How do the laws addressing essential services, mandated services, and accreditation compare to each other?

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	Vital event registration	Vital records registration		Vital event registration Public health surveillance and epidemiology Collect, manage and display health data^ Operate secure and effective information systems^			Registration of vital events Epidemic investigations: Risk assessment Pesticide poisoning Health assessment: Morbidity data Reportable disease Vital records and statistics Chronic disease surveillance^ Communicable disease surveillance^
Health planning	Community health assessments			Community health assessments BOH participates in establishment of public health goals & objectives^ BOH assures the availability of resources to implement essential services^			Comprehensive community health assessment Behavioral risk assessment Health planning^
Partnership development and community mobilization				Convene and collaborate with community partners on community health problems Identify underserved populations and lead efforts to link individuals with preventive and other health services BOH promotes the development of public health partnerships^
Policy development, analysis, and decision support				Support development of public health policy and law Understand, monitor, and enforce compliance with public health laws BOH engages in rule making^			Health code development and enforcement Health planning^
Communication	Community and patient health education			Inform and educate public Health promotion activities^			Health education^ Community health education Interpretation, spoken language^ Health promotion and risk reduction^
Public health research, evaluation, & quality improvement	Quality improvement			Collect, manage and display health data^ Evaluate effectiveness, accessibility, and quality of personal and population-based health services Use research to develop and evaluate public health programs
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	Child health Family planning Maternal health		Maternal health Child health Family planning			Lead abatement^ Primary care—pediatric^ Maternal health^ Prenatal and postpartum care Maternity care coordination SIDS counseling WIC services —mother Family planning^ Pre-conceptional counseling Contraceptive care Fertility services Pregnancy prevention—adolescent Child health^ Well-child services Genetic services Services to developmentally disabled children Child service coordination Adolescent health services School health services^ Lead poisoning services WIC services—children Immunizations^ Newborn home visiting services Behavioral health services^ Children with special health care needs services
Injury control					Health promotion activities^	Health promotion & risk reduction: injury control^
Communicable disease control	Communicable disease control		Communicable disease control		Case investigation protocols for rapid detection and containment of communicable disease outbreaks, environmental health hazards, and other threats^	Communicable disease surveillance^ Child health: immunizations^ Communicable disease control^ Tuberculosis control Acute communicable disease control STD control training/education STD control screening AIDS/HIV screening Hepatitis A & B Rabies control
Chronic disease prevention	Chronic disease control		Adult health^		Health promotion activities^	Chronic disease surveillance^ Chronic disease early detection & referral^ Chronic disease patient education^ Chronic disease monitoring and treatment^ Health promotion and risk reduction^ Nutrition counseling Injury control^ Tobacco cessation
Environmental health	Water and food safety and sanitation Lodging and institutional sanitation Regulation of on-site wastewater systems		Food, lodging, and institutional sanitation Individual on-site water supply Sanitary sewage collection, treatment, and disposal Grade-A milk sanitation*			Restaurant/lodging/institutional sanitation and inspections On-site sewage and wastewater disposal Water sanitation and safety Private water supply Milk sanitation* Shellfish sanitation* Public swimming pool Bedding control* Pest management: mosquito Pest management: rodent Pest management: tick Lead abatement^
Mental health & substance abuse						Child health: behavioral health services^
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			Home health		Serve as health care provider when local needs and authority exist and agency has capacity and resources^	Primary care—adult Home health services Migrant health Refugee health Public health nurse pharmacy dispensing Other pharmacy services
Dental public health	Dental public health		Dental public health			Dental health education Topical fluoride application Sealant application Dental screening & referral Dental treatment Community fluoridation “Into the Mouths of Babes” dental preventive services
Public health laboratory	Public health laboratories		Public health laboratory support		Public health laboratory support	Laboratory services
School health						School nursing services Child health: school health services
Public health preparedness	Public health preparedness				24/7 public health alerts and public health emergency response capability Case investigation protocols for rapid detection and containment of communicable disease outbreaks, environmental health hazards, and other threats^	Bioterrorism & other emergency preparedness and response planning & assessment
Workforce and agency support					Assure a competent public health workforce and health care workforce Provide facilities and administrative services Operate secure and effective information systems^ Assure financial accountability
Local agency governance – activities of the local board of health					Rule making^ Adjudication Participate in training Develop, implement, & evaluate services and programs Participate in establishment of public health goals & objectives Assure the availability of resources to implement essential services Advocate on behalf of public health Promote the development of public health partnerships

^ 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.

[2]. See www.cdc.gov/nphpsp/essentialServices.html.

[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.

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How do the laws addressing essential services, mandated services, and accreditation compare to each other?

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