Local 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 community's 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
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 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.
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 functions 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 policy-related activities they can undertake, should encourage 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.
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.