Legal and Policy Context: Local Public Health Services
This page includes questions and answers about local public health services in North Carolina.
Please Note: These questions and answers have not been updated to reflect the changes from the 2012 legislative session. For more details, see the "legislative updates" page.
FAQs
A North Carolina statute 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 community 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]
The law gives state agencies the responsibility for ensuring that these services are available throughout the state, but the actual provision of most services occurs at the local level.
[1]G.S. 130A-1.1.
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.
- Essential public health services. The law that establishes the mission and purpose of North Carolina’s public health system also 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. This law identifies four general categories of services and specifies some of the services that fall in each category.[1]
- Mandated services. Another statute authorizes the Commission for Public Health to establish standards for the nature and scope of local public health services.[2] 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.[3]
- Local health department accreditation. Each local public health agency in the state must be accredited by the North Carolina Local Health Department Accreditation Board.[4] To be accredited, a local agency must satisfy accreditation standards that address the agency’s capacity to provide the “ten essential public health services,” a nationally recognized set of services that was adopted in 1994 by a national committee charged with providing a framework for effective public health systems.[5]
While each of these three laws addresses many of the services and activities of a local public health agency, none of them offers a complete view of a LPHA’s legal obligations. There are many other state and federal laws that are require an agency to deliver particular services. For example, a state law requires local health directors to hold annual rabies vaccination clinics for dogs, cats, and ferrets;[6] and a federal law requires LPHAs to provide language assistance to their limited-English proficient clients.[7] Other laws may compel an agency to perform activities that arise from the services the agency performs. For example, LPHAs must maintain and secure patient medical information in accordance with the HIPAA medical privacy rule.[8] Among many other things, HIPAA requires agencies to develop numerous policies and procedures, engage in employee training activities, permit clients to inspect their health records, and respond appropriately to requests for the release of health information.
[1]G.S. 130A-1.1.
[2]G.S. 130A-9.
[3]10A NCAC 46 .0201-.0216.
[4]G.S. 130A-34.1.
[6]G.S. 130A-187.
[7]Civil Rights Act of 1964, Title VI, Section 601 (42 U.S.C. § 2001d); see also Policy Guidance: Title VI Prohibition Against National Origin Discrimination As It Affects Persons With Limited English Proficiency, 65 Fed. Reg. 52,762 (August 30, 2000).
[8]See 45 CFR Parts 160 and 164.
The state essential services law describes four categories of services and specifies some of the services that fall in each category.[1]
Table 1. Essential public health services in North Carolina (G.S. 130A-1.1)
| Services |
Health Support Services |
|
Environmental Health Services |
|
Personal Health Services |
|
Public Health Preparedness |
|
The essential services law gives the responsibility for ensuring these services are available to the state Department of Health and Human Services, not local agencies. However, the actual provision of many of the services occurs at the local level under state oversight.
[1]G.S. 130A-1.1.
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 public health 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.
Table 2. Mandated public health services in North Carolina (10A NCAC 46 .0201-.0216)
Services a LPHA must provide | Services a LPHA must provide, contract, or certify are otherwise available |
Food, lodging, and institutional sanitation | Adult health |
Individual on-site water supply | Home health |
Sanitary sewage collection, treatment, and disposal | Dental public health |
Communicable disease control | Grade-A milk certification[1] |
Vital records registration | Maternal health |
| Child health |
| Family planning |
| Public health laboratory |
Each of the mandated services has its own rule that identifies more specifically which services must be provided or assured. For example, the specific services that must be provided for maternal health include pregnancy testing, information, and referral; and prenatal care for women not otherwise served, through direct provision of care, referral to other providers, contracts with other providers, or a combination of those methods.[2]
[1]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).
[2]10A NCAC 46.0205.
North Carolina’s accreditation standards were designed to address a local public health agency’s capacity to provide the “ten essential public health services,” a nationally recognized set of services that was adopted in 1994 by a national committee charged with providing a framework for effective public health systems.[1] The ten essential 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 state accreditation law incorporates the ten essential services, and the state accreditation standards specify the activities local agencies must engage in to ensure their capacity to provide those services. The accreditation standards also address local public health agency facilities, administration, and governance.
Table 3: North Carolina Accreditation Standards (10A NCAC Ch. 48)
Category | Essential service | Accreditation benchmarks |
Assessment | Monitor health status to identify community problems | Conduct and disseminate results of regular community health assessments |
Work with health care providers in the community to report reportable diseases and other health-related events and data | ||
Maintain skills and capacity to collect, manage, integrate and display health-related data | ||
Diagnose and investigate health problems and health hazards in the community | Engage in surveillance activities and assess, investigate and analyze health problems, threats and hazards, maintaining and using epidemiological expertise | |
Establish and maintain a system to receive and provide health alerts and public health response for health care providers, emergency responders, and communities on a 24-hour-a-day, 7-day-a-week basis | ||
Be able to respond to a public health emergency on a 24-hour-a-day, 7-day-a-week basis | ||
Maintain and implement epidemiological case investigation protocols providing for rapid detection and containment of communicable disease outbreaks; environmental health hazards; potential biological, chemical and radiological threats | ||
Provide or have access to laboratory capacity capable of providing for rapid detection and containment of communicable disease outbreaks; environmental health hazards; potential biological, chemical and radiological threats | ||
Policy Development | Inform, educate, and empower people about health issues | Provide the general public and elected and appointed officials with information on health risks, health status, and health needs in the community as well as information on policies and programs that can improve community health |
Provide, support, and evaluate health promotion activities designed to influence the behavior of individuals and groups | ||
Mobilize community partnerships to identify and solve health problems | Convene key constituents and community partners to identify, analyze, and prioritize community health issues | |
Develop strategies in collaboration with community partners to solve existing community health problems | ||
Identify and build upon community assets and direct them toward resolving health problems | ||
Develop policies and plans that support individual and community health efforts | Work with local, state and federal policymakers to enact policies, laws, rules, and ordinances that support individual and community health efforts | |
Develop plans to guide the agency’s work | ||
Assurance | Enforce laws and regulations that protect health and ensure safety | Staff shall have knowledge of public health law and an understanding of the relationship between the law and public health practice |
Monitor compliance with public health laws and rules | ||
Enforce public health laws, rules and ordinances | ||
Link people to needed personal health services and assure the provision of health care when otherwise unavailable | Identify populations that are not receiving preventive services or are otherwise underserved with respect to health care | |
Mobilize the community to address health care resource needs | ||
Lead efforts in the community to link individuals with preventive, health promotion, and other health services | ||
Serve as a health care provider when local needs and authority exist, and the agency capacity and resources are available | ||
Assure a competent public health and personal health care workforce | Require staff to meet statutory and regulatory qualifications for their positions | |
Regularly evaluate staff training and development needs and provide opportunities for continuing education, training and leadership development | ||
Build relationships with entities that conduct education or research to enrich public health practice | ||
Promote diversity in the public health workforce | ||
Evaluate effectiveness, accessibility, and quality of personal and population-based health services | Evaluate all services the agency provides for effectiveness in achieving desired outcomes | |
Research for new insights and innovative solutions to health problems | Use research to develop and evaluate public health programs | |
Ensure that its participation in research meets ethical standards | ||
Additional state law requirements | Provide facilities and administrative services | Provide safe and accessible physical facilities and services |
Develop and implement administrative policies and procedures | ||
Operate a secure and effective management information system | ||
Assure the agency’s financial accountability | ||
Governance | The local board of health shall exercise its authority to adopt and enforce rules necessary to protect and promote the public's health | |
The local board of health shall assure a fair and equitable adjudication process | ||
The local board of health members shall be trained regarding their service on the board | ||
The local board of health shall assure the development, implementation and evaluation of local health services and programs to protect and promote the public’s health | ||
The local board of health shall participate in the establishment of public health goals and objectives | ||
The local board of health shall assure the availability of resources to implement the essential services described in G.S. 130A-34.1(e)(2). | ||
The local board of health shall advocate in the community on behalf of public health | ||
The local board of health shall promote the development of public health partnerships |
All of these laws address the provision of public health services and identify some of the services that must be provided, but there are significant differences between the lists of services. Further, none of the laws provides a comprehensive list of every service that a local public health agency is legally obliged to provide. Some examples of other laws that require or affect local public health services are here. Beyond that, public health agencies may provide additional services that aren’t reflected in any law.
Law is not the only determinant of the types of services that local public health agencies provide or the activities they engage in. Public health services are also influenced by changing public health conditions or changing funding streams for public health agencies. For example, in the early 2000s a series of unrelated events—including the anthrax letter attacks of 2001 and the emergence of new illnesses such as SARS—resulted in increased attention to public health preparedness. North Carolina’s essential services law was amended in 2009 to include public health preparedness,[1] but by then work in that area was already well underway, driven by both need and an infusion of federal funds intended for preparedness efforts.
The determination about which public health services are provided is also influenced by deliberative processes, in which researchers, practitioners, and other stakeholders review information about public health and reach conclusions about the services that are necessary to produce good population health outcomes. The ten essential public health services that are reflected in North Carolina’s local health department laws were the result of one such process.[2]
More recently, on April 10, 2012, the national Institute of Medicine (IOM) released a report which, among other things, defines a minimum package of public health services. While the minimum package was based on the ten essential public health services, it is more specific about the foundational capabilities and basic programs that, according to the authors of the report, “no health department can be without.”[3] Although the minimum package approach is not presently reflected in North Carolina law, it will likely be a factor in future policy discussions regarding local public health. Thus, it offers an organizing principle for looking at North Carolina public health services that may be useful. Table 4 identifies the services and activities from each of the three North Carolina law and a fourth non-legal source—a list of services that appears in a biennial survey of local public health agency activities. It then associates those services and activities with the two components of the IOM’s minimum package:
- Foundational capabilities
- Information systems and resources, including surveillance and epidemiology
- Health planning, including community health improvement planning
- Partnership development and community mobilization
- Policy development, analysis, and decision support
- Communication, including health literacy and cultural competence
- Public health research, evaluation, and quality improvement
- Basic programs
- Maternal and child health promotion
- Injury control
- Communicable disease control
- Chronic disease prevention, including tobacco control
- Environmental health services
- Mental health and substance abuse services
Some services or activities identified in NC law or the biennial survey are listed more than once in each column, as they relate to more than one of the IOM categories.
Table 4. NC Public Health Services and the IOM’s Minimum Package of Public Health Services
Minimum Package: Foundational Capabilities | |||||||
Foundational Capability | NC essential services law | NC mandated services laws | NC accreditation requirements | Services assessed in DHHS biennial survey | |||
Information systems & resources |
|
|
|
| |||
Health planning |
|
|
|
| |||
Partnership development and community mobilization |
|
|
|
| |||
Policy development, analysis, and decision support |
|
|
|
| |||
Communication |
|
|
|
| |||
Public health research, evaluation, & quality improvement |
|
|
|
| |||
Minimum Package: Basic Programs | |||||||
Foundational Capability | NC essential services law | NC mandated services laws | NC accreditation requirements | Services assessed in DHHS biennial survey | |||
Maternal & child health promotion |
|
|
|
| |||
Injury control |
|
|
|
| |||
Communicable disease control |
|
|
|
| |||
Chronic disease prevention |
|
|
|
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Environmental health |
|
|
|
| |||
Mental health & substance abuse |
|
|
|
| |||
Other Public Health Services/Activities in North Carolina | |||||||
Service/ Activity | NC essential services law | NC mandated services laws | NC accreditation requirements | Services assessed in DHHS biennial survey | |||
Personal health programs not reflected in minimum package |
|
|
|
| |||
Dental public health |
|
|
|
| |||
Public health laboratory |
|
|
|
| |||
School health |
|
|
|
| |||
Public health preparedness |
|
|
|
| |||
Workforce and agency support |
|
|
|
| |||
Local agency governance – activities of the local board of health |
|
|
|
| |||
^ This item is listed more than once in this column.
*This program was transferred to another state agency in FY 2011–2012.
*** This program was abolished in FY 2011–2012.
[1]S.L. 2009-442, sec. 1.
[3]. Institute of Medicine, Committee on Public Health Strategies to Improve Health, For the Public’s Health: Investing in a Healthier Future (2012). Pre-publication PDF version available at www.iom.edu.
Funds for local public health services come from various sources, but the exact mix of funding varies significantly from one local public health agency to the next. Local public health agencies receive funding from each of the following sources:
- federal funds that are administered and overseen by the state,
- state funds,
- revenues from fees for services (including reimbursement of fees for clinical services by public and private insurers), and
- local appropriations from the county or counties participating in the local agency.
Agencies may also receive funding from other sources such as grants from private foundations or contracts for services.
No law specifies the level of funding that local governments must provide for local public health services. However, the laws that require local agencies to provide particular services or engage in specific activities may effectively amount to an obligation to ensure that funding levels from all sources are sufficient to permit the local agency to comply with those requirements.[1]
[1]There are two maintenance-of-effort statutes that prohibit counties from reducing local appropriations for particular public health programs when state money increases. G.S. 130A-4.1 is a maintenance-of-effort requirement for maternal and child health services, and G.S. 130A-4.2 is for health promotion programs. These laws do mean that a certain amount of local funding must be provided for these services, but they are not a large factor in local funding for health departments.
A local agency’s board of health may impose fees for services, but this authority is limited.
A state law prohibits the imposition of local fees when the local employee is performing services as an agent of the state, which is the case for many environmental health services. For example, a local board of health may not impose a local fee for food and lodging inspections. However, the same law creates an exception allowing local fees to be imposed in the following environmental health programs: on-site wastewater, swimming pools, tattooing, and private wells.[1] In addition, several state laws prohibit a local agency from charging a fee to the client for a particular service, though in some cases a fee may be charged to a third-party payer such as Medicaid.[2]
Federal laws also prohibit or limit fees for some services. For example, local health departments may not charge clients for language interpretation services.[3] Also, for some programs, fees may be charged only in accordance with sliding scales set by federal regulations.[4]
Fees must be deposited into the local agency’s account and expended for public health purposes.[5] County and district boards of health and consolidated human services boards must base their fees on a plan proposed by the local health director, and any fees adopted by the board must be approved by the county commissioners (in the case of a district health department, all applicable boards of county commissioners).[6] Public health authority boards may establish fee schedules and are not required to obtain commissioner approval.[7]
For more information about the local board of health’s authority to impose fees, click here.
[1]G.S. 130A-39(g).
[2]See, e.g., G.S. 130A-130 (testing or counseling for sickle cell disease); 130A-144(e) (diagnosis or treatment of tuberculosis or sexually transmitted diseases); 130A-153(a) (immunizations for children in families who meet income and other criteria); 10A NCAC 41A .0202(9) (testing and counseling for HIV).
[3]U.S. Dept. of Health and Human Services Office of Civil Rights, Guidance to Federal Financial Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons (August 4, 2003), available at http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/hhslepguidancepdf.pdf.
[4]See, e.g., 42 C.F.R. 59.5 (providing that fees for Title X-funded family planning services must be based on ability to pay).
[5]G.S. 130A-39(g).
[6]G.S. 130A-39(g).
[7]G.S. 130A-45.3(a)(5).
