Types of Local Public Health Agencies: District Health Departments
This page includes questions and answers about district health departments in North Carolina.
FAQs
A district health department is a multi-county agency that provides local public health services for the residents of all counties in the district.
A district health department may be created upon agreement of the county commissioners and the boards of health of two or more counties. A county may join an existing district health department upon a similar agreement entered by each affected county.[1] A district health department is by definition a multi-county agency. It is governed by a single board of health and administered by a single health director.
[1]G.S. 130A-36.
When a new district is created from counties that formerly had single-county boards, those boards are dissolved and a district board is appointed. Similarly, when a county joins an existing district health department, the existing district board of health is dissolved and a new district board of health is appointed.[1] The existing rules of the former county board(s) remain in effect until they are amended or repealed by the district board of health.[2]
[1]G.S. 130A-37(d).
[2]G.S. 130A-36.
A county may withdraw from a district health department when a majority of the county’s commissioners determines that the district is not operating in the best interests of health in that county. A district may be dissolved upon a similar decision by the boards of commissioners of all the counties in the district. Withdrawal or dissolution may take place only after written notice is given to the North Carolina Department of Health and Human Services, and only at the end of the fiscal year. A certified public accountant or an auditor certified by the Local Government Commission distributes surplus funds to the counties according to the percentage each of them contributed during that year.[1]
When a county withdraws from a district, the district board of health is dissolved and a new board is appointed.[2] However, any rules adopted by the district board of health remain in effect in the county or counties involved until amended or repealed by the new board or boards governing the affected counties.[3]
[1]G.S. 130A-38.
[2]G.S. 130A-39(d).
[3]G.S. 130A-38.
A district board of health has 15-18 members. Each county in the district appoints a county commissioner to the board. Those commissioners then appoint the remaining members, which must include a physician, a dentist, an optometrist, a veterinarian, a registered nurse, a pharmacist, and a professional engineer. Any remaining positions may be filled by members of the general public. The professional members of the board must be licensed. All members must be residents of the district. The composition of the board should reasonably reflect the population makeup of the entire district and provide equitable district-wide representation. [1]
[1]G.S. 130A-37.
District board of health members are appointed to three-year terms and may serve a maximum of three consecutive three-year terms. There are a couple of exceptions to this general rule. First, if a person is the only district resident who is a member of one of the licensed professions that must be represented on the board, the person may serve more than three consecutive three-year terms.[1] Second, county commissioner members may only serve as long as the member is a county commissioner.[2] If a member is serving in his or her capacity as a county commissioner, the NC Attorney General has advised that he or she may serve for as long as he or she remains a commissioner, even if that time exceeds three consecutive three-year terms.[3]
[1]G.S. 130A-37(c).
[2] Id.
[3]Attorney General Advisory Opinion to Hal G. Harrison, Mitchell County Attorney, 1998 WL 856356 (Oct. 8, 1998).
A district board of health member may be removed for any of the following reasons:
- Commission of a felony or other crime involving moral turpitude
- Violation of a state law governing conflict of interest
- Violation of a written policy adopted by the boards of county commissioners of each county in the district
- Habitual failure to attend meetings
- Conduct that tends to bring the office into disrepute
- Failure to maintain qualifications for appointment (e.g., maintaining licensure in a profession, being a county resident, etc.)[1]
[1]G.S. 130A-37(h).
The district board of health may remove one of its members for one of the causes listed in question 8. Before it acts to remove a member, the board must give the member written notice of the basis for removal and provide an opportunity for the member to respond.[1]
[1]G.S. 130A-37(h).
A district board of health is charged with protecting and promoting public health in the counties making up the district.[1] The board has the authority to adopt local health rules that apply to all counties and municipalities within the district and may impose fees with the approval of the county commissioners, except when state law prohibits the imposition of local fees.[2] It appoints the local health director after consultation with the county commissioners. It can also hear appeals related to disputes about local health rules or fines imposed by the local health director.[3] More information about the powers and duties of local boards of health is available here.
[1]G.S. 130A-37(a).
[2]G.S. 130A-39.
[3]G.S. 130A-37(a); see also G.S. 130A-24 (appeals procedure).
In general, no – but there is an exception. Local board of health rules pertaining to smoking in public places must be approved by the county commissioners.[1]
[1]G.S. 130A-498(a).
Yes. A district board of health must base any locally imposed fees on a plan proposed by the local health director, and any fees adopted by the board must be approved by all applicable boards of county commissioners.[1]
[1]G.S. 130A-39(g).
The district board of health appoints a local health director, who must meet qualifications set forth in state law. The board must consult with the county commissioners of each county in the district before making the appointment.[1] The local health director hires, and may dismiss, health department employees.[2]
[1]G.S. 130A-40.
[2]G.S. 130A-41(b)(12).
A district health director must meet minimum education and experience requirements prescribed in law.[1] He or she must have one of the following:
- A medical doctorate
- A master’s degree in public health administration plus at least one year of employment in health programs or services
- A master’s degree in another public health discipline plus at least three years of employment in health programs or health services
- A master’s degree in public administration plus at least two years of experience in health programs or health services
- A master’s degree in a field related to public health plus at least three years of experience in health programs or health services[2]
- A bachelor’s degree in public health administration or public administration plus at least three years of experience in health programs or health services
[1]G.S. 130-40.
[2]The State Health Director must review requests by educational institutions to determine whether a master’s degree offered by the institution is related to public health for purposes of this law.
Yes. G.S. 126-5(a)(2) provides that the provisions of the State Human Resources Act apply to certain local entities, including county and district health departments.
A district health department is a public authority for purposes of the Local Government Budget and Fiscal Control Act and may establish its own budget.[1] Funding for all types of local public health agencies comes from several sources, including federal funds (which are often “categorical”—that is, designated for particular services), state funds, and local appropriations from the county or counties served by the public health agency. To receive local appropriations, a district board of health submits a budget request to the boards of commissioners of the counties served by the district health department.
Many local public health agencies receive grant or contract funding from public or private sources. Local agencies may also generate revenue from fees for services. Fees for clinical services may be paid by third-party payers, including Medicaid, NC Health Choice, or other public or private insurers. In some cases clients themselves may be charged a fee for clinical services, but charges to a client may be prohibited or limited by law. The district board of health may impose fees for other local services, such as on-site wastewater or private drinking water well permits, subject to limits imposed in state law.
No law specifies the level of funding required 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 agency to comply with those requirements.[2]
[1]G.S. 130A-36; see also G.S. Ch. 159, Art. 3 (Local Government Budget & Fiscal Control Act).
[2]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.
No, they are not required to maintain offices and staff in each county in the district. In practice, all of the current districts in North Carolina have at least one physical location in each county although the services offered at each location may vary. The administrative offices for the district are typically centralized in a single location.
No. The state law that permits the boards of commissioners in certain counties to abolish their boards of health applies only to boards appointed by or acting under and pursuant to the authority of the board of county commissioners.[1] This extends to traditional county boards of health and county consolidated human services boards, but not district boards of health (which are appointed by a subset of the commissioners of each county in the district).
[1]G.S. 153A-77(a).
There are many similarities between district health departments and public health authorities. For example, they both provide public health services, and have governing boards and directors. They are both public authorities for purposes of the North Carolina Local Government Budget and Fiscal Control Act, which means that they are responsible for their own budgets and financial management, independently from the counties that comprise them. They both are public entities that are subject to laws generally applicable to government agencies, such as open meetings and public records laws.
There are, however, some differences between a district health department and a public health authority:
Governing board: The governing boards of the two types of agencies are composed differently and may be appointed differently.
- Composition: A district board of health has 15-18 members and must include representatives of specific professions, as well as a member of the board of commissioners of each county served by the district. A single-county public health authority is composed of 7-9 members, while a multi-county authority may have up to 11 members.[1] A public health authority board must include either a county commissioner or a commissioner’s designee from each county in the authority. It must also include a hospital administrator and representatives from several other professions, but not every profession mentioned in the statute must be represented. A comparison of the membership of the different types of boards is available in the attached document.
- Appointment: For a district board of health, the boards of commissioners of each county comprising the district appoints one commissioner to serve on the board, then those commissioners appoint the remaining members. A multi-county public health authority board is appointed in the same fashion, except a board of county commissioners may appoint non-commissioner designee. The board of county commissioners appoints all the members of a single-county public health authority board.
Powers and duties of directors and governing boards: District health directors and public health authority directors have the same general powers and duties, such as hiring and firing employees, enforcing public health laws, and investigating and controlling the spread of disease within their jurisdictions. (More information about the powers and duties of public health directors is available here.) However, district health directors have one power that public health authority directors do not: the authority to enter contracts on behalf of the agency.[2] In public health authorities, the power to enter contracts is given to the board, not the director.[3] However, the board could delegate this power to the director.[4]
Public health authority boards have expanded powers and duties compared to district boards of health. For example, a public health authority board may impose fees for services without the approval of county commissioners. A public health authority board also has greater powers related to acquiring and disposing of property.[5]
Jurisdiction: A district health department serves the counties that comprise the department. While it may serve residents of other counties in some circumstances, a district health department does not typically perform services in counties outside the district (unless there is a specific arrangement in place with the other county or counties for it to do so), nor does it operate offices outside the boundaries of the counties comprising the district. In contrast, a public health authority is specifically authorized to provide or contract to provide public health services and to operate public health facilities outside the boundaries of the county or counties making up the authority.[6]
[1]In some instances, a public health authority may want to apply to the federal government to become a community health center so that it may be eligible for additional funding from specific federal programs. The federal law governing community health centers has strict requirements related to board membership. Therefore, state law allows a public health authority interested in applying for that status to have up to 25 board members. See G.S. 130A-45.1(a) (“Boards which intend to pursue federally qualified health center (or look-alike) status may have no fewer than nine and no more than 25 members.).
[2]G.S. 130A-41(b)(13).
[3]G.S. 130A-45.3(a)(12).
[4]G.S. 130A-45.3(a)(9) (authorizing a public health authority board to “delegate to its employees or agents any powers or duties as it may deem appropriate”).
[5]G.S. 130A-45.3.
[6]G.S. 130A-45.6. This law specifies that a public health authority may operate outside the territorial limits of the county or counties it serves “within reasonable limitation,” but this is not further defined. The law also states that a public health authority may not be held liable for failing to provide public health services outside its territorial limits.
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