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Health Objectives for the Nation Selected Characteristics of Local Health Departments -- United States, 1989

Although a goal of the year 2000 health objectives is to increase the proportion of persons who receive services from local health departments (LHDs) (1), information regarding LHDs is limited. To characterize the activities, staff, expenditures, and jurisdictions of LHDs, the National Association of County Health Officials (NACHO), in cooperation with the United States Conference of Local Health Officers (USCLHO) and CDC, conducted a nationwide mail survey of LHDs in 1989 (2). This report reviews the services provided by LHDs, the expenditures required to support these services, and health department jurisdictions.

For this survey, an LHD was defined as "an administrative or service unit of local or state government, concerned with health, and carrying some responsibility for the health of a jurisdiction smaller than the state." LHDs were identified through a review of NACHO and USCLHO member mailing lists and inquiries made to state health agencies. The following were excluded: subunits or satellite offices of LHDs; district units providing support for independent local health units; and substate extensions of the state that were not considered by the state to be LHDs.

The questionnaire was mailed in January 1989 to 2932 LHDs in 46 states (Delaware, Hawaii, Rhode Island, and Vermont indicated they had no LHDs) (Figure 1). Three follow-up mailings were made to nonrespondents. To test reliability of responses, a 5% sample was randomly selected, and staff in these health departments were reinterviewed by phone.

Overall, 2269 (77%) of the LHDs returned completed questionnaires. For 1988, the estimated total population in the jurisdictions served by the responding LHDs was approximately 210 million persons; of those who answered the question, 1860 (82%) respondents served jurisdictions with populations less than 100,000, and 403 (18%) served jurisdictions with greater than or equal to 100,000.

The percentage of LHDs reporting activity in specific functions generally increased as the size of the population served by the jurisdiction increased. At least half the LHDs provided services in the following categories: immunizations; reportable diseases; child health; tuberculosis; health education; sexually transmitted diseases; Women, Infant, and Children (WIC) programs; family planning; prenatal care; acquired immunodeficiency syndrome (AIDS) testing and counseling; chronic diseases; and home health care (Figure 2). From 35% to 49% of LHDs provided services to handicapped children and laboratory and dental health services; less than 25% provided services in the following categories: occupational safety and health, primary care, obstetrical care, drug and alcohol use, mental health, emergency medical services, long-term facilities, and hospitals (Figure 2).

Annual expenditures by health departments tended to increase by the size of population served. For LHDs serving greater than or equal to 100,000 population, the median annual expenditure was $3,176,000, and for LHDs serving less than 100,000 population, $260,000.

Single local jurisdictional units were the governmental base for 72% of responding LHDs: 49% county, 13% town or township, and 10% city. Collaboration by several governmental jurisdictions to operate a combined health department commonly involved a city/county relationship (20%). Multicounty districts were uncommon (7%). Reported by: National Association of County Health Officials. United States Conference of Local Health Officers. Public Health Practice Program Office, CDC.

Editorial Note

Editorial Note: The recent report from the Institute of Medicine entitled The Future of Public Health states, "No citizen from any community, no matter how small or remote, should be without . . . the benefits of public health protection, which is possible only through a local component of the public health delivery system" (3). In addition, one of the proposed year 2000 health objectives states that the nation should "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" (1). The NACHO survey provides a current, comprehensive, and quantitative assessment of the activities, resources, staff, and jurisdictions needed to begin monitoring the achievement of this objective and to measure the effectiveness of efforts to strengthen the capacity of LHDs.

The NACHO survey documented that some of the more traditional functions of public health are performed widely at the local level. For example, immunizations, reportable diseases, child health, and tuberculosis continue to be addressed by almost all LHDs. The survey also demonstrated the level of response of LHDs to emerging health problems. For example, 57% reported services in human immunodeficiency virus (HIV) testing and counseling; in jurisdictions with greater than or equal to 100,000 population, 90% reported HIV activities. In comparison, only 23% of LHDs reported occupational safety and health activities.

This survey had several limitations. First, the response rate was markedly lower for LHDs serving smaller populations than for those serving larger populations. In addition, of the 663 nonrespondents, 23% were from two New England states and 47% were from 12 southern states. Therefore, in those regions, the data are skewed against LHDs in regions that serve less populated jurisdictions.

Second, the data were self-reported and the scope, quality, and quantity of activities were not verified. Respondents could have reported that they were "active in" a given service whether they provided the actual service, provided referrals only, or contracted the service. Conversely, LHDs that do not report provision of specific services may not be indicating a lack of those services in the community. For example, even though only 43% of LHDs reported providing laboratory services, many more may have access to laboratory services through a local provider or a state health agency (4). Finally, the importance of the presence or absence of a service must be judged in relation to the community's need, which was not determined in this survey.

Findings from this survey suggest that additional information is needed about services provided by LHDs, functions and services that need to be provided, and the manner in which LHDs should be supported to assure that their communities' health needs are met. CDC has made the goal of helping to strengthen the public health system a major priority and has developed a detailed plan for achieving this goal (CDC, unpublished data).


  1. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives (Conference ed). Washington, DC: US Department of Health and Human Services, Public Health Service, 1990.

  2. National Association of County Health Officials. National profile of local health departments: an overview of the nation's local public health system. Washington, DC: National Association of County Health Officials, 1990.

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

  4. Jonas S. Provision of Public Health Service. In: Last JM, ed. Public health and preventive medicine. 12th ed. Norwalk, Connecticut: Appleton-Century-Crofts, 1986:1628-9.

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