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Public Health Core Functions -- Alabama, Maryland, Mississippi, New Jersey, South Carolina, and Wisconsin, 1993

The three core functions of public health are assessment, policy development, and assurance (1,2). Within these core functions, CDC has identified 10 basic public health practices that are integral to the operation of state and local health agencies (Table_1) (3). As a part of assessing the core functions of public health, public health officials at local health departments in six states (Alabama, Maryland, Mississippi, New Jersey, South Carolina, and Wisconsin) were surveyed in 1993 by the state local liaison affiliates of the Association of State and Territorial Local Health Liaison Officials, the School of Public Health at the University of North Carolina at Chapel Hill, and CDC. This report summarizes the findings from this survey.

The questionnaire included 26 questions about the three core functions of public health; these questions were derived from previous surveys (4). Respondents were asked to 1) evaluate whether each of the 10 public health practices existed in their jurisdiction and 2) assess the adequacy of the performance of the practice by the entire community. A total of 395 jurisdictions was surveyed, with respondents being either the local health department director or the district health officer. The office of the state local liaison affiliates received and analyzed completed questionnaires.

Overall, completed surveys were received from 370 (94%) of the 395 jurisdictions surveyed. Of these 370, 313 (85%) served areas with populations of less than 100,000; those jurisdictions accounted for 39% of the population for all six states. The survey represented approximately 11% of the U.S. population and 12% of all U.S. local health departments.

For all respondents, the mean percentage score for performance by the community was 56%. For the presence of the three core functions, the mean percentage scores were 46% for assessment, 53% for policy development, and 68% for assurance. The mean percentage scores for the presence of the 10 specific practices ranged from 38% for planning to 91% for informing and educating (Table_1).

The mean percentage score for the perceived adequacy of performance by the community was 32%. For the adequacy of the three core functions, the mean percentage scores were 27% for assessment, 29% for policy development, and 40% for assurance. The mean percentage score for the adequacy of the 10 basic public health practices ranged from 19% for assessing to 51% for informing and educating (Table_1). Reported by: C Barganier, DrPH, Alabama Dept of Public Health. C Devadason, MD, Maryland State Dept of Health and Mental Hygiene. R Caperton, Mississippi State Dept of Health. D McDonough, MPH, AD Miller, MD, New Jersey State Dept of Health. FH Young, Jr, MD, South Carolina Dept of Health and Environmental Control. L Gilbertson, MS, Wisconsin Dept of Health and Social Svcs. CA Miller, MD, KS Moore, School of Public Health, Univ of North Carolina at Chapel Hill. Association of State and Territorial Local Health Liaison Officials. Div of Public Health Systems, Public Health Practice Program Office, CDC.

Editorial Note

Editorial Note: An assessment by the Institute of Medicine in 1988 highlighted the need to improve essential public health functions in the United States (1). In 1989, a survey of state health officers documented a wide range in the presence of the three core functions at the state level: the function of assessment was being performed in 82% of states; policy development, in 72%; and assurance, in 56% (5). Although the findings in this report contrast with previous findings, they extend understanding of the presence and adequacy of core public health functions to the local level.

The results of this survey are subject to at least two limitations: 1) because this survey was designed as a pilot, the findings cannot be generalized; and 2) the diversity in the organization and activities of the different public health agencies restrict the comparability of the findings. Despite these limitations, refinement of this approach will assist in monitoring efforts to achieve the national health objective to "increase to at least 90 percent the proportion of people who are served by a local health department that is effectively carrying out the core functions of public health" (objective 8.14) (2).


  1. Institute of Medicine. The future of public health. Washington, DC: National Academy Press, 1988.

  2. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

  3. Roper WL, Baker EL, Dyal WW, Nicola RM. Strengthening the public health system. Public Health Rep 1992;107:609-15.

  4. Miller CA, Moore KS, Richards TB, Kotelchuck M, Kaluzny AD. Longitudinal observations on a selected group of local health departments. J Public Health Policy 1993;14:34-50.

  5. Scott HD, Tierney JT, Waters WJ. The future of public health: a survey of the states. J Public Health Policy 1990;11:296-304.

Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Mean summary scores for the percentage performance of a public health
practice in a community and the percentage perceived adequacy of performance of
the practice -- Alabama, Maryland, Mississippi, New Jersey, South Carolina, and
Wisconsin, 1993*
                                                            Perceived adequacy
Function and practice                      Performance        of performance
Assessment                                     46%                 27%
  Assess the health needs                      42%                 19%
  Investigate the occurrence of health
    effects and health hazards                 40%                 25%
  Analyze the determinants of identified
    health needs                               63%                 41%

Policy development                             53%                 29%
  Advocate for public health, build
    constituencies, and identify resources     69%                 38%
  Set priorities among health needs            46%                 26%
  Develop plans and policies to address
    priority health needs                      38%                 21%

Assurance                                      68%                 40%
  Manage resources and develop
    organizational structures                  70%                 49%
  Implement programs                           67%                 37%
  Evaluate programs and provide quality
    assurance                                  46%                 22%
  Inform and educate                           91%                 51%
* Of 395 jurisdictions surveyed, 370 (94%) local health department directors or district health
  officers completed surveys.

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