29.4 Public Health Nursing and Public Health Departments

State Health Departments

The CDC is the federal government organization charged with population health protection and improvement activities (Leider et al., 2018). Other federal agencies with public health functions include the U.S. Department of Health and Human Services (HHS), the Health Resources and Services Administration (HRSA), the Food and Drug Administration (FDA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the National Institutes of Health (NIH) (Leider et al., 2018). Although the CDC has set a federal public health agenda, much of the oversight of public health is left to individual states. The structure of state-level public health varies. State health agencies are tasked with implementing federal regulations or policies, such as Medicaid, Medicare, and the Children’s Health Insurance Programs (Leider et al., 2018).

Within the United States, about 55 percent of SHDs are independent, whereas the other 45 percent are organized as one unit of a larger health-related agency that includes mental health services, long-term care services, public assistance, and traditional public health functions (PHLC, 2015). Each state’s health department is usually the primary public health authority and supports delivering public health services. A council or board of health often oversees and directs SHDs. These boards often advise elected officials on PH matters, develop state PH policies, and develop legislative PH agendas. State legislatures approve state PH agency budgets, establish PH laws and regulations, determine fees for health services, and establish taxes to support public health. State PH agencies are often influenced by the elected officials in the state (PHLC, 2015).

Public health system funding is difficult to generalize as the structure of the public health system is determined by how state and local health departments are empowered within a state with much variation across the nation (Leider et al., 2018). SHDs receive both federal and state funds. Alternate funders are foundations and for-profit institutions (Leider et al., 2018). The federal government is the largest funder of state public health. Federal agencies will provide funds for particular diseases or programs, which can decrease the public health program’s ability to respond to local needs and priorities (Leider et al., 2018). Public health systems for territories and tribal nations are funded externally by the federal government. They tend not to have a distinct public health operation as they integrate population-oriented services with direct health care services (Leider et al., 2018).

Local Health Departments

Local health departments obtain authority from the state. Their roles and scope of authority are contingent on state policy and the governing relationship between the state and LHD. As noted previously, the role and governing structure of LHDs vary widely. Some LHDs provide direct clinical care, whereas others focus solely on population-based services (Leider et al., 2018). Some LHDs in large cities have functional abilities similar to those of SHDs, although small LHDs often provide a limited set of public health services. LHDs can be designed as locally governed, a branch of the state health department, a state-created region, or a department serving multiple counties. The commonality is that LHDs have governmental power and are responsible for public health at the local level (PHLC, 2015). They are also responsible for following state laws and regulations (Leider et al., 2018).

The National Association of County and City Health Officials (NACCHO) estimates there are 2,800 LHDs in the United States of varying size and complexity (Leider et al., 2018). Spending estimates for LHDs are complicated and not readily available as they are self-reported by the nation’s LHDs and capture only basic information such as revenues and expenditures. LHDs are often supported by cities, counties, and local governments, partially financed through local property taxes or via a devoted public health revenue stream from the local government (Leider et al., 2018). Local government support of public health agencies averages about 3 percent of total local taxes (Leider et al., 2018). Some state legislatures fund LHDs through grants and contracts managed by the SHD. The federal government will also support some large local governments with grants, but most often federal dollars go to SHDs first to then be further disbursed to LHDs (Leider et al., 2018).

Trends in Public Health Funding

Public health is chronically underfunded with fragmented infrastructure (Johns & Rosenthal, 2022; Leider et al., 2018). Historically, public health is deeply siloed with funding dedicated to specific diseases or focal areas and allocated across many entities in the public health system. State and local health departments fund and conduct public health activities. The federal government provides additional funding through its various branches, with the CDC being the primary funder, yet the CDC’s funding decreased by more than 8 percent between 2010 and 2021 (Johns & Rosenthal, 2022). Federal contributions have remained stagnant, resulting in state and local funding sources compensating for the lack of increased funding. This has created an inequitable system, as each locality has different funding sources (Johns & Rosenthal, 2022). Due to these funding differences, there are also significant differences in local public health services nationwide.

Public health spending increases of as little as $10 per capita have been linked to decreased mortality rates of as much as 7 percent and an overall greater percentage of the population reporting being in good or excellent health (Johns & Rosenthal, 2022). Similarly, decreases in low birth weight, rates of STIs, and foodborne illnesses have been directly linked to spending on public health initiatives (Johns & Rosenthal, 2022). Investments in public health can offload some of the burden on the U.S. health care system. In 2019, less than 3 percent of the overall $3.8 trillion spent on health care in the United States went toward public health (Johns & Rosenthal, 2022). This mirrors the finding that, over the past two decades, between 2 and 3 percent of health spending went directly to public health. Health care costs are increasing, with most of the spending going toward treating preventable conditions, yet population health in the United States continues to decline. For every $1 spent on public health interventions focused on diabetes and cardiovascular health, $5 in health spending is saved (Johns & Rosenthal, 2022).

Role of State Health Departments

State health departments have a variety of responsibilities within public health that include the governance functions of policy development, resource stewardship, legal compliance, partner engagement, continuous improvement, and oversight (PHLC, 2015).

• Policy development
  • Contribute to developing policies to protect, promote, and improve public health.
  • Ensure the agency is consistent with laws, rules, and regulations.
• Resource stewardship
  • Ensure the availability of necessary resources to implement the essential public health services. These resources may include finances, workforce, legal support, and technology.
• Legal compliance
  • Exert legal authority as needed in the roles, responsibilities, and functioning of the governing body, health officers, and staff.
• Partner engagement
  • Develop and fortify community partnerships through engagement and education.
  • Ensure teamwork and partnership among all relevant partners in promoting the community’s health.
• Continuous improvement
  • Evaluate and monitor progress regularly.
  • Set measurable outcomes used to monitor the health status of the community.
  • Assess the health agency’s ability to meet its responsibilities.
• Oversight
  • Accept responsibility for public health performance in the community.
  • Provide supervision and guidance as needed to support the agency in meeting established outcomes.

State health departments provide population-based public health services focusing on prevention—primary, secondary, and tertiary. SHDs promote health and well-being by ensuring access to health care services, focusing on prevention and health equity, and by ensuring water and food safety, ensuring children have access to all childhood vaccines, and overseeing the health care-related professions and services (Commonwealth of Massachusetts, 2023a). The box below presents the typical duties of state health departments.

Role of Local Health Departments

LHDs coordinate public health activities in their jurisdiction and follow the SHDs rules and regulations. The responsibilities are diverse and will vary depending on state law (Commonwealth of Massachusetts, 2023b; PHLC, 2015). They may include:

• Monitoring the health status of the community
• Understanding health issues facing the community
• Protecting the community from health problems and hazards
• Educating the community on a variety of health topics to assist them in making healthy choices
• Engaging the community in identifying and addressing health problems
• Developing public health policies and plans
• Enforcing public health laws and regulations
• Assisting community members in accessing health services
• Maintaining a competent public health workforce
• Evaluating and improving programs and interventions
• Enforcing state sanitary, environmental, housing, and health codes

LHDs are involved in many activities designed to keep communities safe and healthy. There are more than 3,000 LHDs across the nation, and these city, county, and tribal departments work to ensure the safety of food, water, and air, among many other activities (NACCHO, 2017). Examples of activities include immunizations, food safety, infectious disease control, long-term disease service, injury and violence prevention, tobacco control, emergency preparedness, maternal and child health, and environmental health (NACCHO, 2017).