Regionalization of Public Health in New Hampshire: Part I

By Joan H. Ascheim and Neil Twitchell

“What rumors have you heard about public health regionalization?" asked New Hampshire Department of Health and Human Services (DHHS) Division of Public Health Services’ (DPHS) Joan Ascheim of the near 80 municipal health officers attending a May 22 training sponsored by the New Hampshire Health Officers Association, an affiliate group of New Hampshire Local Government Center (LGC). Responses ranged from “the State wants to move to county-based health departments" and “local health officers won’t be around any longer" to “it’s going to cost cities and towns more," among others.

Initiating the Discussion
The discussion that followed was part of an outreach effort by the DPHS to provide key stakeholders an opportunity to learn about and, most importantly, obtain input on, an initiative to regionalize public health services in the state. The goal of the initiative, begun in July 2007, is to develop a performance-based public health delivery system that provides all 10 essential public health services throughout New Hampshire. At that time, a task force was convened of key local and regional public health stakeholders that include municipal and county officials, public health and healthcare services providers, and representatives from LGC plus the New Hampshire Public Health Association, New Hampshire Association of Counties and state agencies.

The task force is charged with proposing a system to provide public health services that acknowledges varying levels of resources, infrastructure and capacity. It has met regularly and come to consensus on a number of significant issues, including the following:

A proposed, two-tiered system of public health (primary and comprehensive);
Regions will be organized in a way that recognizes geographic features, existing healthcare infrastructure and population;
Implementation may proceed differently across regions; and
A lead agency in each region that is linked to local and county government and coordinates or is responsible to provide the 10 essential services.

Each regional lead agency would have the capacity, expertise and leadership to assure a fundamental public health presence in the region while collaborating extensively with regional partners to provide services.

“The purpose of public health regionalization is to have a more comprehensive, coordinated and efficient approach to ensure public health services are available to all residents," states DPHS Director Dr. Jose Montero. “This approach builds on our successes with the Public Health Networks and All Health Hazard Regions’ emergency planning efforts by broadening the scope from public health emergency planning to all 10 essential services, establishing more formal linkages with governmental entities and ensuring every municipality is included in a region. We also know that implementation will have to be incremental in order to be successful."

Regional Functions and Staffing
The task force has spent considerable time identifying activities that would likely be most effectively provided through a coordinated regional approach. Examples include the following:

Conducting objective assessments of community health status and publishing health improvement plans based on the assessments;
Coordinating partnerships to address prioritized health problems, including applying for funding from private and public sector entities;
Developing model health-related ordinances that municipalities throughout a region could consider for adoption;
Increasing training and technical assistance available to municipal health officers; and
Delivering health promotion/disease prevention programs.

Other core public health services, such as laboratory services and disease investigations, would remain the responsibility of DPHS to ensure the most effective use of resources and expertise.

Potential staffing of the public health agency would likely be a mix of positions that serve a single region and others that would be shared across several regions. Core staff would include a regional administrator, health educator, environmental health specialist and administrative support. Positions that task force members believe could be shared across regions include an epidemiologist, public health emergency preparedness coordinator and medical consultant. Other staff, such as finance and information technology positions, might be shared or provided in-kind by a local partnering agency.

“It’s critical to remember that many of the functions that these staff would provide are already being supported by various state and local public and private sector entities now and that we are not starting from the ground up," emphasizes Dr. Montero. “The challenge is to better coordinate current complementary, funding streams to maximize efficiencies and economies of scale that a regional approach would enable."

Municipal and county officials are likely to have a particular interest in the functions of proposed regional environmental health specialists. As proposed by the task force, these individuals would complement the DPHS’ sole employee who provides training and technical assistance to municipal health officers. This would increase the availability of technical assistance to health officers, especially with regard to specific cases, the number of trainings available within each region and the ability to educate the public about the relationship between the environment and health.

As an example, communities in southeastern New Hampshire have been especially impacted recently by threats associated with arboviral diseases such as West Nile Virus (WNV) and Eastern Equine Encephalitis (EEE). Because these diseases are spread by mosquitoes, the benefits derived from a single community taking preventive actions, such as spraying, may be more limited than if all the communities in a region agree to take coordinated action. Likewise, efforts to educate the public about how to reduce risks to their families would be more effective if they were consistent and widespread throughout adjoining communities. A regional, environmental health specialist would provide “boots on the ground" in working with municipal officials to determine what coordinated efforts might be possible throughout the region with respect to spraying (including applying to the state for reimbursement) and community education. None of the activities proposed for regional environmental specialists would impact the statutory or regulatory responsibility and authority of municipalities.

Links to Government
This example is also useful to explore why a major goal of this initiative is to strengthen linkages between municipal and county government and a regional public health entity. Government at all levels retains the primary responsibility for the health of their citizens under the United States and New Hampshire constitutions. Government has intrinsic attributes that correlate with the three core functions of public health, which are assessment, policy development and assurance. Government has a key role in assessing the public’s health due to its obligation to weigh all sides of a question based on objective factors and without regard to self-interest. This obligation requires that the needs and health status of all citizens be included for consideration, unlike private-sector agencies that must have the well being of their clients or customers as the highest priority, in accordance with their fiduciary responsibilities.

Thus, with respect to arboviral disease control, government has the responsibility to conduct surveillance programs to be aware of the prevalence of WNV and EEE in mosquitoes in order to understand the potential threat to their citizens. Government’s role in policy development is well understood to have a special obligation to ensure that the public interest is served by whatever measures are adopted. Government officials also have a unique responsibility to raise the hard issues, communicate with affected parties and strive for fairness and balance. This is demonstrated by the need for government to balance the risk associated with arboviral diseases with the effectiveness and cost of spraying programs, and how one community’s efforts will impact adjoining communities. Other potential policy implications might include canceling or rescheduling public events to reduce risk, carrying out extensive efforts to educate the public and implementing policies to reduce the potential of public health nuisances, such as unmaintained swimming pools, that may serve as reservoirs of mosquito breeding. A regional environmental health specialist would be available to work with local communities to increase the likelihood of coordinated actions that would result in a greater cumulative decrease in risk throughout a region.

Assuring that necessary services are being provided to reach agreed upon goals is also uniquely well suited to governmental leadership. Government, more than any private-sector entity, has a responsibility to assure that its programs and services are available to all citizens and that basic needs related to health and well-being are met. Actions that assure citizens have access—regardless of income or language—to clear, accurate, educational messages about arboviral diseases and how to reduce personal risk are examples of the critical assurance-related function of governmental entities that could be met by a health educator serving an entire region.

Informing the Process
To assist in planning for a regional public health system, we are conducting three assessments to inform the process. These assessments include the following:

National Association of County and City Health Officials Accreditation Readiness Tool – Will assist each region in determining their capacity to deliver the 10 essential services;
Financial Assessment – Will determine state and local resources available by region for public health services and what gaps exist; and
Governance Assessment – Will be a facilitated discussion in each region to determine how public health services would best link to government in that region.

The task force determined that regions should be determined prior to the assessment so they could serve as the geographic unit of analysis. Regions that were already developed for various public health programs were seen as the logical starting point to consider for regional consolidation. These programs are the Strategic Prevention Framework (SPF), which addresses substance abuse prevention, and the All Health Hazards regional public health emergency planning effort. Regional leaders of these two initiatives were asked by the task force to convene their partners to review communities that comprised that region and relay back to the task force a recommendation for how their region should be organized to conduct the assessments. This resulted in some consolidation of the 19 existing All Health Hazard Regions—consistent with the task force’s priority that regions should recognize geographic features, existing healthcare infrastructure and population.

A work plan and timeline were developed for the assessments with a decision to implement a phased approach: each assessment would be piloted in two or three regions, then evaluated and revised, if necessary, before being implemented in the remaining regions. These assessments are being supported by funding received from several national partners that are working to enhance public health infrastructure.

National Funding Support
The DPHS is a participant in the Multi-State Learning Collaborative (MLC) funded by the Robert Wood Johnson Foundation, a major funder of public health and healthcare initiatives. A portion of MLC funds will be used to assess the current capacity of each region’s public health system to provide the 10 essential public health services. The pilot phase of this assessment began in June 2008.

The DPHS also received funding from the National Association of County and City Health Officials (NACCHO) to engage a consultant for assessing the current level of financial resources supporting public health services. The consultant has completed similar work in several other states, which helps ensure that New Hampshire will benefit from previous work done. The financial assessments will be done after each region has completed the capacity assessment. This will allow for the findings from the capacity assessment to inform the scope of the financial assessment.

The third and final assessment is being conceived of as a discussion-based effort among key public health stakeholders plus municipal and county officials in each region to develop specific ideas of how the regional public health agency might be designated by, and accountable to, government. This assessment will inform what future statutory changes might be needed to authorize these regional public health agencies. This governance assessment is planned to begin in the fall. All three assessments are anticipated to be completed in every region by March 2009.

“We, along with all of our partners, obviously have a significant amount of work to do," says DPHS’ Ascheim. “While the task force has done a terrific job developing the priorities and approach, our highest priority now is to reach out and engage all the stakeholders in the public health system, including governmental officials, in these assessments to ensure that they are accurate, comprehensive and inform future decision-making. It’s rewarding to see that our efforts are being recognized by national partners that want to strengthen public health infrastructure. But we know that, due to the unique attributes of New Hampshire, we need to propose a solution that will work for all of us who are responsible for protecting and promoting the public’s health by providing public health services that are evidence-based, recognize our history and resources and have widespread support. At the DPHS, we know it will take time to fully implement any new model but look forward to having the combined knowledge and perspective of all of our partners to inform the process."

Please watch for Part II of this article in an upcoming edition of New Hampshire Town and City magazine in which we will address a voluntary program to credential health officers. For additional information about the public health regionalization initiative, please visit the DHHS Web site at

Joan H. Ascheim, MSN, is Bureau Chief for the New Hampshire Division of Public Health Services’ Bureau of Policy and Performance Management. Neil Twitchell is Administrator of the Division’s Community Public Health Development Section.

Essential Public Health Services

  • Monitor health status to identify community health problems.
  • Diagnose and investigate health problems and health hazards in the community.
  • Inform, educate and empower people about health issues.
  • Mobilize community partnerships to identify and solve health problems.
  • Develop policies and plans that support individual and community health efforts.
  • Enforce laws and regulations that protect health and ensure safety.
  • Link people to needed personal health services and assure the provision of healthcare when otherwise unavailable.
  • Assure a competent public health and personal healthcare workforce.
  • Evaluate effectiveness, accessibility and quality of personal and population-based health services.
  • Research for new insights and innovative solutions to health problems.

Source: Public Health Functions Steering Committee, 1994

Web Sites with More Information Related to Essential Public Health Services

National Public Health Performance Standards Program (NPHPSP)
Defines model standards for public health systems and boards of health, based on the 10 EPHS. Offers performance assessment instruments, reports, guidance and improvement resources.

NPHPSP Online Resource Center
Searchable database to locate online improvement resources related to each of the 10 EPHS, NPHPSP model standards and related topics.

NACCHO Operational Definition of a Functional Local Health Department
Defines what people in any community can reasonably expect from their local health department, based on the 10 EPHS.

Public Health Foundation
Offers a performance management and quality improvement portal for public health as part of its Public Health Infrastructure Resource Center.