service (EIS) program, provides assistance in epidemiologic investigations. EIS officers performing such investigations could benefit by familiarizing themselves with the appropriate profile. Similarly, CDC Public Health Advisors assigned to work in state and local agencies could review their state's profile as part of their orientation process. We invite your comments on other uses of these profiles and ways to improve this document in future years. Edward L. Baker, M.D., M.P.H. Director Public Health Practice Program Office Centers for Disease Control SUMMARY Introduction To achieve National Health Promotion and Disease Prevention Objective 8.14, a new surveillance system will be needed that can measure and evaluate the status of public health practice in state and local systems in the United States. As stated in Objective 8.14, by the Year 2000, the nation needs to "increase to at least 90 percent the proportion of people who are served by a local health department that is effectively carrying out the core functions of public health" (1). The design of such a surveillance system requires an understanding of how public health systems in the United States currently are organized, and how state and local components interact. This information is not routinely collected and summarized, nor easily available. Also, public health systems in the United States change so often that the available information soon becomes out of date. The purpose of this book is to offer a descriptive profile of how public health systems in the United States are organized at state and local levels, and how state and local components interact, based on existing information available between 1989 and 1990. Specifics are included on all 50 states, the District of Columbia, and the 8 territories of the United States. Methods In 1989 and 1990, we collected existing pamphlets, brochures, publications, reports, or other printed materials prepared by state and territorial public health systems on selected topics (e.g., the organization of the State Health Agency (SHA); the head of the SHA; the state board of health or council; regional or district health offices; and state-local relationships). For SHAs with a Local Health Liaison Official (LHLO) (a SHA staff member with responsibility for coordinating with the local health departments in the state), we asked the LHLO to provide this information. For SHAs with no LHLO, we identified other appropriate public health officials and requested that they provide similar information. We simultaneously compiled information from other existing data sources. For example, we obtained information on demographics by state from the 1980 national census, and budget information from the Public Health Foundation (2). To identify local public health agencies (LPHAs), we used the following definition: an administrative and service unit of local or state government, concerned with health, employing at least one full-time person, and carrying some responsibility for health of a jurisdiction smaller than the state. This definition was previously used in a national survey of LPHAs by C. Arden Miller (3). We asked SHA representatives to use the Miller definition in reviewing information about LPHAs in their state (e.g., the number of LPHAs; types of geographic jurisdictions for LPHAs; and the number of LPHAs with local boards of health and local health officers). For determining staff and services in LPHAs, we analyzed data from a survey of LPHAs conducted by the National Association of County Health Officials (NACHO) and the Centers for Disease Control (CDC) (4). For these tabulations, we used the NACHO definition of an LPHA: "an administrative and service unit of local or state government concerned with health and carrying some responsibility for the health of a jurisdiction smaller than a state" (4). The NACHO definition is less restrictive than the Miller definition (i.e., the NACHO definition does not require that an LPHA have a "full-time person"). We developed draft documents for each state and territory and returned them to the SHA for review and verification.Results Selected Sociodemographic Indicators Program requirements for public health agencies may differ depending on the characteristics of the population to be served. The demographics of the population vary considerably in different jurisdictions. For example, the 1988 state populations ranged from a low of about 0.5 million in Alaska to a high of about 28 million people in California. The 1988 population density ranged from a low of about 1 per square mile in Alaska to a high of about 1,000 per square mile in New Jersey. The proportion of the population categorized as rural in states in 1980 ranged from a low of 9 percent in California to a high of 66 percent in Vermont. The percent of the population categorized as non-white in states in 1980 ranged from a low of about 1 percent in Vermont to a high of 67 percent in Hawaii. The median age of the population in states in 1987 ranged from a low of about 26 years in Utah to a high of 36 years in Florida. Public health agencies often are health care providers for the most needy portions of the population. The percent of the population in a state below the poverty level in 1985 ranged from a low of about 6 percent in New Hampshire to a high of about 25 percent in Mississippi. Educational levels are another important consideration in delivery of public health services. In 1980, median years of education in state populations ranged from a low of 12.1 years (Kentucky, South Carolina) to a high of 12.8 years (Alaska, Colorado, Utah). County Government Structure The local government structure directly influences LPHA activities and services. County governments are the most common type of local government structure within which LPHAs operate. The relationship between county governments and LPHAs varies within and betwen states. Geographic jurisdictions of LPHAs are as follows: a county in 72 percent (2,067/2,876) of LPHAs; town/township in 11 percent (325/2,876); city in 7 percent (212/2,876); city-county in 6 percent (158/2,876); and multi- county in 4 percent (114/2,876). County government authority is granted by state constitutions or statutes. Thirty-two (64%) states and the District of Columbia permit home rule authority, or local adoption of a home rule option. This option provides counties with an opportunity to enact a "local constitution" which gives the county additional authority and powers (e.g., to levy taxes for LPHA services and activities). About 70 percent of counties have a county commission form of government structure. The commission consists of an elected board, ranging from 2 to over 100 members. The commission has legislative powers that may include passing ordinances and adopting budgets, and administrative powers that may include supervising some or all departments and appointing administrative employees. A hallmark of the commission form of government is that "county commissioners" share administrative responsibility with several independently elected "row officers" such as the county clerk, auditor and recorder, assessor, treasurer, prosecuting attorney, sheriff, and coroner. About 20 percent of counties have a county administrator. The county administrator position is usually appointed by and accountable to the governing board or legislative body. Other titles given this position include chief administrative officer, appointed administrator, administrator, and county manager. About 5 percent of counties have an elected executive. Similar to the position of a mayor, the executive is elected at large and is responsible for working with the county legislative body. Elected executives have veto power over the legislative body. State Health Agencies (SHAs) All 50 states, the District of Columbia, and 8 territories have SHAs responsible for the administration of public health services within their jurisdictions. SHAs usually are organized as one of two models: as a freestanding, independent agency responsible directly to the governor or the board of health, or as a component of a superagency. The SHA is an independent government agency in 31 (62%) states, and a component of a state government superagency in 19 (38%) states and the District of Columbia. Of the seven territories for which information is available, SHAs are independent agencies in six territories and a component of a superagency in one territory. Depending on how activities in a state are organized, public health responsibilities and authority may not be located in the SHA. For example, only 4 SHAs (8%) are the state mental health authority, and only 15 (29%) SHAs are the lead environmental agency for the state (Table S-1). In The Future of Public Health, the Institute of Medicine recommended that each state have a health department that has responsibility for all primarily health-related functions, such as Medicaid, mental health and substance abuse, environmental responsibilities requiring health expertise, health planning, and regulation of health facilities and professions (5). Head of State Health Agency The position of the official who appoints the head of the SHA affects this individual's level of authority and access to key decision makers in state government. The head of the SHA is appointed by the governor to a cabinet-level position in 32 (64%) states; the head of the superagency in which the SHA resides in 14 (28%); and the state board of health in 4 (8%) (Mississippi, Oklahoma, South Carolina, and Texas). The head of the SHA is appointed by the Mayor of the District of Columbia. The head of the SHA is appointed by the governor in the four territories for which this information is available. The head of the SHA is required to have an M.D. degree in 23 (46%) states and the District of Columbia. Of the four territories for which this information is available, two territories require that the head of the SHA have an M.D. degree, and two territories do not. State Board or Councils of Health State boards or councils of health are used for citizen input into the operation of the SHA by 40 (80%) states. These boards or councils function in a policy-making capacity in 21 (42%) states, in an advisory capacity in 17 (34%), and in both capacities in 2 (4%). Regional or District Health Offices A SHA may organize its jurisdiction into regions or districts to provide closer administrative or technical support to Local Public Health Agencies (LPHAs). Administrative regions or districts are used in 28 (56%) states. The number of regions or districts per SHA ranges from a low of 2 (Massachusetts, New Jersey) to a high of 19 (Georgia). Three of the territories also are divided into administrative regions or districts. State-local Liaison The organizational relationships between local public health agencies (LPHAs) and the SHA fall into four broad categories, ranging from one where LPHAs are semi-independent of the SHA to one where LPHAs are sub-units of the SHA. Map S-1 shows variation of state-local relationships by state. State-local relationships are decentralized in 16 (32%) states (local governments directly operate LPHAs); mixed centralized and decentralized in 16 (32%) (local health services may be provided by the SHA, local governmental units, boards of health, or health departments in other jurisdictions); centralized in 10 (20%) (LPHAs function directly under the state's authority and are operated by the SHA or board of health); and shared in 7 (14%) (LPHAs are under the authority of the SHA, as well as the local government and board of health). Budget Total expenditures for public health by states are difficult to compare and interpret because SHA organization and responsibilities differ, and SHA programs vary in importance and content. Total SHA expenditures in fiscal year 1988 ranged from a low of $14 million (Wyoming) to a high of $793 million (California). The total SHA expenditures for public health in that year were less than $100 million in 25 (50%) states; from $100 to 199 million in 15 (30%) states and the District of Columbia; from $200 to 299 million in 4 (8%); from $300 to 399 million in 3 (6%); and more than $400 million dollars in 3 (6%) (California, Maryland, and New York). Local Public Health Agencies (LPHAs) Using the Miller definition of an LPHA (except for Alaska and Hawaii where the SHA requested that some local administrative/service units not be classified as LPHAs), representatives of SHAs reported 2,876 LPHAs. In the 1989 NACHO survey, a total of 2,932 LPHAs were identified (using the less restrictive NACHO definition) (4), a difference of only 2 percent (56/2,932) more LPHAs. In the 1989 NACHO survey, 2,269 (77%) of LPHAs returned completed questionnaires. Forty-two percent of these LPHAs served less than 25,000 population, and an additional 23 percent served less than 50,000 population (4). Services Provided Activities in assessment, policy development, and assurance reported by the respondent LPHAs in the 1989 NACHO survey are summarized Tables S-2, S-3, and S-4. The percentage of LPHAs reporting activity in specific functions generally increased as the size of the population served by the jurisdiction increased. Immunizations, reportable diseases, child health, and tuberculosis control activities were reported by almost all (80% or more) of LPHAs. At least half the LPHAs reported activities in the following areas: health education; sexually transmitted diseases; Women, Infants, and Children (WIC) program; family planning; prenatal care; acquired immunodeficiency syndrome (AIDS) testing and counseling; chronic diseases; and home health care. From 35 percent to 49 percent of LHDs provided services to handicapped children and laboratory and dental services. Less than 25 percent provided services in the following categories: occupational safety and health, primary care, obstetrical care, drug and alcohol use, mental health, emergency medical services, long-term facilities, and hospitals. Local Board of Health Local boards of health are used in 38 (76%) states to provide local input into or control of the operation of LPHAs. Local boards have policy-making responsibilities in 28 (56%) states, advisory responsibilities in 5 (10%), both advisory and policy-making responsibilities in 3 (6%), and different responsibilities in different geographic areas in 2 (4%). None of the territories reported having local boards of health. Local Health Officer A local health officer (or equivalent official) is assigned responsibility to provide LPHA leadership in 48 (96%) states. Minnesota and Rhode Island have no local health officers. Local health officers are appointed by the local board of health in 19 (38%) states, by the local governmental authority in 16 (32%), by the head of the SHA in 9 (18%), by the State Board of Health in 2 (4%), by the Deputy Commissioner for Health in 1 (2%), and by the state merit system in 1 (2%). Local health officers are required to have an M.D. degree in 22 (44%) states. An additional 3 (6%) states require M.D. degrees in some LPHAs. Staff LPHA staff are employed by the LPHA in 31 (62%) states, by the SHA in 9 (18%), and by combinations of SHA and LPHA in 9 (18%). The number of employees per LPHA ranges from 1 to 26,000. Additional details on the characteristics of LPHA staff are available from the 1989 NACHO questionnaire survey (4). Forty- six percent of 2,137 respondent LPHAs report a staff size of 9 or fewer full-time employees. Typically, the majority of LPHAs serving jurisdictions with less than 25,000 population report employing a clerical or secretarial employee (89%); a registered nurse (83%); and an engineer/sanitarian (65%). In addition to these, the majority of LPHAs serving jurisdictions with 25,000 to 49,999 population also report employing a physician (65%). In addition to these staff, the majority of LPHAs serving jurisdictions with 50,000 to 99,999 population also report employing a health educator (54%) and nutritionist/dietitian (67%). Budget Total expenditures for public health in LPHAs are difficult to compare and interpret for reasons similar to those limiting comparison of SHA expenditures (i.e., LPHA organization and responsibilities may differ, and LPHA programs can vary in importance and content). Total LPHA expenditures for fiscal year 1988 by state ranged from a low of $57,000 (New Hampshire) to a high of $439 million (California). The total LPHA expenditures by state in that year were less than $100 million in 30 (71%) of the 42 states which reported local health department expenditures; from $100 to 199 million in 7 (17%); from $200 to 299 million in 3 (7%); and more than $300 million in 2 (5%) (California and New York).Discussion and Conclusion This book provides a descriptive profile of how public health systems in the United States are organized at the state and local levels, and how state and local components interact, based on information available in 1989 and 1990. Several general patterns are apparent from the profiles. For example, the public health system typically involves the following units of organization: SHAs (100% of states); state administrative regions or districts (56% of states); and counties (72% of states). The SHA usually is an independent government agency (62% of states). LPHAs commonly are operated directly by local government (32% of states) or by a mixture of local and state government (32% of states). Citizen input into the public health system occurs at the state level through state boards or councils of health (80% of states), and at the local level through local boards of health (76% of states). Although SHAs and LPHAs typically have physicians on staff or access to input from physicians, top administrative leadership positions tend to be filled by non- physicians, with only 46% of states requiring the head of the SHA or the LPHA to have a medical degree. In addition, the size of the population served in a jurisdiction is an important factor related to the organization and nature of public health agencies. The number and nature of LPHA activities, and the number and level of specialization of staff, generally increase as the size of the population served by the jurisdiction increases. In 1945, Emerson recommended that LPHAs should serve populations of no less than 50,000 (6). Many experts have debated the merits of this. Additional studies would appear worthwhile, since the majority (65%) of LPHAs in the 1989 study by NACHO report that they served jurisdictions with less than 50,000 population. To monitor progress towards achieving Healthy People 2000 Objective 8.14, the nation must develop a surveillance system that can measure and evaluate the status of public health practice in state and local systems in the United States. Surveillance information will be needed in three broad areas: 1) the geographic boundaries of LPHA jurisdictions; 2) simple descriptive information regarding public health agencies and the populations which they serve (e.g., budgets, workforce, services, demographic information, and organizational structure); and 3) information to describe how effectively LPHAs perform the core functions of public health in their jurisdiction (assessment, policy development, and assurance). CDC has identified 10 organizational practices or processes that must be carried out by a component of the public health system in each locality. These 10 practices or processes are summarized in Table S-5. The profiles in this book represent a first step toward developing a surveillance system for Objective 8.14. The profiles provide information related to the first and second areas of surveillance (i.e., geographic boundaries and simple descriptive information). Much more will be needed. For example, the profiles do not include any information on the 10 practices or processes, nor has any attempt been made to measure or evaluate the effectiveness of LPHAs. At least four challenges remain for future surveillance efforts: The first challenge will be to operationally define the elements of each of the 10 practices or processes for surveillance purposes, and then to develop indicators and validate those indicators as measures of the practices. The second challenge will be the changes that tend to occur in the organization of public health agencies. For example, during the 6 months that elapsed while draft profiles were being circulated to SHAs for review, five states modified their SHA structure. Frequent updates will be needed to keep information current. The third challenge will be the diversity that exists in the organization and activities of SHAs and LPHAs. For example, one LPHA may have an epidemiologist as a staff member, while another LPHA may obtain assistance from an epidemiologist with the SHA. Similarly, environmental health may be the responsibility of one SHA, but not another. As a result of differences in organizational structure and activities, different agencies may need to be evaluated independently (i.e., while comparisons over time within a SHA may be possible, comparisons between different SHAs may not be possible). An area where research is definitely needed is whether a system of classification (or typology) of SHAs and LPHAs might be possible, which would facilitate surveillance, comparison, and evaluation of effectiveness. For example, while comparison of a large LPHA with a small LPHA may be analogous to a comparison of "apples and eggs," comparison of a small LPHA with another small LPHA might be meaningful. The fourth challenge for future surveillance efforts will be to identify the most useful data for describing and monitoring local public health practice in the United States. The hope is that as greater experience is gained, a small number of measures will begin to be identified that will allow monitoring of trends over time in a standardized fashion, facilitate comparisons between and among communities, identify problem areas that managers need to investigate further, and help managers decide how to best use resources.Table S-1 Responsibilities of State Health Agencies (SHAs) in 50 States and the District of Columbia, 1990. SHAs (N=51) Responsibilities n ( %) State Public Health Authority 51 (100) Institutional Licensing Agency 41 ( 80) Institutional Certifying Authority for Federal Reimbursement 40 ( 78) State Agency for Children with Special Health Care Needs 39 ( 77) State Health Planning and Development Agency 22 ( 43) State Institutions/Hospitals 16 ( 31) Lead Environmental Agency in the State 15 ( 29) State Professions Licensing Agency 10 ( 20) Medicaid Single State Agency 5 ( 10) State Mental Health Authority 4 ( 8) SOURCE: Characteristics of State and Local Health Agencies 1988 (7).Table S-2 Assessment and Policy Development: Activities Reported by 2,269 Local Public Health Agencies (LPHAs), 1990. LPHAs Reporting Activities Activities n ( %) Assessment A. Data Collection/Analysis 1. Reportable Diseases 1,978 ( 87) 2. Vital Records and Statistics 1,440 ( 64) 3. Morbidity Data 1,114 ( 49) 4. Behavioral Risk Assessment 752 ( 33) B. Epidemiology/Surveillance 1. Communicable Diseases 2,072 ( 91) 2. Chronic Diseases 1,235 ( 54) Policy Development A. Health Code Development and Enforcement 1,330 ( 59) B. Health Planning 1,299 ( 57) C. Priority Setting 1,166 ( 51) SOURCE: National Association of County Health Officials 1990 (4).Table S-3 Assurance: Inspection, Licensing, Health Education, and Environmental Activities Reported by 2,269 Local Public Health Agencies (LPHAs), 1990. LPHAs Reporting Activities Activities n ( %) Inspection 1. Food and Milk Control 1,639 ( 72) 2. Recreational Facility Safety/Quality 1,233 ( 54) 3. Health Facility Safety/Quality 1,063 ( 47) 4. Other Facility Safety/Quality 722 ( 32) Licensing 1. Other Facilities 1,621 ( 71) 2. Health Facilities 489 ( 22) Health Education 1,679 ( 74) Environmental 1. Sewage Disposal Systems 1,785 ( 79) 2. Individual Water Supply Safety 1,742 ( 77) 3. Vector and Animal Control 1,582 ( 70) 4. Water Pollution 1,353 ( 60) 5. Public Water Supply Safety 1,311 ( 58) 6. Solid Waste Management 1,252 ( 55) 7. Hazardous Waste Management 1,048 ( 46) 8. Air Quality 739 ( 33) 9. Occupational Health and Safety 526 ( 23) 10. Radiation Control 472 ( 21) 11. Noise Pollution 458 ( 20) SOURCE: National Association of County Health Officials 1990 (4).Table S-4 Assurance of Personal Health Services: Activities Reported by 2,269 Local Public Health Agencies (LPHAs), 1990. LPHAs Reporting Activities Activities n ( %) Personal Health Services 1. Immunizations 2,089 ( 92) 2. Child Health 1,903 ( 84) 3. Tuberculosis 1,826 ( 81) 4. Sexually Transmitted Diseases 1,650 ( 73) 5. Chronic Diseases 1,570 ( 69) 6. WIC 1,564 ( 69) 7. Family Planning 1,347 ( 59) 8. Prenatal Care 1,339 ( 59) 9. AIDS Testing and Counseling 1,294 ( 57) 10. Home Health Care 1,139 ( 50) 11. Handicapped Children 1,062 ( 47) 12. Laboratory Services 983 ( 43) 13. Dental Health 851 ( 38) 14. Primary Care 501 ( 22) 15. Obstetrical Care 459 ( 20) 16. Drug Abuse 389 ( 17) 17. Alcohol Abuse 351 ( 16) 18. Mental Health 319 ( 14) 19. Emergency Medical Service 293 ( 13) 20. Long-term Care Facilities 143 ( 6) 21. Hospitals 64 ( 3) SOURCE: National Association of County Health Officials 1990 (4).Table S-5 Ten Organizational Practices or Processes That Must Be Carried Out by a Component of the Public Health System in Each Locality. ASSESSMENT 1. ASSESS the health needs of the community. 2. INVESTIGATE the occurrence of health effects and health hazards in the community. 3. ANALYZE the determinants of identified health needs. POLICY DEVELOPMENT 4. ADVOCATE FOR PUBLIC HEALTH, BUILD CONSTITUENCIES and identify resources in the community. 5. SET PRIORITIES among health needs. 6. DEVELOP PLANS and policies to address priority health needs. ASSURANCE 7. MANAGE resources and develop organizational structure. 8. IMPLEMENT programs. 9. EVALUATE programs and provide quality assurance. 10. INFORM and EDUCATE the public.GUIDE FOR USING THE PROFILE Suggested Uses This book is intended for use by Federal, state, and local public health officials as a reference on the public health system in each state and territory. Federal health officials who are working with state and local health departments can use this book to familiarize themselves with a state or territory. For example, Epidemic Intelligence Service (EIS) Officers or other Federal assignees could use this book to review the public health system before working in a state. The book also enables Federal, state, or local health officials to compare or contrast the public health system in different states or territories. It is a handy source of information on the structure of public health agencies and the interrelationships between the components of these agencies. The book can also be used as a starting point for future research on the public health system. General Format The outline that follows is used throughout the book, with only minor variations, to describe the major components of the public health system in each state or territory and the relationships between the components. For territories, however, an additional section in the outline entitled, "Location, Geography and People," is added. Under each item in the outline is a brief description of the type of information that will be presented for each state or territory. The states and the District of Columbia are presented in alphabetical order followed by the territories in alphabetical order. Rhode Island and Delaware state that they have no local health departments. Hawaii and New Mexico report only a single, autonomous local health department in each state: the city of Honolulu for the former and Los Alamos County for the latter. With the exception of the two small autonomous units in Hawaii and New Mexico, these states classify their systems as completely centralized. With the exception of Rhode Island, which delivers or arranges all public health services from a centralized state health agency, they do, however, deliver services from district offices at the local level. We have included these state-controlled service units in Delaware under the local health department section, while at the same time recognizing that the state does not consider these "local health departments." Hawaii and New Mexico requested that their local service units not be categorized as local health departments.State Public Health System Profile Selected Sociodemographic Indicators State United States Population (1988) 245,803,000 Population Density (1988) 69.4 (per/sq.mi.) Number of Counties 3,139 Median Age (1987) 31.7 Percent Below Poverty Level (1985) 14.0 (persons) Percent of Population Rural (1980) 26.0 Percent of Population White (1980) 83.1 Percent of Population Non-white (1980) 16.9 Median Years of Education (1980) 12.5 (25 Years of age and over) The sources of these data for sociodemographic indicators are Current Population Reports, County Population Estimates: July 1, 1988, 1987, 1986 (8), The State Policy Data Book 1988 (9), State and Metropolitan Area Data Book 1986 (10), Census of Population (11), and Census of Population (12). County Government Structure Home Rule or No Home Rule Authority - This section indicates whether the state and counties have home rule. It also describes the structure and function of county governments in each state. The role and responsibility of key players, such as elected executives or administrators, are described. The roles are described because these players are often quite involved in delivering public health services at the local level. Their involvement may include the budget process and/or policy-making when the governing body serves as the local board of health. Each paragraph discussing a different form of government begins with the form underlined and the number of counties using that form enclosed in parentheses, i.e., Commission Form (25). The adoption of home rule by states and counties is noted as it relates to the ability to levy taxes for specific purposes and as an indicator of an individual county's capacity for self-government. Home Rule Authority - A grant of authority from the state to counties through statutes or constitutions allows local self-determination. Home rule is not a form of government but an authority to effect change in the areas of structure, function, and fiscal powers. Charter Reform is a tool used by the counties to achieve greater levels of home rule authority. It is the mechanism used to form charter commissions for achieving county reform. This is accomplished through state constitutional amendment or legislative measures that ultimately serve as a broader tool for home rule authority. The following are the most common forms of local government: Commission Form - This is the most traditional and widely used form of county government. Under the Commission Form an elected board of from 2 to over 100 has legislative powers, such as passing ordinances, adopting budgets, and also administrative powers such as supervising some or all departments and appointing some administrative employees. A hallmark of the Commission Form is that "county commissioners" share administrative responsibility with several independently elected "row officers" who frequently include a county clerk, auditor and recorder, assessor, treasurer, prosecuting attorney, sheriff, and coroner. County Administrator - This position is usually appointed by and accountable to the governing board or legislative body. Other titles given this position are chief administrative officer, appointed administrator, administrator, and county manager. Elected Executive - Similar to the position of a mayor, this position is elected at large and is responsible for working with the county legislative body. Elected executives are strong, partially due to their veto power over the legislative body. Other forms of county government less frequently seen in the descriptive profiles will be briefly described by individual state. The source of these data for states is County Government Structure: A State By State Report, 1989 (13). The source of information on the government structure of territories is The Europa World Year Book, 1990 (14). The sources of information on the location, geography and people of the territories are The Europa World Year Book, 1990 (14), Evaluation of Federal Support to Health Systems of the Pacific Insular Jurisdictions of the U.S., 1984 (15), and A Reevaluation of Health Services in U.S.-Associated Pacific Island Jurisdictions, 1989 (16). State Health Agency (SHA) General Free-standing, Independent or Component of Superagency - The SHA is categorized as a free-standing, independent agency or a component of a superagency. This section contains information about the SHA, such as its name, mission statement, and some areas of responsibility. The responsibilities are taken from a list that includes the following areas: State Public Health Authority Medicaid Single State Agency Lead Environmental Agency in the State State Mental Health Authority State Agency for Children with Special Health Care Needs State Health Planning and Development Agency State Professions Licensing Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals The source of these data on the responsibilities of SHAs is Characteristics of State and Local Health Agencies, 1988 (7). Head of State Health Agency M.D. Requirement, Cabinet-level Appointment - This section indicates if an M.D. is required for the head of the SHA and whether the position is a cabinet-level office. It identifies the head of the SHA and includes information about the position such as the title, method of appointment, and responsibilities. State Board of Health/Council Advisory or Policy-making - This section describes the State Board of Health/Council as advisory or policy-making in nature. The composition, method of appointment, roles, and responsibilities of the boards and/or councils are discussed. Regional/District Health Offices Here is indicated whether the state has been administratively divided into districts or regions using the terms designated by the particular state, i.e., "management areas," "public health areas," etc. The location of the regional/district offices and the area served by these offices are illustrated on a state map. The structure and types of programs administered are included, as well as line of authority to state and local levels. State-local Liaison Type of Organizational Control, Formal or Informal Liaison Function - In this section the relationship between the SHA and local public health agencies is characterized as one of the following types: Centralized Organizational Control - local health departments function directly under the state's authority and are operated by an SHA or a board of health. Decentralized Organizational Control - local governments directly operate local health departments with or without a board of health. Mixed Centralized and Decentralized Organizational Control - local health services may be provided by the SHA, local governmental units, boards of health, or health departments in other jurisdictions. Shared Organizational Control - local health departments are under the authority of the SHA, as well as the local government and board of health. Also included in this section is a discussion of the state-local liaison function, including authority and responsibility. The source of these data on the relationship between state and local health departments is Characteristics of State and Local Health Agencies, 1988 (7). Budget The total FY 1988 SHA expenditures, by source of funds, are compared with total FY 1988 United States SHA expenditures. The source of these data is Public Health Agencies 1990: An Inventory of Programs and Block Grant Expenditures (2). Local Public Health Agencies (LPHAs) General This section describes local health departments and classifies them according to the administrative/service areas within their jurisdictions. This classification scheme includes city, city-county, county, multicounty, township/town, multitownship, and borough jurisdictions. A map is included to illustrate local public health jurisdictions in each state and territory. When more than one city and/or township/town health department exists in the same county, the symbol on the map designating the type of unit will be followed by the number of units in parentheses. To identify the number and types of local public health agencies (LPHAs), we used the following definition developed by C. Arden Miller: an administrative and service unit of local or state government, concerned with health, employing at least one full-time person, and carrying some responsibility for health of a jurisdiction smaller than the state (3). We also utilized data on services provided and staff employed by LPHAs which were obtained from a survey conducted by the National Association of County Health Officials and the Centers for Disease Control (unpublished survey results, 1989). For these tabulations we used the NACHO definition of an LPHA: "an administrative and service unit of local or state government concerned with health and carrying out some responsibility for the health of a jurisdiction smaller than a state" (4). The NACHO definition is less restrictive than the Miller definition (i.e., the NACHO definition does not require that an LPHA have a "full-time person"). Services Provided Public health services provided by LPHAs in each state are included. The data on services provided by LPHAs are derived, unless stated otherwise, from a survey of LPHAs that was conducted by the National Association of County Health Officials and Centers for Disease Control (unpublished survey results, 1989). The percent of LPHAs reporting is calculated by dividing the total number of LPHAs responding to the survey in each state by the number of LPHAs reporting they provide the particular service. The services that are provided by 70 percent of LPHAs are underlined. The percent of units reporting will not be given for states with five or fewer respondents. The service information is provided in three major categories: assessment activities, assurance activities, and policy development. The data are presented in column format displayed as follows: Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 9 ( 23.1%) 2. Morbidity Data 25 ( 64.1%) 3. Reportable Diseases 33 ( 84.6%) 4. Vital Records and Statistics 36 ( 92.3%) B. Epidemiology/Surveillance 1. Chronic Diseases 21 ( 53.8%) 2. Communicable Diseases 38 ( 97.4%) II. Policy Development A. Health Code Dev. and Enforcement 24 ( 61.5%) B. Health Planning 13 ( 33.3%) C. Priority Setting 21 ( 53.8%) III. Assurance Activities A. Inspection 1. Food and Milk Control 37 ( 94.9%) 2. Health Facility Safety/Quality 20 ( 51.3%) 3. Rec. Facility Safety/Quality 16 ( 41.0%) 4. Other Facility Safety/Quality 11 ( 28.2%) B. Licensing 1. Health Facilities 7 ( 17.9%) 2. Other Facilities 34 ( 87.2%) C. Health Education 27 ( 69.2%) D. Environmental 1. Air Quality 6 ( 15.4%) 2. Hazardous Waste Management 11 ( 28.2%) 3. Individual Water Supply Safety 34 ( 87.2%) 4. Noise Pollution 3 ( 7.7%) 5. Occupational Health and Safety 4 ( 10.3%) 6. Public Water Supply Safety 20 ( 51.3%) 7. Radiation Control 7 ( 17.9%) 8. Sewage Disposal Systems 39 (100.0%) 9. Solid Waste Management 34 ( 87.2%) 10. Vector and Animal Control 38 ( 97.4%) 11. Water Pollution 17 ( 43.6%) E. Personal Health Services 1. AIDS Testing and Counseling 39 (100.0%) 2. Alcohol Abuse 2 ( 5.1%) 3. Child Health 38 ( 97.4%) 4. Chronic Diseases 28 ( 71.8%) 5. Dental Health 12 ( 30.8%) 6. Drug Abuse 2 ( 5.1%) 7. Emergency Medical Service 1 ( 2.6%) 8. Family Planning 39 (100.0%) 9. Handicapped Children 3 ( 7.7%) 10. Home Health Care 38 ( 97.4%) 11. Hospitals 1 ( 2.6%) 12. Immunizations 39 (100.0%) 13. Laboratory Services 19 ( 48.7%) 14. Long-term Care Facilities 10 ( 25.6%) 15. Mental Health 2 ( 5.1%) 16. Obstetrical Care 19 ( 48.7%) 17. Prenatal Care 36 ( 92.3%) 18. Primary Care 22 ( 56.4%) 19. Sexually Transmitted Diseases 38 ( 97.4%) 20. Tuberculosis 39 (100.0%) 21. WIC 38 ( 97.4%) Local Health Officer M.D. Requirement, Appointment - This section shows if an M.D. requirement exists and how the health officer is appointed. The authority and responsibilities that this position holds are described. Local Board of Health Advisory or Policy-making - This section is used to indicate whether the local board of health has advisory or policy-making responsibility. The existence, composition, terms of office, and responsibilities of local boards of health are discussed. Staff This section contains a discussion of the staff of LPHAs. Included is information about the employer of the staff, supervision, and a range of staff size. The sources of these data on the range of staff size are the National Association of County Health Officials and the Centers for Disease Control (unpublished survey results, 1989). Budget The total FY 1988 LPHA expenditures for each state and the United States are provided. The source of funds is also provided. The source of these data is Public Health Agencies 1990: An Inventory of Programs and Block Grant Expenditures (2). Following this outline will be a table of organization for the SHA and a map of the state depicting the type and number of local health departments, administrative regions/districts if they exist, and the location of regional/district offices.ALABAMA Public Health System Profile I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 4,103,000 245,803,000 Population Density (1988) 80.8 69.4 (per/sq.mi.) Number of Counties 67 3,139 Median Age (1987) 31.0 31.7 Percent Below Poverty Level (1985) 20.6 14.0 (persons) Percent of Population Rural (1980) 40.0 26.0 Percent of Population White (1980) 73.8 83.1 Percent of Population Non-white (1980) 26.2 16.9 Median Years of Education (1980) 12.2 12.5 (25 years of age and over) B. County Government Structure No Home Rule Authority The source of power for Alabama counties is state statutes, which establish the legal framework of county government and delineate the authority and duties of the governing bodies. Commission Form - (67) - This form is the basis of all county governments in the state and is made up of three to seven members usually elected from districts. About one-third of the counties elect a probate judge, at large, who serves as the chair of the commission. As chairman and presiding officer the judge is responsible for recording proceedings of the commission, issuing all necessary orders, administering finances, and generally maintaining county authority. The chair is permitted to vote only in tie-breaking situations. Other counties have a chair that is elected from the commission with duties and authority that are similar to those that general law confers on probate judges who serve as chairs of county commissions. Counties that have this arrangement have adopted it through local legislation. Finally, there are 31 other counties that have appointed administrators which assist the commission in daily administration of the county. Data for this state were updated February 1991.II. State Health Agency (SHA) A. General Free-standing, Independent The Alabama Department of Public Health, the SHA, is a free-standing, independent agency. The mission of the SHA is to serve the people in Alabama by assuring conditions in which they can be healthy. The SHA, under the direction of the State Board of Health, has the following general responsibilities: 1. To exercise general control over the enforcement of the laws relating to public health. 2. To investigate the causes, modes of propagation, and means of prevention of diseases. 3. To investigate the influence of localities and employment on the health of the people. 4. To inspect all schools, hospitals, asylums, jails, theaters, opera houses, courthouses, churches, public halls, prisons, stockades where convicts are kept, markets, dairies, milk depots, slaughter pens or houses, railroad depots, railroad cars, street railroad cars, lines of railroads and street railroads, industrial and manufacturing establishments, offices, stores, banks, club houses, hotels, rooming houses, residences and other similar places. Whenever insanitary conditions in any of these places, institutions or establishments or conditions prejudicial to health, or likely to become so, are found, proper steps are taken by the proper authorities to have such conditions corrected or abated. The following are some specific areas of responsibility for the SHA: State Public Health Authority Institutional Licensing Authority Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency M.D. Requirement, Not Cabinet-level Appointment The State Health Officer is appointed by and functions under the direction of the State Committee of Public Health. Statutes require this individual to be a physician. The State Health Officer acts as the executive officer of the Department of Public Health on behalf of the Committee, when the Committee is not in session. The State Health Officer also exercises general supervision over county boards of health and county health officers. It is the responsibility of the Health Officer to keep abreast of all diseases which may be in danger of invading the state, and to take prompt measures to prevent such invasions and keep the Governor and the Legislature informed as to health conditions prevailing in the state, especially as to outbreaks of any notifiable diseases; and submit to the Governor and Legislature recommendations for controlling the outbreaks. C. State Board of Health/Council Policy-making The Medical Association of the state of Alabama serves as the State Board of Health. There is also a State Committee of Public Health which is composed of 12 members of the Board of Censors of the Medical Association and the chairmen of 4 councils: 1) Council of Dental Health; 2) Council on Animal and Environmental Health; 3) Council on the Prevention of Disease and Medical Care; and 4) Council on Health Costs, Administration, and Organization. Physician members of the Committee are selected by the State Board of Health, one from each congressional district in the state and the remainder from the state-at-large. The "State Board of Health" is the same as the "State Committee of Public Health" except when the State Board of Health is actually in session. The State Committee of Public Health possesses all of the prerogatives, powers, and duties prescribed by law for the State Board of Health. The State Board of Health may, by a three-fifths vote, alter or amend any action of the State Committee of Public Health, but only when the board is in session. The duty of the four councils is to provide public health information, evaluation of data, research, advice and recommendation to the State Committee of Public Health and perform other functions requested by the Committee. D. Regional/District Health Offices Alabama is divided into nine administrative regions called Public Health Areas (see attached map). Area offices are commonly staffed by individuals who fill the following positions: Assistant State Health Officer Clinicians Area Disease Coordinator Area Health Educator Coordinator Area Nutrition Coordinator Area Social Worker Coordinator Area Nursing Director Area Environmental Director Area Administrator Assistant Area Administrator Area Clerical Director Area Office Clerks Most of the staffs of the area offices are in the chain of command and involved in the supervision of the local health department staffs. The Assistant State Health Officers supervise the county and area health officers within their geographic area of responsibility. In some counties the Assistant State Health Officer for the Area will be appointed as the county health officer, while in other areas the county will appoint someone else as county health officer. Alabama also has four district health departments. The district health departments are Northwest Alabama Regional Health Department (Colbert, Franklin, and Lauderdale counties), Tri-county District Health Department (Cullman, Lawrence, and Limestone counties), West Alabama District Health Department (Bibb, Greene, Lamar, Pickens, and Tuscaloosa counties), and Gulf Coast District Health Department (Baldwin, Conecuh, and Escambia counties). These are historical, multicounty units which function as units for some issues, such as funding, but generally the counties in these districts have administrative functions which are similar to other counties under the supervision of the area office. While these units still exist, the current focus is on the Public Health Areas rather than district health departments. E. State-local Liaison Shared Organizational Control, Informal Liaison Function The liaison function between the SHA and local health agencies is accomplished through the formal chain of command that extends from the SHA to Public Health Areas and to local health departments. The interaction between state and local public health agencies in Alabama may be characterized as shared organizational control. Under this arrangement local health departments are under the authority of the state as well as the local government and board of health. F. Budget Total FY 1988 SHA expenditures were $90,564,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $52,550,000 State Funds $34,906,000 Local Funds 0 Fees and Reimbursements $2,383,000 Other $726,000 III. Local Public Health Agencies (LPHAs) A. General The 67 county health departments in Alabama function as the LPHAs in the state. They are staffed by State Merit System employees. While general supervision and direction comes from the state, there is also input from the local board of health. Budgets are developed for each county and presented to the State Health Officer for approval. These budgets are made up of a mixture of local and state funds. State-appropriated funds are allocated to the counties according to need. B. Services Provided The following information on services provided by local health departments in Alabama is derived from a survey conducted by NACHO during 1989. Thirty-nine of the 67 local health departments in Alabama responded to the survey. Services provided by 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 9 ( 23.1%) 2. Morbidity Data 25 ( 64.1%) 3. Reportable Diseases 33 ( 84.6%) 4. Vital Records and Statistics 36 ( 92.3%) B. Epidemiology/Surveillance 1. Chronic Diseases 21 ( 53.8%) 2. Communicable Diseases 38 ( 97.4%) II. Policy Development A. Health Code Dev. and Enforcement 24 ( 61.5%) B. Health Planning 13 ( 33.3%) C. Priority Setting 21 ( 53.8%) III. Assurance Activities A. Inspection 1. Food and Milk Control 37 ( 94.9%) 2. Health Facility Safety/Quality 20 ( 51.3%) 3. Rec. Facility Safety/Quality 16 ( 41.0%) 4. Other Facility Safety/Quality 11 ( 28.2%) B. Licensing 1. Health Facilities 7 ( 17.9%) 2. Other Facilities 34 ( 87.2%) C. Health Education 27 ( 69.2%) D. Environmental 1. Air Quality 6 ( 15.4%) 2. Hazardous Waste Management 11 ( 28.2%) 3. Individual Water Supply Safety 34 ( 87.2%) 4. Noise Pollution 3 ( 7.7%) 5. Occupational Health and Safety 4 ( 10.3%) 6. Public Water Supply Safety 20 ( 51.3%) 7. Radiation Control 7 ( 17.9%) 8. Sewage Disposal Systems 39 (100.0%) 9. Solid Waste Management 34 ( 87.2%) 10. Vector and Animal Control 38 ( 97.4%) 11. Water Pollution 17 ( 43.6%) E. Personal Health Services 1. AIDS Testing and Counseling 39 (100.0%) 2. Alcohol Abuse 2 ( 5.1%) 3. Child Health 38 ( 97.4%) 4. Chronic Diseases 28 ( 71.8%) 5. Dental Health 12 ( 30.8%) 6. Drug Abuse 2 ( 5.1%) 7. Emergency Medical Service 1 ( 2.6%) 8. Family Planning 39 (100.0%) 9. Handicapped Children 3 ( 7.7%) 10. Home Health Care 38 ( 97.4%) 11. Hospitals 1 ( 2.6%) 12. Immunizations 39 (100.0%) 13. Laboratory Services 19 ( 48.7%) 14. Long-term Care Facilities 10 ( 25.6%) 15. Mental Health 2 ( 5.1%) 16. Obstetrical Care 19 ( 48.7%) 17. Prenatal Care 36 ( 92.3%) 18. Primary Care 22 ( 56.4%) 19. Sexually Transmitted Diseases 38 ( 97.4%) 20. Tuberculosis 39 (100.0%) 21. WIC 38 ( 97.4%) C. Local Health Officer M.D. Requirement, County Board of Health Appointment The county health officer is elected by the county board of health subject to the approval of the State Committee of Public Health. The local health officer, under the direction of the State Health Officer and the county board of health, has sole direction of all sanitary and public health work within the county and incorporated municipalities. D. Local Board of Health Policy-making The boards of censors of county medical societies, in affiliation with the Medical Association of the state of Alabama and organized in accordance with the provisions of its constitution, are constituted county boards of health of their respective counties under the supervision of the State Board of Health. The duties of the county boards of health subject to the supervision and control of the State Board of Health are as follows: 1. To supervise the enforcement of the health laws of the state, including all ordinances or rules and regulations of municipalities or of county boards of health or of the State Board of Health, and to supervise the enforcement of the law for collection of vital and mortuary statistics and to adopt and promulgate, if necessary, rules and regulations for administering the health laws of the state and rules and regulations of the State Board of Health, which rules and regulations of the county boards of health have the force and effect of law and are executed and enforced by the same bodies, officials, agents and employees as in the case of health laws. 2. To investigate, through county health officers or quarantine officers, cases or outbreaks of any notifiable diseases and to enforce such measures for the prevention or extermination of said diseases as are authorized by law. 3. To investigate, through county health officers or quarantine officers, all nuisances to public health and, through said officers, to take proper steps for the abatement of such nuisances. 4. To exercise, through county health officers or quarantine officers, special supervision over the sanitary conditions of schools, hospitals, asylums, jails, theaters, opera houses, courthouses, churches, public halls, prisons, markets, dairies, milk depots, slaughter pens or houses, railroad depots, railroad cars, dining cars, street railroad cars, lines of railroads and street railroads, airports, industrial and manufacturing establishments, offices, stores, banks, club houses, hotels, rooming houses, residences and the sources of supply, tanks, reservoirs, pumping stations and avenues of conveyance of drinking water and other institutions and places of like character and, whenever unsanitary conditions are found, to use all legal means to have the same abated. E. Staff Staffs of local health departments belong to the State Merit System. They may be employed locally and paid with funds from a variety of sources, but they are technically state employees. The number of full-time employees for local health departments ranges from 7 to 694. F. Budget Total FY 1988 LPHA expenditures were $52,557,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts 0 State Funds $8,101,000 Local Funds $13,999,000 Fees and Reimbursements $29,639,000 Other Sources 0 Source Unknown $818,000 2Alabama Department Of Public Health, 1990 State Government State Board of Health State Committee of Public Health State Health Officer General Counsel Staff Assistant for Legislative Affairs State Assistant for Capital Expansion Staff Assistant for Professional Services Public Health Nursing Office of Administrative Services Office of Health Promotion and Information Office of Internal Audit Office of Management Services Bureau of Clinical Laboratories Division of Administrative Support Services Division of Microbiology Division of Microbacteriology/Mycology Division of Scientific Services Division of Serology Birmingham Division Decatur Division Dothan Division Mobile Division Bureau of Environmental and Health Service Standards Division of Environmental Health Division of Licensure and Certification Public Health Areas County Health Departments Bureau of Disease Control and Rehabilitative Services Division of Disease Control Division of Epidemiology Division of Long-Term Care and Rehabilitation Division of AIDS Prevention and Control Bureau of Family Health Services Division of Family Planning Division of Maternity Services Division of Child Health Division of WIC Dental Health Section Division of Family Planning Bureau of Vital Statistics Division of Record Preservation and Certification Services Division of Record Services Division of Registration Services Division of Statistical Analysis Services 2Types of Local Health Departments by Jurisdiction Alabama, 1990 Jurisdiction Co Autauga X Baldwin X Barbour X Bibb X Blount X Bullock X Butler X Calhoun X Chactaw X Chambers X Cherokee X Chilton X Clark X Clay X Cleburne X Coffee X Colbert X Conecuh X Coosa X Covington X Crenshaw X Cullman X Dale X Dallas X De Kalb X Elmore X Escambia X Etowah X Fayette X Franklin X Geneva X Greene X Hale X Henry X Houston X Jackson X Jefferson X Lamar X Lauderdale X Lawrence X Lee X Limestone X Lowndes X Macon X Madison X Marengo X Marion X Marshall X Mobile X Monroe X Montgomery X Morgan X Perry X Pickens X Pike X Randolph X Russell X Shelby X St. Clair X Sumter X Talladega X Tallapoosa X Tuscaloosa X Walker X Washington X Wilcox X Winston X Co = County HD 1ALASKA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 524,000 245,803,000 Population Density (1988) 0.9 68.8 (per/sq.mi.) Number of Counties 0 3,139 Median Age (1987) 28.4 31.7 Percent Below Poverty Level (1985) 8.8 14.0 (persons) Percent of Population Rural (1980) 36.0 26.0 Percent of Population White (1980) 77.1 83.1 Percent of Population Non-white (1980) 22.9 16.9 Median Years of Education (1980) 12.8 12.5 (25 years of age and over) B. Local Government Structure Home Rule Authority The organization of local government in Alaska is governed by the state constitution and statutes. Cities and boroughs are legal entities (municipalities) which perform both regulatory and proprietary functions. Alaska has three types of general law boroughs and two types of general law cities. In addition, both boroughs and cities may also adopt charters providing for home rule. General law cities may adopt charters providing for home rule. General law cities and boroughs can perform only those functions permitted by law, while home rule cities and boroughs can perform functions that are not prohibited by law or charter. Unified home rule municipalities are entities composed of an organized borough and all the cities within the geographic limits of that borough. Alaska currently has 14 organized boroughs that include about 40 percent of the state's land mass and 85 percent of the population. The remainder of the state consists of a single unorganized borough. Data for this state were updated February 1991. 3II. State Health Agency (SHA) A. General Component of Superagency The Division of Health, the SHA, is a component of the superagency, the Department of Health and Social Services (DHSS). The Department is under the direction of a Commissioner who is appointed by the Governor and is a member of his cabinet. The Division of Public Health exists to prevent disease and premature mortality through promotion of positive health practices and to minimize disability and the need for institutionalization through the early detection of disease and appropriate intervention. Programs are directed from the central office in Juneau and supervisory offices in Juneau, Anchorage, Fairbanks, and Bethel. Activities of the Division run the gamut from genetic screening to training of emergency medical services personnel. The Division's programs are both directly operated by state employees and by grants and contracts with non-profit entities. The following are some areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs B. Head of State Health Agency No M.D. Requirement, Commissioner Appointment The Director of the Division of Public Health is the head of the SHA. This official is appointed by the Commissioner of Health and Social Services and is not required to be a physician. The Director's responsibilities include overall policy and operational direction of the Division. C. State Board of Health/Council Alaska does not have a State Board or Council of Health. D. Regional/District Health Offices Public health nursing programs have regional offices in Anchorage, Bethel, and Juneau. No single regional official or office has jurisdiction over all public health programs within the geographic limits of the region. Although local governmental units generally can choose to provide public health services, most have not done so because of small populations and tax bases and the high cost of providing such services. E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Informal Liaison Function No single individual or office has responsibility for state-local liaison functions. Communications between these levels usually follow the chain of command. The interaction between state and local public health agencies in Alaska may be characterized as mixed centralized and decentralized organizational control. Under this arrangement local health services may be provided by the SHA in some jurisdictions and by local governmental units or by non-profit agencies which receive grants from the SHA to provide specific services. F. Budget Total FY 1988 Alaska SHA expenditures were $29,403,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $5,377,000 State Funds $23,733,000 Local Funds 0 Fees and Reimbursements $292,000 Other 0 3III. Local Public Health Agencies (LPHAs) A. General Alaska has two LPHAs: the North Slope Borough and the Anchorage Municipal Health Department. These units receive financial assistance from the state for specified public health activities. In addition, some public health services, often in the realm of personal health services, are provided by the Regional Native Health Corporations. The state provides grant funds for these services in response to specific grant applications. In the case of two such corporations, the state grants include funds for public health nursing services. For both local governmentally sponsored and corporation sponsored systems, the state continues to provide certain direct services such as epidemiology. In areas that are not served by local health departments, the state provides direct health services through the Section of Nursing in the Division of Public Health. The Section of Nursing supports 21 health centers which are staffed by public health nurses and itinerate public health nurses. The staff of these centers consist of state employees who are under state direction and who report within the state chain of command. While these health centers probably meet the Miller definition for local health departments, the state prefers not to include them in this category. In Alaska has evolved a unique system of health care which provides services to the state's ethnically diverse and geographically scattered population. This system is composed of the State Division of Public Health, the Indian Health Service (IHS), Native Regional Health Corporations, and private physicians. Public health nursing supports 21 health centers. The public health nurse network, which currently consists of 100 nurses, provides the first line of primary care by delivering services to over 200 communities. The U.S. Public Health Service plays an important role in the state's health care system. The IHS operates a system of eight service units. Each service unit's field hospital or clinic serves as the activity hub for health centers. Although public health nursing and IHS serve many of the same people, a general agreement regarding responsibilities avoids service duplication. Under powers granted in the Alaska Native Claims Settlement Act of 1971, Native corporations have established regional health authorities. Each of the 12 regional health corporations have assumed administrative responsibility for the village-based community health aides (CHAs). The CHAs work in village health clinics and are guided by radio and/or telephone communications with IHS physicians. CHAs comprise a significant portion of the rural primary health care network. To prevent service duplication of effort, public health nursing, the IHS, and the Native Regional Health Corporations work to coordinate services at three levels. DHSS program managers, IHS service unit administrators, and the regional health authorities consult with each other on long-range planning. Public health nurses, IHS medical staff and CHA program coordinators meet at regular intervals to coordinate efforts. Moreover, when public health nurses and IHS physicians visit a village, they join the CHAs in a team effort to deliver necessary services. B. Services Provided The following information on services provided by local health departments in Alaska is derived from a survey conducted by NACHO during 1989. Both local health departments in Alaska responded to the survey. Services Provided by LPHAs Number of LPHAs I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment - 2. Morbidity Data - 3. Reportable Diseases 1 4. Vital Records and Statistics 1 B. Epidemiology/Surveillance 1. Chronic Diseases - 2. Communicable Diseases 2 II. Policy Development A. Health Code Dev. and Enforcement 2 B. Health Planning 2 C. Priority Setting 2 III. Assurance Activities A. Inspection 1. Food and Milk Control 1 2. Health Facility Safety/Quality 1 3. Rec. Facility Safety/Quality 2 4. Other Facility Safety/Quality 2 B. Licensing 1. Health Facilities - 2. Other Facilities 1 C. Health Education 2 D. Environmental 1. Air Quality 1 2. Hazardous Waste Management 2 3. Individual Water Supply Safety 2 4. Noise Pollution 1 5. Occupational Health and Safety - 6. Public Water Supply Safety 1 7. Radiation Control - 8. Sewage Disposal Systems 2 9. Solid Waste Management 1 10. Vector and Animal Control 2 11. Water Pollution 2 E. Personal Health Services 1. AIDS Testing and Counseling 2 2. Alcohol Abuse 2 3. Child Health 2 4. Chronic Diseases 1 5. Dental Health 2 6. Drug Abuse 1 7. Emergency Medical Service 1 8. Family Planning 2 9. Handicapped Children 1 10. Home Health Care 1 11. Hospitals 1 12. Immunizations 2 13. Laboratory Services 1 14. Long-term Care Facilities - 15. Mental Health 1 16. Obstetrical Care 1 17. Prenatal Care 1 18. Primary Care 1 19. Sexually Transmitted Diseases 2 20. Tuberculosis 2 21. WIC 2 C. Local Health Officer The Municipality of Anchorage is the only area in Alaska with a local health officer. The health officer is appointed by the local governing body and is not required to be a physician. Responsibility of the health officer includes overall management of the department and its programs. D. Local Board of Health Some communities have formal or informal health councils or boards with membership drawn from the general population and representative of voluntary and official agencies. E. Staff The staffs of local health departments range in size from 120 to 200. The staff of the Municipality of Anchorage Health Department and the North Slope Borough Health Department are employed and supervised by the local jurisdiction. F. Budget Total FY 1988 LPHA expenditures were $1,388,000*. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts 0 State Funds $1,388,000 Local Funds 0 Fees and Reimbursements 0 Other Sources 0 Source Unknown 0 * These data include only state funds that were given to the 2Alaska Department Of Health And Social Services, 1990 Commissioner, Department of Health and Social Services Director, Division of Public Health Family Health Section Early Prevention Program Infant Learning Program Handicapped Children's Program Communicable Disease Unit Genetics Services Maternal and Adolescent Health Unit WIC Nutrition Services Nursing Section Bethel Nursing Northern Region Nursing Southeast Region Nursing Southcentral Region Nursing Contract Services Home Health EPSDT Record Patient Management System Emergency Medical Services Section Statewide Coordination and Administration Training/Licensing Injury Prevention Education Epidemiology Section Disease Reporting, Survey and Investigation Chronic Diseases Data Processing and Statistical Analysis Infectious Diseases Administrative Support Occupational Health/Environmental Risk Assessment/Injury Prevention Laboratory Section Public Health Lab-Juneau Public Health Lab-Anchorage Public Health Lab-Fairbanks Radiological Health Vital Statistics Records Research Training 2Types of Local Health Departments by Jurisdiction Alaska, 1990 Jurisdiction Bu C Anchorage X North Slope X Bu = Burrough HD C = City HD 1ARIZONA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 3,487,000 245,803,000 Population Density (1988) 30.7 69.4 (per/sq.mi.) Number of Counties 15 3,139 Median Age (1987) 31.0 31.7 Percent Below Poverty Level (1985) 10.7 14.0 (persons) Percent of Population Rural (1980) 16.0 26.0 Percent of Population White (1980) 82.4 83.1 Percent of Population Non-white (1980) 17.6 16.9 Median Years of Education (1980) 12.7 12.5 (25 years of age and over) B. County Government Structure No Home Rule Authority The Arizona Constitution and Statutes establish and empower the county governments. They also give the legislature responsibility for establishing the mission for counties. Commission Form - (15) - All 15 county governments are based on the Commission Form. The commissions are made up generally of three-member Boards of Supervisors. Five counties have chosen to increase the number of supervisors on their boards from three to five. The Boards of Supervisors and other elected county officials fulfill the executive function for counties since there are no elected executive officers. All 15 counties appoint an administrator to handle the administrative responsibilities of the counties, even though this position is not supported by the constitution or statutes. Arizona counties are administrative arms of the state and do not have any authority that is not granted them by the constitution and statutes. They have no authority to adopt home rule provisions or charters. Data for this state were updated December 1990. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Arizona Department of Health Services (ADHS), the SHA, is a free-standing, independent agency. Its mission is to protect and improve the health status of residents by identifying health issues and developing interventions to prevent disease, disability, and premature death. The following are some areas of responsibility for the SHA: State Public Health Authority State Mental Health Authority State Agency for Children with Special Health Care Needs State Health Planning and Development Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Director of ADHS is appointed by and responsible to the Governor. The Director is responsible for formulating policies, plans, and programs to effectuate the mission and purpose of the Department. Requirements for office include administrative experience and an educational background that prepares the Director for the administrative responsibilities assigned to the position. C. State Board of Health/Council There is no State Board of Health. D. Regional/District Health Offices Although the state is not divided into districts or regions, ADHS does have two satellite offices located in Flagstaff and Tucson. The staffs in these offices are employees of the ADHS. Typical positions in these offices are for purposes of monitoring, i.e., certification and licensure surveyors. E. State-local Liaison Decentralized Organizational Control, Formal Liaison Function The Office of Local Health Services has the responsibility for state-local liaison activities. Major functions that fall within the liaison role are communication, coordination, and representing the local health department perspective to the SHA. Other activities include generalized public health consultation, technical assistance, facilitation, and education. The interaction between state and local public health agencies in Arizona may be characterized as decentralized organizational control. Under this arrangement, local government directly operates a health department with or without a board of health. F. Budget Total FY 1988 Arizona SHA expenditures (data provided by SHA) were $170,276,332. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $40,676,564 State Funds $112,655,609 Local Funds 0 Fees and Reimbursements $3,976,483 Other $15,622,651 3III. Local Public Health Agencies (LPHAs) A. General Arizona has 15 LPHAs that exist in the form of county health departments. Local health departments are each independent and separate from the ADHS. The local health agency selectively accepts delegation and agrees to perform the functions, conferred in accordance with standards of performance established by the Director of the ADHS. In summary, the local health department is the direct service extension of the ADHS to insure mandatory services are provided at the local level. State funds are provided to local health departments mainly in the form of contracts for services; however, some funds are available through grant mechanisms. B. Services Provided The following information on services provided by local health departments in Arizona is derived from a survey conducted by NACHO during 1989. All 15 of the local health departments in Arizona responded to the survey. Services provided by 70 percent of the local health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 6 ( 40.0%) 2. Morbidity Data 4 ( 26.7%) 3. Reportable Diseases 15 (100.0%) 4. Vital Records and Statistics 5 ( 33.3%) B. Epidemiology/Surveillance 1. Chronic Diseases 7 ( 46.7%) 2. Communicable Diseases 15 (100.0%) II. Policy Development A. Health Code Dev. and Enforcement 12 ( 80.0%) B. Health Planning 11 ( 73.3%) C. Priority Setting 12 ( 80.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 13 ( 86.7%) 2. Health Facility Safety/Quality 9 ( 60.0%) 3. Rec. Facility Safety/Quality 12 ( 80.0%) 4. Other Facility Safety/Quality 9 ( 60.0%) B. Licensing 1. Health Facilities 2 ( 13.3%) 2. Other Facilities 13 ( 86.7%) C. Health Education 13 ( 86.7%) D. Environmental 1. Air Quality 4 ( 26.7%) 2. Hazardous Waste Management 5 ( 33.3%) 3. Individual Water Supply Safety 9 ( 60.0%) 4. Noise Pollution 1 ( 6.7%) 5. Occupational Health and Safety 2 ( 13.3%) 6. Public Water Supply Safety 10 ( 66.7%) 7. Radiation Control 3 ( 20.0%) 8. Sewage Disposal Systems 14 ( 93.3) 9. Solid Waste Management 9 ( 60.0%) 10. Vector and Animal Control 13 ( 86.7%) 11. Water Pollution 8 ( 53.3%) E. Personal Health Services 1. AIDS Testing and Counseling 13 ( 86.7%) 2. Alcohol Abuse - 3. Child Health 11 ( 73.3%) 4. Chronic Diseases 8 ( 53.3%) 5. Dental Health 2 ( 13.3%) 6. Drug Abuse - 7. Emergency Medical Service 1 ( 6.7%) 8. Family Planning 13 ( 86.7%) 9. Handicapped Children 4 ( 26.7%) 10. Home Health Care 7 ( 46.7%) 11. Hospitals - 12. Immunizations 14 ( 93.3%) 13. Laboratory Services 6 ( 40.0%) 14. Long-term Care Facilities 1 ( 6.7%) 15. Mental Health 2 ( 13.3%) 16. Obstetrical Care 1 ( 6.7%) 17. Prenatal Care 7 ( 46.7%) 18. Primary Care 2 ( 13.3%) 19. Sexually Transmitted Diseases 15 (100.0%) 20. Tuberculosis 15 (100.0%) 21. WIC 12 ( 80.0%) C. Local Health Officer No M.D. Requirement, Board of Supervisors Appointment The local health officer is appointed by the County Board of Supervisors. Each county establishes individual requirements, experience, and education for the health officer. Authority and responsibilities of local health officers include: providing full-time public health services; employing qualified personnel and utilizing local, state, Federal, and other funds, or any combination of funds to provide services at the local level in conformity with the rules, regulations and policies of the State Health Department. D. Local Board of Health Advisory The size of the board of health of each county is dependent upon the number of supervisory districts. The board must include a member of the board of supervisors, a licensed physician, and citizen members. The term served by each member is 4 years. The local health department director serves as an ex officio member. The board acts in an advisory capacity to the Board of Supervisors and the local health department. E. Staff Staffs of the local health departments are employed and supervised by the local health jurisdiction. Some local staff are part of the State Merit System, but most belong to local systems. Authority of the staff is determined at the local level in accordance with policy, rules, and regulations set at the state level. The number of employees of local health departments ranges from 7 to 500. F. Budget Total FY 1988 LPHA Expenditures (data provided by SHA) were $220,556,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $6,077,000 State Funds 5,010,000 Local Funds $86,681,000 Fees and Reimbursements $101,901,000 Other Sources $2,571,000 Source Unknown $19,000,000 The SHA reported that there were additional fees and reimbursements not retained by the local health departments, but which reverted to the general revenues of the local or state government. The SHA also reported that these figures include the total amount of additional local health department monies expended by all local health departments. 2Arizona Department Of Health Services, 1990 Governor Director Disease Control Research Commission Deputy Director Division of Disease Prevention Services Chronic Disease Epidemiology Infectious Disease Services Health Education Risk Assessments and Investigations Division of Laboratory Services Chemistry Lab Certification Microbiology Regional Labs Division of Family Health Services Children's Rehabilitation Services Dental Health Maternal and Child Health Nutrition Division of Emergency Medical Services and Health Care Facility Emergency Medical Services Child Day Care Licensing Health Facilities Licensure Health Economics and Facility Development Director/Departmental Support Services Affirmative Action Planning and Health Status Monitoring Local and Border Health Public Information Operations Division of Behavioral Health Services Arizona State Hospital South Arizona Mental Health Clinic Community Behavioral Health Chronically Mentally Ill Behavioral Health Licensure 2Types of Local Health Departments by Jurisdiction Arizona, 1990 Jurisdiction Co Apache X Cochise X Coconino X Gila X Graham X Greenlee X La Paz X Maricopa X Mohave X Navajo X Pima X Pinal X Santa Cruz X Yavapai X Yuma X Co = County HD 1ARKANSAS 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 2,395,000 245,803,000 Population Density (1988) 46.0 69.4 (per/sq.mi.) Number of Counties 75 3,139 Median Age (1987) 32.2 31.7 Percent Below Poverty Level (1985) 22.9 14.0 (persons) Percent of Population Rural (1980) 48.0 26.0 Percent of Population White (1980) 82.7 83.1 Percent of Population Non-white (1980) 17.3 16.9 Median Years of Education (1980) 12.2 12.5 (25 years of age and over) B. County Government Structure No Home Rule Authority Arkansas counties receive their structure and authority from what is known as the County Government Code. This Code is actually a part of the constitution that was amended in 1975 (Amendment 55) and Act 742 that was passed in 1977. Quorum Court Form - (75) - Under this type of government the legislative body is made up of 9 to 15 justices of the peace who are elected from single-member districts. A county judge who is elected at large serves as chairman of the legislative body and administers the affairs of the government. Home Rule - While it is not called home rule, Chapter 37 of the County Government Code gives county governments authority that is similar to home rule. It provides counties with options to establish different governmental organizations and structures, such as consolidations. Also, the constitution empowers Quorum Courts to enact any legislation that is not prohibited by the constitution or state statutes. Data for this state were updated October 1990. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Arkansas Department of Health (ADH) is a free-standing, independent agency. The agency's mission is to promote and protect the public health and well-being of the citizens of Arkansas. Efforts are directed in the areas of direct provision of preventive, environmental, and personal health care services; certification and monitoring of certain health facilities, systems, and providers; and serving as a catalyst to improve the state's health care system and environmental quality. The following are some areas of responsibility for the SHA: State Public Health Authority State Professions Licensing Authority Institutional Licensing Authority Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency M.D. Requirement, Cabinet-level Appointment The head of the SHA is the Director of the ADH. This office is a cabinet-level appointment that is made by the Governor. The Director is required to be a physician and also serves as Secretary of the State Board of Health. The role of the Director is to oversee the general operations of the agency and to promote public health in Arkansas. C. State Board of Health/Council Policy-making The State Board of Health is a policy-making body made up of 21 members, appointed by the Governor. The Governor selects the members from lists of names submitted by organizations, such as the State Medical Society, that are represented on the Board. The following professions or groups are represented on the Board: seven licensed medical doctors; one licensed, registered dentist; one registered, professional engineer; one licensed, professional nurse; one licensed pharmacist; one licensed veterinarian; one registered sanitarian; one hospital administrator; one licensed, registered optometrist; one licensed chiropractor; one restaurant operator; one consumer representative; one licensed doctor of podiatric medicine; one member of the Arkansas Public Health Association; and one member over 60 who is not actively engaged in or retired from any occupation, profession, or industry to be regulated by the State Board of Health. D. Regional/District Health Offices The ADH has divided the state into 10 management areas, each with an area office. These area offices are responsible for the day-to-day administrative oversight of the local health units and for the oversight of programs, operations, and professional standards in the health units. The administrative structure of the area office consists of an area manager and his/her core team. The core team includes a nursing supervisor, sanitarian supervisor, and a records and clerical supervisor. E. State-local Liaison Centralized Organizational Control, Formal Liaison Function The Bureau of Community Health Services is ADH's liaison with the area offices and local health units. The Bureau has line authority over the area offices and local health units (field operations). The Bureau provides direction and general supervision to the area offices which, in turn, provide the same to local health units. The interaction between state and local public health agencies in Arkansas may be characterized as centralized organizational control. Under this arrangement, local health departments function directly under the state's authority and are operated by the SHA or State Board of Health. F. Budget Total FY 1988 SHA expenditures were $67,265,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $29,150,000 State Funds $26,101,000 Local Funds 0 Fees and Reimbursements $10,694,000 Other $1,321,000 3III. Local Public Health Agencies (LPHAs) A. General Ninety-seven LPHAs, called local health units in Arkansas, provide various services throughout the state. The basic administrative/service jurisdiction is the county. Several counties, however, have more than one local health unit. B. Services Provided The following information on services provided by local health departments in Arkansas is derived from a survey conducted by NACHO during 1989. Fifty of the 97 local health departments in Arkansas responded to the survey. The services provided by 70 percent of the local health units in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 14 ( 28.0%) 2. Morbidity Data 19 ( 38.0%) 3. Reportable Diseases 45 ( 90.0%) 4. Vital Records and Statistics 46 ( 92.0%) B. Epidemiology/Surveillance 1. Chronic Diseases 29 ( 58.0%) 2. Communicable Diseases 49 ( 98.0%) II. Policy Development A. Health Code Dev. and Enforcement 13 ( 26.0%) B. Health Planning 24 ( 48.0%) C. Priority Setting 19 ( 38.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 46 ( 92.0%) 2. Health Facility Safety/Quality 22 ( 44.0%) 3. Rec. Facility Safety/Quality 34 ( 68.0%) 4. Other Facility Safety/Quality 9 ( 18.0%) B. Licensing 1. Health Facilities 3 ( 6.0%) 2. Other Facilities 27 ( 54.0%) C. Health Education 34 ( 68.0%) D. Environmental 1. Air Quality 6 ( 12.0%) 2. Hazardous Waste Management 15 ( 30.0%) 3. Individual Water Supply Safety 42 ( 84.0%) 4. Noise Pollution 2 ( 4.0%) 5. Occupational Health and Safety 4 ( 8.0%) 6. Public Water Supply Safety 27 ( 54.0%) 7. Radiation Control 9 ( 18.0%) 8. Sewage Disposal Systems 44 ( 88.0%) 9. Solid Waste Management 16 ( 32.0%) 10. Vector and Animal Control 37 ( 74.0%) 11. Water Pollution 22 ( 44.0%) E. Personal Health Services 1. AIDS Testing and Counseling 43 ( 86.0%) 2. Alcohol Abuse 1 ( 2.0%) 3. Child Health 50 (100.0%) 4. Chronic Diseases 37 ( 74.0%) 5. Dental Health 10 ( 20.0%) 6. Drug Abuse 3 ( 6.0%) 7. Emergency Medical Service 4 ( 8.0%) 8. Family Planning 48 ( 96.0%) 9. Handicapped Children 9 ( 18.0%) 10. Home Health Care 46 ( 92.0%) 11. Hospitals 1 ( 2.0%) 12. Immunizations 50 (100.0%) 13. Laboratory Services 21 ( 42.0%) 14. Long-term Care Facilities 1 ( 2.0%) 15. Mental Health 2 ( 4.0%) 16. Obstetrical Care 15 ( 30.0%) 17. Prenatal Care 42 ( 84.0%) 18. Primary Care 5 ( 10.0%) 19. Sexually Transmitted Diseases 49 ( 98.0%) 20. Tuberculosis 50 (100.0%) 21. WIC 50 (100.0%) C. Local Health Officer M.D. Requirement, State Board of Health Appointment Arkansas law created the position of county health officer and describes the duties. The statute requires the State Board of Health to appoint a county health officer for each county. The appointment is subject to the approval of the county judge. The State Board of Health appoints the county health officers for 2-year terms, but has very limited interaction with them. The county health officer is directed by the Local Health Unit Administrator, the Director of ADH, and the State Board of Health. The county health officer was used more in the past during quarantines, but because quarantines are now rare, the health officer is much less active. Specific duties set by statute and by the health department for a county health officer include the following: Requirements Set by ADH 1. Maintain interest and knowledge of health unit activities and of county's health needs; represent needs to those in power; serve as an advocate for the health unit in the community and as a liaison between health unit and peers (medical society), State Board of Health, state medical officer and political leadership. 2. Uphold and observe ADH standards, policies, and procedures. 3. Have a role in planning, coordinating, and approving community services; serve on health advisory board. 4. Assist and act as medical consultant in handling epidemics; report contagious diseases to the ADH in an effort to prevent communicable disease. 5. Maintain good rapport and regular contact with health unit staff. 6. Be available for consultation in event of public disaster or emergency. Requirements Set by Statute 1. Caring for prisoners in county jails. 2. Caring for inmates of county poor farms and hospitals. 3. County quarantine. 4. Assist the ADH and State Board of Health in the following: a. Matters of local quarantine b. Inspection for sanitary purposes c. Prevention and suppression of disease d. General sanitation e. Vital statistics f. Submission of reports to the Board of Health where required D. Local Board of Health There are no local boards of health in Arkansas. E. Staff The staffs of the area offices and local health units are employed by ADH. The number of employees in a local health unit ranges from 2 to 65. F. Budget Since Arkansas does not consider the local service units to be local health departments, expenditure data are not available. 2Arkansas Department Of Health, 1990 Director Deputy Director Deputy Director Health Promotion and Services Bureau of Administrative Support Services Division of Data Processing Division of Financial Management Division of Maintenance Division of Personnel Management Office of Legal Services Division of Central Supply and Services Bureau of Public Health Program Section of Maternal and Child Health Division of Infant and Child Health Division of Perinatal Health Division of Reproduction Health Office of Hearing, Speech and Vision Division of WIC Section of In-Home Service Division of Home Health Division of Personal Care Office of Home Care Office of Hospice Office of Independence Plan Office of Blood Alcohol Office of Dental Health Section of Health Maintenance Division of AIDS/STD Division of Communicable Disease and Immunization Division of Tuberculosis Division of Chronic Diseases and Disabilities Prevention Bureau of Community Health Services 10 Area Offices (with Support Teams) 97 Local Health Units Office of Policies and Procedures Office of Quality Assurance Division of Epidemiology Office of Epizootic Diseases Bureau of Health Resources Division of Health Education and Promotion Division of Medical Social Services Division of Nursing Services Division of Nutrition Services Division of Pharmacy and Drug Control Division of Records and Clerical Section of Health Facilities Services and Systems Division of Vital Records Center for Health Statistics Bureau of Environmental Health Services Division of Engineering Division of Radiation Control and Emergency Management Division of Public Health Laboratories Division of Sanitarian Services Division of Plumbing and Natural Gas Control 2Types of Local Health Departments by Jurisdiction Arkansas, 1990 Jurisdiction Co Arkansas X Ashley X Baxter X Benton X Boone X Bradley X Calhoun X Carroll X Chicot X Clark X Clay X Cleborne X Cleveland X Columbia X Conway X Craighead X Crawford X Crittenden X Cross X Dallas X Desha X Drew X Faulkner X Franklin X Fulton X Garland X Grant X Greene X Hemstead X Hot Spring X Howard X Independence X Izard X Jackson X Jefferson X Johnson X Lafayette X Lawrence X Lee X Lincoln X Little River X Logan X Lonoke X Madison X Marion X Miller X Mississippi X Monroe X Montgomery X Nevada X Newton X Ocachita X Perry X Phillips X Pike X Poinsett X Polk X Pope X Prairie X Pulaski X Randolph X Saline X Scott X Searcy X Sebastian X Sevier X Sharp X St. Francis X Stone X Union X Van Buren X Washington X White X Woodruff X Yell X Co = County HD 1CALIFORNIA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 28,314,000 245,803,000 Population Density (1988) 181.1 69.4 (per/sq.mi.) Number of Counties 58 3,139 Median Age (1987) 31.3 31.7 Percent Below Poverty Level (1985) 13.6 14.0 (persons) Percent of Population Rural (1980) 9.0 26.0 Percent of Population White (1980) 76.2 83.1 Percent of Population Non-white (1980) 23.8 16.9 Median Years of Education (1980) 12.7 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority County governments in California are given two options under the state constitution: General Law or Charter status. General Law - (46) - Authority for the operation of General Law counties is found in Article XI of the California Constitution and Law found in the Government Code. Charter - (12) - Charter counties operate under the authority of the Charter. A charter may be proposed by a County Board of Supervisors or by a Charter Commission. Commission Form - (7) - Both General Law and Charter governments have several options they can chose as to the structure of their governments. They can operate under a "pure" Commission with a Board of Supervisors which serves as the legislative and executive bodies for the county. County Administrator - (50) - Fifty counties have appointed County Administrators. Elected Executive - (1) - San Francisco is the only county operating with an elected executive (mayor). This option is open only to Charter counties. San Francisco is also the only Data for this state were updated October 1990. city-county consolidation. Another unique feature of this government is the presence of two executive officers. The mayor is elected at large and the chief administrative officer is appointed. The legislative body for the county is made up of an 11-member Board of Supervisors. 3II. State Health Agency (SHA) A. General Component of Superagency The Department of Health Services is a component of the superagency called the California Health and Welfare Agency. The mission of the Department is to protect the health of all Californians. The goals set to accomplish this mission are to: promote an environment that will contribute to human health and well-being; assure the availability to equal access to comprehensive health services; emphasize prevention-oriented health care programs; promote the development of knowledge concerning the causes and cures of illness and the means of delivering health services to the public; assure economic expenditure of public funds to serve those with the greatest need. These goals are carried out through the following 11 programs: Preventive Medical Services Toxic Substance Control Environmental Health AIDS Family Health Services Laboratory Services Rural and Community Health Medical Care Services Licensing and Certification Audits and Investigations Special Projects The following are some areas of responsibility for the SHA: State Public Health Authority Medicaid Single State Agency Lead Environmental Agency in the State State Agency for Children with Special Health Care Needs Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The head of the SHA is the Director of Health Services. This individual is appointed by the Governor and approved by the legislature. There is no M.D. requirement. The responsibilities are to administer the activities of the Department of Health. C. State Board of Health/Council No State Board of Health There is no state board of health. Several advisory groups, however, have been formed that have no mandated authority (the California Conference of Local Health Officers is an example). D. Regional/District Health Offices California is not regionalized nor does it have district health offices in relationship to the Department of Health Services. The state does have field offices which are solely an administrative arm of the state to provide a closer administrative structure for the purpose of authorizing treatment and fielding provider problems. No patient or health services are provided from these offices. E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Formal Liaison Function The Chief of the County Health Services Branch, Division of Rural and Community Health Services, is designated as the state-local liaison. In addition there is support from the Office of External Affairs which is responsible for organizing the Conference of Local Health Officers. These two organizational units also are responsible for the dissemination of information and issues surrounding local health departments. The interaction between state and local public health agencies in California may be characterized as mixed centralized and decentralized organizational control. Under this arrangement, local health services in the state may be provided by the SHA in some jurisdictions and by local governmental units in others. F. Budget Total FY 1988 California SHA expenditures (excluding Medi-Cal and so forth) were $792,670,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $259,746,000 State Funds $531,076,000 Local Funds 0 Fees and Reimbursements 0 Other $1,848,000 3III. Local Public Health Agencies (LPHAs) A. General There are 61 local public health agencies in California. These consist of 58 county and 3 city health departments (see map). There are 12 contract counties which, due to their small population, are supplied with public health nurses and sanitarians by the state. The county is responsible for the building and health officer. These offices usually consist of a staff of two to four. All local health departments receive funds from a local tax base. The state then subsidizes this by matching county costs for public health on a dollar for dollar basis, up to a maximum amount. This includes inpatient and outpatient services since California's counties are considered providers of last resort. B. Services Provided The following information on services provided by local health departments in California is derived from a survey conducted by NACHO during 1989. Fifty-two of the 61 local health departments responded to the survey. Services provided by 70 percent of the local health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 15 ( 28.8%) 2. Morbidity Data 40 ( 76.9%) 3. Reportable Diseases 49 ( 94.2%) 4. Vital Records and Statistics 46 ( 88.5%) B. Epidemiology/Surveillance 1. Chronic Diseases 26 ( 50.0%) 2. Communicable Diseases 50 ( 96.2%) II. Policy Development A. Health Code Dev. and Enforcement 34 ( 65.4%) B. Health Planning 38 ( 73.1%) C. Priority Setting 36 ( 69.2%) III. Assurance Activities A. Inspection 1. Food and Milk Control 35 ( 67.3%) 2. Health Facility Safety/Quality 24 ( 46.2%) 3. Rec. Facility Safety/Quality 35 ( 67.3%) 4. Other Facility Safety/Quality 21 ( 40.4%) B. Licensing 1. Health Facilities 9 ( 17.3%) 2. Other Facilities 37 ( 71.2%) C. Health Education 43 ( 82.7%) D. Environmental 1. Air Quality 2. Hazardous Waste Management 41 ( 78.8%) 3. Individual Water Supply Safety 39 ( 75.0%) 4. Noise Pollution 18 ( 34.6%) 5. Occupational Health and Safety 23 ( 44.2%) 6. Public Water Supply Safety 42 ( 80.8%) 7. Radiation Control 16 ( 30.8%) 8. Sewage Disposal Systems 41 ( 78.8%) 9. Solid Waste Management 40 ( 76.9%) 10. Vector and Animal Control 38 ( 73.1%) 11. Water Pollution 40 ( 76.9%) E. Personal Health Services 1. AIDS Testing and Counseling 49 ( 94.2%) 2. Alcohol Abuse 24 ( 46.2%) 3. Child Health 50 ( 96.2%) 4. Chronic Diseases 43 ( 82.7%) 5. Dental Health 25 ( 48.1%) 6. Drug Abuse 24 ( 46.2%) 7. Emergency Medical Service 41 ( 78.8%) 8. Family Planning 44 ( 84.6%) 9. Handicapped Children 43 ( 82.7%) 10. Home Health Care 15 ( 28.8%) 11. Hospitals 9 ( 17.3%) 12. Immunizations 51 ( 98.1%) 13. Laboratory Services 42 ( 80.8%) 14. Long-term Care Facilities 7 ( 13.5%) 15. Mental Health 17 ( 32.7%) 16. Obstetrical Care 16 ( 30.8%) 17. Prenatal Care 28 ( 53.8%) 18. Primary Care 18 ( 34.6%) 19. Sexually Transmitted Diseases 51 ( 98.1%) 20. Tuberculosis 50 ( 96.2%) 21. WIC 38 ( 73.1%) C. Local Health Officer M.D. Requirement, Board of Supervisors' Appointment The local health officer is appointed by the county board of supervisors. He/she must be an M.D. Responsibilities include hiring, firing, and supervising the staff. D. Local Board of Health Some counties have boards but the state does not require them. The authority of the boards also varies. E. Staff There is a full range of laboratory, clinical, and field staffs. Office staff size ranges from 2 to 2,600, with the average being from 50 to 100. They are all under local administration, except for the nurses and sanitarians who work in public health contract counties as stated previously. F. Budget Total FY 1988 LPHA expenditures were $439,343,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $179,517,000 State Funds $259,772,000 Local Funds 0 Fees and Reimbursements 0 Other Sources 0 Source Unknown 0 The SHA reported that there were additional fees and reimbursements not reported by local health departments, but which reverted to the general revenues of the local or state government. 2Calfornia Department Of Health Services, 1990 Secretary of Health and Welfare Chief Deputy Director Office of Civil Rights Office of Legal Services External Affairs Office of Quality Improvement Public Health Deputy Director Assistant Deputy Director Office of AIDS Environmental Health Family Health Division Division of Laboratories Preventive Medical Services Division Rural and Community Health Division Chief Deputy Director Director of Health Services Assistant Director 2Types of Local Health Departments by Jurisdiction California, 1990 Jurisdiction Co C Alameda X Alpine X Amador X Berkeley X Butte X Calavaras X Colusa X Contra Costa X Del Norte X El Dorado X Fresno X Glenn X Humboldt X Imperial X Inyo X Kern X Kings X Lake X Lassen X Long Beach X Los Angeles X Madera X Marin X Mariposa X Mendocino X Merced X Modoc X Mono X Monterey X Napa X Nevada X Orange X Pasadena X Placer X Plumas X Riverside X Sacramento X San Benito X San Bernardino X San Diego X San Francisco X San Joaquine X San Luis Obispo X San Mateo X Santa Barbara X Santa Clara X Santa Cruz X Shasta X Sierra X Siskiyou X Solano X Sonoma X Stanislaus X Sutter X Tehama X Trinity X Tulare X Tuolumne X Ventura X Yolo X Yuba X Co = County HD C = City HD 1COLORADO 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) * 3,300,000 245,803,000 Population Density (1988) 31.9 69.4 (per/sq.mi.) Number of Counties 63 3,139 Median Age (1987) 30.8 31.7 Percent Below Poverty Level (1985) 10.3 14.0 (persons) Percent of Population Rural (1980) 19.0 26.0 Percent of Population White (1980) 89.0 83.1 Percent of Population Non-white (1980) 11.0 16.9 Median Years of Education (1980) 12.8 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The Colorado Constitution, Colorado Revised Statutes, and case law developed in state and Federal courts serve as the basis for the structure and function of county governments. Most counties have boards of commissioners that serve as the legislative and administrative bodies. The counties for the most part have three-member boards with the option for five-member boards. The boards are elected at large but have district residency requirements. Several options for the structure and function of county governments are available in Colorado. City-county Consolidation - (1) - This form is authorized and has been selected by Denver city-county. Home Rule Charters - (2) - These are available and have been selected by two counties. Home rule authority in Colorado provides little additional authority, but it does allow counties to provide some additional services. * These data were provided by the SHA. Data for this state were updated October 1990. Appointed Administrator - (45) - Still another option that is available to counties is the possibility of appointing an administrator. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Colorado Department of Health (CDH), the SHA, is an independent, free-standing agency. Major functions of the Department are managed under the Office of Health and Environmental Protection, Office of Administration and Support, Office of Health Care and Prevention. CDH is dedicated to protecting and improving the health and environment of the people of Colorado; to prevent disease, disability, and premature death; to protect and improve the quality of Colorado's air, land and water; to promote public policies and individual lifestyles which maintain and improve personal and environmental health; and to provide health services to Coloradans with special needs. The following are some areas of responsibility for the SHA: State Public Health Authority Lead Environmental Agency in the State State Agency for Children with Special Health Care Needs State Health Planning and Development Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Executive Director is the head of the CDH. The position is a cabinet-level appointment that is made by the Governor and requires an M.P.H. or equivalent degree. Responsibilities and powers of the Executive Director include the following: serving as secretary to the State Board of Health; appointing authority for all SHA staff; formulating policy for public health; and serving as chief executive officer for the Department. C. State Board of Health/Council Policy-making The State Board of Health is composed of nine members appointed by the Governor. One member is appointed from each of the six congressional districts, with consent of the Senate, and the remaining positions are appointed from the state-at-large. No more than five members can be from the same political party, and no business or professional group may constitute a majority. The law also requires that one member be a county commissioner. The board adopts rules and regulations to carry out public health laws and functions in an advisory capacity to the Executive Director of the CDH. D. Regional/District Health Offices Although CDH has not divided the state into administrative regions or districts, two regional offices are located in Pueblo and Grand Junction. These offices are extensions of the central office and exist to make the services of the central office more assessable to the local health departments. E. State-local Liaison Decentralized Organizational Control, Formal Liaison Function The Local Health Services Director administers financial support for and maintains close liaison with local health departments to develop and implement state public health policy and to resolve local and statewide issues. Departmental technical staffs work with their local counterparts to assure the public access to essential health services. The interaction between state and local public health agencies in Colorado may be characterized as decentralized organizational control. Under this arrangement local government directly operates health departments with a local board of health. F. Budget Total FY 1988 Colorado SHA expenditures were $109,099,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $71,980,000 State Funds $23,590,000 Local Funds 0 Fees and Reimbursements $8,083,000 Other $5,447,000 3III. Local Public Health Agencies (LPHAs) A. General Colorado has 52 local health departments, consisting of four multicounty health departments (called regional and district health departments in Colorado) and 48 county health departments. Colorado counts 10 county health departments and the regional and district health departments as full-fledged health departments. These local health departments provide services to 23 counties and 90 percent of the state's population. Thirty-eight counties use county nursing services and county sanitarian and environmentalist services to provide public health services and function as the local health department. The county commissioners serve as the board of health. Thirty-eight counties have county nursing services. The nurses offer basic public health care such as immunizations, communicable and chronic disease control, maternal and child health, home care of the sick, preventive assessments of children and elderly. The CDH, through the Community Nursing Section, provides training, technical assistance, and supervision to these nurses. Additionally, the Department assists the local areas by reimbursing for a portion of the nurse's salary. Fifteen boards of county commissioners and the city of Vail employ public health sanitarians to provide public health services. Three additional counties purchase the services of sanitarians from nearby counties. The sanitarians work under contract with the Consumer Protection Division and perform inspections of restaurants, grocery stores, motels, child care centers, schools and summer camps. They also provide services mandated by local laws and regulations and provide advice to local elected officials on matters related to environmental health issues. The Department reimburses local governments for part of the sanitarians' salaries. One county (Hinsdale) with a population of about 400 does not have a health department. B. Services Provided The following information on services provided by local health departments in Colorado is derived from a survey conducted by NACHO during 1989. Thirty-six of the 54 local health departments in Colorado responded to the survey. Services provided by 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 8 ( 22.2%) 2. Morbidity Data 15 ( 41.7%) 3. Reportable Diseases 27 ( 75.0%) 4. Vital Records and Statistics 14 ( 38.9%) B. Epidemiology/Surveillance 1. Chronic Diseases 14 ( 38.9%) 2. Communicable Diseases 31 ( 86.1%) II. Policy Development A. Health Code Dev. and Enforcement 12 ( 33.3%) B. Health Planning 22 ( 61.1%) C. Priority Setting 20 ( 55.6%) III. Assurance Activities A. Inspection 1. Food and Milk Control 19 ( 52.8%) 2. Health Facility Safety/Quality 13 ( 36.1%) 3. Rec. Facility Safety/Quality 16 ( 44.4%) 4. Other Facility Safety/Quality 20 ( 55.6%) B. Licensing 1. Health Facilities 4 ( 11.1%) 2. Other Facilities 21 ( 58.3%) C. Health Education 25 ( 69.4%) D. Environmental 1. Air Quality 18 ( 50.0%) 2. Hazardous Waste Management 17 ( 47.2%) 3. Individual Water Supply Safety 22 ( 61.1%) 4. Noise Pollution 8 ( 22.2%) 5. Occupational Health and Safety 10 ( 27.8%) 6. Public Water Supply Safety 15 ( 41.7%) 7. Radiation Control 9 ( 25.0%) 8. Sewage Disposal Systems 20 ( 55.6%) 9. Solid Waste Management 15 ( 41.7%) 10. Vector and Animal Control 21 ( 58.3%) 11. Water Pollution 19 ( 52.8%) E. Personal Health Services 1. AIDS Testing and Counseling 20 ( 55.6%) 2. Alcohol Abuse 6 ( 16.7%) 3. Child Health 28 ( 77.8%) 4. Chronic Diseases 23 ( 63.9%) 5. Dental Health 8 ( 22.2%) 6. Drug Abuse 6 ( 16.7%) 7. Emergency Medical Service 6 ( 16.7%) 8. Family Planning 21 ( 58.3%) 9. Handicapped Children 28 ( 77.8%) 10. Home Health Care 18 ( 50.0%) 11. Hospitals 2 ( 5.6%) 12. Immunizations 29 ( 80.6%) 13. Laboratory Services 15 ( 41.7%) 14. Long-term Care Facilities 5 ( 13.9%) 15. Mental Health 2 ( 5.6%) 16. Obstetrical Care 6 ( 16.7%) 17. Prenatal Care 27 ( 75.0%) 18. Primary Care 6 ( 16.7%) 19. Sexually Transmitted Diseases 21 ( 58.3%) 20. Tuberculosis 22 ( 61.1%) 21. WIC 28 ( 77.8%) C. Local Health Officer No M.D. Requirement, Local Governing Body Appointment Local health officers are appointed by the local governing body. They must have an M.P.H. degree or equivalent and, when not an M.D., must appoint a medical advisor. The candidate must have had experience in the management or supervision of a public health program or its equivalent. The titles for local health officers in Colorado are Public Health Administrator I and II. A Public Health Administrator I can serve a local health department in a jurisdiction under 100,000 population and a Public Health Administrator II serves jurisdictions that are over 100,000 population. The administrators are responsible for managing full-time health departments. This includes the direction and supervision of all programs and activities; interpretation and administration of their purposes; enforcement of public health laws, rules, and regulations; provision of or arrangement for medical services in public health clinics and school health programs. D. Local Board of Health Policy-making Full service departments have boards of health appointed by county commissioners. Boards are policy setting bodies. They also appoint health officers who serve at the pleasure of the board. In the 40 counties without full service departments, the commission serves as the board. E. Staff The staffs of local health departments are employed and supervised by the local jurisdiction. The number of employees for local health departments ranges from 1 to 200. F. Budget Total FY 1988 LPHA expenditures were $27,897,000. Total FY 1988 United States LPHA expenditures were $ 3,978,948,000. SHA funds are distributed to local health agencies on a per capita basis. In counties that have no local health departments, the state pays 20 percent of the public health nurses' salaries and 40 percent of the sanitarians' salaries. Source of Funds Federal Grants and Contracts $425,000 State Funds $3,969,000 Local Funds $18,476,000 Fees and Reimbursements $1,155,000 Other Sources $3,873,000 Source Unknown 0 The SHA reported that there were additional fees and reimbursements not retained by local health departments, but which reverted to the general revenues of the local or state government. The SHA also reported that these figures include the total of additional local health department monies expended by all local health departments. 2Colorado Department of Health, 1990 Governor Colorado Department of Health State Board of Health Executive Director Office of External Affairs Public Relations Governmental Liaison Local Health Services Office of Health and Environmental Protection Rocky Flats Program Unit Air Pollution Control Division Technical Services Stationary Sources Mobile Sources Water Quality Control Division Field Support Permits and Enforcement Ground Water and Standards Drinking Water Disease Control and Environmental Epidemiology Division Communicable Disease Control Environmental Epidemiology STD/AIDS Hazardous Waste Management Division Hazardous Waste Control Section Solid Waste and Incident Management Section Remedial Programs Section Consumer Protection Division Field Services Technical Assistance Radiation Control Division X-Ray Regulation and Inspection Uranium and Special Projects Environmental Surveillance Radioactive Materials Licensure and Inspection Office of Administration and Support Administrative Services Division Business Management Human Resources Data Services Support Services Emergency Medical Services Division Laboratory Division Microbiology Chemistry Toxicology Newborn Screening Health Facilities Division Administrative Services Program Development Evaluation Long-Term Care Hospital Medicare Residential Investigations Office of Health Care and Prevention Health Statistics & Vital Records Division Certification Health Statistics Data Management Alcohol and Drug Abuse Division Prevention/Intervention Treatment Services Administrative Support/Planning and Evaluation Prevention Programs Division Chronic Disease Control Injury Prevention Colorado Action for Healthy People Family and Comm. Health Services Division Family Health Services Childrens' Health Services Migrant Health Dental Health Nutrition Services Community Services Medical Affairs and Special Programs Cooperative Agreement/Primary Care 2Types of Local Health Departments by Jurisdiction Colorado, 1990 Jurisdiction Co M/Co N/Co Adams X Alamosa X Arapahoe X Archuletta X Baca X Bent X Boulder X Chaffee X Cheyenne X Clear Creek X Conejos X Costilla X Crowley X Custer X Delta X Denver X Dolores X Douglas X Eagle X El Paso X Elbert X Fremont X Garfield X Gilpin X Grand X Gunnison X Hinsdale X Huerfano X Jackson X Jefferson X Kiowa X Kit Carson X La Plata X Lake X Larimer X Lincoln X Logan X Los Animas X Mesa X Mineral X Moffat X Montezuma X Montrose X Otero X Ourey X Park X Phillips X Pitkin X Prowers X Pueblo X Rio Blanco X Rio Grande X Routt X Saguache X San Juan X San Miguel X Sedgwick X Summit X Teller X Washington X Weld X Yuma X Co = County HD M/Co= Multicounty HD N/Co =No County HD 1CONNECTICUT 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 3,233,000 245,803,000 Population Density (1988) 663.6 69.4 (per/sq.mi.) Number of Counties 8 3,139 Median Age (1987) 33.9 31.7 Percent Below Poverty Level (1985) 7.6 14.0 (persons) Percent of Population Rural (1980) 21.0 26.0 Percent of Population White (1980) 90.1 83.1 Percent of Population Non-white (1980) 9.9 16.9 Median Years of Education (1980) 12.6 12.5 (25 years of age and over) B. County Government Structure Connecticut has no functioning county governments. Counties are used for geographic designation only. 3II. State Health Agency (SHA) A. General Free-standing, Independent Agency The Connecticut Department of Health Services (CDHS), the SHA, is a free-standing, independent agency. The mission of CDHS is to become the best state health department in the nation. In doing so, the CDHS will promote and enhance the public's health by employing the most efficient and practical means to prevent and suppress disease. The following are some areas of responsibility for the SHA: State Public Health Authority Lead Environmental Agency in the State State Agency for Children with Special Health Care Needs Data for this state were updated February 1991. State Health Planning and Development Agency State Professions Licensing Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement The Department encourages the development and expansion of full-time local health services by subsidizing the cost of such services to local communities. Grants-in-aid are made to all departments and districts with full-time health officers. To be eligible for funding, the local health departments must comply with funding regulations in the public health code. B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment As the chief executive officer of the CDHS, the Commissioner is appointed by the Governor for a term of office concurrent with the gubernatorial term and required to have M.D./M.P.H or M.P.H. degrees. It is the duty of the Commissioner of CDHS to use the most efficient and practical means for prevention and suppression of disease, and administer the health laws and the public health code. The Commissioner is also responsible for the overall operation and administration of CDHS. C. State Board of Health/Council No State Board of Health Although Connecticut has no State Board or Council of Health, it does have a statewide advisory committee on public health. The advisory committee is composed of 25 members who are health care professionals, providers, and consumers. D. Regional/District Health Offices CDHS has two regional offices located in Norwich and Bridgeport which are extensions of the central office and have only managerial functions. The offices do not have specific geographic areas of service. E. State-local Liaison Decentralized Organizational Control, Formal Liaison Function The Office of Local Health Administration has responsibility for state-local liaison. This function began in the fall of 1989 when CDHS began a major local health initiative to focus on the needs of local health officers, their departments, and districts in the state by establishing an Office of Local Health Administration. An objective of this office is to enhance communication between the Department and other state agencies with local health officers through periodic forums, resource materials, advisory groups, and other mechanisms. The interaction between state and local public health agencies in Connecticut may be characterized as decentralized organizational control. Under this arrangement local governments directly operate health departments with or without local boards of health. F. Budget Total FY 1988 Connecticut SHA expenditures were $72,983,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $35,225,000 State Funds $37,758,000 Local Funds 0 Fees and Reimbursements 0 Other 0 3III. Local Public Health Agencies (LPHAs) A. General Connecticut has 49 local health departments, consisting of full and part-time local health departments and district health departments. The districts consist of towns, cities, and boroughs which have voted to combine their health services into a district health department. Currently there are 13 districts, 28 full-time, and 8 part-time health departments. The designation of full- or part-time depends on the presence or absence of a full-time health officer. There are 70 other jurisdictions in Connecticut which have health services but do not have at least one full-time position. B. Services Provided The following information on services provided by local health departments in Connecticut is derived from a survey conducted by NACHO during 1989. Seventy of the local health jurisdictions in Connecticut responded to the survey. These respondents include several service units known as part-time health departments, which do not meet our definition of a local health department. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 14 ( 20.0%) 2. Morbidity Data 24 ( 34.3%) 3. Reportable Diseases 63 ( 90.0%) 4. Vital Records and Statistics 18 ( 25.7%) B. Epidemiology/Surveillance 1. Chronic Diseases 22 ( 31.4%) 2. Communicable Diseases 61 ( 87.1%) II. Policy Development A. Health Code Dev. and Enforcement 58 ( 82.9%) B. Health Planning 35 ( 50.0%) C. Priority Setting 30 ( 42.9%) III. Assurance Activities A. Inspection 1. Food and Milk Control 58 ( 82.9%) 2. Health Facility Safety/Quality 32 ( 45.7%) 3. Rec. Facility Safety/Quality 46 ( 65.7%) 4. Other Facility Safety/Quality 32 ( 45.7%) B. Licensing 1. Health Facilities 17 ( 24.3%) 2. Other Facilities 61 ( 87.1%) C. Health Education 43 ( 61.4%) D. Environmental 1. Air Quality 26 ( 37.1%) 2. Hazardous Waste Management 43 ( 61.4%) 3. Individual Water Supply Safety 57 ( 81.4%) 4. Noise Pollution 25 ( 35.7%) 5. Occupational Health and Safety 23 ( 32.9%) 6. Public Water Supply Safety 34 ( 48.6%) 7. Radiation Control 20 ( 28.6%) 8. Sewage Disposal Systems 66 ( 94.3%) 9. Solid Waste Management 31 ( 44.3%) 10. Vector and Animal Control 42 ( 60.0%) 11. Water Pollution 61 ( 87.1%) E. Personal Health Services 1. AIDS Testing and Counseling 18 ( 25.7%) 2. Alcohol Abuse 8 ( 11.4%) 3. Child Health 34 ( 48.6%) 4. Chronic Diseases 22 ( 31.4%) 5. Dental Health 15 ( 21.4%) 6. Drug Abuse 11 ( 15.7%) 7. Emergency Medical Service 16 ( 22.9%) 8. Family Planning 8 ( 11.4%) 9. Handicapped Children 8 ( 11.4%) 10. Home Health Care 15 ( 21.4%) 11. Hospitals - 12. Immunizations 53 ( 75.7%) 13. Laboratory Services 11 ( 15.7%) 14. Long-term Care Facilities 5 ( 7.1%) 15. Mental Health 11 ( 15.7%) 16. Obstetrical Care 4 ( 5.7%) 17. Prenatal Care 8 ( 11.4%) 18. Primary Care 5 ( 7.1%) 19. Sexually Transmitted Diseases 33 ( 47.1%) 20. Tuberculosis 32 ( 45.7%) 21. WIC 18 ( 25.7%) C. Local Health Officer No M.D. Requirement, Local Governing Body Appointment Local health officers are hired by the municipality or health district and approved by the Commissioner of CDHS. Local health officers are not required to be physicians. They are, however, required to have a graduate degree in public health as a result of at least 1 year's training that has included at least 60 hours in local health administration. The health officers are responsible for all duties assigned by the local board of health as well as those required by statutes and the public health code. D. Local Board of Health Policy-making District boards of health represent districts that are formed when a group of local jurisdictions (towns, cities, and boroughs) vote to form district departments of health. Each town, city, and borough which voted to become part of the district may appoint one member to the board. Jurisdictions with populations of more than 10,000 are entitled to an additional representative for each 10,000 population, with a limit of five representatives. The members are appointed by the governing bodies of the respective jurisdictions to terms of 3 years. The terms are staggered so that approximately one-third of the terms expire each year. The board is responsible for managing the affairs of the district health department. Some towns and municipalities have boards of health that function in an advisory capacity to the local governing body. The board members are appointed by the local governing body. The number of members vary greatly for these boards. E. Staff The staffs of the local health departments are employed and supervised by the local jurisdiction. The number of staff employed by local health departments ranges from 1 to 140. F. Budget Total FY 1988 LPHA expenditures were $29,957,000*. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $2,696,000 State Funds $5,748,000 Local Funds $21,513,000* Fees and Reimbursements 0 Other Sources 0 Source Unknown 0 * The SHA reported that these figures were estimated. 2Connecticut Department of Health Services, 1990 Advisory Committee Commissioner Commission on Long-Term Care Commission on Hospitals and Health Care Center for Chronic Disease Urban/Rural Health Executive Secretary Center for Governmental Relations Center for Communications Internal/External Deputy Commissioner Bureau of Health Promotion Environmental Epidemiology and Occupational Health Environmental Health Services Infectious Disease Epidemiology Local Health Administration Health Surveillance and Planning Bureau of Community Health Child/Adolescent Health Division Community Health Systems Division Family/Reproductive Health Division Executive Assistant Executive Assistant Executive Assistant Deputy Commissioner Bureau of Health System Regulation Community Nursing and Home Health Emergency Medical Services Hospitals and Medical Care Medical Quality Assurance Regulations Administrative Services Affirmative Action Data Processing Personnel Services Program Monitoring and Fiscal Review Bureau of Laboratory Services Biological Sciences Environmental Chemistry Laboratory Standards Organic Chemistry Toxicology and Criminology 2Types of Local Health Departments by Jurisdiction Connecticut, 1990 Jurisdiction N/Co T/T M/T Avon X Bethel X Bloomfield X Brigdeport X Bristol-Burlington X Chesprocott Dist. X Clinton X Danbury X Durham X East Hartford X East Shore Dist. X Fairfield X Fairfield X Farmington X Farmington Valley X Glastonbury X Greenwich X Groton X Hartford X Hartford X Litchfield X Manchester X Meriden X Middlesex X Middletown X Milford X Naugatuck Valley X New Britain X New Fairfield X New Haven X New Haven X New London X New Milford X New Tolland X Newtown X North Central Dist. X Northeast Dist X Norwalk X Old Lyme X Pomeraug Dist. X Quinnipiack Valley X Southington X Stafford Dist. X Stamford X Stratford X Tolland X Tolland X Torrington Area X Uncas Region Dist. X Wallingford X Waterbury X West Hartford X West Haven X Weston-Westport X Windham X Windsor X N/Co = No county HD T/T = Town/Township HD M = Multitownship HD 1DELAWARE 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 660,000 245,803,000 Population Density (1988) 341.6 69.4 (per/sq.mi.) Number of Counties 3 3,139 Median Age (1987) 31.6 31.7 Percent Below Poverty Level (1985) 11.4 14.0 (persons) Percent of Population Rural (1980) 29.0 26.0 Percent of Population White (1980) 82.1 83.1 Percent of Population Non-white (1980) 17.9 16.9 Median Years of Education (1980) 12.5 12.5 (25 years of age and over) B. County Government Structure No Home Rule Authority The state constitution and statutes establish the authority and structural framework for the three counties of Delaware. Council Form - (2) - New Castle and Sussex counties use the Council Form of government with only slight variations between them. They both have a six-member council elected from districts. New Castle has a seventh member who is elected from the county at large. New Castle also has an elected executive officer and an appointed administrative officer who is responsible to the executive officer. Sussex county appoints a county administrator to fulfill the administrative functions of the county. Levy Court System - (1) - Kent county operates under a Levy Court System which has five Levy Court Commissioners and an appointed county administrator. Data for this state were updated December 1990. 3II. State Health Agency (SHA) A. General Component of Superagency The Delaware Division of Public Health, the SHA, is a component of a superagency called the Department of Health and Social Services (DHSS). For the well-being of Delaware families and communities, the Division of Public Health provides leadership and fosters partnerships to promote healthy lifestyles, prevent disease, disability and premature death, protect human health from environmental hazards, and provide or assure access to health care for vulnerable populations in need. The following are some areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals B. Head of State Health Agency M.D. Requirement, Not Cabinet-level Appointment The Director of the Division of Public Health is the head of the SHA. The Director is appointed by the Secretary of the Department of Health and Social Services with the Governor's approval and serves at the will of the administration. Law requires that the Director be a physician, preferably with an M.P.H. and at least 5 years of increasing administrative responsibility. The Director is the chief administrative officer of the Division and a member of the State Board of Health, where the regulatory and enforcement authority is derived. Membership in several committees and task forces result from both appointment and law. These include: 1. Authority on Radiation Control 2. Controlled Substance Abuse Committee 3. Delaware Emergency Medical Services Advisory Committee 4. Title XIX Medical Advisory Committee 5. Developmental Disabilities Advisory Committee Direct supervision of two deputies and the Directors of the State Laboratory, Offices of Narcotics and Dangerous Drugs, Health Facilities Standards and Licensing Office, and Office of Emergency Medical Services are part of the Director's responsibilities. C. State Board of Health/Council Policy-Making The State Board of Health consists of two members, the Secretary of DHSS and the Director of the Division of Public Health. The Secretary of DHSS serves as Chair, and the Director acts as the secretary of the board, responsible for the agenda, minutes, and preparation of agenda items. D. Regional/District Health Offices The SHA does not divide the state into administrative regions or districts. E. State-local Liaison Centralized Organizational Control, No Liaison Function The local service units are elements of the SHA so there is no need for a liaison function. Delaware is a state that has achieved the highest level of centralization. All of the service units are elements of the SHA and function without any local funds or input. The interaction between state and local public health agencies in Delaware may be characterized as centralized organizational control. Under this arrangement local health departments function directly under the state's authority and are operated by the SHA or State Board of Health. F. Budget Total FY 1988 Delaware SHA expenditures were $52,806,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $7,916,000 State Funds $43,613,000 Local Funds $49,000 Fees and Reimbursements $563,000 Other $666,000 3III. Local Public Health Agencies (LPHAs) A. General Delaware does not consider the three service units to be local health departments. The SHA, however, has a branch office located in each county to provide public health services in that jurisdiction. We recognize that these units are part of the SHA and receive no local funding or input, but they are providing public health services in local jurisdictions. B. Services Provided The following information on services provided by local health departments in Delaware is derived from a list of state-mandated services that are carried out by the three regional offices. Since Delaware does not consider the regional offices to be local health departments, they did not respond to the NACHO survey of local health departments. Services Provided by LPHAs Number of LPHAs I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 3 2. Morbidity Data - 3. Reportable Diseases 3 4. Vital Records and Statistics 3 B. Epidemiology/Surveillance 1. Chronic Diseases 3 2. Communicable Diseases 3 II. Policy Development A. Health Code Dev. and Enforcement - B. Health Planning - C. Priority Setting - III. Assurance Activities A. Inspection 1. Food and Milk Control 3 2. Health Facility Safety/Quality - 3. Rec. Facility Safety/Quality - 4. Other Facility Safety/Quality - B. Licensing 1. Health Facilities - 2. Other Facilities - C. Health Education - D. Environmental 1. Air Quality - 2. Hazardous Waste Management - 3. Individual Water Supply Safety 3 4. Noise Pollution - 5. Occupational Health and Safety - 6. Public Water Supply Safety 3 7. Radiation Control 3 8. Sewage Disposal Systems - 9. Solid Waste Management - 10. Vector and Animal Control - 11. Water Pollution - E. Personal Health Services 1. AIDS Testing and Counseling 3 2. Alcohol Abuse - 3. Child Health 3 4. Chronic Diseases - 5. Dental Health - 6. Drug Abuse - 7. Emergency Medical Service - 8. Family Planning 3 9. Handicapped Children 3 10. Home Health Care - 11. Hospitals - 12. Immunizations 3 13. Laboratory Services - 14. Long-term Care Facilities - 15. Mental Health - 16. Obstetrical Care - 17. Prenatal Care 3 18. Primary Care - 19. Sexually Transmitted Diseases 3 20. Tuberculosis 3 21. WIC 3 C. Local Health Officer No M.D. Requirement, State Merit System Appointment Assistant State Health Officers are in charge of each of the three local health units. They may be physicians but are not required to be. They are responsible for enforcing public health regulations in their county and supervising activities in their area, including contracting for the local services. These Assistant State Health Officers are State Merit System employees and are appointed through the standard process for hiring state employees. Their responsibilities resemble those of the State Director except for formulating budget and proposing legislation. D. Local Board of Health There are no local boards of health in Delaware. E. Staff The staffs for the local service units are employees of the SHA and part of the State Merit System. The number of employees in the local service units range from 40 to 100. F. Budget Funding for providing local public health services in Delaware is handled entirely by the SHA without the input of any local funds. 2Delaware Division of Public Health, 1990 Governor Department of Health and Social Services Board of Health Office of the Secretary Division of Aging Division of Alcohol, Drug Abuse and Mental Health Division of Business Administration and General Services Division of Child Support Enforcement Division of Medical Examiner Division of Public Health Director Long-Term Care Section Community Health Section Office of Narcotics and Dangerous Drugs Office of Emergency Medical Services Office of Health Facilities Standards and Licensing Laboratory Division of Mental Retardation Division of Social Services Division of State Services Centers Division of Visually Impaired Division of Planning and Research Evaluation 2Types of Local Health Departments by Jurisdiction Delaware, 1990 Jurisdiction Co Kent X New Castle X Sussex X Co = County HD 1DISTRICT OF COLUMBIA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 617,000 245,803,000 Population Density (1988) 9,793.7 69.4 (per/sq.mi.) Number of Counties 0 3139 Median Age (1987) 32.9 31.7 Percent Below Poverty Level (1979) 18.6 12.4 (persons) Percent of Population Rural (1980) 0.0 26.0 Percent of Population White (1980) 26.9 83.1 Percent of Population Non-white (1980) 73.1 16.9 Median Years of Education (1980) 12.7 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The government of the District of Columbia is unique among local governments in the United States in that it functions as a state, a county, a city, a school district and special districts combined. Home Rule Charter - The District of Columbia is also different from other local governments because it was chartered by Congress. In 1973 Congress passed the District of Columbia Self-Government Reorganization Act, which is commonly called home rule. With the Home Rule Charter, Congress retained the authority to review legislation passed by the District of Columbia Council and to control policy through the appropriation process. The tax base for the District of Columbia is different because the charter restricts the ability of the government to tax. It prohibits non-resident income tax and property tax on 56 percent of the land. Each year the Federal government makes a payment to the District government to compensate for costs incurred in delivering services to the Federal establishment, for revenue lost to the District because of the presence of the Federal government and for the Federal restrictions on the District tax authority. The Federal payment, which began when the District was established as the Nation's capital in 1800, is determined each year by the President and Congress through the Data for the District of Columbia were updated February 1991. legislative process. Despite the intended purpose of the Federal payment, it has not kept pace with the revenue lost due to Federal restrictions on the District's taxing authority. Council Form - The District of Columbia Council, which is the legislative body, is composed of a 13-member board including a Council Chairman. Terms of office for the Council members are 4 years. Eight Council members are elected from each of eight wards, with four others and the Council Chairman elected at-large. Only two of the at-large members may be from the same political party (excluding the Chairman). Terms of office are staggered so that the terms of six members expire and 2 years later terms of the other six members plus the Chairman expire. The Chairman is the chief executive for the Council, conducting all meetings and signing all legislation on behalf of this body. This official is responsible for referring all bills to the appropriate committee and transmitting all approved bills to the Mayor for signature and to the Congress. The Chairman nominates council officers, Chairman pro tempore, committee chairmanships, committee members, and others such as auditor and representatives for independent boards. The Executive Officer of the District of Columbia government is the Mayor. The District has a non-voting delegate to the U.S. House of Representatives. This delegate is elected by popular vote every 2 years. 3II. State Health Agency (SHA) A. General Component of Superagency The Commission of Public Health is the SHA for the District of Columbia. The Commission has SHA responsibility, including providing local health services. It is a component of a superagency called the Department of Human Services. The mission of the Commission of Public Health is to assure equitable access to comprehensive, high quality public health services to all residents and visitors and to monitor and improve their health status. The following is a list of areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs Emergency Medical Services State Agency (included by SHA) Local Public Health Responsibility Responsibility for Institutions/Hospitals (public long-term care only) B. Head of State Health Agency M.D. Requirement, Mayoral Appointment The Commissioner of Public Health, the title for director of the SHA, is appointed by the Mayor. The Office of Commissioner is responsible for the formulation, implementation and evaluation of health care services delivered to both residents and visitors. The Commissioner has responsibility to manage in an effective and efficient manner and to provide the public with preventive and treatment programs that will help the sick and reduce suffering. C. State Board of Health/Council The District of Columbia does not have a Council or Board of Health. D. Regional/District Health Offices The Commission of Public Health in the Department of Human Services functions as both the state and local public health agency (LPHA) for the District. The Commission provides public health services through a network of 25 public health care clinics. The clinics provide a range of specialized and primary health services on an outpatient basis. The clinics are not uniform in services provided or in staffing patterns. Individual clinics tend to specialize in specific areas of service such as control of sexually transmitted diseases, tuberculosis, drug abuse, or ambulatory care. The following is a list of services provided by the Commission of Public Health: Services Provided by LPHA Number of LPHA Reporting I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 1 2. Morbidity Data 1 3. Reportable Diseases 1 4. Vital Records and Statistics - B. Epidemiology/Surveillance 1. Chronic Diseases 1 2. Communicable Diseases 1 II. Policy Development A. Health Code Dev. and Enforcement - B. Health Planning 1 C. Priority Setting 1 III. Assurance Activities A. Inspection 1. Food and Milk Control - 2. Health Facility Safety/Quality - 3. Rec. Facility Safety/Quality - 4. Other Facility Safety/Quality - B. Licensing 1. Health Facilities - 2. Other Facilities - C. Health Education 1 D. Environmental 1. Air Quality - 2. Hazardous Waste Management - 3. Individual Water Supply Safety - 4. Noise Pollution - 5. Occupational Health and Safety - 6. Public Water Supply Safety - 7. Radiation Control - 8. Sewage Disposal Systems - 9. Solid Waste Management - 10. Vector and Animal Control 1 11. Water Pollution - E. Personal Health Services 1. AIDS Testing and Counseling 1 2. Alcohol Abuse 1 3. Child Health 1 4. Chronic Diseases 1 5. Dental Health 1 6. Drug Abuse 1 7. Emergency Medical Service 1 8. Family Planning 1 9. Handicapped Children 1 10. Home Health Care 1 11. Hospitals (long term care) 1 12. Immunizations 1 13. Laboratory Services 1 14. Long-term Care Facilities 1 15. Mental Health - 16. Obstetrical Care 1 17. Prenatal Care 1 18. Primary Care 1 19. Sexually Transmitted Diseases 1 20. Tuberculosis 1 21. WIC 1 E. State-Local Liaison The District of Columbia performs the functions of both state and local government. Hence, there is no need for a liaison function. F. Budget Total 1987 District of Columbia SHA expenditures were $194,329,000. Total 1987 United States SHA expenditures were $8,148,511,000. Source of Funds Federal Grants and Contracts $37,074,000 State Funds $155,114,000 Local Funds 0 Fees and Reimbursements $2,140,000 Other 0 2District of Columbia Comission of Public Health, 1990 Commissioner Deputy Commissioner Office of Management and Budget Office of Health Care Access Office of Chief Medical Examiner Alcohol and Drug Abuse Services Office of Emergency Health and Medical Services Ambulatory Health Care Office of Medical Affairs for Social Services Long-Term Care Office of Health Planning and Development Preventive Health Services Bureau of Sexually Transmitted Disease Control Bureau of Laboratories Bureau of Epidemiology and Disease Control Bureau of Cancer Control Bureau of Tuberculosis Control Office of AIDS Activities Office of Dental Health Office of Maternal and Child Health Office of Nutrition 2Types of Local Health Departments by Jurisdiction District of Columbia, 1990 Jurisdiction C N/Co District X C = City HD 1FLORIDA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) * 12,503,800 245,803,000 Population Density (1988) * 230.8 69.4 (per/sq.mi.) Number of Counties 67 3,139 Median Age (1987) 36.0 31.7 Percent Below Poverty Level (1985) 13.4 14.0 (persons) Percent of Population Rural (1980) 16.0 26.0 Percent of Population White (1980) 84.0 83.1 Percent of Population Non-white (1980) 16.0 16.9 Median Years of Education (1980) 12.5 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority Florida counties derive their power from the state constitution and state statutes. The general form of county government is a five-member board of commissioners that is elected at large. Exceptions to this rule are Volusia and Jacksonville-Duval which have county councils and Hillsborough and Dade which have seven- and nine-member county commissions. Dade also has a county mayor. County governments in Florida fall into either Charter or non-Charter status. Both Charter and non-Charter counties have the legal option of utilizing a county administrator position to perform administrative affairs of the board. At the present time 40 counties have chosen to utilize some form of appointed county administrator. Charter Form - (12) - In charter governments the commission retains legislative and policy-making roles, but executive functions may be delegated to an appointed or elected official. The counties may utilize a County Manager, a County Chairman-Administrator, or a County Executive to fulfill the executive function. * These data were provided by the SHA. Data for this state were updated October 1990. Non-Charter Form - (55) - Counties utilizing this form of government have many of the same powers granted to charter counties. Non-Charter counties, however, do not have the option of changing the structure or the manner of selection for the governing body and county officers. 3II. State Health Agency (SHA) A. General Component of Superagency The Department of Health and Rehabilitative Services (HRS) is responsible for the provision of state-supported public health services in Florida. The purpose of HRS is to integrate the delivery of all health, social, and rehabilitative services offered by the state. As a result, HRS is the primary provider of public assistance services. Public health activities represent only a fraction of the Department's overall activities. The Department is headed by a Secretary appointed by the Governor and confirmed by the Senate. The Secretary is served by five Deputy Secretaries responsible for the major organizational units that comprise the Department (see attached table of organization). The following are some of the areas of responsibility for the SHA: State Public Health Authority State Institutions/Hospitals Environmental health activities are divided between HRS and the Department of Environmental Regulation. B. Head of State Health Agency No M.D. Requirement, Not Cabinet-level Appointment The Deputy Secretary for Health is the State Health Officer. The State Health Officer is appointed by and serves at the pleasure of the Secretary of HRS. The State Health Officer must be a licensed physician or hold a master's degree or doctorate in public health from an accredited university, and must have specialized training and experience in public health service and administration. The State Health Officer is responsible for defining the mission and setting the policy direction for the state public health system, directing and coordinating the activities of four assistant health officers, providing leadership to public health staffs, conveying the public health mission and program to the public and the legislature, ensuring coordination and interaction between the public health system and related programs within HRS and the external community, and providing medical supervision to the HRS county public health units. The State Health Officer provides policy guidance for public health unit staff, but does not have line authority over employees in the public health units. The State Health Officer directs the State Health Office. C. State Board of Health/Council Advisory Florida has two state health councils. However, neither is a board of health in the traditional sense. Both are strictly advisory. They are the Advisory Council on Health and the Statewide Health Council. The Advisory Council on Health serves in an advisory capacity to the State Health Officer. It is composed of 11 members who are appointed by the Secretary of HRS in consultation with the State Health Officer. Members of this council must include three physicians; the Secretary of the Department of Environmental Regulation; the Dean of the College of Public Health at the University of South Florida; a dentist; a registered nurse; a veterinarian; an individual with professional expertise in environmental health; and a consumer or representative of an advocacy group. In addition to advising the State Health Officer on general policies affecting public health in the state, the Council recommends programs to carry out the purposes of the Department. The second council, the Statewide Health Council, advises the Governor, Legislature, and Department on state health policy issues, health planning activities, and regulation programs. The Statewide Health Council is composed of the chairman of the 11 local health councils, 2 individuals appointed by the Speaker of the House of Representatives, and 2 individuals appointed by the President of the Senate. Much of the Statewide Health Council's work involves collating the information and planning materials gathered by 11 local health planning councils. However, the Statewide Health Council also reviews district health plans for consistency with the state health goals and policies, prepares a state report on the adequacy, appropriateness, and effectiveness of state funds distributed to meet the needs of the medically indigent, and assists the local health councils in developing an analysis of service and facility needs of persons with AIDS-related illnesses. D. Regional/District Health Offices HRS service areas in Florida are divided into 11 districts. Each district is headed by a District Administrator. The District Administrator is appointed by the Secretary and is directly responsible to the Deputy Secretary for Operations. The District Administrator has line authority over all Department programs assigned to the district. The Deputy District Administrator for Health and district administrators in each district have direct supervisory authority over the public health unit directors and administrators. Although staffing levels in the different district offices vary, district staff with responsibility for public health activities generally include the following: District Administrator Deputy Assistant Administrator for Health Environmental Health Consultant Nursing Consultant Human Services Program Manager(s) Human Services Program Analysts E. State-local Liaison Centralized Organizational Control, Informal Liaison Function State-local liaison activities are primarily handled by District Administrators and County Public Health Unit Directors and Administrators. There are no positions allocated for purely liaison purposes. The majority of day-to-day contact between state public health officials and local officials is handled by the county public health unit directors and administrators. The interaction between state-local public health agencies in Florida may be characterized as centralized organizational control. Under this arrangement, local health departments function directly under the state's authority and are operated by the SHA. F. Budget Total FY 1988 SHA expenditures were $366,796,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $98,553,000 State Funds $198,694,000 Local Funds $29,358,000 Fees and Reimbursements $38,439,000 Other $1,752,000 3III. Local Public Health Agencies (LPHAs) A. General There are 67 county health departments in Florida. HRS enters into contracts with the 67 counties in Florida to identify funding for the services that will be provided by the public health units. All contracts are negotiated and approved by the appropriate local governing bodies and the appropriate district administrators on behalf of the Department. The county public health units are part of the Department of Health and Rehabilitative Services. County health unit employees are HRS employees. B. Services Provided The following information on services provided by local health departments in Florida is derived from a survey conducted by NACHO during 1989. Sixty-three of the 67 local health departments in Florida responded to the survey. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 26 ( 41.3%) 2. Morbidity Data 40 ( 63.5%) 3. Reportable Diseases 62 ( 98.4%) 4. Vital Records and Statistics 62 ( 98.4%) B. Epidemiology/Surveillance 1. Chronic Diseases 48 ( 76.2%) 2. Communicable Diseases 62 ( 98.4%) II. Policy Development A. Health Code Dev. and Enforcement 36 ( 57.1%) B. Health Planning 45 ( 71.4%) C. Priority Setting 42 ( 66.7%) III. Assurance Activities A. Inspection 1. Food and Milk Control 51 ( 81.0%) 2. Health Facility Safety/Quality 46 ( 73.0%) 3. Rec. Facility Safety/Quality 38 ( 60.3%) 4. Other Facility Safety/Quality 25 ( 39.7%) B. Licensing 1. Health Facilities 20 ( 31.7%) 2. Other Facilities 47 ( 74.6%) C. Health Education 52 ( 82.5%) D. Environmental 1. Air Quality 16 ( 25.4%) 2. Hazardous Waste Management 48 ( 76.2%) 3. Individual Water Supply Safety 59 ( 93.7%) 4. Noise Pollution 12 ( 19.0%) 5. Occupational Health and Safety 23 ( 36.5%) 6. Public Water Supply Safety 55 ( 87.3%) 7. Radiation Control 30 ( 47.6%) 8. Sewage Disposal Systems 60 ( 95.2%) 9. Solid Waste Management 40 ( 63.5%) 10. Vector and Animal Control 59 ( 93.7%) 11. Water Pollution 44 ( 69.8%) E. Personal Health Services 1. AIDS Testing and Counseling 63 (100.0%) 2. Alcohol Abuse 7 ( 11.1%) 3. Child Health 63 (100.0%) 4. Chronic Diseases 59 ( 93.7%) 5. Dental Health 32 ( 50.8%) 6. Drug Abuse 11 ( 17.5%) 7. Emergency Medical Service 6 ( 9.5%) 8. Family Planning 63 (100.0%) 9. Handicapped Children 15 ( 23.8%) 10. Home Health Care 26 ( 41.3%) 11. Hospitals 2 ( 3.2%) 12. Immunizations 63 (100.0%) 13. Laboratory Services 45 ( 71.4%) 14. Long-term Care Facilities 7 ( 11.1%) 15. Mental Health 2 ( 3.2%) 16. Obstetrical Care 37 ( 58.7%) 17. Prenatal Care 61 ( 96.8%) 18. Primary Care 62 ( 98.4%) 19. Sexually Transmitted Diseases 63 (100.0%) 20. Tuberculosis 62 ( 98.4%) 21. WIC 62 ( 98.4%) C. Local Health Officer M.D. or D.O. Requirement, Secretary Appointment County public health units are headed by a Director or Administrator. The Director is a doctor of medicine or osteopathy who is trained in public health administration and appointed by the Secretary of HRS after consultation with the State Health Officer, the District Administrator, and after concurrence of the Board of County Commissioners. The Administrator is trained in public health administration, but is not a physician. Administrators are appointed in the same fashion as directors. Directors and Administrators are HRS employees. D. Local Board of Health Florida does not have local boards of health. E. Staff The county public health unit employees are HRS employees. They are supervised, with the exceptions of the unit directors and administrators, by the supervisory staff in the unit. Unit directors and administrators are supervised by the district administrators and deputy administrators. The number of employees for public health units ranges from 4 to 680. F. Budget Total FY 1988 LPHA expenditures were $216,402,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $19,105,000 State Funds $146,531,000 Local Funds $29,358,000 Fees and Reimbursements $21,407,000 Other Sources 0 Source Unknown 0 The SHA reported that these figures include the total amount of additional monies expended by all local health departments. 2Florida Department of Health and Rehabilitative Services, 1990 Secretary Deputy Secretary for Administrative Services Deputy Secretary for Programs Deputy Secretary for Health Assistant Deputy Program and Financial Assessment Director of Quality Assurance and Public Health Nursing Assistant Health Officer for Disease Control and AIDS Prevention Assistant Health Officer for Family Health Services Assistant Health Officer for Technical Health Services Assistant Health Officer for Environmental Health Deputy Secretary for Operations District Administrator Deputy District Administrator for Health HRS County Public Health Units Deputy Secretary for Management Systems 2Types of Local Health Departments by Jurisdiction Florida, 1990 Jurisdiction Co Alachua X Baker X Bay X Bradford X Brevard X Broward X Calhoun X Charlotte X Citrus X Clay X Collier X Columbia X Dade X De Soto X Dixie X Duval X Escambia X Flagler X Franklin X Gadsden X Gilchrist X Glades X Gulf X Hamilton X Hardee X Hendry X Hernando X Highlands X Hillsborough X Holmes X Indian River X Jackson X Jefferson X Lafayette X Lake X Lee X Leon X Levy X Liberty X Madison X Manatee X Marion X Martin X Monroe X Nassau X OKaloosa X Okeechobee X Orange X Osceola X Palm Beach X Pasco X Pinellas X Polk X Putnam X Santa Rosa X Sarasota X Seminole X St. Johns X St. Lucie X Sumter X Suwannee X Taylor X Union X Volusia X Wakulla X Walton X Washington X Co = County HD 1GEORGIA 2Georgia Divison of Public Health, 1990 3I. General State Information A. Selected Socio-Demographic Indicators State United States Population (1988) 6,342,000 245,803,000 Population Density (1988) * 107.7 69.4 (per/sq.mi.) Number of Counties 159 3,139 Median Age (1987) * 30.6 31.7 Percent Below Poverty Level (1985) * 16.6 14.0 (persons) Percent of Population Rural (1980) * 37.6 26.0 Percent of Population White (1980) * 72.8 83.1 Percent of Population Non-white (1980) * 27.2 16.9 Median Years of Education (1980) 12.2 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority Georgia counties operate under powers granted to them by the Georgia Constitution and Statutes. Commission Form - (159) - The county government is based on the Commission Form and is usually made up of three- to nine-member boards. However, 22 counties have only one commissioner. Sixty-one counties appoint an administrative manager who is responsible for the daily administration of the county government. Home Rule - (39) - The power of county governments in Georgia is limited to that conferred on them by law or implied in the granting of other authority. In 1965 the state constitution was amended under home rule legislation giving counties legislative authority to pass ordinances, regulations, and resolutions on subjects that were not otherwise restricted by the state constitution or other laws. City-County Consolidation - (1) - Although the state constitution permits cities and counties to consolidate their * These date were provided by the SHA. Data for this state were updated October 1990. governments, only Columbus-Muscogee have chosen to do so. This consolidated government functions with an elected mayor and 10 councilmen. County governments do not have charters in Georgia. Instead, legislative acts function in the same way and establish boards of commissioners, their terms of office, salaries, powers, and duties. 3II. State Health Agency (SHA) A. General Component of Superagency The SHA in Georgia is called the Division of Public Health. It is a component of a superagency that is called the Georgia Department of Human Resources (GDHR). The mission of the GDHR is to assist Georgians in achieving their highest levels of health, development, independence, and self sufficiency. The following are some areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs B. Head of State Health Agency M.D. Required, Not Cabinet-level Appointment The head of the SHA is the Director of the Division of Public Health. This position is appointed by the Commissioner of the Department of Human Resources. There is a legal requirement that the Director be a physician. The Director has responsibility for the management and administration of the Division of Health. C. State Board of Health/Council Policy-making Georgia has a Board of Human Resources rather than a State Board of Health or Health Council. It is composed of 15 members, but not more than two, from each congressional district in the state. The members are appointed by the Governor and confirmed by the Senate for staggered 5-year terms. Seven members of the board must be professionally engaged in rendering health services, and at least five of those seven must be licensed to practice medicine in Georgia. The Board establishes the general policy to be followed by the agency. It also appoints the commissioner for the department, subject to approval of the Governor. The Commissioner of the GDHR is required by law to be the chief administrative officer of the Board and subject to the policy established by the Board. D. Regional/District Health Offices State law permits the establishment of administrative multicounty districts with the consent of the county governments and boards of health of the counties involved. Nineteen administrative areas (known as districts) currently exist in Georgia. The districts range in size from 1 to 16 counties. Each district has a health director who is appointed by the Commissioner and approved by the boards of health of the concerned counties. The District Health Director serves all of the counties in common and has all of the powers and duties as the director of a single county board of health. The district offices are staffed with the following employees: District Health Director District Administrator District Community Epidemiologist District Chief of Nursing District Program Manager District Environmental Chief District Program Heads District Typists and Clerks District offices are in the "lead" county of the district, which is usually the largest county in population. The district office is usually housed separately from a county health department. Staff from the district office are involved in the direct provision of services, but the services are usually provided at a county health department rather than the district office. E. State-local Liaison Shared Organizational Control, Informal Liaison Function The state does not have a single individual or office that has responsibility for the interface between the SHA and local health agencies. The Director of the Division of Public Health, however, has four individuals who function as regional coordinators, relating to counties and regions within their geographic areas of responsibility. The interaction between state and local public health agencies in Georgia may be characterized as shared organizational control. Under this arrangement, local health departments are under the authority of the board of health and certain indirect authority from the state which is provided contractually. F. Budget Total FY 1988 Georgia SHA expenditures were $198,845,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $81,008,000 State Funds $116,710,000 Local Funds 0 Fees and Reimbursements $788,000 Other $339,000 3III. Local Public Health Agencies (LPHAs) A. General Each of the 159 counties in Georgia has a county health department which functions as the LPHA. B. Services Provided The following information on services provided by local health departments in Georgia is derived from a survey conducted by NACHO during 1989. One Hundred and fourteen of the 159 local health departments responded to the survey. Services provided by 70 percent of the local health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 55 ( 48.2%) 2. Morbidity Data 86 ( 75.4%) 3. Reportable Diseases 107 ( 93.9%) 4. Vital Records and Statistics 56 ( 49.1%) B. Epidemiology/Surveillance 1. Chronic Diseases 57 ( 50.0%) 2. Communicable Diseases 106 ( 93.0%) II. Policy Development A. Health Code Dev. and Enforcement 55 ( 48.2%) B. Health Planning 71 ( 62.3%) C. Priority Setting 59 ( 51.8%) III. Assurance Activities A. Inspection 1. Food and Milk Control 72 ( 63.2%) 2. Health Facility Safety/Quality 64 ( 56.1%) 3. Rec. Facility Safety/Quality 61 ( 53.5%) 4. Other Facility Safety/Quality 13 ( 11.4%) B. Licensing 1. Health Facilities 39 ( 34.2%) 2. Other Facilities 90 ( 78.9%) C. Health Education 89 ( 78.1%) D. Environmental 1. Air Quality 23 ( 20.2%) 2. Hazardous Waste Management 26 ( 22.8%) 3. Individual Water Supply Safety 97 ( 85.1%) 4. Noise Pollution 10 ( 8.8%) 5. Occupational Health and Safety 39 ( 34.2%) 6. Public Water Supply Safety 52 ( 45.6%) 7. Radiation Control 14 ( 12.3%) 8. Sewage Disposal Systems 89 ( 78.1%) 9. Solid Waste Management 31 ( 27.2%) 10. Vector and Animal Control 64 ( 56.1%) 11. Water Pollution 37 ( 32.5%) E. Personal Health Services 1. AIDS Testing and Counseling 112 ( 98.2%) 2. Alcohol Abuse 51 ( 44.7%) 3. Child Health 112 ( 98.2%) 4. Chronic Diseases 88 ( 77.2%) 5. Dental Health 70 ( 61.4%) 6. Drug Abuse 50 ( 43.9%) 7. Emergency Medical Service 28 ( 24.6%) 8. Family Planning 114 (100.0%) 9. Handicapped Children 74 ( 64.9%) 10. Home Health Care 31 ( 27.2%) 11. Hospitals 7 ( 6.1%) 12. Immunizations 114 (100.0%) 13. Laboratory Services 82 ( 71.9%) 14. Long-term Care Facilities 8 ( 7.0%) 15. Mental Health 56 ( 49.1%) 16. Obstetrical Care 34 ( 29.8%) 17. Prenatal Care 110 ( 96.5%) 18. Primary Care 16 ( 14.0%) 19. Sexually Transmitted Diseases 113 ( 99.1%) 20. Tuberculosis 111 ( 97.4%) 21. WIC 113 ( 99.1%) C. Local Health Officer (District Health Director) M.D. Requirement, Commissioner of Department of Human Resources Appointment The District Health Director usually serves as the county health officer for each of the counties in the district. He/she is appointed by the Commissioner of the Department of Human Resources with the consent of the county boards of health in the district. In fact, the boards of health in each county subsequently appoint the district health director to the position of county medical director. The district health officer is required to provide those services mandated by the SHA, but he/she has the authority to provide other services. The limiting factor is the availability of local funds to support additional services. The Director is subject to the policies and directives of the county board of health and the policies and directives of the Division of Public Health. The Director is required to devote his/her entire time to service and to the health districts and to be vigilant in procuring compliance with its rules and regulations and with Georgia health laws and rules and regulations that have application within the county and district. The Director is also directed to make reports to the county board of health and to the Division of Public Health as required. D. Local Board of Health Policy-making State law provides for the creation of county boards of health, their membership, powers and responsibilities. Each board of health is specified by law to be composed of the following seven members: 1. The Chief Executive Officer of the governing authority of the county. 2. The county superintendent of schools. 3. A practicing physician (a nurse or dentist if no physician is available). 4. A consumer to represent mental health, mental retardation, and substance abuse services. 5. A consumer or nurse who is interested in promoting public health. 6. A consumer who represents the county's needy, underprivileged, or elderly. 7. The Chief Executive Officer of the governing authority of the largest municipality in the county. In counties with a population between 250,000 and 400,000, the board may appoint the superintendent of the county's largest municipal school system as an ex officio member. The county boards of health are empowered by state statutes to perform the following functions: 1. Establish and adopt bylaws for its own governance. 2. Exercise responsibility and authority in all matters within the county pertaining to health unless the responsibility is designated to another agency. 3. Take such steps as may be necessary to prevent and suppress disease and conditions deleterious to health and determine compliance with health laws and rules, regulations, and standards. 4. Adopt and enforce rules and regulations appropriate to its functions and powers. 5. Receive and administer all grants, gifts, moneys, and donations for purposes of health. 6. Make contracts and establish fees for the provision of mental health and other public health services by county boards of health. 7. Contract with the Department of Human Resources or other agencies for assistance in the performance of its functions and the exercise of its powers and for supplying services which are within its purview to perform. Counties with more than 550,000 population may create boards of health by ordinance. The board of health in these counties is very similar in structure (seven members) and functions by operating under state law. The board of health is directed to appoint a director who is a licensed physician to serve as its chief executive officer. The director, with approval of the board, may designate aides and assistants. E. Staff The county health department staffs are employees of the county board of health, but under the State Merit and Retirement Systems. Additionally, they are not considered to be county employees, but rather board of health employees. The funds for staff salaries may come from all sources available such as fees, grants-in-aid, county money, and state money. Employees are not categorized according to the source of funds for their salaries and are generally unaware of the source. The number of employees for local health departments ranges from 2 to 698. F. Budget Total FY 1988 Georgia LPHA expenditures were $91,371,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $5,307,000 State Funds $44,987,000 Local Funds $25,110,000 Fees and Reimbursements $11,175,000 Other Sources $4,794,000 Source Unknown 0 2Georgia Division of Public Health, 1990 Director Office of Epidemiology Employees' Health Service Administrative Services Section Planning and Evaluation Library Fiscal Management Personnel Vital Records and Health Statistics Research and Special Studies Emergency Health Section Field Services Research and Evaluation Training Administrative Services Environmental Health Section Environmental Services Special Services Occupational Health Family Health Services Section Immunization Program Women's Health Office of Dental Health Office of Medicine Office of Nursing Office of Nutrition Children's Medical Services Office of Pharmacy Children and Adolescent Health WIC Community Health Section Field Laboratory Services Administrative Support Services Micro-Immunology Services Chemistry Services Sexually Transmitted Disease Adult Health Genetic Screening Tuberculosis Control Primary Health Care Section Appalachia Resource Development Coastal Plains District/Unit Health Directors County Health Departments County Boards of Health 2Types of Local Health Departments by Jurisdiction Georgia, 1990 Jurisdiction Co Appling X Atkinson X Bacon X Baker X Baldwin X Banks X Barrow X Bartow X Beckley X Ben Hill X Berrien X Bibb X Brantley X Brooks X Bryan X Bulloch X Burke X Butts X Calhoun X Camden X Carroll X Catoosa X Chandler X Charlton X Chatham X Chattahoochee X Chattoga X Cherokee X Clarke X Clay X Clayton X Clinch X Cobb X Coffee X Columbia X Cook X Coweta X Crawford X Crisp X Dade X Dawson X De Kalb X Decatur X Dodge X Dooly X Dougherty X Douglas X Early X Echols X Effingham X Elbert X Emanuel X Evans X Fannin X Fayette X Floyd X Forsyth X Franklin X Fulton X Gilmer X Glascock X Glynn X Gordon X Grady X Greene X Gwinnett X Habersham X Hall X Hancock X Haralson X Harris X Hart X Heard X Henry X Irwin X Jackson X Jasper X Jeff Davis X Jefferson X Jenkins X Johnson X Jones X Lamar X Lanier X Laurens X Lee X Liberty X Lincoln X Long X Lowndes X Lumpkin X Macon X Madison X Marion X McDuffie X McIntosh X Meriwether X Miller X Mitchell X Monroe X Montgomery X Morgan X Murray X Muscogee X Newton X Oconee X Oglethorpe X Paulding X Peach X Pickens X Pierce X Pike X Polk X Pulaski X Putnam X Quitman X Rabin X Randolph X Richmond X Rockdale X Schley X Screven X Seminole X Spalding X Stephens X Stewart X Sumter X Talbot X Taliaferro X Tattanall X Taylor X Telfair X Terrel X Thomas X Tift X Toombs X Towns X Treutlen X Troup X Turner X Twiggs X Union X Upson X Walker X Walton X Ware X Warren X Washington X Wayne X Webster X Wheeler X White X Whitefield X Wilcox X Wilkerson X Wilkes X Worth X Colquitt X Houston X Co = County HD 1HAWAII 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 1,098,000 245,803,000 Population Density (1988) 170.9 69.4 (per/sq.mi.) Number of Counties 4 3,139 Median Age (1987) 30.9 31.7 Percent Below Poverty Level (1985) 10.7 14.0 (persons) Percent of Population Rural (1980) 13.0 26.0 Percent of Population White (1980) 33.0 83.1 Percent of Population Non-white (1980) 67.0 16.9 Median Years of Education (1980) 12.7 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The structure and authority for county governments in Hawaii are established by the state constitution. Charter Form - (4) - All of the counties have this form of government. The governing body for the counties is the council, the members of which are elected at-large, except for Honolulu city-county which elects them from districts. Three counties are served by nine-member councils, and one is served by a seven-member council. While the legislative function of county government is served by the council, the executive function is served by a mayor. City-County Consolidation - (1) - The state constitution permits the consolidation of city and county governments. At the present time, only Honolulu city-county has merged. Home rule authority is also provided for in the constitution. The constitution states that each county shall have power to develop and adopt a charter for its own self-government within limits established by law. One county, Kalawao, is administratively associated with the County of Maui and does not have full county status. Data for this state were updated December 1990 3II. State Health Agency (SHA) A. General Free-standing, Independent The Hawaii Department of Health (HDH), the SHA, is a free-standing, independent agency. The mission of the Department is to provide leadership to monitor, protect, and enhance the health of all people in Hawaii. The following are some areas of responsibility for the SHA: State Public Health Authority Lead Environmental Agency in the State State Mental Health Authority State Agency for Children with Special Health Care Needs State Health Planning and Development Agency (attached to the HDH for administrative purposes) Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Director is the head of the HDH. The Director, under the general direction of the Governor and with the advice of the Board of Health, plans, directs, and administers statewide activities designed to protect, preserve and improve the physical and mental well-being of the people of the state of Hawaii. The Governor appoints the Director and the Senate confirms the appointment. C. State Board of Health/Council Advisory The State Board of Health is composed of 11 members appointed by the Governor with confirmation by the Senate. Terms of office are 4 years and not to exceed two terms. One member is appointed from each of the counties, including Kalawao, and six members are appointed at-large. The Director of the Department of Human Services serves as an ex officio member. The Board functions to provide advice to the Director on matters within the jurisdiction of the Department to hold hearings for the Department at the request of the Director and to undertake special projects at the request of the Director. D. Regional/District Health Offices The central health office is located on the island of Oahu and district health offices are on Kauai, Maui and Hawaii. The district offices administer and coordinate the delivery of public health services. Services for some programs are delivered directly through the district offices, but services for other programs are provided by private providers through contracts. E. State-local Liaison Centralized Organizational Control, Informal Liaison Function Since the service-providing units, the district health offices, are part of the HDH, there is no need for a formal liaison between the state and local units. Communications between the different levels take place through the normal chain of command. The interaction between state and local public health agencies in Hawaii may be characterized as centralized organizational control. Under this arrangement local health departments function directly under the state's authority and are operated the HDH or State Board of Health. F. Budget Total FY 1988 Hawaii SHA expenditures were $218,116,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $19,099,000 State Funds $110,419,000 Local Funds 0 Fees and Reimbursements $88,033,000 Other $567,000 3III. Local Public Health Agencies (LPHAs) A. General The Honolulu City Health Department is the only local health department in Hawaii. Three district health offices are located on the islands of Kauai, Maui, and Hawaii. The central office on Oahu functions as a district office. The district offices provide public health services to local areas and perform the same basic function as local health departments in other states. However, Hawaii does not consider these district units to be local health departments. B. Services Provided The following are services provided by the district health offices in Hawaii. Information on all three district health departments was provided by the HDH. Honolulu City Health Department provides physical examinations for city employees and runs the ambulance service on Oahu under contract with the state. Services provided by the Honolulu City Health Department are not included in the following list: Services Provided by LPHAs Number of LPHAs I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment - 2. Morbidity Data - 3. Reportable Diseases - 4. Vital Records and Statistics 3 B. Epidemiology/Surveillance 1. Chronic Diseases - 2. Communicable Diseases 3 II. Policy Development A. Health Code Dev. and Enforcement - B. Health Planning - C. Priority Setting - III. Assurance Activities A. Inspection 1. Food and Milk Control 3 2. Health Facility Safety/Quality 3 3. Rec. Facility Safety/Quality 3 4. Other Facility Safety/Quality 3 B. Licensing 1. Health Facilities - 2. Other Facilities 3 C. Health Education 3 D. Environmental 1. Air Quality 3 2. Hazardous Waste Management 3 3. Individual Water Supply Safety 3 4. Noise Pollution - 5. Occupational Health and Safety - 6. Public Water Supply Safety 3 7. Radiation Control - 8. Sewage Disposal Systems 3 9. Solid Waste Management 3 10. Vector and Animal Control 3 11. Water Pollution 3 E. Personal Health Services 1. AIDS Testing and Counseling 3 2. Alcohol Abuse 3 3. Child Health 3 4. Chronic Diseases - 5. Dental Health 3 6. Drug Abuse 3 7. Emergency Medical Service - 8. Family Planning 3 9. Handicapped Children 3 10. Home Health Care 1 11. Hospitals - 12. Immunizations 3 13. Laboratory Services 3 14. Long-term Care Facilities - 15. Mental Health 3 16. Obstetrical Care - 17. Prenatal Care 3 18. Primary Care 3 19. Sexually Transmitted Diseases 3 20. Tuberculosis 3 21. WIC 3 C. Local Health Officer M.D. Requirement, State Health Director Appointment The District Health Services Administrator is equivalent to the local health officer and is appointed by the State Director of Health. This position requires an M.D. degree. The District Health Services Administrator is responsible for managing the district health office and its programs. D. Local Board of Health There are no local boards of health in Hawaii. E. Staff The staffs of the district health offices are employees of the HDH and part of the State Civil Service System. F. Budget Total FY 1988 LPHA expenditures were $7,028,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts 0 State Funds $6,582,000 Local Funds $445,000 Fees and Reimbursements 0 Other Sources 0 Source Unknown 0 The SHA reported that these figures include the total amount of additional local health department monies spent by the Honolulu City Health Department. 2Hawaii Department of Health, 1990 Director of Health Administrative Services Office Personnel Office Health Information Systems Office Office of Affirmative Action District Health Office Hawaii District Health Office Maui District Health Office Kauai Personal Health Services Administration Family Health Services Administration Developmental Disabilities Division Community Health Nursing Division Office of Elder Health Environmental Health Administration Environmental Health Services Division Environmental Management Division Hazardous Evaluation and Emergency Response Office Environmental Planning Office Environmental Resources Office Community Hospital Administration Community Hospital Division Health Promotion and Disease Prevention Administration Health Prevention and Education Division Communicable Disease Division Dental Health Division Office of Refugee Immigrant Health Behavioral Health Services Administration Adult Mental Health Division Alcohol and Drug Abuse Division Children and Adolescent Mental Health Division Health Resources Administration State Laboratory Division Health Quality Assurance Division Office of Health Status Monitoring Office of Hawaiian Health Office of Planning, Policy and Program Development 2Types of Local Health Departments by Jurisdiction Hawaii, 1990 Jurisdiction C N/Co Hawaii X Honolulu X Honolulu X Kalawao X Kauai X Maui X C = City HD N/Co = No county HD 1IDAHO 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 1,003,000 245,803,000 Population Density (1988) 12.2 69.4 (per/sq.mi.) Number of Counties 44 3,139 Median Age (1987) 29.8 31.7 Percent Below Poverty Level (1985) 16.0 14.0 (persons) Percent of Population Rural (1980) 46.0 26.0 Percent of Population White (1980) 95.5 83.1 Percent of Population Non-white (1980) 4.5 16.9 Median Years of Education (1980) 12.6 12.5 (25 years of age and over) B. County Government Structure No Home Rule Authority County governments in Idaho are empowered by the state constitution which provides the legal framework for the county government, establishes the authority of county officials and their terms of office, lists the function that counties perform, creates limits on county indebtedness, and contains detailed provisions on county boundaries. Commission Form - (44) - Three-member county commissions are the governing bodies of the counties. The boards of commissioners exercise both legislative and executive powers. They are elected at large but must meet district residency requirements. Counties in Idaho function as units of the state government by administering elections, enforcing state laws, and performing other functions required by the state. They also function as units of local government in meeting needs of citizens by providing standard services at the local level. Data for this state were updated October 1990. 3II. State Health Agency (SHA) A. General Component of Superagency The SHA in Idaho is the Department of Health and Welfare, with primary health-related responsibility delegated to the Division of Health. The information provided is restricted to the Division of Health. The mission of the Division of Health is to effectively and efficiently mobilize and manage appropriate resources for the protection and improvement of the health of the citizens of Idaho. The following are some areas of responsibility for the Department of Health and Welfare: State Public Health Authority State Agency for Children with Special Health Care Needs Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement The following are some areas of responsibility for the Division of Health: Preventive Medicine Maternal and Child Health Emergency Medical Services Health Policy Vital Statistics State Laboratories Epidemiology Services B. Head of State Health Agency No M.D. Requirement, Not Cabinet Level Appointment The Administrator for the Division of Health is the head of the SHA. The Administrator is appointed by the Director of the Department of Health and Welfare with concurrence of the State Board of Health and Welfare. The Administrator reports to the Director. It is the responsibility of this person to administer the numerous programs of the Division of Health in a manner that most efficiently protects the citizens of the state from communicable disease, substance abuse, improperly administered health facilities, accidents, and aggravated conditions due to lack of early diagnosis. C. State Board of Health/Council Policy-making Idaho has a Board of Health and Welfare which consists of seven members who are appointed by the Governor with the charge to formulate rules and regulations for the Department of Health and Welfare and to advise its directors. The members are chosen with regard for their knowledge and interest in environmental protection and health. D. Regional/District Health Offices The state is subdivided into seven administrative regions. The regions have offices which function as extensions of the central office. They provide direct services to their jurisdictions in the areas of mental health, food stamps, and Medicaid. E. State-Local Liaison Decentralized Organizational Control, Informal Liaison Function The district health departments are autonomously governed by local boards of health. The relationship between the Division of Health and the district health departments is basically a contractual arrangement wherein the Bureaus of Preventive Medicine and Maternal and Child Health contract with the districts to provide program services. The interaction between state and local public health agencies in Idaho may be characterized as decentralized organizational control. Under this arrangement local governments directly operate health departments with a local board of health. F. Budget Total FY 1988 Idaho SHA expenditures were $21,005,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $14,195,000 State Funds $6,809,000 Local Funds 0 Fees and Reimbursements 0 Other 0 3III. Local Public Health Agencies (LPHAs) A. General During the 1970's, Idaho passed legislation to provide for fairly uniform public health services for every county in the state through seven multicounty health departments which are called district health departments. Each district is autonomously governed by a local board of health. These agencies are answerable to the public through the county commissioners and district boards of health. The districts receive state money in the form of contracts for services. B. Services Provided The following information on services provided by local health departments in Idaho is derived from a survey conducted by NACHO during 1989. All seven of the local health departments in Idaho responded to the survey. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 3 ( 42.9%) 2. Morbidity Data 4 ( 57.1%) 3. Reportable Diseases 7 (100.0%) 4. Vital Records and Statistics 6 ( 85.7%) B. Epidemiology/Surveillance 1. Chronic Diseases 6 ( 85.7%) 2. Communicable Diseases 7 (100.0%) II. Policy Development A. Health Code Dev. and Enforcement 5 ( 71.4%) B. Health Planning 6 ( 85.7%) C. Priority Setting 6 ( 85.7%) III. Assurance Activities A. Inspection 1. Food and Milk Control 7 (100.0%) 2. Health Facility Safety/Quality - 3. Rec. Facility Safety/Quality 6 ( 85.7%) 4. Other Facility Safety/Quality 3 ( 42.9%) B. Licensing 1. Health Facilities - 2. Other Facilities 6 ( 85.7%) C. Health Education D. Environmental 1. Air Quality 2 ( 28.6%) 2. Hazardous Waste Management 5 ( 71.4%) 3. Individual Water Supply Safety 7 (100.0%) 4. Noise Pollution 1 ( 14.3%) 5. Occupational Health and Safety - 6. Public Water Supply Safety 5 ( 71.4%) 7. Radiation Control 2 ( 28.6%) 8. Sewage Disposal Systems 6 ( 85.7%) 9. Solid Waste Management 7 (100.0%) 10. Vector and Animal Control 7 (100.0%) 11. Water Pollution 6 ( 85.7%) E. Personal Health Services 1. AIDS Testing and Counseling 7 (100.0%) 2. Alcohol Abuse 1 ( 14.3%) 3. Child Health 7 (100.0%) 4. Chronic Diseases 6 ( 85.7%) 5. Dental Health 7 (100.0%) 6. Drug Abuse - 7. Emergency Medical Service - 8. Family Planning 7 (100.0%) 9. Handicapped Children 7 (100.0%) 10. Home Health Care 3 ( 42.9%) 11. Hospitals - 12. Immunizations 7 (100.0%) 13. Laboratory Services 4 ( 57.1%) 14. Long-term Care Facilities - 15. Mental Health - 16. Obstetrical Care 2 ( 28.6%) 17. Prenatal Care 7 (100.0%) 18. Primary Care 1 ( 14.3%) 19. Sexually Transmitted Diseases 7 (100.0%) 20. Tuberculosis 7 (100.0%) 21. WIC 7 (100.0%) C. Local Health Officer No M.D. Requirement, Local Board of Health Appointment The District Health Director is appointed by the District Board of Health. Although there is no M.D. requirement, each district must have a doctor of medicine licensed in Idaho as a staff member or as a regular consultant. The Director is responsible for administration of the health department. D. Local Board of Health Policy-making District boards of health are appointed by the boards of county commissioners within each district. The duties and responsibilities of the boards include both advisory and policy making. E. Staff District health department staffs are employed and supervised by the jurisdiction which they serve. The number of employees for district health departments in Idaho ranges from 45 to 104. F. Budget Total FY 1988 LPHA Expenditures were $3,174,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $3,174,000 State Funds 0 Local Funds 0 Fees and Reimbursements 0 Other Sources 0 Source Unknown 0 2Idaho Department Of Health and Welfare, 1990 Division of Health Office of Epidemiological Services Office of Policy and Resource Development Emergency Medical Service Bureau Southwest/South Central Region East Region North Region/Central Region EMGE Project Training Bureau of Laboratories Virology/Serology Chemistry Genetics Lab Improvement Microbiology Inorganic Organic Center for Health Statistics Vital Records Health Statistics Maternal and Child Health Bureau Children's Special Health Program Improved Pregnancy Family Planning WIC Dental Health Nutrition Preventive Medicine Bureau AIDS/STD Environmental Health Immunization Food Protection Film Library Health Promotion/Disease Prevention 2Types of Local Health Departments by Jurisdiction Idaho, 1990 Jurisdiction M/Co Ada X Adams X Bannock X Bear Lake X Benewah X Bingham X Blaine X Boise X Bonner X Bonneville X Boundary X Butte X Camas X Canyon X Caribou X Cassia X Clark X Clearwater X Custer X Elmore X Franklin X Fremont X Gem X Gooding X Idaho X Jefferson X Jerome X Kootenai X Latah X Lemhi X Lewis X Lincoln X Madison X Minidoka X Nez Perce X Oneida X Owyhee X Payette X Power X Soshone X Teton X Twin Falls X Valley X Washington X M/Co = Multicounty HD 1ILLINOIS 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 11,615,000 243,915,000 Population Density (1988) 208.7 69.4 (per/sq.mi.) Number of Counties 102 3,139 Median Age (1987) * 32.0 31.7 Percent Below Poverty Level (1985) 15.6 14.0 (persons) Percent of Population Rural (1980) * 16.7 26.0 Percent of Population White (1980) * 83.6 83.1 Percent of Population Non-white (1980) * 16.4 16.9 Median Years of Education (1980) 12.5 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The state constitution and statutes establish the structure and authority for county governments in Illinois. County Board Form - (85) - This form has 5 to 29 board members elected from districts. Commission Form - (17) - In this form are three commissioners elected from the county at large. Elected Executive Form - (1) - Under the Illinois Constitution, counties may adopt home rule authority. The home rule authority comes through the adoption of an Elected County Executive Form of government. Home rule counties are entitled to exercise any power or perform any function related to government affairs. However, the General Assembly may deny or limit any power granted to local governments. Cook county is the only county that has adopted home rule. Non-home rule counties have only the general powers granted to them by law. They elect an executive officer from the board or commission. * These data were provided by the SHA. The following are four variations from which counties can choose in regard to an executive officer: Elected Executive Plan -(1) - Although this plan is part of the home rule packet, counties can adopt the elected executive portion of the plan and reject the home rule elements. This option establishes a separate legislative and executive branch. At the present time, only Will county has adopted this plan. Appointed County Administrator Plan - (12) - Under this plan the appointed administrator has responsibility for administration and coordination. County Board President Plan - (2) - DuPage and St. Clair utilize this plan and grant the president general administrative responsibility for the affairs of the county. County Manager Plan - (0) - This option has not been used at the present time, but it gives administrative authority to a professional administrator appointed and supervised by the board. 3II. State Health Agency (SHA) A. General Free-standing, Independent The SHA in Illinois, the Department of Public Health (IDPH), is a free-standing, independent agency. The mission of the Department is to fulfill society's interest in assuring conditions in which people can be healthy. The Department has authority to promulgate rules and regulations setting minimum program and performance standards for local health departments, while prescribing minimum qualifications for professional, technical and administrative staff of local health departments. Other responsibilities include the approval of counties seeking to form multicounty health departments and the determination of classifications for local health departments. The IDPH contains five administrative units, with staff located in two co-centralized offices in Springfield and Chicago, eight regional offices and three public health laboratories. The following are some areas of responsibility for the SHA: State Public Health Authority State Health Policy and Planning Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency M.D. Requirement, Cabinet-level Appointment The Director of the IDPH, appointed by the Governor, must be either a person licensed to practice medicine and surgery in this state, having had at least 5 years' practical experience in the practice of medicine and surgery, have administrative knowledge of and experience in public health or a person with the general knowledge of and administrative experience in public health. C. State Board of Health/Council Advisory The State Board of Public Health Advisors is an advisory committee composed of nine members, one of whom is a senior citizen, appointed by the Governor. The Governor will appoint four members who will be physicians (licensed to practice medicine in all branches); one member who is a local public health administrator; one member who is a dentist licensed to practice dentistry and who has been active in public health; one member who is a registered professional nurse (licensed) and who has been active in public health; one member who is a member of the statewide Health Coordinating Council, who represents a professional group; and one member who is a public health sanitarian or sanitary engineer. D. Regional/District Health Offices The IDPH operates eight regional offices located in Chicago, Rockford, Peoria, Springfield, Edwardsville, Marion, Champaign, and West Chicago. Each of the regional offices operates under the direction of a Regional Health Officer (RHO) and is responsible for a specified geographic area of the state. The general duties of the Regional Health Officer are as follows: Under the direction of the IDPH Associate Director, Office of Program Administrative Support, to coordinate, monitor and evaluate the effectiveness of programs. To be the focal point for regional activities by requiring all Governor's office, legislative, press, consumer or interest group inquiries be handled through the RHO. To be responsible for conflict resolution within the regional office; however, if a resolution cannot be accomplished, the RHO shall initiate and participate in discussion with the central office to ensure resolution. To coordinate regional activities as they affect local health agencies. To develop grants and contracts for services in consultation with the regional program supervisor or division chiefs. The following are some of the principal positions that are included in the 30- to 35-member staffs of regional offices: Regional Health Officer Communicable Disease Coordinator Immunization Coordinator MCH Nurse Coordinator Long-term Care Nurse Regional Engineer Swimming Pool Inspector Plumbing Inspector Food Inspector Environmental Health Inspector Architect Clerical Staff E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Formal Liaison Function The local liaison unit within IDPH is the Division of Local Health Administration (DLHA). Organizationally it is one division within the Office of Program and Administrative Support. The overall mission of DLHA is to maintain and improve communication with local health departments (LHDs). The division serves as the state health department contact point for LHDs; promotes the development of LHDs; promulgates program standards and minimum qualifications for LHDs; provides oversight to the evaluation of LHD basic public health services; distributes formula grant funds to LHDs; provides consultation and technical assistance to LHDs; offers training to LHD personnel; assists LHDs with personnel recruitment; processes evaluation of LHD personnel; updates and distributes LHD directories; provides information to LHDs regarding legislation, rules or policies that may affect them; provides orientation to newly appointed LHD administrators; consults or meets with LHD administrators, boards of health and other local officials on local health issues; participates in planning retreats for boards of health; participates on various committees comprised of Department personnel and LHD administrators on issues of common interest; staffs Project Health; maintains electronic communication with LHDs in emergency and non-emergency situations; provides environmental health liaison and training for LHDs; and provides nursing liaison and training for LHDs. The interaction between state and local public health agencies in Illinois may be characterized as mixed centralized and decentralized organizational control. Under this arrangement, local health services may be provided by the SHA in some jurisdictions and by local governmental units, boards of health, or health departments in others. F. Budget Total FY 1988 SHA expenditures were $189,333,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $101,659,000 State Funds $86,119,000 Local Funds 0 Fees and Reimbursements $1,510,000 Other $44,000 3III. Local Public Health Agencies (LPHAs) A. General There are 81 local health departments covering 85 counties and 94 percent of the Illinois population. Five city, 3 township (known as districts in Illinois), 6 multicounty units (serving 17 counties), 1 city-county, and 66 county health departments make up the 81 local health departments. In Illinois, local governments are the primary source of support for local public health services; whether these services exist or not is decided by the people in local political units. Counties may establish a health department by resolution of the county board or by referendum vote. Resolution health departments can be established by a majority of the county board. Upon passage of the resolution, the chairman of the county board appoints a board of health. The primary funding source for resolution health departments comes from the general fund of the county government. Referendum health departments have a tax base established in the referendum to provide local support. The structure and function of the two types of health departments is the same, only the source of local funds is different. The IDPH provides Basic Health Service Grant funds through a formula distribution to both resolution and referendum health departments. No matching local funds are required for receiving these funds. During the health department's first 3 years of development, a Development Grant in the range of $17,500-$27,500 (depending on population size) is available each year. After the third year of operation, resolution and referendum health departments are expected to have implemented the 10 required programs. Due to autonomy of local health departments in Illinois, the IDPH cannot mandate a specific role for them. Through the Department's standard setting and funding roles, however, attempts have been made to encourage the following activities for local health departments: 1. Provide a local operation sufficient to meet local public health needs. 2. Develop and maintain local fiscal support. 3. Maintain and continue to upgrade all required programs. 4. Develop and maintain all recommended and optional programs which are appropriate to the needs and priorities of the area served. 5. Provide consultation to the state agency through service on various Departmental task forces designed to review standards and other mutual problems. 6. Endeavor to enhance local programs through contracts or merger with adjacent departments. The IDPH divides local health departments into four primary types: 1. Developmental: A local health department which has been in operation less than 3 full years and has not been approved for the five core programs. 2. Unaccredited: A local health department which has been in operation more than 3 full years and has not been approved for all five core programs. 3. Accredited: A local health department which is approved for the five core programs but currently is not approved for at least one of the five non-core programs. 4. Certified: A local health department which is currently approved for all 10 of the required programs. B. Services Provided The following information on services provided by local health departments in Illinois is derived from a survey conducted by NACHO during 1989. Sixty-eight of the 81 local health departments in Illinois responded to the survey. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 32 ( 47.1%) 2. Morbidity Data 44 ( 64.7%) 3. Reportable Diseases 66 ( 97.1%) 4. Vital Records and Statistics 40 ( 58.8%) B. Epidemiology/Surveillance 1. Chronic Diseases 58 ( 85.3%) 2. Communicable Diseases 68 (100.0%) II. Policy Development A. Health Code Dev. and Enforcement 54 ( 79.4%) B. Health Planning 52 ( 76.5%) C. Priority Setting 49 ( 72.1%) III. Assurance Activities A. Inspection 1. Food and Milk Control 62 ( 91.2%) 2. Health Facility Safety/Quality 18 ( 26.5%) 3. Rec. Facility Safety/Quality 11 ( 16.2%) 4. Other Facility Safety/Quality 11 ( 16.2%) B. Licensing 1. Health Facilities 6 ( 8.8%) 2. Other Facilities 55 ( 80.9%) C. Health Education 59 ( 86.8%) D. Environmental 1. Air Quality 4 ( 5.9%) 2. Hazardous Waste Management 21 ( 30.9%) 3. Individual Water Supply Safety 60 ( 88.2%) 4. Noise Pollution 6 ( 8.8%) 5. Occupational Health and Safety 5 ( 7.4%) 6. Public Water Supply Safety 21 ( 30.9%) 7. Radiation Control 6 ( 8.8%) 8. Sewage Disposal Systems 63 ( 92.6%) 9. Solid Waste Management 58 ( 85.3%) 10. Vector and Animal Control 42 ( 61.8%) 11. Water Pollution 37 ( 54.4%) E. Personal Health Services 1. AIDS Testing and Counseling 50 ( 73.5%) 2. Alcohol Abuse 16 ( 23.5%) 3. Child Health 65 ( 95.6%) 4. Chronic Diseases 67 ( 98.5%) 5. Dental Health 22 ( 32.4%) 6. Drug Abuse 14 ( 20.6%) 7. Emergency Medical Service 5 ( 7.4%) 8. Family Planning 48 ( 70.6%) 9. Handicapped Children 12 ( 17.6%) 10. Home Health Care 40 ( 58.8%) 11. Hospitals 1 ( 1.5%) 12. Immunizations 67 ( 98.5%) 13. Laboratory Services 25 ( 36.8%) 14. Long-term Care Facilities 5 ( 7.4%) 15. Mental Health 15 ( 22.1%) 16. Obstetrical Care 6 ( 8.8%) 17. Prenatal Care 54 ( 79.4%) 18. Primary Care 14 ( 20.6%) 19. Sexually Transmitted Diseases 65 ( 95.6%) 20. Tuberculosis 58 ( 85.3%) 21. WIC 65 ( 95.6%) C. Local Health Officer M.D. Requirement for Medical Health Officer, Local Board of Health Appointment Two job titles in Illinois are equivalent to the title of local health officer: Public Health Administrator and Medical Health Officer. The primary duties for the Public Health Administrator are as follows: planning, organizing, and directing the work of all staff while establishing operational methods and procedures; assisting in policy development while recommending the establishment and revision of rules and regulations; preparing statistical, financial and special reports while holding periodic conferences with subordinates; directing staff services and developing data, budget estimates, and requests; directing the department personnel program; supervising purchasing and storekeeping activities; performing public standards development, research and planning programs; writing, assigning, and reviewing correspondence; interpreting statistics, regulations and rules while adapting methods and procedures to change legal and policy conditions. Requirements for the Public Health Administrator are a master's degree in public health or public administration and 2 years of full-time administrative experience in public health; or graduation from a 4-year college with a broad educational background and 4 years of full-time experience, of which at least 2 years must be in public health. Medical Health Officer has identical distinguishing work features to the Public Health Administrator; however, the minimum requirements for each job title differ. This position requires completion of courses in an approved medical school or completion of courses approved by the Education Council for Foreign Medical Graduates supplemented by 1 year of internship or its equivalent; a license to practice medicine in Illinois; a master's degree in public health or equivalent experience in a health field; a certification in public health by the American Board of Preventive Medicine or board certification in a related specialty is desirable; and a year of full-time experience in public health administration. D. Local Board of Health Policy-making County boards of health consist of eight members appointed by the president or chairman of the county board. Membership, as defined under Illinois Statutes, requires "at least two members of each county board of health shall be physicians licensed in Illinois to practice medicine in all of its branches, at least one member shall be a dentist licensed in Illinois and one member shall be chosen from the county board of supervisors or commissioners as the case may be." Public health districts and municipalities may also establish a board of health. In counties not under township organization, the county commissioners are the board of health for each district in the county. Districts in counties under township organization that consist of a single town have the supervisor, assessor and town clerk as members of the board. When a district consists of two or more adjacent towns, the supervisors of the towns in conjunction with the chairman of the county board make up the board of health. In municipalities with Commission Form of government, the Mayor, with the approval of the corporate authorities, appoints the board of five directors, two of whom must be physicians. E. Staff Local health department staffs are employed and supervised by the local jurisdiction. The number of employees for a local health department ranges from 2 to 2,100. F. Budget Total FY 1988 LPHA expenditures were $197,791,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $33,786,000 State Funds $45,547,000 Local Funds $66,263,000 Fees and Reimbursements $17,401,000 Other Sources $12,563,000 Source Unknown $22,232,000 2Illinois Department of Public Health, 1990 Director Board of Public Health Advisors Medical Determinations Board Assistant Director Center for Rural Health Office of Health Policy and Planning Division of Facilities Development Division of Health Statistics and Policy Development Division of Legal Services Division of Governmental Affairs Division of Audits Division of Communications Equal Employment Opportunity Officer Public Health Deputy Director Office of Program and Administrative Support Employee Services and Benefits Unit/Word Processing Center Training Center Regional Operations Division of Local Health Administration Division of Personnel and Labor Relations Division of General Services Division of Financial Services Division of Vital Records Division of Data Processing Office of Health Services Assistant Associate Director Center for Health Promotion Division of Family Health Division of Chronic Diseases Division of Dental Health Division of Alcohol and Substance Abuse Testing Division of Health Assessment and Screening Office of Health Care Regulation Division of Administrative and Technical Support Bureau of Long-Term Care Division of LTC Quality Assurance Division of LTC Field Operations Division of LTC Information and Research Division of Health Care Facilities and Programs Division of Emergency Medical Services and Highway Safety Office of Health Protection Assistant Associate Director Emergency Officer Division of Infectious Diseases Division of Food, Drugs and Dairies Division of Environmental Health Division of Epidemiologic Studies Division of Laboratories 2Types of Local Health Departments by Jurisdiction Illinois, 1990 Jurisdiction Co C C/Co M/Co N/Co T/T Adams X Alexander X Bond X Boone X Brown X Bureau X Calhoun X Carroll X Cass X Champaign X Champaign-Urbana X Chicago X Christian X Clark X Clay X Clinton X Coles X Cook X Crawford X Cumberland X De Kalb X Dewitt X Douglas X Du Page X East Side District X Edgar X Edwards X Effingham X Evanston X Fayette X Ford X Franklin X Fulton X Gallatin X Greene X Grundy X Hamilton X Hancock X Hardin Henderson X X Henry X Iroquois X Jackson X Jasper X Jefferson X Jersey X Jo Daviess X Johnson X Kane X Kankakee X Kendall X Knox X La Salle X Lake X Lawrence X Lee X Livingston X Logan X Macon X Macoupin X Madison X Marion X Marshall X Mason X Massac X McDonough X McHenery X McLean X Menard X Mercer X Monroe X Montgomery X Morgan X Oak Park X Ogle X Peoria City/Co X Perry X Piatt X Pike X Pope X Pulaski X Putnam X Randolph X Richland X Rock Island X Saline X Sangamon X Schuyler X Scott X Shelby X Skokie X Springfield X St. Clair X Stark X Stephenson X Stickney Township X Tazwell X Union X Vermillion X Wabash X Warren X Washington X Wayne X White X Whiteside X Will X Williamson X Winnebago X Woodford X Co = County HD C = City HD C/Co = City/County HD M/Co = Multicounty HD N/Co = No County HD T/T = Town/Township HD 1INDIANA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 5,556,000 245,803,000 Population Density (1988) 154.6 69.4 (per/sq.mi.) Number of Counties 92 3,139 Median Age (1987) 31.3 31.7 Percent Below Poverty Level (1985) 12.0 14.0 (persons) Percent of Population Rural (1980) 36.0 26.0 Percent of Population White (1980) 91.2 83.1 Percent of Population Non-white (1980) 8.8 16.9 Median Years of Education (1980) 12.4 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The structure and function of counties in Indiana are established by the state constitution and Title 36 of the Indiana Code. Commission Form - (92) - The Commission Form of government is used by the counties in Indiana. Most county governments in Indiana have two governing bodies, a board of commissioners and a county council. The boards of commissioners are made up of three members elected at large with residency requirements in existing districts. They serve as the executive and legislative bodies of county governments. The county councils serve as the fiscal bodies of the governments and are usually made up of seven members. Four council members are elected from single-member districts and three members are elected at large. Additionally, two counties have appointed administrators to handle the administrative duties of the county. Counties in Indiana have home rule authority as granted in Title 36 of the Indiana Code. The section of code relating to home rule specifies that counties have the powers granted by law and other powers necessary or desirable to conduct county affairs. Data for this state were updated February 1991. In 1969, the Indiana General Assembly passed a law facilitating the consolidation of Marion County and Indianapolis. This unified government consists of a 29-member city-county council and a mayor. Twenty-five members of the council are elected from single-member districts and four are elected at large. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Indiana State Board of Health (ISBH), the SHA, is a free-standing, independent agency. The following are some areas of responsibility for the SHA: State Public Health Authority State Health Planning and Development Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement Special State Institutions such as School for Blind B. Head of State Health Agency M.D. Requirement, Cabinet-level Appointment The State Health Commissioner serves as the Chief Executive Officer of the Department and as Secretary for the Executive Board of the State Board of Health. The Commissioner is appointed by and serves at the pleasure of the Governor. As Chief Executive Officer, the Commissioner is responsible for overall management of the SHA and its programs. C. State Board of Health/Council Policy-making The Executive Board of the State Board of Health is composed of 11 members appointed by the Governor. The members of the Board elect a Chairman from among its membership. The Executive Board is responsible for making policy for the State Board of Health and approving appointments made by the Commissioner. D. Regional/District Health Offices The ISBH has not divided the state into regions or districts. E. State-local Liaison Decentralized Organizational Control, Formal Liaison Function The primary mission of the staff members of the State Board of Health is to function as consultants to local health department staff within the state. In addition staff members of the Division of Local Support are assigned on a geographical basis to work directly with local health department staff and to provide both technical and management consultative services. Interaction between state and local public health agencies in Indiana may be characterized as decentralized organizational control. Under this arrangement local governments directly operate health departments with or without a board of health. F. Budget Total FY 1988 Indiana SHA expenditures were $106,237,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $48,357,000 State Funds $57,881,000 Local Funds 0 Fees and Reimbursements 0 Other 0 3III. Local Public Health Agencies (LPHAs) A. General Indiana has 96 local health departments, composed of 1 multicounty, 5 city, and 90 county health departments. According to state law, the ISBH is the "superior agency" to each of the local health departments. In this capacity the ISBH is charged with the responsibility of approving the appointment of local health officers and overseeing the programs and activities of the local health departments. B. Services Provided The following information on services provided by local health departments in Indiana is derived from a survey conducted by NACHO during 1989. Ninety-four of the 95 local health departments in Indiana responded to the survey. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 13 ( 13.8%) 2. Morbidity Data 38 ( 40.4%) 3. Reportable Diseases 71 ( 75.5%) 4. Vital Records and Statistics 89 ( 94.7%) B. Epidemiology/Surveillance 1. Chronic Diseases 38 ( 40.4%) 2. Communicable Diseases 85 ( 90.4%) II. Policy Development A. Health Code Dev. and Enforcement 51 ( 54.3%) B. Health Planning 49 ( 52.1%) C. Priority Setting 21 ( 22.3%) III. Assurance Activities A. Inspection 1. Food and Milk Control 67 ( 71.3%) 2. Health Facility Safety/Quality 21 ( 22.3%) 3. Rec. Facility Safety/Quality 30 ( 31.9%) 4. Other Facility Safety/Quality 8 ( 8.5%) B. Licensing 1. Health Facilities 6 ( 6.4%) 2. Other Facilities 63 ( 67.0%) C. Health Education 56 ( 59.6%) D. Environmental 1. Air Quality 41 ( 43.6%) 2. Hazardous Waste Management 50 ( 53.2%) 3. Individual Water Supply Safety 76 ( 80.9%) 4. Noise Pollution 9 ( 9.6%) 5. Occupational Health and Safety 12 ( 12.8%) 6. Public Water Supply Safety 51 ( 54.3%) 7. Radiation Control 17 ( 18.1%) 8. Sewage Disposal Systems 87 ( 92.6%) 9. Solid Waste Management 61 ( 64.9%) 10. Vector and Animal Control 76 ( 80.9%) 11. Water Pollution 65 ( 69.1%) E. Personal Health Services 1. AIDS Testing and Counseling 22 ( 23.4%) 2. Alcohol Abuse 3 ( 3.2%) 3. Child Health 61 ( 64.9%) 4. Chronic Diseases 50 ( 53.2%) 5. Dental Health 9 ( 9.6%) 6. Drug Abuse 6 ( 6.4%) 7. Emergency Medical Service 4 ( 4.3%) 8. Family Planning 16 ( 17.0%) 9. Handicapped Children 53 ( 56.4%) 10. Home Health Care 45 ( 47.9%) 11. Hospitals 2 ( 2.1%) 12. Immunizations 89 ( 94.7%) 13. Laboratory Services 17 ( 18.1%) 14. Long-term Care Facilities 1 ( 1.1%) 15. Mental Health 4 ( 4.3%) 16. Obstetrical Care 11 ( 11.7%) 17. Prenatal Care 29 ( 30.9%) 18. Primary Care 5 ( 5.3%) 19. Sexually Transmitted Diseases 26 ( 27.7%) 20. Tuberculosis 75 ( 79.8%) 21. WIC 30 ( 31.9%) C. Local Health Officer M.D. or D.O. Requirement, Local Board of Health Appointment The role of the local health officer is to serve as chief executive officer for the local health department and carry out the policies and programs as determined by the local board. Local health officers are appointed to 4-year terms by members of the local board of health. D. Local Board of Health Policy-making The board of a county health department is composed of seven members--no more than four of whom may be from the same political party. The members of the board are appointed by their respective city or county executives for a 4-year term. The authority for this organization and function lies in state statutes. The local board is responsible for the appointment of a health officer. The local health officer and the local board of health work with the county commissioners in establishing annual budgets which are submitted to the county councils for approval. Those health departments which are based within the city structure follow a similar process with the city officials. The board of health for multicounty health departments is composed of four members from each county represented in the department. E. Staff The staffs of local health departments are employed and supervised by the local jurisdiction. The number of staff for a local health department ranges from 1 to 550. F. Budget Total FY 1988 LPHA expenditures were $41,920,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $5,416,000 State Funds $2,805,0000 Local Funds $28,281,000 Fees and Reimbursements $5,058,000 Other Sources $360,000 Source Unknown 0 The SHA reported that there were additional fees and reimbursements not retained by the local health departments, but which reverted to the general revenues of the local or state government. 2Indiana State Board of Health, 1990 State Health Commissioner Office of External Affairs Office of Legal Affairs Executive Assistant Executive Assistant Executive Assistant Office of Assistant Commissioner for Health Support Services Bureau of Laboratories Environmental Laboratories Division Disease Control Laboratories Division Laboratory Support Division Consumer Health Lab Division Bureau of Administrative Services Management Information Services Division Human Resources Division Finance Division Bureau of Institutional Services Internal Support Services Division Indiana Veterans' Home Indiana School for the Blind Indiana School for the Deaf Soldiers' and Sailors' Children's Home Silvercrest Children's Development Center Office of Assistant Commissioner for Health Maintenance Bureau of Disease Intervention Acute Disease Division Chronic Disease Division Acquired Disease Division Bureau of Family Health Services Nutrition Division MCH Division Child Specialty Services Division Bureau of Local Health Services Dental Health Local Support Services Division Industrial Hygiene and Radiologic Health Division Sanitary Engineering Division Office of Assistant Commissioner for Health Marketing Bureau of Quality Assurance Health Facilities Division Acute Care Services Division Child Care Facilities Division Bureau of Policy Development Public Health Research Division Public Health Statistics Division Division of Health Planning Bureau of Health Promotion Health Education Division Graphic Arts Division Bureau of Consumer Protection Wholesale Consumer Affairs Division Retail Consumer Affairs Division Food Animal Affairs Division 2Types of Local Health Departments by Jurisdiction Indiana, 1990 Jurisdiction Co C M/Co Adams X Allen X Bartholomew X Benton X Blackford X Boone X Brown X Carroll X Cass X Clark X Clay X Clinton X Crawford X Daviess X De Kalb X Dearborn X Decatur X Delaware X Dubois X East Chicago X Elkhart X Fayette X Floyd X Fountain X Franklin X Fulton X Gary X Gibson X Grant X Greene X Hamilton X Hammond X Hancock X Harrison X Hendricks X Henry X Howard X Huntington X Jackson X Jasper X Jay X Jefferson X Jennings X Johnson X Knox X Kosciusko X La Porte X Lafayette X Lagrange X Lake X Lawrence X Madison X Marion X Marshall X Martin X Miami X Monroe X Montgomery X Morgan X Newton X Noble X Ohio X Orange X Owen X Parke X Perry X Pike X Porter X Posey X Pulaski X Putnam X Randolph X Ripley X Rush X Scott X Shelby X Spencer X St. Joseph X Starke X Steuben X Sullivan X Switzerland X Tippecanoe X Tipton X Union X Vanderburgh X Vermillion X Vigo X Wabash X Warren X Warrick X Washington X Wayne X Wells X West Lafayette X White X Whitley X Co = County HD C = City HD M/Co = Multicounty HD 1IOWA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 2,834,000 245,803,000 Population Density (1988) 50.6 69.4 (per/sq.mi.) Number of Counties 99 3,139 Median Age (1987) 32.0 31.7 Percent Below Poverty Level (1985) 8.0 14.0 (persons) Percent of Population Rural (1980) 41.0 26.0 Percent of Population White (1980) 97.4 83.1 Percent of Population Non-white (1980) 2.6 16.9 Median Years of Education (1980) 12.5 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The structure and authority of county governments in Iowa are established by the state constitution and statutes. Commission Form - (99) - All 99 counties in Iowa operate under a County Commission Form of government. The board is made up of three or five members called county supervisors. They are elected from single-member districts and have residency requirements. Two counties, Scott and Polk, have appointed administrators. Iowa counties have had constitutional home rule since 1979. Under home rule, counties have been able to pass legislation without permission from the state. The constitution, under home rule provisions, permits the consolidation of counties or city-counties. These jurisdictions are granted authority to establish their governments and perform governmental functions but not to levy tax unless specifically authorized by the General Assembly. A new county government law became effective in 1988. It provides five new, optional governmental structures and a Data for this state were updated October 1990. mechanism for establishing a charter commission. The five options are as follows: 1. Board-elected Executive - a strong elected executive with veto power over the board. 2. Board-manager - an elected board with an appointed manager. 3. Charter - Specific charter proposed by a charter commission county may have an elected or appointed administrative officer. 4. City-county Consolidation - a city-county consolidation is conferred with all of the powers granted to cities or counties. 5. County-county Consolidation - permits the consolidation of contiguous counties upon approval of the voters in the affected areas. Counties have not yet adopted any of these new options. 3II. State Health Agency (SHA) A. General Free-standing, Independent The SHA is a free-standing, independent agency named the Iowa Department of Public Health (IDPH). The IDPH exists to promote, protect, and ensure the health and well-being of Iowans, and to provide for access, quality and affordability of services. The Department promotes health and prevents disease by the following: Conducting research, planning and evaluating as a basis for initiating and revising programs and policies. Assuring compliance with public health laws through regulation and enforcement. Administering state and Federal statutory requirements and programs through direct and contracted services. Promoting and supporting health and well-being through education and consultation. The Department is responsible for substance abuse prevention, health planning, vital records, health professional licensure, communicable disease control, radiation control, emergency medical services, maternal and child health, nutrition, dental health, birth defects/genetics counseling, health promotion, public health nursing, homemaker-home health aide, and a few environmental programs. The following are some broad areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs (through contract with the University of Iowa) State Health Planning and Development Agency State Health Professions Licensing Agency B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Director of Health is the chief administrative officer of the Department. The Director is a cabinet-level officer appointed by the Governor and confirmed by the Senate. The Director is responsible for directing and administering the programs and services of the Department. The duties of the Director include: recommendations to the state board of health; the adoption of rules for the implementation of statutes; service as Secretary of the State Board of Health; the establishment of the administrative organization; and other actions to administer and direct the Department's programs. C. State Board of Health/Council Policy-making The Board of Health is made up of nine members. Five members are to be learned in the health professions and four are to represent the general public. The members are appointed by the Governor for 3-year terms. They approve all Department rules before they become effective, establish policies for the performance of the Department, and advise the Department, the Governor, and the Legislature on public health matters. D. Regional/District Health Offices The Department does not have regional/district offices. Specific programs have field staffs with assigned territories, but these staffs are housed in the central office, in a local health department, or some other individual arrangement. E. State-local Liaison Decentralized Organizational Control, Formal Liaison Function The state-local liaison function is currently being performed by a nurse consultant in the Division of Family and Community Health. The interaction between state and local public health agencies in Iowa may be characterized as decentralized organizational control. Under this arrangement local governments directly operate health departments. F. Budget Total FY 1988 Iowa SHA expenditures were $58,273,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $30,538,000 State Funds $27,510,000 Local Funds 0 Fees and Reimbursements $73,000 Other $152,000 3III. Local Public Health Agencies (LPHAs) A. General Iowa has 99 local health departments. These consist of 93 county units, 5 city units and 1 city-county unit (the city-county unit is designated as a district by Iowa). Iowa uses the term "boards of health" rather than health departments. Boards of health that employ at least one full-time employee are referred to as a health department in this document. Nine boards employ only a nurse and 16 boards employ only an environmentalist. All other boards have more than one employee. The SHA provides the funds to the local areas to support public health nursing services and homemaker-home health aide services. These funds may go through the local board of health, board of supervisors, or other governmental or non-profit organization. B. Services Provided The following information on services provided by local health departments in Iowa is derived from a survey conducted by NACHO during 1989. Since only 9 of the 99 Iowa counties participated in this survey, the results may not be representative of the total state. Services provided by 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 1 ( 11.1%) 2. Morbidity Data 5 ( 55.6%) 3. Reportable Diseases 6 ( 66.7%) 4. Vital Records and Statistics 2 ( 22.2%) B. Epidemiology/Surveillance 1. Chronic Diseases 3 ( 33.3%) 2. Communicable Diseases 8 ( 88.9%) II. Policy Development A. Health Code Dev. and Enforcement 4 ( 44.4%) B. Health Planning 7 ( 77.8%) C. Priority Setting 6 ( 66.7%) III. Assurance Activities A. Inspection 1. Food and Milk Control 7 ( 77.8%) 2. Health Facility Safety/Quality 2 ( 22.2%) 3. Rec. Facility Safety/Quality 1 ( 11.1%) 4. Other Facility Safety/Quality 2 ( 22.2%) B. Licensing 1. Health Facilities - 2. Other Facilities 8 ( 88.9%) C. Health Education 6 ( 66.7%) D. Environmental 1. Air Quality 7 ( 77.8%) 2. Hazardous Waste Management 5 ( 55.6%) 3. Individual Water Supply Safety 6 ( 66.7%) 4. Noise Pollution 5 ( 55.6%) 5. Occupational Health and Safety 1 ( 11.1%) 6. Public Water Supply Safety 3 ( 33.3%) 7. Radiation Control 1 ( 11.1%) 8. Sewage Disposal Systems 7 ( 77.8%) 9. Solid Waste Management 4 ( 44.4%) 10. Vector and Animal Control 8 ( 88.9%) 11. Water Pollution 8 ( 88.9%) E. Personal Health Services 1. AIDS Testing and Counseling 9 (100.0%) 2. Alcohol Abuse - 3. Child Health 4 ( 44.4%) 4. Chronic Diseases 4 ( 44.4%) 5. Dental Health 1 ( 11.1%) 6. Drug Abuse - 7. Emergency Medical Service 2 ( 22.2%) 8. Family Planning 2 ( 22.2%) 9. Handicapped Children 1 ( 11.1%) 10. Home Health Care 6 ( 66.7%) 11. Hospitals - 12. Immunizations 8 ( 88.9%) 13. Laboratory Services 3 ( 33.3%) 14. Long-term Care Facilities - 15. Mental Health - 16. Obstetrical Care - 17. Prenatal Care 2 ( 22.2%) 18. Primary Care - 19. Sexually Transmitted Diseases 8 ( 88.9%) 20. Tuberculosis 7 ( 77.8%) 21. WIC 3 ( 33.3%) C. Local Health Officer No M.D. Requirement, Board of Health Appointment The primary authority in local public health resides with the local boards of health. The boards delegate responsibility to their employees. This can include the formal naming of a health officer for certain functions but this is not routinely done. If named, the health officer would only have authority through the local board of health. D. Local Board of Health Policy-making Each county must have a board of health unless they are part of a district health department. Cities with populations over 25,000 may have a board of health and 5 cities have chosen to do so. Local boards of health may apply to create district boards of health. The boards are consist of five volunteer members (one of which must be a physician) appointed by the board of supervisors or city council. These boards are planning and policy-making boards, and their rules must be approved by the board of supervisors before they take effect. Funds for the local boards of health must be appropriated by the board of supervisors. E. Staff The staffs are employees of the local boards of health. The number of employees for a local health department ranges from 5 to 84. F. Budget Total FY 1988 LPHA expenditures were $23,494,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contract $990,000 State Funds $4,266,000 Local Funds $7,080,000 Fees and Reimbursements $760,000 Other Sources $1,254,000 Source Unknown $682,000 The SHA reported that there were additional fees and reimbursements not retained by the LPHA, but which reverted to the general revenues of the local or state government. The SHA also reported that these figures include the total amount of additional local health department monies expended by all local health departments. 2Iowa Department of Public Health, 1990 Governor State Board of Health Substance Abuse Commission Health Facilities Council Professional Licensing Boards Director of Public Health Health Data Commission Health Advisory Committee and Councils Division of Substance Abuse Bureau of Prevention and Training Bureau of Licensure Division of Central Administration Bureau of Accounting/Finance Bureau of Information Management Bureau of Communications Bureau of Vital Records Bureau of Professional Licensure Division of Disease Prevention Bureau of Radiological Health Bureau of Health Engineering/Consumer Safety Bureau of Veterinarian P.H. Environmental Epidemiology Bureau of Compliance/Health Care Services Bureau of Disease Assessment Bureau of Epidemiology Office of Health Planning Planning Office of Rural Health Health Data Commission Primary Care Certificate of Need Division of Family and Community Health Bureau of Maternal and Child Health Bureau of Nutrition Bureau of Dental Health Bureau of Birth Defects/Genetics Complex Bureau of Public Health Nursing Bureau of Homemaker/Home Health Aide Bureau of Support Services Well Elderly Clinics 2Types of Local Health Departments by Jurisdiction Iowa, 1990 Jurisdiction Co C C/Co N/Co Adair X Adams X Allamakee X Ames X Appanoose X Audubon X Benton X Blackhawk X Boone X Bremer X Buchanan X Buena Vista X Butler X Calhoun X Carroll X Cass X Cedar X Cerro Gordo X Cherokee X Chicksaw X Clarke X Clay X Clayton X Clinton X Council Bluffs X Crawford X Dallas X Davis X Decatur X Delaware X Des Moines X Des Moines X Dickenson X Dubuque X Dubuque X Emmet X Fayette X Floyd X Franklin X Fremont X Greene X Grundy X Gutherie X Hamilton X Hancock X Hardin X Harrison X Henry X Howard X Humboldt X Ida X Iowa X Jackson X Jasper X Jefferson X Johnson X Jones X Keokuk X Kossuth X Lee X Linn X Louisa X Lucas X Lyon X Madison X Mahaska X Marion X Marshall X Mills X Mitchell X Monona X Monroe X Montgomery X Muscatine X O'Brien X Osceola X Ottumwa X Page X Palo Alto X Plymouth X Pocohontas X Polk X Pottawattamie X Poweshiek X Ringgold X Sac X Scott X Shelby X Sioux X Siouxland Dist X Story X Tama X Taylor X Union X Van Buren X Wapello X Warren X Washington X Wayne X Webster X Winnebago X Winneshiek X Worth X Wright X Co = County HD C = City HD C/Co = City/County HD N/Co = No County HD 1KANSAS 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 2,496,000 245,803,000 Population Density (1988) 30.5 69.4 (per/sq.mi.) Number of Counties 105 3,139 Median Age (1987) 31.7 31.7 Percent Below Poverty Level (1985) 13.8 14.0 (persons) Percent of Population Rural (1980) 33.0 26.0 Percent of Population White (1980) 91.7 83.1 Percent of Population Non-white (1980) 8.3 16.9 Median Years of Education (1980) 12.6 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority County governments in Kansas are established and empowered by the state constitution. Commission Form - (105) - All counties in the state use this form of government. The commissions are made up of three- or five-member boards that are elected from single-member districts. Seven counties utilize an appointed administrator for their administrative functions. Authority for home rule was established in 1974. This legislation gives counties authority to conduct business and perform legislative and administrative functions that are considered appropriate and not otherwise prohibited by statutes. The data for this state were updated September 1990. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Kansas Department of Health and Environment (KDHE) is the official SHA. It is a free-standing, independent agency. The mission of the KDHE is to protect and maintain the health of Kansans and the quality of the environment through information, education, prevention, and regulation. The Division of Health, one of the major units within KDHE, is responsible for protecting and promoting the health of Kansans through a variety of public health service delivery and regulatory programs. The Division's role is to assure services through funding assistance to local agencies; establishing policy and procedures; technical assistance; and program consultation, planning, implementation, and continuation. The following are some areas of responsibility for the SHA: State Public Health Authority Lead Environmental Agency in the State State Agency for Children with Special Health Care Needs Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Secretary of KDHE, entrusted with broad powers to ensure public health and a safe environment, directs the management of the Department in the provision of services to the citizens of Kansas. The Secretary, a member of the Governor's Cabinet, sets agency policy and assigns staff to carry out regulatory enforcement and public health tasks. The Secretary is not required to be a physician. The Director of Health, the State Health Officer, is appointed by the Secretary KDHE. The Director is the state's chief public health medical official and is responsible for the management of the Division of Health. The Director is required to be a physician. Specifically, the Director of Health is charged with the responsibility of maintaining surveillance of indicators of disease and disability, and overseeing and assisting in the provision of public health services to the citizens of Kansas. C. State Board of Health/Council Advisory The Advisory Commission on Health and Environment is a 13-member body which advises the Secretary, KDHE, on public health and environmental issues. Members serve as a sounding board for departmental initiatives. The Governor appoints individuals to represent a cross-section of the health and environmental interests. D. Regional/District Health Offices Six district offices are located in cities throughout the state, but the state has not been divided into geographic regions. The district offices serve as an extension of the central office programs in Topeka, providing consultation and technical assistance to local health departments, enabling the agency to maintain closer ties to citizens and local health departments in more remote geographic areas, and permitting the agency to respond more quickly and appropriately to problems or requests. Program field staffs are assigned to each district office. Management responsibilities, including provision of support services for field staffs, are carried out in each district office by a District Office Manager and administrative support staff. District Office Managers are supervised by staff from the Office of the Secretary in Topeka. E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Formal Liaison Function The Office of Local Health serves as the liaison with local health departments. Community consultants, which are a part of the central office but physically are located in KDHE district offices, serve as the Division of Health's field staff and liaison to local health departments. The consultants deliver state-level administrative leadership, consultation, and support services to local health units, and assist program consultants in monitoring quality and standards-of-care given by local agencies. The office administers the Aid-to-Counties Program; this provides local health departments and other eligible community agencies with state and Federal funding of public health services at the local level. The state aid is provided through a formula which requires an equal match of local tax funds. The office also maintains a Continuing Education for Nursing Providership Agreement with the Kansas State Board of Nursing. The Office of Rural Health serves as a focal point in the effort to maintain rural health care services. It exists to facilitate and coordinate locally generated ideas to improve the availability of a variety of rural health services. The office draws on the resources, program activities, and staffing of the Division to ensure that Department activities are responsive to rural health needs. The interaction between state and local health agencies in Kansas may be characterized as mixed centralized and decentralized organizational control. Under this arrangement, local health services in the state may be provided by the SHA in some jurisdictions and by local governmental units, boards of health, or health departments in other jurisdictions. F. Budget Total FY 1988 SHA expenditures were $46,945,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $28,923,000 State Funds $17,148,000 Local Funds 0 Fees and Reimbursements $546,000 Other $328,000 3III. Local Public Health Agencies (LPHAs) A. General There are 97 local health departments in Kansas. Local health departments exist in 104 of 105 counties in Kansas. Three multicounty agencies provide service to 10 counties, 12 counties are served by city/county health departments, and the other 82 counties are served by county health departments. Two of the counties, Stevens and Nemaha, provide health services through contract with a county hospital and a private provider, respectively. Within the 82 counties there are several informal "program sharing" arrangements whereby one county health department may contract with KDHE to provide service for a number of surrounding, usually contiguous, counties. B. Services Provided The following information on services provided by local health departments in Kansas is derived from a survey conducted by NACHO during 1989. Eighty-one of 97 local health departments in Kansas responded to the survey. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 21 ( 25.9%) 2. Morbidity Data 12 ( 14.8%) 3. Reportable Diseases 62 ( 76.5%) 4. Vital Records and Statistics 14 ( 17.3%) B. Epidemiology/Surveillance 1. Chronic Diseases 36 ( 44.4%) 2. Communicable Diseases 68 ( 84.0%) II. Policy Development A. Health Code Dev. and Enforcement 24 ( 29.6%) B. Health Planning 32 ( 39.5%) C. Priority Setting 17 ( 21.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 8 ( 9.9%) 2. Health Facility Safety/Quality 21 ( 25.9%) 3. Rec. Facility Safety/Quality 10 ( 12.3%) 4. Other Facility Safety/Quality 8 ( 9.9%) B. Licensing 1. Health Facilities 30 ( 37.0%) 2. Other Facilities 22 ( 27.2%) C. Health Education 61 ( 75.3%) D. Environmental 1. Air Quality 8 ( 9.9%) 2. Hazardous Waste Management 14 ( 17.3%) 3. Individual Water Supply Safety 36 ( 44.4%) 4. Noise Pollution 1 ( 1.2%) 5. Occupational Health and Safety 5 ( 6.2%) 6. Public Water Supply Safety 20 ( 24.7%) 7. Radiation Control 5 ( 6.2%) 8. Sewage Disposal Systems 29 ( 35.8%) 9. Solid Waste Management 16 ( 19.8%) 10. Vector and Animal Control 22 ( 27.2%) 11. Water Pollution 24 ( 29.6%) E. Personal Health Services 1. AIDS Testing and Counseling 40 ( 49.4%) 2. Alcohol Abuse 7 ( 8.6%) 3. Child Health 73 ( 90.1%) 4. Chronic Diseases 51 ( 63.0%) 5. Dental Health 13 ( 16.0%) 6. Drug Abuse 8 ( 9.9%) 7. Emergency Medical Service 2 ( 2.5%) 8. Family Planning 58 ( 71.6%) 9. Handicapped Children 33 ( 40.7%) 10. Home Health Care 47 ( 58.0%) 11. Hospitals 1 ( 1.2%) 12. Immunizations 79 ( 97.5%) 13. Laboratory Services 32 ( 39.5%) 14. Long-term Care Facilities 13 ( 16.0%) 15. Mental Health 4 ( 4.9%) 16. Obstetrical Care 7 ( 8.6%) 17. Prenatal Care 37 ( 45.7%) 18. Primary Care 12 ( 14.8%) 19. Sexually Transmitted Diseases 41 ( 50.6%) 20. Tuberculosis 53 ( 65.4%) 21. WIC 67 ( 82.7%) C. Local Health Officer M.D. Requirement in Jurisdictions over 100,000 Population, County Board of Health Appointment The local health officer is appointed by the county board of health. In counties or multicounty units with less than 100,000 population the board may appoint a qualified local health administrator (generally a nurse) as the local health officer, if a person licensed to practice medicine, surgery, or dentistry is designated as medical consultant to the administrator. Counties with more than 100,000 population must appoint a health officer who has been licensed to practice medicine and surgery, with preference being given to persons who have training in public health. The local health officer in each county is responsible for keeping accurate records of all the transactions of the department, and for receiving and distributing all forms from the Secretary of KDHE. In addition, the health officer is responsible for having an annual sanitary inspection made of each school building and grounds within the county, and investigating, reporting, and taking measures to prevent the spread of infectious, contagious, or communicable disease. The health officer is also responsible for performing such other duties as may be required by the county, joint board of health, or the Secretary. D. Local Board of Health Policy-making Boards of county commissioners act as county boards of health for their respective counties. The board of county commissioners in any county having a population of less than 15,000 may contract with the governing body of any hospital located in the county for the provision of services to the county board of health. E. Staff The staffs of local health departments are employed and supervised by the local jurisdiction. The number of employees for a local health department ranges from 1 to 183. In 15 health departments there is only 1 nurse on staff. There are 76 health departments that do not employ a sanitarian. F. Budget Total FY 1988 LPHA expenditures were $23,821,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $6,010,000 State Funds $2,190,000 Local Funds 0 Fees and Reimbursements $186,000 Other Sources 0 Source Unknown $15,435,000 2Kansas Department of Health and Environment, 1990 Governor Department of Health and Environment Advisory Commission on Health and Environment Task Forces, Boards Assistant Secretary and General Counsel Executive Manager Legal Services General Services Personnel Services Health and Environmental Laboratory Analytical Chemistry Microbiology Laboratories Laboratory Information and Reporting Office Laboratory Improvement Program Office Division of Environment Bureau of Environmental Remediation Bureau of Air and Waste Management Bureau of Water Bureau of Environmental Quality Surface Mining Section Division of Health Assistant Director for Medical Services Office of Local and Rural Health Systems Bureau of Environmental Health Services Bureau of Disease Control Bureau of Adult and Child Care Bureau of Family Health Office of Chronic Disease and Health Promotion Division of Information Systems Office of Communication Services Office of Vital Statistics Office of Public Information Services Office of Health and Environmental Education District Offices (answer to all of the above). 2Types of Local Health Departments by Jurisdiction Kansas, 1990 Jurisdiction Co C/Co M/Co N/Co Allen X Anderson X Atchinson X Barber X Barton X Bourbon X Brown X Butler X Chase X Chatauqua X Cherokee X Cheyenne X City-Cowley Co X Clark X Clay X Cloud X Coffee X Commanche X Crawford X Dickinson X Doniphan X Edwards X Elk X Ellis X Ellsworth X Emporia-Lyon Co X Finney X Ford X Franklin X Gove X Graham X Grant X Gray X Greeley X Greenwood X Hamilton X Harper X Harvey X Haskell X Hodgeman X Hutchinson-Reno Co X Jackson X Jefferson X Jewell X Johnson X Junction C.-Geary X Kansas C-Wyandotte X Kearny X Kingmen X Kiowa X Labette X Lane X Lawrence-Douglas Co X Levenworth X Liberal-Seward Co X Lincoln X Linn X Logan X Manhattan-Riley Co X Marion X Marshall X McPherson X Meade X Miami X Mitchell X Montgomery X Morris X Morton X Nemaha X Neosho X Ness X Norton X Oberlin-Decatur Co X Osage X Osborne X Ottowa X Pawnee X Phillips X Pottawatomie X Pratt X Rawlings X Republic X Rice X Rooks X Rush X Russell X Salina-Saline Co X Scott X Sheridan X Sherman X Smith X Stafford X Stanton X Stevens X Sumner X Thomas X Topeka-Shawnee Co X Trego X Wabaunsee X Wallace X Washington X Wichita X Wichita-Sedwick Co X Wilson X Woodson X Co = County HD C/Co = City/County HD M/Co = Multicounty HD N/Co = No County HD 1KENTUCKY 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 3,726,000 245,803,000 Population Density (1988) 93.9 69.4 (per/sq.mi.) Number of Counties 120 3,139 Median Age (1987) 31.1 31.7 Percent Below Poverty Level (1985) 19.4 14.0 (persons) Percent of Population Rural (1980) 49.0 26.0 Percent of Population White (1980) 92.3 83.1 Percent of Population Non-white (1980) 7.7 16.9 Median Years of Education (1980) 12.1 12.5 (25 years of age and over) B. County Government Structure No Home Rule Authority Kentucky counties receive their authority to exist and function from the state constitution and statutes. County governments are based on the Fiscal Court System. Under this system the counties are given the choice of Magistrate or Commission status. Magistrate Variety - (106) - This form consists of a County Judge/Executive and three to eight justices of the peace who are elected from separate districts. The County Judge serves as the executive officer for the county and presiding officer of the Fiscal Court. The justices of the peace have duties and authority that relate only to the Fiscal Court. Commission Form - (13) - The Commission Form of government under the Fiscal Court System consists of county judge/executive and three commissioners elected at large. The authority of the commissioners is related to the fiscal court. Urban-County Form - (1) - The state constitution does not provide for charter, consolidated city-county or other structural forms of government. In 1970, however, the General Assembly passed a Data for this state were updated October 1990. law authorizing an Urban-County government form. The merger provided for in this law produces an entity that is neither a city nor a county but has the authority and characteristics of a city or county. Lexington-Fayette chose this form of government. Additionally, Louisville-Jefferson developed a limited consolidation under which there is an agreement on sharing taxes, annexation, and specific services. Home Rule Authority - The Fiscal Court depends on authority delegated to it by the General Assembly under Kentucky Revised Statutes. The home rule provision that was amended in 1978, however, granted the counties more authority so they could operate more efficiently while still operating under some constraints. Under these acts counties may pass ordinances, issue regulations, levy taxes, issue bonds, and appropriate funds. 3II. State Health Agency (SHA) A. General Component of Superagency The Department of Health Services is the SHA for Kentucky. It is a component of a superagency called the Cabinet for Human Resources. The mission of the SHA is to protect and promote the health of the citizens of Kentucky. The following are some areas of responsibility for the SHA: State Public Health Authority State Health Planning and Development Agency B. Head of State Health Agency M.D. Requirement, Not Cabinet-level Appointment The Department for Health Services is headed by a Commissioner. The Commissioner is appointed by the Secretary of the Cabinet for Human Resources with the approval of the Governor. The Commissioner must be a licensed physician with training and experience in the administration and management of public health. The Commissioner is responsible for advising the head of major organizational units on policies and programs relating to all matters of public health and on any actions necessary to safeguard the health of the citizens of Kentucky. The Commissioner serves as the chief medical officer of Kentucky. The Commissioner exercises authority over the Department for Health Services under the direction of the Secretary of the Cabinet for Human Resources and is responsible only for what is delegated by the Secretary. C. State Board of Health/Council Advisory The Council for Health Services is a citizen advisory body which provides advice to the Citizens' Commission for Human Resources (a citizen advisory body to the Cabinet for Human Resources), the Secretary for Human Resources, the Commissioner for Health Services, and other officials of the commonwealth on policy matters concerning the delivery of health services. The Council for Health Services is composed of no more than 19 citizen members appointed by the Governor. Members are chosen to broadly represent public interest groups concerned with health services, recipients of health services provided by the state, minority groups, and the general public. The Governor appoints the Chairman of the Council who also serves as a voting member of the Citizens' Commission for Human Resources. The Secretary for Human Resources and the Commissioner for Health Services are non-voting ex officio members of the Council and the Commissioner is staff director and secretary to the Council. The Council meets quarterly or on the call of the Secretary of Human Resources or the Commissioner for Health Services. D. Regional/District Health Offices The Department of Health Services has not divided the state into administrative regions or districts. There are district health departments, but these are counties that have combined their health departments to make one service unit. The only membership restriction is that counties within a district health department must be within the same governmental Area Development District (ADD). E. State-local Liaison Shared Organizational Control, Informal Liaison Function The Department for Health Services, Cabinet for Human Resources, does not employ state-local liaisons as such. Rather, the Department's program, professional, and support staffs provide direct technical assistance to local health departments via telephone consultations, written communications, and on-site consultations. The Department does employ regional nurse consultants in the Home Health Program and program/field representatives in the sexually transmitted diseases (STD) immunization, women, infants, and children (WIC) and environmental health programs. The function of these staffs is to relay the program-specific priorities of Federal and state agencies and to provide readily available, on-site assistance and supervision to local health department staff. In turn, the "regional" field staff can relate local concerns and the local perspective to state program staff. The interaction between state and local public health agencies in Kentucky may be characterized as shared organizational control. Under this arrangement local health departments are under the authority of the SHA, as well as the local government and board of health. F. Budget Total FY 1988 Kentucky SHA expenditures were $110,232,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $63,620,000 State Funds $44,404,000 Local Funds 0 Fees and Reimbursements $2,135,000 Other $73,000 3III. Local Public Health Agencies (LPHAs) A. General There are 52 local health departments in Kentucky. Seventeen of these are district (multicounty health departments), 33 are single-county health departments, and 2 are city-county health departments. The districts contain five health departments that were city-county units before their merger into the districts. The two city-county health departments consist of Jefferson County which has a city of the 1st class (Louisville) and Fayette County\Lexington City which has an Urban County Form of government. The Cabinet for Human Resources determines the areas in which district (multicounty) health departments may be established. The fiscal court for each of the counties must approve the formation of the district by a simple majority vote. Each county included in the district will be responsible for providing its share of the expense of creating, establishing, operating, and maintaining the department. B. Services Provided The following information on services provided by local health departments in Kentucky is derived from a survey conducted by NACHO during 1989. Forty-four of the 52 local health departments in Kentucky responded to the survey. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 15 ( 34.1%) 2. Morbidity Data 30 ( 68.2%) 3. Reportable Diseases 43 ( 97.7%) 4. Vital Records and Statistics 43 ( 97.7%) B. Epidemiology/Surveillance 1. Chronic Diseases 34 ( 77.3%) 2. Communicable Diseases 42 ( 95.5%) II. Policy Development A. Health Code Dev. and Enforcement 23 ( 52.3%) B. Health Planning 31 ( 70.5%) C. Priority Setting 28 ( 63.6%) III. Assurance Activities A. Inspection 1. Food and Milk Control 40 ( 90.9%) 2. Health Facility Safety/Quality 26 ( 59.1%) 3. Rec. Facility Safety/Quality 34 ( 77.3%) 4. Other Facility Safety/Quality 16 ( 36.4%) B. Licensing 1. Health Facilities 6 ( 13.6%) 2. Other Facilities 37 ( 84.1%) C. Health Education 35 ( 79.5%) D. Environmental 1. Air Quality 4 ( 9.1%) 2. Hazardous Waste Management 11 ( 25.0%) 3. Individual Water Supply Safety 38 ( 86.4%) 4. Noise Pollution 2 ( 4.5%) 5. Occupational Health and Safety 4 ( 9.1%) 6. Public Water Supply Safety 29 ( 65.9%) 7. Radiation Control 15 ( 34.1%) 8. Sewage Disposal Systems 40 ( 90.9%) 9. Solid Waste Management 17 ( 38.6%) 10. Vector and Animal Control 35 ( 79.5%) 11. Water Pollution 22 ( 40.0%) E. Personal Health Services 1. AIDS Testing and Counseling 36 ( 81.8%) 2. Alcohol Abuse 3 ( 6.8%) 3. Child Health 44 (100.0%) 4. Chronic Diseases 37 ( 84.1%) 5. Dental Health 25 ( 56.8%) 6. Drug Abuse 6 ( 13.6%) 7. Emergency Medical Service 1 ( 2.3%) 8. Family Planning 44 (100.0%) 9. Handicapped Children 19 ( 43.2%) 10. Home Health Care 19 ( 43.2%) 11. Hospitals - 12. Immunizations 44 (100.0%) 13. Laboratory Services 32 ( 72.7%) 14. Long-term Care Facilities - 15. Mental Health - 16. Obstetrical Care 21 ( 47.7%) 17. Prenatal Care 43 ( 97.7%) 18. Primary Care 5 ( 11.4%) 19. Sexually Transmitted Diseases 44 (100.0%) 20. Tuberculosis 44 (100.0%) 21. WIC 44 (100.0%) C. Local Health Officer M.D. Requirement, Local Board of Health Appointment County and district boards of health have authority to appoint a health officer. The appointments are subject to the approval of the Cabinet for Human Resources. The health officer is subject to Merit System provisions and holds office at the pleasure of both the board of health and the Cabinet for Human Resources. The health officer of a county or district health department is directed to devote his entire time to the duties of his office and not be engaged in the private practice of medicine, serve as the secretary to the county board of health and keep minutes of the proceedings, and be the chief administrative officer of the county health department. A local health officer may serve as health officer for more than one county if the local boards of health and the Cabinet for Human Resources approve. D. Local Board of Health Policy-making County boards of health consist of nine members, except for the five city-county boards of health which consist of seven members. On the county boards of health, seven members are appointed by the Cabinet for Human Resources; one member is appointed by the Fiscal Court; and the County Judge/Executive is a member by virtue of his office. On the city-county boards of health, the seven-member board is composed of the mayor or city manager; the County Judge/Executive; and five appointed members which include one dentist, one nurse, and three physicians. In the event that qualified persons are not available to fill specific positions on the board, the Secretary of the Cabinet for Human Resources may appoint a resident lay person knowledgeable in consumer affairs to fill each vacancy. District boards of health, except for districts which serve a county containing a city of the first class or an urban-county government, are composed of the one county judge/executive or his designee from each county in the district and one additional member per county per 15,000 population. The fiscal court of each county submits names to the Secretary of the Cabinet for Human Resources, who makes the appointments. Nominations to the Secretary are to include two nominations from each of the following groups: fiscal court of each county; county board of health for each county; county medical society; county dental society; district nursing association; and veterinarians from the county, when available. The district boards are composed of the following: at least 25 percent doctors of medicine or osteopathy licensed in Kentucky; at least one licensed, registered nurse; one dentist; and one veterinarian, when available. The remaining members of the board will be concerned community leaders residing within the county they are to represent. The term of office for district boards of health is 2 years, with the terms staggered so that half of the members are appointed each year. Responsibilities for county, city-county, and district boards of health include the following: appoint a health officer and establish his salary; hold regular meetings at least once every 3 months; adopt rules and regulations necessary to protect the health of the people; act in a general advisory capacity to the health officer on all matters relating to the local department of health; hear and decide appeals from rulings, decisions, and actions of the local health department or health officer; perform all other functions necessary to carry out the provisions of law and the rules and regulations that have been adopted. E. Staff The staffs of local health departments are employed and supervised by the local jurisdiction. The number of employees for a local health department ranges from 5 to 289. F. Budget Total FY 1988 LPHA expenditures were $78,678,000. Total FY 1988 LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $15,759,000 State Funds $18,215,000 Local Funds $20,983,000 Fees and Reimbursements $23,721,000 Other Sources 0 Source Unknown 0 2Kentucky Department for Health Services, 1990 Commissioner Division of Administration and Financial Management Budget and Fiscal Planning Branch Administrative Branch Local Fiscal Systems Branch Division of Vital Records and Health Development Health Data Branch Vital Statistics Branch Community Health Development Branch Division of Disability Determination Claims Adjudication Branch (A) Claims Adjudication Branch (B) Operations Support Branch Medical Services Branch Hearings Branch Administrative Support Branch Lexington Branch Louisville Branch Division of Epidemiology Health Promotion Branch Communicable Disease Branch Surveillance and Investigation Branch Chronic Disease Branch Division of Community Safety Product Safety Branch Radiation Control Branch Drug Control Branch EMS Branch Milk Control Branch Division of Laboratory Services Chemistry Branch Microbiology Branch Technical and Administrative Services Branch Division of Local Health Environmental Sanitation Branch Food Branch Information and Support Branch Local Health Personnel Merit System Branch Local Program Support Branch Division of Maternal and Child Health Nutrition Services Branch Central Support Branch Maternal and Family Planning Services Branch 2Types of Local Health Departments by Jurisdiction Kentucky, 1990 Jurisdiction Co C/Co M/Co Adair X Allen X Anderson X Ballard X Barren X Bath X Bell X Boone X Bourbon X Boyd X Boyle X Bracken X Breathitt X Breckinridge X Bullitt X Butler X Caldwell X Calloway X Campbell X Carroll X Carslile X Carter X Casey X Christian X Clark X Clay X Clinton X Crittenden X Cumberland X Daviess X Edmondson X Elliott X Estill X Fleming X Floyd X Franklin X Fulton X Gallatin X Garrard X Grant X Graves X Grayson X Green X Greenup X Hancock X Hardin X Harlan X Harrison X Hart X Henderson X Henry X Hickman X Hopkins X Jackson X Jessamine X Johnson X Kenton X Knott X Larue X Laurel X Lawrence X Lee X Leslie X Letcher X Lewis X Lexington-Fayette X Lincoln X Livingston X Logan X Louisville-Jefferso X Lyon X Madison X Magoffin X Marion X Marshall X Martin X Mason X McCracken X McCreary X McLean X Meade X Menifee X Mercer X Metcalfe X Monroe X Montgomery X Morgan X Muhlenberg X Nelson X Nicholas X Ohio X Oldham X Owen X Owsley X Pendleton X Perry X Pike X Powell X Pulaski X Robertson X Rockcastle X Rowan X Russell X Scott X Shelby X Simpson X Spencer X Taylor X Todd X Trigg X Trimble X Union X Warren X Washington X Wayne X Webster X Whitley X Wolfe X Woodford X Co = County HD C = City HD C/Co = City/County HD M/Co = Multicounty HD 1LOUISIANA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 4,408,000 245,803,000 Population Density (1988) 99.0 69.4 (per/sq.mi.) Number of Counties 64 3,139 Median Age (1987) 29.1 31.7 Percent Below Poverty Level (1985) 18.1 14.0 (persons) Percent of Population Rural (1980) 31.0 26.0 Percent of Population White (1980) 69.2 83.1 Percent of Population Non-white (1980) 30.8 16.9 Median Years of Education (1980) 12.2 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The state constitution and statutes provide the structure and authority for county equivalents, called parishes, to operate in Louisiana. Parishes may choose any of three variations in structure for their governments: Commission, Police Jury System, or Parish Home Rule Charter. Police Jury System - (50) - In this system the governing body, the Police Jury, has both legislative and administrative authority. The Jury is made up of 5 to 15 members who are elected from single-member districts. The exact number of members is determined by historical and population factors. The administrative structure varies widely in parishes with Police Jury. They have the authority to appoint a manager or administrator position. Sixteen parishes have appointed an administrator. Parish Home Rule Charter - (14) - Home rule parishes may use a President-Council plan involving the election of a full-time chief executive, elected at large. Thirteen of the 14 home rule parishes elect an executive. The other parish uses a Council-Administrator who is appointed by the board and is Data for this state were updated November 1990. responsible for administrative functions. Consolidation of parish and city governments is authorized under home rule charters and has been implemented in three metropolitan areas: the City of Baton Rouge and East Baton Rouge Parish, the City of New Orleans and Orleans Parish, and the City of Houma and Terrebonne Parish. 3II. State Health Agency (SHA) A. General Component of Superagency The SHA is the Office of Public Health (OPH). It is a component of a superagency called the Department of Health and Hospitals. The mission of the SHA is to protect and enhance the health of the people of Louisiana and to help create the conditions in which all can enjoy the best of health. The following are some areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs State Maternal and Child Health Agency State Title 10/Family Planning Agency State Safe-drinking Water Program Agency B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The OPH is administered by an Assistant Secretary appointed by the Secretary of the Department of Health and Hospitals (DHH) in accordance with the provisions of law. It is not a requirement for the Director of the OPH to be a physician. When he/she is not a physician, the designation of State Health Officer falls upon a person meeting the requirements stated below: "The State Health Officer shall be a licensed and practicing physician in the state of Louisiana and continue to be so qualified during his term of office. He shall be a full-time employee of the DHH. The Secretary of DHH may designate any department employee, including himself, as State Health Officer." The State Health Officer is responsible at all times for taking all of the necessary steps to execute the sanitary laws of the state and to carry out the rules, ordinances, and regulations that are contained in the state sanitary code. He/she may issue warrants only to arrest or prevent epidemics or abate any imminent menace to the public health. All other actions are governed by the administrative enforcement procedures contained in the State Sanitary Code. C. State Board of Health/Council Currently the state of Louisiana does not have a State Board or Council of Health. D. Regional/District Health Offices The OPH has divided the state into nine administrative regions (see attached map). The health regions function as administrative units in the field. They coordinate health activities, administrative, programmatic, and professional supervision, and are a direct link for parish health units and the central office. All but two of the parish health units act under the supervision and direction of the regional offices of the OPH of the Department of Health and Hospitals. Five of the largest parishes in the OPH system have physician health directors. The other 57 have a chief nurse, chief sanitarian, and chief clerk who answers to their counterparts at the regional office. None of them have administrative authority over the entire parish health unit, and there is no administrator or administrative assistant. Two of the 64 parishes, Orleans and Plaquemines, have local health departments that answer to the parish, not to OPH. Despite this difference in management structure, these two local health departments maintain excellent working relationships with the Office of Public Health. The regional offices are staffed with 15 to 50 employees. Each region has a Regional Administrator, Assistant Administrator, Regional Public Health Nurse, Regional Sanitarian, clerical support staff and program consultants. Programs administered by regional offices include maternal and child health, family planning, nutrition, genetic diseases, social services, handicapped children, adult health, disease control, laboratory services and regulatory services such as water and sewage, sanitary services, and oyster water monitoring. E. State-local Liaison Centralized Organizational Control, Informal Liaison Function The liaison between state and local public health units is accomplished through the normal chain of command. The interaction between state and 62 of the 64 local public health agencies in Louisiana may be characterized as centralized organizational control. The other two are decentralized. Under this arrangement local health services in the state are provided by the SHA in most jurisdictions and by local government in two jurisdictions. F. Budget Total FY 1988 Louisiana SHA expenditures were $116,726,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $71,560,000 State Funds $28,051,000 Local Funds $6,845,000 Fees and Reimbursements $10,243,000 Other 24,000 3III. Local Public Health Agencies (LPHAs) A. General There is a health unit in each of the 64 parishes. Sixty-two of these are parish health units, which are units of the OPH. The other two are independent, local health departments located in Orleans and Plaquemines Parishes. The Orleans Parish unit is a city-parish (county) unit and Plaquemines is a parish (county) unit. The state does not consider the parish health units they administer to be local health departments. However, they are included in our count of local health departments because they meet our definition of a local health department. B. Services Provided The following information on services provided by local health departments in Louisiana is derived from a survey conducted by NACHO during 1989. Twenty-five of the 64 local health departments in Louisiana responded to the survey. Services provided by 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 7 ( 28.0%) 2. Morbidity Data 18 ( 72.0%) 3. Reportable Diseases 25 (100.0%) 4. Vital Records and Statistics 25 (100.0%) B. Epidemiology/Surveillance 1. Chronic Diseases * - 2. Communicable Diseases 25 (100.0%) II. Policy Development A. Health Code Dev. and Enforcement 13 ( 52.0%) B. Health Planning 15 ( 60.0%) C. Priority Setting 12 ( 48.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 20 ( 80.0%) 2. Health Facility Safety/Quality 18 ( 72.0%) 3. Rec. Facility Safety/Quality 13 ( 52.0%) 4. Other Facility Safety/Quality 13 ( 52.0%) B. Licensing 1. Health Facilities * - 2. Other Facilities 17 ( 68.0%) C. Health Education 17 ( 68.0%) D. Environmental 1. Air Quality 2 ( 8.0%) 2. Hazardous Waste Management 7 ( 28.0%) 3. Individual Water Supply Safety 24 ( 96.0%) 4. Noise Pollution 3 ( 12.0%) 5. Occupational Health and Safety * - 6. Public Water Supply Safety 24 ( 96.0%) 7. Radiation Control * - 8. Sewage Disposal Systems 25 (100.0%) 9. Solid Waste Management 16 ( 64.0%) 10. Vector and Animal Control 19 ( 76.0%) 11. Water Pollution 17 ( 68.0%) E. Personal Health Services 1. AIDS Testing and Counseling 19 ( 76.0%) 2. Alcohol Abuse * - 3. Child Health 25 (100.0%) 4. Chronic Diseases * - 5. Dental Health 10 ( 40.0%) 6. Drug Abuse * - 7. Emergency Medical Service * - 8. Family Planning 25 (100.0%) 9. Handicapped Children 21 ( 84.0%) 10. Home Health Care * - 11. Hospitals - 12. Immunizations 25 (100.0%) 13. Laboratory Services 20 ( 80.0%) 14. Long-term Care Facilities - 15. Mental Health * - 16. Obstetrical Care 10 ( 40.0%) 17. Prenatal Care 23 ( 92.0%) 18. Primary Care 4 ( 16.0%) 19. Sexually Transmitted Diseases 24 ( 96.0%) 20. Tuberculosis 25 (100.0%) 21. WIC 25 (100.0%) * The SHA provided additional information indicating that these particular activities are not performed by any local health departments in Louisiana. C. Local Health Officer No M.D. Requirement, State Health Officer Appointment Local health departments may have local health officers. These health officers are appointed by the State Health Officer after consultation with the parish governing authority and with the approval of the Secretary of the Department of Health and Hospitals. The parish health officer is a full-time licensed physician, if possible, and if a physician is not available, the parish health officer is a full-time employee experienced in the administration and enforcement of public health programs. The health officer must live in the parish in which appointed unless service to more than one parish is provided. These officers are responsible for administering the local health department, including all of its programs and functions. D. Local Board of Health With the exception of Orleans Parish there are no local boards of health in Louisiana. Informal advisory committees are present in 42 of the 62 parishes run by OPH. E. Staff The staffs of local health departments except Orleans and Plaquemines Parishes are state employees. Orleans Parish staff are local employees and part of the City of New Orleans Merit System. Plaquemines Parish staff are employees of that parish merit system. Administrative supervision of parish health units is performed by regional staff. The number of employees for a local health department ranges from 2 to 300. F. Budget Total FY 1988 LPHA expenditures were $685,000 **. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $548,000 State Funds $103,000 Local Funds $32,000 Fees and Reimbursements 2,000 Other Sources 0 Source Unknown 0 ** These data include only money provided to the City of New Orleans and Plaquemines Parish in the form of contracts for services. The SHA reported that there were additional fees and reimbursements not retained by the local health departments, but which reverted to the general revenues of the local or state government. 2Louisiana Department of Health and Hospitals, 1990 Secretary Undersecretary Deputy Secretary Assistant Secretary Office of Public Health Deputy Assistant Secretary - Programs Division of Family Health Services Maternal and Child Health Section Family Planning Section Nutrition Section Genetic Diseases Section Social Services Section Handicapped Children's Services Section Division of Disease Control Tuberculosis Control Section Sexually Transmitted Diseases Section Health Promotion Section Epidemiology Section Immunization Section Division of Environmental Health Services Engineering Services Section Sanitarian Services Section Division of Laboratories Amite Milk Lab Section Lake Charles Regional Lab Section Alexandria Regional Lab Section Shreveport Regional Lab Section Monroe Regional Lab Section Lafayette Regional Lab Section Central Lab Section Chemistry Section Microbiology Section Virology-Immunology Section Biochemistry Section Quality Assurance Section Radiation Section Deputy Assistant Secretary - Administration Division of Local Health Services Region I Region II Region III Region IV Region V Region VI Region VII Region VIII Region X Division of Records and Statistics Public Health Statistics Section Vital Records Section Tumor Registry Section LA Cancer and Lung Trust Fund Board Section Division of Administrative Services Pharmacy Section Policy, Planning and Evaluation Section Human Resources Section Data Processing Section Operations and Support Section Administrative Services Section 2Types of Local Health Departments by Jurisdiction Louisiana, 1990 Jurisdiction Co C/Co Acadia X Allen X Ascension X Assumption X Avoyelles X Beauregard X Bienville X Bossier X Caddo X Calcasieu X Caldwell X Cameron X Catahoula X Claiborne X Concordia X De Soto X E. Baton Rouge X East Carroll X East Feliciana X Evangeline X Franklin X Grant X Iberia X Iberville X Jackson X Jefferson X Jefferson Davis X La Salle X Lafayette X Lafourche X Lincoln X Livingston X Madison X Morehouse X Natchitoches X New Orleans X Ouachita X Plaquemines X Pointe Coupee X Rapides X Red River X Richland X Sabine X St. Bernard X St. Charles X St. Helena X St. James X St. John Baptis X St. Landry X St. Martin X St. Mary X St. Tammany X Tangipahoa X Tensas X Terrebonne X Union X Vermilion X Vernon X W. Baton Rouge X Washington X Webster X West Carroll X West Feliciana X Winn X Co = County HD C/Co = City/County HD 1MAINE 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 1,206,000 245,803,000 Population Density (1988) 38.9 69.4 (per/sq.mi.) Number of Counties 16 3,139 Median Age (1987) 32.4 31.7 Percent Below Poverty Level (1985) 11.9 14.0 (persons) Percent of Population Rural (1980) 53.0 26.0 Percent of Population White (1980) 98.7 83.1 Percent of Population Non-white (1980) 1.3 16.9 Median Years of Education (1980) 12.5 12.5 (25 years of age and over) B. County Government Structure No Home Rule Authority The structure of authority of county governments in Maine is determined by statutes enacted by the legislature. Commission Form - (16) - This form of government is used by all counties in Maine. The commissions are composed of three-member boards elected from single-member districts. Counties can appoint an administrator to perform administrative functions in the county. Two counties currently have appointed administrators. There are no provisions for home rule authority. The commission, however, may determine if a charter should be adopted or amended. Voters can also petition for the establishment of a charter by submitting petitions with signatures that represent 10 percent of the vote in the last gubernatorial election. At the present, no counties operate under a charter. Data for this state were updated April 1991. 3II. State Health Agency (SHA) A. General Component of Superagency The Bureau of Health, the SHA, is a component of a superagency called the Department of Human Services. The mission of the Bureau of Health is to preserve, protect, and promote the health and well-being of the population through the organization and delivery of services designed to reduce the risk of disease by: (1) modifying physiological and behavioral characteristics of population groups; (2) controlling environmental hazards to human health; and (3) promoting health/wellness through education, counseling and access to health services. The following are some broad areas of responsibility for the SHA: State Public Health Authority Lead Environmental Agency in the State State Agency for Children with Special Health Care Needs State Health Planning and Development Agency Institutional Licensing Agency These are some additional areas of responsibility for the SHA: Wastewater and Plumbing Radiological Health Drinking Water Regulations Maternal and Child Health Immunizations Epidemiology Disease Control AIDS Sexually Transmitted Diseases Tuberculosis B. Head of State Health Agency No M.D. Requirement, Not Cabinet-level Appointment The head of the SHA is the Director of the Bureau of Health. The Commissioner of the Department of Human Services appoints the Director. The Director of the Bureau functions as the state's Health Officer. In addition to overseeing the Bureau's programs, the Director is instrumental in furthering cooperative relationships with the medical and public health communities in the state and in the Nation. The director represents the Bureau of Health's interests through active participation in the work of numerous state boards, committees, and organizations, and at the national level, represents Maine through membership in the Association of State and Territorial Health Officers. C. State Board of Health/Counil Maine does not have a State Board of Health or State Council of Health. D. Regional/District Health Offices The SHA has not divided the state into administrative regions or districts. E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Informal Liaison Function Responsibility for liaison between the SHA and local public health/community health agencies has not been assigned to any particular office or individual. Liaison activities are handled informally by individual agencies, programs and offices. The interaction between state and local public health agencies in Maine may be characterized as mixed centralized and decentralized organizational control. Under this arrangement local health services may be provided by the SHA in some jurisdictions and by local governmental units, boards of health, or health departments in other jurisdictions. F. Budget Total FY 1988 Maine SHA expenditures were $25,736,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $15,002,000 State Funds $8,869,000 Local Funds 0 Fees and Reimbursements $1,865,000 Other 0 3III. Local Public Health Agencies (LPHAs) A. General The eight local health departments in Maine consist of three city health departments (located in the cities of Bangor, Lewiston, and Portland) and five Department of Human Service regions (one county and four multicounty units). The city health departments are autonomous units, and the public health nursing services are elements of the SHA that provide public health services to local areas. B. Services Provided The following information on services provided by local health departments in Maine is derived from a survey conducted by NACHO during 1989. Five of the eight local health departments in Maine responded to the survey. Services Provided by LPHAs Number of LPHAs I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment - 2. Morbidity Data - 3. Reportable Diseases 3 4. Vital Records and Statistics 1 B. Epidemiology/Surveillance 1. Chronic Diseases - 2. Communicable Diseases 3 II. Policy Development A. Health Code Dev. and Enforcement 1 B. Health Planning 1 C. Priority Setting 1 III. Assurance Activities A. Inspection 1. Food and Milk Control 1 2. Health Facility Safety/Quality 2 3. Rec. Facility Safety/Quality 1 4. Other Facility Safety/Quality 1 B. Licensing 1. Health Facilities 2 2. Other Facilities 2 C. Health Education 2 D. Environmental 1. Air Quality 1 2. Hazardous Waste Management 1 3. Individual Water Supply Safety 1 4. Noise Pollution 1 5. Occupational Health and Safety 1 6. Public Water Supply Safety 1 7. Radiation Control 1 8. Sewage Disposal Systems 2 9. Solid Waste Management 1 10. Vector and Animal Control 1 11. Water Pollution 1 E. Personal Health Services 1. AIDS Testing and Counseling 1 2. Alcohol Abuse - 3. Child Health 2 4. Chronic Diseases - 5. Dental Health 1 6. Drug Abuse - 7. Emergency Medical Service 1 8. Family Planning 1 9. Handicapped Children - 10. Home Health Care 1 11. Hospitals - 12. Immunizations 3 13. Laboratory Services 1 14. Long-term Care Facilities - 15. Mental Health - 16. Obstetrical Care 1 17. Prenatal Care 2 18. Primary Care 1 19. Sexually Transmitted Diseases 1 20. Tuberculosis 2 21. WIC - C. Local Health Officer No M.D. Requirement, Local Governing Body Appointment Each municipality in Maine is required to appoint a health officer. Maine has approximately 325 local health officers. A listing is maintained by the Bureau of Health. Over one-third of them have a medical/health/public health background (doctors, nurses, physician assistants, and emergency medical technicians). These people are considered a valuable resource for the state and, to date, have not been used to their full potential. There is presently no structural statewide organization for health officers. D. Local Board of Health Information on local boards of health is not available. E. Staff Autonomous local health departments employ and supervise their staffs. The staffs of Public Health Nursing Services are employed and supervised by the SHA. The number of employees for a local service unit ranges from 1 to 30. F. Budget Total FY 1988 LPHA expenditures are not available. 2Maine Department of Human Services, 1990 Department of Human Services Advisory Comm. on Radioactive Waste Human Services Council Maine AFDC Coordinating Committee Certificate of Need Advisory Committee Office of Attorney General Office of Public and Legislative Affairs Environmental Health Advisory Committee Alcohol and Drug Abuse Plan Committee Advisory Committee on Radiation Bureau of Health Division of Health Engineering Radiological Emergency Prep. Committee Scientific Advisory Panel Division of Disease Control Maine-Dental Health Council Emergency Medical Services Board Division of Health Promotion and Education Bureau of Medical Services Comm. to Advise D.H.S. on AIDS Division of Maternal and Child Health Public Health Laboratory Office of Dental Health Division of Public Health Nursing Office of Emergency Medical Services Maine Medical Lab Commission Advisory Board for Water Treatment Plant Operations Bureau of Medical Services Office of Vital Statistics Office of Mgmt. and Budget Division of Regional Administration Office of Programs Bureau of Income Maintenance Bureau of Maine's Elderly Bureau of Social Services Bureau of Rehabilitation Division of Deafness Division of Eye Care Office of Alcohol & Drug Abuse Prevention 2Types of Local Health Departments by Jurisdiction Maine, 1990 Jurisdiction Co C M/Co Androscoggin X Aroostook X Bangor X Cumberland X Franklin X Hancock X Kennebec X Knox X Lewiston X Lincoln X Oxford X Penobscot X Piscataquis X Portland X Sagadahoc X Somerset X Waldo X Washington X York X Co = County HD C = City HD M/Co = Multicounty HD 1MARYLAND 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 4,622,000 245,803,000 Population Density (1988) 469.9 69.4 (per/sq.mi.) Number of Counties 24 3,139 Median Age (1987) * 32.5 31.7 Percent Below Poverty Level (1985) 8.7 14.0 (persons) Percent of Population Rural (1980) 20.0 26.0 Percent of Population White (1980) 74.9 83.1 Percent of Population Non-white (1980) 25.1 16.9 Median Years of Education (1980) 12.5 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The structure of county government in Maryland is established by the state constitution and is either Commission, Code Home Rule, or Charter Home Rule. The governing bodies are elected from single-member districts, at large, or by a combination of the methods. Commission Form - (11) - These counties have not adopted a level of home rule. They have a board of commissioners made up of five members with administrative and legislative responsibility. Seven of the commission counties have appointed administrators. Maryland has provided counties with home rule authority under two structures: code home rule and charter home rule. Under both of these options the state has delegated some legislative authority for local matters to the counties. The primary difference in the two structures is the method by which they are adopted and changed. All home rule counties can use either commission, elected executive-council, or council-manager as the structure of their governmental body. *These data were provided by the SHA. Data for this state were updated November 1990. Code Home Rule - (4) - In these counties the governmental board makes structural changes in the county government by enacting laws. These counties operate with a board of county commissioners, and each has an appointed county administrator. Charter Home Rule - (8) - In these counties the governmental body is required to submit any proposed amendments of the charter to the voters for approval. Six of these counties have a county council with an elected executive, and two counties use the Council-manager Form. Independent City - (1) - Baltimore City is an independent city which operates as a county with an elected executive/mayor. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Maryland Department of Health and Mental Hygiene (MDHMH), the SHA, is a free-standing, independent agency. The mission of public health services in Maryland is to prevent and reduce the consequences of illness and disability on individuals and society and to assure a dynamic system of prevention, intervention, and rehabilitation services. The following are some areas of responsibility for the SHA: State Public Health Authority State Mental Health Authority State Agency for Children with Special Health Care Needs State Health Planning and Development Agency State Professions Licensing Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Secretary of MDHMH is the head of the SHA. This official is appointed by the Governor with advice and consent of the Senate. The Secretary is responsible directly to the Governor and serves at the pleasure of the Governor. The Secretary has responsibility for advising the Governor on all matters assigned to the Department and is responsible for carrying out the Governor's policies on these matters. Full responsibility for operation of the Department, including the establishment of guidelines and procedures to promote the orderly and efficient administration of the Department, rests with the Secretary. C. State Board of Health/Council Advisory Maryland has a board entitled the Board of Review of the Department. This board is composed of seven members appointed by the Governor with advice and consent of the Senate. At least four of the members must come from the general public and the other three must have knowledge and experience in at least one of the fields under the jurisdiction of the Department. The term of office for members is 3 years. The terms of members are staggered so that no more than three members' terms will expire on any given year. The Board is responsible for making recommendations to the Secretary on the operation and administration of the Department as the Board considers necessary or desirable. If an advisory board for the department is not created, the Board will advise the Secretary on any departmental matter that the Secretary submits to the Board. Unless otherwise provided for in policy or law, the Board will hear and determine appeals from decisions involving the Secretary or any unit of the Department. D. Regional/District Health Offices The state is not generally divided into administrative districts or regions. The local service units are organized along county lines, and the services are provided at the county level. Some individual programs such as Mental Hygiene and WIC, however, have established administrative regions. E. State-Local Liaison Shared Organizational Control, Formal Liaison Function The Office of Local and Family Health Administration is responsible for the liaison function between local health agencies and the MDHMH. In this role the office serves as a primary focus of communications between the state and local health agencies. Some functions of this office include the management of monthly local health officers' roundtable meetings, assisting local areas in recruiting health officers, and participation in meetings of the Association of Local Health Officers when invited and upon request. The interaction between state and local public health agencies in Maryland may be characterized as shared organizational control. Under this arrangement local health departments are under the authority of the SHA, as well as the local government and board of health. F. Budget Total FY 1988 Maryland SHA expenditures were $732,553,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $63,006,000 State Funds $590,872,000 Local Funds $32,079 Fees and Reimbursements 0 Other $46,597,000 3III. Local Public Health Agencies (LPHAs) A. General There are 24 local health jurisdictions in Maryland. Twenty-three of these are county health departments, and one is a city health department (Baltimore City). The state supports local health services through a mechanism called Case Formula. This formula provides money to local health departments on an approximate 50/50 percent matching basis. The exact percentage of the match is based on the population and the equalized property tax in each county. B. Services Provided The following information on services provided by local health departments in Maryland is derived from a survey conducted by NACHO during 1989. All 24 of the local health departments in Maryland responded to the survey. Services provided by at least 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities 1. Behavioral Risk Assessment 16 ( 66.7%) 2. Morbidity Data 20 ( 83.3%) 3. Reportable Diseases 23 ( 95.8%) 4. Vital Records and Statistics 22 ( 91.7%) B. Epidemiology/Surveillance 1. Chronic Diseases 12 ( 50.0%) 2. Communicable Diseases 24 (100.0%) II. Policy Development A. Health Code Dev. and Enforcement 18 ( 75.0%) B. Health Planning 21 ( 87.5%) C. Priority Setting 18 ( 75.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 21 ( 87.5%) 2. Health Facility Safety/Quality 15 ( 62.5%) 3. Rec. Facility Safety/Quality 18 ( 75.0%) 4. Other Facility Safety/Quality 12 ( 50.0%) B. Licensing 1. Health Facilities 9 ( 37.5%) 2. Other Facilities 23 ( 95.8%) C. Health Education 23 ( 95.8%) D. Environmental 1. Air Quality 19 ( 79.2%) 2. Hazardous Waste Management 16 ( 66.7%) 3. Individual Water Supply Safety 22 ( 91.7%) 4. Noise Pollution 15 ( 62.5%) 5. Occupational Health and Safety 5 ( 20.8%) 6. Public Water Supply Safety 19 ( 79.2%) 7. Radiation Control 8 ( 33.3%) 8. Sewage Disposal Systems 22 ( 91.7%) 9. Solid Waste Management 14 ( 58.3%) 10. Vector and Animal Control 20 ( 83.3%) 11. Water Pollution 18 ( 75.0%) E. Personal Health Services 1. AIDS Testing and Counseling 24 (100.0%) 2. Alcohol Abuse 22 ( 91.7%) 3. Child Health 24 (100.0%) 4. Chronic Diseases 22 ( 91.7%) 5. Dental Health 16 ( 66.7%) 6. Drug Abuse 23 ( 95.8%) 7. Emergency Medical Service 5 ( 20.8%) 8. Family Planning 24 (100.0%) 9. Handicapped Children 21 ( 87.5%) 10. Home Health Care 19 ( 79.2%) 11. Hospitals - 12. Immunizations 24 (100.0%) 13. Laboratory Services 13 ( 54.2%) 14. Long-term Care Facilities 3 ( 12.5%) 15. Mental Health 23 ( 95.8%) 16. Obstetrical Care 12 ( 50.0%) 17. Prenatal Care 22 ( 91.7%) 18. Primary Care 6 ( 25.0%) 19. Sexually Transmitted Diseases 24 (100.0%) 20. Tuberculosis 24 (100.0%) 21. WIC 22 ( 91.7%) C. Local Health Officer No M.D. Requirement, Secretary Appointment County health officers are nominated by the county governing body and are appointed by the Secretary of MDHMH. The local health officer is the chief executive officer of the local health department. Health officers are required to have a master's degree in public health and at least 2 years' work in the field of public health, or at least 5 years' work in the field of public health. The following are powers and duties of county health officers: 1. The health officer for a county is the Executive Officer and Secretary of the county board of health. 2. The health officer for a county has responsibility for appointing the staff of the county health department. 3. A health officer may obtain samples of food and drugs for analysis. 4. A county health officer, under the direction of the Secretary, will enforce the state health laws and the policies, rules, and regulations that the Secretary adopts. 5. The health officer will have an office at an accessible place in the county. 6. Except for particular situations specified by law, the county health officer will, under the direction of the county board of health, enforce the rules and regulations that the county board adopts. 7. The county health officer will enforce in each municipality or special taxing district in the county the rules and regulations that the county board of health adopts, unless the municipality or district has a charter provision or ordinance that specifies otherwise. 8. A health officer will perform any investigation or other duties or function directed by the Secretary or the county board of health and submit appropriate reports to them. D. Local Board of Health Policy-making In general, the county governing body functions as the board of health for the county. In a code county or charter county the governing body has the option of appointing a board of health or serving that function themselves. Responsibilities of the local boards of health are to meet each May and October, to coordinate its activities with the Department, to report to the Department on the sanitary conditions of the county whenever the Board considers it important and necessary, and to adopt and enforce rules and regulations on any nuisance or cause of disease in the county. E. Staff In three jurisdictions the local staff is employed by the county. In 21 jurisdictions the staff is employed by the state. However, in all jurisdictions, except Baltimore City, the health officer is a state employee. The number of employees for an individual local health department ranges from 49 to 706. F. Budget Total FY 1988 LPHA expenditures were $99,542,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $2,424,000 State Funds $41,575,000 Local Funds $32,079,000 Fees and Reimbursements 0 Other Sources $23,463,000 Source Unknown 0 2Maryland Department of Health and Mental Hygiene, 1990 Governor Secretary Deputy Secretary for Operations Deputy Secretary for Public Health Services Office of Health Program Support/Special Projects Local Health Administration AIDS Administration Alcohol and Drug Abuse Administration Community Health Surveillance and Laboratory Administration Developmental Disabilities Administration Family Health Administration Mental Hygiene Administration Deputy Secretary for Health Care Policy, Finance and Regulation 2Types of Local Health Departments by Jurisdiction Maryland, 1990 Jurisdiction Co C Allegany X Anne Arundel X Baltimore X Baltimore City X Calvert X Caroline X Carroll X Cecil X Charles X Dorchester X Frederick X Garrett X Harford X Howard X Kent X Montgomery X Prince Georges X Queen Annes X Somerset X St. Marys X Talbot X Washington X Wicomico X Worchester X Co = County HD 1MASSACHUSETTS 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 5,890,000 245,803,000 Population Density (1988) 752.8 69.4 (per/sq.mi.) Number of Counties 14 3,139 Median Age (1987) 33.0 31.7 Percent Below Poverty Level (1985) 9.3 14.0 (persons) Percent of Population Rural (1980) 16.0 26.0 Percent of Population White (1980) 93.5 83.1 Percent of Population Non-White (1980) 6.5 16.9 Median Years of Education (1980) 12.6 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The structure and authority for counties in Massachusetts are provided by the state constitution and statutes. Commission Form - (10) - Ten of the 14 counties in Massachusetts have 3-member county commissions, treasurers, and county advisory boards made up of locally elected officials. The primary function of counties under this framework is the administration of jails, houses of correction, court houses, and registries of deeds. Home Rule Charter - (2) - In 1985 Massachusetts enacted provisions of home rule authority which provided the counties with greater legislative authority. Home Rule Charters were adopted in Hampshire and Barnstable counties. Hampshire County adopted a charter plan which has a government body with 26 commissioners elected to 2-year terms from 26 towns in the county and an appointed administrator. The vote of each commissioner is weighted according to the population of the town from which he/she is elected. Barnstable County has a 3-member executive body elected at large, a 15-member legislative assembly elected by district, and an appointed administrator. The vote of the assembly members is weighted according to the population of their respective districts. Data for this state were updated February 1991. City/County Consolidation - (2) - These consolidations are Boston and Suffolk County and Nantucket and Nantucket County. Both governments operate with an elected executive. 3II. State Health Agency (SHA) A. General Component of Superagency The Massachusetts Department of Public Health (MDPH), the SHA, is a component of a superagency known as the Executive Office of Human Services. MDPH is one of 11 departments within the Secretariat of Human Services. The MDPH includes the following bureaus: Communicable Disease Control; Laboratory and Environmental Sciences, Environmental Monitoring and Regulation; Parent; Child and Adolescent Health; Health Statistics Research and Evaluation; Community Health Programs; Health Care Systems; Public Health Hospitals; and Substance Abuse. Initiatives of MDPH include the following: strengthen efforts to fight AIDS and substance abuse; promote better adolescent health; reduce infant deaths; decrease environmental health hazards; reduce health risks for the poor; improve health care for the elderly; assure high quality, accessible health care for all citizens; and maximize the use of MDPH resources. The following are some broad areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Commissioner is head of the Department of Public Health. This officer is appointed by the Governor and responsible to the Secretary of Human Services. The Commissioner sits on the Public Health Council, the final decision-making body for the state public health policies. C. State Board of Health/Council Policy-making Massachusetts has a State Public Health Council which consists of eight members and the Commissioner who serves as chairman. Three of the appointed members must be providers of health services, of whom two must be physicians. The five remaining members must not be providers of health care. Three of these must be selected from a list of candidates submitted by the Secretary of Elder Affairs. The term of office is 6 years. Members are appointed by the Governor with advice and consent of the Senate. The Council is responsible for approving public health policy for the operation of the health department and its programs. D. Regional/District Health Offices MDPH has two regional units which serve local health departments and boards--one in western Massachusetts and the other in the Boston central office. They provide consultation and technical assistance, planning and coordination, inspection and code enforcement, and continuing education and training. Overall, staff in the two regional offices represent the following MDPH programs: community sanitation, childhood lead poisoning prevention, radon control, AIDS, communicable diseases, prenatal outreach, high-risk infant and early childhood intervention, school nursing and case management for children with special health care needs. E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Informal Liaison Function MDPH has not designated one office or individual the responsibility for liaison between the SHA and local health agencies. Specific programs communicate directly with the local boards of health. Staff units in the two regional offices, which are extensions of the central office, function as liaisons for information and referral. The interaction between state and local public health agencies in Massachusetts may be characterized as mixed centralized and decentralized organizational control. Under this arrangement local health services may be provided by the SHA in some jurisdictions and by local governmental units, boards of health, or health departments in other jurisdictions. F. Budget Total FY 1988 Massachusetts SHA expenditures were $281,759,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $61,555,000 State Funds $220,204,000 Local Funds 0 Fees and Reimbursements 0 Other 0 3III. Local Public Health Agencies (LPHAs) A. General Massachusetts has 351 cities and towns, each with their own local board of health. Although the commonwealth has no direct authority over these health units, it does have authority by regulation and mandate to determine their functions and activities. The local units range from offices staffed only with volunteer, part-time board members or part-time staff, to full-fledged health departments. While information on the specifics of local staffing is limited, estimates are that Massachusetts has approximately 183 local units which have at least one full-time employee and thereby meet our definition of a local health department. Seven of these represent multitown jurisdictions (intermunicipal health districts) which enable member towns to share staff and other resources. Massachusetts has one county health department (Barnstable). B. Services Provided The following information on services provided by local health departments in Massachusetts is derived from a survey conducted by NACHO during 1989. Two hundred and thirty-nine of the 359 local boards of health in Massachusetts responded to the survey. Services provided by at least 70 percent of the boards of health in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 17 ( 7.1%) 2. Morbidity Data 70 ( 29.3%) 3. Reportable Diseases 172 ( 72.0%) 4. Vital Records and Statistics 82 ( 34.3%) B. Epidemiology/Surveillance 1. Chronic Diseases 48 ( 20.1%) 2. Communicable Diseases 174 ( 72.8%) II. Policy Development A. Health Code Dev. and Enforcement 198 ( 82.8%) B. Health Planning 87 ( 36.4%) C. Priority Setting 70 ( 29.3%) III. Assurance Activities A. Inspection 1. Food and Milk Control 201 ( 84.1%) 2. Health Facility Safety/Quality 125 ( 52.3%) 3. Rec. Facility Safety/Quality 154 ( 64.4%) 4. Other Facility Safety/Quality 83 ( 34.7%) B. Licensing 1. Health Facilities 89 ( 37.2%) 2. Other Facilities 215 ( 90.0%) C. Health Education 103 ( 43.1%) D. Environmental 1. Air Quality 100 ( 41.8%) 2. Hazardous Waste Management 155 ( 64.9%) 3. Individual Water Supply Safety 150 ( 62.8%) 4. Noise Pollution 87 ( 36.4%) 5. Occupational Health and Safety 57 ( 23.8%) 6. Public Water Supply Safety 117 ( 49.0%) 7. Radiation Control 40 ( 16.7%) 8. Sewage Disposal Systems 204 ( 85.4%) 9. Solid Waste Management 166 ( 69.5) 10. Vector and Animal Control 133 ( 55.6%) 11. Water Pollution 163 ( 68.2%) E. Personal Health Services 1. AIDS Testing and Counseling 18 ( 7.5%) 2. Alcohol Abuse 16 ( 6.7%) 3. Child Health 76 ( 31.8%) 4. Chronic Diseases 50 ( 20.9%) 5. Dental Health 34 ( 14.2%) 6. Drug Abuse 24 ( 10.0%) 7. Emergency Medical Service 17 ( 7.1%) 8. Family Planning 11 ( 4.6%) 9. Handicapped Children 13 ( 5.4%) 10. Home Health Care 73 ( 30.5%) 11. Hospitals 6 ( 2.5%) 12. Immunizations 139 ( 58.2%) 13. Laboratory Services 25 ( 10.5%) 14. Long-term Care Facilities 10 ( 4.2%) 15. Mental Health 27 ( 11.3%) 16. Obstetrical Care 6 ( 2.5%) 17. Prenatal Care 23 ( 9.6%) 18. Primary Care 11 ( 4.6%) 19. Sexually Transmitted Diseases 29 ( 12.1%) 20. Tuberculosis 96 ( 40.2%) 21. WIC 12 ( 5.0%) C. Local Health Officer No M.D. Requirement, Local Government Body Appointment Approximately 75 percent of Massachusetts towns and cities hire health agents; in 45 percent, the agents are full-time, in 30 percent part-time. The local health officer may or may not supervise staff. Except for the larger communities, local health officers are hired by local boards of health, or the mayor (with council approval), depending on the form of local government. The local board of health usually develops a contract with its health officer. Local personnel policies and employee benefits generally apply. He/she is involved in direct health protection activities, which include inspections for permits and licenses, responding to emergencies and complaints and reviewing plans for facilities siting. Areas of responsibility include food service, retail food, swimming pools, and beaches, private wells, septic systems, recreational camps for children, solid waste transfer, and housing and nuisance complaints. He/she also maintains public records, keeps local board of health members informed and organizes their regular meetings, hearings, and public education campaigns. There is no involvement of county government, except in Barnstable County, where county-level staff coordinate activities with additional staff hired by the local health boards. MDPH regional office staffs in western Massachusetts, as well as Boston, provide consultation and training for local health officers and board members on code enforcement and other health-related programs such as cancer reduction and AIDS education. Outside western Massachusetts, these functions are performed solely by MDPH staff in Boston. The State Department of Environmental Protection carries out similar functions for program areas under its jurisdiction, including subsurface sewage and solid waste disposal. D. Local Board of Health Policy-making The local board of health was established by state legislation. If a town does not choose to elect or have its Board of Selectmen appoint a board of health, the Board of Selectmen act as the Board of Health. Terms of office are generally staggered--1, 2 and 3 years. Most boards have three members; some have five. Local health boards may appoint agents to act in their behalf to handle code enforcement matters; however, final responsibility rests with the board, which must conduct all its business at regular or special public meetings, posted in advance. Functions include: enforcement of the state sanitary and environmental codes mentioned above, and handling of public emergencies, nuisance problems and facilities siting. The local board of health has extensive authority to enact local regulations, to act in emergencies or to abate public health nuisances, and to review and make decisions regarding definitive housing subdivisions plans. Most are involved in vector control programs, many conduct lead paint inspections and approximately one-third manage solid waste disposal facilities and programs. E. Staff Local staffs are all employed by the local boards of health or health departments. Some 3-year state seed grants have been available for newly created, multitown health districts to encourage smaller towns to obtain shared professional expertise. The District boards, which employ the staff, contain equal representation from their constituent towns, which still maintain their individual health boards. No county or state unit employs local public health staff. F. Budget Total FY 1988 LPHA expenditures were $2,396,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $1,529,000 State Funds $868,000 Local Funds 0 Fees and Reimbursements 0 Other Sources 0 Source Unknown 0 2Massachusetts Department of Public Health, 1990 Commissioner's Office Planning and Policy Government Relations General Counsel Management and Resources Administration Finance AIDS Office Communicable Disease Center Laboratory and Environmental Sciences Environmental Monitoring and Regulation Parent, Child and Adolescent Health Health Statistics, Research and Evaluation Community Health Programs Health Care Systems Public Health Hospitals Substance Abuse 2Types of Local Health Departments by Jurisdiction Massachusetts, 1990 Jurisdiction Co C N/Co T/T M/T Abington X Achusnet X Acton X Agawam X Amesbury X Amhurst X Andover X Arlington X Athol X Attleboro X Auburn X Avon X Barnstable X Barnstable X Bedford X Bellingham X Belmont X Berkshire X Beverly X Billerica X Blackstone X Boston X Bourne X Boxford-Topsfield X Braintree X Bridgewater X Bristol X Brocton X Brookline X Burlington X Cambridge X Canton X Charlton X Chelmsford X Chelsea X Chicopee X Clinton X Cohasset X Concord X Danvers X Dartmouth X Dedham X Dighton X Dracut X Dudley X Dukes X E. Franklin Co. X Easton X Essex X Essex X Everett X Fall River X Falmouth X Fitchburg X Foothills X Foxborough X Framington X Franklin X Franklin X Freetown X Gardner X Georgetown X Glouchester X Greenfield X Hamilton X Hampden X Hampden X Hampshire X Hanover X Harwich X Haverhill X Hingham X Holbrook X Holden X Holliston X Holyoke X Hopkinton X Hudson X Hull X Ipswich X Kingston X Lakeville X Lawrence X Leominster X Lexington X Longmeadow X Lowell X Ludlow X Lynn X Lynnfield X Malden X Manchester X Mansfield X Marblehead X Marion X Marlborough X Marshfield X Mashpee X Mattapoisett X Maynard X Medford X Medway X Melrose X Methuen X Middleborough X Middlesex X Middleton X Milford X Milton X Nahant X Nantucket X Nantucket X Nashoba Association X Natick X New Bedford X Newburyport X Newton X Norfolk X North Adams X North Andover X North Attleboro X North Reading X Northampton X Northborough X Norwell X Norwood X Orange X Orleans X Oxford X Paxton X Peabody X Pembroke X Pepperell X Pittsfield X Plymouth X Plymouth X Provincetown X Quabbin District X Quincy X Randolph X Raynham X Reading X Rehoboth X Revere X Rockland X Rockport X Rowe X Salem X Saugus X Scituate X Seekonk X Sharon X Sheffield X Sherborn X Shrewsbury X Somerset X Somerville X Southborough X Southbridge X Spencer X Springfield X Sterling X Stoneham X Stoughton X Stow X Sudbury X Suffolk X Swampscott X Swansea X Taunton X Tewksbury X Tri-town District X Tyngsborough X Wakefield X Walpole X Waltham X Wareham X Watertown X Wayland X Welfleet X Wellesley-Needham X West Newbury X West Springfield X Westborough X Westfield X Westport X Westwood X Weymouth X Whitman X Williamstown X Wilmington X Winchendon X Winthrop X Woburn X Worcester X Worchester X Co = County HD C = City HD T/T = Town/Township HD N/Co = No County HD M/T = Multitownship HD 1MICHIGAN 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 9,240,000 245,803,000 Population Density (1988) 162.2 69.4 (per/sq.mi.) Number of Counties 83 3,139 Median Age (1987) 31.1 31.7 Percent Below Poverty Level (1985) 14.5 14.0 (persons) Percent of Population Rural (1980) 29.0 26.0 Percent of Population White (1980) 85.0 83.1 Percent of Population Non-white (1980) 15.0 16.9 Median Years of Education (1980) 12.5 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The structure and authority of county governments in Michigan are determined by the state constitution, state statutes and court cases. Three forms of government are available to Michigan counties: Commission, Charter, and United Forms. Commission Form - (80) - Commissions are used by 80 counties. The boards of commissioners are made up of 5 to 35 members, determined by population, and elected from single-member districts. State law permits commission counties to hire other employees that they consider necessary. Under this provision 31 counties have appointed an administrator and 18 have hired a fiscal controller. Charter Form - (1) - One county has adopted the Charter Form of government. The Charter has home rule provisions which permit the county to elect an executive officer. Under the Charter the board of commissioners become primarily a legislative body with administrative functions transferred to the executive. United Form - (2) - The United Form is currently being used by two counties: Oakland and Bay. This type of government provides more local options than the Commission but fewer than the Charter. While it allows counties to elect an executive officer Data for this state were updated December 1990. or appoint a manager, both counties have chosen elected executives. The executive is elected to 4-year terms and is stronger than an appointed manager because of veto power. 3II. State Health Agency (SHA) A. General Free-standing, Independent The State Health Agency is an independent, free-standing agency known as the Michigan Department of Public Health (MDPH). The mission of the Department is to continually and diligently endeavor to prevent disease, prolong life, and promote the public health through organized programs, including prevention and control of environmental hazards; prevention and control of diseases; prevention and control of health problems of particularly vulnerable population groups; development of health care facilities and agencies and health services delivery systems; and regulation of health care facilities and agencies and health services delivery systems to the extent provided by law. Major department functions are divided among the following four bureaus and two centers: Center for Environmental Health Sciences; Bureau of Environmental and Occupational Health; Bureau of Community Health Services; Center for Health Promotion; Bureau of Health Facilities; and Bureau of Laboratory and Epidemiological Services. The following are some areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The head of the SHA is the State Health Director, who is a cabinet-level officer appointed by the Governor. Under state law if the state health director is not a physician, the Director must designate a physician as the chief medical executive of the department. The Director, with the approval of the Governor, may establish the internal organization of the department and is responsible for all internal administrative procedures. C. State Board of Health/Council Advisory Michigan has the Public Health Advisory Council that consists of 16 members who are appointed by the Governor. The Council is to represent consumers and providers of health and to be representative of the population as to sex, race, and ethnicity and will include representatives of the local governing body. The term of office is 4 years. As the name indicates, the duties of this Council involve advising and consulting with the Director on public health programs and policy. D. Regional/District Health Offices The Bureau of Community Services has divided the state into three administrative regions: Northern region, Eastern region, and Western region. Each of the regions has a regional office, located in Lansing. Through the regional offices the bureau provides advice, policy direction, and technical support to local agencies charged with the delivery of health services. Also, they develop comprehensive plans, execute performance contracts with local agencies, and monitor and evaluate local agency performance. The typical regional office staff consists of 15 to 20 persons led by an administrative head, the Regional Chief. Under the Regional Chief are two sections, the Operations Section and the Program Section, which are supervised by section chiefs. The Operations Section is staffed by administrative types of personnel. The Program Section is staffed primarily by individuals who are program consultants. E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Formal Liaison Function The function of state-local liaison has evolved from a separate office within the Department, with some oversight responsibilities, to a single position reporting to the Director. It is this individual's responsibility to see that the Department's programs with local public health departments are coordinated, to act as an ombudsman for local health department concerns, and to represent the Director in dealing with local issues. The interaction between state and local public health agencies in Michigan may be characterized as mixed centralized and decentralized organizational control. Under this arrangement local health services may be provided by the SHA in some jurisdictions and by local governmental units, boards of health, or health departments in other jurisdictions. F. Budget Total FY 1988 Michigan SHA expenditures were $306,640,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $126,208,000 State Funds $142,265,000 Local Funds $414,000 Fees and Reimbursements $32,085,000 Other $4,896,000 3III. Local Public Health Agencies (LPHAs) A. General Michigan has 50 local health departments, consisting of 35 county health departments, 14 multicounty health departments (known as districts) and 1 city health department. These local departments can be organized in any of the four following ways: single county units; district health departments comprised of two or more counties; city health departments in cities with 750,000 or more population; or associated health departments in which two or more local governing entities may contract for employment of personnel or the consolidation of functions of their local health departments. Eight of these units are currently associated units. Each county maintaining an approved county health department is entitled to participate in cost sharing by the state. Other state and Federal funds are also available to local health departments through MDPH in the form of general and categorical appropriations made by the State Legislature and Congress to meet specific needs or health problems. B. Services Provided The following information on services provided by local health departments in Michigan is derived from a survey conducted by NACHO during 1989. Forty-seven of 50 local health departments in Michigan responded to the survey. Services provided by 70 percent of health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 24 ( 51.1%) 2. Morbidity Data 28 ( 59.6%) 3. Reportable Diseases 45 ( 95.7%) 4. Vital Records and Statistics 23 ( 48.9%) B. Epidemiology/Surveillance 1. Chronic Diseases 28 ( 59.6%) 2. Communicable Diseases 46 ( 97.9%) II. Policy Development A. Health Code Dev. and Enforcement 43 ( 91.5%) B. Health Planning 28 ( 59.6%) C. Priority Setting 31 ( 66.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 31 ( 66.0%) 2. Health Facility Safety/Quality 20 ( 42.6%) 3. Rec. Facility Safety/Quality 37 ( 78.7%) 4. Other Facility Safety/Quality 9 ( 19.1%) B. Licensing 1. Health Facilities 4 ( 8.5%) 2. Other Facilities 44 ( 93.6%) C. Health Education 35 ( 74.5%) D. Environmental 1. Air Quality 15 ( 31.9%) 2. Hazardous Waste Management 29 ( 61.7%) 3. Individual Water Supply Safety 45 ( 95.7%) 4. Noise Pollution 5 ( 10.6%) 5. Occupational Health and Safety 10 ( 21.3%) 6. Public Water Supply Safety 42 ( 89.4%) 7. Radiation Control 14 ( 29.8%) 8. Sewage Disposal Systems 43 ( 91.5%) 9. Solid Waste Management 32 ( 68.1%) 10. Vector and Animal Control 41 ( 87.2%) 11. Water Pollution 40 ( 85.1%) E. Personal Health Services 1. AIDS Testing and Counseling 45 ( 95.7%) 2. Alcohol Abuse 12 ( 25.5%) 3. Child Health 47 (100.0%) 4. Chronic Diseases 37 ( 78.7%) 5. Dental Health 13 ( 27.7%) 6. Drug Abuse 14 ( 29.8%) 7. Emergency Medical Service 11 ( 23.4%) 8. Family Planning 44 ( 93.6%) 9. Handicapped Children 42 ( 89.4%) 10. Home Health Care 24 ( 51.1%) 11. Hospitals - 12. Immunizations 47 (100.0%) 13. Laboratory Services 16 ( 34.0%) 14. Long-term Care Facilities 7 ( 14.9%) 15. Mental Health 2 ( 4.3%) 16. Obstetrical Care 14 ( 29.8%) 17. Prenatal Care 39 ( 83.0%) 18. Primary Care 7 ( 14.9%) 19. Sexually Transmitted Diseases 46 ( 97.9%) 20. Tuberculosis 47 (100.0%) 21. WIC 39 ( 83.0%) C. Local Health Officer No M.D. Requirement, Board of Health or Governing Body Appointment State law requires that each local public health department have a full-time local health officer. This officer may be a medical health officer or an administrative health officer. The medical health officer must be a licensed physician while the administrative health officer has no such requirement. If the health officer is not a physician, a medical director must be employed who is responsible to the health officer for medical decisions. The health officer functions as the administrative officer of the board of health and as the director of the department. In single county health departments, the board of health usually selects and refers the preferred candidate to the local governing entity with the recommendation for appointment. In districts the board of health selects and appoints the health officer. D. Local Board of Health Policy-making County governments are authorized by state law to appoint a board of health. Cities with 750,000 or more population also have this authority. State law provides for formation of district boards of health when district health departments are created. The district board of health is composed of two members from each county board of commissioners, or two members appointed by the mayor in the case of a city. A county or city may have more representatives with consent of the local governing bodies. The major responsibility of the local board of health is to learn as much as possible about health problems of the community and to participate actively in finding solutions for these problems. Other duties of the local boards of health include the following: approve the health department programs; interpret health department programs; approve the budget; approve expenditures; and adopt regulation for approval by the local governing body. E. Staff All local public health departments have as a minimum the following staff members: medical or administrative health officer, medical director (if an administrative health officer is employed), administrator, public health nurses, environmental health staff, office manager, bookkeepers, clerks, health educators, vision and hearing technicians, accountants, laboratory technicians, dentists, physical therapists, and home health aids. The number of staff for a local health department ranges from 9 to 911. The staff are employed and supervised by the jurisdiction that they serve. F. Budget Total FY 1988 LPHA expenditures were $287,078,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $41,347,000 State Funds $77,990,000 Local Funds $112,338,000 Fees and Reimbursements $47,388,000 Other Sources $8,014,000 Source Unknown 0 The SHA reported that these figures include the total amount of additional monies expended by all local health departments. 2Michigan Department of Public Health, 1990 State Health Director Public Health Advisory Council Office of Substance Abuse Services Chief Medical Executive Food and Nutrition Commission Deputy Directors Affirmative Action Office of Budget and Finance Office of Personnel Office of General Services Office of Management Information Systems Office of State Registrar and Center for Health Statistics Office of the Director Publications and Media Services Legislative Liaisons Federal Liaison Center for Environmental Health Sciences Bureau of Environmental and Occupational Health Bureau of Community Services 50 Local Health Departments Center for Health Promotion Bureau of Health Facilities Bureau of Laboratory and Epidemiological Services 2Types of Local Health Departments by Jurisdiction Michigan, 1990 Jurisdiction Co M/Co Alcona X Alger X Allegan X Alpena X Antrim X Arenac X Baraga X Barry X Bay X Benzie X Berrien X Branch X Calhoun X Cass X Charlevoix X Cheboygan X Chippewa X Clare X Clinton X Crawford X Delta X Dickinson X Eaton X Emmet X Genesee X Gladwin X Gogebic X Grand Traverse X Gratiot X Hillsdale X Houghton X Huron X Ingham X Iona X Iron X Isabella X Jackson X Kalamazoo X Kalkaska X Kent X Keweenaw X Lake X Lapeer X Leeanau X Lenawee X Livingston X Losco X Luce X Mackinac X Macomb X Manistee X Marquette X Mason X Mecosta X Midland X Minominee X Missaukee X Monroe X Montcalm X Montmorency X Muskegon X Newaygo X Oakland X Oceana X Ogemaw X Ontonagon X Osceola X Oscoda X Otsego X Ottawa X Presque Isle X Roscommon X Saginaw X Sanilac X Scoolcraft X Shiawassee X St. Clair X St. Joseph X Tuscola X Van Buren X Washtenaw X Wayne X Wexford X Co = County HD M/Co = Multicounty HD 1MINNESOTA 2Public Helath System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) 4,307,000 245,803,000 Population Density (1988) 54.1 69.4 (per/sq.mi.) Number of Counties 87 3,139 Median Age (1987) 31.5 31.7 Percent Below Poverty Level (1985) 12.6 14.0 (persons) Percent of Population Rural (1980) 33.0 26.0 Percent of Population White (1980) 96.6 83.1 Percent of Population Non-white (1980) 3.4 16.9 Median Years of Education (1980) 12.6 12.5 (25 years of age and over) B. County Government Structure Home Rule Authority The state constitution and statutes provide authority and structure for county governments in Minnesota. Commission Form - (87) - Commission is the basic structure for county governments. The boards are made up of three, five, seven, or nine members who are elected from single-member districts. Minnesota counties may choose one or more options from the following five choices: 1. Elected Executive Plan 2. County Manager Plan 3. At-large Chair Plan 4. County Administrator Plan 5. Auditor-Administrator Plan APPOINTED ADMINISTRATORS - (30) - This is an appointed position with full administrative powers. Data for this state were updated November 1990. AUDITOR-ADMINISTRATOR PLAN - (12) - This involves the election of an auditor who serves primarily in a fiscal capacity but also has some administrative responsibilities. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Minnesota Department of Health (MDH), the SHA, is a free-standing, independent agency. The mission of MDH is to protect, maintain, and improve the health of citizens of the state through the development and maintenance of an organized system of programs and services carried out by both state and local government with the cooperation of non-governmental entities. The following are some areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement State Institutions/Hospitals B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Commissioner of Health is the Chief Executive Officer for the SHA. The Commissioner is appointed by the Governor with the consent of the Senate. There is no requirement for the Commissioner to be a physician. Selection is to be based on ability and experience in matters of public health. Responsibilities of the position include the administration of the SHA and its offices, establishing standards for community health boards, and assisting in the development, administration, and implementation of community health services. C. State Board of Health/Council Advisory Minnesota does not have a State Board of Health or Health Council. However, it does have an advisory committee called the State Community Health Services Advisory Committee. The Committee is composed of representatives from each of the 48 local community health boards. The State Committee is required by law to meet at least four times a year and provide advice, consultation, and recommendations to the Commissioner regarding the development, maintenance, funding and evaluation of community health services (CHS). The Department relies on the State CHS Advisory Committee for assistance in making policy and technical decisions related to the CHS subsidy program and to local public health in general. D. Regional/District Health Offices MDH has seven district offices. The geographic area that these district offices serve varies from program to program depending on the service and the population served. In fact district maps are different for almost every program. The district offices are staffed with MDH employees. The following is a list of staff that is housed in a district: District Representative District Clerk Typist District Epidemiologist Community Environmental Services Consultant Environmental Field Services Sanitarian/Supervisor Emergency Medical Services Consultant Health Facility Evaluator Unit Supervisor Health Facility Evaluator Administrative Specialist Health Facility Evaluator Laboratory Specialist Health Facility Evaluator Nurse Consultant Health Facility Evaluator Sanitarian Specialist Mothers and Children Program Consultant Public Health Nurse Consultant Quality Assurance and Review Registered Nurse Senior Quality Assurance and Review Social Worker Senior Services for Children with Handicaps Nurse Consultant Services for Children with Handicaps Social Worker Vision and Hearing Consultant Women, Infants and Children Program Consultant Water Supply and Engineering Engineer/Sanitarian/Supervisor E. State-local Liaison Shared Organizational Control, Formal Liaison Function The Local Public Health Act of 1987 (MN stay. 145A) was enacted to develop and maintain an integrated system of community health services under local administration and within a system of state guidelines and standards. The mission of Community Health Services is to bring people to protect and promote the health of the general population within a community health service area. This is accomplished by the prevention of disease, injury, disability, and preventable death through the promotion of effective coordination and use of community resources, and by extending health services into the community. The Community Health Services Division of MDH serves as the entity with responsibility for state-local liaison activities. In this role the Division assists the State CHS Advisory Committee by coordinating, facilitating, and providing staff support for the committee. The District Representatives that are assigned to the district offices work for the Division. They are responsible for maintaining the regional offices and assisting the community health boards with administrative questions. The Division also assigns public health nursing consultants to the regional offices to provide technical assistance to the 48 community health boards on matters relating to programs. Other program specialists are in the regional offices to provide assistance to the community health boards. The interaction between state and local public health agencies in Minnesota may be characterized as shared organizational control. Under this arrangement local health departments are under the authority of the SHA as well as the local government and board of health. F. Budget Total FY 1988 Minnesota SHA expenditures were $87,454,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $49,983,000 State Funds $35,675,000 Local Funds 0 Fees and Reimbursements $1,748,000 Other $48,000 3III. Local Public Health Agencies (LPHAs) A. General In Minnesota all 87 counties are served by 48 local health entities. These entities consist of 20 county health departments, 23 multicounty units and 5 city health departments. The SHA provides funds to eligible local boards of health through a formula established in 1987. This formula is a base allocation of funds equal to or above the 1985 appropriation plus a per capita allocation of that amount above the 1985 base. The local match required is now a dollar of local effort for each dollar of state subsidy. B. Services Provided The following information on services provided by local health departments in Minnesota is derived from a survey conducted by NACHO during 1989. Forty-six of the 48 local health departments in Minnesota responded to the survey. Services provided by 70 percent of the local health departments in the state responding to the survey are underlined. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 26 ( 56.5%) 2. Morbidity Data 18 ( 39.1%) 3. Reportable Diseases 32 ( 69.6%) 4. Vital Records and Statistics 13 ( 28.3%) B. Epidemiology/Surveillance 1. Chronic Diseases 20 ( 43.5%) 2. Communicable Diseases 30 ( 65.2%) II. Policy Development A. Health Code Dev. and Enforcement 24 ( 52.2%) B. Health Planning 39 ( 84.8%) C. Priority Setting 40 ( 87.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 14 ( 30.4%) 2. Health Facility Safety/Quality 7 ( 15.2%) 3. Rec. Facility Safety/Quality 18 ( 39.1%) 4. Other Facility Safety/Quality 5 ( 10.9%) B. Licensing 1. Health Facilities 3 ( 6.5%) 2. Other Facilities 20 ( 43.5%) C. Health Education 35 ( 76.1%) D. Environmental 1. Air Quality 12 ( 26.1%) 2. Hazardous Waste Management 12 ( 26.1%) 3. Individual Water Supply Safety 30 ( 65.2%) 4. Noise Pollution 9 ( 19.6%) 5. Occupational Health and Safety 5 ( 10.9%) 6. Public Water Supply Safety 16 ( 34.8%) 7. Radiation Control 3 ( 6.5%) 8. Sewage Disposal Systems 22 ( 47.8%) 9. Solid Waste Management 18 ( 39.1%) 10. Vector and Animal Control 25 ( 54.3%) 11. Water Pollution 23 ( 50.0%) E. Personal Health Services 1. AIDS Testing and Counseling 16 ( 34.8%) 2. Alcohol Abuse 8 ( 17.4%) 3. Child Health 44 ( 95.7%) 4. Chronic Diseases 43 ( 93.5%) 5. Dental Health 10 ( 21.7%) 6. Drug Abuse 3 ( 6.5%) 7. Emergency Medical Service 26 ( 56.5%) 8. Family Planning 34 ( 73.9%) 9. Handicapped Children 37 ( 80.4%) 10. Home Health Care 43 ( 93.5%) 11. Hospitals - 12. Immunizations 44 ( 95.7%) 13. Laboratory Services 10 ( 21.7%) 14. Long-term Care Facilities 2 ( 4.3%) 15. Mental Health 13 ( 28.3%) 16. Obstetrical Care 4 ( 8.7%) 17. Prenatal Care 39 ( 84.8%) 18. Primary Care 15 ( 32.6%) 19. Sexually Transmitted Diseases 23 ( 50.0%) 20. Tuberculosis 29 ( 63.0%) 21. WIC 37 ( 80.4%) C. Local Health Officer No Local Health Officer There are no local health officers in Minnesota. The local board of health is required to appoint an "agent" to act on the board's behalf, but this agent functions as an administrator rather than a health officer. D. Local Board of Health Policy-making The governing body of a city or county is responsible for assuming the duties of a board of health or appointing and empowering a community health board. One political jurisdiction may request a neighboring jurisdiction to undertake the responsibilities of a board of health. Two or more contiguous counties or city and county combinations may establish a joint board of health (joint powers board). The board consists of at least five members appointed by the local governing body(ies). They are required to meet at least twice a year. A county or multicounty board of health has responsibility and power of a board of health for the entire jurisdiction unless a city board of health is present within the jurisdiction. The board, under supervision of the Commission, enforces laws, regulations and ordinances within its jurisdiction and areas of responsibility. A community health board has the powers and duties of a board of health, as well as the general responsibility for development and maintenance of an integrated system of community health services. There are currently 48 community health boards in Minnesota. These boards were initiated to develop and maintain an integrated system of community health services under local administration and within a system of state guidelines and standards. Boards of health may qualify as community health boards if they meet specific requirements established by law. The following are some of the requirements: meets requirements specified in sections 145A.09 to 145A.13 of the Local Public Health Act and is eligible for community health subsidy under section 145A.13; the board must include within its jurisdiction a population of 30,000 or more or be composed of three or more contiguous counties; and a city which meets requirements of law and is eligible for a community health subsidy. Within a year of the approval of a community health plan by the commissioner, all other boards of health within the jurisdiction are generally required to cease to exist. Some exceptions include: a joint powers agreement; a delegation agreement; or a jurisdiction which includes a city with 300,000 or more population. Local community health boards are required to meet at least three times a year to assist in the process of community assessment, priority setting, program planning and budgeting, and other functions related to community health services activities. They are also required to submit formal plans every 2 years, submit annual activity reports and to meet other eligibility requirements established in statute and rule. E. Staff Local health department staffs are employed and supervised by the jurisdiction that they serve. The number of employees for a local health department ranges from 1 to 200. F. Budget Total FY 1988 LPHA expenditures were $128,537,000. Total FY 1988 United States LPHA expenditures were $3,978,948,000. Source of Funds Federal Grants and Contracts $13,230,000 State Funds $16,500,000 Local Funds $40,944,000 Fees and Reimbursements $51,132,000 Other Sources 0 Source Unknown $6,731,000 The SHA reported that these figures include the total amount of additional local health department monies expended by all local health departments. 2Minnesota Department of Health, 1990 Governor Commissioner of Health Assistant to Commissioner Health Law Executive Budget Officer Office of Health Facility Complaints Bureau of Administration Health Information and General Services Deputy Commissioner Office of Legal and Policy Affairs Bureau of Health Delivery Systems Community Health Services Health Resources Health Systems Development Maternal and Child Health Bureau of Health Protection Disease Prevention and Control Environmental Health Health Promotion and Education Public Health Laboratory 2Types of Local Health Departments by Jurisdiction Minnesota, 1990 Jurisdiction Co C M/Co Aitkin X Anoka X Becker X Beltrami X Benton X Big Stone X Bloomington X Blue Earth X Brown X Carlton X Carver X Cass X Chippewa X Chisago X Clay X Clearwater X Cook X Cottonwood X Crow Wing X Dakota X Dodge X Douglas X Edina X Faribault X Fillmore X Freeborn X Goodhue X Grant X Hennepin X Houston X Hubbard X Isanti X Itasca X Jackson X Kanabec X Kandiyohi X Kittson X Koochiching X Lac qui Parle X Lake X Le Sueur X Lincoln X Lyon X Mahonomen X Marshall X Martin X McLeod X Meeker X Mille Lacs X Minneapolis X Morrison X Mower X Murray X Nicollet X Nobles X Norman X Olmstead X Otter Tail X Pennington X Pine X Pipestone X Polk X Pope X Ramsey X Red Lake X Redwood X Renville X Rice X Richfield X Rock X Roseau X Scott X Sherburne X Sibley X St Louis X St. Paul X Stearns X Steele X Stevens X Swift X Todd X Traverse X Wabasha X Wadena X Waseca X Washington X Watonwan X Wilkin X Winona X Co = County HD C = City HD M/Co = Multicounty HD 1MISSISSIPPI 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1988) * 2,748,786 245,803,000 Population Density (1988) * 57.5 69.4 (per/sq.mi.) Number of Counties 82 3,139 Median Age (1987) 29.1 31.7 Percent Below Poverty Level (1985) 25.1 14.0 (persons) Percent of Population Rural (1980) * 52.7 26.0 Percent of Population White (1980) 64.1 83.1 Percent of Population Non-white (1980) 35.9 16.9 Median years of Education (1980) 12.2 12.5 (25 Years of age and over) B. County Government Structure Home Rule Authority Counties are empowered by the state constitution and the Mississippi Code. Commission Form - (82) - County governments utilize a five-member Board of Supervisors, based on the Commission Form of government. The supervisors, who are the governing body, are elected from single-member districts. Within this form of government are two different organizational structures, the Unit System and the Beat System. Unit System - (47) - The five supervisors elected from single-member districts serve as the governing body. It differs in that administrative functions are placed under the authority of a county road manager who is appointed by the board of supervisors. This system includes more centralization in the area of policy, administrative, and budgetary affairs. Fourteen of these counties also have appointed county administrators. Beat System - (35) - Supervisors in this system have general authority over the whole county and limited responsibility Data for this state were updated November 1990. for managing roads and bridges in their individual districts. Two of these counties have appointed county administrators. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Mississippi State Department of Health (MSDH) is a free-standing, independent agency. The mission of the MSDH is to achieve the best possible health status for the citizens of Mississippi. This mission incorporates the following goals of public health: 1. To prevent or control diseases in the most cost-effective manner possible. 2. To provide protection for the public from threats to health and safety from several sources: unsanitary conditions related to food, drinking water, and sewage, unnecessary exposure to radiation, and unsafe and unhealthy conditions in health care facilities, child care facilities and the workplace. 3. To promote public policy and individual lifestyles which will improve the health status of all citizens. 4. To assure access to essential health services for the state's most vulnerable populations: low income women, infants and children, the elderly, and the disabled. The following are some areas of responsibility for the SHA: State Public Health Authority State Agency for Children with Special Health Care Needs State Health Planning and Development Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency M.D. Requirement, Not Cabinet-level Appointment The State Health Officer is the Executive Officer for the SHA and has all authority and responsibility incumbent on the position by law. The State Health Officer is appointed by the State Board of Health for a term of 6 years. The appointee must be a physician with a graduate degree in public health or be a physician who, in the opinion of the Board, is fitted and equipped to execute the duties incumbent on the position by law. The State Health Officer may not engage in the private practice of medicine. This position has the authority of the board when it is not in session and is subject to the rules and regulations established by the State Board of Health. C. State Board of Health/Council Policy-making The State Board of Health consists of 13 members appointed by the Governor and confirmed by the Senate. Terms of office are 6 years and are staggered so that expirations are spread out. The members must be engaged professionally in rendering health services or be consumers of health services and have no financial conflict of interest. The members must also be knowledgeable in at least one of the matters of jurisdiction of the board. The following are some areas of responsibility for the State Board of Health: 1. To organize the SHA into bureaus and divisions that are considered necessary and to assign appropriate functions as required by law. 2. To provide general supervision of the health interest of the people of the state and to exercise the right, powers, and duties of those acts which it is authorized by law to enforce. 3. To establish programs to promote the public health, to be administered by the State Department of Health. 4. To make and publish all reasonable rules and regulations necessary to enable it to discharge its duties and powers and to carry out the purposes and objectives of its creation. D. Regional/District Health Offices The SHA has subdivided the state into nine public health districts. Each district has an office which has direct line authority over the local health departments within its jurisdiction. They also provide support and consultative services. The offices are staffed by 15 to 25 employees. The staffs usually include the following positions: District Health Officer District Administrator District Supervisor Nurse District Environmentalist District Office 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 29.1 31.7 Percent Below Poverty Level (1985) 12.0 14.0 (persons) Percent of Population Rural (1980) 37.0 26.0 Percent of Population White (1980) 95.1 83.1 Percent of Population Non-white (1980) 4.9 16.9 Median Years of Education (1980) 12.7 12.5 (25 years of age and over) B. County Government Structure No Home Rule The structure and function of county governments in Wyoming are established by the constitution and statutes. The counties in Wyoming are generally extensions of the state and function to provide mandated services at the local level. Recently, however, counties have begun to provide many additional services that are not required. Commission Form - (23) - All Wyoming counties use the Commission Form of government. Three to five commissioners are elected at large. Their duties are to administer the functions of the county and enact only those ordinances and regulations that are permitted by statutes. There is no provision for counties to adopt home rule, charters, or any other alternate form of county government. In fact, only the Commission Form of government is authorized by the legislature. Data for this state were updated November 1990. 3II. State Health Agency (SHA) A. General Component of Superagency * The SHA, the Division of Health and Medical Services (DHMS), is a component of a superagency called the Department of Health and Social Services. The mission of the Division of Health and Medical Services is to preserve and enhance the health of the people of Wyoming and to assure conditions in which people can be healthy. The Division is structured with an administrator and six deputy administrators who manage programs in health administration, preventive medicine, nursing services, family health services, dental health and Title XIX medical assistance. The following are some areas of responsibility for the SHA: State Public Health Authority Medicaid Single State Agency State Agency for Children with Special Health Care Needs (called Maternal and Child Health Services) State Health Planning and Development Agency Institutional Licensing Agency Institutional Certifying Authority for Federal Reimbursement B. Head of State Health Agency M.D. Requirement, Department Director Appointment The Administrator of the Division of Health and Medical Services is the head of the SHA. The Administrator position requires an M.D. or Ph.D. degree in a health field. The Administrator is responsible for providing leadership and direction to the Division of Health and Medical Services to promote and protect public health and the safety of the citizens of Wyoming. * Wyoming is undergoing a reorganization of all state agencies toward a cabinet style of government. Scheduled to be operating by July 1991, the superagency will be the Wyoming Department of Health, and the Division will be the Division of Public Health. Title XIX Medical Assistance will become a separate division. Legislation will most likely be introduced in 1991 clarifying the role, responsibilities and qualifications of the State Health Officer. C. State Board of Health/Council Advisory A 16-member advisory council is appointed by the Governor to provide consultation to the Department, and a 9-member advisory council assists the Division in establishing general policies and setting priorities for budget requests. The council is composed of health professionals, community leaders, and legislative representatives. D. Regional/District Health Offices The counties in Wyoming have been divided into five regions for more efficient planning and health delivery. However, there are no regional offices in these areas. The units within the regions are brought together from time to time at various geographic locations within the region to discuss important issues. It is also important to note that some regions have independent public health nursing units or no public health nursing units, which affects the dollar amounts allocated by DHMS to each region. E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Informal Liaison Function The state-local liaison function is handled by the State Nursing Deputy Director. This is a natural flow for communications between the state and local areas because nurses, most employed by the state, are found in all areas but one county. The interaction of state and local health agencies in Wyoming 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 Wyoming SHA expenditures were $13,895,000. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $5,939,000 State Funds $7,956,000 Local Funds NA Fees and Reimbursements NA Other 0 3III. Local Public Health Agencies (LPHAs) A. General There are 22 local health units in Wyoming. Twenty of these are county units and two are city-county departments. All except the two largest (Natrona and Laramie counties) are solely Public Health Nursing Offices. Although support for the local units is generally a mix of state and local funds, three counties (Platte, Converse, and Campbell) have only local funding, at their choice. B. Services Provided The following information on services provided by local health departments in Wyoming is derived from a survey conducted by NACHO during 1989. Ten of the 22 local health departments in Wyoming responded to the survey. Services provided by 70 percent of health departments in the state responding to the survey are underlined. Some of the services, such as air quality, are provided by departments other than Health and Social Services. Services Provided by LPHAs Number and Percent I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment 2 ( 20.0%) 2. Morbidity Data 3 ( 30.0%) 3. Reportable Diseases 10 (100.0%) 4. Vital Records and Statistics 6 ( 60.0%) B. Epidemiology/Surveillance 1. Chronic Diseases 3 ( 30.0%) 2. Communicable Diseases 9 ( 90.0%) II. Policy Development A. Health Code Dev. and Enforcement 4 ( 40.0%) B. Health Planning 5 ( 50.0%) C. Priority Setting 4 ( 40.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control 4 ( 40.0%) 2. Health Facility Safety/Quality 1 ( 10.0%) 3. Rec. Facility Safety/Quality 2 ( 20.0%) 4. Other Facility Safety/Quality 3 ( 30.0%) B. Licensing 1. Health Facilities - 2. Other Facilities 2 ( 20.0%) C. Health Education 7 ( 70.0%) D. Environmental 1. Air Quality 1 ( 10.0%) 2. Hazardous Waste Management 1 ( 10.0%) 3. Individual Water Supply Safety 3 ( 30.0%) 4. Noise Pollution - 5. Occupational Health and Safety 1 ( 10.0%) 6. Public Water Supply Safety 4 ( 40.0%) 7. Radiation Control - 8. Sewage Disposal Systems 4 ( 40.0%) 9. Solid Waste Management 1 ( 10.0%) 10. Vector and Animal Control 2 ( 20.0%) 11. Water Pollution 3 ( 30.0%) E. Personal Health Services 1. AIDS Testing and Counseling 7 ( 70.0%) 2. Alcohol Abuse 2 ( 20.0%) 3. Child Health 8 ( 80.0%) 4. Chronic Diseases 5 ( 50.0%) 5. Dental Health 3 ( 30.0%) 6. Drug Abuse 1 ( 10.0%) 7. Emergency Medical Service 1 ( 10.0%) 8. Family Planning 6 ( 60.0%) 9. Handicapped Children 7 ( 70.0%) 10. Home Health Care 9 ( 90.0%) 11. Hospitals 1 ( 10.0%) 12. Immunizations 9 ( 90.0%) 13. Laboratory Services 3 ( 30.0%) 14. Long-term Care Facilities 2 ( 20.0%) 15. Mental Health 1 ( 10.0%) 16. Obstetrical Care - 17. Prenatal Care 5 ( 50.0%) 18. Primary Care 2 ( 20.0%) 19. Sexually Transmitted Diseases 8 ( 80.0%) 20. Tuberculosis 5 ( 50.0%) 21. WIC 6 ( 60.0%) C. Local Health Officer M.D. Required, Local Board of Health Appointment The health officer is appointed by the local board of health or county commission. This position requires a licensed M.D. Responsibilities include assisting the administrative division of the State Department of Public Health in carrying out the provisions of all health and sanitary laws and regulations of the state. County health officers of this state are by statute under the supervision and direction of the State Health Officer (Department of Health and Social Services). D. Local Board of Health Policy-making Two types of local health boards may be formed in Wyoming: district and county and/or city. According to the Wyoming statutes, the word "district" shall mean and include any combination of towns, villages, cities, and counties of the state. County and/or city and district boards of health may enact rules and regulations pertaining to the prevention of disease and the promotion of public health in the areas over which such perspective boards have jurisdiction. The number of members on a district board will be at least equal to the number of participating political subdivisions, with at least one of each represented on the board. Members must also include one physician and one dentist. A county or city board of health consists of five members. These members must be qualified electors of the county in which they serve, one of which must be a physician and one a dentist. A county may elect not to form a board of health, in which case the county commission acts as a health advisory board. E. Staff The staffs of the local health departments are generally a mixture of state and local employees. In these cases they are supervised by the state through an agreement with the local jurisdictions. In three counties (Platte, Converse, and Campbell), the staff consists of all local employees and is supervised locally. The number of staff for a local health department ranges from 2 to 26. F. Budget Data on FY 1988 LPHA expenditures are not available. 2Wyoming Division of Health and Medical Services, 1990 Governor Director DHMS Administrator DHMS Deputy Administrator Health Administration Budget and Personnel Vital Records Data Authority Tumor Registry Medical Facilities Public Information Deputy Administrator Preventive Medicine AIDS STD Immunization Emergency and Injury Control Health Promotion Risk Reduction Radiological Health Environmental Health Public Health Laboratory TB Screening Rheumatic Fever Deputy Administrator Public Health Nursing Services Management Assistant Director Preventive Medicine Nursing Consultant Consultants' Supervisors Adult Health Nursing Consultant Maternal Child Health Consultant Deputy Administrator Family Health Services Children's Health Adolescent Health Renal Disease Genetics Programs WCH Special Programs WIC Deputy Administrator Medical Assistance Title XIX Deputy Administrator Dental Health 2Types of Local Health Departments by Jurisdiction Wyoming, 1990 Jurisdiction Co C/Co N/Co Albany X Big Horn X Campbell X Carbon X Casper-Natrona Co X Cheyenne-Laramie Co X Converse X Crook X Fremont X Goshen X Hot Springs X Johnson X Lincoln X Niobrara X Park X Platte X Sheridan X Sublette X Sweetwater X Teton X Unita X Washakie X Weston X Co = County HD C/Co = City/County HD N/Co = No County HD 1AMERICAN SAMOA 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators Territory United States Population (1990)* 46,329 (1988) 245,803,000 Population Density (1990)* 609.6 (1988) 69.4 (per/sq.mi.) Number of Counties 14 3,139 Median Age (1980)* 20.0 (1985) 31.7 Percent Below Poverty Level (1980)* 60.6 14.0 (persons) Percent of Population Rural (1980) 82.5 26.0 Percent of Population White (1980) * 00.3 83.1 Percent of Population Non-white (1980)* 98.2 16.9 Median Years of Education (1980) NA 12.5 (25 years of age and over) B. Location, Geography, and People American Samoa consists of the main Island of Tutuila and the islands east and north of it: Aunu'u; the Manu'a Group of three islands east of Tutuila; Swain's Island to the north; and the uninhabited Rose Atoll. The islands lie in the southern central Pacific Ocean about 2,300 miles southwest of Hawaii. The main island, Tutuila, contains over half of the land mass (42 of 76 sq. mi.) of the territory and about 96 percent of the population. Native Samoans are believed to have occupied these islands for over 2,000 years. Both Samoan and English are spoken. C. Territorial Government Structure American Samoa is an unincorporated territory of the United States. The government for the territory has legislative, judicial and executive branches. The legislative branch is made up of a bicameral legislature (the Fono). The legislature has 18 Senators and 21 members of the House of Representatives. Members of the Senate are elected from local chiefs or Matai for a term of 4 years. One Senator representing Swain's Island is a non-voting delegate who is selected in an open meeting by all permanent adult residents. Representatives are elected for *These data were provided by the SHA. Data for this territory were updated December 1990. 2-year terms. The executive branch includes the Governor, Lieutenant Governor and departmental office heads. The Governor is elected to a 4-year term by popular vote and exercises authority under the direction of the U.S. Secretary of the Interior. Local government of the territory, except for Swain's Island, has been divided into three administrative districts, each with an appointed district Governor. The districts are subdivided into a total of 14 counties. Chiefs, representing each family, form village and district councils. The independent village governments are linked through the three district Governors who are appointed by the Governor of the territory. 3II. State Health Agency (SHA) A. General Free-standing, Independent In American Samoa almost all medical care is provided by the government through a single agency, the Department of Health. No private medical care, no health insurance, nor third party payment for medical care is available. Even most off-island care is administered through the Department. The Department functions as the SHA as well as the local public health agency for the territory. LBJ Tropical Medical Center on the main Island of Tutuila provides all inpatient medical care for the islands and much of the outpatient care. LBJ is a 124-bed acute-care hospital providing a fairly comprehensive array of primary and secondary medical, promotive, and preventive services. Eight health centers provide additional outpatient care. The main island of Tutulia has three health centers, Aunu'u has one, and the Manu'a Island group has four. The health centers vary greatly in the size of the population served, size, condition, and type of facility, staffing and utilization by the villages within their service areas. Some of the more developed and busier health centers are supervised by physician's assistants, while others are headed by a registered nurse or licensed practical nurse. Primary medical and emergency medical care and various preventive services are delivered in these health centers. B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Director of Health is the head of the Department of Health. Administration of the health care system is quite centralized, but the administrative relationships seem to vary greatly depending on who is in the Office of Director. C. State Board of Health/Council No State Board of Health D. Regional/District Health Offices The Department of Health has not divided American Samoa into geographical regions or districts. E. State-local Liaison The American Samoa Department of Health functions as both a state and a local health agency, thus eliminating the need for state-local liaison. F. Budget Total FY 1991 American Samoa SHA budget is $12,000,000 for operations, not including capital improvement programs. Total FY 1988 United States SHA expenditures were $8,312,928,000. 3III. Local Public Health Agencies (LPHAs) A. General American Samoa has no local health departments. Local public health services are provided by elements of the Department of Health. B. Services Provided Services available to inpatients at LBJ include the following: Pediatrics General Medicine General Surgery Obstetrics and Gynecology Dental Care Clinical Laboratory Radiological Pharmacy Dietetics Services Intensive Care Unit Neonatal Intensive Care Eye Ear, Nose, and Throat Physical Therapy Public health services provided by the Department of Health through the outpatient clinics, health centers and public health nurses include the following: Environmental Health Health Education Public Health Nursing Public Health Laboratory Maternal and Child Health Control and Staffing of Dispensaries Chronic Disease (CDC Diabetes Control Grant) Nutrition Services Communicable Disease Control AIDS Prevention STD Prevention and Control Immunization Tuberculosis Control C. Local Health Officer Information about local health officers was not available at the time of printing. D. Local Board of Health American Samoa has no local boards of Health. E. Staff The number of staff employed by the American Samoa Department of Health is 520. F. Budget The budget for all local health services is included within the budget for the SHA. 2American Samoa Department of Health, 1990 At the time of printing, organizational chart was not available. 2Types of Local Health Departments by Jurisdiction America Samoa, 1990 American Samoa does not have local health departments 1COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators Commonwealth United States Population (1989) 40,000 (1988) 245,803,000 Population Density (1989) 217.9 (1988) 69.4 (per/sq.mi.) Number of Counties NA 3,139 Median Age (1987) NA 31.7 Percent Below Poverty Level (1985) NA 14.0 (persons) Percent of Population Rural (1980) NA 26.0 Percent of Population White (1980) NA 83.1 Percent of Population Non-white (1980) NA 16.9 Median Years of Education (1980) NA 12.5 (25 years of age and over) B. Location, Geography, and People The Commonwealth of the Northern Mariana Islands (CNMI) consists of 16 small islands with a total land mass of 183.6 square miles. The islands are peaks of a massive volcanic mountain range which rises from the floor of the Marianas Trench; they are located 3,300 miles west of Hawaii and 120 miles from their closest neighbor, Guam. The three main islands, Saipan, Rota, and Tinian, support 90 percent of the population. Saipan is the administrative center for the commonwealth. English is the official language. Chamorros constitute the native and majority population of the Marianas. The traditional society, however, has been largely destroyed by depopulation, forced resettlement, disease, and colonial abuse. The Chamorros still retain their characteristic strong extended family ties and individualism but are more a blend of Spanish, Filipino, German, Japanese, and American. Approximately 25 percent of the inhabitants are descendants of people who migrated to Saipan from the atolls between Yap and Chuuk after fierce typhoons devastated their islands. A small but growing number of aliens and expatriates also reside on the islands. Data for this territory are based on the best available information and were updated December 1990. C. Commonwealth Government Structure The Commonwealth of the Northern Mariana Islands is referred to as a "Flag Territory" and holds territorial status with the United States. This results from a 1975 referendum in which the Northern Marianas voted for a separate status as a United States commonwealth territory. The government of the Commonwealth of the Northern Mariana Islands consists of the Governor and a bicameral legislature. The legislature is composed of a 9-member Senate and a 15-member House of Representatives with all members elected to 2-year terms. 3II. State Health Agency (SHA) A. General The Department of Health and Environmental Services is the primary health agency for the Commonwealth of the Northern Mariana Islands. The government uses the SHA to provide most of the medical and health care available to residents. This agency serves as both the SHA and the local provider of public health care. The services are fairly centralized on the island of Saipan. Public health services are provided through a central clinic on Saipan, sub-hospitals on Rota and Tinian, and dispensaries on Saipan and Pagan. Scheduled field medical services are provided to Rota, Tinian, and the Northern Islands. These facilities serve as entry points into the health care systems and provide a limited range of basic medical services. Patients who require more specialized medical care are referred to the central public health clinic or to the hospital. Acute medical care is provided by a 74-bed general acute medical-surgical hospital that was recently completed on Saipan. If specialized care beyond the capacity of the commonwealth facilities is needed, the patients are referred to Guam, Hawaii, Japan, the Philippines, or the United States mainland. B. Head of State Health Agency The Director of the Department of Health and Environmental Services is the head of the SHA. C. State Board of Health/Council Information about the presence or function of a state board or council of health was not available at the time of printing. D. Regional/District Health Offices CNMI does not have regional or district public health offices. E. State-local Liaison Because the CNMI Department of Health and Environmental Services functions as both a state and a local health agency, a state-local liaison function is not needed. F. Budget Budget information for the Department of Health and Environmental Services was not available at the time of printing. 3III. Local Public Health Agencies (LPHAs) A. General There are no local health departments in the CNMI. Local public health services are provided by elements of the CNMI Department of Health and Environmental Services. B. Services Provided These services include, but are not limited to, communicable disease control, hypertension control, immunizations, maternal and child care, crippled children services, dental care, environmental health services, and home medical care services. Patients who require more specialized medical care are referred to the central public health clinic or to the hospital. C. Local Health Officer Information about the presence and function of local health officers was not available at the time of printing. D. Local Board of Health Information about the presence and function of local boards of health was not available at the time of printing. E. Staff Staff are employed by the CNMI Department of Health and Environmental Services. F. Budget The budget for local health services was not available at the time of printing. 2Commonwealth of Northern Mariana Islands Department of public Health and Environmental Services, 1990 Governor Director Division of Hospital Services Inpatient Outpatient Division of Public Health Services Division of Dental Health Services Division of Vocational Rehabilitation Services Division of Medicaid Services Division of Environmental Quality Services 2Types of Local Health Departments by Jurisdiction Commonwealth of the Northern Mariana Islands, 1990 The Commonwealth of the Northern Mariana Islands does not have local health departments 1COMMONWEALTH OF PUERTO RICO 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators Commonwealth United States Population (1990)* 3,293,050 (1988) 245,803,000 Population Density (1990)* 1,040 (1988) 69.4 (per/sq.mi.) Number of Counties 00 3,139 Median Age 24.6 31.7 Percent Below Poverty Level (1980) 62.4 14.0 (persons) Percent of Population Rural (1980) 33.2 26.0 Percent of Population White (1980) NA 83.1 Percent of Population Non-white (1980) NA 16.9 Median Years of Education (1980) NA 12.5 (25 Years of age and over) B. Location, Geography, and People The Commonwealth of Puerto Rico lies in the Caribbean Sea about 50 miles east of Hispaniola. The commonwealth consists of the main island of Puerto Rico, the small offshore islands of Vieques and Culebra, and numerous smaller islets. The total land mass is 3,459 square miles. Puerto Rico was ruled by Spain from 1509 until 1898, when it became an unincorporated territory of the United States as a result of the Spanish American War. In 1952 Puerto Rico enacted a new constitution which granted it the status of a self-governing commonwealth in its relationship with the United States. Spanish is the official language, but English is widely spoken. C. Commonwealth Government Structure Neither a state nor a territory, Puerto Rico enjoys a unique relationship with the United States under its current commonwealth status. Puerto Ricans are citizens of the United States and have most of the rights, privileges, and * These data were provided by the SHA. The data for this territory were revised January 1991. obligations of other citizens. In practice, Puerto Rico functions much as a State of the Union. It operates under a constitution adopted by the Puerto Ricans and ratified by Congress. Puerto Rico's legislature controls law-making in all matters that are normally under the authority of individual state governments. The commonwealth, therefore, completely controls the administration of its schools, police, and public works. The island, however, is excluded from the Federal tax structure, but, for purposes of Federal funds, is treated as a state except for Medicaid, food stamps, Social Security taxes, and Aid to Dependent Children. The Puerto Rican Constitution, like that of the United States, provides for checks and balances of the legislative, executive, and judicial branches of the government. Broader than the United States Constitution, however, the Puerto Rican Constitution guarantees representation, even if the candidates fail to win a majority of votes in particular contests. In national elections, Puerto Ricans may vote in presidential primaries, but not in the general election itself (unless they become voters in one of the states). Puerto Rico does have a voice (but not a vote) in the United States Congress through a Resident Commissioner who is elected by the people to a 4-year term. The Commissioner has all the privileges of a member of the Congress without the right to vote, except in House committees to which he/she belongs. The commonwealth enjoys fiscal autonomy and a customs union that allows free trade anywhere in the world, and duty-free trade with all other parts of the United States. The Federal government does retain control of customs, interstate trade, the Postal Service, defense, Coast Guard, Lighthouse Service, licensing of radio and television stations and so forth. Federal courts are maintained to adjudicate civil and criminal matters that fall under the jurisdiction of the United States Government. Puerto Rico does not have county administrative or political structure but is divided into 78 municipalities that include the island municipalities of Vieques and Culebra. Puerto Rico has a Governor, 27 Senators, 51 Representatives, the Resident Commissioner, local mayors, and assemblies elected once every 4 years, coinciding with Federal presidential elections. The Puerto Rican legislature is bicameral, with a Senate and a House of Representatives. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Puerto Rico Department of Health (PRDH), the SHA, is a free-standing, independent agency. Under its jurisdiction are all the health-related affairs of Puerto Rico. The PRDH performs the following functions: Planning, evaluating, and regulating as well as auditing the programmatic, administrative, and fiscal aspects of health facilities and services. The PRDH performs these duties in the public and private health sectors of the commonwealth. Several affiliated organizations function under the SHA. Included in this group are the General Health Council, Administration of Health Facilities and Services, Administration of Medical Services of Puerto Rico, and Central Areawide Comprehensive Health Services Corporation (CACHSC). The CACHSC is a private non-profit organization which serves as fiscal agent to the SHA for Federal grants earmarked to provide high-quality primary and migrant health care to medically underserved and low income residents of the mountainous municipalities of Barranquitas, Comerio, Corozal, Naranjito and Orocovis. B. Head of State Health Agency M.D. Requirement, Cabinet-level Appointment The Secretary of Health is the State Health Officer and the Chief Executive Officer of the PRDH. Responsibilities of the position include overseeing the health of the people and carrying out all other functions assigned by the Puerto Rico Legislature. Part of the function as Health Commissioner is to serve as an ex officio member of the following boards, commissions, and councils: 1. Puerto Rico Food and Nutrition Commission 2. Puerto Rico Family Protection and Strengthening Commission 3. Transit Security Commission 4. University of Puerto Rico Medical Sciences Campus Loans and Scholarships Committee 5. Advisory Council For Youth Affairs 6. State Council For Developmental Deficiencies 7. State Board for Vocational, Technical, and High Skills Education 8. Advisory Board for Sports and Recreation 9. Consultive Board for the Children Medical Treatment Fund 10. Examining Board for Surgery Assistant Technicians 11. Examining Board for Physical Therapy 12. Consulting Board of the Administration of Youth Institutions 13. Consultive Council of Old Age Affairs 14. Board of Directors of the Puerto Rico Institute of Forensic Sciences 15. Board of Directors of the Puerto Rico and the Caribbean Cardiovascular Center Corporation 16. Radiation Control Commission 17. Chairman of the Board of Participating Entities of the Puerto Rico Medical Center 18. Council for the Improvement of the Quality of Life in Urban Areas 19. Board to Determine Dangerous Occupations for Minors 20. Board for Nursing Home Affairs 21. Consultive Council of Environmental Protection 22. State Board to Supervise Medical/Surgical and Hospitalization Service Plans for Municipal Employees 23. Commission for Drug Addiction Control 24. Board for the Disposal of Human Bodies, Organs, and Tissue 25. Commission for the Responses to Environmental Emergencies of the Commonwealth of Puerto Rico 26. Examining Board of Embalmers The Secretary of Health will create, reorganize, consolidate or suppress all those health department divisions, bureaus, offices, services, etc., for the better functioning of the Department, as long as it does not conflict with legislative dispositions. The Secretary has authority to appoint all necessary personnel following the procedures of the Public Service Personnel Law of Puerto Rico. C. State Board of Health/Council Advisory The General Council of Health serves as the Puerto Rico State Board of Health. The Council was created to advise the public and private sectors in planning, coordinating, revising, and evaluating the health systems of Puerto Rico. As the advisory body for the Secretary of Health, the Council also develops criteria and guidelines for establishing Health Department Policy related to health services. The Council has 25 members representing the diverse geographical areas of Puerto Rico. Among its members are health providers such as physicians, dentists, nurses, occupational therapists, pharmacists, health service administrators, and health educators. Members from the consumer sector, including women, civic groups, medical plans, and medically indigent patients are represented, as are those from the financial and legal professions. Ex officio members are included from several of the health-related agencies such as the Department of Education, Social Services, Anti-addiction Services, the Administrator of the State Insurance Fund, the Director of the Administration of Medical Services, and the Chancellor of the Medical Sciences Campus of the University of Puerto Rico. D. Regional/District Health Offices Geographically, Puerto Rico is divided into six regions and three sub-regions. The regional administrative level called the Administration of Health Services and Facilities (AHSF) is responsible for providing health services. At the regional level the directions of the PRDH and AHSF are implemented. The regional offices administer public health programs, but the offices themselves do not provide direct patient care. The regional managing structure utilizes the following staff positions: Regional Director Regional Administrator Administrative Support Staff E. State-local Liaison Mixed Centralized and Decentralized Organizational Control, Informal Liaison Function Since the SHA also serves as the local health agency, there is no particular need for a liaison between the levels. This function is accomplished through the normal chain of command. The Office of Federal Affairs does have responsibility for coordination and liaison between the SHA and community health centers. The interaction between state and local public health agencies in Puerto Rico 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 1991 SHA budget is $719,822,665. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $248,897,396 State Funds $470,925,269 Local Funds 0 Fees and Reimbursements 0 Other 0 3III. Local Public Health Agencies (LPHAs) A. General The municipality of San Juan has the only autonomous local health department in Puerto Rico. The San Juan Health Department (SJHD) employs approximately 3,500 people with an annual budget of over $71 million, which represents almost 33 percent of the total budget of the government of San Juan. SJHD offers preventive as well as curative health services to anyone requesting them. Many people from surrounding municipalities receive health care from the facilities of the SJHD. Several other municipalities have health centers serving their communities. The city of Bayamon has a municipal hospital and several diagnostic and treatment centers. Several of the smaller municipalities have small health units and share the expenses of the community health centers. The municipal health facilities report to the mayors of the towns where they are located, but must abide by all of the rules and regulations of the PRHD in terms of accreditation of health facilities, quality of care, and all other procedures of the SHA. At several municipalities, especially those that have been identified as having an underserved population and where there is a health care personnel shortage, community health centers operate with Federal, state, and municipal funds. Such centers are located in the towns of Florida, Camuy, Barceloneta, Ciales, Lares, Rincon, Patillas, Hatillo, Santurce (Belaval), Loiza, Ponce (Playa de Ponce), and Castaner. The Central Areawide Health Services Corporation is the umbrella non-profit organization that manages the community health centers in the town of Barranquitas, Comerio, Corozal, Naranjita y Orocovis. These centers also provide health care to migrant workers in the towns of Cidra, Mayaguez Migrant Health Center-Western Region, and San Sabastian. B. Services Provided The three levels of health care delivery in the Puerto Rico Public Health System are primary, secondary, and tertiary. At the primary level the main services offered are preventive and ambulatory care. This level is formed by Diagnostic and Treatment Centers, Family Health Centers, Health Centers, and Public Health Units. At the Family Health Centers, services are given through family health teams which consist of physicians, nurses, health technicians, nutritionists, and social workers. The teams are organized to render health services to the family as a unit. The secondary level is provided by the area hospitals, subregional hospitals, and area health centers. At the secondary level, hospitalization services and specialized clinics are offered in sub-regions as well as in the areas that form each region. Ambulatory clinics are of a specialized nature and provide services to no less than two municipalities and no more than six. Four essential services must be offered: internal medicine, surgery, pediatrics, and obstetrics and gynecology. Services are available to those patients referred from the primary level. Services in the tertiary level are offered at the regional hospitals. These hospitals are specialized in the ambulatory area as well as in hospitalization. Patients are referred from the secondary level. At the medical centers of Mayaguez, Ponce, and Rio Piedras, very specialized services are offered. At the medical center in Rio Piedras two supra-tertiary hospitals (pediatric and adult hospitals affiliated with the University of Puerto Rico Medical Sciences Campus) serve referrals from all of Puerto Rico. SJHD operates nine diagnostic and treatment centers, an acute general hospital, a community mental health center, a day care center for AIDS patients, an emergency shelter for the homeless, a rehabilitation and extended care center, a nursing home, an animal control and adoption center, an AIDS Institute, and a system for emergency medical service. Primary care services are delivered through the diagnostic and treatment centers which are strategically located throughout San Juan. Services include clinics for general medicine, pediatrics, well babies, immunizations, obstetrics and gynecology, internal medicine, emergency room, dentistry, radiology, nutrition, social work, health education, and pharmacy. C. Local Health Officer M.D. Requirement, Secretary of Health Appointment The position of local health officer is filled by regional health officers in Puerto Rico. They are appointed by and serve at the pleasure of the Secretary of Health. D. Local Board of Health There are no local boards of health in Puerto Rico. E. Staff The San Juan Health Department employs a staff of 3,500 who are employed and supervised by the local jurisdiction. F. Budget Total FY 1988 LPHA expenditures were not available. 2Puerto Rico Department of Health and Adminstration of Health Facilities Services, 1990 Office of the Secretary Board of General Health Administration of Medical Services of Puerto Rico Deputy Secretary Assistant Secretariat of Administration Office of Planning, Operations and Statistics Office of Inspector General Office of Internal Audits Office of Legal Services Office of Federal Affairs Office of Communications Assistant Secretariat of Regulations and Accreditations of Health Facilities Assistant Secretariat of Medical Emergencies Assistant Secretariat of Health Education Assistant Secretariat of Preventive Medicine and Family Health Assistant Secretariat of Environmental Health Assistant Secretariat of Nursing Assistant Secretariat of Mental Health Puerto Rico Forensic Institute of Psychiatry Office of Women, Infants and Children Office of Economic Assistance and Medically Indigent Demographic Registry Office of Regulations and Certifications of Health Professionals Health Services for Correctional Facilities Sexually Transmitted Diseases Laboratory Services Administration of Health Facilities and Services Health Regions 2Types of Local Health Departments by Jurisdiction Puerto Rico, 1990 Jurisdiction C San Juan X C = City HD 1FEDERATED STATES OF MICRONESIA -- CHUUK STATE 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1987)* 49,365 243,416,000 Population Density (1987)* 1,004.0 68.8 (per/sq.mi.) Number of counties 00 3,139 Median Age (1987)* 16.0 31.7 Percent Below Poverty Level (1985) NA 14.0 (persons) Percent of Population Rural (1980)* 90.0 26.0 Percent of Population White (1980)* 1.0 83.1 Percent of Population Non-white (1980)* 99.0 16.9 Median Years of Education (1980) NA 12.5 (25 years of age and over) B. Location, Geography, and People The Federated States of Micronesia (FSM) is part of the archipelago of the Caroline Islands. Chuuk (formerly Truk) is located about 600 miles southeast of Guam. The state of Chuuk is made up of volcanic islands which are centrally located in the lagoon of Chuuk atoll and the outer island atolls which are divided into the Hall Islands, the Mortlocks and the southwestern atolls. The entire land mass of the state is about 45 square miles. C. National and State Government Structure In 1982 the United States signed a Compact of Free Association with the FSM. Since that time FSM has been referred to as a freely associated state. FSM is made up of four states: Yap, Chuuk, Pohnpei, and Kosrae. The national government is located on Pohnpei and consists of executive, legislative, and judicial branches. A President and Vice-president make up the executive branch. The legislative branch consists of a bicameral legislature. * These data are provided by the SHA. Data for this territory were revised December 1990. The state of Chuuk has a bicameral legislature made up of a Senate (10 members) and a House of Representatives (28 members), with all members elected for 4-year staggered terms. Chuuk also has an elected Governor. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Chuuk Department of Health Services (CDHS) is the primary health agency for the state. Health services are centralized to the Chuuk State Hospital which is located on the Island of Moen and a "super-dispensary" in the Mortlock Islands. There are 62 dispensaries scattered throughout the state. They range from one dispensary on the smaller islands to five on the bigger island in the Chuuk Lagoon. Most of the inhabited islands have dispensaries which provide the population with basic health care. Field trip services are provided to the outer islands approximately every 6 weeks or on an emergency basis. Information about the structure of the FSM National Health Agency and its relationship to the SHA was not available at the time of printing. B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Secretary of the Department of Human Resources is the head of the health agency for FSM, and the Director of Health Services is the head of the health agency for the state of Chuuk. C. State Board of Health/Council Chuuk State does not have a state board of health. D. Regional/District Health Offices Dispensaries are scattered throughout the state, but no offices are designated as regional or district offices. E. State-local Liaison The CDHS functions as both the state and local health agency, so there is no need for a state-local liaison. F. Budget The CDHS is operated on an annual budget appropriated through the Chuuk State Legislature. The exact amount was not available at the time of printing. 3III. Local Public Health Agencies (LPHAs) A. General Chuuk State has no local health departments. Local public health services are provided by elements of the CDHS. B. Services Provided Services provided by the CDHS include environmental health, health education, communicable disease control, family planning, and child health. C. Local Health Officer Information on the presence and function of local health officers was not available at the time of printing. D. Local Board of Health Chuuk State does not have local boards of health. E. Staff The number of staff employed by the CDHS was not available at the time of printing. F. Budget The budget for local health services was not available at the time of printing. 2Chuuk State Department of Health Services, 1990 Governor Director MHCC Chuuk EPAB Chuuk Assistant Director Hospital Services *Nursing Services Clinical Nursing Public Health Nursing Public Health Clinics Field/Dispensaries Field Teams Health Assistants Midwives Hospital Support Dietary/Food Services Maintenance/Housekeeping Medical Supplies Business Office Medical Support Services X-ray Pharmacy Laboratory Medical Records Dental Health Services Environmental Health Public Health Services Health Education Federal Programs Mental Health Cervical Cancer Detection Family Planning Hypertension Geriatric *Nursing Services (same as Hospital Services) Medical Staff Medical Doctors Medical Officers Medex, Physician Assistants/Extenders 2Types of Local Health Departments by Jurisdiction Chuuk State, 1990 Chuuk State does not have local health departments 1FEDERATED STATES OF MICRONESIA -- KOSRAE STATE 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1987) 6,000 243,416,000 Population Density (1987) 150.0 68.8 (per/sq.mi.) Number of Counties NA 3,139 Median Age (1987) NA 31.7 Percent Below Poverty Level (1985) NA 14.0 (persons) Percent of Population Rural (1980) NA 26.0 Percent of Population White (1980) NA 83.1 Percent of Population Non-white (1980) NA 16.9 Median Years of Education (1980) NA 12.5 (25 years of age and over) B. Location, Geography, and People The Federated States of Micronesia (FSM) is part of the archipelago of the Caroline Islands. Kosrae is located about 350 miles southeast of Pohnpei. The state of Kosrae consists of a single island about 40 square miles in size. The population has primarily a single language and culture, Kosrean. The governmental center, the hospital, the post office, the high school, and the courthouse are located in Tofol of the Lelu municipality. C. National and State Government Structure In 1982 the United States signed a Compact of Free Association with the FSM. Since that time FSM has been referred to as a "freely associated state." FSM is made up of four states: Yap, Chuuk, Pohnpei, and Kosrae. The national government is located on Pohnpei and consists of executive, legislative, and judicial branches. A President and Vice-president make up the executive branch. The legislative branch consists of a bicameral legislature. The state of Kosrae has a unicameral legislature made up of 14 members. The members serve 4-year staggered terms. Two popularly elected Senators represent Kosrae in the FSM Congress. Kosrae also has a popularly elected Governor. Data for this territory are based on the best available information and were updated December 1990. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Department of Health Services is the primary health agency for the state of Kosrae. Other than some services provided by traditional birth attendants, all medical and health care are provided by the government through the Department of Health Services. At the center of this system lies the Kosrae State Hospital, a 35-bed general medical facility. Patients are charged a nominal fee for in-patient and out-patient services. All services (except some basic services provided by public health nurses and the school health program) are provided through the hospital. Information about the structure of the FSM National Health Agency and its relationship to the SHA was not available at the time of printing. B. Head of State Health Agency The Secretary of the Department of Human Resources is the head of the health agency for FSM, and the Director of Health is the head of the health agency for the state of Kosrae. C. State Board of Health/Council Information about the presence and function of a State Board or Council of Health was not available at the time of printing. D. Regional/District Health Offices Kosrae does not have regional or district health offices. E. State-local Liaison Because the State Department of Health functions as both a state and a local health agency, there is no need for a state-local liaison function. F. Budget Budget information for the SHA was not available at the time of printing. 3III. Local Public Health Agencies (LPHAs) A. General Kosrae State has no local health departments. Local public health services are provided by elements of the Kosrae Department of Health Services. B. Services Provided Primary and secondary medical care are available through the state hospital. All clinical services, except for a few basic services provided by nurses through the School Health Program, are provided through the hospital. Patients with complications or those requiring tertiary care are referred to Pohnpei, then to Guam or Honolulu. The following are some of the services provided by the outpatient clinics: General Medical Clinics Communicable Disease Control Health Education Services Laboratory Services Well-child Clinics Prenatal Clinics Postnatal Clinics Family Planning Diabetes Clinics Hypertension Services Pediatric and Obstetrical Supervision Dental Services Dental Health Education Immunizations Services to Elderly Teams of public health nurses conduct weekly visits to communities and provide well-baby clinics, immunizations, postnatal follow-ups, basic clinical services, and services to the elderly. C. Local Health Officer Kosrae does not have local health officers. D. Local Board of Health Information about the presence or function of local boards or councils of health was not available at the time of printing. E. Staff The number of staff employed by the Kosrae State Department of Health Services was not available at the time of printing. F. Budget The budget for local health services was not available at the time of printing. 2Kosrae State Department of Health Services, 1990 Director Hospital Division Nursing Services Medical Services Support Services Sanitation Division Food/Water Sanitation Public Facility Coastal Area Monitoring Plane/Ship Inspections Village Inspections Dental Division Preventive Dental Clinical Services Public Health Division Preventive Programs Clinical Programs 2Types of Local Health Departments by Jurisdiction Kosrae State, 1990 Kosrae State does not have local health departments 1FEDERATED STATES OF MICRONESIA -- POHNPEI STATE 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1985)* 28,671 (1987) 243,416,000 Population Density (1985) 197.7 68.8 (per/sq.mi.) Number of Counties NA 3,139 Median Age (1985)* 15.9 (1987) 31.7 Percent Below Poverty Level (1985) NA 14.0 (persons) Percent of Population Rural (1985)* 79.0 (1980) 26.0 Percent of Population White (1980)* 00.9 83.1 Percent of Population Non-white (1980)* 95.0 16.9 Median Years of Education (1980) NA 12.5 (25 years of age and over) B. Location, Geography, and People The Federated States of Micronesia (FSM) is part of the archipelago of the Caroline Islands. The state of Pohnpei is located about 450 miles east of Chuuk (formerly known as Truk) and 2,600 miles west of Hawaii. Pohnpei is made up of a high volcanic island and eight atolls. The land mass is 145 square miles. Pohnpei has three distinct Micronesian cultural groups which include Ponapeans, Mokilese, and Pingelapese. Pohnpei State serves as the administrative center for the state government and for the national government of FSM. C. National and State Government Structure In 1982 the United States signed a Compact of Free Association with FSM. Since that time FSM has been referred to as a freely associated state. FSM is made up of four states: Yap, Chuuk, Pohnpei, and Kosrae. The national government is located on Pohnpei and consists of executive, legislative and judicial branches. The President and Vice-president make up the executive branch. The legislative branch consists of a bicameral legislature. * These data were provided by the SHA. Data for this territory were updated January 1991. The state of Pohnpei has a uicameral legislature made up of 27 members. The members are elected for 4-year staggered terms. Pohnpei also has a Governor. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Pohnpei Department of Health Services (PDHS) is the primary health agency. Health services are centralized to the 116-bed Pohnpei State Hospital. In addition to the hospital 22 dispensaries, staffed by mobile health teams, provide public health services. Private medicine is not available in Pohnpei. Information about the structure of the FSM National Health Agency and its relationship to the SHA was unavailable at the time of printing. B. Head of State Health Agency The Secretary of the Department of Human Resources is the head of the health agency for FSM and the State Director of Health Services is the head of the health agency for the state of Pohnpei. Information about the requirements of the position and means of appointment were not available at the time of printing. C. State Board of Health/Council Information about the presence and function of a State Board or Council of Health was not available at the time of printing. D. Regional/District Health Offices Twenty-two dispensaries are distributed throughout the state, but these are service units. E. State-local Liaison Because the Department of Health Services functions as both a state and a local health agency, there is no need for a state-local liaison function. F. Budget Budget information on the Department of Health Services was not available at the time of printing. 3III. Local Public Health Agencies (LPHAs) A. General Pohnpei has no local health departments. Local public health services are provided by elements of the PDHS. B. Services Provided Services provided by Pohnpei State Hospital include obstetrics and gynecology, internal medicine, orthopedics, pediatrics, surgery, eye problems, dental care, and maternal and child health. Patients pay a small fee for both in-patient and out-patient services. This source of income accounts for approximately one-fourth of the annual health budget. C. Local Health Officer Information about local health officers was not available at the time of printing. D. Local Board of Health Information about the presence and function of local boards of health was not available at the time of printing. E. Staff The number of staff employed by the PDHS was not available at the time of printing. F. Budget The budget for all local health services was not available at the time of printing. 2Pohnpei State Department of Health Sevices, 1990 Director Chief, Administration Division Management and Admin. Services Medical Record/Vital Statistics Fiscal Services Dietary and Food Services Personnel Services Laundry Services Budget and Finance Housekeeping and Janitorial Procurement and Supply Training and Employee Development Security Services Health Planning Ambulance Services Chief, Medical Services Professional Services X-ray Services Pharmacy Services Laboratory Services Anesthesia Hemodialysis Special Clinics Nursing Services In-patient Operation and Recovery Labor and Delivery Physio-therapy Emergency Services Medical Referrals CRS Services Chief, Public Health Division Maternal and Child Health Communicable Diseases Health Education and Nutrition Special Clinics Drug/Alcohol and Mental Health Sanitation and EPA Public Health Nursing Services Personnel and Admin. Services Primary Health Care (CHC) Disp. Chief, Dental Division Dental Preventive Services Elementary School Program Dental Health Education Dental Dispensary Services Dental Clinics Dental Laboratory Services Dental Headstart Services Dental Old-age Services CDC Services Dental Nursing Services Dental X-ray Services Personnel and Admin. Services Types of Local Health Departments by Jurisdiction Phonpei State, 1990 Pohnpei State does not have local health departments 1FEDERATED STATES OF MICRONESIA -- YAP STATE 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators State United States Population (1987) 10,200 243,416,000 Population Density (1987) 85.7 68.8 (per/sq.mi.) Number of Counties NA 3,139 Median Age (1987) NA 31.7 Percent Below Poverty Level (1985) NA 14.0 (persons) Percent of Population Rural (1980) NA 26.0 Percent of Population White (1980) NA 83.1 Percent of Population Non-white (1980) NA 16.9 Median Years of Education (1980) NA 12.5 (25 years of age and over) B. Location, Geography, and People The Federated States of Micronesia (FSM) is part of the archipelago of the Caroline Islands. Yap proper is located about 550 miles southwest of Guam. The state of Yap is made up of the Island of Yap and several inhabited atolls which extend as far as 600 miles to the east. The population of Yap and the outer islands is culturally and linguistically different. Two-thirds of the population of the state resides on the Island of Yap. C. National and State Government Structure In 1982 the United States signed a Compact of Free Association with FSM. Since that time FSM has been referred to as a freely associated state. FSM is made up of four states: Yap, Chuuk, Pohnpei, and Kosrae. The national government is located on Pohnpei and consists of executive, legislative, and judicial branches. A President and Vice-president make up the executive branch. The legislative branch consists of a bicameral legislature. The state of Yap has a unicameral legislature made up of 10 members who serve 4-year terms. Six members are elected from the Yap Islands proper and four are elected from the outer islands. Yap also has a Governor. Data for this territory were updated January 1991. 3II. State Health Agency (SHA) A. General Free-standing, Independent The Department of Health Services is the primary health agency for the state of Yap. Health services are centralized to the Yap State Hospital which is located on the Island of Yap. Dispensaries are located on most of the outer islands, manned by health assistants and physician assistants. Traveling medical services called "field trip services" provide care and supplies to these islands every 4 to 6 weeks. Patients with needs beyond the capacity of the dispensaries are evacuated to the hospital on Yap. Information about the structure of the FSM National Health Agency and its relationship with the SHA was not available at the time of printing. B. Head of State Health Agency No M.D. Requirement, Cabinet-level Appointment The Secretary of the Department of Human Resources is the head of the health agency for FSM and the Director of Health is the head of the health agency for the state of Yap. The Director is appointed by the Governor and approved by the State Legislature. C. State Board of Health/Council Information about the presence and function of a state board or council of health was not available at the time of printing. D. Regional/District Health Offices Dispensaries are located on many of the outer islands, but these are strictly service units. E. State-local Liaison The State Department of Health functions as both the state and local health agency, so there is no need for a state-local liaison. F. Budget Total FY 1991 Yap SHA budget is $1,900,000*. Total FY 1988 United States SHA expenditures were $8,312,928,000. The Yap budget data were provided by the SHA. *These data were provided by the SHA. 3III. Local Public Health Agencies (LPHAs) A. General Yap State has no local health departments. Local public health services are provided by elements of the Yap State Department of Health. B. Services Provided Services provided by the Department include environmental health, health education, communicable disease control, family planning, maternal and child health, and prenatal care. C. Local Health Officer Information about the presence and function of local health officers was not available at the time of printing. D. Local Board of Health Yap does not have local boards of health. E. Staff The number of staff employed by the Yap State Department of Health was not available at the time of printing. F. Budget The budget for all local health services is included within the budget for the SHA. 2Yap State Department of Health Services, 1990 Director Board of Health Assistant Director Administrative Support Division of Public Health Primary Health Care Programs Mental Health Care Programs Dispensary Programs Special Programs Regular Clinics Division of Clinical Care Out-patient Services In-patient Services Continuing Education Emergency Services Physical Therapy Labor and Delivery Surgical Unit Security Division of Dental Health Clinical Services Community Services Sub-Dental Clinics Field Programs Division of Ancillary Services Medical Records Medical Supply Maintenance Laboratory Laundry Kitchen X-ray 2Types of Local Health Departments by Jurisdiction Yap State, 1990 Yap State does not have local health departments 1GUAM 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators Territory United States Population (1990)* 132,726 (1988) 245,803,000 Population Density (1990)* 635.1 (1988) 69.4 (per/sq.mi.) Number of Counties NA 3,139 Median Age (1980)* 22.3 31.7 Percent Below Poverty Level (1990)* 8.0 (1985) 14.0 (persons) Percent of Population Rural (1980) 60.5 26.0 Percent of Population White (1980)* 25.4 83.1 Percent of Population Non-white (1980)* 74.6 16.9 Median Years of Education (1980)* 12.5 12.5 (25 years of age and over) B. Location, Geography, and People The southernmost of the Mariana Islands and located in the west central Pacific, Guam is about 1,500 miles east of the Philippines, 1,350 miles south of Tokyo, and 3,300 miles west of Honolulu. The territory consists of a single island that is 30 miles long and 4 to 8 miles wide totaling 209 square miles. The native and predominant population of the island is Chamorros. C. Territorial Government Structure Guam is an unincorporated territory of the United States. The government consists of executive, legislative, and judicial branches. The legislative branch is made up of a 21-member unicameral legislature. The legislature is elected to 2-year terms and is responsible primarily for internal affairs. Guam has a non-voting delegate to the U.S. House of Representatives who is elected by popular vote every 2 years. The executive branch is made up of the Governor, Lieutenant Governor, and executive department. The Governor and Lieutenant Governor are elected by popular vote and serve 4-year terms. * These data and total FY 1990 Guam expenditures were provided by the SHA. Data for this territory were updated January 1991. 3II. State Health Agency (SHA) A. General Component of Superagency The Guam Department of Public Health and Social Services (GDPHSS) is the primary health agency for the territory. It serves as the State Health Agency as well as the provider of local health services. The GDPHSS has four divisions which perform its major functions: Environmental Health, Senior Citizens, Public Health, and Public Welfare Division. The Department is authorized and funded by both Federal and local jurisdictions. GDPHSS provides basic public health and medical services to approximately 10,000 residents per month through three regional health centers. Several other governmental agencies are providing services related to health care. The recently reactivated Guam Health Planning and Development Agency is a distinct and separate department which will serve as the government's primary planning unit for health services. The Environmental Protection Agency shares many surveillance and monitoring activities with the Division of Public Health and the Division of Environmental Health. The Guam Fire Department operates the emergency medical services system, but central planning and administration are vested in the GDPHSS. B. Head of State Health Agency No M.D. Requirement, Not Cabinet-level Appointment The Director of GDPHSS is the head of the territorial health agency. C. State Board of Health/Council Guam does not have a state board of health. D. Regional/District Health Offices Health services are provided through three regional health centers: in Inaranjan village in the southern area of the island; in Mangilao in the central area; and in Dededo in the northern area. E. State-local Liaison Because the GDPHSS functions as both a state and a local health agency, there is no need for a state-local liaison. F. Budget Total FY 1990 Guam SHA expenditures were $8,252,300. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $3,138,875 State Funds $5,113,425 Local Funds 0 Fees and Reimbursements $363,699 Other 0 3III. Local Public Health Agencies (LPHAs) A. General GDPHSS serves as both the territorial and local public health department. B. Services Provided All of the regional health centers provide maternal and child health, family planning, chronic disease prevention and control, generalized community health nursing, dental, pharmacy, nutrition, and health education. In addition, the central and southern centers provide x-ray and laboratory services. Services to children with special health care needs and for communicable disease control are available only at the central center. The Southern Regional Community Health Center in Inarajan is the only facility funded as a community health center under Section 330 of the Public Health Service Act. This center provides comprehensive primary care on a fee-for-service basis adjusted for patient's ability to pay. C. Local Health Officer Information about the presence and function of local health officers was not available at the time of printing. D. Local Board of Health Information about the presence and function of local boards of health was not available at the time of printing. E. Staff Staff of GDPHSS are employed and supervised by the central agency. F. Budget The budget for all local health services is included within the budget for the SHA. 2Guam Department of Public Health and Social Services, 1990 Director Physician Services Office of Planning and Evaluation Office of Vital Statistics Health Info. Systems Office of Epidemiology and Research Bureau of Community Health Services Chronic Disease Prevention and Control Dental Health Services Nutrition Health Services Speech and Hearing Bureau of Communicable Disease Control Enteric Disease and Foreign Quarantine Immunization Sexually Transmitted Diseases and AIDS Tuberculosis Bureau of Family Health and Nursing Services Home Care Services Maternal Child Health Services Central Region Housing Services Northern Region Housing Services Southern Region Housing Services Bureau of Professional Support Services Emergency Medical Services Health Education Laboratory Medical Support Services Pharmacy Medical Records X-rays Medical Social Services Biomedical Equipment Maintenance Southern Region Community Health Center Community Outreach Program Medical Services 2Types of Local Health Departments by Jurisdiction Guam, 1990 Guam does not have local health departments 1REPUBLIC OF THE MARSHALL ISLANDS 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators Republic United States Population (1988) 43,355 245,803,000 Population Density (1988) 656.9 69.4 (per/sq.mi.) Number of Counties NA 3,139 Median Age (1987) NA 31.7 Percent Below Poverty Level (1985) NA 14.0 Percent of Population Rural (1980) NA 26.0 Percent of Population White (1980) NA 83.1 Percent of Population Non-white (1980) NA 16.9 Median Years of Education (1980) NA 12.5 (25 years of age and over) B. Location, Geography, and People The Republic of the Marshall Islands is located in an area of the Pacific Ocean known as Micronesia. The islands are about 2,000 miles southwest of Hawaii and about 1,300 miles southeast of Guam. The Marshall "Islands" are made up of two chains of atolls. These chains have 29 low-lying coral atolls and 5 low-lying coral islands. Atolls consist of loosely connected coral masses which ring a central lagoon. The lagoons may be only a few miles across or massive in their breadth. Although the islands which comprise the atoll chain are usually considerable distances apart, some are sufficiently close to walk between them at low tide. The republic consists of 66 square miles of land mass. The population is distributed unevenly over 24 populated atolls and 2 small islands. The islands are only a few feet above sea level and most are less than 15 miles in length and 400 yards in width. None of the islands have sufficient space for more than two parallel roads on the atoll. On most islands the population lives on either side of a single road or street. C. Republic Government Structure The Republic of the Marshall Islands and the United States signed a Compact of Free Association in 1982. Since that time the Data for this territory are based on the best available information and were updated December 1990. political relationship of the Republic of the Marshall Islands with the United States has been as a freely associated state. The Republic has a President who is elected by the Legislature from among its own members. The legislative branch of government is a unicameral legislature (the Nitijela) that has 33 members. 3II. State Health Agency (SHA) A. General The Republic of the Marshall Islands Department of Health Services (RMIDHS) is the SHA. Almost all medical and health care is provided by the government through this agency. The principal facility is an 81-bed acute care hospital in Majuro. A second 22-bed hospital is located on Ebeye in the Kwajalein Atoll. Management staff for all medical, dental, and public health services are located at these facilities. In addition, most out-patient clinics, emergency medical services, and public health clinics are at these two locations. There are, however, 60 dispensaries located on 25 outer islands. Health assistants staff the clinic, often living in the facility. These individuals are trained to provide basic medical care for common illnesses, diseases, and minor injuries. Patients who need more sophisticated care than that available at the dispensaries must be transferred to one of the hospitals. B. Head of State Health Agency The Minister of Health is a cabinet-level officer responsible for public health. The Secretary of Health Services is the chief executive for operating health services. The only other administrative officer is a health services administrator who reports directly to these officials. C. State Board of Health/Council Information on the presence and function of a territorial board or council of health was not available at the time of printing. D. Regional/District Health Offices The Republic of the Marshall Islands does not have regional or district health offices. E. State-local Liaison The RMIDHS functions as both a state and a local health agency, thereby eliminating need for a state-local liaison function. F. Budget No budget information for the SHA was available at the time of printing. 3III. Local Public Health Agencies (LPHAs) A. General The Republic of the Marshall Islands does not have local health departments but provides public health services through the SHA. B. Services Provided Hospitals provide general medical and surgical care, pediatric and obstetrical care. General clinical laboratory, radiological and pharmacy services support both in- and out-patient care. Rehabilitative services are available at the Majuro Hospital. Public health services include prenatal, well-baby, and child health services including immunizations. Environmental health services, which include surveillance over water quality and food sanitation, are also provided. Public health dentistry is limited to clinical dentistry, with much of the care provided by dental nurses. Health education activities are limited to those that can be supported by one individual. Rudimentary vital statistics are kept. Communicable disease investigations, screening, and casefinding for some chronic diseases are performed on a limited basis by public health nurses. C. Local Health Officer Information about the presence or function of local health officers was not available at the time of printing. D. Local Board of Health The Republic of the Marshall Islands does not have local boards of health. E. Staff Public health staff are employed and supervised by the Department of Health Services. F. Budget The budget for local health services was not available at the time of printing. 2Marshall Islands Department of health Services, 1990 At time of printing, organizational chart was not available. Figure 120 Types of Local Health Departments by Jurisdiction Republic of the Marshall Islands, 1990 Republic of the Marshall Islands does not have local health departments 1REPUBLIC OF PALAU 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators Republic United States Population (1987) 14,000 243,416,000 Population Density (1987) 81.4 68.8 (per/sq.mi.) Number of Counties NA 3,139 Median Age (1987) NA 31.7 Percent Below Poverty Level (1988)* 88.0 (1985) 14.0 (persons) Percent of Population Rural (1988)* 21.0 (1980) 26.0 Percent of Population White (1986)* 1.5 (1980) 83.1 Percent of Population Non-white (1986)* 98.5 (1980) 16.9 Median Years of Education (1980) NA 12.5 (25 years of age and over) B. Location, Geography, and People The Republic of Palau is made up of approximately 200 small volcanic and limestone islands which are part of the Caroline Island Chain. The total land mass is 172 square miles. Palau lies about 7 degrees, 30 minutes north of the equator. The Philippines are about 600 miles to the west and Guam is 900 miles to the northeast. Only about eight of the islands are inhabited. Although most of the native population is of Western Carolinian extraction, a small but growing group of aliens and individuals from the United States reside in Palau. Some blending of ethnicities and cultures has occurred, but the islanders have retained many of their traditional characteristics such as strong matrilineal clan kinship ties and hierarchial rank system. C. Republic Government Structure The Republic of Palau is functioning as a "Freely Associated State" in its relationship with the United States. Several referenda on a Compact of Free Association were approved by the electorate, but not by the 75-percent vote required by the constitution. Therefore, technically Palau is the last remaining * These data were provided by the SHA. Data for this territory were revised January 1991. part of the Trust Territory of the Pacific Islands which is a United Nations Trusteeship, administered by the United States. Under the trusteeship, executive and administrative authority are given to a High Commissioner. The Commissioner is appointed by the President of the United States with consent and approval of the United States Senate. Palau drafted and approved a local constitution in 1981 which formed the Republic of Palau. Under this constitution, the role of the High Commissioner was amended to provide for local self-government. The Republic has a President and Vice-president who are elected by popular vote for 4-year terms. The Palau National Congress is the legislative body, consisting of a Senate and House of Delegates. The Republic is divided into 16 states, each with an elected Governor and legislature. 3II. State Health Agency (SHA) A. General The Ministry of Health is the primary health agency for the Republic of Palau. Most medical and health care in the Republic of Palau is provided by the government and administered through the Ministry of Health. The principal acute-care facility in Palau is the 65-bed MacDonald Memorial Hospital, limited to primary and secondary care. The hospital also houses all administrative and public health offices. Government-sponsored dispensaries are located in 13 outlying areas. Eleven dispensaries are located in the intermediate islands. Only nine are staffed, either full-time or part-time. Three dispensaries are located on the outer islands, but only two are staffed full-time. The facilities offer a limited range of basic medical services. Public health services are also provided to other areas through scheduled medical field trips. Patients requiring more specialized care are referred to the hospital at Koror. Patients who require treatment beyond the capabilities of the local facilities are referred to hospitals on Guam, Hawaii, the Philippines or United States mainland. B. Head of State Health Agency New legislation has established a Ministry of Health, with the Minister as head of the SHA. C. State Board of Health/Council Formerly, a Health Planning Council existed but is now defunct. Many of the responsibilities are now carried out by the Board of Directors of the Palau Community Health Center, a component of the Bureau of Health Services. This body is responsible for health policy-making with a preventive approach. D. Regional/District Health Offices Palau has no regional health offices. The Ministry of Health is responsible for providing of all health services through regional dispensaries. E. State-local Liaison National-state liaison is not a problem because all health services are provided by the national government. F. Budget Public health activities are predominately supported by U.S. Federal grants with minor grants, coming from the Palauan Government Budget. These average $1.2 million annually, although support for facilities and some personnel is also included in the $2.3 million annual budget for MacDonald Memorial Hospital*. 3III. Local Public Health Agencies (LPHAs) A. General The Republic of Palau has no local health departments. Local public health services are provided by elements of the Palau Ministry of Health. B. Services Provided The Division of Primary Health (preventive services) provides a range of still-evolving services at out-patient clinics held at the hospital, and to a lesser extent, at the various outlying dispensaries. These services include, but are not limited to, maternal and child care, crippled children services, hypertension screening and protection, communicable disease control, cancer detection, vector control, consumer protection, and community hygiene. C. Local Health Officer Information about the presence and function of local health officers was not available at the time of printing. * These data were provided by the SHA. D. Local Board of Health Information about the presence and function of local boards of health was not available at the time of printing. E. Staff The number of staff employed by the Ministry of Health Services was not available at the time of printing. F. Budget The budget for all local health services is included within the budget for the SHA. 2Republic of Palau Bureau of Health Services, 1990 At time of printing, State Health Agency undergoing reorganization. 2Types of Local Health Departments by Jurisdiction Republic of Palau, 1990 Republic of Palau does not have local health departments 1UNITED STATES VIRGIN ISLANDS 2Public Health System Profile 3I. General State Information A. Selected Sociodemographic Indicators Territory United States Population (1988)* 106,000 245,803,000 Population Density (1988)* 779.4 69.4 (per/sq.mi.) Number of Counties 00 3139 Median Age (1989)* 27.0 (1987) 31.7 Percent Below Poverty Level (1989)* 23.0 (1985) 14.0 (persons) Percent of Population Rural (1980)* 100.0 26.0 Percent of Population White (1980)* 15.6 83.1 Percent of Population Non-white (1980)* 84.2 16.9 Median Years of Education (1980)* 12.0 12.5 (25 years of age and over) B. Location, Geography, and People The territory of the U.S. Virgin Islands is made up of three main inhabited (St. Croix, St. Thomas, and St. John) islands and about 50 small mostly uninhabited islands. The location of the territory is the Caribbean Sea about 40 miles east of Puerto Rico and at the eastern end of the Greater Antilles. The territory has a combined land mass of approximately 137 square miles. The Virgin Islands were originally inhabited by Carib and Arawak Indians. After discovery by Europeans in 1493 the islands were controlled by the English, French, Dutch, and the western islands colonized by Denmark. The people of the U.S. Virgin Islands, however, are predominately of African descent. English is the official language but Spanish and Creole have wide usage. C. Territorial Government Structure The U.S. Virgin Islands is an unincorporated territory of the United States. The Capitol is Charlotte Amalie, on the Island of St. Thomas. The islands have been associated with the United States since they were purchased from Denmark in 1917. * These data were provided by the SHA. The data for this territory were updated February 1991. The government of the U.S. Virgin Islands consists of a Governor, a Lieutenant Governor, and a unicameral legislature. The legislature is made up of 15 Senators who are elected by popular vote. Since 1973 the territory has sent a non-voting delegate to the U.S. House of Representatives. 3II. State Health Agency (SHA) A. General Free-standing, Independent The U.S. Virgin Island Department of Health is a free-standing independent agency that serves as the SHA. It is the second largest government department, owning nearly all of the health facilities and providing most of the health care services. It serves as the SHA and local health agency. The U.S. Virgin Island Department of Health is responsible for providing comprehensive quality care, including health education, to all residents of the U.S. Virgin Islands, especially the under-insured, uninsured, and poor. B. Head of State Health Agency M.D. Requirement, Cabinet-level Appointment The U.S. Virgin Islands Department of Health is directed by the Commissioner of Health who is appointed by the Governor of the U.S. Virgin Islands and approved by the U.S. Virgin Islands Legislature. C. State Board of Health/Council Presently, no boards are assigned to the Department of Health. The rural health centers on two islands, however, do have boards with members appointed by the Governor. D. Regional/District Health Offices St. Croix and St. Thomas have three districts on each island (East District, Mid-Island, and West Districts). St. John has two districts (Cruz Bay and Coral Bay). E. State-Local Liaison The U.S. Virgin Islands Department of Health functions as the territorial and local health department, so there is no need for a liaison function. F. Budget Total FY 1989 U.S. Virgin Islands SHA expenditures were $91,888,542. Total FY 1988 United States SHA expenditures were $8,312,928,000. Source of Funds Federal Grants and Contracts $897,684 State Funds $90,990,858 Local Funds 0 Fees and Reimbursements $0,000,000 Other $000,000 3III. Local Public Health Agencies (LPHAs) A. General The U.S. Virgin Islands has no local health departments. Local public health services are provided by elements of the Virgin Islands Department of Health. B. Services Provided The following information on local health services was provided by the U.S. Virgin Islands Department of Health. Since the U.S. Virgin Islands has no local health departments, the SHA is responsible for all local health services. Responsibility for some of the services listed below, however, are shared by the Department of Health and other departments. The percentage indicates the portion of responsibility for the service residing with the Department of Health. Services Provided Percent of Service I. Assessment Activities A. Data Collection/Analysis 1. Behavioral Risk Assessment (100.0%) 2. Morbidity Data (100.0%) 3. Reportable Diseases (100.0%) 4. Vital Records and Statistics (100.0%) B. Epidemiology/Surveillance 1. Chronic Diseases (100.0%) 2. Communicable Diseases (100.0%) II. Policy Development A. Health Code Dev. and Enforcement (100.0%) B. Health Planning (100.0%) C. Priority Setting (100.0%) III. Assurance Activities A. Inspection 1. Food and Milk Control (100.0%) 2. Health Facility Safety/Quality (100.0%) 3. Rec. Facility Safety/Quality (100.0%) 4. Other Facility Safety/Quality (100.0%) B. Licensing 1. Health Facilities (100.0%) 2. Other Facilities (100.0%) C. Health Education (100.0%) D. Environmental 1. Air Quality ( 0.0%) 2. Hazardous Waste Management ( 50.0%) 3. Individual Water Supply Safety (100.0%) 4. Noise Pollution ( 0.0%) 5. Occupational Health and Safety ( 0.0%) 6. Public Water Supply Safety ( 0.0%) 7. Radiation Control ( 0.0%) 8. Sewage Disposal Systems (100.0%) 9. Solid Waste Management ( 50.0%) 10. Vector and Animal Control (100.0%) 11. Water Pollution ( 50.0%) E. Personal Health Services 1. AIDS Testing and Counseling (100.0%) 2. Alcohol Abuse (100.0%) 3. Child Health (100.0%) 4. Chronic Diseases (100.0%) 5. Dental Health (100.0%) 6. Drug Abuse (100.0%) 7. Emergency Medical Service (100.0%) 8. Family Planning (100.0%) 9. Handicapped Children (100.0%) 10. Home Health Care (100.0%) 11. Hospitals ( 0.0%) 12. Immunizations (100.0%) 13. Laboratory Services ( 0.0%) 14. Long-term Care Facilities ( 0.0%) 15. Mental Health (100.0%) 16. Obstetrical Care (100.0%) 17. Prenatal Care (100.0%) 18. Primary Care (100.0%) 19. Sexually Transmitted Diseases (100.0%) 20. Tuberculosis (100.0%) 21. WIC (100.0%) C. Local Health Officer M.D. Requirement, Gubernatorial Appointment Two District Health Officers are appointed to the Division of Prevention Health Promotion and Protection, one of which is responsible for St. Thomas and St. John Islands and the other is responsible for St. Croix. They report to the Assistant Commissioner of Prevention, Health Promotion and Protection (PHPP). They assist the Assistant Commissioner of PHPP in investigating possible outbreaks of diseases and in preventing epidemics at high-risk times. They are recommended by the Assistant Commissioner of PHPP, approved by the Commissioner of Health and appointed by the Governor. D. Local Board of Health The United States Virgin Islands does not have local boards of health. E. Staff The number of staff employed by the U.S. Virgin Islands Department of Health is 794. F. Budget The budget for all local health services is included within the budget for the SHA. 2United States Virgin Islands Department of Health, 1990 Commissioner of Health Territorial Assistant Commissioner Marketing Services Computer and Communications Risk Management Health Professions Institute Emergency Medical Services Deputy Commissioner Planning Assistant Commissioner Operations Renovations Project Deputy Commissioner Financial Services Deputy Commissioner Administrative Services Administrator Health Services St. John, U.S.V.I. Assistant Commissioner PHPP WIC/Nutrition Services Mental Health Services Alcohol/Drug Dependency Medical Assistance Health Education Environmental Health Dental Health Services Assistant Commissioner PHPP Community Health MCH and CSHCN Program Family Planning Program East End Family Health Center Frederiksted Health Center Public Health Nursing Bureau of Rehabilitation Social Services St. John Health Services 2Types of Local Health Departments by Jurisdiction United States Virgin Islands, 1990 The United States Virgin Islands do not have local health departments 1LIST OF TABLES Table S-1 Responsibilities of State Health Agencies ... 10 (SHAs) in 50 states and the District of Columbia, 1990. Table S-2 Assessment and policy development: .......... 11 activities reported by 2,269 local public health agencies (LPHAs), 1990. Table S-3 Assurance: inspection, licensing, health .... 12 education, and environmental activities reported by 2,269 local public health agencies (LPHAs), 1990. Table S-4 Assurance of personal health services: ...... 13 activities reported by 2,269 local public health agencies (LPHAs), 1990. Table S-5 Ten organizational practices or processes ... 14 that must be carried out by a component of the public health system in each locality. 1ACKNOWLEDGMENTS Completion of these profiles is due in a large part to the information and assistance provided by state and territorial public health officials. The following public health officials provided information and assistance: Alabama Michael Mann, Director, Planning and Evaluation Branch, Office of Management Services, Alabama Department of Health Alaska Alfred G. Zangri, Acting Director, Division of Public Health, Alaska Department of Health and Social Services Arizona Vanessa Nelson Hill, Chief, Office of Local Health Services, Arizona Department of Health Services Arkansas James L. Mills, Director, Bureau of Community Health Services, Arkansas Department of Health California Alan Oppenheim, Research Program Specialist, Office of County Health Services and Local Public Health Assistance, California Department of Health Services Colorado Roger Donahue, Director, Local Health Services, Colorado Department of Health Connecticut Judy Sartucci, Director, Office of Local Health Administration, Connecticut Department of Health Services Delaware Lyman T. Olsen, M.D., Medical Director, Division of Public Health, Delaware Department of Health and Social Services District of Carlessia A. Hussein, D.P.H., Deputy Columbia Commissioner, District of Columbia Commission of Public Health John Heath, Chief, Sexually Transmitted Disease Epidemiology Service, District of Columbia Commission of Public Health Florida Phillip Street, Analyst, State Health Office, Department of Health and Rehabilitative Services Georgia Sarah Price, Budget Officer, Administrative Services, Division of Public Health, Georgia Department of Human Resources Carol E. Harris, Grant-in-Aid Budget Officer, Division of Public Health, Georgia Department of Human Resources Hawaii Fay Nakamoto, Assistant to Director, Hawaii Department of Health Idaho Jane S. Smith, R.N., Chief, Bureau of Preventive Medicine, Division of Public Health, Idaho Department of Health and Welfare Diane Bowen, Supervisor, Office of Health Policy and Resource Development, Division of Health, Idaho Department of Health and Welfare Illinois George S. Rudis, Chief, Division of Local Health Administration, Office of Administrative Services, Illinois Department of Public Health Indiana James L. Rice, Director, Division of Local Support Services, Indiana State Board of Health Iowa Ronald Eckoff, M.D., M.P.H., Acting Director, Iowa Department of Public Health Kansas Connie Hanson, R.N., M.S., Director, Special Services Section, Bureau of Local Health Services, Kansas Department of Health and Environment Garth Hulse, B.A., Management Analyst, Office of Local and Rural Health Systems, Kansas Department of Health and Environment Kentucky James T. Corum, D.M.D., Director, Division of Local Health, Department of Health Services, Kentucky Cabinet for Human Resources Lynn Owens, Public Health Administrator, Division of Local Health, Department of Health Services, Kentucky Cabinet for Human Resources Louisiana Miguel Zuniga, M.D., Health Services Planner/Resident, Louisiana Department of Health and Hospitals Joel L. Nitzkin, M.D., D.P.A., Director, Office of Public Health, Louisiana Department of Health and Hospitals Maine Lani Graham, M.D., M.P.H., Director, Bureau of Health, Maine Department of Human Services Eleanor Bruce, Director of Public Health Nursing, Bureau of Health, Maine Department of Human Services N. Warren Bartlett, M.Div., Assistant Director, Bureau of Health, Maine Department of Human Services Maryland C. Devadason, M.D., D.P.H., Director, Local and Family Health Administration, Maryland Department of Health and Mental Hygiene Massachusetts Gerry E. Desilets, Associate Commissioner, Office of Policy Development and Planning, Massachusetts Department of Public Health Hillel Liebert, Policy Development Coordinator, Office of Planning and Policy Development, Massachusetts Department of Public Health Michigan Carol Ogan, Administrative Assistant, Bureau of Community Services, Michigan Department of Public Health Minnesota Jim Parker, Director, Division of Community Health Services, Minnesota Department of Health Ryan Church, Division of Community Health, Section of Community Development, Minnesota Department of Health Bill Brand, Division of Community Health, Section of Community Development, Minnesota Department of Health Mississippi Randy Caperton, Director, Field Services, Office of the State Health Officer, Mississippi State Department of Health Missouri Mary Lou Gillilan, R.N., Assistant Director, Division of Local Health and Institutional Services, Missouri Department of Health Montana Mike Craig, Health Planning Bureau, Montana Department of Health and Environmental Sciences Nebraska Franklin Harris, Director, Bureau of Community Health Services, Nebraska Department of Health Nevada Ron Lang, Administrative Services Officer, Health Division, Nevada Department of Human Resources New Hampshire John D. Bonds, Assistant Director for Planning, Division of Public Health Services, New Hampshire Department of Health and Human Services New Jersey Andrew D. Miller, M.D., M.P.H., Director Local Health Development Services, New Jersey State Department of Health Anthony Kobylarz, M.P.H., Health Systems Specialist I, Health Aid Services, New Jersey Department of Health New Mexico Alice Boss, Planner, Public Health Division, New Mexico Health Department New York Donald Davidoff, Director of Field Operations, Office of Public Health, New York Department of Health North Carolina Phyllis A. Gray, Special Assistant, State Health Director's Office, North Carolina Department of Environment, Health, and Natural Resources North Dakota LaVerne Lee, Director, Division of Local Health Services and Public Health Nursing, North Dakota State Department of Health Ohio Paul Dalton, Administrative Assistant, Division of Local Services, Bureau of Supportive Services, Ohio Department of Health Oklahoma Jerry R. Nida, M.D., Senior Medical Consultant, Oklahoma State Department of Health Oregon Donna Clark, Assistant Administrator Health Services, MCH Program Director, Oregon Department of Human Resources Pennsylvania William Kcenich, Acting Deputy Secretary for Community Health, Pennsylvania Department of Health and Welfare Rhode Island William Waters Jr., Ph.D., Associate Director of Health, Rhode Island Department of Health South Carolina Jerry Dell Gimarc, Director, Officer of External Affairs, South Carolina Department of Health and Environmental Control South Dakota Jan Smith, Director, Center for Health Policy and Statistics, South Dakota State Department of Health Tennessee Richard Light, M.D., Director, Bureau of Health Services, Tennessee Department of Health and Environment Texas Albert G. Randall, M.D., M.P.H., Associate Commissioner, Community and Rural Health, Texas Department of Health Ann Henry, Health Planner, State Health Data and Policy Analysis, Texas Department of Health Susan R. Griffin, Director, Special Projects for Local Health Services, Community and Rural Health, Texas Department of Health Utah Robert W. Sherwood, Jr., Director, Bureau of Local and Rural Health Services, Division of Community Health Services, Utah Department of Health Vermont Patricia Berry, Director, Local Health Services, Vermont Department of Health Virginia Robert B. Stroube, M.D., M.P.H., Deputy Commissioner for Community Health Services, Virginia Department of Health Washington Eileen Keith, Acting Supervisor, Office of Local Health Support Services, Washington Department of Health John Church, Local Fiscal Consultant, Washington Department of Health Linda Chapman, Public Health Advisor, Office of Local Health Support Services, Washington Department of Health Jim Harris, Public Health Advisor, Office of Local Health Support Services, Washington Department of Health Dan Rubin, Chief, Office of Health Policy Support, Washington Department of Health West Virginia Joan R. Kenny, R.N., M.S., Director, Division of Local Health, West Virginia Department of Health Jim Doria, Administrative Assistant, West Virginia Department of Health and Human Resources Wisconsin George F. MacKenzie, Administrator, Wisconsin Division of Health Mary Erikson, Regional Office Coordinator, Wisconsin Division of Health Wyoming Donna Griffin, R.N., M.S., Management Assistant, Division of Health and Medical Services, Wyoming Department of Health and Social Services American Samoa Charles R. McCuddin, M.P.H., Deputy Director for Planning and Development, American Samoa Department of Health Commonwealth of Northern Mariana Islands Roylinne F. Wada, M.S., M.P.H., Assistant Professor of Public Health and Executive Director, Pacific Island Health Officers Association (PIHOA) Federated States of Micronesia (FSM) FSM, Chuuk State Sanphy William, Acting Director of Health Services, Chuuk State Department of Health Roylinne F. Wada, M.S., M.P.H., Assistant Professor of Public Health and Executive Director, PIHOA FSM, Korsae State Roylinne F. Wada, M.S., M.P.H., Assistant Professor of Public Health and Executive Director, PIHOA FSM, Pohnpei Aminis David, M.O., Director of Health State Services, Pohnpei State Department of Health Services FSM, Yap State Mary Figir, Director, Department of Health Services, Yap State Department of Health Services Roylinne F. Wada, M.S., M.P.H., Assistant Professor of Public Health and Executive Director, PIHOA Guam Leticia V. Espaldon, M.D., Director, Public Health and Social Services, Guam Department of Public Health and Social Services Roylinne F. Wada, M.S., M.P.H., Assistant Professor of Public Health and Executive Director, PIHOA Marshall Islands Roylinne F. Wada, M.S., M.P.H., Assistant Professor of Public Health and Executive Director, PIHOA Republic of Palau Nobuo Swei, M.O., Director, Bureau of Health Services, Republic of Palau Roylinne F. Wada, M.S., M.P.H., Assistant Professor of Public Health and Executive Director, PHIOA Puerto Rico Antonio R. Silva, M.D., Director of the Office of Federal Affairs, Puerto Rico Department of Health Virgin Islands Cora L. E. Christian, M.D., M.P.H., Assistant Commissioner of Health, United States Virgin Islands Overall responsibility for developing the concept, collecting the information, and preparing this document belongs to Edward H. Vaughn of the Division of Public Health Systems, Public Health Practice Program Office, Centers for Disease Control. Special thanks are due to Public Health Practice Program Office staff who participated in this project and made this report possible. Pomeroy Sinnock, the branch chief when the project began, supported the idea of developing profiles of state and territorial public health systems and provided encouragement and guidance during the crucial early phase of the project. Computer graphics for the tables of organization and maps were created primarily by Barbara Rice with some assistance from Tami Laplante and Willie Richardson. Angela Cooper carefully proofread documents and made many useful suggestions for improvements. Philip Thompson, the PHPPO editor, edited the document and provided assistance and suggestions on all aspects of the project. This project is also indebted to Deborah Wachtel, an Association for Schools of Public Health intern during the summer of 1990, for her work in collating information, preparing draft profiles of state public health systems, and providing suggestions which improved the quality of the profiles. 1SELECTED BIBLIOGRAPHY OF SOURCES 1. U.S. Department of Health and Human Services, Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, D.C.: Public Health Service, 1990. 2. Public Health Foundation, Public Health Agencies 1990: An Inventory of Programs and Block Grant Expenditures. Washington, D.C.: Public Health Foundation, 1990. 3. Miller, C.A., Brooks E, DeFriese G, Gilbert B, Jain S, and Kavaler F. A Survey of Local Health Departments and Their Directors. Am J Public Health, 1977;67:931-939. 4. National Association of County Health Officials. National Profile of Local Health Departments: An Overview of the Nation's Local Public Health System. Washington, D.C.: National Association of County Health Officials, 1990. 5. Institute of Medicine. The Future of Public Health. Washington, D.C.: National Academy Press, 1989. 6. Emerson, H. Local Health Units for the Nation. New York, New York: Commonwealth Fund, 1945. 7. Mullan, F. and Smith, J. Characteristics of State and Local Health Agencies. Baltimore, Maryland: Johns Hopkins School of Hygiene and Public Health, 1988. 8. U.S. Department of Commerce, Bureau of the Census. Current Population Reports, County Population Estimates: July 1, 1988, 1987, 1986. Washington, D.C.: U.S. Department of Commerce, 1989. 9. State Policy Research, Inc. The State Policy Data Book '88. Alexandria, Virginia: State Policy Research, Inc., 1988. 10. U.S. Department of Commerce, Bureau of the Census. State and Metropolitan Area Data Book 1986. Washington, D.C.: U.S. Department of Commerce, 1986. 11. U.S. Department of Commerce, Bureau of the Census. Census of Population. Vol. 1. Chapter C. General Social and Economic Characteristics. Washington, D.C.: U.S. Department of Commerce, 1983. 12. U.S. Department of Commerce, Bureau of the Census. Census of Population. Vol. 1. Chapter A. Number of Inhabitants. Washington, D.C.: U.S. Department of Commerce 1983. 13. National Association of Counties. County Government Structure: A State By State Report. Washington, D.C.: National Association of Counties, 1989. 14. The Europa World Year Book. United States External Territories. Volume II. London: Europa Publications, 1990. 15. University of Hawaii. An Evaluation of Federal Support to Health Systems of the Pacific Insular Jurisdictions of the U.S. Honolulu: University of Hawaii Schools of Medicine, Nursing and Public Health, 1984. 16. University of Hawaii. A Reevaluation of Health Services in U.S.-Associated Pacific Island Jurisdictions. Honolulu: University of Hawaii School of Public Health, 1989.