News From NACCHO

A Look at Local Public Health Governance:

Findings From the 2015 Local Board of Health
National Profile
Sarah J. Newman, MPH; Carolyn J. Leep, MS, MPH
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ocal boards of health (LBOHs) play an important

role in our public health system. They work with
local health departments (LHDs) in a variety of
ways, including establishing public health priorities,
approving budgets, and overseeing local public health
regulations. They serve as an essential link between
LHDs and the communities they serve by representing the communitys interest in adopting priorities and
establishing needed services, while also communicating with the community about LHD goals and services
available.
The National Association of County & City Health
Officials (NACCHO) conducted a survey of LHD administrators to determine the characteristics and functions of LBOHs. The survey assessed LBOH engagement in the 6 functions of public health governance:
policy development, resource stewardship, legal authority, partner engagement, continuous improvement,
and oversight. These functions were identified, reviewed, and developed by the National Association
of Local Boards of Health (NALBOH), the Centers
for Disease Control and Prevention (CDC), and other
partners.1 A sample of findings are presented in following text; all findings are available on the NACCHO
Web site.2

Methods
NACCHO administered the survey to 685 LHDs with 1
or more LBOHs using Qualtrics, an online survey tool,
from July to September 2015. (Refer to the Technical
Documentation for details on how NACCHO determined whether an LHD had an LBOH.)3 A total of 394
J Public Health Management Practice, 2016, 22(6), 609611
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Copyright 

LHDs completed the survey (response rate of 58%).

NACCHO generated nationally representative statistics using estimation weights to account for sampling
and nonresponse. Descriptive statistics were analyzed
using Stata 14 for all respondents and by LHD characteristics, including size of population served by the
LHD (small, <50 000 people; medium, 50 000-499 999
people; and large, 500 000 people) and type of governance (state, local, and shared).
In addition, survey implications and recommendations on LBOH functions were developed on the basis of semistructured interviews with or written feedback from key stakeholders, including LHD leaders,
researchers of LBOHs, and staff from the CDC and
NALBOH.

Percentage of LHDs With an LBOH

More than three-fourths of LHDs (77%) have an LBOH;
however, this varies by the size of the population served
by the LHD and LHD governance (as shown in the
Table). A larger proportion of LHDs that serve small
populations have LBOHs, and locally governed LHDs
are more likely to have an LBOH than LHDs that are
units of their state health department or governed by
both state and local authorities.
Author Affiliation: National Association of County & City Health Officials,
Washington, District of Columbia.
This survey was supported by a grant from the Centers for Disease Control
and Prevention.
The authors declare no conflicts of interest.
Correspondence: Sarah J. Newman, MPH, National Association of County &
City Health Officials, 1100 17th St NW, Seventh Floor, Washington, DC 20036
(snewman@naccho.org).
DOI: 10.1097/PHH.0000000000000476

609
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610 Journal of Public Health Management and Practice

TABLE Percentage of LHDs With LBOHsa

qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Percentage of
LHDs With an
LBOH

All LHDs
Size of population served
Small (<50 000 people)
Medium (50 000-499 000 people)
Large (500 000)
LHD governance
State (local or regional units of the state health
department)
Local (agencies of local government)
Shared (governed by both state and local
authorities)

77
84
68
50
41
86
54

Abbreviations: LBOH, local board of health; LHD, local health department; NACCHO,
National Association of County & City Health Officials.
a N = 2664. These statistics are based on data from all LHDs in the United States on
the presence or absence of LBOHs from NACCHOs National Profile of Local Health
Department surveys and other sources of information.3

Key Findings and Implications

Who serves on LBOHs?
On average, LBOHs have 7 members, although this
varies greatly across LBOHs (ranging from 3 to >30
members). Some LBOHs include members specifically elected or designated by statute to serve on the
board, but LBOH members are most often appointed
to their positions by local elected officials. Nearly half
of LBOHs (47%) appoint all, and 71% appoint some
of their members in this way. Most LBOHs (88%)
include health care professionals, and many include
elected officials (72%) and individuals with public
health training (61%). LBOHs whose membership reflects the diversity of their communities and includes
people from key sectors of the local public health
system are well positioned to develop or strengthen
relationships that are critical for improving community
health.

How are LBOH members trained to do their jobs?

Less than 20% of LBOH members had formal public
health training or experience prior to their service, so
some kind of education program is needed to help them
be effective in their roles. Two-thirds of LBOHs (67%)
provide an orientation for new members, and 61%
also provide ad hoc training on public health-related
topics. Only 20% have a formal ongoing training program for their members, and 35% provide ad hoc training on governance-related topics. This suggests that
LBOHs could benefit from more comprehensive education programs that focus on both governance func-

tions and public health concepts and issues. National

organizations (such as the CDC, NALBOH, and NACCHO) and state organizations (such as state health
agencies and state associations for LBOHs and LHDs)
can assist by developing curricula that could be used
or adapted for local situations.

What guides the activities of LBOHs?

Although 79% of LBOHs are involved in strategic planning for their LHDs, only one-third of boards have
their own vision or mission statement, strategic plan,
or goals and objectives to guide their activities. LBOHs
work collaboratively with LHDs but have different
roles that should be reflected in their own guiding documents. Without a vision, plan, or goals, LBOHs are
unlikely to operate strategically or efficiently, or act as
leaders in the local public health system. Many LBOHs
can bring skills built through participating in strategic planning for the LHD to the process of developing
their own vision, strategic plan, goals, and objectives.
LHD leaders, most of whom also have experience in
agency and community planning, should encourage
and support LBOHs as they develop these guiding
documents.

How do LBOHs work with LHDs?

Most LHDs report a number of ways that that LBOHs
interface with the activities of LHDs, including participating in LHD strategic planning (79%), evaluating the
performance of the LHD top executive (56%), and approving the LHD budget (55%). However, these ties are
not universal. One in 5 LBOHs (21%) are not involved in
their strategic planning process, and more than half of
LHDs where the LBOHs have the final authority to hire
or fire the LHD top executive report that their LBOHs
had not conducted a formal performance evaluation of
their top executive within the past year. A quarter of
LHDs (24%) reported that their LBOHs have not advocated for funding to support public health activities,
and 30% reported that they had not discussed LHD accreditation with their LBOHs. In these cases, LHD and
LBOH leaders should work together to identify and
institutionalize mechanisms to ensure LHD oversight
and improve communication between the LHD and
the LBOH.

How do LBOHs contribute to policy development?

Nearly all LHDs (93%) reported that their LBOHs had
some involvement in policy-related activities during
the previous year, and half reported that their LBOHs
had a major role in at least 1 area of public health policy.
LHD leaders, who may be limited in the kinds of policyrelated activities they can undertake, should encourage

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Local Public Health Governance

their LBOHs to build on their past work and become

more active in public health policy development. In
addition to more traditional areas of public health (eg,
tobacco control, food safety, sanitation), LBOHs should
become more familiar with the broad range of policies with public health implications, such as access to
health care, the built environment, and economic development.

Do LBOHs focus on continuous improvement?

Only 15% of LBOHs have evaluated their own effectiveness, and only 24% have engaged in quality improvement (QI) activities focused on their own operations.
In contrast, 55% of LBOHs have evaluated progress
against community health improvement goals and 36%
have been involved in QI focused on their LHD operations. Thus, while unaccustomed to assessing their own
work, LBOHs likely have some of the skills needed to
undertake their own continuous improvement activities. In fact, LBOHs that have been involved in LHD
QI activities are more likely to engage in their own QI
activities than LBOHs that have not been involved in
LHD QI. In addition to leading by example, LHD leaders can promote training in continuous improvement
for the LBOHs and share resources, tools, and techniques that have proven useful in LHD QI activities.

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Conclusion
Not surprisingly, LBOHs showed great differences in
composition, operations, authorities, and performance
of the 6 governance functions. Overall, this survey
demonstrated some areas of relative strength (eg, policy development, oversight) and some areas for improvement (LBOH strategic planning and continuous
improvement). We encourage LBOHs (and their LHDs)
to assess their own performance of the 6 governance
functions to identify additional ways that they can contribute to the goal of improving community health and
health equity.
REFERENCES
1. National Association of Local Boards of Health. NALBOHs Six Functions of Public Health Governance Web site.
http://www.nalboh.org/?page=GovernanceResources. Published November 2012. Accessed June 15, 2016.
2. National Association of County & City Health Officials. Local Board of Health Profile. www.nacchoprofilestudy.org/
other-materials. Published June 2016. Accessed June 22, 2016.
3. National Association of County & City Health Officials. Local Board of Health Profile: technical documentation. http://nacchoprofilestudy.org/wp-content/uploads/
2014/02/Technical-Documentation.pdf. Published June 2016.
Accessed June 22, 2016.

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