A North Carolina law describes the purpose and mission of the state’s public health system. The purpose is “to ensure that all citizens in the State have equal access to essential public health services,” and the mission is “to promote and contribute to the highest level of health possible for the people of North Carolina” by:

• identifying and preventing or reducing health risks
• detecting, investigating and preventing the spread of disease
• promoting healthy lifestyles and a safe and healthful environment
• promoting the accessibility and availability of quality health care services in the private sector, and
• providing health care services when they are not otherwise available.[1]

This mission and purpose is consistent with the Institute of Medicine’s 1988 definition of public health as “what we, as a society, do collectively to ensure the conditions in which people can be healthy.”[2] The emphasis this definition places on collective action and the conditions that promote good health reveals a distinction between public health and clinical health care: public health is concerned with the health of populations, not just the health status or condition of a particular individual.

Although the mission and purpose of the public health system is set by the state legislature and extends to all residents, most public health activities and services are carried out locally. Under North Carolina law, the legal responsibility for providing local public health services is given to counties. A county may satisfy this duty by operating a county health department, participating in a multi-county district health department, forming or joining a public health authority, establishing a consolidated human services agency, or contracting with the state to provide public health services.[3]

Local public health agencies provide services at both the community and individual levels. While there is no single law describing the minimum services that a local agency must provide, there are three primary state laws that affect the scope and range of local service provision.

The first is a law that describes the public health services that the General Assembly has determined are essential to promoting and contributing to the highest levels of health and that should be available to everyone in the state.[1]  This law incorporates the “ten essential public health services,” a set of services that was adopted in 1994 by a national committee charged with providing a framework for effective public health systems,[2] and directs local health departments to ensure the services are available and accessible to the population served by the department. The ten essential public health services fall into three categories: assessment of community health status and health problems; policy development to educate the community about health, solve community health problems, support individual and community health, and protect health and ensure safety; and assurance of quality public health and public and private health care services within the community. The table below identifies the specific services in each category.

Essential Public Health Services (G.S. 130A-1.1)

Another law requires each local public health agency in the state to be accredited by the North Carolina Local Health Department Accreditation Board.[3] To be accredited, a local agency must satisfy standards that address the agency’s capacity to provide the ten essential public health services, as well as several additional duties imposed by state law.[4] The standards are divided into three categories: agency core functions and essential services, facilities and administrative services, and local boards of health. The Accreditation Board assesses a local health department’s performance of 148 specific activities. A health department must satisfy about 90 percent of the activities in order to obtain or maintain accreditation.[5]

A third law authorizes the N.C. Commission for Public Health to establish standards for the nature and scope of local public health services.[6]  The commission has adopted rules, known as the mandated services rules, which specify some of the public health services that local public health agencies must guarantee.[7]  The mandated services  rules address thirteen types of services that fall into one of two categories: (1) services that the local agency must provide under the direction of the local health director and supervision of the local board of health; or (2) services that a county may provide through the local agency, contract with another entity to provide, or not provide at all if the local agency can certify to the state’s satisfaction that the services are available in the county from other providers. Each of the mandated services has its own rule that identifies more specifically which services must be provided or assured. 

The mandated services that a local health department must provide are:

• Food, lodging, and institutional sanitation
• Individual on-site water supply
• Sanitary sewage collection, treatment, and disposal
• Communicable disease control
• Vital records registration

The mandated services that a local health department must provide, contract for, or certify as available are:

• Adult health
• Home health
• Dental public health
• Grade A milk certification*
• Maternal health
• Child health
• Family planning
• Public health laboratory

* In 2011, responsibility for milk sanitation at the state level was transferred from the former Division of Environmental Health, Department of Environment and Natural Resources, to the Food and Drug Protection Division of the Department of Agriculture and Community Services. S.L. 2011-145, sec. 13.3.(b).

These laws provide a starting point for understanding local public health services, but they do not paint the complete picture. Local public health agencies also must provide services or perform activities to comply with other laws. For example, in order to comply with the federal HIPAA medical privacy rule, local health departments must develop and maintain numerous forms, notices, and policies and procedures for keeping health information confidential and secure and for honoring individuals’ rights regarding their health information.[8]

The North Carolina Department of Health and Human Services (DHHS) conducts a biennial survey of services that are provided by local public health agencies in North Carolina, which provides additional insight into the range of local public health services that are provided by the state’s local agencies. The services that are typically included in the survey cover a wide range of activities, from epidemic investigations, to school nursing services, to childhood lead poisoning prevention, to chronic disease control, to name just a few.[9]

Funds for local public health services come from various sources, and the exact mix of funding varies significantly from one local public health agency to the next. The sources of funds may be grouped into four general categories:

• Federal and state funds: The state receives federal funds through block grants that are paid to the state and then distributed by the state to local agencies. The state also provides general aid-to-county funds. In fiscal year 2012, the total amount of state and federal funds allocated to the state Division of Public Health was approximately $748 million. About 73 percent of that amount ($547 million) was distributed to counties.[1]
• Medicaid:  A major source of funding for many local health departments is the state Medicaid program, which in fiscal year 2012 was composed of about 75% federal funds and 25% state funds. Medicaid provides direct reimbursement for services to Medicaid-eligible clients, as well as an annual cost settlement.
• County appropriations: County appropriations are a source of revenue for every local health department in the state, though the percentage of a health department’s budget that comes from county appropriations varies a great deal.[2] A new maintenance of effort requirement was enacted by the legislature in 2012. Effective July 1, 2014, in order to remain eligible for state and federal funding, a county must maintain its appropriation to its local public health agency from ad valorem tax receipts at a level equal to the amount appropriated in fiscal year 2010-2011.[3]
• Other: Local health departments also receive revenues from a variety of other sources, including fees for environmental health services, fees for clinical services that have sliding fee scales, grants received directly by the local health department, and in some areas Medicare reimbursements for services such as home health or diabetes care.

All funds received or spent by a local health department must be budgeted, disbursed, and accounted for in accordance with the Local Government Budget and Fiscal Control Act.[4] The budgeting, disbursing, and accounting for a county health department or consolidated human services agency is done by the county’s budget officer and finance officer. District health departments and public health authorities are responsible for performing these functions themselves.

North Carolina law defines five types of local public health agencies:

• County health department
• District health department (multi-county)
• Public health authority (single-county or multi-county)
• Consolidated human services agency
• Public hospital authority

Any county may operate a county health department, participate in a multi-county district health department, or establish a public health authority. A county with a county manager appointed pursuant to G.S. 153A-81 may provide public health services through a consolidated human services agency. The fifth type—public hospital authority—is available only to Cabarrus county. Each type of agency is captured in the generic term "local health department."[1]

The mix of types of local public health agencies in North Carolina is in the process of changing as a result of 2012 legislation authorizing more consolidated human services agencies. The table below shows the number of each type that existed on July 1, 2012 and on March 1, 2013. It is expected the numbers in the right-hand column will continue to change.

* The six district health departments cover 21 North Carolina counties.

An up-to-date map showing the types of LPHAs in North Carolina is maintained on the School of Government’s website. Click here and scroll down to the heading Local Public Health Agencies.

Each local public health agency has a director. The directors of county health departments, district health departments, and public health authorities must meet minimum education and experience requirements that are set out in state law. There is no similar education and experience requirement for the director of a consolidated human services agency. However, if the director of a consolidated agency that provides public health services does not meet those qualifications he or she must appoint a person who does.[1]

There is also a state regulation that addresses minimum staffing requirements for local public health agencies. It specifies that each agency must employ a local health director, a public health nurse, an environmental health specialist, and a secretary. These staff members must be full-time employees, but an agency may share a health director with another agency.[2]

The state’s local health department accreditation standards also address staffing directly and indirectly. One of the standards requires an agency to employ or contract with one or more licensed physicians to serve as medical director.[3] Other portions of the accreditation rules refer to additional categories of agency staff members or to particular types of expertise that the agency must possess or have access to, but they do not explicitly require the agency to have staff positions for those categories or expertise.[4]

The minimum requirements of the state regulations are a foundation but not a complete description of local public health agency staffing, which is determined primarily by the functions the departments must perform and the services they must provide.

Yes, if the board of county commissioners approves the decision to change. In some cases the approval of the local board of health is required as well.

In order for a county to join a district health department, form a new public health authority, or join an existing public health authority, both the board of county commissioners and the board of health must agree to the change.[1] Other decisions regarding the type of local public health agency may be made by the board of county commissioners alone. For example, the board of county commissioners may create a consolidated human services agency that includes public health without the local board of health’s agreement.[2] County commissioners also may act alone in deciding to dissolve a single-county public health authority, withdraw from a multi-county public health authority, or withdraw from a district health department.[3]

Each local public health agency in North Carolina has a board, a director, and an agency with staff members who provide public health services at the local level. Each agency is required to be accredited by the North Carolina Local Health Department Accreditation Board.

• Boards:  The boards governing the agencies serve as the policy-making, rule-making, and adjudicatory body for public health within the department’s jurisdiction. Each type of board may impose fees for public health services, subject to some conditions. 
• Directors:  Each local agency has a director whose role is defined in part by laws that specify the powers and duties of a local health director.[1] The powers and duties do not vary much by agency type, but there are a few differences that apply to a director of a public health authority or a consolidated human services agency.
• Services and Functions:  Each agency must perform functions and provide services necessary to satisfy state laws.

There are important differences between the types of agencies in five general areas:  budget and finance, boards, appointment of directors, director qualifications, and personnel policies.

• Budget and finance:  County health departments and consolidated human services agencies are components of county government and are units of the county for many purposes, including finance and budgeting. The budget of a county health department or consolidated human services agency is established by the county it serves, and the county is held accountable for financial management under state law. In contrast, public health authorities and district health departments function as separate entities. They establish their own budgets, separate from the county, and are directly accountable for compliance with state financial management laws.[1] They may submit budget requests to the county for funding to support their work, but the overall budget remains within their control.
• Boards: The boards of the different types of agencies differ, both in powers and duties and in membership. Click here to see a table comparing the membership requirements, powers, and duties. In general, public health authority boards have expanded powers and duties compared to county and district boards of health. Consolidated human services boards have all of the powers of county and district boards of health, except a consolidated human services board may not appoint the agency director (who is appointed instead by the county manager, with the advice and consent of the board). The number of board members may be as few as seven for a public health authority board, or as many as 25 for a consolidated human services board. Finally, in counties with county health departments or consolidated human services agencies, the board of county commissioners may abolish the appointed governing board for the agency and directly assume its powers and duties. A board of commissioners that takes this action must appoint an advisory committee on health that has the same membership as a county board of health.[2]

• Appointment of directors: The appointment of the local health director is managed differently by the different types of agencies.
  • In county and district health departments, the director is appointed by the local board of health after consultation with all applicable boards of county commissioners.
  • In a public health authority, the authority board appoints the director after consultation with all applicable boards of county commissioners.
  • In a consolidated human services agency, the agency director is appointed by the county manager with the advice and consent of the consolidated human services board. The agency director then appoints a person who meets the statutory qualifications of a local health director. The county manager must approve the appointment of that person.

If the county commissioners have abolished the board of health pursuant to G.S. 153A-77(a), then the commissioners have all the powers and duties of the local board of health. For a county health department, this includes the power to directly appoint the local health director. For a consolidated human services agency, this includes the power to advise and consent to the county manager’s appointment of the consolidated human services director.

• Director qualifications: The directors of county health departments, district health departments, and public health authorities must meet minimum education and experience requirements set forth in state laws, which generally require a background in medicine, public health, or public administration related to health services. There is no similar education and experience requirement for the director of a consolidated human services agency. However, if the director of a consolidated agency that provides public health services does not meet those qualifications he or she must appoint a person who does.[3] In addition, North Carolina’s standards for local public health agency accreditation specify that the agency’s governing board must appoint a local health director who meets the requirements of the law that applies to county and district health directors.[4]   
• Personnel policies: The employees of county and district health departments are ordinarily subject to the State Personnel Act (SPA).[5] Public health authorities are exempt from the State Personnel Act and establish their own personnel policies and salary plans.[6] The employees of consolidated human services agencies are subject to county personnel policies or ordinances, unless the board of county commissioners elects to make the agency employees subject to the SPA.[7] The directors of all of the different types of local public health agencies may appoint employees, but appointments made by a director of a consolidated human services agency must be approved by the county manager. The directors of the other types of departments are not required to obtain the county manager’s approval before appointing employees.

North Carolina law requires counties to provide public health services to their residents. County commissioners take several actions to ensure that this happens:

• Selection of agency type: Commissioners are key players in the selection of the type of local public health agency. The commissioners alone may choose to operate a county health department or to provide public health services through a consolidated human services agency. The commissioners may jointly resolve with the local board of health to join a district health department or form a public health authority.
• Appointment of board: County commissioners make appointments to the local public health board. The board of county commissioners appoints all the members of a county board of health, a single-county public health authority board, or a consolidated human services board. The boards of district health departments or multi-county public health authorities are appointed somewhat differently: the board of county commissioners of each participating county appoints one county commissioner to the health board, and then those commissioners appoint all the remaining members. Finally, the county commissioners may serve as the local board of health by adopting a resolution assuming the powers and duties of the county board of health or county consolidated human services board.
• Approval of budget or budget request: County commissioners approve the budgets of local public health agencies that are county departments (either a county health department or a consolidated human services agency that includes public health). If the county participates in a public health authority or district health department, the commissioners are involved in approving budget requests or providing funding to the agency.
• Other duties: A board of commissioners may have other duties as well. Here are a few examples:
  
  • If the local board of health imposes fees for services, those fees must be approved by the county commissioners (except in counties that participate in a public health authority).
  • If the county forms a consolidated human services agency, the commissioners must decide whether the employees will be subject to the State Personnel Act.
  • If the county commissioners directly assume the powers and duties of the local board of health, the commissioners become the body that is responsible for protecting and promoting the public health in the jurisdiction, and for exercising the rule-making, adjudicatory, and policy-making authority of a board of health. A board of commissioners that assumes the powers and duties of a local board of health must also appoint an advisory committee on health. 

Yes. A state law requires each local public health agency to obtain and maintain accreditation.[1] State regulations set the standards that must be met for an agency to be accredited.[2] This requirement applies to any agency functioning as a “local health department” under North Carolina law. The statutory definition of “local health department” includes a county health department, a district health department, or a public health authority. Although the definition does not mention consolidated human services agencies, a separate law states that such agencies “shall have the responsibility to carry out the duties of a local health department.”[3] Obtaining and maintaining accreditation appears to be one such duty.

There is a national initiative encouraging local health departments to obtain voluntary accreditation by the Public Health Accreditation Board (PHAB).[4] This initiative is separate from North Carolina’s program.  A North Carolina LPHA must obtain accreditation through the state program. It may pursue accreditation through PHAB as well, but that is voluntary. The accreditation standards are similar in both programs, but the North Carolina program’s standards incorporate numerous elements of North Carolina law, while PHAB’s standards are necessarily more generic.