Who establishes the budget for a county health department, and where does the money come from?

A county health department is a unit of the county for many purposes, including finance and budgeting. The budget of a county health department must be approved by the county commissioners, and the county is held accountable for financial management under state law.[1] It is customary for a county board of health to approve a proposed budget for the department before it is submitted to the county commissioners. North Carolina’s standards for local public health agency accreditation specify that the agency’s governing board must review and approve the department’s budget annually.[2] This does not create an absolute requirement for local boards of health to review agency budgets, because the accreditation program does not require compliance with every provision in the standards—agencies may skip a small proportion of the standards and still be accredited.[3]  Therefore, it is possible that a local health department could be accredited without meeting the specific standard that requires board of health review of the budget.

Funding for county health departments 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. Many health departments receive grant or contract funding from public or private sources. A county health department 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 county 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.