The National Association of Local Boards of Health (NALBOH) is the national voice of health department boards and shapes public health policy. Since its founding in 1992, NALBOH has formed connections with board of health members and elected officials across the nation. Uniquely positioned to deliver technical expertise in governance and leadership, board development, health priorities, and public health policy, NALBOH strives to strengthen governance where public health begins—at the local level.
One of NALBOH's enduring contributions has been the development and advancement of a defined set of governance functions to guide boards of health in their work. Driven by a mission to strengthen and improve public health governance, NALBOH identified, reviewed, and developed a model that would be accepted as the core purpose of a board of health. With support from a variety of national partners—including the Public Health Accreditation Board (PHAB)—the “Six Functions of Public Health Governance” were introduced. This model has become the focus of education and training for board members and provided the guiding principles for board development (Figure).
These functions share many characteristics of the accreditation standards. It is no surprise then that nearly 20% of NALBOH members are from accredited health departments. This congruence is increasingly important as boards work to provide support to health departments facing increasing pressures. Boards of health are always looking for new and innovative ways to help departments secure the funding, resources, and workforce necessary to manage new and emerging threats in their communities.
One such development is the need for increased community partnerships. Highlighted throughout the PHAB standards, and specifically named as a core function of board governance, community and partner engagement has become a necessity.
How can the board of a single public health agency or hospital make a meaningful and sustainable improvement in the health of a community—not only in terms of patients' health but also with respect to crime, water, shelter, employment, and other pressing community issues?
It Cannot Alone!
If, on the contrary, the local board of health and the hospital board—along with those of relevant nongovernmental organizations and private sector institutions—were to collaborate, the community's collective good could be well served. This is the simple proposition that underlies the concept of “collaborative governance”—defined as a structured process in which boards with a common interest across a community engage in joint needs analysis, planning, and implementation in service of the collective good and then share accountability to pool resources and collectively monitor progress to plan for better health gain, not just health care.1 Several examples of this cooperation are described in the report summarizing insights from the Foster McGaw Award program.2
In many communities, however, it is not easy to accomplish such collaboration across governing bodies. Recent surveys of local public health department leaders suggest 8 constraints to collaborative governance:
- Many local county health departments still have modest budgets and staff to support new program enhancements.3,4
- Only 33% of local health departments have a clear strategic plan for their region.5
- Only 34% of local health boards know other community leaders serving on boards of local hospitals or health centers.6
- Community organizations lack a critical mass of shared funding.
- There is a weak understanding of the social determinants of health.
- Many lack a conceptual model for “collaboration.”
- There is a lack of experience in scenario-based strategy.
- There is a lack of “backbone organization” for support.
Practical strategies to strengthen collaborative governance can be found in the recent NALBOH survey calling for expanded local board educational opportunities6 and in the Ontario, Canada experiences for cross-sectoral cooperation and planning.7
An essential starting point for the cooperation has been found in joint planning built from collaboration to define community health needs8 and then cocreating and funding sustainable initiatives to attack the top 5 community health issues and improvement opportunities in “collective impact”–style programming.9
Early results from such collaborative planning can be seen in rural Montevideo, Minnesota,10 where the Critical Access Hospital (Chippewa County Montevideo Hospital)11 joined forces with community leaders and the Countryside Public Health Agency12 to develop enhanced shared community health initiatives.
To catalyze and accelerate collaborative governance for health gain, local boards of health will find it useful to use language and concepts about cooperative community health planning familiar to their partner hospital boards, according to this study of 25 years of insights from the Foster McGaw Award program,2 and also work done with Federally Qualified Health Centers.13
In addition, PHAB Standard 4.1 requires public health agencies to demonstrate that they “Engage with the public health system and the community in identifying and addressing health problems through collaborative processes.”14 The public health agency has a clear responsibility to work toward a collaborative community approach.
Domain 12 of the PHAB Standards and Measures is devoted to the governing body functions and is titled, “Maintain Capacity to Engage the Public Health Governing Entity.”14 Throughout these standards, the capacity of the health department's governing body is critically evaluated and capacity of the health department to conduct the governance function is objectively reviewed. Examples of a specific governance standard include the following: “The health department must document communications with the governing entity on plans and processes for improving health department performance.”14 Documentation to support achievement of this standard requires the health department to provide at least 2 examples within the past 5 years that were provided to the governing board.
Beyond the governance standards in Domain 12, PHAB accreditation of the public health agency is an essential tool of effective public health department governance. The process of conducting the self-study and each of the prerequisite elements provide evidence of a commitment by the health department and its board to serious evaluation and accountability. The results of the PHAB accreditation process provide the board with important information regarding both baseline organizational capacity and the achievement of PHAB accreditation—a tangible and impartial symbol of national achievement of public health capacity that the health agency provides on behalf of the community. While the general public may not understand all of the intricacies of public health requirements, most community members will recognize the “Good Housekeeping Seal of Approval” that is conferred by PHAB. Board members can point with pride to their health department “meeting or exceeding national standards” and further remind the community of the importance of “their nationally accredited public health agency.”
These are just a few of the many examples across the country of boards applying the governance functions and accreditation standards to strengthen and improve public health. Boards of health, working in partnership with other community leaders, have best been able to assess and prioritize their community needs, as well as plan for action together.
NALBOH looks forward to continued work with PHAB and others to find and promote new ways for board of health members to improve public health through board governance. Innovations and practices such as those shared are just one example of how we can move forward, together.
14. Public Health Accreditation Board. Standards & Measures Version 1.5. Alexandria, VA: Public Health Accreditation Board; 2013.