ASTHO Profile

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Attachment F

ASTHO Profile of State Public Health
Volume Three

Contents
Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
A Letter from the Executive Director. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
A Letter from CDC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
A Letter from RWJF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Top 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Part I–State Public Health: Who We Are. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Chapter 1: State Health Agency Structure, Governance, and Priorities. . . . . . . . . . . . . . . 17
Chapter 2: State Health Agency Workforce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Part II–State Public Health: What We Do. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Chapter 3: State Health Agency Activities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Part III–State Public Health: How We Do It. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Chapter 4: Planning and Quality Improvement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Chapter 5: Health Information Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Chapter 6: State Health Agency Finance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

State Profiles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

ASTHO Profile of State Public Health, Volume Three 3

Acknowledgments
We are grateful to the many people who made substantial contributions to this report. Publication
of the ASTHO Profile of State Public Health, Volume Three would not be possible without generous
financial support from the Robert Wood Johnson Foundation and CDC. The vision and support
provided by RWJF and CDC leaders has been invaluable to this effort.
We are thankful to Jim Pearsol for his leadership, guidance, and dedication to state public health.
The members of the ASTHO Survey Advisory Workgroup and Data Harmonization Workgroup
provided thoughtful recommendations and useful suggestions for further improvement of the
survey throughout the process.
Kyle Bogaert assisted in followup with state health agencies, cleaned and analyzed the data, and
generated the tables and figures that appear in this report. Kunthea Nhim verified all of the data in
the report and created a master codebook, available online at www.astho.org/profile, which allows
researchers to compare the 2007, 2010, and 2012 questionnaires item by item.
Lisa Junker and ASTHO’s Communications team provided editorial support. PCE Systems developed
and hosted the web-based survey. Belmont, Inc. designed the publication and Linemark printed it.
Most importantly, we would like to thank the staff of the 49 state health agencies that responded
to the survey. They put a substantial amount of effort into answering the lengthy questionnaire that
forms the basis of this dataset. We appreciate their commitment to their work and their willingness
to make time for this important effort.

Katie Sellers, DrPH, CPH
Chief Science & Strategy Officer
ASTHO

4 Association of State and Territorial Health Officials

Rivka Liss-Levinson, PhD
Director, Survey Research
ASTHO

A Letter from the Executive Director
I am honored to share the ASTHO Profile of State Public Health, Volume Three, with
results from our third survey of state and territorial health agencies. Since 2007, the
profile report has served as an essential guide to understanding the current activities
of state health agencies and new developments on issues such as governance,
quality improvement and accreditation, workforce, finance, and health information
technology. I hope you enjoy this comprehensive look at state public health.
Volume three of the ASTHO Profile of State Public Health details some exciting developments and
continued challenges for state health agencies. The survey found that they are making substantial
strides forward to complete the prerequisites for national voluntary accreditation through the
Public Health Accreditation Board. The percentage of state health agencies that have completed a
state health assessment plan, state health improvement plan, and agency-wide strategic plan has
increased from 2010 to 2012.
Many health agencies have also made significant progress in their use of health information
exchanges and health information technology. States are increasingly engaging in bidirectional
information sharing and using health information exchanges to monitor and communicate about a
variety of health topics.
Both of these accomplishments speak to the resilience of state health departments in the face
of budget cuts. Despite limited funding and an estimated decrease in the size of the state health
agency workforce from 2010 to 2012 of nearly 6,000 full-time equivalents, agencies continue to
provide a broad array of services and are taking on new projects and initiatives to further improve
health and well-being in their jurisdictions.
We remain continuously grateful to ASTHO’s members for devoting time and effort to completing
this exhaustive survey. The Profile report would not be possible without their generosity and
willingness to share their experiences.
We welcome your feedback on this report and the survey. Please feel free to provide comments and
suggestions on our survey scope and questions or what future analyses would be most valuable to
you. Reliable and comprehensive data is one of the best ways to demonstrate the value of public
health to this nation. Thank you for reading and your support for state public health.

Paul E. Jarris, MD, MBA
Executive Director
Association of State and Territorial Health Officials

ASTHO Profile of State Public Health, Volume Three 5

A Letter from CDC
Dear Colleague:
The Centers for Disease Control and Prevention (CDC) is pleased to
have supported the Association of State and Territorial Health Officials
(ASTHO) in its work to develop the ASTHO Profile of State Public Health,
Volume Three. CDC congratulates ASTHO for the release of this report,
which will help state and local health departments, policymakers,
federal agencies, governing bodies, researchers, and others better understand the foundational
public health capabilities of our nation’s states.
The ASTHO Profile of State Public Health, Volume Three provides comprehensive data about state
health department responsibilities, organization and structure, workforce, planning, and quality
improvement activities. I would like to commend ASTHO and the state health departments that
provided these data for their dedication and contribution to public health. We anticipate that
the data presented in this report will provide many opportunities to inform policy, practice, and
research, as well as advance our mutual goal of improving population health outcomes.
Sincerely,

Thomas R. Frieden, MD, MPH
Judith A. Monroe, MD
Director, CDC
Director, Office for State, Tribal, Local,
and Territorial Support, and

Deputy Director, CDC

6 Association of State and Territorial Health Officials

A Letter from RWJF
Dear Colleague:
We are pleased to support the ASTHO Profile of State Public Health, Volume Three.
This report provides a comprehensive look at state public health that enables
public officials and policymakers to make critical, well-informed decisions working
with partners across the public and private sectors to strengthen America’s public
health system.
This profile is part of a collaborative effort between ASTHO and the National Association of City and
County Health Officials (NACCHO)—with leadership from the National Coordinating Center for Public
Health Services and Systems Research (PHSSR) at the University of Kentucky—to develop a complete
picture of governmental public health in the United States. This partnership assists in identifying
best practices to organize, manage, finance, and structure public health systems and services and
to answer questions relevant to public health practice and policymaking, including those emerging
in our work with CDC to develop a national agenda for PHSSR. In addition, information in the
profile on key trends such as state health agencies’ intent to pursue accreditation and use of health
information technology to communicate about a variety of health topics informs the system-level
changes that are needed to improve the nation’s health.
We applaud the 49 agencies that so generously devoted time and effort to respond to the
questionnaire. It is a testament to your dedication and to the leadership of ASTHO to ensure the
success of this effort. I would like to express our gratitude and commend all who have contributed
to this invaluable resource, and I look forward to continuing our work together building a national
Culture of Health.

Risa Lavizzo-Mourey, MD, MBA
President and CEO
Robert Wood Johnson Foundation

ASTHO Profile of State Public Health, Volume Three 7

Executive Summary
The ASTHO Profile of State Public Health, Volume Three
highlights findings from the 2012 ASTHO Profile Survey.
ASTHO is the national nonprofit organization representing
public health agencies in the United States, its territories
and freely-associated states, and the District of Columbia
and the more than 100,000 public health professionals
that these agencies employ. ASTHO members, the
chief health officials of these jurisdictions, develop and
influence public health policy and ensure excellence
in state-based public health practice. ASTHO’s primary
function is to track, evaluate, and advise its members on
the impact and formation of public or private health policy
that may affect them and provide them with guidance and
technical assistance on improving the nation’s health.
The ASTHO Profile of State Public Health is the only
comprehensive source of information about state
public health agency activities, structure, and resources.
Launched in 2007 and fielded every two to three years,
the Profile Survey aims to define the scope of state public
health services, identify variations in practice among state
public health agencies, and contribute to the development
of best practices in governmental public health.
This report describes the structure, functions, and
resources of state health agencies and indicates what data
are available for public use from the 2012 ASTHO Profile
Survey. Comparisons by state governance classification,
geographic region, and state population size are discussed
when appropriate. Also, when applicable, the 2012
findings are compared with data from the 2010 and 2007
ASTHO Profile Surveys.
Part I—State Public Health: Who We Are is comprised
of two chapters. The first chapter describes the structure
and governance of state health agencies, including the
number of local and regional health departments in each
state, and the appointment of the health official. The
second chapter provides a detailed picture of the roughly
101,000 employees at state health agencies, including
information on the positions, salaries, and demographics
of state health agency workers, trends in retirements and
vacancies, and information about the qualifications of
state health officials.

Part II—State Public Health: What We Do outlines
the public health activities conducted by state health
agencies. Activities documented include prevention;
screening and treatment services; laboratory services;
data, epidemiology, and surveillance activities; maternal
and child health services; environmental health activities;
and research activities, among others. Additionally, this
chapter includes information on various federal programs
that state health agencies have responsibility for, as well
as the technical assistance agencies provide to a number
of different related parties.
Part III—State Public Health: How We Do It is composed
of three chapters that examine how state health agencies
are able to accomplish the myriad activities they perform
by describing planning and quality improvement and
health information management at state health agencies,
as well as state health agency finance. The chapter on
planning and quality improvement describes states’
progress toward accreditation as well as the status of
quality improvement and performance management in
state health agencies. The chapter on health information
management discusses the status of informatics and
health information exchanges at agencies, as well as the
electronic collection and dissemination of data. The final
chapter in this section, on state health agency finance,
provides insight into the expenditure categories at
state health agencies, the various revenue and funding
sources for public health, and funds distributed from
state health agencies.
State Profiles provide a snapshot of the health
agencies in each of the 48 responding states and the
District of Columbia, including information about their
governance, finances, local health departments, and top
priorities.
To view or download the complete Profile report, or
request access to Profile data, visit www.astho.org/profile.
ASTHO thanks the Centers for Disease Control and
Prevention and the Robert Wood Johnson Foundation for
their generous support of the Profile.
Recommended citation: Association of State and Territorial Health
Officials. ASTHO Profile of State Public Health, Volume Three. Washington, DC: Association of State and Territorial Health Officials. 2014.

ASTHO Profile of State Public Health, Volume Three 9

Top 20
The top 20 consists of the most significant, timely, and relevant findings from
the 2012 ASTHO Profile Survey. They include the following:

1. Nearly 30 percent of states (n=14) have a

centralized or largely centralized governance
structure where local health units are primarily led
by state employees, with a mean number of 28
state-run local health departments in each state.
2. State health agencies do not generally share

resources with each other. When they do, it is
typically for all-hazards preparedness and response
(58%) and epidemiology or surveillance (36%).
3. State health agencies serve as leaders in the

integration of the public health and healthcare
sectors by being highly collaborative with
hospitals, physicians, and other entities in the
healthcare sector.
4. The state health agency workforce was comprised

of approximately 101,000 full-time equivalents
(FTEs) in 2012. From 2010 to 2012, both the
number of FTEs and the number of staff members
have shown a decrease of more than 5,000.
5. The 2012 Profile Survey represents the first time

ASTHO has collected demographic data on the
state health agency workforce. The majority
of the state health agency workforce is white,
non-Hispanic/Latino, and female. Overall, the state
health agency workforce has a greater proportion
of women than the U.S. population, is more
racially diverse than the U.S. population, and has
a smaller proportion of Hispanics/Latinos than the
overall U.S. population.
6. In 2012, 12 percent of state health agency positions

were vacant on average, but only 24 percent of
those positions were being actively recruited for.

10 Association of State and Territorial Health Officials

7. From FY 2012 to FY 2016, the percentage of state

health agency employees who are eligible to retire
is expected to increase from 18 to 25 percent.
8. State health agencies frequently have programmatic

and fiscal responsibility for federal initiatives.
When they do not have sole responsibility, they
typically share it with a local governmental agency
or nonprofit organization. Nearly all state health
agencies have responsibility for CDC’s Public Health
Emergency Preparedness cooperative agreement,
Title V Maternal and Child Health funding, vital
statistics, the Preventive Health and Health Services
Block Grant, and the ASPR Hospital Preparedness
Program cooperative agreement.
9. State health agencies provide technical assistance and

training to a variety of partners, including emergency
medical services, healthcare providers, hospitals,
and laboratories. The most common topic area for
which technical assistance and training are provided is
quality improvement, accreditation, and performance.
States most commonly provide training for local
health departments. The most common training
topics are disease prevention and control, tobacco
prevention and control services, and preparedness.
10. State health agencies serve a critical role in

promoting and protecting the health of their citizens,
and access to healthcare services is a key element
of that effort. The majority of state health agencies
engage in health disparities, minority health, and
rural health initiatives; 71% of state health agencies
provide financial support to primary care providers.

11. State health agencies provide a wide range of

population-based primary prevention services.
The greatest numbers of states provide tobacco
prevention and control services, HIV prevention
programs, and sexually transmitted disease
counseling and partner notification.
12. Research plays an important role at state health

agencies, with 90 percent reporting both collecting,
exchanging, or reporting on data and results and
disseminating research findings to stakeholders. The
mean number of studies conducted by state health
agencies in the two-year timeframe was 46 and the
median number was 15.
13. State health agencies have been engaged in

accomplishing the prerequisites for the Public
Health Accreditation Board’s (PHAB) voluntary
national accreditation program, with 69 percent
having completed a state health assessment, 57
percent a state health improvement plan, and
75 percent a strategic plan. From 2010 to 2012,
the percentage of state health agencies that have
completed each prerequisite has increased.
14. In 2012, 80 percent of state health agencies indicated

that they had decided to seek accreditation through
the voluntary national accreditation program. Of the
26 states that indicated that they planned to pursue
accreditation but had not yet submitted a letter of
intent, 85 percent intended to do so in 2013 or 2014.
15. Quality improvement continues to play a significant

role in state health agencies, with state health
agencies frequently using the Plan-Do-Check-Act or

Plan-Do-Study-Act framework, and 96 percent of
agencies having implemented some kind of formal
quality improvement activities.
16. The capacity for electronic data exchange is

significant at state health agencies, with the
majority of electronic data collected through
systems implemented on the state level.
17. State health agencies have made progress toward

the Meaningful Use public health objectives,
with the majority of state health agencies having
the systems in place to meet those objectives.
Additionally, the majority of state health agencies
have the capacity to send and receive data with
federal agencies.
18. For FY 2010 and FY 2011, the two largest spending

categories in state health agency budgets were
improving consumer health, which includes clinical
services, and WIC.
19. More than half of state health agency revenue

(53%) was sourced from federal funds in FY 2011,
with the U.S. Department of Agriculture and CDC
providing the greatest percentage of those funds.
20. State health agencies partner with a number of

other entities, distributing funding to local health
departments, nonprofit organizations, other
governmental entities, and other recipients.
Forty-four percent of state health agency
contracts, grants, and awards were awarded to
local health departments.

ASTHO Profile of State Public Health, Volume Three 11

Introduction
This report marks the 2014 release of the Association
of State and Territorial Health Officials (ASTHO) Profile
Survey of State Public Health. The ASTHO Profile Survey
is the only comprehensive source of information about
state, territorial, and freely associated state public health
agency activities, structure, and resources. The Profile
Survey aims to define the scope of state public health
services, identify variations in practice among state public
health agencies, and contribute to the development of
best practices in governmental public health. The Profile
drives improvement at state health agencies, educates

policymakers, enables the sharing of best practices
among state health agencies, and is a resource to the field
of public health systems and services research (PHSSR).
This is the third survey in a series; prior surveys were
completed by state and territorial health agencies in 2007
and 2010. In October 2012, ASTHO launched the third
version, sending a link to the web-based survey to senior
deputies from the 50 states, DC, and eight territories and
freely associated states. The 121-question instrument
covers the following topic areas:

Figure 0.1: State Population Size

MN
OR

VT
MI

NJ
DE

TN
AR
MS

MA
CT

NE
NV

No Data*

Small

Medium

Large

* States that did not respond to the survey were not used in the calculation of population
tertiles for subsequent analyses.

12 Association of State and Territorial Health Officials

1. Structure, governance, and priorities
2. Workforce
3. State health agency activities
4. Planning and quality improvement
5. Health information management
6. Finance
Along with general instructions, senior deputies
received recommendations on the most appropriate
staff/departments to fill out each section of the survey.
Surveys could be filled out by multiple personnel in
multiple sittings. A question-and-answer webinar was
held midway through the survey administration period to
clarify instructions, resolve technical issues, and respond
to item-specific questions. Senior deputies were asked
to complete the survey by Dec. 1, 2012. However, the

survey administration system was held open until May
2013 to allow as many states and territories to complete
the survey as possible. At the close of survey administration, the Profile Survey response rate was 96 percent
among the 50 states and DC, and 92 percent among all
states, territories, and freely associated states. Results
from the five territories and freely associated states that
responded to the survey will be published in a separate
report. Extensive followup was conducted with the states
throughout 2013 to verify responses. When response
errors were identified, ASTHO’s Survey Research team
worked with the state to correct these responses. In
instances where the state did not respond to multiple
follow-up attempts, the Survey Research team used their
expertise to determine whether or not to retain the data.

Figure 0.2: Combined Health and Human Services Regional Classification

WA
10

ND
8

MT
8

OR
10

ID
10

NV
9

SD
8

WY
8

UT
8

MN
5

AZ
9

MO
7

KS
7

CA
9

OK
6

NM
6
TX
6

MI
5

IA
7

NE
7
CO
8

WI
5

IL
5

LA
6

NY 2

IN
5

PA
3

OH
5
WV
3

KY 4

MS
4

AL
4

VA
3

MA 1

NJ 2
DE 3
MD 3

RI 1
CT 1

NC
4

TN 4

AR
6

VT
1 NH
1

ME
1

GA
4

SC 4

DC 3

FL
4

HI
9
AK
10

New England; HHS Region 1 and 2

Mountains and Midwest; 7 and 8

Mid-Atlantic and Great Lakes; 3 and 5

West; 9 and 10

South; 4 and 6

ASTHO Profile of State Public Health, Volume Three 13

Differences Between Surveys
In an effort to continuously improve the Profile Survey
and the quality of our data, several notable changes
were made to the survey from the 2010 version. ASTHO
convened a Survey Advisory Workgroup consisting of
state health agency senior staff, researchers, ASTHO staff
and alumni, and representatives from national public
health partner organizations to review initial drafts of the
survey instrument, make recommendations on content,
formatting, survey administration, and analyses, and
pilot test the survey. Staff also leveraged the expertise
of two of ASTHO’s peer networks, the Human Resources
(HR) Directors Peer Network and the Chief Financial

Officers Peer Network, in making modifications to the
Workforce and Finance sections of the instrument.
Findings from these meetings and the 2010 Profile
Survey evaluation report were used to make revisions to
the 2012 survey instrument, including the following:
1. The number of questions in the Structure,
Governance, and Priorities sections of the survey was
significantly reduced between 2010 and 2012.
2. Questions about state health official authority,
qualifications, and salary were moved to the
Workforce section. ASTHO recommended that HR
directors fill out these questions instead of state
health officials. In addition, text boxes for additional
comments and clarifications were included in the
Workforce section based on the feedback of the HR
Directors Peer Network.

Figure 0.3: Governance Classifications*

MN
OR

IL
UT

NM
TX

NJ
DE

TN
AR
LA

WV
KY

MA
CT

VT
NH

NE
NV

* Governance classification categories were collapsed such that centralized/largely centralized
states were compared to decentralized/largely decentralized states in subsequent analyses.

14 Association of State and Territorial Health Officials

Largely Centralized

Largely Shared

Centralized

Shared

Mixed

Decentralized
L argely
Decentralized

3. Response options for the Activities section questions
were modified between 2010 and 2012 to ease
response burden and clarify instructions.
4. The Planning and Quality Improvement section was
modified to ask additional questions about accreditation status and preparations.
5. The Health Information Management section was
redesigned to collect the most useful information
on health information exchanges and to include
questions on Meaningful Use public health objectives.
6. In the Finance section, respondents were asked to
report actual expenditures for a list of expenditure
categories (e.g., chronic disease, all-hazards
preparedness and response) by source of funding
(e.g., state general funds, fees and fines). In addition,
respondents were asked to further break down
federal spending by source of funding (e.g., CDC,
HRSA, Medicare) for each expenditure category.

Structure of Report
The report is structured to provide a narrative of state
health agencies and has been divided into several
sections. Part I—State Public Health: Who We Are
provides background on the structure and composition
of state public health agencies. Within this section is
Chapter 1: State Health Agency Structure, Governance,
and Priorities and Chapter 2: State Health Agency
Workforce. Part II—State Public Health: What We Do
describes the roles and responsibilities of state health
agencies and contains Chapter 3: State Health Agency
Activities. The third section of the report, Part III—State
Public Health: How We Do It, reviews the mechanisms
state health agencies use to accomplish the activities
described in Part II. Chapters in this section include the
following: Chapter 4: Planning and Quality Improvement,
Chapter 5: Health Information Management, and
Chapter 6: State Health Agency Finance. Finally, Part
IV—State Profiles contains a one-page summary of key
information about each state from the report.
When possible, 2012 data are compared with data from
2010, and in some instances, data from 2007 as well.
Care has been taken to include only those comparisons
that represent meaningful differences between data
from 2012 and data collected in prior rounds of the
survey. While it is possible that some variations in
the data reported between 2007, 2010, and 2012
may be due to survey refinement or changes within
the particular state health agencies that responded

to each question rather than actual changes in state
health agency practices, we have tried to minimize this
possibility in the development of the questionnaire.
When relevant, chapters also include discussion of notable
differences based on three organizational characteristics:
1. Size of population served. State health agencies
were categorized as small, medium, or large based on
tertiles of the size of the population served. To estimate
the size of the population served, 2012 population
estimates from the U.S. Census Bureau1 were used.
Figure 0.1 displays a map of states by population size.
2. Region of the United States. Regional classifications
are based on the U.S. Department of Health and
Human Services regions,2 which were paired to
increase the number of state health agencies for
comparison in each region. Figure 0.2 displays a map
of states by HHS region.
3. State health agency governance. State health
agencies classified as centralized/largely centralized
were compared with state health agencies classified
as decentralized/largely decentralized. Chapter 1
provides more detailed information on governance
categories. State health agencies with a shared or
mixed governance structure were not included in
the governance comparisons. A map of states by
governance structure is displayed in Figure 0.3.

Additional Information
The ASTHO Profile of State Public Health, Volume Three
is available online as a downloadable PDF on ASTHO’s
website at http://www.astho.org/Profile. Also available
on this page is additional information about the Profile
Survey, including a downloadable questionnaire,
codebook, slides of all tables and figures that appear
in this report, and several issue briefs and infographics.
ASTHO also encourages researchers who are interested
in conducting analyses using Profile Survey data to visit
http://www.astho.org/Research.aspx for details on how
to request data and the process for obtaining a data use
agreement. General inquiries about the Profile Survey or
this report may be sent to [email protected].
1 U.S. Census Bureau. “State & County QuickFacts.” Available at
http://quickfacts.census.gov/qfd/index.html. Accessed 3-5-2014.
2 U.S. Department of Health and Human Services. “HHS Region
Map.” Available at http://www.hhs.gov/about/regionmap.html.
Accessed 3-5-2014.
ASTHO Profile of State Public Health, Volume Three 15

Part I–State Public Health:

Who We Are

Chapter 1: State Health Agency Structure,
Governance, and Priorities

Key Findings:
• In 2012, 28 state public health agencies (58%)

are freestanding/independent agencies, while 20
(42%) are a unit of a larger umbrella agency.
• In 2012, 48 state public health agencies reported

having a total of 2,744 local health departments
and 298 regional or district offices.
• Twenty-two state health agencies (45%) report

having a state board of health. An additional four
states (8%) report having an entity that performs
similar functions.

• States health agencies do not generally share

resources with each other. When they do, it is
typically for all-hazards preparedness and response
(58%) and epidemiology or surveillance (36%).
• State health agencies report being highly collab-

orative with local public health agencies, hospitals,
and many other entities in the healthcare field.
• In three-quarters of state health agencies (76%),

the state health official is appointed by the
governor of the state.

ASTHO Profile of State Public Health, Volume Three 17

Structure, Governance, & Priorities

This chapter addresses the structure, governance, and priorities of state public
health agencies. The manner in which a state health agency is structured can
vary; some state health agencies are part of a larger agency, while others are
not. States also vary in the extent of state governmental authority over local
health agencies, the rules surrounding the appointment of the state health
official, and the types of partnerships and collaborations they engage in with
other governmental and nongovernmental entities. This chapter will explore
the structure of agencies, comparing 2012 data with 2010 and 2007 data,
when possible, and will note differences in structure by agency characteristics
when applicable.

The structure of a state public health agency refers to the
placement of the state public health agency within the
larger departmental/organizational structure for the state.
State public health agencies can either be freestanding/
independent agencies or a unit of a larger agency, also
referred to as an umbrella agency or super-agency. State
public health agencies located within a larger agency
often reside in that agency with other programs such as
Medicaid and Medicare, public assistance, and substance
abuse and/or mental health services.
In 2012, 28 state public health agencies (58%) were
freestanding/independent agencies, while 20 (42%) were
a unit of a larger umbrella agency.3 These proportions
have remained almost identical to the percentages for
2007 and 2010 (in both years, 56% were freestanding/
independent agencies and 44% were under a larger
agency). While these numbers show that a net total of
one state moved from being under a larger agency to
being a freestanding/independent agency, it is worth
noting that seven states actually changed structures from
2010 to 2012. A similar percentage of centralized/largely
centralized4 and decentralized/largely decentralized5
states are freestanding/independent agencies (62% and
60%, respectively). Twice as many state health agencies in
the South are freestanding/independent agencies (n=8)

than are under a larger agency (n=4). States with medium
and large populations are more likely to be freestanding/
independent agencies (65% of medium-sized states
and 80% of large states) than are states with small
populations (31%).
States that reported being under a larger agency
(n=19-21) were asked the major areas of responsibility
of the larger agency that are separate from the statutory
responsibility of the state/territorial public health agency.
Figure 1.1 shows the other major areas of responsibility
of the larger agency that reported data in 2007, 2010,
and 2012. In 2012, the top three areas of responsibility were long-term care (95%), state mental health
authority with substance abuse (90%), and Medicaid
and public assistance (both 70%). While responsibility
for mental health and substance abuse has continued to
rise among the larger umbrella agencies over time (68%
in 2007, 76% in 2010, and 90% in 2012), responsibility
for Medicaid has demonstrated the reverse trend (90%
in 2007, 81% in 2010, and 70% in 2012). In the New
England region, 75 percent of states report larger agency
responsibility for mental health without substance abuse
in 2012. In contrast, this service is provided by 0 to 33
percent of states in the other four regions. State health
agencies in states with medium-sized populations are
less likely to provide public assistance (33%) than are
state health agencies in large states (67%) and small

Figure 1.1: Responsibilities of Larger Umbrella Agencies, 2007-2012 (n=19-21)
100%

95%

90%

90%
81%

79%

76%
70%

68%

Percentage of states

75%

71% 70%

67%
50%
43%

47%

43%

32%

30%

2007

24%

21%
5%

2010

Super-Agency Responsibility

18 Association of State and Territorial Health Officials

Other

Environmental protection

State/territorial mental
health authority without
substance abuse

Substance abuse

Public assistance

Medicaid

State/territorial mental
health authority with
substance abuse

2012
Long-term care

Structure, Governance, & Priorities

Agency Structure

Numbers and Types of Local
Health Departments
In 2012, 48 state public health agencies reported
having a total of 2,744 local health departments and
298 regional or district offices.6 Table 1.1 displays
the mean, median, minimum, and maximum number
of independent local health departments (led by
staff employed by local government), state-run local
health departments (led by staff employed by state
government), independent regional or district offices
(led by non-state employees), and state-run regional
or district offices (led by state employees). The average
number of local and regional health departments has
not changed notably from 2010 to 2012.

3 One state did not respond to this survey item.
4 “Centralized/largely centralized” refers to a governance structure
in which local health units are primarily led by employees of the
state and the state retains authority over most decisions related
to the budget, issuing public health orders, and the selection of
the local health official. See pages 20 and 21 for more detailed
information about governance classifications.
5 “Decentralized/largely decentralized” refers to a governance
structure in which local health units are primarily led by
employees of local governments and the local governments
retain authority over most key decisions. See pages 16 and 17
for more detailed information about governance classifications.
6 One state did not respond to this survey item.

Table 1.1: Number of Local and Regional Health Departments, 2010-2012 (n=48)
2010

2012

Mean

Median

Min

Max

Mean

Median

Min

Max

Independent local health departments

44.40

20.00

351.00

State-run local health departments

11.25

94.00

43.79

19.50

351.00

13.38

94.00

Independent regional or district offices

0.92

State-run regional or district offices

4.29

20.00

1.60

21.00

33.00

4.60

1.50

33.00

Table 1.2: Average Number of Types of Local and Regional Health Departments by State Health Agency Characteristics
SHA Characteristic

Mean Number of Health Departments
Local Health Departments

Regional Health Departments

Governance (n=38)

Independent Local

State-Run Local

Independent Regional

State-Run Regional

Centralized/largely centralized

1.00

28.00

0.38

6.23

Decentralized/largely decentralized

73.72

2.88

2.92

New England

72.88

7.13

5.00

South

30.83

48.92

0.92

5.08

Mid-Atlantic and Great Lakes

46.58

2.00

5.50

Mountains/Midwest

49.70

3.10

0.90

2.40

West

15.50

5.00

Small

11.31

5.38

0.56

3.63

Medium

39.94

28.76

1.53

3.71

Large

82.80

4.47

2.80

6.67

Region (n=48)

Population Size (n=48)

ASTHO Profile of State Public Health, Volume Three 19

Structure, Governance, & Priorities

The number of local and regional health departments
shows an expected relationship with governance classification, such that decentralized/largely decentralized
states report many more independent local health
departments than centralized/largely centralized states
do, while centralized/largely centralized states report
many more state-run local health departments than
decentralized/largely decentralized states do. This
finding, along with regional and population trends,
is displayed in Table 1.2. Other notable findings
include the South having a greater average number
of state-run local health departments (48.92) than all

states (91%). None of the larger umbrella agencies in
large states provide substance abuse services, while
64 percent of umbrella agencies in small states and 50
percent of those in medium states do. Only in small
states (55%) do the larger umbrella agencies provide
mental health without substance abuse services. No
umbrella agencies in medium or large states do so.

Structure, Governance, & Priorities

other regions (averages for other four regions range
from 0-3.10), and large states having significantly more
independent local health departments on average
(82.80) as compared with small (mean = 11.31) and
medium (mean = 39.94) states. The number of local
health departments by state is displayed in Figure 1.2.

Governance Structure
The relationship between state health agencies and
regional/local public health departments differs across
states. These structural differences have important
implications for the delivery of essential public health
services. Identifying these differences is integral to
understanding the roles, responsibilities, and authorities
across levels of government for services provided

Figure 1.2: Number of Local Health Departments

MN
OR

IL
UT

NE
NV
*

OH
WV

CA
*

OK
AZ

NM
TX

MA
CT

NJ
DE

AR
MS

SC
*

No Data

20 Association of State and Territorial Health Officials

50 - 99

1 - 10

100 - 199

11 - 49

> 200

Regional Health
Departments
No
Yes
* No data

Nearly 30 percent of states (n=14) have a centralized/
largely centralized governance structure, in which local
health units are primarily led by employees of the state
and the state retains authority over most decisions
related to the budget, issuing public health orders, and
the selection of the local health official. Four states
(10%) have a shared governance system, in which local

Figure 1.3: State and Local Health Department Governance Classification System
Leadership of Local Health Units

Authorities

State is centralized
AR, DE, DC, HI, MS, NM, RI, SC, VT

If NO

Does the state have local health units
that serve at least 75% of the state’s
population?*

Classification of Governance

OR largely centralized
AL, LA, NH, SD, VA

If YES

Is 75% or more of the population
served by a local health unit led by a
state employee?*

If NO
If YES

Do health units meet three or more
of the criteria for having shared
authority with local governments?

If YES

If NO

Is 75% or more of population served
by a local health unit led by a local
employee?*

If YES
If YES

Do health units meet three or more
of the criteria for having shared
authority with state government?

If NO

State has shared governance
FL, GA, KY
OR largely shared governance
MD

State is decentralized
AZ, CA, CO, CT, ID, IL, IN, IA, KS,
MA, MI, MN, MO, MT, NE, NJ, NY,
NC, ND, OH, OR, UT, WA, WV, WI
OR largely decentralized
NV, TX

State has a mix of centralized,
decentralized, and/or shared
governance
AK, ME, OK, PA, TN, WY

Criteria for state‐led health units having shared authority with
local government

Criteria for local‐led health units having shared authority with
state government

• Local governmental entities have authority to make budgetary decisions

• S tate governmental entities have authority to make budgetary decisions

• Local government can establish taxes for public health or establish fees
for services AND this revenue goes to local government

• L ocal government cannot establish taxes for public health nor establish
fees for services OR this revenue goes to state government

• 50% or less of local heath unit budget is provided by state public
health agency

•M
ore than 50% of local heath unit budget is provided by state public
health agency

• Local governmental entities can issue public health orders

• L ocal governmental entities cannot issue public health orders

• Local chief executives are appointed by local officials

• L ocal chief executives are appointed by state officials

• Local chief executives are approved by local officials

• Local chief executives are approved by state officials

* If the majority (75 percent or more) but not all of the state population meets this designation, then the state is largely centralized, decentralized, or shared.
ASTHO Profile of State Public Health, Volume Three 21

Structure, Governance, & Priorities

within the community. ASTHO developed a uniform and
objective classification of state health agency governance
to describe the ways in which public health structure
influences health agency operations, financing, and
performance. The following decision tree (Figure 1.3) was
developed to aid classification of states and the District of
Columbia according to their governance structure.

Structure, Governance, & Priorities

health units may be led by employees of the state or
employees of local government. If they are led by state
employees, the local government has the authority to
make key decisions. In states with a shared governance
system, local health departments are led by local
employees and the state health agency has the authority
to make key decisions. Over half of states (n=27) have
a decentralized/largely decentralized system, in which
local health units are primarily led by employees of local
governments and the local governments retain authority
over most key decisions. Twelve percent of states (n=6)
have a mixed governance structure, in which some local
health units are led by employees of the state and some
are led by employees of local government. In states with
a mixed governance structure, no one arrangement
predominates in the state.

Board of Health
Twenty-two state health agencies (45%) report having
a state board of health. In addition, four states (8%)
report having an entity that, while not called a board
of health, performs similar functions. Decentralized/
largely decentralized states are more likely to have
a board of health or equivalent entity than are
centralized/largely centralized states (62% and 54%,
respectively). There are no notable differences in board
of health status by geographic region. Large states are
more likely to have a board of health (56%) than are
medium (41%) or small states (38%).

Resource Sharing
A topic in public health that is receiving increased
attention is states’ engagement in the sharing of resources
such as staff, funding, or equipment with other state, local,
or tribal health agencies. Resource sharing, when done
effectively, can fill gaps in services, assist with running
programs and providing services more efficiently, and
encourage collaboration between agencies in other areas.
Of the 46 responding states in 2012, only four (9%) report
sharing resources with other states on a continuous,
recurring (non-emergency) basis. Three of those four are
states with small populations.
While less than 10 percent of state health agencies report
sharing resources with other states, two-thirds (n=31)
report facilitating the sharing of resources among local
health departments on a continuous, recurring basis.
22 Association of State and Territorial Health Officials

Percentage of states

None of the above

Other

Clinical services

2%
Administrative services

Inspections

Epidemiology or surveillance

All-hazards preparedness and response

Figure 1.5: Shared Services and Functions Between State Health
Agencies and Tribes, 2012 (n=46)

43%
30%

28%

24%

Clinical services

Administrative services

No tribes in jurisdiction

2%
None of the above

Other

4%
Inspections

17%

Epidemiology or surveillance

Similar to trends for resource sharing among states,
when states share resources with tribes, they are
most likely to do so for all-hazards preparedness and
response (43%) and epidemiology and surveillance
(28%). The percentage of state health agencies that
share resources with tribes for a variety of functions
and services is displayed in Figure 1.5. As is the case
with resource sharing among states, when states share
resources with tribes (n=21), they are most likely to
engage in formal, written agreements (52%) followed

38%

36%

All-hazards preparedness and response

The services and functions for which states are
most likely to share resources with other states are
displayed in Figure 1.4. When states do share resources
with other states, they are most likely to do so for
all-hazards preparedness and response (58%) and
epidemiology or surveillance (36%). Among states that
share resources with other states, 62 percent report
having some sort of agreement in place. Of the 28
states reporting agreements, 57 percent report formal,
written agreements, 36 percent report some formal and
some informal agreements, and only one state reports
having only an informal agreement. Decentralized/
largely decentralized states take part in formal, written
agreements more than centralized/largely centralized
states do (64% and 38%, respectively).

58%

16%

Percentage of states

With regard to population size, medium (75%) and large
(80%) states are more likely to facilitate local sharing
than are small states (47%). While many states (41%)
do not have any laws or regulations related to the
sharing of resources between local health departments
on a continuous, recurring basis, one state has laws or
regulations that prohibit such sharing, one state has laws
or regulations requiring sharing, and 41 percent have laws
and regulations that facilitate the sharing of resources. Of
the 18 states that have laws facilitating resource sharing,
78 percent are decentralized/largely decentralized states.
In addition, larger states are more likely to have laws facilitating sharing of resources (67%) than are medium (40%)
and small (14%) states.

Figure 1.4: Shared Services and Functions Between State Health
Agencies, 2012 (n=45)

ASTHO Profile of State Public Health, Volume Three 23

Structure, Governance, & Priorities

States that are decentralized/largely decentralized report
facilitating local sharing more frequently as compared
with centralized/largely centralized states (79% and 58%,
respectively). The majority of states in the South (83%)
and in the Mountains and Midwest (80%) facilitate local
health department resource sharing, while states in New
England, the Mid-Atlantic and Great Lakes, and West are
more evenly split as to whether or not they facilitate local
health department resource sharing.

Structure, Governance, & Priorities

Table 1.3: Activities in Collaboration with Other Agencies/Organizations (n=39-49)
State Health
Agency Has
Leadership
Role Within the
Partnership

No
Relationship Yet

Organization
Does Not Exist
In Jurisdiction

Exchange
Information

Work Together
on Projects

State Health
Agency Provides
Financial
Resources

Local public health agencies

90%

88%

80%

10%

Hospitals

98%

84%

59%

Physician practices/medical groups

94%

91%

49%

38%

Community health centers

92%

98%

75%

50%

Other healthcare providers

90%

81%

52%

42%

Health insurers

72%

81%

17%

11%

Regional cancer centers

92%

90%

35%

25%

Emergency responders

98%

61%

67%

Land use/planning agencies

62%

56%

24%

Economic and community
development agencies

66%

68%

11%

18%

Housing agencies

70%

76%

24%

11%

Utility companies/agencies

48%

38%

10%

36%

Environmental and conservation agencies

81%

84%

12%

14%

Cooperative extensions

80%

85%

26%

17%

11%

Schools

90%

98%

67%

40%

Parks and recreation

80%

85%

15%

Transportation

76%

78%

15%

11%

Community-based organizations

94%

96%

81%

49%

Faith communities

90%

86%

47%

22%

Other voluntary or nonprofit organizations
(e.g., libraries)

80%

76%

33%

17%

11%

Higher education (e.g., universities,
medical schools, community colleges)

96%

65%

37%

Business

82%

87%

11%

Media

90%

75%

27%

19%

Tribal government agencies or other
tribal community

72%

68%

47%

30%

21%

Continuing education (e.g., pharmacy,
medical, nursing)

93%

80%

27%

20%

State boards of health

65%

50%

26%

33%

39%

Local boards of health

77%

66%

43%

32%

18%

Food agencies

89%

80%

20%

13%

Energy agencies

59%

51%

31%

13%

Law enforcement

92%

19%

13%

Justice system

79%

24 Association of State and Territorial Health Officials

by some formal and some informal agreements (29%)
and then informal agreements (10%). The final 10
percent of states that share resources with tribes
report not knowing the nature of their agreements.

in whether or not the state health agency has the
leadership role within that particular partnership.

Partnerships

The resource sharing, collaborations, and partnerships
just discussed cannot occur without support from the
highest level at a state public health agency—the state
health official. All state health agencies are led by a state
health official (SHO), sometimes referred to as a state
health secretary or commissioner of health. As of 2012,
37 of 49 state health agencies (76%) report that the
SHO is appointed by the governor of the state. SHOs are
also appointed by the state health and human services
secretary, boards or commissions, or by the legislature.
Of the 47 states that answered this question in 2010 and
2012, the proportion of SHOs appointed by the governor
has increased by eight percentage points. A graph showing
who appointed the SHO in 2010 and 2012 is displayed in
Figure 1.6. Only medium-sized states in the South (n=3)
have SHOs that are appointed by boards or commissions.

Figure 1.6: Appointment of the State Health Official, 2010-2012
(n=47)
2010

Once the SHO is appointed, 73 percent of state health
agencies require confirmation of the appointment by
the legislature, governor, board or commission, secretary

Figure 1.7: Confirmation of the State Health Official, 2010-2012
(n=46)

2012

2010

2012

Percentage of states

48% 46%
33%
28%

2% 2%

4% 4%
Other

No confirmation
is required

State secretary of HHS

Governor

Legislature

2% 0%

Other

Board or commission

State secretary of HHS

6% 6%

Board or commission

13% 15%

13%

Legislature

19%

Governor

Percentage of states

74%
66%

Note: "Board or commission" was not a response option in 2010.
ASTHO Profile of State Public Health, Volume Three 25

Structure, Governance, & Priorities

In addition to sharing resources with other states, local
health departments, and tribes, state health agencies
collaborate with many types of governmental and
nongovernmental agencies. State health agency collaborative activities with other agencies/organizations are
displayed in Table 1.3. In general, state health agencies
report being highly collaborative with local public
health agencies, hospitals, and many other entities in
the healthcare field. At least 90 percent of state health
agencies report exchanging information with hospitals,
physician practices/medical groups, community health
centers, and other health providers. At least 90 percent
also report exchanging information with schools, faith
communities, the media, and law enforcement. The
percentage of state health agencies that report working
together on projects with these organizations is also very
high. Providing financial resources to these organizations
is less common overall, and there is a large variation

State Health Officials

When SHOs are appointed to a specific term, the term
length varies from two to six years, with an average
term of 3.9 years. Centralized/largely centralized states
have SHOs with official term lengths slightly longer than
those of decentralized/largely decentralized states (an
average of 4.2 years and 3.6 years, respectively). The
state with the longest set term is in the South (6.0 years),
while states in the Mid-Atlantic and Great Lakes have
the shortest set term lengths on average (3.3 years).
Medium-sized states have longer set terms (average
length = 4.4 years) than do small states (average length
= 3.7 years) and large states (average length = 3.0 years).
When SHOs are appointed to a specific term, the term is
set by law, rather than contract, for all states (n=10).
More than half of state health officials (53%) report
directly to the governor, while about one-third (33%)
report to the state secretary of health and human
services (HHS). As shown in Figure 1.8, the percentage
of SHOs that directly report to various entities has not

26 Association of State and Territorial Health Officials

2010

2012

55% 53%

31% 33%

Other

Board or commission

State secretary of HHS

6% 6%

Governor

When state health officials are appointed, only 10 states
(20%) appoint the SHO to a specific term. This percentage
is identical to the percentage appointed to a specific
term in 2010. Centralized/largely centralized state health
agencies are twice as likely to appoint SHOs to a specific
term as are decentralized/largely decentralized state
health agencies (38% and 19%, respectively). States in
New England are the most likely to appoint SHOs to a
specific term (38% of them do), while states in the South
are the least likely (only 8% of them do). The appointment
of SHOs to a specific term shows some variation by state
size (19% of small, 29% of medium, and 13% of large
states have SHOs with a set term).

Figure 1.8: State Health Official Direct Report, 2010-2012
(n=49)

Percentage of states

Structure, Governance, & Priorities

of health and human services, or another entity. The
percentage of state health agencies that require confirmation of the SHO by each of these entities among states
who responded in 2010 and 2012 is displayed in Figure
1.7. Only decentralized/largely decentralized states (24%)
report having SHOs confirmed by the governor. While the
entity responsible for confirming the SHO generally varies
across regions, all nine Mountains and Midwest states
that require confirmation of the SHO require it from the
legislature. Of the seven states that indicated that the
SHO’s appointment was confirmed by the governor, six
indicated that the SHO was both appointed and confirmed
by the governor. Confirmation by the governor is more
often required in large states (40%) than in medium (0%)
or small (6%) states.

changed substantively from 2010 to 2012. SHOs in
decentralized/largely decentralized states are most likely
to report directly to the governor (65%), while SHOs from
centralized/largely centralized states are most likely to
report directly to the state secretary of HHS (46%). Only
SHOs in the South (25%) report directly to a board or
commission. In the Mountains and Midwest, 80 percent of
SHOs report directly to the governor. Small states are twice
as likely to have SHOs that report to the state secretary of
HHS (50%) than medium (24%) and large (25%) states.
When asked who is involved in the budget approval
process, the governor (92%), legislature (90%), and the
state budget office (69%) were the top three entities
selected. Other entities involved in the budget approval
process are the state secretary of HHS (35%), the board
of health (4%), and other (6%). This distribution is
quite similar to the distribution for 2010. States in New
England are more likely to have the state secretary of
HHS involved in the budget approval process (63%)
than are states in other regions (values range from
20-43%). Large states are more likely than small or
medium-sized states to have the state budget office
involved in the budget approval process. The reverse
trend is found for the state secretary of HHS, such that
large states are less likely than small or medium-sized
states to have the state secretary of HHS involved in the
budget approval process.

Table 1.4: State Health Agency Top Priorities, 2010-2012
Category

2010: n (%)

2012: n (%)

Administration

77 (30.2%)

88 (34.5%)

Chronic disease

43 (16.9 %)

38 (14.9%)

Other

39 (16.3%)

37 (14.5%)

Improving consumer health

21 (8.2%)

27 (10.8%)

Infectious disease

17 (6.7%)

12 (4.7%)

All-hazards preparedness and
response

13 (5.1%)

11 (4.3%)

Health data

13 (5.1%)

9 (3.5%)

State Health Agency Priorities

Environmental protection

10 (3.9%)

2 (0.8%)

Quality of health services

5 (2.0%)

The portfolio of the state health official is large and
diverse. SHOs must strategize and prioritize the many
important topics that come to their attention during
their tenure. Senior deputies, who responded on behalf
of the state health official, were asked to list the top
five priorities for their state public health agency for the
current fiscal year. The most common top priorities for
2010 and 2012 (categorized by expenditure category7)
are displayed in Table 1.4. Though responses varied
by state, several common themes emerged. As in
2010, the prevention and treatment of chronic disease
was mentioned by many states, as was dealing with
funding issues. Improvement of internal operations,
such as workforce capacity, infrastructure, and quality
improvement, was also frequently mentioned. In 2012,
many states listed priorities that did not fit neatly into
a single health topic (accreditation, reducing health
disparities), possibly reflecting a trend toward crosscutting programs in public health.

Injury prevention

4 (1.6%)

6 (2.4%)

Health laboratory

0 (0.0%)

1 (0.4%)

Vital statistics

0 (0.0%)

1 (0.4%)

Missing

13 (5.1%)

18 (7.1%)

Total

255 (100%)

State health officials cannot address these priorities
alone. In the next chapter, we will describe the men
and women that comprise the state public health
agency workforce and explore the integral role they
play in the success of the state health agency.
7 Definitions for expenditure categories can be found on page 83.

ASTHO Profile of State Public Health, Volume Three 27

Structure, Governance, & Priorities

Just as the SHO is most frequently appointed by and
reporting directly to the governor, in the majority of states
(88%), the state health official can be removed from his or
her position at the will of the governor. This is more often
the case in decentralized/largely decentralized states
(96%) than in centralized/largely centralized states (69%).
In some instances, the SHO can be removed by board
or commission action (only in the South; 25%) and by
legislative action (only in New England; 13%).

Key Findings:
• Based on the figures reported in 2012, the total

number of FTEs for the 50 states and District
of Columbia is estimated to be approximately
101,000. Both the number of FTEs and number of
staff have shown a decrease of more than 5,000
from 2010 to 2012.
• The number of staff and FTEs are related to state

population size, such that smaller states tend to
have the fewest number of staff and FTEs and
larger states tend to have the greatest number of
staff and FTEs. However, a state’s size is inversely
related to FTEs per 100,000 population, such that
smaller states have the greatest number of FTEs
per 100,000 population on average, while larger

28 Association of State and Territorial Health Officials

states have the fewest number of FTEs per 100,000
population on average.
• The occupational classifications with the greatest

mean number of staff at state health agencies
are administrative and clerical staff, public health
nurses, and environmental health workers.
• ASTHO collected the demographics of state health

agency employees for the first time in the 2012
Profile Survey. The majority of employees at state
health agencies are female (71%), white (73%),
and non-Hispanic/Latino (93%). Overall, the state
health agency workforce has a greater proportion
of women than the U.S. population, is more racially

This chapter describes the workforce of state public health agencies. It
details the size of the state health agency workforce, salaries by occupational
categories, and demographics of state health agency employees. It includes
information on vacancies and projected retirements. This chapter also
describes the appointment, qualifications, tenure, and salaries of state health
officials. Throughout the chapter, 2012 data will be compared with 2010 and
2007 data when possible, and differences in state health agency workforce
by governance structure, region, and state population size will be noted when
applicable.

diverse than the U.S. population, and has a smaller
proportion of Hispanics/Latinos than the overall U.S.
population. However, there are some differences in
the racial composition of state health agency staff,
with Southern states having on average the highest
proportion of black/African-American employees
(25%) and Western states having on average the
highest proportion of Asian employees (15%); the
racial composition of these regions is relatively
representative of the populations that they serve.
• On average, 12 percent of positions at state health

agencies are currently vacant. However, only 24
percent of vacant positions are currently being
actively recruited for.

• From FY 2012 to FY 2016, the percentage of state

health agency employees who are eligible for
retirement is expected to increase from 18 to 25
percent on average.
• The length of time that state health officials have held

their position is highly variable. As of December 2012,
the range in length of time state health officials had
been in their position was one month to 20 years.
Nearly 75 percent of state health officials hold a
medical degree, and nearly 50 percent hold an MPH.
• State health agencies prioritize workforce

development. More than half of state health agencies
have a workforce development plan in place, and half
have a workforce development director.

ASTHO Profile of State Public Health, Volume Three 29

State Health Agency Workforce

Chapter 2: State Health Agency
Workforce

State Health Agency Workforce

Number of State Health
Agency Employees
In 2012, the 49 responding state health agencies
reported a total of 97,127 FTEs, and 40 responding
state health agencies reported a total of 72,794 staff
members. Based on the figures reported in 2012, the
total number of FTEs for all states and the District of
Columbia is estimated to be approximately 101,000.8
Among responding states from 2010 to 2012, the
number of FTEs has decreased by approximately
5,500 and the number of staff has decreased by 5,000
individuals (Table 2.1). These results are in alignment
with data from ASTHO’s Budget Cuts Survey series,
which has been tracking the effects of budget cuts on
the state health agency workforce since 2008.9
The number of FTEs per 100,000 for each state is
displayed in Figure 2.1. On average, centralized/largely
centralized states tend to have more staff and FTEs than
decentralized/largely decentralized states. States in the
South have the most staff and FTEs on average, while
states in the Mountains and Midwest have the lowest
number of staff and FTEs. Looking at the raw data alone,
number of staff and FTEs are related to state population
size such that smaller states tend to have the lowest
number of staff and FTEs, while larger states tend to have
the highest number of staff and FTEs. However, a state’s
size is inversely related to FTEs per 100,000 population,
such that smaller states have the highest number of FTEs
per 100,000 population on average, while larger states
have the lowest number of FTEs per 100,000 population
on average. Table 2.2 displays the average number
of FTEs and the mean number of FTEs per 100,000
population for states that serve small, medium, and large
populations. As the size of the population increases, the
mean number of FTEs per 100,000 population decreases.
Respondents were also asked to classify workers by
employment category (e.g., part-time, hourly worker)
and by assignment (e.g., central office, regional or
district office). Results are displayed in Table 2.3.
8 State population and the mean number of FTEs per 100,000
population for states who responded were used to estimate the
number of FTEs for states who did not report data in 2012.
9 Visit http://www.astho.org/Research/StateHealth-Agency-Budget-Cuts/ for the most recent Budget Cuts
Impact Research Brief.
10 Only states that reported values in both 2010 and 2012 are
included in Table 2.1.
11 Only states that reported values above 0 were included.

30 Association of State and Territorial Health Officials

Table 2.1: Number of State Health Agency Employees,
2010-201210
2010

2012

Mean

Median

Total

Mean

Median

Total

Number of
FTEs (n=48)

2,117

1,210

101,623

2,001

1,151

96,070

Number of
staff members
(n=38)

1,994

1,212

75,778

1,862

1,158

70,768

Table 2.2: Average Number of FTEs and Average Number of FTEs
per 100,000 Population by State Size (n=49)
State Size

Mean Number of FTEs

Mean Number of
FTEs per 100,000
population

Small (n=16)

803

Medium (n=17)

1,894

Large (n=16)

3,255

Table 2.3: Number of State Health Agency Employees by
Category and Assignment11
n

Mean

Median

Minimum

Maximum

Hourly/temporary or
as-needed

146

2,426

Part-time workers

433

Assigned to the
central office

966

735

176

3,722

Assigned to local
health departments

1,682

1,097

9,720

Assigned to regional
or district offices

694

215

9,343

Figure 2.1: Full-Time Equivalents per 100,000

MN
OR

VT
MI

IL
UT

NE
NV

OH
KY

NM
TX

NJ
DE

TN
AR
LA

MA
CT

No Data

51 - 75

1 - 25

76 - 100

26 - 50

> 100

ASTHO Profile of State Public Health, Volume Three 31

State Health Agency Workforce

greater percentage of employees in centralized/largely
centralized states (72%) are represented by a union
than employees in decentralized/largely decentralized
states (66%). States in the New England region have the
greatest average percentage of employees represented
by unions (90%), while states in the Mountains and
Midwest have the lowest percentage (50%). There are no
trends in union membership by state size.

In 2012, union membership in state health agencies
ranged from a low of 3 percent to a high of 100 percent.
Of the 29 states reporting percentages for collective
bargaining, on average, 70 percent of employees are
represented by a union. Union membership among
agencies that responded in both 2010 and 2012 (n=21)
is the same, with an average of 73 percent of employees
represented by a union in both 2010 and 2012. A

State Health Agency Workforce

State Health Agency Employee
Occupational Classifications,
Salary Ranges, and Fringe Benefits

In 2012 (as in 2010), the occupational classifications
at state health agencies with the greatest number of
employees are administrative/clerical staff, public health
nurses, and environmental health workers. In 2012, the
highest paid state public health agency professionals
are public health managers, physicians, and oral health
professionals. As in 2010, these positions also have the
widest range in salary in 2012. Average fringe benefits as
a percentage of salary are fairly even across occupational
classifications, ranging from an average low of 34 percent
(for physician assistants) to 41 percent (for public health
nurses, lab workers, and epidemiologists/statisticians).

Employees at state health agencies fulfill a variety of
roles that span a number of occupational classifications.
Table 2.4 displays the average number of FTEs for the
most common occupational classifications in state
public health agencies, the average salary range for each
position, and the average employee and fringe benefits
as a percentage of salary.

States were also asked to provide salary range and
benefits information for leadership staff (other than
the state health official). Responses from states are
shown in Table 2.5. Among all leadership positions, the

Please see page 39 for descriptions and examples of
occupational classifications.

Table 2.4: Average Number of FTEs, Salary Range, and Fringe Benefits by State Health Agency Occupational Classification
Occupational Classification

Average Number
of FTEs

Median Number
of FTEs

Average Salary Range

Average Fringe Benefits
as a % of Salary

Administrative/clerical staff
Public health nurse
Environmental health worker
Public health manager
Lab worker
Social worker
Epidemiologist/statistician
Health educator
Nurse practitioner
Nutritionist
Public health informatics specialist
Preparedness staff
Public health physician
Oral health professional
Physician assistant
Public health information specialist
Primary care director

39
37
34
37
34
26
37
34
13
38
27
36
34
28
7
33
20

395.3
223.3
116.4
97.1
78.3
75.9
52.0
51.6
42.1
35.6
32.5
27.7
19.1
16.2
7.6
5.3
1.6

140
74
67
59
65
17
34
27
29
16.5
9
20
5.2
3.5
6
3
1

$23,602-$71,169
$42,827-$79,248
$33,692-$82,465
$47,916-$131,213
$26,173-$81,552
$35,693-$61,892
$38,621-$86,232
$37,519-$66,661
$54,009-$86,053
$39,736-$67,770
$42,580-$85,217
$35,086-$94,852
$101,941-$171,917
$46,654-$117,391
$48,511-$83,002
$46,683-$80,176
$61,674-$94,563

40%
41%
40%
39%
41%
37%
41%
39%
35%
40%
40%
39%
39%
39%
34%
38%
37%

Note: For each occupational classification, only states that responded to all elements of the question (number of FTEs, salary range, and fringe
benefits) were included in the analysis.
Table 2.5: Salary Range and Fringe Benefits of State Health Agency Leadership
Occupational Classification

Average Salary Range

Average Fringe Benefits as a % of Salary

Senior deputy
Chief medical officer
Chief science officer
Chief financial officer
Chief information officer
State epidemiologist
State lab director
Local health department liaison

32
25
3
35
31
28
30
22

$90,943-$148,263
$130,788-$195,842
$99,865-$156,169
$69,925-$116,132
$71,403-$110,616
$89,706-$137,430
$75,091-$114,794
$60,200-$103,946

40%
39%
37%
40%
40%
41%
41%
42%

Note: For each occupational classification, only states that responded to both elements of the question (salary range and fringe benefits) were
included in the analysis.
32 Association of State and Territorial Health Officials

State Health Agency Employee
Demographics
In 2012, on average 71 percent of state health agency
employees are female.12 On average, decentralized/
largely decentralized state health agencies have a
greater percentage of male employees (32%) than do
centralized/largely centralized states (26%). On average,
states in the Mid-Atlantic and Great Lakes have the
highest percentage of male employees (35%), while
states in the South have the lowest percentage of male
employees (21%).
Respondents were asked to provide the number of
staff working at their state health agency by racial
category. Responses are presented in Table 2.6. On
average, nearly three-quarters of all state health agency
employees are white, with the next largest percentage
being black/African-American (14.9%). On the whole,
the racial composition of a state health agency is
relatively similar to that of the racial composition of
the United States in 2012. Employees in decentralized/
largely decentralized states are more likely to be white
than are employees in centralized/largely centralized
states (78.6% vs. 59.6%). Employees at centralized/
largely centralized states are more likely to be black/
African-American (20.1%), another race (12.1%), or
two or more races (18.0%) than are employees at
decentralized/largely decentralized states (10.8%, 6.4%,
and 1%, respectively). On average, the Mountains
and Midwest have the greatest percentage of white
employees (90%; other regions range from 62-80%),
the South has the greatest percentage of black/AfricanAmerican employees (25%; other regions range from
3-17%), and the West has the greatest percentage of
Asian employees (15%; other regions range from 2-4%).
The West also has the greatest percentage of employees
of two or more races (11%; other regions range from
0-1%). The racial composition of the state health agency
workforce by region is, on average, reflective of the

Table 2.6: Mean Percentage of State Health Agency Staff by
Racial Category, 2012
Racial Category

Average Percentage

White

72.6%

Black/African-American

14.9%

American Indian/Alaska Native

1.1%

Asian

4.5%

Native Hawaiian/Other Pacific Islander

0.7%

Another race

6.9%

Two or more races

2.5%

Missing data on race

2.5%

populations each region serves. State size does not
show consistent patterns with racial categories of state
health agency employees.13
State health agencies were also asked about the
ethnicity of their employees. Of the responding agencies
(n=41), on average 5 percent of state health agency
employees in 2012 are Hispanic/Latino. In centralized/
largely centralized states, about 8 percent of employees
are Hispanic/Latino, while in decentralized/largely
decentralized states only about 4 percent are. States
in the South (9%) and the West (8%) have the greatest
percentage of Hispanic/Latino employees; these two
regions also have on average higher proportions of their
populations who are Hispanic/Latino. Smaller states
have a greater percentage of Hispanic/Latino employees
(8%) than do medium (3%) or large (5%) states.
State health agencies report that the average age of
employees is 47 and the median age of employees is 48;
the state health agency workforce is on average older
than the general U.S. workforce, which has a median
age of 42 years.14 The average number of years of
service by a state health agency employee is 12. These
findings are consistent with results from the 2007 and
2010 ASTHO Profile Surveys. Average age of employees,
median age, and average number of years of service
does not vary substantially by governance classification.
While the average age of employees is fairly constant
across regions, employees in the West tend to have
the fewest years of service (average = 10 years), while
12 N=46, as three states did not respond to this item.
13 To create an average demographic picture of each region, 2012
Census data about the racial and ethnic makeup of each state was
compared with the state health agency workforce for each region.
14 U.S. Department of Labor, Bureau of Labor Statistics. “Labor
Force Statistics from the Current Population Survey.” Available at
http://www.bls.gov/cps/industry_age.htm. Accessed 3-6-2014.

ASTHO Profile of State Public Health, Volume Three 33

State Health Agency Workforce

chief medical officer is the highest paid staff member
on average, while the local health department liaison
is the lowest paid staff member on average. Average
fringe benefits for leadership staff as a percentage
of salary are similar to fringe benefits for other state
health agency employees, on average ranging from 37
percent (for chief science officers) to 42 percent (for
local health department liaison).

State Health Agency Workforce

employees in New England tend to have the most
(average = 14 years). There are also trends in average
years of service by state size, such that larger states tend
to have employees with more years of service.

In addition to being asked about the average age of
current employees, agencies were also asked to report
the average age of new employees. Over the past three
fiscal years, the average age of new employees at state
health agencies was 40 (FY09), 40 (FY10), and 41 (FY11).
The average age of new employees is fairly constant
across state health agencies; it does not vary substantively by governance classification, region, or state size.

Figure 2.2: Percentage of Vacant Positions

MN
OR

VT
MI

IL
UT

NE
NV

NJ
DE

TN
AR
MS

MA
CT

34 Association of State and Territorial Health Officials

No Data

10 - 19%

< 5%

20 - 29%

5 - 9%

> 30%

Vacancies and Retirements

State Health Agency Workforce

In FY 2011, an average of 274 nontemporary
employees separated from state health agencies.15 On
average, states in the South had substantially more
employees separate from the state health agency than
did other regions (South mean for FY11 = 637; other
regions’ means range from 86 to 199). The number of
separations was associated with state population size,
such that more employees separated from states with
larger populations. This may be related to states with
large populations having a greater average number of
employees than states with smaller populations.
In 2012, on average 12 percent of state health agency
positions were vacant. This percentage is similar to
the percentage of vacant positions in 2010 (11%).
States in New England have the greatest percentage
of vacancies (15%), while states in the Mountains and
Midwest have the lowest percentage of vacancies
(8%). Larger states have a greater percentage of
vacancies (15%) than do small (11%) and medium
(12%) states. Figure 2.2 shows the percentage of
vacant positions by state.
The average number of vacant positions at state
health agencies in 2012 is 303. Among the 41 states
that responded to this question in both 2010 and
2012, the average number of vacant positions
increased from 282 to 304.16 State health agencies
in the Mountains and Midwest have fewer vacant
positions on average than do state health agencies
in other regions (mean Mountains and Midwest =
67; other regions’ means range from 241 to 506
vacancies). Larger states have more vacancies on
average (536) than do small (133 vacancies) and
medium (256 vacancies) states. Despite the large
number of vacancies, on average state health agencies
are only actively recruiting for 74 positions, or 24
percent of vacancies. The results of ASTHO’s Budget
Cuts Survey series suggest that agencies are often
unable to fill vacancies due to hiring freezes.17
15 This number includes retirements.
16 The change in average number of vacant positions from 2010 to
2012 excludes states that did not respond at both time points.
17 Visit http://www.astho.org/Research/StateHealth-Agency-Budget-Cuts/ for the most recent Budget Cuts
Impact Research Brief.

ASTHO Profile of State Public Health, Volume Three 35

Figure 2.3: Mean Percentage of Full-Time Classified Employees
Eligible for Retirement, FY10-FY16 (n=27)

Percentage of FTEs

State Health Agency Workforce

From fiscal year 2012 to fiscal year 2016, the
percentage of state health agency employees that are
eligible for retirement is expected to increase from 18
to 25 percent on average. The projected percentage
of employees eligible for retirement among states that
answered this item in both 2010 and 2012 is displayed
in Figure 2.3. Among the 27 states that responded in
2010 and 2012, the percentage of employees eligible
for retirement is expected to increase from 19 percent
in FY10 to 26 percent in FY16. Figure 2.4 shows the
projected retirement eligibility percentage for each
state in FY16.

19%

18%

FY10

FY11

FY12

FY13

21%

23%

FY14

FY15

26%

FY16

Figure 2.4: Percentage of Employees Eligible for Retirement in FY 2016

MN
OR

VT
MI

IL
UT

NE
NV

OH
KY

NM
TX

NJ
DE

TN
AR
LA

MA
CT

36 Association of State and Territorial Health Officials

No Data

20 - 29%

< 5%

30 - 39%

5% - 9%

40 - 49%

10 - 19%

> 50%

Figure 2.5: State Health Official Educational Qualifications, 2007-2012 (n=48)
2007

2010

2012

48%
40%
35%

31%
25%

23%
15% 17%

17% 17%
2% 2%

MPH

6% 6% 5% 4% 6%

DrPH

PhD

0% 2%

BSN

State Health Officials
As of December 2012, the average tenure of a state health
official is 3.4 years, the median tenure is 1.8 years, and
the range is one month to 20 years.18 On average, SHOs
have been in the public health profession for 19.5 years.
The average number of years of experience in public
health before becoming a SHO is 16.4 years (n=35). A total
of 96 percent of SHOs have had executive management
experience before becoming the state health official.
Since 2007, ASTHO has been tracking SHOs’ levels of
educational attainment. The educational qualifications
of the current state health official are displayed in
Figure 2.5. In 2012, the percentage of SHOs with MDs
increased by 6 percent to nearly three-quarters of all
SHOs, the percentage of SHOs with MPHs increased by
8 percent to nearly half of all SHOs, the percentage of
SHOs with a DrPH increased from 2 to 6 percent, and
for the first time one state has a SHO with a DO. Twenty
state health officials in 2012, or 42 percent, had dual
advanced degrees, with the most common combination
being MD and MPH. In contrast, the percentage of
SHOs with MBAs decreased from 8 to 2 percent, and
the percentage of SHOs with JDs decreased from 6
to 2 percent. Other degrees held by SHOs include
master’s degrees in social work, education, and public
administration. More than half of states (53%) have the
official statutory requirement that the SHO possess an
MD or DO. In the West, only one state requires this.
Nearly one-third of states (29%) report no statutory
requirements for the education level of the SHO.
On average, state health officials in 2012 were paid a
salary of $160,162 (median salary = $153,960). SHO

6% 8%

10%
2% 0% 0% 2%

MBA

13%
6%

17%

2% 4% 4% 0% 4% 2% 0% 2% 0% 0% 0% 0% 0%

MSN

DDS

DVM

Other

salaries range from a minimum of $94,640 to a maximum
of $268,996. While the average salary has increased
by about $3,600 since 2010, the range of salaries has
become narrower at both the high and low end, such
that the lowest-paid SHO is being paid approximately
$12,000 more than in 2010, while the highest-paid SHO
receives a salary that is nearly $19,000 less than the
maximum salary in 2010. On average, SHOs are paid
more if they work in a centralized/largely centralized
state (mean salary = $163,820) than if they work in a
decentralized/largely decentralized state (mean salary =
$157,453). SHOs in the South receive higher salaries on
average than do SHOs in other regions, as can be seen
in Table 2.7. SHOs from medium-sized states tend to
receive a higher average salary than do SHOs from small
or large states. For SHOs that have an MD, 17 percent of
states provide a salary differential.
Table 2.7: Average and Median SHO Salary by U.S. Region (n=48)
Region

Average SHO Salary

Median SHO Salary

New England

$148,436

$138,768

South

$187,814

$184,622

Mid-Atlantic and Great
Lakes

$159,087

$158,155

Mountains and Midwest

$149,057

$134,600

West

$142,284

$137,304

The salaries for state health officials are determined
through one of several methods: governor’s discretion
(55%), state legislature’s discretion (29%), state pay scale
(25%), board or commission (8%), or another method
18 Since Jan. 1, 2013, 26 new state health officials have been
appointed. Currently there are no vacancies.
ASTHO Profile of State Public Health, Volume Three 37

State Health Agency Workforce

Percentage of states

71%
65% 65%

Respondents were also asked to indicate their familiarity
with and use of various public health core competencies
in the course of managing agency personnel. Results
are displayed in Figure 2.6. More than half of state
health agencies were familiar with but had not used
informatics competencies for public health professionals
and National League for Nursing (NLN) leadership
competencies. When states used any of the core
competencies, it was most frequently for the purpose
of developing training plans. Nearly one-third of state
health agencies were unfamiliar with informatics
competencies, Quad Council of Public Health Nursing
competencies, and NLN leadership competencies.

Workforce Development
State health agencies are committed to workforce
development. The Core Competencies for Public Health
Professionals,19 determined through a consensus process
by the Council on Linkages Between Academia and Public
Health Practice, reflect the desirable skills and characteristics of public health workers to effectively deliver
the essential public health services. The competencies
are designed to serve as a starting point to guide organizations’ workforce development efforts (e.g., recruitment,
training, performance management, and workforce
planning) and help public health professionals to manage
their career development and learning. More than half
(59%) of state health agencies have created a health
department workforce development plan that addresses
staff training needs and core competency development.
Thirty percent of state health agencies have not
developed such a plan, while 11 percent of respondents
did not have access to information about a workforce
development plan. Medium-sized states and states in
the South are most likely to have developed a plan. Half
of state health agencies also report having a designated
workforce development director. Decentralized/largely
decentralized states and states in the South and West are

In this chapter and the first section of the Profile Report,
discussion has centered on the structure of state
health agencies and the individuals who work in state
public health. In the next section of the report, State
Public Health: What We Do, focus moves to the myriad
services and activities that state health agencies provide
throughout the country.
19 Public Health Foundation. “About the Core Competencies for Public
Health Professionals.” Available at http://www.phf.org/programs/
corecompetencies/Pages/About_the_Core_Competencies_for_
Public_Health_Professionals.aspx. Accessed 3-6-2014.
20 For more information on Core Competencies for Public Health
Professionals, see http://www.phf.org/programs/corecompetencies/Pages/About_the_Core_Competencies_for_Public_
Health_Professionals.aspx. For information on Informatics
Competencies for Public Health Professionals, see http://
nwcphp.org/docs/phi/comps/phic_web.pdf. For information on
NLN leadership competencies, see http://www.nln.org/facultyprograms/Competencies/index.htm.

Figure 2.6: Familiarity with and Use of Public Health Core Competencies20

Familiar with but have
not used

Percentage of states

State Health Agency Workforce

most likely to have a designated workforce development
director, while small states are least likely to have one.

(12%). A greater percentage of decentralized/largely
decentralized states’ SHO salaries are determined by
the governor, while a greater percentage of centralized/
largely centralized states’ SHO salaries are determined
by the state legislature. Governors in the Mountains and
Midwest states are more likely to determine SHO salaries
than those in other regions (Mountains and Midwest
mean = 80%; other regions range from 42-57%).

Conducting performance
evaluations
58%
52%

58%

Developing training plans

48%

Preparing job descriptions

39%
31%

29%

25%
15%

22%

17%
2%

Core competencies
for public health
professionals

33%

28%

30%

22%
7% 9% 9% 7%

7% 7%

Emergency preparedness
competencies for all
public health workers

Informatics competencies
for public health
professionals

38 Association of State and Territorial Health Officials

14%

16%

29%

19%

16%
3%

Quad council public
health nursing
competencies

Other use
Not familiar

NLN leadership
competencies

Descriptions and Examples of 2012 Occupational Classifications
Administrative or clerical personnel. Support staff providing assistance in agency programs or operations.
Environmental health worker. Environmental health specialists, scientists, and technicians, including registered
and other sanitarians.

Health educator. Designs, implements, evaluates, and provides consultation on educational programs and
strategies to support and modify health-related behaviors of individuals, families, organizations, and communities
and to promote the effective use of health programs and services.
Laboratory worker. Laboratorians, laboratory scientists, laboratory technicians, and microbiologists planning,
designing, and implementing laboratory procedures.
Nurse practitioners.
Nutritionist. Dietitian developing, implementing, and evaluating population-based strategies to assure effective
interventions related to nutrition and physical activity behaviors, the nutrition environment, and food and
nutrition policy. May directly provide nutrition services.
Oral health professional. Includes public health dentists and dental hygienists.
Other.
Physician assistants.
Preparedness and response staff. Includes planners, responders, preparedness directors, preparedness policy
staff, SNS [Strategic National Stockpile] coordinator, preparedness volunteer coordinator.
Primary care office director. Identifies health professional shortage areas and medically underserved areas/
populations, which allows primary care providers to receive federal funding, recruit National Health Corps
providers, and receive enhanced reimbursement from Medicare and Medicaid. Addresses recruitment and
retention issues of primary care providers to increase access to care; works with HRSA’s [the Health Resources
and Services Administration’s] bureaus to address primary care provider shortages; works with or is the state/
territorial office of rural health; works with the state office of minority health.
Public health informatics specialist. Also known as public health information systems specialist or public health
informaticist.
Public health manager. Health service managers, administrators, and health directors overseeing the operations
of a department/division.
Public health nurse. Registered nurse conducting public health nursing (e.g., school nurse, community health nurse).
Public health physician. Physician who identifies persons or groups at risk of illness or disability and develops,
implements, and evaluates programs or interventions designed to prevent, treat, or improve such risks.
May provide direct medical services.
Public information specialist. Also known as public information officer.
Social worker. Behavioral health professional (e.g., community organizers, HIV/AIDS counselors, and public health
social workers).

ASTHO Profile of State Public Health, Volume Three 39

State Health Agency Workforce

Epidemiologist/statistician. Conducts ongoing surveillance, field investigations, analytic studies, and evaluation of
disease occurrence and disease potential and makes recommendations on appropriate interventions.

Part II–State Public Health:

What We Do

Chapter 3: State Health Agency Activities

Key Findings:
• State health agencies often have primary

programmatic and fiscal responsibility for a
variety of federal initiatives. When state health
agencies do not have sole responsibility for an
initiative, they typically share it with another state
health agency, a local governmental agency, or a
nonprofit organization.
• With the high level of collaboration between

state health agencies, local health departments,
the healthcare sector, and others, state health
agencies often provide technical assistance and
training to a variety of partners on different
topics, most commonly on quality improvement,
performance, and accreditation. Nearly all state
health agencies provide training to local health
agencies on disease prevention and control (94%),
tobacco (92%), and preparedness (90%).
• The majority of state health agencies engage

in activities to promote access to healthcare,
particularly health disparities and minority
health initiatives (94%) and rural health (72%).
Additionally, the majority of state health agencies
report providing financial support to primary
care providers.

• State health agencies provide a number of services

related to population-based primary prevention,
screening, and treatment of diseases and conditions.
The services provided by the greatest number of
agencies are tobacco, HIV, and sexually transmitted
disease counseling and partner notification.
• State health agencies perform a variety of functions

related to surveillance, data collection, and
laboratory functions. The three laboratory services
provided by the greatest number of state health
agencies are bioterror agent testing, foodborne
illness testing, and influenza typing. Additionally,
the majority of state health agencies perform the
majority of data collection, epidemiology, and
surveillance activities listed in the survey, with 100
percent of state health agencies directly performing
reportable disease data collection, epidemiology, and
surveillance activities, and 98 percent performing
communicable/infectious disease, foodborne illness,
and vital statistics activities in 2012.
• Fifty-nine percent of responding states indicated

that their state would be establishing a health
insurance exchange as part of the implementation
of the Affordable Care Act. Among the 28 states that
are establishing exchanges, the state health agency
was engaged in that process in 20 of those states.

ASTHO Profile of State Public Health, Volume Three 41

State Health Agency Activities

This chapter describes the variety of activities and services that state health
agencies provide. It also addresses state health agencies’ involvement in worksite
wellness programs, health insurance exchanges, health impact assessments, and
research studies. Responsibility for federal initiatives, training for local health
agency personnel, and technical assistance will also be discussed.

State Health Agency Activities

As in previous chapters, 2012 data will be compared with
2010 and 2007 data when possible, and differences in
state health agency workforce by governance structure,
region, and state population size will be noted when
applicable. However, rather than note differences by
agency characteristic for each of 248 public health
activities, an index was created for each public health
activity category by summing the number of activities
performed by each state and the percentage of activities
performed in a given category was compared by agency
characteristic. For example, the 2012 Profile Survey had
15 items about screenings for diseases and conditions; the
screening index was calculated by summing the number of
those 15 types of screenings performed by each state.

Responsibility for Federal Initiatives
State health agencies often have programmatic and
financial responsibility for federal initiatives. When they
do not have sole responsibility, state health agencies
typically share responsibility with another state health
agency, a local governmental agency (e.g., a local health
department), or a nonprofit organization. The 10 federal
initiatives for which state health agencies most frequently
report having responsibility are displayed in Table 3.1.

In addition to providing technical assistance, state health
agencies provide training to local health department
personnel. As shown in Figure 3.1, the three topics for
which the greatest percentage of state health agencies
provide training to local health department personnel
are disease prevention and control, tobacco, and
preparedness. These were also the top three topics in
2010. On average, states in the South were more likely
to provide technical assistance on a greater percentage
of topics (90% performed in South; 71-77% performed
in other regions). On average, small states provided
technical assistance on fewer topics (mean = 5.81) than
did medium and large states (mean = 8.88 for both).

Access to Healthcare Services
Access to healthcare services is an essential first step
in receiving the appropriate care to prevent illness and
treat diseases and conditions. State health agencies
were asked to indicate the services they provide related
Table 3.1: State Health Agency Responsibility for Federal Initiatives
Federal Initiative

Public Health Emergency Preparedness cooperative
agreement (CDC)

100%

Maternal and Child Health/Title V

98%

Technical Assistance and Training

Vital statistics (National Center for Health Statistics)

98%

Preventive Health and Health Services Block Grant (CDC)

96%

State health agencies provide technical assistance
and training to a variety of partners on a number
of different topics. As shown in Table 3.2, technical
assistance is most frequently provided overall to local
public health departments, most often for the topic of
quality improvement/performance and accreditation.

ASPR Hospital Preparedness Program cooperative agreement

96%

National Cancer Prevention and Control Program Grant (CDC)

94%

Immunization Funding, Section 317

92%

Women, Infants, and Children program (U.S. Department
of Agriculture)

92%

Healthy People

90%

Injury Prevention (CDC)

81%

Table 3.2: Technical Assistance Provided by State Health Agencies to Partners
State Health Agency Partner

QI/Performance/
Accreditation

Data
Management

Public
Health Law

Policy
Development

Workforce
Issues

None of
These Topics

Emergency medical services

83%

75%

63%

Providers

87%

68%

55%

60%

62%

Hospitals

90%

69%

58%

60%

46%

Laboratories

88%

54%

44%

38%

40%

Local public health agencies

84%

74%

76%

84%

74%

10%

Nonprofits/community-based
organizations

56%

44%

53%

71%

42%

16%

42 Association of State and Territorial Health Officials

to healthcare. Figure 3.2 shows the percentage of state
health agencies that engage in activities to ensure access
to healthcare services. The three activities performed
by the greatest percentage of state health agencies
to ensure access were health disparities and minority
health initiatives, rural health initiatives, and emergency
medical services. Health disparities/minority health

initiatives showed the greatest increase from 2010 (85%)
to 2012 (94%), while acting as the institutional certifying
authority for federal reimbursement showed the greatest
decrease from 2010 (47%) to 2012 (38%). In 2012,
71 percent of state health agencies report providing
financial support to primary care providers.

2010
94%
89%

92%

89% 89%

83%

89%

83%

79%

83%

81%

79%

75%

79%

Percentage of states

87%

2012

75%
62%

30%
23%

None of the above

Other

Administrative procedures

Vital records, statistics,
or surveillance

Cultural competencies/
health disparities

Environmental health

Food safety

Maternal & child health

Preparedness

Tobacco

Disease prevention & control

6% 4%

Note: Food safety only appeared on the 2012 Profile Survey.

Figure 3.2: State Health Agency Access to Healthcare Services, 2010-2012 (n=47)
2010

2012

94%
85%

Percentage of states

75% 72%

53%
47%

47%
38%

38% 38%

32%

36%
30%

28%

28%
21%
6%

Health insurance
regulation

State/territorial provided
health insurance (not
supported by federal funds)

Tribal health

Faith-based health
programs

State/territorial children’s
health insurance program
(SCHIP)

Outreach and enrollment
for medical insurance

Institutional certifying
authority for federal
reimbursement

Emergency
medical services

Rural health

Health disparities and
minority health initiatives

11%

ASTHO Profile of State Public Health, Volume Three 43

State Health Agency Activities

Figure 3.1: State Health Agency Training Provided to Local Health Department Personnel, 2010-2012 (n=47)

Figure 3.3: State-Sponsored Loan Repayment Programs to
Increase the Supply of Providers, 2010-2012 (n=26)
2010

2012

85% 85%

Percentage of states

69% 69%
54%
46%

42%

39%

Other primary care
providers

Nurses

Mid-level providers

Physicians

Dentists

23%

Figure 3.4: Population-Based Primary Prevention Services Performed Directly by State Health Agencies, 2010-2012 (n=47)
2010

85%
79%

83%

2012

81%

79% 79% 77%
75%
68%

66% 68%

70%

68%
53%

53%

66%
60%

57%
51%

47%

47% 47% 45%

43% 43%
30% 32%

28%

44 Association of State and Territorial Health Officials

Mental illness

Substance abuse

Asthma

Sex education

Suicide

Skin cancer

Violence

Unintended pregnancy

Hypertension

Injury

Diabetes

Physical activity

Nutrition

Sexually transmitted disease
counseling and partner
notification

HIV

Tobacco

21%

19%

Abstinence only education

87% 87% 85% 85%

Percentage of states

State Health Agency Activities

Many states do have state-sponsored loan
repayment programs in place to increase the supply
of select positions in the community. As shown in
Figure 3.3, 85 percent of states have loan repayment
programs to increase the supply of physicians and
more than two-thirds have programs to increase the
supply of dentists. The percentage of states with loan
repayment programs for nurses has seen a decrease
from 54 percent of states in 2010 to 42 percent
in 2012. In contrast, the percentage of states with
loan repayment programs for other primary care
providers has increased from 23 percent in 2010 to
39 percent in 2012.

Population-Based Primary
Prevention Services

92%

2012

92%

Percentage of states

81%

International travel vaccines

Adult immunizations

Childhood immunizations

25% 27%

Figure 3.6: Vaccine Administration to Population Performed
Directly by State Health Agency, 2010-2012 (n=48)
2010

42%

48%

2012

46% 44%

19%

International travel vaccines

15%

Adult immunizations

More than 90 percent of state health agencies are
responsible for vaccine order management and
inventory distribution for childhood immunizations,
and more than 80 percent are responsible for vaccine
order management and inventory distribution for adult
immunizations. In contrast, approximately one-quarter
perform order management for international travel
immunizations directly (see Figure 3.5). When it
comes to administering vaccines, less than half of
state health agencies directly administer childhood
and adult vaccines, and less than one-quarter directly
administer international travel vaccines to populations
(see Figure 3.6).

98%

Childhood immunizations

Immunization Services

2010

Percentage of states

Looking at population-based primary prevention
activities overall, centralized/largely centralized
states on average perform a greater percentage
of population-based primary prevention services
(67% of 17 activities) than do decentralized/largely
decentralized states (50% of 17 activities). On average,
states in the West perform the most population-based
primary prevention services (72%) while states in
the Mid-Atlantic and Great Lakes perform the fewest
on average (44%). Performance of population-based
primary prevention services is inversely related to
population size, such that small states directly perform
the greatest percentage of population-based primary
prevention services on average (64%), followed by
medium (57%) and large states (46%). Only the number
of the prevention services provided was measured,
and no information was collected about the quality or
intensity of each service provided.

Figure 3.5: Vaccine Order Management Performed Directly by
State Health Agencies, 2010-2012 (n=48)

ASTHO Profile of State Public Health, Volume Three 45

State Health Agency Activities

State health agencies provide a variety of populationbased primary prevention services. Figure 3.4 displays
the percentage of state health agencies that directly
performed population-based primary prevention
services in 2010 and 2012. While provision of STD
counseling and partner notification increased from 2010
(79%) to 2012 (85%), the percentage of state health
agencies directly performing all other services remained
the same or decreased from 2010 to 2012, with the
overall trend decreasing.

Figure 3.7 displays the percentage of state health
agencies that directly perform screenings for diseases
and conditions. The three diseases and conditions
screened for directly by the most state health agencies
are HIV/AIDS, other STDs, and newborn screenings. From
2010 to 2012, blood lead screenings showed the greatest
increase in frequency (31% in 2010 to 42% in 2012),
while breast and cervical cancer screenings showed the
greatest decrease in frequency of performance, dropping
from 46 percent of state health agencies performing this
service directly in 2010 to 25 percent in 2012.
Overall, centralized/largely centralized states performed
a greater percentage of the 15 screening activities (45%
performed on average) than did decentralized/largely
decentralized states (24% performed on average). These
data do not account for screenings that may be done at
the local level by local health departments. States in the
South performed substantially more screening activities
(62% on average) than did states in other regions
(percentages ranged from 20-28%).

Other Clinical Services Provided
to Individuals
State health agencies provide a variety of clinical services
directly to individuals. As shown in Figure 3.8, oral
health, pharmacy, and substance abuse education/
prevention services were the three clinical services
performed directly by the greatest percentage of state
health agencies in 2012. All clinical services showed a
decrease in direct performance by state health agencies
from 2010 to 2012, with the exception of home
healthcare, which remained stable at 15 percent. The
performance of both domestic violence victim services
and sexual assault victim services showed large drops
from 2010 to 2012 (decreases of 17% and 23%, respectively). Performance of rural health clinical services also
dropped 17 percentage points from 2010 to 2012. On
average, centralized/largely centralized states performed
a greater percentage of all clinical services listed (24%)
than did decentralized/largely decentralized states (14%).

Figure 3.7: Screening for Diseases and Conditions Performed Directly by State Health Agencies, 2010-2012 (n=48)
2010

46%

27%

Note: Body mass index and prediabetes only appeared on the 2012 Profile Survey.

46 Association of State and Territorial Health Officials

25%

25%
17%

23%

17%

21% 23%
13% 15%

13%

Other

23%

High blood pressure

29% 27%

Diabetes

29%

Body mass index

Blood lead

Tuberculosis

Newborn screenings

31%

Other cancers

42%

HIV/AIDS

2012

56% 58%

Asthma

63%

Prediabetes

69%

Cardiovascular disease

63%

Colon/rectum cancer

56%

60%

Breast and
cervical cancer

65%

Other STDs

Percentage of states

State Health Agency Activities

Screening for Diseases and Conditions

Treatment for Diseases
In addition to screening for diseases, state health
agencies provide a variety of treatment services
for diseases and conditions. Figure 3.9 displays the
percentage of state health agencies that directly
provided treatment for select diseases and conditions
from 2010 to 2012. In both 2010 and 2012, the greatest
percentage of state health agencies provided treatment
services for tuberculosis, HIV/AIDS, and other STDs.

Figure 3.8: Other Clinical Services Performed Directly by State Health Agencies, 2010-2012 (n=48)
2012

56%
46%

42%
31%
25%
8%

13%

19%
8%

Sexual assault victim services

15%

Child protection services/
medical evaluation

Managed care (patient
centered medical homes)

Disability

10%

Physical therapy

10%

Disability determination

19%
10%

Correctional health

Comprehensive primary
care clinics for adults

Substance abuse
treatment services

Home healthcare

State/territorial nursing
home eligibility
determination

17%
17% 15% 15% 19%
15%
13% 13%

Mental health
treatment services

21% 21%

21%

25%

Domestic violence
victim services

29%

Mental health education
and prevention services

25%

Rural health

Pharmacy

29% 31% 29%

Substance abuse education
and prevention services

35%

Oral health

Percentage of states

2010

Figure 3.9: Treatment for Diseases and Conditions Performed Directly by State Health Agencies, 2010-2012 (n=46)

57% 54%

2012

57%
50%

50%

30%
20%
7% 7%

11%

17%
7%

Other cancers

Colon/rectum
cancer

Coronary
heart disease

11%

Asthma

Diabetes

Breast/cervical
cancer

HIV/AIDS

Other STDs

Tuberculosis

13%

Obesity

13%

Blood lead

15%

11%

Other

24%

High blood
pressure

Percentage of states

2010

Note: Obesity only appeared on the 2012 Profile Survey, while colon/rectum cancer and other cancers only appeared on the 2010 Profile Survey.
ASTHO Profile of State Public Health, Volume Three 47

State Health Agency Activities

On average, centralized/largely centralized states
directly perform 20 percent of 13 treatment services
for diseases, while decentralized/largely decentralized
states perform 10 percent. On average, states in
the South perform a greater percentage of disease
treatment services directly than do states from
other regions (35% for the South; range of 9-15% for
other regions).

Registry Maintenance

The laboratory services performed directly by state health
agencies in 2010 and 2012 are displayed in Figure 3.10.
In both 2010 and 2012, the three lab services performed
by the most state health agencies directly are bioterrorism agent testing, foodborne illness testing, and
influenza typing; the percentage of state health agencies
performing each of these activities remained stable from
2010 to 2012. Blood lead screening showed a notable
decrease from 69 percent of state health agencies
performing this service directly in 2010 to 50 percent in
2012. On average, medium and larger states performed
a greater percentage of lab services (67% and 70% of lab
services, respectively) than did small states (53%).

State health agencies maintain registries in response to
state and federal mandates and to promote the health
and well-being of their residents. The percentage of
state health agencies that performed these activities
directly in 2010 and 2012 is displayed in Figure 3.11.
The three registries maintained by the greatest
percentage of state health agencies in 2010 and 2012
were childhood immunization, birth defects, and cancer.
All have shown some decrease in the percentage of
state health agencies performing these activities from
2010 to 2012. Other registries maintained by state
health agencies include autism, asthma, HIV/AIDS, and
blood lead level registries, among others.

Figure 3.10: Laboratory Activities Performed Directly by State Health Agencies, 2010-2012 (n=48)
2010
96% 96%

94% 94%

2012

94% 94%
77%

Percentage of states

81%
73%

69%
50%

46%
35%

40%

21%

Other

Other environmental toxins

Cholesterol screening

Biomonitoring

Blood lead screening

Newborn screening

Influenza typing

Foodborne illness testing

17%

Bioterrorism agent testing

State Health Agency Activities

State Laboratory Services

Note: Other environmental toxins only appeared on the 2010 Profile Survey; biomonitoring only appeared on the 2012 Profile Survey.

48 Association of State and Territorial Health Officials

Figure 3.11: Registry Maintenance Activities Performed Directly
by State Health Agencies, 2010-2012 (n=48)
2010
98% 96%

2012

92%
75%

Percentage of states

75%

31%
15%

Other

Diabetes

Cancer

Childhood
immunization

Brith defects

Note: Other only appeared on the 2012 Profile Survey.

The maternal and child health (MCH) services performed
by state health agencies are displayed in Figure 3.12.
Services for children with special healthcare needs, the
U.S. Department of Agriculture’s Women, Infants, and
Children (WIC) program, and home visits were the three
maternal and child health services provided directly
by the greatest percentage of state health agencies in
2010 and 2012. While WIC and home visits remained
fairly stable over time, a notable drop was observed
for services for children with special healthcare needs,
with 79 percent of state health agencies performing this
service directly in 2010, but only 60 percent in 2012.
On average, centralized/largely centralized states
offered a greater percentage of maternal and child
health services (47%) directly than did decentralized/
largely decentralized states (19% of services provided on
average). States in the South provided more of 14 MCH
services on average than did states in other regions (55%
of MCH activities offered in South on average; 21-28% of
MCH activities offered in other regions on average).

Figure 3.12: Maternal and Child Health Activities Performed Directly by State Health Agencies, 2010-2012 (n=48)
2010

2012

54% 56%
42%

40%

Non-WIC nutritional
assessment and counseling

Family planning

EPSDT

Early intervention

MCH home visits

WIC

31% 31%

29%

25% 27%

29%

25%

21% 23%
10% 13%

13%
6% 4%
Obstetrical care

44%

Comprehensive school
health clinical services

38% 38%

Comprehensive primary
care clinics for children

42%

Prenatal care

48%

Well child services

44%

Child nutrition
(daycare providers)

48%

School health services
(non-clinical)

60%

Children with special
healthcare needs

Percentage of states

79%

ASTHO Profile of State Public Health, Volume Three 49

State Health Agency Activities

79%

Maternal and Child Health Services

Figure 3.13: Data Collection, Epidemiology, and Surveillance Activities Performed Directly by State Health Agencies, 2010-2012 (n=48)

96%

100%

96% 98%

98%
92%

96% 98%

92% 94%

94% 94%

96% 94%

94%

94% 94%

88%

92%

88%

92%

94%

2012

90%

79%

77% 77%

Percentage of states

52%

Data Collection, Epidemiology, and
Surveillance Activities
State health agencies often serve as the front lines for
data collection, epidemiology, and surveillance activities
(Figure 3.13). The majority of state health agencies
perform the majority of data collection, epidemiology,
and surveillance activities, and a number of activities
showed increases in percentage of state health agencies
performing them from 2010 to 2012. All state health
agencies reported directly performing reportable
diseases activities in 2012, and 98 percent of state
health agencies reported performing communicable/
infectious disease, foodborne illness, and vital statistics
activities in 2012. Syndromic surveillance activities
showed the greatest increase over time, with 79 percent
of state health agencies directly performing this activity
in 2010 and 94 percent performing it directly in 2012.

50 Association of State and Territorial Health Officials

Uninsured, outreach,
and enrollment for
medical insurance

Adolescent behavior

Cancer incidence

Injury

Environmental health

Syndromic surveillance

Chronic diseases

Behavioral risk factors

Perinatal events or
risk factors

Morbidity data

Vital statistics

Foodborne illness

Communicable/
infectious diseases

44%

Reportable diseases

State Health Agency Activities

2010

Regulation, Inspection, and Licensing
State health agencies enforce the laws and regulations
that protect health and ensure safety. Figure 3.14
shows the 15 most commonly performed regulation,
inspection, and licensing activities. The four regulatory
activities performed by the greatest percentage of state
health agencies in 2012 were regulation, inspection, and
licensing of laboratories, food service establishments,
hospitals, and trauma systems. While regulation of
labs remained constant from 2010 to 2012, regulation
of hospitals showed a small decrease over time (2%),
regulation of food service showed an increase from 75
percent in 2010 to 81 percent in 2012, and regulation of
trauma systems showed an increase of 2 percent from
2010 to 2012.
Looking at all the regulation, inspection, and licensing
activities together, states in New England performed
a greater percentage of these activities on average

Figure 3.14: Top 15 Regulation, Inspection, and Licensing Activities Performed Directly by State Health Agencies, 2010-2012 (n=47)
2010

2012

66%

72%

72% 70%

75%

70%

70%
64% 64%

62%

60%

Campgrounds/RVs

Hospice

Body piercing
and tattooing

Nursing homes

Long-term-care facilities

53%

64%
57%

2010

55%

2012

24% 24%

26% 24%

Nurses

Physicians

Physician assistants

54% 54%

Dentists

State health agencies are also involved in oversight of
professional licensure activities. Figure 3.15 displays
the percentage of state health agencies that directly
performed professional licensure activities in 2010 and
2012. Overall, the percentage of state health agencies
performing the various professional licensure activities
remained stable from 2010 to 2012, with about
one-quarter of state health agencies directly performing
professional licensure activities. States in New England
tended to perform more professional licensure activities
than did states in other regions (40% performed on
average in New England; range of 21-33% performed
by other regions). The category “other professionals”
included emergency medical technicians, midwives, and
nurse aides, among many others.

62%

Figure 3.15: Professional Licensure Activities Performed Directly
by State Health Agencies, 2010-2012 (n=46)

Percentage of states

than did other regions (57% New England; 40-47% for
other regions). Medium and large states on average
also performed a greater percentage of regulation,
inspection, and licensing activities (49% and 50%,
respectively) than did small states (42%).

Public swimming pools

Lead inspection

Emergency medical services

Trauma system

Hospitals

Food service establishments

Laboratories

49%

60%

Smoke-free ordinances

Percentage of states

77%

22% 22%

Other professionals

79%
70%

Assisted living

79% 81%

Pharmacists

83% 81%

Food processing

81%
75%

ASTHO Profile of State Public Health, Volume Three 51

State Health Agency Activities

89% 89%

State Health Agency Activities

Environmental Health Activities
Human health is inextricably linked to the environments in
which we live, so state health agencies are key players in
environmental health. Table 3.3 shows the percentage of
state health agencies that performed select environmental
health activities in 2010 and 2012. In 2012, 94 percent
of state health agencies were involved in environmental

epidemiology (a slight increase from 2010) and 83 percent
were involved in food safety training and education (a
7% decrease from 2010). Outdoor air quality showed the
greatest increase over time, from 10 percent in 2010 to
25 percent in 2012, while performance of poison control
activities showed the greatest decrease over time, from
33 percent of state health agencies performing this
directly in 2010 to only 13 percent in 2012.

Table 3.3: Environmental Health Activities Performed Directly by
State Health Agencies, 2010-2012 (n=48)

Table 3.4: Other Public Health Activities Performed Directly by
State Health Agencies, 2010-2012 (n=48)

2010

2012

2010

2012

Percentage of State
Health Agencies

Environmental epidemiology

92%

94%

Trauma system coordination

81%

88%

Food safety training/education

90%

83%

81%

69%

Veterinarian public
health activities

71%

Radiation control
Toxicology

75%

69%

77%

Indoor air quality

71%

65%

State/territorial health planning
and development

Radon control

58%

63%

Health consultations for
childcare environments

69%

Vector control

63%

56%

Institutional review board

67%

63%

Groundwater protection

46%

48%

60%

63%

Public water supply safety

52%

48%

Nonclinical services in
correctional facilities

Private water supply safety

52%

46%

35%

27%

Hazmat response

35%

Occupational safety and
health services

Surface water protection

35%

29%

State/territorial mental health
institutions/hospitals

23%

27%

Outdoor air quality

10%

25%

Medical examiner

23%

25%

Animal control

19%

17%

23%

Hazardous waste disposal

21%

17%

Support for military personnel,
veterans, and their families

Collection of unused
pharmaceuticals

19%

13%

Forensics laboratory

31%

21%
21%

15%

13%

State/territorial mental health
authority with substance abuse

19%

Land use planning
Poison control

33%

13%

Eldercare services

15%

17%

27%

13%

Noise pollution

Needle exchange

Coastal zone management

15%

13%

Other pollution prevention

10%

State/territorial tuberculosis
hospitals

Air pollution

21%

10%

Mosquito control

40%

State/territorial mental
health authority without
substance abuse
Substance abuse facilities

17%

Agriculture regulation

Note: Coastal zone management only appeared on the 2012 Profile
Survey; air pollution and mosquito control only appeared on the
2010 Profile Survey.

52 Association of State and Territorial Health Officials

Note: Health consultations for childcare environments and support
for veterans and military personnel and their families only appeared
on the 2012 Profile Survey.

Looking at the environmental health activities overall,
small states on average performed a lower percentage
of environmental health activities (33%) than did
medium and large states (43% and 41%, respectively).

State Health Agency Activities

Other Public Health Activities
Other public health activities frequently provided
directly by state health agencies in 2010 and 2012 are
displayed in Table 3.4. In both 2010 and 2012, the
three other public health activities performed directly
by the greatest percentage of state health agencies are
trauma system coordination, veterinarian public health
activities, and state health planning and development
services. The percentage of state health agencies
performing veterinary public health activities directly
increased from 71 percent in 2010 to 81 percent in
2012. The largest decrease over time in the percentage
of state health agencies performing an activity was
seen for needle exchange, with 27 percent providing
this service directly in 2010 and only 13 percent
providing it directly in 2012.

Health Insurance Exchanges
State health agencies were asked whether or not their
state was currently establishing a health insurance
exchange. Of the 48 states that responded to this
question, more than half are establishing health
insurance exchanges (see Figure 3.16). On average,
decentralized/largely decentralized states are slightly
more likely to be establishing health insurance exchanges
than are centralized/largely centralized states (68%
vs. 62%). States in the Mid-Atlantic and Great Lakes
are most likely to be establishing health insurance
exchanges on average (83%), while states in the South
are least likely to be doing so on average (33%). A greater
percentage of medium (65%) and large (67%) states are
establishing health insurance exchanges than are small
states (44%). Among the 28 states that are establishing
health insurance exchanges, the state health agency
is engaged in the process of establishing the health
insurance exchange in 20 of these states (71%).

Figure 3.16: Establishment of Health Insurance Exchanges by
States in 2012 (n=48)

Yes 58%
No 42%

ASTHO Profile of State Public Health, Volume Three 53

Research Activities

Worksite wellness programs can help state health
agencies support the physical and emotional well-being
of their employees and serve as a model for other
agencies and businesses in their communities.
Components of worksite wellness programs offered
at state health agencies in 2010 and 2012 are shown
in Figure 3.17. A greater percentage of state health
agencies engaged in almost every worksite wellness
activity in 2012 compared with 2010, except for three:
weight loss or physical activity challenges or incentives,
smoke-free venues for offsite meetings, and menu
labeling in the office building cafeteria. The greatest
increase was observed for healthy maternity policies
(80% in 2010 to 96% in 2012) and insurance coverage
for tobacco cessation programs (62% in 2010 to 81%
in 2012). On average, smaller states tended to offer
fewer worksite wellness program components than did
medium and large states.

State health agencies promote research and
disseminate research findings in various ways.
Figure 3.18 shows the types of research activities
state health agencies participated in over the past
two years. A substantially greater percentage of
decentralized/largely decentralized states (72%)
reported participating in activities to help other organizations apply research findings to practice than did
centralized/largely centralized states (23%). States in
the Mid-Atlantic and Great Lakes and the Mountains
and Midwest were less likely to apply research findings
to practices within the organization (33% and 50%,
respectively) than were states in the other three
regions (percentages for other regions ranged from
83%-100%).

Figure 3.17: Components of Worksite Wellness Programs Implemented at State Health Agencies, 2010-2012 (n=47)
2010
98% 100%

2012

96%
80%

84% 83%

Percentage of states

81%

75%

72%
66%

62%

60%
49%
40%

34%

38%
32%

36%
21%

54 Association of State and Territorial Health Officials

15%

Other

Menu labeling in
office building cafeteria

Healthy vending policy
in office building

Farmer’s market for staff

Healthy eating policies
for catered events

Smoke-free venues
for offsite meetings

Weight loss or physical activity
challenges or incentives for staff

Insurance coverage for
tobacco cessation programs

Footage requirements outside of
building for smoke-free area

Healthy maternity policies

Smoke-free building

State Health Agency Activities

Worksite Wellness

State Health Agency Activities

Figure 3.18: Participation in Research Studies in Past Two Years
by State Health Agencies (n=48)

85%

81%

75%

Recruiting study sites
and/or study participants

Developing or refining research plans
and/or protocols for public health studies

Applying research findings to
practices within own organization

Identifying research topics and questions
relevant to public health practice

Analyzing and interpreting
study data and findings

Disseminating research
findings to key stakeholders

Collecting, exchanging,
or reporting data for a study

58%

54%

Helping other organizations apply
research findings to practice

90%

Percentage of states

90%

The number of research studies that state health
agencies have engaged in over the past two years
ranges from a minimum of one to a maximum of
427 (mean number of studies = 46; median = 15).
On average, 41 percent of these studies are led by
the state health agency. On average, states in New
England have participated in the greatest number
of studies (mean = 99; median = 35) while states in
the Mountains and Midwest have participated in the
lowest number of studies (mean = 16; median = 6).
On average, large states have participated in more
research studies in the past two years than have
medium and small states.
When states do participate in research studies, an
average of 27 studies are conducted with researchers
based at a university or research institute. When state
health agencies do collaborate with researchers, about
30 percent of the studies involve a formal research
agreement between the agency and the university
or research institute to conduct joint studies on a
reoccurring basis.

ASTHO Profile of State Public Health, Volume Three 55

State Health Agency Activities

56 Association of State and Territorial Health Officials

Health Impact Assessments
Figure 3.19: Participation in HIA Training in Past Two Years by
Anyone in State Health Agency (n=46)

Yes 61%
No 15%
I don’t know 24%

States were also asked if their state health agency
had participated in an HIA in the past two years; less
than half had (45%). Of those states that reported
participating in a health impact assessment, state health
agencies had conducted or been part of two to three
HIAs in the past two years on average.

Public Health Institute Collaboration

42%
35%

13%

10%

No collaboration in
the past two years

17%

Other

Health communications/
social marketing

Health policy development
implementation and evaluation

Research and evaluation

Convening/partnering
with community stakeholders

21%

Health information
technology and services

38%

Fiscal/administrative
management

42%

Population-based health
program delivery

44%

Training and
technical assistance

This chapter has explored the range of roles and responsibilities that state health agencies have and the services
and activities that they provide. The next section of the
report, State Public Health: How We Do It, addresses the
tools and techniques that state health agencies utilize to
provide these services that protect the nation’s health.

Figure 3.20: Collaboration Between Public Health Institutes and
State Health Agencies (n=48)

Percentage of states

Public health institutes are nonprofit organizations that
leverage resources and build partnerships across sectors
in different geographic areas. In some instances, state
health agencies report some form of collaboration with
public health institutes over the past two years (see
Figure 3.20). Collaboration with public health institutes
most frequently occurs for training and technical
assistance, convening/partnering with community
stakeholders, and research and evaluation. The larger the
state, the more likely they are on average to collaborate
with public health institutes on the following: training
and technical assistance; convening/partnering with
community stakeholders; research and evaluation;
health policy development, implementation, and
evaluation; health communications/social marketing;
and population-based health program delivery.

ASTHO Profile of State Public Health, Volume Three 57

State Health Agency Activities

Health impact assessments are the process by which
the potential health effects of a project or policy are
systematically evaluated. State health agencies were
asked if anyone in the agency had attended a health
impact assessment (HIA) training in the past two years.
More than half of state health agencies reported that
someone in the agency attended a HIA training in the
past two years (see Figure 3.19). Nearly one-quarter
(24%) of states were unsure whether or not anyone in
the state health agency had attended an HIA training in
the past two years. Individuals from states in the West
were most likely to have participated in an HIA training
(80%), while individuals from states in the Mountains
and Midwest were least likely to have done so (44%).

Part III–State Public Health:

How We Do It

Chapter 4: Planning and Quality
Improvement

Key Findings:
• In 2012, 69 percent of state health agencies

reported completing a state health assessment,
with 85 percent of those having done so within the
last three years.
• The percentage of state health agencies that

reported developing or participating in developing
a state health improvement plan within the last
three years increased from 23 percent in 2007 to
38 percent in 2010 to 43 percent in 2012.
• As of 2012, 75 percent of state health agencies

have developed an agency-wide strategic plan.
From 2010 to 2012, the percentage of state health
agencies that planned to develop an agency-wide
strategic plan in the next year increased from 7
percent to 23 percent.
• Four-fifths of state health agencies reported that they

• The three most common frameworks/approaches

used for quality improvement in state health
agencies are Plan-Do-Check-Act or Plan-Do-StudyAct (used by 88% of state health agencies), Lean
(used by 43%), and Six Sigma (used by 20%).
• When asked about their use of specific quality

improvement techniques, all state health agencies
reported obtaining baseline data, 96 percent
reported setting measurable objectives, and 88
percent reported mapping a process.
• The most common ways that state health agencies

support or encourage staff involvement in quality
improvement efforts is through staff training on
QI methods (85%), a QI committee to coordinate
QI efforts (48%), and job descriptions that include
QI-related responsibilities (44%).

plan to seek accreditation through the Public Health
Accreditation Board’s voluntary national accreditation
program. Of the 26 states that plan to pursue accreditation but have not yet submitted a letter of intent,
85 percent intend to do so in 2013 or 2014.

ASTHO Profile of State Public Health, Volume Three 59

Planning & Quality Improvement

This chapter describes state health agencies’ completion of accreditation
prerequisites and intentions to apply for accreditation, state health agency
performance management systems and quality improvement (QI) efforts, staff
involvement in quality improvement, and use of U.S. Preventive Services Task
Force’s Community Guide to Preventive Services. Where available, 2012 data
will be compared with 2010 and 2007 data, and differences in state health
agency planning and quality improvement efforts by governance structure,
region, and state population size will be described.

2010

Percentage of states

The Public Health Accreditation Board (PHAB) established
a voluntary national accreditation program for state,
local, and tribal health agencies in 2011. Accreditation
through PHAB provides agencies with the opportunity to
measure their performance and demonstrate accountability. There are three prerequisites for accreditation,
all of which relate to planning and quality improvement:
1) conducting a state health assessment, 2) creation of a
state health improvement plan, and 3) development of an
agency-wide strategic plan.

Figure 4.1: Development of State Health Assessment Plans by
State Health Agencies, 2010-2012 (n=47)
2012

57%
49%

28%
21%
4%

Yes, five or more years ago

Yes, within the last
three years

2007

2010

2012

57%
43%
36%

23%
17%

19% 21%
9%

No, but plan to in the
next year

Yes, five or more years ago

15%

38%

Yes, more than three but
less than five years ago

Centralized/largely centralized states are twice as likely
as decentralized/largely decentralized states to be
planning to develop a health assessment in the next
year (31% of centralized/largely centralized vs. 15%
decentralized/largely decentralized). The Mid-Atlantic
and Great Lakes had the highest proportion of states
(75%) that had developed a health assessment in the
last three years, while the lowest proportion was in the
West (29%). Larger states (69%) are more likely to have
completed a health assessment in the last three years
than small (56%) and medium (53%) states. Conversely,
small (31%) and medium (29%) states are more likely
to be planning to develop a health assessment in the
next year than are large states (19%). The three-year
timeframe is tied to PHAB’s prerequisites for voluntary
accreditation.

Figure 4.2: Development or Participation in Development of a
State Health Improvement Plan, 2007-2012 (n=47)

Yes, within the last
three years

As of 2012, 69 percent of state health agencies have
developed a state health assessment; 85 percent of
those have done so within the last three years. From
2010 to 2012, the percentage of state health agencies
that developed a state health assessment in the last
three years increased from 49 percent to 57 percent.
Additionally, from 2010 to 2012 the percentage of
state health agencies that plan to develop a health
assessment in the next year increased from 11 to 28
percent (see Figure 4.1).

11%
4%

Yes, more than three but
less than five years ago

State Health Assessments

11%

No, but plan to in the
next year

Percentage of states

Planning & Quality Improvement

Accreditation Prerequisites

Note: In 2007, the response options were “Yes, within the last three
years,” “Yes, more than three years ago,” and “No.” “Yes, more than
three years ago” responses from 2007 were categorized under “Yes,
more than three years ago but less than five years ago” in this figure.

60 Association of State and Territorial Health Officials

2007

2010

2012

51%

49%

28%
18% 18%

18%

21%

10%

15%

23% 21%

Not applicable

28%

Linked to some plans

Of the 27 states reporting a state health improvement
plan in 2012, 23 (85%) intend to update the plan within
the next three years. Seventy-four percent of state health
agencies with a health improvement plan have one
that was developed using the results of a state health
assessment. Decentralized/largely decentralized states
are substantially more likely to have developed their state
health improvement plan using the results of a state
health assessment than are centralized/largely centralized
states (94% of decentralized/largely decentralized
states vs. 17% of centralized/largely centralized states).
Additionally, the larger the state, the more likely they are
to have developed their state health improvement plan
using the results of a state health assessment (44% of
small states, 78% of medium states, and 100% of large
states have done so).

Figure 4.3: Linking of State Health Improvement Plans to Local
Health Improvement Plans, 2007-2012 (n=39)

Yes

Decentralized/largely decentralized states are more than
four times as likely as centralized/largely centralized states
to have developed or participated in developing a state
health improvement plan in the last three years (62% of
decentralized/largely decentralized vs. 15% centralized/
largely centralized). A greater percentage of states in New
England plan to develop or participate in developing a
state health improvement plan in the next year (63%)
than states in the other four regions (percentages range
from 25-33%). A greater percentage of medium (47%)
and large (56%) states have developed or participated in
developing a state health improvement plan in the last
three years than small (25%) states.

ASTHO Profile of State Public Health, Volume Three 61

Planning & Quality Improvement

As of 2012, 57 percent of the 49 responding state health
agencies developed or participated in developing a state
health improvement plan. Of those that had developed
or participated in developing a state health improvement
plan, 75 percent had done so within the last three years.
From 2007 to 2012, the percentage of state health
agencies that developed or participated in developing
a state health improvement plan in the last three years
increased from 23 percent in 2007 to 38 percent in
2010 to 43 percent in 2012. Additionally, from 2010 to
2012, the percentage of state health agencies that plan
to develop or participate in developing a state health
improvement plan in the next year more than doubled,
from 15 percent to 36 percent (see Figure 4.2).

State health agencies were also asked whether their
state health improvement plan was linked to local health
improvement plans. In 2012, 37 percent of state health
agencies with state health improvement plans had plans
that were linked to local health improvement plans. The
percentage of state health agencies with state health
improvement plans linked to local health improvement
plans from 2007 to 2012 is displayed in Figure 4.3.
From 2007 to 2012, the percentage of all state health
agencies with state health improvement plans linked
to local health improvement plans decreased from 28
percent in 2007 to 18 percent in 2010 and 2012; the
percentage linked to some plans decreased from 51
percent in 2010 to 18 percent in 2012. Decentralized/
largely decentralized states are more likely to have
state health improvement plans linked to local health
improvement plans than are centralized/largely
centralized states (47% vs. 0%).

Percentage of states

State Health Improvement Plans

62 Association of State and Territorial Health Officials

2010

2012

73%
59%

23%

25%

16%

Yes, five or more years ago

Yes, more than three but
less than five years ago

Yes, within the last
three years

0%
No

No, but plan to in the
next year

Note: In 2007, the response options for this question were “Yes” and
“No.” ‘Yes” responses from 2007 were categorized under “Yes, within
the last three years” in this figure.

Figure 4.5: State Health Agency Implementation of Agency-Wide
Strategic Plan, 2010-2012 (n=43)
2010

35%
26%

Implemented more than
one year ago; annual
written evaluation on
progress not yet conducted

12%

14% 14%

16%

Not applicable

19%
7%

2012

28%

Not yet implemented

30%

Implemented in
the past year

A greater percentage of decentralized/largely
decentralized states (62%) implemented the strategic
plan within the past year than centralized/largely
centralized states (0%). A smaller percentage of states in
the West (17%) implemented plans in the past year than
states in other regions (percentages range from 43-57%
for the other four regions), and a greater percentage
of medium (50%) and large states (69%) implemented
plans within the past year than did small states (0%).

75%

Implemented more
than one year ago; one
or more written
evaluations conducted

State health agencies were also asked about the status
of the implementation of their strategic plan. In 2012,
31 percent of state health agencies had implemented
their agency-wide strategic plan in the past year and
another 17 percent had implemented the plan more
than one year ago with an annual written evaluation on
progress not yet conducted. Implementation status for
state health agencies from 2010 to 2012 is displayed in
Figure 4.5. From 2010 to 2012, the percentage of state
health agencies that had implemented agency-wide
strategic plans in the past year increased substantially
from 7 percent to 30 percent.

2007

Percentage of states

As of 2012, 75 percent of state health agencies have
developed an agency-wide strategic plan; 95 percent of
those have done so within the last three years. A greater
percentage of decentralized/largely decentralized states
(81%) have developed a strategic plan in the last three
years than centralized/largely centralized states (54%).
The percentage of state health agencies with strategic
plans from 2007 to 2012 is displayed in Figure 4.4. From
2007 to 2010, the percentage of state health agencies
that had developed an agency-wide strategic plan in
the last three years decreased from 75 percent to 59
percent. This number was near 2007 levels in 2012, with
73 percent having developed an agency-wide strategic
plan in the last three years. Additionally, from 2010 to
2012, the percentage of state health agencies that plan
to develop an agency-wide strategic plan in the next
year increased from 7 percent to 23 percent.

Figure 4.4: State Health Agency Development of Agency-Wide
Strategic Plan, 2007-2012 (n=44)

Percentage of states

Planning & Quality Improvement

Agency-Wide Strategic Plans

Intention to Apply for Accreditation

Of the 26 states that plan to pursue accreditation but
have not yet submitted a letter of intent, 85 percent
intend to do so within the next two years (see Figure 4.7).
Only two state health agencies indicated that they do
not intend to apply for accreditation, with one citing the
reason as the fees being too high.

State health agency plans to apply
for accreditation but has not
submitted a letter of intent yet 53%
State health agency has submitted
a statement of intent to pursue
accreditation 19%
State health agency has not
decided whether to apply for
accreditation 16%
State health agency has submitted
an application for accreditation 8%
State health agency has decided
not to apply for accreditation 4%

Figure 4.7: Anticipated Year of Letter of Intent Submission for
Accreditation, 2012 (n=26)

2013 54%
2014 31%

Performance Management Systems

2015 4%

A performance management system is made up of four
components: performance standards, performance
measures, reporting of progress, and quality
improvement. Over the last few years, the definitions
of these four components have been refined to better
reflect consensus. The following definitions are adapted
from the PHAB Acronyms and Glossary of Terms:21

Have not decided on a target
year 11%

2016 or later 0%

Performance standards are generally accepted,
objective forms of measurement that serve as a rule
or guideline against which an organization’s level of
performance can be compared. Standards may be set
by benchmarking against similar organizations, or they
may be based on national, state/territory, or scientific
guidelines such as Healthy People 2010 and 2020.22
21 PHAB. “Acronyms and Glossary of Terms, Version 1.0.” 2011.
Available at http://www.phaboard.org/wp-content/uploads/
PHAB-Acronyms-and-Glossary-of-Terms-Version-1.0.pdf.
Accessed 3-7-2014.
22 Healthy People. “2020 Topics and Objectives—Objectives A-Z.”
Available at http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx. Accessed 3-7-2014.

ASTHO Profile of State Public Health, Volume Three 63

Planning & Quality Improvement

As states begin to earn PHAB accreditation, state health
agencies are at different stages in the process. As
shown in Figure 4.6, the greatest percentage of state
health agencies (53%) plan to apply for accreditation
but have not yet submitted a letter of intent. A greater
percentage of centralized/largely centralized state
health agencies have submitted a statement of intent
to pursue accreditation (31% vs. 15%), while a greater
percentage of decentralized/largely decentralized
states have submitted an application for accreditation
(12% vs. 0%). States in the West are more likely to have
submitted an application for accreditation (29% in West
vs. 0-8% in the other four regions).

Figure 4.6: State Health Agency Participation in PHAB
Accreditation Program, 2012 (n=49)

Planning & Quality Improvement

State Health Agency Quality
Improvement Efforts

Performance measures are any quantitative measures
or indicators of capacities, processes, or outcomes
relevant to the assessment of an established
performance goal or objective.
Reporting of progress refers to documentation and
reporting of progress in meeting standards and targets
and sharing of such information through feedback.
Quality improvement (QI) is an integrative process that
links knowledge, structures, processes, and outcomes to
enhance quality throughout an organization. The intent
is to improve the level of performance of key processes
and outcomes within an organization. The ASTHO survey
defined QI as a formal, systematic approach (such as
Plan-Do-Check-Act) applied to the processes underlying
public health programs and services to achieve
measurable improvements.
For state health agencies reporting data in 2010 and
2012, the percentage of state health agencies with a
formal performance management plan increased
from 68 percent in 2010 to 74 percent in 2012 (see
Figure 4.8). State health agencies were slightly more
likely to have fully implemented a performance
management plan department-wide in 2012 than
they were in 2010 (13% vs. 9%), and they also were
more likely to have fully implemented a performance
management plan for specific programs in 2012 than in
2010 (19% vs. 15%). A greater percentage of states in
the Mid-Atlantic and Great Lakes do not have a formal
performance management plan than states in other
regions (42% do not have a plan in the Mid-Atlantic and
Great Lakes vs. 13%-29% for other regions).

64 Association of State and Territorial Health Officials

State health agencies engage in a variety of
frameworks or approaches to quality improvement.
In 2012, the three most common frameworks/
approaches used were Plan-Do-Check-Act or Plan-DoStudy-Act (used by 88% of state health agencies), Lean
(used by 43%), and Six Sigma (used by 20%). Figure
4.9 shows the quality improvement frameworks/
approaches used by state health agencies in 2010 and
in 2012. From 2010 to 2012, use of all frameworks
increased, except for Balanced Scorecard (which
decreased). In addition, the percentage of state health
agencies reporting no specific framework or approach
used decreased from 28 percent in 2010 to 4 percent
in 2012.
State health agencies indicated that they had used a
number of techniques in their quality improvement
efforts in the past year. The most frequently used
techniques are obtaining baseline data (100%), setting
measurable objectives (96%), and mapping a process
(88%). The percentage of state health agencies using
these techniques in 2010 and 2012 is displayed in
Figure 4.10. There was an increase in the use of all
techniques from 2010 to 2012, with the greatest
increases for obtaining baseline data, mapping a
process, and identifying root causes.
When asked about the nature of their agency’s current
quality improvement activities, more than two-thirds
of all state health agencies reported formal quality
improvement activities implemented in specific
programmatic/functional areas but not agency-wide
(see Figure 4.11). A greater percentage of centralized/
largely centralized states (85%) reported formal quality
improvement activities than decentralized/largely
decentralized states (65%).

Figure 4.8: Formal Performance Management Program in Place
at State Health Agencies, 2010-2012 (n=47)
2010

Figure 4.9: Quality Improvement Frameworks/Approaches Used
at State Health Agencies, 2010-2012 (n=46)

2012

2010

2012

20% 20%

Balanced Scorecard

Six Sigma

Lean

Yes, fully implemented
department-wide

Balbridge Performance Excellence
Criteria (or state version)

11%
4%
Other framework
or approach

15%

13%

Figure 4.11: Nature of State Health Agency’s Current Quality
Improvement Activities, 2012 (n=49)

2010

2012

96%
89%

87%

83%

Formal quality improvement
activities are being implemented in
specific programmatic/functional
areas but not on an agency-wide
basis 69%

79%

Percentage of states

68%

64%

62%
51%

55%
49%

Agency has implemented a formal
quality improvement program
agency-wide 27%
Agency’s quality improvement
activities are informal or ad-hoc
by nature 2%

Agency is not currently involved in
quality improvement activities 2%

None of the above

Analyzing results of a test

Testing effects of an
intervention

Identifying root causes

Mapping a process

Setting measurable objectives

0%
Obtaining baseline data

28%

26%

No specific framework
or approach

22%

Figure 4.10: Elements of State Health Agency Quality
Improvement Efforts, 2010-2012 (n=47)

100%

28%

Plan-Do-Check-Act
or Plan-Do-Study-Act

Yes, fully implemented
for specific programs

Yes, partially implemented
department-wide

15%

26%

41%

19%

19% 21%

Percentage of states

32%
21%

Yes, partially implemented
for specific programs

Percentage of states

26%

54%

ASTHO Profile of State Public Health, Volume Three 65

Planning & Quality Improvement

87%

Figure 4.12: Elements of Formal, Agency-Wide Quality Improvement
Programs in Place at State Health Agencies, 2012 (n=47)

Figure 4.13: Staff Involvement in Quality Improvement Efforts
at State Health Agencies, 2010-2012 (n=46)
2010

85%

30%

26%

23%

43%

41%

37%
28%

24%

28%

33%

28%
20%
4% 2%

State health agencies range in terms of which elements
of a formal agency-wide quality improvement program
they have in place. As shown in Figure 4.12, the most
common elements in place are a staff member with
dedicated time as part of his or her job description
to monitor QI work throughout the agency (89%),
leadership that dedicates resources (e.g., time, funding)
to QI (85%), and QI resources and training opportunities
that are offered to staff on an ongoing basis (70%). Less
than one-quarter of state health agencies (23%) report
having an agency-wide QI plan.
A greater percentage of decentralized/largely
decentralized states (81%) offer QI resources and
training opportunities to staff on an ongoing basis
than do centralized/largely centralized states (58%).
Decentralized/largely decentralized states are also
more likely to have QI incorporated in employee job
descriptions (35% of decentralized/largely decentralized
states vs. 8% of centralized/largely centralized states).
A smaller percentage of state health agencies in New
England (13%) have an agency QI council or other
committee that coordinates QI efforts (percentages for
other four regions range from 56-67%). Small states are
less likely to have an agency-wide QI program than are
medium and large states (7% of small states vs. 31% of
medium and large states).
66 Association of State and Territorial Health Officials

Participation in QI efforts included as
part of employee performance goals

Recognition of outstanding QI work
with employee recognition award(s)

Funding to support QI efforts

QI is included in job descriptions
for some employees

QI committee that
coordinates QI efforts

Training to staff in QI methods

None of the above

Agency-wide QI plan

QI is incorporated in employee
performance appraisals

QI is incorporated in
employee job descriptions

Agency performance data is used
on an ongoing basis to drive
improvement efforts

Agency QI council or other committee
that coordinates QI efforts

QI resources and training opportunities
offered to staff on ongoing basis

Leadership dedicates resources (e.g.,
time, funding) to QI

Staff member with dedicated time as
part of their job description to monitor
QI work throughout the agency

13%

9%
0%

Other

40%

50%

Monetary incentives

51%

65%
59%

Do not actively encourage staff

Percentage of states

70%

Percentage of states

Planning & Quality Improvement

89%

2012

Staff Involvement in Quality
Improvement
In 2012, the most common ways that state health
agencies supported or encouraged staff involvement
in quality improvement efforts was through training
to staff in QI methods (85%), a QI committee that
coordinates QI efforts (48%), and job descriptions that
include QI (44%). Decentralized/largely decentralized
states were equally or more likely to support or
encourage staff involvement in QI efforts in all ways than
were centralized/largely centralized states. A greater
percentage of large state health agencies (56%) had
recognition awards for staff QI excellence than small
(7%) or medium (18%) states.
Change in staff involvement in QI efforts at state health
agencies from 2010 to 2012 is shown in Figure 4.13.
Staff training in QI methods, having a QI committee
that coordinates QI efforts, and funding to support QI
efforts all increased from 2010 to 2012. In contrast, job
descriptions including QI, recognition awards for staff QI
excellence, and participation in QI efforts included as part
of employee performance goals all decreased from 2010
to 2012.

87% 85%

2012

83%
72%

67%

63%
50%

48%

11% 9%

None of the above

Other

Policy development

Priority setting

Grant writing

2%
Program planning

Changes in state health agencies’ use of The Community
Guide from 2010 to 2012 are displayed in Figure 4.14.
Use of the guide for priority setting increased from 50
percent in 2010 to 63 percent in 2012. Use for all other
purposes decreased from 2010 to 2012.

2010

This chapter has described state health agencies’
accreditation readiness and engagement in quality
improvement efforts. In the next chapter, focus will shift
to the increased use of health information systems and
technology in state public health agencies.

ASTHO Profile of State Public Health, Volume Three 67

Planning & Quality Improvement

In 2012, state health agencies had most commonly
used the U.S. Preventive Services Task Force’s Guide
to Community Preventive Services (“The Community
Guide”) in the past two years for program planning
(86%), grant writing (67%), and priority setting (61%).
Decentralized/largely decentralized states were more
likely to use the guide for program planning, grant
writing, priority setting, and priority development than
were centralized/largely centralized states. A smaller
percentage of states in the West (29%) used the
guide for grant writing than did states in other regions
(percentages ranged from 58% to 88%). Similarly, a
smaller percentage of states in the West (29%) and
Mid-Atlantic and Great Lakes (17%) used the guide for
policy development (percentages for other regions
ranged from 58% to 75%).

Figure 4.14: Use of the Guide to Community Preventive Services
at State Health Agencies, 2010-2012 (n=46)

Percentage of states

Use of The Community Guide

Key Findings
• Chief information officers or chief medical information

officers (or equivalents) most frequently have primary
responsibility for decisions around health information
exchange and overall decisionmaking authority for
public health information management systems at
state health agencies.
• More than half (59%) of informatics offices for state

health agencies are located within the agency itself.
Only 4 percent of informatics offices serving state
health agencies are centralized at the state level.

68 Association of State and Territorial Health Officials

• While just more than half (51%) of state health

agencies use health information exchanges to
monitor health topics, this is more than in 2010,
when 42 percent reported using health information
exchanges to monitor health topics. The most
common topics monitored using health information
exchanges are emerging infectious diseases (33%),
environmental exposures (21%), and chronic disease
indicators and risk factors (both 13%).

Health information technology (HIT) supports the electronic use and exchange
of health information between providers across the healthcare system as well
as insurers, pharmacies, and public health; it includes the use of electronic
health records.23 Health information exchange (HIE) is the electronic movement
of health-related information among organizations according to nationally
recognized standards.24 As more healthcare providers adopt health information
technologies, public health agencies will be more likely to exchange data
directly with them.

• Among state health agencies that responded in

2010 and 2012, 39 percent used health information
exchanges to communicate about a variety
of health topics in 2012, which represents a
slight decrease from 2010. In 2012, state health
agencies most commonly used health information
exchanges to communicate about the notification
of communicable disease outbreaks, drug warnings,
or environmental risks (31%); vaccination guidelines
and requirements (24%); and disease case definitions
and diagnostic guidelines or criteria (18%).

• Electronic data exchange is common at the majority

of state health agencies, though less so in the areas
of water wells, electronic health records, and onsite
waste water treatment. Bidirectional data exchange
is most common for electronic health records (71%),
Medicaid billing (56%), and lab results (53%). Data are
most commonly collected using a state system rather
than local for all topic areas.
• The majority of state health agencies have all of the

systems in place to meet Meaningful Use public health
objectives, and while bidirectional data reporting and
exchange varies among systems, most state health
agencies send and receive data from federal agencies.

23 For more information, visit http://www.healthit.gov/.
24 HHS and the National Alliance for Health Information Technology. “The National Alliance for Health Information Technology Report to the
Office of the National Coordinator for Health Information Technology on Defining Key Health Information Technology Terms.” April 28, 2008.
ASTHO Profile of State Public Health, Volume Three 69

Health Information Management

Chapter 5: Health Information
Management

Health Information Management

This chapter includes detailed information on state
health agencies’ use of public health information
systems and how they interact electronically with the
healthcare system and other public health entities.
Topics include individuals within state health agency
leadership who have responsibility for HIE/HIT issues;
entities with which SHAs exchange data and how those
data are exchanged; and how state health agencies use
HIE for specific programs. There is also a discussion of
program areas for which state health agencies collect
data electronically and systems in place to address the
Meaningful Use public health objectives.

Primary Responsibility for Health
Information Exchange
As of 2012, in 41 percent of state health agencies, the
chief information officer/chief medical information officer
or the equivalent for the state health agency has primary
responsibility for decisions regarding HIE or HIT issues;
in another 16 percent of state health agencies, the chief
information officer or equivalent for multiple agencies has
primary responsibility. From 2010 to 2012, the percentage
of state health agencies with a chief information officer/
chief medical information officer or equivalent for the
state health agency or another entity with primary
responsibility has shown increases, while the percentage
of chief information officer or equivalent for multiple
agencies, boards or committees for multiple agencies
within the state government, and informatics directors
with primary responsibility has decreased. The percentage
with a board or committee for the state health agency
with primary responsibility for decisions regarding HIE or
HIT issues has remained constant (see Figure 5.1).
Centralized/largely centralized states are nearly twice
as likely as decentralized/largely decentralized states
(69% vs. 35%) to have the chief information officer/
chief medical information officer or equivalent for the
state health agency having primary responsibility for
HIE or HIT issues. A greater percentage of medium and
large states (47% and 44%, respectively) have the chief
information officer/chief medical information officer or
equivalent for the state health agency having primary
responsibility than do small states (31%). Conversely, a
greater percentage of small states (31%) have the chief
information officer or equivalent for multiple agencies
with primary responsibility for these decisions than do
medium (12%) and large (6%) states.

70 Association of State and Territorial Health Officials

Decisionmaking Authority for
Public Health Information
Management Systems
In more than half of state health agencies, the chief
information officer or chief medical information
officer (or equivalent) for the state health agency
has overall decisionmaking authority for state public
health information management systems. In 29
percent of state health agencies, another entity has
the overall decisionmaking authority; in the remainder
of state health agencies, overall decisionmaking
authority resides with the chief information officer (or
equivalent) for multiple agencies in state government
(8%) or the informatics director (8%). From 2010 to
2012, the percentage of state health agencies with the
chief information officer or chief medical information
officer (or equivalent) for the state health agency
having overall decisionmaking authority for public
health information management systems increased
from 47 percent to 53 percent. The percentage with
chief information officer (or equivalent) for multiple
agencies in state government and informatics directors
having overall decisionmaking authority decreased,
while the percentage with another entity remained
stable over time (see Figure 5.2).
A greater percentage of centralized/largely centralized
states reported that the chief information officer or
chief medical information officer (or equivalent) for
the state health agency had overall decisionmaking
authority than decentralized/largely decentralized
states (77% vs. 46%). Decentralized/largely
decentralized states were more likely to have another
entity with overall decisionmaking authority than were
centralized/largely centralized states (38% vs. 15%).
States in the Mid-Atlantic and Great Lakes and the West
were most likely to have the chief information officer
or chief medical information officer (or equivalent)
for the state health agency having overall decisionmaking authority (75% and 71%, respectively), while
states in New England and the Mountains and Midwest
were least likely (38% and 30%, respectively). Only
small states (25%) reported that the chief information
officer (or equivalent) for multiple agencies in state
government had overall decisionmaking authority for
state public health management systems.

4%
2012

9%
13%
9%
11%

Other

23%

Informatics director

34%

Chief information officer (or equivalent) for
multiple agencies in state government

38%

Percentage of states

2010

Chief information officer/chief medical information
officer (or equivalent) for state health agency

17%

Other

Informatics director

4% 4%

Board or committee for multiple
agencies in the state government

21%

Board or committee for the state health agency

34%

Chief information officer (or equivalent)
for multiple agencies

Chief information officer/chief medical information
officer (or equivalent) for state health agency

Percentage of states

Health Information Management

Figure 5.1: Primary Decisionmaking Authority for Health
Information Exchange or Health Information Technology Issues
at State Health Agencies, 2010-2012 (n=47)
Figure 5.2: Overall Decisionmaking Authority for State Public
Health Information Management Systems, 2010-2012 (n=47)

2010
2012

47%
53%

30% 30%

2%
9%

ASTHO Profile of State Public Health, Volume Three 71

Figure 5.3: Location of Informatics Office at State Health
Agencies, 2012 (n=49)

In more than half of state health agencies, the
informatics office is located within the state health
agency. For nearly one-quarter of state health agencies,
the informatics office is located in separate teams for
each program area. For the remaining state health
agencies, the office is centralized at the state level or at
another location (see Figure 5.3). A greater percentage
of state health agencies in New England (75%) and the
Mid-Atlantic and Great Lakes (83%) have informatics
offices located within the state health agency than
states in the South (33%) or West (43%). A greater
percentage of small (31%) and large (25%) states have
informatics offices located in separate teams for each
program area than do medium-sized states (12%).

Within the state health agency
59%
Separate team for each program
area 23%
Centralized at the state level 4%
Other 14%

Health Information Exchange:
Monitoring

72 Association of State and Territorial Health Officials

2010

2012

58%
49%
33%
22%

20%
9% 9%

13% 11% 11%

None of the above

13%

Other

Healthcare quality indicators

Chronic disease indicators

13% 13%

Indicators of health disparities

24%

Chronic disease risk factors

29%

Environmental exposures

Centralized/largely centralized states were slightly
more likely to use health information exchanges for
monitoring emerging infectious diseases and environmental exposures than were decentralized/largely
decentralized states. States in the West were most likely
to use health information exchanges for monitoring
other topics (50% of states in West as compared with

Figure 5.4: Use of Electronic Health Information Exchanges for
Monitoring, 2010-2012 (n=45)

Emerging infectious diseases

State health agencies use health information exchanges
to monitor a variety of public health topics. In 2012,
health information exchanges were most frequently
used to monitor emerging infectious diseases (33%),
environmental exposures (21%), and chronic disease
indicators and risk factors (both 13%). Nearly half
of state health agencies (48%) did not use health
information exchanges to monitor any topics. From
2010 to 2012, the percentage of state health agencies
using health information exchanges for monitoring
emerging infectious diseases, chronic disease risk
factors, and other health topics increased. In contrast,
the percentage of state health agencies using health
information exchanges for monitoring environmental
exposures, healthcare quality indicators, and for no
health topics decreased. The percentage of state
health agencies using health information exchanges for
monitoring chronic disease indicators and indicators
of health disparities remained constant over time (see
Figure 5.4).

Percentage of states

Health Information Management

Location of Informatics Office

2012

57%

33%

28%

24% 22%

24%

61%

20%
11% 11%

None of the above

Other

Promotion of healthy behaviors

Disease case definitions and diagnostic
guidelines or criteria

Vaccination guidelines and requirements

4% 4%
Notification of communicable disease outbreaks,
drug warnings, or environmental risks

State health agencies also use health information
exchanges for communication purposes. In 2012,
state health agencies most frequently used
health information exchanges for notification of
communicable disease outbreaks, drug warnings, or
environmental risks (31%); vaccination guidelines and
requirements (24%); and disease case definitions and
diagnostic guidelines or criteria (18%). More than
half (59%) of state health agencies did not use health
information exchanges for communication. From 2010
to 2012, there was little change in the percentage of
state health agencies that used health information
exchanges for communication of specific topics—no
increase or decrease was greater than 5 percent, or
two state health agencies (see Figure 5.5).

2010

Percentage of states

Health Information Exchange:
Communication

Figure 5.5: Use of Electronic Health Information Exchanges for
Communication, 2010-2012 (n=46)

Centralized/largely centralized states were twice as
likely to use health information exchanges for notification of communicable disease outbreaks, drug
warnings, or environmental risks as were decentralized/
largely decentralized states (38% vs. 19%). In contrast,
decentralized/largely decentralized states were
approximately twice as likely to use health information
exchanges for disease case definitions and diagnostic
guidelines or criteria as were centralized/largely
centralized states (15% vs. 8%). States in the South
(42%), Mid-Atlantic and Great Lakes (50%), and West
(43%) were more likely to use health information
exchanges for notification of communicable disease
outbreaks, drug warnings, or environmental risks than
were states in New England (13%) and the Mountains
and Midwest (0%). Small states (19%) were more likely
to use health information exchanges to communicate
other health topics than were medium and large states
(both 6%).

ASTHO Profile of State Public Health, Volume Three 73

Health Information Management

8-33% of states in other four regions). Medium-sized
states (53%) were more likely to use health information
exchanges to monitor emerging infectious diseases
than were small (19%) or large (27%) states. Mediumsized states (24%) were also more likely to use health
information exchanges for monitoring chronic disease
indicators and risk factors than were small (0%) or large
(13%) states.

Health Information Management

74 Association of State and Territorial Health Officials

Electronic Data Exchange

Table 5.1: Program Areas for Which State Health Agencies Collect Data Electronically, 2012
Agency Collects
Information
Electronically

Data Received
Through HIE Entity

Bidirectional Data
Reporting and
Exchange Capacity

Data Collected
Primarily with
State System

Data Collected
Primarily with
Local System

Total n

Lab results

98%

28%

53%

94%

Reportable diseases

98%

19%

50%

94%

Vital records

94%

48%

93%

WIC

85%

43%

85%

15%

Outbreak management

79%

18%

39%

89%

11%

MCH reporting

77%

24%

88%

12%

Geocoded data
for mapping

76%

11%

37%

94%

Healthcare systems data

70%

39%

94%

Case management

69%

52%

88%

12%

Medicaid billing

59%

22%

56%

93%

Food service inspections

51%

35%

83%

17%

Water wells

38%

25%

94%

Electronic health
records

37%

35%

71%

88%

12%

Onsite waste water
treatment systems

26%

18%

100%

ASTHO Profile of State Public Health, Volume Three 75

Health Information Management

State health agencies collect, receive, and exchange
program specific information electronically. Table
5.1 shows the program areas for which state health
agencies collect data electronically. More than half of
state health agencies collect information electronically
for all areas except water wells, electronic health
records, and onsite waste water treatment systems. It is
notably less common for agencies to receive data about
these program areas through a health information
exchange entity (percentages of state health agencies
doing so range from 0-35%). Bidirectional data reporting
and exchange is greatest for electronic health records
(71%), Medicaid billing (56%), and lab results (53%).
For all topic areas, data are collected primarily with
the state system for more than 80 percent of state
health agencies. It is much less common for data to be
collected primarily with local systems.

Decentralized/largely decentralized states are substantially more likely to collect geocoded data for mapping
than are centralized/largely centralized states (95% vs.
50%) and to collect healthcare systems data (80% vs.
58%). In contrast, centralized/largely centralized states
are more likely to collect Medicaid billing data, WIC data,
food inspection data, water wells data, electronic health
records, and onsite waste water treatment data than are
decentralized/largely decentralized states. States in New
England are less likely to collect healthcare systems data
than are states in other regions (25% for New England
vs. 57-91% for other four regions). States in the South
are more likely to collect onsite waste water treatment
data than are states in other regions (63% for South vs.
0-36% for other regions). Small states (43%) are less
likely to collect geocoded data for mapping than are
medium (86%) and large states (100%). Similarly, small
states (43%) are less likely to collect healthcare systems
data than are medium (79%) and large (83%) states.

Health Information Management

Meaningful Use
The Health Information Technology for Economic
and Clinical Health (HITECH) Act promotes the use
of electronic health records and health information
exchanges to promote high quality care, reduce costs,
facilitate coordination of care among providers, and
improve population health. Implementing Meaningful
Use of electronic health records by providers will
require a public health infrastructure that can
support the receipt and exchange of data with the
provider community.

State health agencies have systems in place to address
the Meaningful Use public health objectives, and
as shown in Table 5.2, the majority of state health
agencies have all the systems in place. Bidirectional
data reporting and exchange are currently performed
most frequently with immunization registry systems,
electronic communicable disease reporting systems,
and electronic laboratory communicable disease
reports. Bidirectional reporting with immunization
registries by state is displayed in Figure 5.6. State
health agencies also frequently send and receive data
to and from federal agencies. This most frequently

Figure 5.6: Capable of Bidirectional Reporting with Immunization Registries

MN
OR

VT
MI

NJ
DE

TN
AR
MS

MA
CT

NE
NV

No Data
Yes
No

76 Association of State and Territorial Health Officials

Does not have
immunization
registry

occurs with electronic communicable disease reporting
systems, cancer registries, and electronic laboratory
communicable disease reports. For all registries and
systems, data are collected primarily with the state
system rather than primarily with the local system.

This chapter has focused on the electronic use and
exchange of health information between providers
across multiple systems. In the next and final chapter
of this section, attention will turn to state health
agency finance and how agencies receive and
distribute funds to improve public health.

Table 5.2: Meaningful Use Objectives, 2012

Agency Has System

System Currently
Performs Bidirectional Data Reporting
& Exchange

Agency Sends/
Receives Data
to/from Federal
Agencies

Data Collected
Primarily with
State System

Data Collected
Primarily with
Local System

Total n

Immunization
registry

98%

62%

94%

Cancer registry

96%

24%

83%

96%

Electronic laboratory 43
communicable
disease reports

95%

44%

78%

93%

Electronic
communicable
disease reporting
system

94%

47%

91%

Electronic
syndromic
surveillance system

80%

24%

62%

89%

11%

Other registry

57%

17%

50%

92%

ASTHO Profile of State Public Health, Volume Three 77

Health Information Management

Decentralized/largely decentralized states were
slightly more likely to have systems for Meaningful Use
related to immunization registries, cancer registries,
and electronic lab communicable disease reports
than centralized/largely centralized states. States in
the Mid-Atlantic and Great Lakes were more likely
than other regions to have all of the Meaningful Use
systems they were surveyed about. Additionally, large

states were slightly more likely than small and medium
states to have systems in place for communicable
disease reporting, cancer registries, and electronic lab
communicable disease reports. Medium-sized states
(60%) were less likely to have syndromic surveillance
systems than were small (94%) or large (92%) states.

Key Findings
• Between FY10 and FY11, there were increases

in total revenue for federal funds, state/territory
general funds, fees and fines, and other sources.
• Federal funds were the largest source of state

health agency revenue for FY10 and FY11.

78 Association of State and Territorial Health Officials

• State health agency total federal revenue for FY10

was approximately $14.3 billion and exceeded
$14.9 billion for FY11. More than half of state
health agency total federal revenue in FY11 was
from the U.S. Department of Agriculture.

In 2012, state health agencies were asked to report on revenues, expenditures,
and dollars distributed to local and regional health agencies and nonprofit
organizations. This chapter describes state health agency funding sources,
expenditures, and dollars distributed to health agencies and community-based
organizations for FY 2010 and FY 2011 and examines differences between
those two years. States were also asked to provide more detailed information
on sources of federal funding received in FY10 and FY11.

• The average per capita expenditure for the states

and DC in FY11 was $98; the median per capita
expenditure was $78.
• Between FY10 and FY11, average and total state

health agency expenditures increased for most
categories. The two largest spending categories were
improving consumer health and WIC.

• State health agencies distributed approximately

$5.8 billion through contracts, grants, and awards
in FY10 and nearly $6.1 billion in FY11. Forty-four
percent of state health agency contracts, grants, and
awards were awarded to local health departments,
and nearly one-third (32%) of state health agency
contracts, grants, and awards were distributed to
nonprofit organizations.

ASTHO Profile of State Public Health, Volume Three 79

State Health Agency Finance

Chapter 6: State Health Agency Finance

State health agencies were asked to report revenue for
FY10 and FY11 by funding source (see Figure 6.1 for
definitions of funding sources). Results are displayed
in Figure 6.2. State health agency total revenue for
FY10 exceeded $26.5 billion, while state health agency
total revenue for FY11 was approximately $28.1 billion.
Between FY10 and FY11, there were increases in total
revenue for federal funds, state general funds, fees
and fines, and other sources. Conversely, from FY10 to
FY11, there were decreases in total revenue for state/
territory other funds. More than half (53%) of state
health agency revenue in FY11 was from federal funds,
while just under one-quarter (24%) was from state/
territory general funds (see Figure 6.3).
Table 6.1 presents the mean, median, minimum, and
maximum revenue for FY10 and FY11 by source of
funding. For all sources of funding, the mean exceeds
the median, in some cases by a substantial amount,
indicating several state health agencies with particularly high revenues from specific sources that skewed
(increased) the mean.

Figure 6.1: Funding Source Descriptions

State general funds. Include revenues received
from state general revenue funds to fund state
operations. Exclude federal pass-through funds.
Federal funds. Include all federal grants,
contracts, and cooperative agreements.
Fees and fines. Include fines, regulatory fees,
and laboratory fees.
Other sources. Include tobacco settlement
funds, payment for direct clinical services (except
Medicare and Medicaid), and foundation and
other private donations.
Other state/territory funds. Include revenues
received from the state/territory that are not
from the state general fund.

Figure 6.2: Total State Health Agency Revenue for FY10 and FY11 by Source of Funding (n=49*)

$16,000
$14,000
$12,000
$10,000
In millions

State Health Agency Finance

State Health Agency Revenue

$8,000
$6,000
$4,000
$2,000
$0
Federal funds

State/territory
general funds

Fess and fines

State/territory
other funds

Other sources

FY 2010:

$14,309

$6,046

$1,083

$2,808

$2,334

FY 2011:

$14,991

$6,772

$1,113

$2,768

$2,450

*Note: Not all states provided values for all revenue sources and expenditure categories. Ns range from 35 to 49.

80 Association of State and Territorial Health Officials

Figure 6.3: Percentage of State Health Agency Revenue by
Funding Source for FY11 (n=49*)

Federal funds 53%
State/territory general funds 24%
State/territory other funds 10%
Other sources 9%

*Note: Not all states provided values for all revenue sources or
expenditure categories. Ns range from 35 to 49.

In 2012, state health agencies were also asked to further
break down federal revenue by source/agency for FY10
and FY11. Results are displayed in Figure 6.4. State health
agency federal revenue for FY10 was approximately $11.9
billion, while state health agency federal revenue for
FY11 exceeded $12.9 billion.25 Between FY10 and FY11,
there were increases in total federal revenue from U.S.
25 For both total federal funds as well as the breakdown by agency,
there were increases from FY10 to FY11. However, the total
federal funds we report is larger than the total broken down by
agency, due to some states including federal funds in their total
that they received from agencies not specified.

Table 6.1: Average State Health Agency Revenue by Source of Funding for FY10 and FY11, in Millions (n=49*)

FY10 (in millions)

FY11 (in millions)

Mean

Median

Min

Max

Mean

Median

Min

Max

State/territory general funds

$128

$58

$1,320

$138

$53

$1,306

State/territory other funds

$70

$24

$0.02

$927

$71

$23

$0.02

$958

Federal funds

$298

$177

$24

$1,954

$306

$185

$20

$1,880

Fees and fines

$33

$19

$131

$34

$21

$118

Other sources

$60

$18

$0.2

$887

$64

$16

$0.01

$871

*Note: Not all states provided values for all revenue sources or expenditure categories. Ns range from 35 to 49.

Figure 6.4: State Health Agency Federal Revenue by Source for FY10 and FY11 (n=46*)
$8,000
$7,000
$6,000

In millions

$5,000
$4,000
$3,000
$2,000
$1,000
$0
USDA

CDC

HRSA

DHS

Medicaid

EPA

Medicare

Federal
indirect

FY 2010:

$6,521

$2,395

$936

$528

$389

$293

$366

FY 2011:

$7,100

$2,112

$1,285

$886

$561

$386

$299

$357

*Note: Not all states provided values for all federal revenue sources or expenditure categories. Ns range from 29 to 46.

ASTHO Profile of State Public Health, Volume Three 81

State Health Agency Finance

Fees and fines 4%

Federal Revenue

Figure 6.5: Percentage of State Health Agency Federal Revenue
by Funding Source for FY11 (n=46*)

USDA 55%
CDC 16%
HRSA 10%
State Health Agency Finance

DHS 7%
Medicaid 4%
EPA 3%
Federal indirect 3%
Medicare 2%

*Note: Not all states provided values for all revenue sources or
expenditure categories. Ns range from 29 to 46.

Department of Agriculture (USDA), Health Resources and
Services Administration (HRSA), Medicaid, Medicare, and
the Department of Homeland Security (DHS). Conversely,
there were decreases in total federal revenue between
FY10 and FY11 from CDC, EPA, and federal indirect funds.
As shown in Figure 6.5, more than half (55%) of state
health agency total federal revenue in FY11 was from
USDA; the next highest percentage came from CDC (16%).
Table 6.2 presents the mean, median, minimum, and
maximum federal revenue for FY10 and FY11 by source of
funding. As with all sources of funding, the means for all
federal sources of funding exceed the medians, in some
cases by substantial amounts, indicating several state
health agencies with particularly high federal revenues
from specific sources that skewed (increased) the mean.

Table 6.2: Average State Health Agency Federal Revenue by Source of Funding for FY10 and FY11 (n=46*)

FY10 (in millions)

FY11 (in millions)

Mean

Median

Min

Max

Mean

Median

Min

Max

CDC

$53

$38

$263

$46

$37

$182

HRSA

$21

$0.1

$186

$28

$11

$0.2

$353

Medicaid

$13

$0.001

$99

$14

$0.02

$119

Medicare

$10

$0.01

$166

$0.01

$158

USDA

$145

$101

$1,136

$154

$94

$1,215

DHS

$14

$0.003

$104

$23

$0.05

$366

EPA

$10

$0.003

$174

$10

$0.1

$164

Federal indirect

$12

$0.1

$148

$12

$0.1

$126

*Note: Not all states provided values for all federal revenue sources or expenditure categories. Ns range from 29 to 46.

82 Association of State and Territorial Health Officials

Figure 6.6: Expenditure Category Descriptions

Infectious disease. Include TB
prevention, family planning education
and abstinence programs, and AIDS
and STD prevention and control.
Include immunization programs
(including the cost of vaccine and
administration), infectious disease
control, veterinary diseases affecting
human health and health education,
and communications related to
infectious disease.
Injury prevention. Include
childhood safety and health
programs, safety programs,
consumer product safety, firearm
safety, fire injury prevention,
defensive driving, highway safety,
mine and cave safety, onsite safety
and health consultation, workplace
violence prevention, child abuse
prevention, occupational health,
safe schools, and boating and
recreational safety.

cave safety, pesticide regulation and
disposal, and nuclear power safety.
Also include food service inspections
and lodging inspections.
Improving consumer health. Include
all clinical programs such as funds
for Indian healthcare, access to care,
pharmaceutical assistance programs,
Alzheimer’s disease, adult day care,
medically handicapped children, AIDS
treatment, pregnancy outreach and
counseling, chronic renal disease,
breast and cervical cancer treatment,
TB treatment, emergency health
services, genetic services, state/
territory assistance to local health
clinics (prenatal, child health, primary
care, family planning direct services),
refugee preventive health programs,
student preventive health services,
and early childhood programs.

Health data. Include surveillance
activities, data reports and
collections costs, report production,
analysis of health data (including
vital statistics analysis), monitoring
of disease and registries, monitoring
of child health accidents, and injuries
and death reporting.
Health laboratory. Include costs
related to administration of the state/
territorial health laboratory including
chemistry lab, microbiology lab,
laboratory administration, building
related costs, supplies.
Vital statistics. Include all
costs related to vital statistics
administration including records
maintenance, reproduction,
generation of statistical reports,
and customer service at the state/
territory level.

All-hazards preparedness and
response. Include disaster
preparedness programs, bioterrorism, disaster preparation, and
disaster response including costs
associated with response such as
shelters, emergency hospitals and
clinics, and distribution of medical
countermeasures (vaccination clinics
and points of distribution/pods).

Administration. Include all costs
related to department management,
executive office (state/territorial
health official), human resources,
information technology, and finance,
in addition to indirect costs such
as building-related costs (rent,
supplies, maintenance, and utilities),
budget, communications, legal
affairs, contracting, accounting,
Quality of health services. Include
purchasing, procurement, general
quality regulatory programs such as security, parking, repairs, and facility
health facility licensure and certifimanagement. Also include expenses
WIC. Include all expenditures
cation, equipment quality such as
related to health reform and
related to the WIC program,
X-ray, mammogram, etc., regulation policy (only if they are not already
including nutrition education and
of emergency medical system such
embedded in program areas), such
voucher dollars.
as trauma designation, health
as participation in state/territorial
related boards or commissions
health plan reform and federal
Environmental health. Include lead
administered by the health agency,
reform efforts such as health reform
poisoning programs, non-point source physician and provider loan program, advisory committees, as well as
pollution control, air quality, solid
licensing boards and oversight
payment reform and benefit reform.
and hazardous waste management,
when administered by the health
hazardous materials training, radon,
agency, provider and facility quality
Other. Include forensic examination
water quality and pollution control
reporting, and institution compliance and infrastructure funds to local public
(including safe drinking water, fishing audits. Also include the development health agencies.
advisories, swimming), water and
of health access planning and
waste disposal systems, mine and
financing activities.
ASTHO Profile of State Public Health, Volume Three 83

State Health Agency Finance

Chronic disease. Include chronic
disease prevention such as heart
disease, cancer, and tobacco
prevention control programs, as
well as substance abuse prevention.
Include programs such as disease
investigation, screening, outreach, and
health education. Also include Safe and
Drug-Free Schools, health education
related to chronic disease, and
nutrition education (excluding WIC).

State Health Agency Finance

State Health Agency Expenditures
State health agencies were asked to report expenditures
for FY10 and FY11 by expense category (see Figure 6.6
for definitions of expenditure categories). In FY10,
state health agency total expenditures were approximately $26.5 billion; in FY11, state health agency
total expenditures were just over $28 billion. For all
respondents, average per capita expenditures were

$99 for FY10 and $98 for FY11. Median per capita
expenditures were somewhat lower at $80 for FY10 and
$78 for FY11. FY11 per capita expenditures, categorized
based on spending range, are displayed in Figure 6.7 for
all responding states and DC.
The mean and median per capita expenditures for
all states and DC, as well as based on structure and
governance classification, are displayed in Table 6.3.

Figure 6.7: FY 2011 Per Capita Expenditures

MN
OR

VT
MI

IL
UT

NE
NV

OH
KY

NM
TX

NJ
DE

TN
AR
LA

MA
CT

No Data

$60 - $79.99

$20 - $39.99

$80 - $99.99

$40 - $59.99

$100 - $119.99
> $120

84 Association of State and Territorial Health Officials

State Health Agency Finance

Centralized and largely centralized states have higher
average per capita expenditures than do decentralized
and largely decentralized states. This is due to local health
department expenditures that are included in centralized
and largely centralized states, whereas in decentralized
and largely decentralized states only the state health
agency contribution to local health department
expenditures is included. Similarly, freestanding health
agencies have higher average per capita expenditures
than do agencies that are under a larger agency.

Table 6.3: Per Capita Expenditures by Governance Classification and Structure for FY10 and FY11 (n=49)

FY10

FY11

Mean

Median

Mean

Median

States and DC

$99

$80

$98

$78

Centralized

$130

$115

$131

$107

Decentralized

$88

$71

$88

$76

Freestanding

$107

$73

$108

$80

Under a larger agency

$88

$81

$86

$80

ASTHO Profile of State Public Health, Volume Three 85

Figure 6.8: State Health Agency Expenditures by Expense Category for FY10 and FY11 (n=49*)
$8,000
$7,000

$5,000
In millions

State Health Agency Finance

$6,000

$4,000
$3,000
$2,000
$1,000
$0

Consumer
health

WIC

Infectious
disease

All-hazards
preparedness

Environmental
health

Chronic
disease

Quality
of health
services

Administration

Health lab

Injury prevention

Vital
statistics

Health
data

Other

FY 2010:

$7,213

$6,793

$2,268

$1,755

$1,253

$1,350

$1,287

$904

$480

$199

$173

$169

$2,735

FY 2011:

$7,608

$7,315

$2,832

$1,216

$1,403

$1,454

$1,334

$962

$653

$201

$168

$187

$2,763

*Note: Not all states provided values for all revenue sources and expenditure categories. Ns range from 40 to 49.

Figure 6.8 shows total state health agency expenditures
for FY10 and FY11 by expense category. Between FY10
and FY11, there were increases in total expenditures
for WIC, consumer health (which includes clinical
services), infectious disease, environmental health,
chronic disease, quality of health services, administrative services, health laboratory, injury prevention,
health data, and other services. Conversely, there were
decreases in total expenditures between FY10 and FY11
for all-hazards preparedness and vital statistics. In FY11,
the greatest percentage of expenditures was accounted
for by consumer health and WIC (each accounting for
approximately one-quarter of all state health agency
expenditures). Vital statistics, injury prevention, and
health data accounted for the lowest amount of
expenditures, with only 1 percent of total expenditures
spent on each of the three categories (see Figure 6.9).

86 Association of State and Territorial Health Officials

Figure 6.9: Percentage of State Health Agency Expenditures by
Expense Category for FY11 (n=49*)

Consumer health 27%
WIC 26%
Infectious disease 10%
Environmental health 5%
Chronic disease 5%
Quality of health services 5%
All-hazards preparedness 4%
Administration 3%
Health lab 2%
Vital statistics 1%
Injury prevention 1%
Health data 1%
Other 10%

*Note: Not all states reported values for all expenditure categories
or sources of revenue. Ns ranged from 40 to 49.

Table 6.4: Average State Health Agency Expenditures by Expense Category for FY10 and FY11 (n=49*)

FY10 (in millions)

FY11 (in millions)

Median

Min

Max

Mean

Median

Min

Max

Consumer health

$176

$53

$0.1

$2,946

$181

$57

$0.1

$2,899

WIC

$148

$91

$11

$1,371

$156

$94

$1,438

Infectious disease

$47

$25

$295

$58

$31

$522

Environmental health

$26

$0.1

$287

$29

$0.1

$375

Chronic disease

$29

$17

$189

$30

$16

$187

Quality of health services

$32

$19

$0.4

$163

$32

$17

$0.04

$204

All-hazards preparedness

$37

$24

$0.3

$219

$25

$16

$0.1

$131

Administrative

$20

$17

$0.1

$76

$20

$18

$0.004

$78

Health lab

$11

$45

$15

$150

Vital statistics

$0.4

$20

$0.5

$15

Injury prevention

$0.1

$47

$0.04

$45

Health data

$0.2

$22

$0.01

$19

Other

$83

$21

$0.04

$1,005

$84

$20

$0.3

$1,022

* Note: Not all states provided values for all revenue sources and expenditure categories. Ns range from 40 to 49.

Table 6.4 presents the mean, median, minimum, and
maximum expenditures for FY10 and FY11 by expense
category. Once again, the means for all expenditure
categories exceeded the medians, in some cases by
substantial amounts, indicating several state health
agencies with particularly high expenditures from
specific categories that skewed (increased) the mean.

State Agency Contracts, Grants, and
Awards to Local Health Departments
and Community-Based Organizations
State health agencies were asked to report dollars
distributed via contracts, grants, and awards to local
health departments and community-based organizations. In FY10, state health agencies distributed
approximately $5.8 billion; in FY11, state health agencies

ASTHO Profile of State Public Health, Volume Three 87

State Health Agency Finance

Mean

Table 6.5 presents the mean, median, minimum, and
maximum dollars distributed by state health agencies
through contracts, grants, and awards to local health
departments and community-based organizations for
FY10 and FY11. Once again, the means for all organizations exceeded the medians, in some cases by
substantial amounts, indicating several state health
agencies with particularly high expenditures to various
entities that skewed (increased) the mean. Spending
was fairly constant from FY10 to FY11.

The first three sections of the ASTHO Profile of State
Public Health have focused on the structure of state
health agencies, the individuals that comprise state health
agencies, the activities and services that state health
agencies perform, and the tools, processes, and resources
utilized by state health agencies to perform these
functions. In the final section of the report, State Profiles,
a snapshot will be provided of each state health agency
and the District of Columbia that responded to the survey.
Figure 6.11: Percentage of State Health Agency Contracts,
Grants, and Awards Distributed to Local Health Departments
and Community-Based Organizations for FY11 (n=41*)

State-run local health agencies 16%
Independent local health agencies
29%
State-run regional or district
health offices 1%
Independent regional or district
health offices 6%
Tribal health agencies 0.5%
Nonprofit organizations 32%
Other governmental entities 16%

*Note: Not all states provided values for all organizations. Ns range
from 7 to 41.

Figure 6.10: State Health Agency Contracts, Grants, and Awards Distributed to Local Health Departments and Community-Based
Organizations for FY11 (n=41*)
$2,500
$2,000

In millions

State Health Agency Finance

distributed nearly $6.1 billion through contracts, grants,
and awards. Between FY10 and FY11, there were slight
increases in dollars distributed to all entities, except
for other government entities, which showed a slight
decrease from FY10 to FY11 (see Figure 6.10). As
shown in Figure 6.11, nearly one-third (32%) of state
health agency contracts, grants, and awards were
distributed to nonprofit organizations; the next highest
percentage was distributed to independent local health
departments (28%). The combined category of local
health departments, including both state-run local
health departments and independent local health
departments, receives the greatest proportion (44%) of
state health agency contracts, grants, and awards. (See
Figure 6.12 for definitions of organization types.)

$1,500
$1,000
$500
$0

State/territoryrun local health
agencies

Independent
local health
agencies

State/territoryrun regional or
district health
offices

Independent
regional or
district health
offices

Tribal health
agencies

Nonprofit
organizations

Other
governmental
entities

FY 2010:

$929

$1,618

$78

$345

$26

$1,823

$1,020

FY 2011:

$950

$1,735

$79

$366

$33

$1,927

$997

*Note: Not all states provided values for all organizations. Ns range from 7 to 41.

88 Association of State and Territorial Health Officials

Figure 6.12 Contracts, Grants, and Awards Recipient Type Descriptions

State/territory-run regional or
district health offices. Include
expenditures passed through
the state/territory health agency
onto regional or district public
health offices that are led by
state/territory employees.

Independent local health
agencies. Include expenditures
passed through the state/
territory health agency onto local
public health agencies that are
led by staff employed by local
government.

Independent regional or
district health offices. Include
expenditures passed through
the state/territory health agency
onto regional or district public
health offices that are led by
non-state/territory employees.

Tribal health agencies. Include
expenditures passed through the
state/territory health agency onto
tribal public health agencies.
Nonprofit organizations. Include
expenditures passed through the
state/territory health agency onto
nonprofit organizations such as
community-based organizations.
Other governmental entities.
Include expenditures passed
through the state/territory health
agency to other governmental
entities such as public schools,
parks and recreation, public
safety, etc.

Table 6.5: Average Dollars Distributed by State Health Agencies Through Contracts, Grants, and Awards Distributed to Local Health
Departments and Community-Based Organizations for FY10 and FY11 (n=41*)

FY10 (in millions)

FY11 (in millions)

Mean

Median

Min

Max

Mean

Median

Min

Max

State/territory-run local
health agencies

$84

$20

$475

$86

$21

$438

Independent local
health agencies

$52

$24

$0.3

$216

$54

$25

$0.4

$242

State/territory-run regional
or district health offices

$11

$45

$11

$0.5

$49

Independent regional or
district health offices

$43

$18

$0.2

$191

$46

$20

$0.1

$203

Tribal health agencies

$0.001

$11

$0.001

$15

Nonprofit organizations

$57

$17

$0.1

$311

$60

$17

$0.1

$364

Other governmental entities

$35

$10

$0.01

$374

$34

$10

$0.01

$354

*Note: Not all states provided values for all organizations. Ns range from 7 to 41.

ASTHO Profile of State Public Health, Volume Three 89

State Health Agency Finance

State/territory-run local health
agencies. Include expenditures
passed through the state/
territory health agency onto local
public health agencies that are
led by staff employed by state/
territory government.

State Profiles
Index (Alphabetically by State)

Alabama........................................................................ 92

Missouri....................................................................... 117

Alaska............................................................................ 93

Montana...................................................................... 118

Arizona.......................................................................... 94

Nebraska..................................................................... 119

Arkansas........................................................................ 95

New Hampshire........................................................... 120

California....................................................................... 96

New Jersey................................................................... 121

Colorado....................................................................... 97

New Mexico................................................................. 122

Connecticut................................................................... 98

New York..................................................................... 123

Delaware....................................................................... 99

North Carolina............................................................. 124

District of Columbia..................................................... 100

North Dakota............................................................... 125

Florida......................................................................... 101

Ohio............................................................................ 126

Georgia....................................................................... 102

Oklahoma.................................................................... 127

Hawaii......................................................................... 103

Oregon........................................................................ 128

Idaho........................................................................... 104

Pennsylvania................................................................ 129

Illinois.......................................................................... 105

Rhode Island................................................................ 130

Indiana........................................................................ 106

South Dakota............................................................... 131

Iowa............................................................................ 107

Tennessee.................................................................... 132

Kansas......................................................................... 108

Texas............................................................................ 133

Kentucky..................................................................... 109

Utah............................................................................ 134

Louisiana..................................................................... 110

Vermont...................................................................... 135

Maine.......................................................................... 111

Virginia........................................................................ 136

Maryland..................................................................... 112

Washington................................................................. 137

Massachusetts............................................................. 113

West Virginia............................................................... 138

Michigan..................................................................... 114

Wisconsin.................................................................... 139

Minnesota................................................................... 115

Wyoming..................................................................... 140

Mississippi.................................................................... 116

ASTHO Profile of State Public Health, Volume Three 91

Alabama
Alabama Department of Public Health

STATE PROFILES

Agency Mission
To serve the people of Alabama by assuring conditions in
which they can be healthy.
Top 5 Priorities for State Health Agency
1. Funding to maintain public health services
2. Substance abuse (tobacco, prescription drugs, and
illicit drugs)
3. Infant mortality
4. Obesity
5. Population-based health (i.e., prevention and
chronic disease)
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a largely centralized relationship with local
health departments.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 36.7%
Fees and Fines 4.0%
Other Sources 50.4%
Other State Funds 1.9%
State General Funds 6.9%

Number of independent local health agencies
(led by local government staff): 2
Number of state-run local health agencies
(led by state government staff): 65
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official does not report directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:

Expenditures (FY11)
Administration 10.8%
ll-Hazards Preparedness and
A
Response 2.5%
Chronic Disease 1.8%
Environmental Health 3.3%
Health Data 0.3%

State Health Assessment

Health Laboratory 3.0%

State Health Improvement Plan

Improving Consumer Health 33.6%

Strategic Plan

State Health Agency Workforce
The state health agency has 4,129 FTEs, including 2,071
state workers assigned to local/regional offices.

Infectious Disease 4.1%
Injury Prevention 0.2%
Other 13.8%
Quality of Health Services 2.9%
Vital Statistics 0.9%
WIC 22.7%

Total Expenditures FY10: $552,647,855
Total Expenditures FY11: $563,582,818
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

92 Association of State and Territorial Health Officials

Alaska
Alaska Department of Health and Social Services,
Alaska Division of Public Health

Agency Mission
The mission of the Alaska Division of Public Health is to
protect and promote the health of all Alaskans.

Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
mixed relationship with local health departments.
Number of independent local health agencies
(led by local government staff): 2
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 25
State Organizational Structure
The health official does not report directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:

STATE PROFILES

Top 5 Priorities for State Health Agency
1. Obesity prevention and control
2. Tobacco prevention and control
3. Infectious disease and childhood immunizations
4. Oral health and community water fluoridation
5. Injury prevention

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 33.5%
Fees and Fines 5.0%
Other Sources 9.8%
Other State Funds 2.6%
State General Funds 49.1%

Expenditures (FY11)
Administration 2.1%
All-Hazards Preparedness and
Response 7.5%
Chronic Disease 15.3%

State Health Assessment

State Health Improvement Plan

Health Data 1.7%

Strategic Plan

Health Laboratory 6.8%

Environmental Health 0.5%

Improving Consumer Health 42.0%

State Health Agency Workforce
The state health agency has 441 FTEs, including 164 state
workers assigned to local/regional offices.

Infectious Disease 8.8%
Injury Prevention 0.9%
Other 3.0%
Quality of Health Services 8.5%
Vital Statistics 2.9%
WIC 0.0%

Total Expenditures FY10: $85,474,700
Total Expenditures FY11: $87,724,840
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 93

Arizona
Arizona Department of Health Services

STATE PROFILES

Agency Mission
To promote, protect, and improve the health and wellness
of individuals and communities in Arizona.
Top 5 Priorities for State Health Agency
1. Impact Arizona’s Winnable Battles
2. Integrate behavioral and physical health services
3. Promote public health and safety
4. Strengthen statewide public health system
5. Maximize Arizona Department of Health Services’
effectiveness through policy, continuous quality
improvement, technology, and workforce development
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 73.8%
Fees and Fines 0.0%
Other Sources 0.0%
Other State Funds 12.7%
State General Funds 13.5%

Number of independent local health agencies
(led by local government staff): 15
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official reports directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 1,647 FTEs. There are no state
health agency workers assigned to local/regional offices.

Expenditures (FY11)
Administration 7.2%
All-Hazards Preparedness and
Response 6.9%
Chronic Disease 4.6%
Environmental Health 0.9%
Health Data 0.6%
Health Laboratory 3.5%
Improving Consumer Health 25.7%
Infectious Disease 2.7%
Injury Prevention 0.0%
Other 0.0%
Quality of Health Services 4.2%
Vital Statistics 1.0%
WIC 42.6%

Total Expenditures FY10: $406,885,400
Total Expenditures FY11: $378,542,600
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

94 Association of State and Territorial Health Officials

Arkansas
Arkansas Department of Health

Agency Mission
To protect and improve the health and well-being of
all Arkansans.

Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a centralized relationship with local health
departments.

STATE PROFILES

Top 5 Priorities for State Health Agency
1. Strengthen and expand statewide clinical and
other services
2. Focus on high burden health issues
3. Strengthen the statewide public health system
4. Strengthen organizational effectiveness and infrastructure
5. Strengthen resource acquisition and utilization

State Public Health Agency Finance*
Sources of Funding (FY11)

Number of independent local health agencies
(led by local government staff): 0
Number of state-run local health agencies
(led by state government staff): 94
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 5
State Organizational Structure
The health official reports directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 2,636 FTEs, including 1,887
state workers assigned to local/regional offices.

Federal Funds 39.4%
Fees and Fines 6.7%
Other Sources 31.0%
Other State Funds 0.0%
State General Funds 22.9%

Expenditures (FY11)
Administration 6.3%
All-Hazards Preparedness and
Response 2.2%
Chronic Disease 4.8%
Environmental Health 4.3%
Health Data 1.1%
Health Laboratory 3.7%
Improving Consumer Health 17.0%
Infectious Disease 5.0%
Injury Prevention 0.0%
Other 27.9%
Quality of Health Services 5.9%
Vital Statistics 0.5%
WIC 21.3%

Total Expenditures FY10: $342,159,340
Total Expenditures FY11: $362,005,147
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 95

California
California Department of Public Health

STATE PROFILES

Agency Mission
The California Department of Public Health is dedicated
to optimizing the health and well-being of the people in
California.
Top Priorities for State Health Agency
1. Achieve health equity through public health programs
2. Prepare for and respond to public health threats
3. Strengthen the department as an innovative, highperforming organization by retaining and recruiting
a skilled workforce, optimizing the department’s
organizational structure and processes, and making
continuous quality improvement a way of life in
the department
4. Achieve national public health accreditation

State Public Health Agency Finance*
Sources of Funding (FY11)

Structure and Relationship with Local Health Departments
Data are not available about the structure of the agency.
The state health agency has a decentralized relationship
with local health departments.

Federal Funds 57.6%
Fees and Fines 0.0%
Other Sources 7.5%
Other State Funds 29.3%
State General Funds 5.6%

Data are not available about the number of local health
agencies and regional/district health offices.

State Organizational Structure
The health official does not report directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 3,313 FTEs, including 1,817
state workers assigned to local/regional offices.

Expenditures (FY11)
Administration 0.0%
All-Hazards Preparedness
and Response 4.0%
Chronic Disease 5.7%
Environmental Health 11.5%
Health Data 0.4%
Health Laboratory 1.2%
Improving Consumer Health 22.7%
Infectious Disease 3.1%
Injury Prevention 1.4%
Other 0.0%
Quality of Health Services 5.5%
Vital Statistics 0.5%
WIC 44.0%

Total Expenditures FY10: $3,182,410,054
Total Expenditures FY11: $3,266,005,147
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

96 Association of State and Territorial Health Officials

Colorado
Colorado Department of Public Health and Environment

Agency Mission
The mission of the Colorado Department of Public Health
and Environment is to protect and improve the health of
Colorado’s people and the quality of its environment.
STATE PROFILES

Top 5 Priorities for State Health Agency
1. Colorado Winnable Battles
2. Public health improvement planning
3. Health equity and environmental justice
4. Lean quality improvement
5. Strengthen public health system
Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
decentralized relationship with local health departments.
Number of independent local health agencies
(led by local government staff): 54
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 2
State Organizational Structure
The health official reports directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 1,272 FTEs, including 25 state
workers assigned to local/regional offices.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 57.9%
Fees and Fines 16.3%
Other Sources 4.8%
Other State Funds 13.6%
State General Funds 7.3%

Expenditures (FY11)
Administration 12.0%
All-Hazards Preparedness and
Response 4.3%
Chronic Disease 8.2%
Environmental Health 16.6%
Health Data 1.3%
Health Laboratory 2.5%
Improving Consumer Health 0.7%
Infectious Disease 10.2%
Injury Prevention 1.6%
Other 11.7%
Quality of Health Services 7.8%
Vital Statistics 0.0%
WIC 23.0%

Total Expenditures FY10: $425,645,086
Total Expenditures FY11: $406,825,422
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 97

Connecticut

STATE PROFILES

Connecticut Department of Public Health

Agency Mission
To protect and improve the health and safety of the people
of Connecticut by:
• Assuring the conditions in which people can be healthy.
• Preventing disease, injury, and disability.
• Promoting the equal enjoyment of the highest attainable
standard of health, which is a human right and a priority
of the state.
Top 5 Priorities for State Health Agency
1. Addressing health disparities and inequities with a
particular focus on infant mortality and low birth weight
2. Building a comprehensive, coordinated chronic disease
program that includes injury prevention
3. Integrating public health and primary care
4. Remaining focused and strategically realigning programs
in order to provide the core public health functions with
the same or potentially less funding
5. Implementing a federally compliant vital records birth
registry system

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 54.1%
Fees and Fines 0.0%
Other Sources 5.0%
Other State Funds 8.2%
State General Funds 32.7%

Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.
Number of independent local health agencies
(led by local government staff): 53
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 21
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official reports directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 798 FTEs, including 11 state
workers assigned to local/regional offices.

98 Association of State and Territorial Health Officials

Expenditures (FY11)
Administration 2.3%
All-Hazards Preparedness
and Response 8.7%
Chronic Disease 4.2%
Environmental Health 7.4%
Health Data 2.1%
Health Laboratory 2.5%
Improving Consumer Health 25.2%
Infectious Disease 12.1%
Injury Prevention 0.4%
Other 14.4%
Quality of Health Services 4.2%
Vital Statistics 0.2%
WIC 16.2%

Total Expenditures FY10: $255,118,639
Total Expenditures FY11: $253,810,899
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

Delaware
Delaware Department Health & Social Services, Division of Public Health

STATE PROFILES

Agency Mission
The Division of Public Health’s mission is to protect and
enhance the health of the people of Delaware by: working
together with others; addressing issues that affect the health
of Delawareans; keeping track of the state’s health; promoting
positive lifestyles; responding to critical health issues and
disasters; and promoting the availability of health services.
Top Priorities for State Health Agency
1. Obesity
2. Health reform
3. Health equity
4. Performance improvement
Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and is
classified as centralized governance because it does not
have local health departments.
Number of independent local health agencies
(led by local government staff): 0
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official does not report directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 630 FTEs.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 33.5%
Fees and Fines 0.0%
Other Sources 8.5%
Other State Funds 28.3%
State General Funds 29.7%

Expenditures (FY11)
Administration 15.3%
All-Hazards Preparedness
and Response 4.4%
Chronic Disease 16.7%
Environmental Health 4.9%
Health Data 0.1%
Health Laboratory 2.9%
Improving Consumer Health 0.0%
Infectious Disease 2.8%
Injury Prevention 0.0%
Other 25.4%
Quality of Health Services 1.0%
Vital Statistics 1.4%
WIC 25.0%

Total Expenditures FY10: $106,069,920
Total Expenditures FY11: $93,253,009
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 99

District of Columbia
District of Columbia Department of Health

STATE PROFILES

Agency Mission
The mission of the Department of Health is to promote and
protect the health, safety, and quality of life of residents,
visitors, and those doing business in the District of Columbia.
Top Priorities for State Health Agency
1. School health
2. Home visiting
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a centralized relationship with local health
departments.
Number of independent local health agencies
(led by local government staff): 0
Number of state-run local health agencies
(led by state government staff): 1
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 58.5%
Fees and Fines 4.9%
Other Sources 15.2%
Other State Funds 0.1%
State General Funds 21.3%

State Organizational Structure
The health official does not report directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 798 FTEs.

Expenditures (FY11)
Administration 16.8%
All-Hazards Preparedness
and Response 2.7%
Chronic Disease 3.9%
Environmental Health 3.8%
Health Data 3.6%
Health Laboratory 0.5%
Improving Consumer Health 44.3%
Infectious Disease 8.7%
Injury Prevention 0.1%
Other 0.0%
Quality of Health Services 5.5%
Vital Statistics 1.2%
WIC 8.7%

Total Expenditures FY10: $175,659,936
Total Expenditures FY11: $204,320,692
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

100 Association of State and Territorial Health Officials

Florida
Florida Department of Health

Agency Mission
Promote, protect, and improve the health of all people
in Florida.

Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a shared relationship with
local health departments.
Number of independent local health agencies
(led by local government staff): 0
Number of state-run local health agencies
(led by state government staff): 67
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official reports directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 15,026 FTEs, including 9,720
state workers assigned to local/regional offices.

STATE PROFILES

Top 5 Priorities for State Health Agency
1. Health protection
2. Chronic disease prevention
3. Community redevelopment and partnerships
4. Access to care
5. Health finance and infrastructure

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 37.0%
Fees and Fines 5.5%
Other Sources 40.4%
Other State Funds 6.5%
State General Funds 10.6%

Expenditures (FY11)
Administration 2.3%
All-Hazards Preparedness
and Response 2.0%
Chronic Disease 4.4%
Environmental Health 4.3%
Health Data 0.1%
Health Laboratory 1.5%
Improving Consumer Health 51.7%
Infectious Disease 13.2%
Injury Prevention 0.7%
Other 0.0%
Quality of Health Services 2.5%
Vital Statistics 0.3%
WIC 17.0%

Total Expenditures FY10: $2,193,575,221
Total Expenditures FY11: $2,157,422,882
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 101

Georgia
Georgia Department of Public Health

STATE PROFILES

Agency Mission
The mission of the Georgia Department of Public Health is
to prevent disease, injury, and disability; promote health and
well-being; and prepare for and respond to disasters.
Top 5 Priorities for State Health Agency
1. Childhood obesity
2. Infant mortality
3. Immunizations
4. Tobacco cessation
5. Workforce development
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a shared relationship with local health
departments.

State Public Health Agency Finance*
Sources of Funding (FY11)

Number of independent local health agencies
(led by local government staff): 159
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 18
State Organizational Structure
The health official reports directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 1,001 FTEs, including 182 state
workers assigned to local/regional offices.

Federal Funds 73.6%
Fees and Fines 0.0%
Other Sources 0.2%
Other State Funds 1.7%
State General Funds 24.6%

Expenditures (FY11)
Administration 4.0%
All-Hazards Preparedness
and Response 6.6%
Chronic Disease 2.8%
Environmental Health 0.6%
Health Data 1.2%
Health Laboratory 2.0%
Improving Consumer Health 16.9%
Infectious Disease 12.3%
Injury Prevention 0.2%
Other 11.9%
Quality of Health Services 0.0%
Vital Statistics 0.6%
WIC 41.1%

Total Expenditures FY10: $615,462,654
Total Expenditures FY11: $690,032,912
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

102 Association of State and Territorial Health Officials

Hawaii
Hawaii State Department of Health

Agency Mission
The mission of the Department of Health is to protect and
improve the health and environment for all people in Hawaii.

Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a centralized relationship with local health
departments.
Number of independent local health agencies
(led by local government staff): 0
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 1
State Organizational Structure
The health official reports directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 2,593 FTEs. Data are not
available on the number of state health agency workers
assigned to local/regional offices.

STATE PROFILES

Top 5 Priorities for State Health Agency
1. Health equity
2. Disease prevention
3. Emergency preparedness
4. Clean and sustainable environment
5. Quality and service excellence

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 18.3%
Fees and Fines 1.3%
Other Sources 23.8%
Other State Funds 1.7%
State General Funds 54.9%

Expenditures (FY11)
Administration 1.8%
All-Hazards Preparedness
and Response 0.0%
Chronic Disease 8.1%
Environmental Health 56.8%
Health Data 0.5%
Health Laboratory 1.6%
Improving Consumer Health 0.0%
Infectious Disease 4.5%
Injury Prevention 0.3%
Other 18.6%
Quality of Health Services 0.1%
Vital Statistics 0.4%
WIC 7.3%

Total Expenditures FY10: $459,480,968
Total Expenditures FY11: $442,480,464
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 103

Idaho
Idaho Department of Health and Welfare

STATE PROFILES

Agency Mission
Our mission is to promote and protect the health and safety
of Idahoans.
Top 5 Priorities for State Health Agency
1. Prevent communicable disease and other health threats
2. Support and encourage healthy communities and
environments
3. Implement models of healthcare and public
health integration
4. Implement business practices that address
workforce quality
5. Build sustainability in public health through
targeted efforts
Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
decentralized relationship with local health departments.
Number of independent local health agencies
(led by local government staff): 7
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official does not report directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 214 FTEs. There are no state
health agency workers assigned to local/regional offices.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 74.6%
Fees and Fines 0.0%
Other Sources 0.0%
Other State Funds 16.0%
State General Funds 9.4%

Expenditures (FY11)
Administration 1.7%
All-Hazards Preparedness
and Response 9.0%
Chronic Disease 8.2%
Environmental Health 0.5%
Health Data 1.0%
Health Laboratory 4.5%
Improving Consumer Health 0.0%
Infectious Disease 18.2%
Injury Prevention 0.9%
Other 13.0%
Quality of Health Services 0.0%
Vital Statistics 1.6%
WIC 41.3%

Total Expenditures FY10: $86,342,346
Total Expenditures FY11: $87,032,365
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

104 Association of State and Territorial Health Officials

Illinois
Illinois Department of Public Health

Agency Mission
The mission of the Illinois Department of Public Health is
to promote the health of the people of Illinois through the
prevention and control of disease and injury.
STATE PROFILES

Top 5 Priorities for State Health Agency
1. Enhanced stakeholder engagement (partnerships)
2. Improve data quality and dissemination
3. Broaden agency marketing, communication, and branding
4. Improve regulatory compliance
5. Reduce health disparities
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.

State Public Health Agency Finance*
Sources of Funding (FY11)

Number of independent local health agencies
(led by local government staff): 96
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 7
State Organizational Structure
The health official reports directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 1,057 FTEs, including 520 state
workers assigned to local/regional offices.

Federal Funds 40.8%
Fees and Fines 7.9%
Other Sources 0.0%
Other State Funds 9.0%
State General Funds 42.3%

Expenditures (FY11)
Administration 6.8%
All-Hazards Preparedness
and Response 15.0%
Chronic Disease 9.0%
Environmental Health 6.9%
Health Data 4.9%
Health Laboratory 6.2%
Improving Consumer Health 0.0%
Infectious Disease 31.4%
Injury Prevention 0.0%
Other 7.1%
Quality of Health Services 10.8%
Vital Statistics 1.9%
WIC 0.0%

Total Expenditures FY10: $368,982,775
Total Expenditures FY11: $316,133,550
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 105

Indiana

STATE PROFILES

Indiana State Department of Health

Agency Mission
The Indiana State Department of Health supports Indiana’s
economic prosperity and quality of life by promoting,
protecting, and providing for the health of Hoosiers in their
communities.
Top 5 Priorities for State Health Agency
1. Decrease disease incidence and burden
2. Improve response and preparedness networks
and capabilities
3. Reduce administrative costs by improving efficiencies
4. Recruitment, evaluation, and retention of public
health workforce
5. Information and electronic data use to develop outcomedriven programs

State Public Health Agency Finance*
Sources of Funding (FY11)

Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.
Number of independent local health agencies
(led by local government staff): 93
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official reports directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 792 FTEs, including 216 state
workers assigned to local/regional offices.

Federal Funds 74.2%
Fees and Fines 0.0%
Other Sources 0.0%
Other State Funds 17.4%
State General Funds 8.4%

Expenditures (FY11)
Administration 4.1%
All-Hazards Preparedness
and Response 8.1%
Chronic Disease 2.8%
Environmental Health 1.8%
Health Data 1.5%
Health Laboratory 2.4%
Improving Consumer Health 16.8%
Infectious Disease 11.6%
Injury Prevention 0.0%
Other 0.0%
Quality of Health Services 5.9%
Vital Statistics 0.7%
WIC 44.3%

Total Expenditures FY10: $353,322,522
Total Expenditures FY11: $330,033,623
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

106 Association of State and Territorial Health Officials

Iowa
Iowa Department of Public Health

Agency Mission
Promoting and protecting the health of Iowans.

STATE PROFILES

Top 5 Priorities for State Health Agency
1. Continue to work with Preparedness Advisory Committee
2. Guidance and support to local public health and hospitals
to build healthcare coalitions
3. Support local public health and hospitals in implementing
preparedness capabilities
4. Program management, fiscal oversight, and accountability
of preparedness programs
5. Sustain response capabilities in Iowa Department of Public
Health and with partners
State Public Health Agency Finance*
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.
Number of independent local health agencies
(led by local government staff): 101
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official reports directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 410 FTEs. There are no state
health agency workers assigned to local/regional offices.

Sources of Funding (FY11)
Federal Funds 59.6%
Fees and Fines 7.8%
Other Sources 6.6%
Other State Funds 0.0%
State General Funds 26.0%

Expenditures (FY11)
Administration 3.2%
All-Hazards Preparedness
and Response 6.8%
Chronic Disease 10.3%
Environmental Health 1.9%
Health Data 1.8%
Health Laboratory 0.0%
Improving Consumer Health 33.7%
Infectious Disease 4.2%
Injury Prevention 2.2%
Other 2.5%
Quality of Health Services 8.6%
Vital Statistics 1.4%
WIC 23.3%

Total Expenditures FY10: $223,425,133
Total Expenditures FY11: $205,661,795
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 107

Kansas
Kansas Department of Health and Environment, Division of Health

STATE PROFILES

Agency Mission
The mission of the Division of Health is to promote and
protect health and prevent disease and injury among the
people of Kansas.
Top 5 Priorities for State Health Agency
1. Public health accreditation
2. Quality improvement/performance management
3. Tribal health
4. Reducing infant mortality
5. Obesity
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.

State Public Health Agency Finance*
Sources of Funding (FY11)

Number of independent local health agencies
(led by local government staff): 100
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 6
State Organizational Structure
The health official reports directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 386 FTEs, including 66 state
workers assigned to local/regional offices.

Federal Funds 69.7%
Fees and Fines 0.0%
Other Sources 5.2%
Other State Funds 11.3%
State General Funds 13.8%

Expenditures (FY11)
Administration 8.1%
All-Hazards Preparedness
and Response 7.0%
Chronic Disease 5.6%
Environmental Health 1.2%
Health Data 1.1%
Health Laboratory 3.3%
Improving Consumer Health 24.6%
Infectious Disease 7.0%
Injury Prevention 0.2%
Other 0.0%
Quality of Health Services 1.4%
Vital Statistics 1.7%
WIC 38.7%

Total Expenditures FY10: $189,260,493
Total Expenditures FY11: $192,070,034
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

108 Association of State and Territorial Health Officials

Kentucky
Kentucky Department for Public Health

Agency Mission
To promote and protect the health and safety of Kentuckians
through professional services.

Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
shared relationship with local health departments.
Number of independent local health agencies
(led by local government staff): 59
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official does not report directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 470 FTEs. There are no state
health agency workers assigned to local/regional offices.

STATE PROFILES

Top 5 Priorities for State Health Agency
1. HPV vaccination
2. Smoke-free legislation
3. Obesity
4. Neonatal abstinence syndrome
5. Expansion of home visiting program, HANDS

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 50.0%
Fees and Fines 30.2%
Other Sources 3.9%
Other State Funds 0.0%
State General Funds 15.9%

Expenditures (FY11)
Administration 8.1%
All-Hazards Preparedness
and Response 4.2%
Chronic Disease 4.0%
Environmental Health 1.3%
Health Data 0.4%
Health Laboratory 1.8%
Improving Consumer Health 16.9%
Infectious Disease 7.1%
Injury Prevention 0.0%
Other 0.1%
Quality of Health Services 21.6%
Vital Statistics 0.9%
WIC 33.5%

Total Expenditures FY10: $389,724,405
Total Expenditures FY11: $386,479,989
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 109

Louisiana

STATE PROFILES

Louisiana Department of Health & Hospitals,
Office of Public Health

Agency Mission
The mission of the Office of Public Health is to: promote
health through education that emphasizes the importance
of individual responsibility for health and wellness; enforce
regulations that protect the environment and to investigate
health hazards in the community; collect and distribute
information vital to informed decisionmaking on matters related
to individual, community, and environmental health; provide
for leadership for the prevention and control of disease, injury,
and disability in the state; and provide assurance of essential
preventive healthcare services for all citizens and a safety net
for core public health services for the underserved.
Top 5 Priorities for State Health Agency
1. Clinic operations improvement project/environmental
health overhaul
2. Integrating public health and primary care
3. Statewide state health improvement plan for better
health outcomes
4. Strategic planning
5. Improving outdated and inefficient processes

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 68.1%
Fees and Fines 6.7%
Other Sources 2.7%
Other State Funds 7.2%
State General Funds 15.3%

Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and
has a largely centralized relationship with local health
departments.
Number of independent local health agencies
(led by local government staff): 2
Number of state-run local health agencies
(led by state government staff): 69
Number of independent regional or district offices
(led by non-state employees): 5
Number of state-run regional or district offices
(led by state employees): 9
State Organizational Structure
The health official does not report directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 1,157 FTEs.
Data are not available on the number of state health agency
workers assigned to local/regional offices.

110 Association of State and Territorial Health Officials

Expenditures (FY11)
Administration 0.0%
All-Hazards Preparedness
and Response 5.2%
Chronic Disease 2.8%
Environmental Health 11.4%
Health Data 0.0%
Health Laboratory 0.0%
Improving Consumer Health 17.9%
Infectious Disease 20.2%
Injury Prevention 0.3%
Other 0.0%
Quality of Health Services 0.0%
Vital Statistics 2.6%
WIC 39.5%

Total Expenditures FY10: $325,278,239
Total Expenditures FY11: $317,836,888
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

Maine
Maine Department of Health and Human Services,
Center for Disease Control and Prevention

Agency Mission
Our mission at Maine Center for Disease Control and
Prevention is to develop and deliver services to preserve,
protect, and promote the health and well-being of the
citizens of Maine.
STATE PROFILES

Top Priorities for State Health Agency
1. Ensure programmatic excellence
2. Promote the value and contributions of public health
3. Secure sustainable funding
4. Support and maintain a competent, empowered workforce
Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
mixed relationship with local health departments.
Number of independent local health agencies
(led by local government staff): 2
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 8

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 60.4%
Fees and Fines 0.0%
Other Sources 0.0.%
Other State Funds 26.7%
State General Funds 12.9%

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 387 FTEs.
Data are not available on the number of state health agency
workers assigned to local/regional offices.

Administration 0.0%
All-Hazards Preparedness
and Response 15.0%
Chronic Disease 38.8%
Environmental Health 8.4%
Health Data 0.0%
Health Laboratory 0.0%
Improving Consumer Health 0.0%
Infectious Disease 11.6%
Injury Prevention 0.0%
Other 4.6%
Quality of Health Services 0.0%
Vital Statistics 0.0%
WIC 21.5%

Total Expenditures FY10: $107,751,511
Total Expenditures FY11: $108,077,254
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 111

Maryland

STATE PROFILES

Maryland Department of Health and Mental Hygiene

Agency Mission
The mission of the Maryland Department of Health and
Mental Hygiene is to protect, promote, and improve the
health and well-being of all Maryland citizens in a fiscally
responsible way.
Top 5 Priorities for State Health Agency
1. Access
2. Quality
3. Disparities
4. Data
5. Local engagement
Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
largely shared relationship with local health departments.

State Public Health Agency Finance*
Sources of Funding (FY11)

Number of independent local health agencies
(led by local government staff): 1
Number of state-run local health agencies
(led by state government staff): 23
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 3
State Organizational Structure
The health official reports directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 8,246 FTEs, including 2,466
state workers assigned to local/regional offices.

Federal Funds 56.1%
Fees and Fines 17.0%
Other Sources 0.0%
Other State Funds 0.5%
State General Funds 26.3%

Expenditures (FY11)
Administration 2.9%
All-Hazards Preparedness
and Response 6.2%
Chronic Disease 11.5%
Environmental Health 1.3%
Health Data 0.6%
Health Laboratory 5.6%
Improving Consumer Health 13.3%
Infectious Disease 24.5%
Injury Prevention 0.1%
Other 4.7%
Quality of Health Services 3.7%
Vital Statistics 0.9%
WIC 24.8%

Total Expenditures FY10: $427,487,221
Total Expenditures FY11: $423,845,330
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

112 Association of State and Territorial Health Officials

Massachusetts
Massachusetts Department of Public Health

STATE PROFILES

Agency Mission
The mission of the Massachusetts Department of Public
Health is to prevent illness, injury, and premature death; to
assure access to high quality public health and healthcare
services; and to promote wellness and health equity for all
people in the Commonwealth.
Top 5 Priorities for State Health Agency
1. Supporting implementation of health reform
2. Achieving health equity/eliminating health disparities
3. Preventing youth violence
4. Strengthening public health infrastructure
5. Promoting wellness/managing chronic disease
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 38.8%
Fees and Fines 2.1%
Other Sources 0.7%
Other State Funds 4.7%
State General Funds 53.7%

Number of independent local health agencies
(led by local government staff): 351
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 16
Number of state-run regional or district offices
(led by state employees): 5
State Organizational Structure
The health official does not report directly to the governor.
The state has a public health council, which is similar to a
board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 2,933 FTEs. There are no state
health agency workers assigned to local/regional offices.

Expenditures (FY11)
Administration 1.7%
All-Hazards Preparedness
and Response 4.1%
Chronic Disease 4.6%
Environmental Health 1.6%
Health Data 1.1%
Health Laboratory 1.1%
Improving Consumer Health 9.3%
Infectious Disease 27.1%
Injury Prevention 2.4%
Other 25.7%
Quality of Health Services 5.3%
Vital Statistics 0.3%
WIC 15.6%

Total Expenditures FY10: $766,247,024
Total Expenditures FY11: $762,569,729
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 113

Michigan

STATE PROFILES

Michigan Department of Community Health

Agency Mission
The Michigan Department of Community Health will protect,
preserve, and promote the health and safety of the people
of Michigan with particular attention to providing for the
needs of vulnerable and underserved populations.
Top 5 Priorities for State Health Agency
1. Reduce obesity and improve wellness
2. Reduce infant mortality
3. Reduce health disparities/promote health equity
4. Promote integration of public health within the primary
care system
5. Enhance the safety planning and response to all hazards,
public health, and healthcare emergencies
Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
decentralized relationship with local health departments.
Number of independent local health agencies
(led by local government staff): 45
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official reports directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 487 FTEs, including 21 state
workers assigned to local/regional offices.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 65.8%
Fees and Fines 2.5%
Other Sources 10.9%
Other State Funds 2.4%
State General Funds 18.3%

Expenditures (FY11)
Administration 2.5%
All-Hazards Preparedness
and Response 6.0%
Chronic Disease 3.6%
Environmental Health 0.3%
Health Data 0.0%
Health Laboratory 2.1%
Improving Consumer Health 0.0%
Infectious Disease 10.6%
Injury Prevention 0.3%
Other 40.6%
Quality of Health Services 0.0%
Vital Statistics 1.1%
WIC 32.8%

Total Expenditures FY10: $769,041,300
Total Expenditures FY11: $814,665,900
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

114 Association of State and Territorial Health Officials

Minnesota
Minnesota Department of Health

Agency Mission
Protecting, maintaining, and improving the health of all
Minnesotans.

Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.
Number of independent local health agencies
(led by local government staff): 50
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 8
State Organizational Structure
The health official reports directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 1,440 FTEs, including 207 state
workers assigned to local/regional offices.

STATE PROFILES

Top 5 Priorities for State Health Agency
1. State health improvement program—stable funding,
statewide
2. Access to healthcare with strong emphasis on prevention
3. Health careers—workforce to meet primary and
preventive needs
4. Maintain strong public health infrastructure at Minnesota
Department of Health and local public health
5. Maintain a quality workforce through continuous quality
improvement

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 52.3%
Fees and Fines 7.7%
Other Sources 2.5%
Other State Funds 25.8%
State General Funds 11.8%

Expenditures (FY11)
Administration 10.6%
All-Hazards Preparedness
and Response 4.6%
Chronic Disease 3.3%
Environmental Health 6.7%
Health Data 1.3%
Health Laboratory 4.9%
Improving Consumer Health 27.3%
Infectious Disease 4.5%
Injury Prevention 0.5%
Other 0.0%
Quality of Health Services 10.9%
Vital Statistics 0.7%
WIC 24.8%

Total Expenditures FY10: $500,432,252
Total Expenditures FY11: $505,192,264
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 115

Mississippi
Mississippi State Department of Health

STATE PROFILES

Agency Mission
The Mississippi State Department of Health mission is
to promote and protect the health of the citizens of
Mississippi.
Top 5 Priorities for State Health Agency
1. Infant mortality
2. Chronic disease implemented locally
3. HIV/STDs
4. Immunizations
5. Electronic laboratory reporting/billing
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a centralized relationship with local health
departments.

State Public Health Agency Finance*
Sources of Funding (FY11)

Number of independent local health agencies
(led by local government staff): 0
Number of state-run local health agencies
(led by state government staff): 81
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 9
State Organizational Structure
The health official does not report directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 2,338 FTEs, including 1,399
state workers assigned to local/regional offices.

Federal Funds 32.5%
Fees and Fines 21.5%
Other Sources 9.0%
Other State Funds 9.1%
State General Funds 27.9%

Expenditures (FY11)
Administration 7.4%
All-Hazards Preparedness
and Response 0.1%
Chronic Disease 9.5%
Environmental Health 10.9%
Health Data 0.1%
Health Laboratory 1.3%
Improving Consumer Health 8.0%
Infectious Disease 2.4%
Injury Prevention 0.5%
Other 0.1%
Quality of Health Services 25.8%
Vital Statistics 1.4%
WIC 32.5%

Total Expenditures FY10: $253,898,742
Total Expenditures FY11: $248,925,981
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

116 Association of State and Territorial Health Officials

Missouri
Missouri Department of Health & Senior Services

Agency Mission
To be the leader in promoting, protecting, and partnering
for health.

Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.
Number of independent local health agencies
(led by local government staff): 115
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 9
State Organizational Structure
The health official reports directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 1,816 FTEs, including 819 state
workers assigned to local/regional offices.

STATE PROFILES

Top Priorities for State Health Agency
1. Ensure Missourians are healthy, safe, and informed
2. Maximize health and safety outcomes
3. Engage and invest in our staff
4. Position resources to ensure maximum returns
5. Increase health equity

State Public Health Agency Finance*
Sources of Funding (FY11)

Federal Funds 83.6%
Fees and Fines 2.2%
Other Sources 0.0%
Other State Funds 2.0%
State General Funds 12.2%

Expenditures (FY11)

Administration 6.7%
All-Hazards Preparedness
and Response 6.5%
Chronic Disease 3.8%
Environmental Health 1.2%
Health Data 1.6%
Health Laboratory 2.6%
Improving Consumer Health 30.2%
Infectious Disease 2.0%
Injury Prevention 0.2%
Other 0.0%
Quality of Health Services 11.1%
Vital Statistics 0.4%
WIC 33.6%

Total Expenditures FY10: $393,529,045
Total Expenditures FY11: $377,768,078
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 117

Montana
Montana Department of Public Health and Human Services

STATE PROFILES

Agency Mission
Our mission is to improve and protect the health, wellbeing, and self-reliance of all Montanans.
Top 5 Priorities for State Health Agency
1. Prepare for PHAB accreditation
2. Implement our state health improvement plan
3. Enhance and develop the workforce
4. Achieve operational efficiencies
5. Enhance health information technology
Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
decentralized relationship with local health departments.
Number of independent local health agencies
(led by local government staff): 57
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 1
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official reports directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 192 FTEs. There are no state
health agency workers assigned to local/regional offices.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 66.6%
Fees and Fines 0.0%
Other Sources 0.0%
Other State Funds 27.5%
State General Funds 5.9%

Expenditures (FY11)
Administration 4.4%
All-Hazards Preparedness
and Response 8.9%
Chronic Disease 26.1%
Environmental Health 2.2%
Health Data 1.7%
Health Laboratory 6.2%
Improving Consumer Health 17.2%
Infectious Disease 6.3%
Injury Prevention 1.3%
Other 0.0%
Quality of Health Services 0.0%
Vital Statistics 0.9%
WIC 24.7%

Total Expenditures FY10: $68,801,137
Total Expenditures FY11: $62,740,185
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

118 Association of State and Territorial Health Officials

Nebraska
Nebraska Department of Health & Human Services

Agency Mission
We help Nebraskans live better lives.

STATE PROFILES

Top 5 Priorities for State Health Agency
1. Trusted source of state health data
2. Addressing health disparities
3. Media and education plan
4. Create a culture of wellness
5. Budget transparency
Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
decentralized relationship with local health departments.
Number of independent local health agencies
(led by local government staff): 24
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 56.1%
Fees and Fines 9.6%
Other Sources 6.0%
Other State Funds 19.2%
State General Funds 9.0%

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 463 FTEs. There are no state
health agency workers assigned to local/regional offices.

Expenditures (FY11)
Administration 1.5%
All-Hazards Preparedness
and Response 7.3%
Chronic Disease 14.1%
Environmental Health 3.7%
Health Data 2.0%
Health Laboratory 1.4%
Improving Consumer Health 20.6%
Infectious Disease 2.8%
Injury Prevention 1.4%
Other 5.0%
Quality of Health Services 13.6%
Vital Statistics 1.1%
WIC 25.5%

Total Expenditures FY10: $159,369,227
Total Expenditures FY11: $156,736,377
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 119

New Hampshire

STATE PROFILES

New Hampshire Department of Health and Human Services,
Division of Public Health Services

Agency Mission
The New Hampshire Division of Public Health Services is a
responsive, expert, leadership organization that promotes
optimal health and well-being for all people in New
Hampshire and protects them from illness and injury.
Top 5 Priorities for State Health Agency
1. Develop, implement, and maintain approaches to
integrate population health
2. Fully implement a systematic quality and performance
improvement system
3. Improve effectiveness and resource allocation
4. Develop and implement a public health management system
5. Develop and implement a strategy for social media
Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and
has a largely centralized relationship with local health
departments.
Number of independent local health agencies
(led by local government staff): 5
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official does not report directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 244 FTEs. There are no state
health agency workers assigned to local/regional offices.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 49.9%
Fees and Fines 1.2%
Other Sources 24.1%
Other State Funds 0.0%
State General Funds 24.8%

Expenditures (FY11)
Administration 0.0%
All-Hazards Preparedness
and Response 14.5%
Chronic Disease 6.9%
Environmental Health 3.2%
Health Data 1.6%
Health Laboratory 5.4%
Improving Consumer Health 19.6%
Infectious Disease 27.5%
Injury Prevention 0.2%
Other 2.0%
Quality of Health Services 1.3%
Vital Statistics 0.0%
WIC 17.8%

Total Expenditures FY10: $87,410,665
Total Expenditures FY11: $84,841,539
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

120 Association of State and Territorial Health Officials

New Jersey
New Jersey Department of Health

Top 5 Priorities for State Health Agency
1. Funding for mandated services
2. Staff resources
3. Public health infrastructure
4. Data based public health policy
5. State and federal grant availability
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.
Number of independent local health agencies
(led by local government staff): 114
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 20
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official reports directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 1,208 FTEs, including 59 state
workers assigned to local/regional offices.

STATE PROFILES

Agency Mission
Our mission is to foster accessible and high-quality health
and senior services to help all people in New Jersey achieve
optimal health, dignity, and independence. We work to
prevent disease, promote and protect well-being at all life
stages, and encourage informed choices that enrich quality
of life for individuals and communities.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 53.8%
Fees and Fines 0.0%
Other Sources 0.0%
Other State Funds 13.9%
State General Funds 32.2%

Expenditures (FY11)
Administration 0.9%
All-Hazards Preparedness
and Response 1.1%
Chronic Disease 1.3%
Environmental Health 0.3%
Health Data 0.1%
Health Laboratory 0.8%
Improving Consumer Health 83.5%
Infectious Disease 1.3%
Injury Prevention 0.0%
Other 0.0%
Quality of Health Services 5.9%
Vital Statistics 0.1%
WIC 4.7%

Total Expenditures FY10: $3,514,717,482
Total Expenditures FY11: $3,472,819,064
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 121

New Mexico

STATE PROFILES

New Mexico Department of Health

Agency Mission
The mission of the Department of Health is to promote
health and sound health policy, prevent disease and
disability, improve health services systems, and assure that
essential public health functions and safety net services are
available to New Mexicans.
Top 5 Priorities for State Health Agency
1. Public health accreditation
2. Filling staff vacancies
3. Employee engagement
4. Reducing prescription drug overdose death
5. Reducing pertussis morbidity
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a centralized relationship with local health
departments.
Number of independent local health agencies
(led by local government staff): 1
Number of state-run local health agencies
(led by state government staff): 54
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 5
State Organizational Structure
The health official reports directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 3,246 FTEs, including 766 state
workers assigned to local/regional offices.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 57.7%
Fees and Fines 0.0%
Other Sources 0.1%
Other State Funds 26.9%
State General Funds 15.3%

Expenditures (FY11)
Administration 0.0%
All-Hazards Preparedness
and Response 6.7%
Chronic Disease 13.4%
Environmental Health 1.3%
Health Data 0.0%
Health Laboratory 0.0%
Improving Consumer Health 0.0%
Infectious Disease 28.7%
Injury Prevention 1.9%
Other 0.0%
Quality of Health Services 0.0%
Vital Statistics 1.6%
WIC 46.4%

Total Expenditures FY10: $122,268,795
Total Expenditures FY11: $113,323,670
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

122 Association of State and Territorial Health Officials

New York
New York State Department of Health

Agency Mission
The New York State Department of Health protects
and promotes the health of the people of New York by
preventing and reducing threats to public health and by
assuring access to affordable, high quality health services.
STATE PROFILES

Top 5 Priorities for State Health Agency
1. Implement New York State Prevention Agenda 2013-17
2. Obtain public health agency accreditation
3. Implement Medicaid reform
4. Implement Affordable Care Act
5. Achieve certificate of need reform
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 59.8%
Fees and Fines 0.0%
Other Sources 0.0%
Other State Funds 0.0%
State General Funds 40.2%

Number of independent local health agencies
(led by local government staff): 58
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 15
Expenditures (FY11)

State Organizational Structure
The health agency reports directly to the governor.
The state has a board of health.

Administration 1.2%
All-Hazards Preparedness
and Response 2.2%
Chronic Disease 7.7%
Environmental Health 4.1%
Health Data 0.0%
Health Laboratory 8.7%
Improving Consumer Health 20.7%
Infectious Disease 32.0%
Injury Prevention 0.0%
Other 0.0%
Quality of Health Services 0.0%
Vital Statistics 0.1%
WIC 23.2%

State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 3,127 FTEs, including 849 state
workers assigned to local/regional offices.

Data not available for total expenditures for FY10.
Total Expenditures FY11: $1,721,808,483
*FY11 was defined as 4/1/10 - 3/31/11.

ASTHO Profile of State Public Health, Volume Three 123

North Carolina
North Carolina Division of Public Health

STATE PROFILES

Agency Mission
The mission of the public health system is to promote and
contribute to the highest level of health possible for the
people of North Carolina.
Top 5 Priorities for State Health Agency
1. Maintain public health infrastructure
2. Reduce health disparities
3. Build healthy communities through community
transformation
4. Reform the health system to value prevention and
improve health
5. Create a nimble, quality-driven organization
Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
decentralized relationship with local health departments.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 61.0%
Fees and Fines 1.7%
Other Sources 2.3%
Other State Funds 16.2%
State General Funds 18.8%

Number of independent local health agencies
(led by local government staff): 80
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 6
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official does not report directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 1,828 FTEs, including 791 state
workers assigned to local/regional offices.

Expenditures (FY11)
Administration 3.2%
All-Hazards Preparedness
and Response 2.5%
Chronic Disease 1.9%
Environmental Health 0.4%
Health Data 1.4%
Health Laboratory 2.7%
Improving Consumer Health 22.2%
Infectious Disease 11.7%
Injury Prevention 1.1%
Other 2.4%
Quality of Health Services 4.1%
Vital Statistics 0.4%
WIC 46.0%

Total Expenditures FY10: $788,957,975
Total Expenditures FY11: $739,133,562
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

124 Association of State and Territorial Health Officials

North Dakota
North Dakota Department of Health

Agency Mission
Protect and enhance the health and safety of all North
Dakotans and the environment in which we live.

Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.

STATE PROFILES

Top 5 Priorities for State Health Agency
1. Environmental oil/energy impact
2. Integration of public health and private sector/primary care
3. Obesity
4. Aging IT infrastructure, health information, and
interoperability
5. Accreditation and quality improvement

State Public Health Agency Finance*
Sources of Funding (FY11)

Number of independent local health agencies
(led by local government staff): 28
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 8
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official reports directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 331 FTEs. There are no state
health agency workers assigned to local/regional offices.

Federal Funds 70.4%
Fees and Fines 4.5%
Other Sources 4.4%
Other State Funds 2.3%
State General Funds 18.4%

Expenditures (FY11)
Administration 2.4%
All-Hazards Preparedness
and Response 11.3%
Chronic Disease 10.3%
Environmental Health 27.3%
Health Data 0.3%
Health Laboratory 5.0%
Improving Consumer Health 8.4%
Infectious Disease 7.2%
Injury Prevention 4.4%
Other 2.8%
Quality of Health Services 4.4%
Vital Statistics 1.1%
WIC 15.2%

Total Expenditures FY10: $78,083,351
Total Expenditures FY11: $80,965,605
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 125

Ohio
Ohio Department of Health

STATE PROFILES

Agency Mission
To protect and improve the health of all Ohioans.
Top Priorities for State Health Agency
1. Reduce tobacco use
2. Reduce infant mortality
3. Expand patient centered medical home model across
the state
4. Reduce obesity
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.
Number of independent local health agencies
(led by local government staff): 125
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 4
State Organizational Structure
The health official reports directly to the governor.
The state has an advisory board that provides
recommendations on new rules.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 1,146 FTEs, including 223 state
workers assigned to local/regional offices.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 68.5%
Fees and Fines 5.3%
Other Sources 0.0%
Other State Funds 12.4%
State General Funds 13.8%

Expenditures (FY11)
Administration 4.3%
All-Hazards Preparedness
and Response 7.1%
Chronic Disease 2.1%
Environmental Health 2.5%
Health Data 0.2%
Health Laboratory 1.4%
Improving Consumer Health 1.0%
Infectious Disease 10.2%
Injury Prevention 0.8%
Other 23.8%
Quality of Health Services 6.5%
Vital Statistics 1.5%
WIC 38.5%

Total Expenditures FY10: $653,445,283
Total Expenditures FY11: $622,994,267
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

126 Association of State and Territorial Health Officials

Oklahoma
Oklahoma State Department of Health

Agency Mission
To protect and promote the health of the citizens of
Oklahoma, to prevent disease and injury, and to assure the
conditions by which our citizens can be healthy.
STATE PROFILES

Top 5 Priorities for State Health Agency
1. Mandates (licensing, consumer protection, medical
facilities, long-term care)
2. Infectious disease control
3. Emergency preparedness and response
4. Wellness (tobacco, physical activity, obesity)
5. Children’s health programs
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a mixed relationship with local health
departments.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 54.1%
Fees and Fines 18.2%
Other Sources 4.6%
Other State Funds 6.2%
State General Funds 17.0%

Number of independent local health agencies
(led by local government staff): 2
Number of state-run local health agencies
(led by state government staff): 68
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
Expenditures (FY11)

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 2,030 FTEs, including 1,074
state workers assigned to local/regional offices.

Administration 7.1%
All-Hazards Preparedness
and Response 4.6%
Chronic Disease 2.6%
Environmental Health 0.0%
Health Data 0.4%
Health Laboratory 2.1%
Improving Consumer Health 1.5%
Infectious Disease 9.2%
Injury Prevention 0.5%
Other 43.0%
Quality of Health Services 0.4%
Vital Statistics 1.2%
WIC 27.4%

Total Expenditures FY10: $353,653,469
Total Expenditures FY11: $337,939,571
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 127

Oregon
Oregon Department of Human Services, Public Health Division

STATE PROFILES

Agency Mission
To protect and promote the health of all the people of Oregon.
Top 5 Priorities for State Health Agency
1. Tobacco
2. Obesity
3. Suicide
4. Heart disease and stroke
5. Health reform
Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
decentralized relationship with local health departments.
Number of independent local health agencies
(led by local government staff): 34
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official does not report directly to the governor.
The Oregon Health Policy Board and the Oregon Public
Health Advisory Board carry out some oversight and
advisory functions that typically would be provided by a
board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 634 FTEs, including 61 state
workers assigned to local/regional offices.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 67.3%
Fees and Fines 6.8%
Other Sources 18.0%
Other State Funds 0.0%
State General Funds 7.9%

Expenditures (FY11)
Administration 6.9%
All-Hazards Preparedness
and Response 6.7%
Chronic Disease 5.4%
Environmental Health 4.0%
Health Data 0.1%
Health Laboratory 3.6%
Improving Consumer Health 20.3%
Infectious Disease 14.4%
Injury Prevention 0.5%
Other 0.0%
Quality of Health Services 2.2%
Vital Statistics 1.5%
WIC 34.3%

Total Expenditures FY10: $235,349,681
Total Expenditures FY11: $275,054,858
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

128 Association of State and Territorial Health Officials

Pennsylvania
Pennsylvania Department of Health

Agency Mission
The department’s mission is to promote healthy lifestyles,
prevent injury and disease, and to assure the safe delivery of
quality healthcare for all Commonwealth citizens.
STATE PROFILES

Top 5 Priorities for State Health Agency
1. Streamlining administration of programs
2. Passing updated regulations for infectious disease
3. Preparedness planning at regional level
4. Chronic care
5. Reprioritizing based on federal and state funding
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a mixed relationship with local health
departments.

State Public Health Agency Finance*
Sources of Funding (FY11)

Number of independent local health agencies
(led by local government staff): 10
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 6
State Organizational Structure
The health official reports directly to the governor.
The agency has a health policy board.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 1,255 FTEs, including 712 state
workers assigned to local/regional offices.

Federal Funds 62.5%
Fees and Fines 0.4%
Other Sources 0.3%
Other State Funds 11.3%
State General Funds 25.5%

Expenditures (FY11)
Administration 2.5%
All-Hazards Preparedness
and Response 9.3%
Chronic Disease 9.6%
Environmental Health 1.5%
Health Data 0.2%
Health Laboratory 0.8%
Improving Consumer Health 0.0%
Infectious Disease 6.0%
Injury Prevention 1.1%
Other 31.0%
Quality of Health Services 4.2%
Vital Statistics 1.0%
WIC 32.8%

Total Expenditures FY10: $900,064,000
Total Expenditures FY11: $888,579,000
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 129

Rhode Island
Rhode Island Department of Health

STATE PROFILES

Agency Mission
The primary mission of the Rhode Island Department of
Health is to prevent disease and to protect and promote the
health and safety of the people of Rhode Island.
Top 5 Priorities for State Health Agency
1. Shape the healthcare delivery system for best outcomes
at affordable cost
2. Build a population based primary care system
3. Promote the value and contributions of public health
4. Optimize department resources in strategic direction
5. Secure and align financial resources with strategic
requirements
Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and is
considered centralized because it does not have local health
departments.
Number of independent local health agencies
(led by local government staff): 0
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official does not report directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 390 FTEs.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 58.0%
Fees and Fines 0.0%
Other Sources 19.0%
Other State Funds 0.0%
State General Funds 23.0%

Expenditures (FY11)
Administration 2.9%
All-Hazards Preparedness
and Response 5.8%
Chronic Disease 5.7%
Environmental Health 5.3%
Health Data 1.2%
Health Laboratory 6.7%
Improving Consumer Health 16.1%
Infectious Disease 36.4%
Injury Prevention 3.4%
Other 2.0%
Quality of Health Services 7.8%
Vital Statistics 1.3%
WIC 5.6%

Total Expenditures FY10: $131,649,235
Total Expenditures FY11: $119,439,169
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

130 Association of State and Territorial Health Officials

South Dakota
South Dakota Department of Health

Agency Mission
The mission of the South Dakota Department of Health is to
promote, protect, and improve the health and well-being of
all South Dakotans.
STATE PROFILES

Top Priorities for State Health Agency
1. Improve the birth outcomes and health of 0- to 18-yearolds in South Dakota
2. Improve the health behaviors of South Dakotans to reduce
chronic diseases
3. Strengthen healthcare delivery system in South Dakota
4. Strengthen responses to current and emerging public
health threats
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a largely centralized relationship with local
health departments.
Number of independent local health agencies
(led by local government staff): 1
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 7
State Organizational Structure
The health official reports directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 412 FTEs. There are no state
health agency workers assigned to local/regional offices.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 60.0%
Fees and Fines 0.0%
Other Sources 31.3%
Other State Funds 0.0%
State General Funds 8.7%

Expenditures (FY11)
Administration 2.4%
All-Hazards Preparedness
and Response 7.3%
Chronic Disease 4.4%
Environmental Health 0.9%
Health Data 0.5%
Health Laboratory 6.1%
Improving Consumer Health 1.9%
Infectious Disease 16.8%
Injury Prevention 0.0%
Other 33.2%
Quality of Health Services 6.8%
Vital Statistics 0.8%
WIC 18.9%

Total Expenditures FY10: $90,174,839
Total Expenditures FY11: $89,464,874
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 131

Tennessee
Tennessee Department of Health

STATE PROFILES

Agency Mission
Protect, promote, and improve the health and prosperity of
people in Tennessee.
Top 5 Priorities for State Health Agency
1. Primary prevention (including overall health ranking)
2. Performance excellence (including electronic knowledge
management)
3. Infant mortality
4. Childhood obesity
5. Substance abuse (including tobacco)
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a mixed relationship with local health
departments.

State Public Health Agency Finance*
Sources of Funding (FY11)

Number of independent local health agencies
(led by local government staff): 6
Number of state-run local health agencies
(led by state government staff): 89
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 7
State Organizational Structure
The health official reports directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 3,046 FTEs, including 1,835
state workers assigned to local/regional offices.

Federal Funds 45.3%
Fees and Fines 5.8%
Other Sources 18.9%
Other State Funds 0.0%
State General Funds 30.0%

Expenditures (FY11)
Administration 2.8%
All-Hazards Preparedness
and Response 5.9%
Chronic Disease 1.3%
Environmental Health 2.0%
Health Data 1.0%
Health Laboratory 3.0%
Improving Consumer Health 36.3%
Infectious Disease 6.0%
Injury Prevention 0.0%
Other 3.2%
Quality of Health Services 8.0%
Vital Statistics 0.8%
WIC 29.8%

Total Expenditures FY10: $507,258,978
Total Expenditures FY11: $526,580,019
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

132 Association of State and Territorial Health Officials

Texas
Texas Department of State Health Services

Agency Mission
To improve health and well-being in Texas.

Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
largely decentralized relationship with local health departments.
Number of independent local health agencies
(led by local government staff): 59
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 8
State Organizational Structure
The health official does not report directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 11,862 FTEs, including 9,343
state workers assigned to local/regional offices.

STATE PROFILES

Top 5 Priorities for State Health Agency
1. Enhancing public health response to disasters and
disease outbreaks
2. Preventing chronic diseases and infectious diseases
3. Improving the health of infants and women
4. Meeting increased regulatory demands due to
business growth
5. Increasing emphasis on healthcare quality

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 42.6%
Fees and Fines 4.1%
Other Sources 5.3%
Other State Funds 2.9%
State General Funds 45.0%

Expenditures (FY11)
Administration 2.3%
All-Hazards Preparedness
and Response 3.5%
Chronic Disease 6.2%
Environmental Health 1.2%
Health Data 0.7%
Health Laboratory 1.6%
Improving Consumer Health 9.5%
Infectious Disease 7.3%
Injury Prevention 1.5%
Other 35.2%
Quality of Health Services 3.7%
Vital Statistics 0.3%
WIC 26.9%

Total Expenditures FY10: $3,126,006,174
Total Expenditures FY11: $2,900,850,300
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 133

Utah

STATE PROFILES

Utah Department of Health

Agency Mission
To protect the public’s health through preventing avoidable
illness, injury, disability, and premature death; assuring
access to affordable, quality healthcare; and promoting
healthy lifestyles.
Top 5 Priorities for State Health Agency
1. Implement Medicaid accountable care organization
2. Develop plan to make Utahans the healthiest people in
the United States
3. Obtain funding via budget request for obesity program
4. Complete and implement statewide health
improvement plan
5. Complete reporting deliverables from All Payer
Claims Database

State Public Health Agency Finance*
Sources of Funding (FY11)

Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.
Number of independent local health agencies
(led by local government staff): 12
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official reports directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 1,000 FTEs. There are no state
health agency workers assigned to local/regional offices.

Federal Funds 60.7%
Fees and Fines 13.8%
Other Sources 5.3%
Other State Funds 6.2%
State General Funds 14.0%

Expenditures (FY11)
Administration 5.0%
All-Hazards Preparedness
and Response 8.0%
Chronic Disease 10.4%
Environmental Health 0.6%
Health Data 4.6%
Health Laboratory 4.8%
Improving Consumer Health 25.1%
Infectious Disease 4.2%
Injury Prevention 0.9%
Other 2.1%
Quality of Health Services 3.8%
Vital Statistics 1.2%
WIC 29.4%

Total Expenditures FY10: $186,384,346
Total Expenditures FY11: $204,861,700
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

134 Association of State and Territorial Health Officials

Vermont
Vermont Department of Health

Agency Mission
To protect and promote optimal health for all Vermonters.

STATE PROFILES

Top 5 Priorities for State Health Agency
1. Tobacco
2. Obesity
3. Drug/alcohol use
4. Immunization
5. Injury
Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
centralized relationship with local health departments.
Number of independent local health agencies
(led by local government staff): 0
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 12

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 67.2%
Fees and Fines 6.6%
Other Sources 1.1%
Other State Funds 0.0%
State General Funds 25.0%

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 445 FTEs, including 184 state
workers assigned to local/regional offices.

Expenditures (FY11)
Administration 9.7%
All-Hazards Preparedness
and Response 3.2%
Chronic Disease 11.2%
Environmental Health 2.7%
Health Data 2.3%
Health Laboratory 3.7%
Improving Consumer Health 18.2%
Infectious Disease 8.2%
Injury Prevention 0.1%
Other 26.8%
Quality of Health Services 1.9%
Vital Statistics 0.6%
WIC 11.8%

Total Expenditures FY10: $100,595,513
Total Expenditures FY11: $101,937,807
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 135

Virginia
Virginia Department of Health

STATE PROFILES

Agency Mission
The mission of the Virginia Department of Health is to
promote and protect the health of all Virginians.
Top 5 Priorities for State Health Agency
1. Preserve funding for core public health services
2. Foster a culture of continuous quality improvement
3. Reduce infant mortality rate
4. Increase immunization rate
5. Reduce obesity rate
Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a largely centralized relationship with local
health departments.
Number of independent local health agencies
(led by local government staff): 2
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 33
State Organizational Structure
The health official does not report directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 3,751 FTEs, including 2,977
state workers assigned to local/regional offices.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 47.2%
Fees and Fines 10.0%
Other Sources 6.4%
Other State Funds 8.7%
State General Funds 27.7%

Expenditures (FY11)
Administration 13.9%
All-Hazards Preparedness
and Response 7.7%
Chronic Disease 1.5%
Environmental Health 13.9%
Health Data 0.2%
Health Laboratory 0.0%
Improving Consumer Health 22.0%
Infectious Disease 9.8%
Injury Prevention 0.8%
Other 1.7%
Quality of Health Services 4.8%
Vital Statistics 1.0%
WIC 22.6%

Total Expenditures FY10: $528,826,887
Total Expenditures FY11: $561,734,353
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

136 Association of State and Territorial Health Officials

Washington
Washington State Department of Health

Agency Mission
The department of health works to protect and improve the
health of people in Washington state.

Structure and Relationship with Local Health Departments
The state health agency is a freestanding/independent
agency and has a decentralized relationship with local health
departments.

STATE PROFILES

Top 5 Priorities for State Health Agency
1. Preventing communicable disease and other health threats
2. Fostering healthy communities and environments
3. Partnering with the healthcare system
4. Promoting a framework for foundational public
health services
5. Enhancing the use of performance management tools

State Public Health Agency Finance*
Sources of Funding (FY11)

Number of independent local health agencies
(led by local government staff): 35
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 4
State Organizational Structure
The health official reports directly to the governor.
The state has a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 1,650 FTEs, including 285 state
workers assigned to local/regional offices.

Federal Funds 49.7%
Fees and Fines 11.7%
Other Sources 9.6%
Other State Funds 11.4%
State General Funds 17.5%

Expenditures (FY11)
Administration 7.1%
All-Hazards Preparedness
and Response 5.6%
Chronic Disease 6.4%
Environmental Health 5.6%
Health Data 1.8%
Health Laboratory 2.7%
Improving Consumer Health 7.3%
Infectious Disease 19.6%
Injury Prevention 0.5%
Other 0.4%
Quality of Health Services 9.5%
Vital Statistics 0.6%
WIC 33.0%

Total Expenditures FY10: $484,411,369
Total Expenditures FY11: $537,213,509
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 137

West Virginia
West Virginia Department of Health & Human Resources

STATE PROFILES

Agency Mission
To help shape the environments within which people and
communities can be safe and healthy.
Top 5 Priorities for State Health Agency
1. Reduce the prevalence of chronic disease in West
Virginia’s population
2. Maintain a competent public health workforce in a
changing environment
3. Maximize use of all human and fiscal resources
4. Assure infrastructure is in place to meet statutory
requirements
5. Reduce mortality in West Virginia from selected conditions
Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
decentralized relationship with local health departments.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 52.0%
Fees and Fines 2.4%
Other Sources 15.5%
Other State Funds 0.0%
State General Funds 30.2%

Number of independent local health agencies
(led by local government staff): 49
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official does not report directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 651 FTEs, including 95 state
workers assigned to local/regional offices.

Expenditures (FY11)
Administration 1.4%
All-Hazards Preparedness
and Response 5.6%
Chronic Disease 6.3%
Environmental Health 18.7%
Health Data 1.8%
Health Laboratory 2.7%
Improving Consumer Health 35.0%
Infectious Disease 6.0%
Injury Prevention 0.3%
Other 2.2%
Quality of Health Services 2.4%
Vital Statistics 0.6%
WIC 16.9%

Total Expenditures FY10: $207,829,417
Total Expenditures FY11: $218,083,952
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

138 Association of State and Territorial Health Officials

Wisconsin
Wisconsin Department of Health Services

Agency Mission
Protecting and promoting the health and safety of the
people of Wisconsin.

Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
decentralized relationship with local health departments.

STATE PROFILES

Top Priorities for State Health Agency
1. Reduce preterm births and infant mortality
2. Chronic disease prevention and management
3. Integration and partner collaboration in emergency
preparedness
4. Improve data exchange to enhance health
5. Support creating innovative care models for special
populations
State Public Health Agency Finance*
Sources of Funding (FY11)

Number of independent local health agencies
(led by local government staff): 88
Number of state-run local health agencies
(led by state government staff): 0
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 5
State Organizational Structure
The health official does not report directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 395 FTEs, including 22 state
workers assigned to local/regional offices.

Federal Funds 73.3%
Fees and Fines 6.1%
Other Sources 4.7%
Other State Funds 1.6%
State General Funds 14.3%

Expenditures (FY11)
Administration 9.9%
All-Hazards Preparedness
and Response 8.8%
Chronic Disease 3.3%
Environmental Health 3.2%
Health Data 2.6%
Health Laboratory 0.0%
Improving Consumer Health 16.6%
Infectious Disease 13.3%
Injury Prevention 0.6%
Other 0.0%
Quality of Health Services 1.0%
Vital Statistics 1.1%
WIC 39.6%

Total Expenditures FY10: $259,283,072
Total Expenditures FY11: $258,546,185
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

ASTHO Profile of State Public Health, Volume Three 139

Wyoming
Wyoming Department of Health

STATE PROFILES

Agency Mission
Our mission is to promote, protect, and enhance the health
of all Wyoming citizens.
Top 5 Priorities for State Health Agency
1. Preserving services with respect to budget cuts
2. Changing focus to population based (vs. direct care)
services
3. Fostering programmatic excellence
4. Workforce development/recruitment
5. Promoting value/relevance of public health

Structure and Relationship with Local Health Departments
The state health agency is under a larger agency and has a
mixed relationship with local health departments.
Number of independent local health agencies
(led by local government staff): 5
Number of state-run local health agencies
(led by state government staff): 31
Number of independent regional or district offices
(led by non-state employees): 0
Number of state-run regional or district offices
(led by state employees): 0
State Organizational Structure
The health official does not report directly to the governor.
The state does not have a board of health.
State Health Planning
The state health agency has developed the following within
the past five years:
Y

State Health Assessment

State Health Improvement Plan

Strategic Plan

State Health Agency Workforce
The state health agency has 1,411 FTEs, including 241 state
workers assigned to local/regional offices.

State Public Health Agency Finance*
Sources of Funding (FY11)
Federal Funds 54.6%
Fees and Fines 0.0%
Other Sources 14.6%
Other State Funds 1.1%
State General Funds 29.8%

Expenditures (FY11)
Administration 2.9%
All-Hazards Preparedness
and Response 13.6%
Chronic Disease 5.5%
Environmental Health 0.3%
Health Data 3.2%
Health Laboratory 6.5%
Improving Consumer Health 7.9%
Infectious Disease 23.7%
Injury Prevention 0.3%
Other 0.0%
Quality of Health Services 5.9%
Vital Statistics 1.7%
WIC 28.7%

Total Expenditures FY10: $41,126,850
Total Expenditures FY11: $37,022,012
*FY11 was defined as 7/1/10 - 6/30/11. FY10 was defined as
7/1/09 - 6/30/10.

140 Association of State and Territorial Health Officials

STATE PROFILES

ASTHO Profile of State Public Health, Volume Three is a publication
of the Association of State and Territorial Health Officials. It describes
the structure, functions, and resources of state and territorial health
agencies and highlights their contributions to public health.
To view this publication online, visit ASTHO’s website at

www.astho.org/profile.

Vision
Healthy people thriving in a nation free of preventable
illness and injury.

Mission
To transform public health within states and territories to
help members dramatically improve health and wellness.

2231 Crystal Drive, Suite 450
Arlington, VA 22202
Phone: (202) 371-9090
Fax (571) 527-3189
www.astho.org

File Type	application/pdf
File Modified	2018-06-27
File Created	2014-06-11