Minnesota's public health system: History and context

History of Minnesota's public health system
Community health boards
Public health system strengths
Issues and challenges facing the public health system
Key resources and references

Minnesota’s public health system can best be described as a state and local partnership. It was created with the passage of the Community Health Services Act (Minn. Stat. § 145A) in 1976, which was subsequently revised in 1987 and 2003. Now called the Local Public Health Act, the legislation delineates the responsibilities of the state (MDH) and city and county governments in the planning, development, funding, and delivery of public health services.

This partnership, known as the community health services (CHS) system, enables state and local governments to combine resources to serve public health needs in an efficient, cost-effective way. It is fundamental to the success of Minnesota’s public health system because it is the infrastructure for nearly all public health efforts in Minnesota. The system is structured to be flexible so it can meet the different needs of communities around the state and promote direct and timely communications between state and local health departments. The CHS system relies on shared goals and a desire to work together to improve the lives of all Minnesotans. This partnership is the basis of Minnesota’s public health system—one entity cannot function without the other.

"The vision for public health is a strong and dynamic partnership of governments fully equipped to address the changing needs of the public’s health."
– SCHSAC Strategic Planning Workgroup, 2003

Minnesota's first public health laboratory in Red Wing, MN (c. 1890)

The public health responsibilities of both local and state governments in Minnesota date back to the mid-1800swhen towns and cities were authorized to enact regulations for controlling infectious disease. They formed township boards of health, and all early public health work was done at the local level. There was no central or organized public health body in the state.

In 1872, a State Board of Health was established in Red Wing. Recognizing that local communities often are more aware of local threats to health than the state, and are better suited to address specific issues, the State Board of Health encouraged communities to create local boards of health in the 1900s.

The responsibilities of these local boards were three-fold:

• To assess the health of their community, including reporting live births and causes of death and disease;
• To develop policies to limit the spread of communicable disease; and
• To assure sanitary conditions conducive to a healthy community. Minnesota’s system of local boards of health prior to the 1976 Community Health Services Act.

State field offices opened to support the local boards of health in the 1930s. Each was staffed with a medical director, an engineer, and a public health nurse. In the mid-1940s, legislation gave local health departments updated authority including responsibility in the areas of maternal and child health, health education, disease prevention, and restaurant inspections. In addition, the Legislature provided small amounts of state aid for the cost of providing local public health nursing services. Such services typically included maternity services, health supervision of infants and children, communicable disease control with immunizations for diphtheria/tetanus and smallpox, and some bedside nursing. Other early activities of the state and local health boards focused on four areas—sewage management, restaurant and food inspections, milk quality, and meat inspections. In the late 1960s and early 1970s, additional programs were created as a part of President Johnson’s "Great Society" reform package.

Minnesota's system of local boards of health prior to the 1976 Community Health Services Act

Prior to 1977, over 2,100 local boards of health existed to serve Minnesota’s communities. The 1976 Community Health Services Act (now the Local Public Health Act, or Minn. Stat. § 145A) allowed boards of health to join together and work as Community Health Boards, to serve a larger population and geographic area. The legislation aimed to:

• Overcome confusion over roles and authorities
• Make the public health system more comprehensive
• Make community health boards eligible for state subsidy
• Make communication and collaboration easier across the system

The Local Public Health Act outlines the shared public health responsibilities of the state and local governments in Minnesota and establishes accountability for funding on statewide initiatives, provides guidelines for assessment and planning, requires documented progress toward the achievement of statewide goals, and assigns oversight of the statewide system to the commissioner of health.

The community health board is the legal governing authority for local public health in Minnesota, and community health boards work with MDH in partnership to prevent diseases, protect against environmental hazards, promote healthy behaviors and healthy communities, respond to disasters, ensure access to health services, and assure an adequate local public health infrastructure.

Community health boards have statutory responsibility under the Local Public Health Act and must address and implement the essential local public health activities. Additionally, community health boards must assure that:

• A community health assessment and plan are completed on a regular cycle
• Community health needs are prioritized in a manner that involves community participation
• Needed public health services are developed and implemented

The Local Public Health Act requires each community health board to serve a population of at least 30,000 people. If a single county doesn’t meet the population requirement, it can form a community health board with one or more neighboring counties. If a community health board serves three or more contiguous counties, the minimum population requirement does not apply. The number of community health boards in the system has varied over time and is subject to change; MDH maintains a map of current community health boards (PDF) online.

Community health boards in Minnesota take a number of forms:

• Single-county
• Multi-county
• Statutory (city-based)
• Human services board
• Contracted services
• More info: Governance and organizational structures of Minnesota's community health boards (PDF)

Community health boards are required to have a community health services administrator and a medical consultant, and may appoint an advisory committee. Members of the community health board are either elected themselves or appointed by elected officials. Due to local control and local investment of resources, the membership, composition, and business practices of community health boards vary throughout the state. This flexibility is a great strength of the state’s public health system; it helps ensure public health activities are aligned with community need.

Organizational and governance changes

Over the past decade, several counties and community health boards have made changes to their public health organizational and governance structures, and more changes are being considered as local elected officials look for ways to address significant budget concerns, create efficiencies, and anticipate the retirements of public health leaders. Between May 2009 and May 2010, 28 percent of county boards and 28 percent of community health boards considered, proposed, or decided to change their organizational or governance structure (Minnesota Public Health Research to Action Network, 2011). Some top public health officials expressed satisfaction with current structures, whereas others identified limitations with current structures or concerns about the motivation for changing structures.

To find contact information for other community health boards, visit: Find a Community Health Board / Local Health Department.

A partnership of governments

Minnesota's public health system functions as a partnership between state and local governments, and is designed to ensure that the public's health and safety are protected statewide while providing local governments with the flexibility needed to identify and address local needs. Both levels of government have statutory authorities and responsibilities.

The commissioner of health has general authority as the state's public health official, and is responsible for the development and maintenance of an organized system of programs and services for protecting, maintaining, and improving health. State statutes also require the commissioner to provide administrative and program support to local public health.

Community health boards are statutorily required to establish local public health priorities based on an assessment of community health needs and assets; to determine the mechanisms by which the community health board will address those priorities; to work to achieve statewide health outcomes developed in partnership with MDH; and to address infectious disease and certain public health nuisances.

Several states have copied Minnesota’s statutes and modeled their state public health system on Minnesota’s partnership.

Complementary roles that build on strengths

The Minnesota Department of Health and local health departments play complementary roles in protecting and improving health, within a system of shared responsibility. The coordinated partnership between the state and local levels of government in Minnesota is an efficient way to make the best use of public health resources. Because public health in Minnesota is locally delivered, in many cases certain functions are more efficiently handled by one of the partners.

The Minnesota Department of Health provides specialized scientific, technical, and program expertise, and serves the entire state. It also provides data that local health departments need to carry out their work, and is responsible for overall public health policy development. MDH funnels funding to the local public health system, and is accountable to the Legislature and the federal government for those funds. Categorical grant programs have reporting mechanisms in place to collect information. Collaborative state and local work has resulted in a broad-based performance measurement and reporting system that collects information on how local health departments are meeting the essential local public health activities.

Local health department strengths include deep connections within communities; an understanding of local conditions, needs, and resources; and trained staff to carry out public health activities so that all people in Minnesota have an opportunity to be healthy, regardless of where they live. For example, the Statewide Health Improvement Partnership (SHIP) works at the community level and supports unique programs statewide to create sustainable, systemic changes that produce widespread, lasting results

The State Community Health Services Advisory Committee

The State Community Health Services Advisory Committee (SCHSAC) is a statutory advisory body made up of one representative from each of the state’s community health boards; it meets quarterly with the commissioner of health and key MDH managers to develop shared goals, clarify roles, and develop agreement on how to address emerging public health issues.

SCHSAC provides a forum for the state and community health boards to regularly, systematically, and intentionally exchange information, and collaboratively address key public health issues. Its work is primarily conducted through the quarterly meetings, conferences, workgroups, and distance learning; all SCHSAC activity is based in its annual work plan. SCHSAC members are encouraged to regularly solicit information from and disseminate information to members of their Community Health Boards at local and regional meetings.

SCHSAC was established to "advise, consult with, and make recommendations to the commissioner on the development, maintenance, funding, and evaluation of community health services."
– Community Health Services Act, 1976

Having been established with the original CHS Act in 1976, SCHSAC remains a vital and important body as it moves into its fourth decade. You can find a map of SCHSAC Regions online.

Minnesota Department of Health resources and support

MDH public health system consultants, epidemiologists and preparedness coordinators are deployed across the state, and provide technical assistance and support to local health departments within their assigned geographic regions. Those state employees live and work in the regions they serve (at the seven MDH regional offices, for example), understand local context, and provide expertise that connects MDH with local health departments. These MDH employees provide service and expertise which is not otherwise practical or cost-effective for an individual local health department to maintain. Some of these services include epidemiologic consultation and investigations, emergency preparedness planning and exercises, environmental health, maternal and child health, and nursing consultation, as well as general support in the practice of public health. In addition to this, centrally located MDH staff provide training, and develop tools, templates, guidelines, websites and other resources.

Local governments working across jurisdictional boundaries

Since the existing state public health system was created in 1976, local governments have been granted the authority to work across jurisdictional boundaries to address public health issues, by forming multi-county community health boards. Today, almost two-thirds of Minnesota counties have partnered to create larger, multi-county community health boards—public health jurisdictions that have the potential to extend scarce resources and allow for economies of scale. Many other regional, multi-county, or city-based shared service arrangements are in place to address specific public health issues in a cost-effective and efficient way.

Dedicated public health funding

Funding for local public health is comprised of a mix of local, state, and federal funds, as well as fees and reimbursements. A base of stable, non-categorical state funding is critical to public health in Minnesota. It assures that all areas of the state have a local health department that can respond to a diverse array of public health issues. Approximately $20 million in flexible state funding (as of 2012) supports public health in communities around the state. This flexible funding can be used to fulfill public health responsibilities and support local priorities identified during community assessments.

To name a very small number of interventions, this funding goes toward:

• Directly observed therapy for tuberculosis
• Investigating public health nuisances
• Promoting healthy communities
• Addressing health care service gaps/barriers
• Improving cultural competency among service providers
• Preparing for emergencies
• Responding to foodborne outbreaks
• Providing vaccinations

Despite Minnesota’s reputation for a strong and effective public health system and its proven record in promoting population health, the state faces a number of challenges. In an era of funding constraints, public health departments are faced with increased responsibility for emerging health threats while still maintaining other fundamental health protection and promotion activities.

Minnesota’s public health system is facing many challenges, and working actively to address them. In recent discussions, SCHSAC members and local public health administrators identified the following issues and challenges as faced by their departments:

• An aging public health workforce, which leads to leadership turnover
• Changing community demographics, including declining populations in many rural counties
• Organizational changes and/or reorganizations of many local health departments (e.g., creating health and human service agencies by merging public health departments with social services departments)
• Capacity and resource disparities between a number of small and large jurisdictions
• Reliance on multiple, categorical funding streams with time-consuming administrative requirements and unpredictable funding.
• Large-scale budgetary pressures, which require new strategies to preserve the public health protection and prevention currently enjoyed by state residents

SCHSAC has advocated for meeting these challenges head-on, proactively finding opportunity in challenges, and "raising the bar" for public health in Minnesota. The public health system requires sustained action to enhance its agility and ensure its future success, and can count on the established state-local partnership to help it weather financial and other constraints. As one SCHSAC member recently said, "We are setting a course for the future based on the strong foundation we’ve built."

• Local Public Health Act (Minn. Stat. § 145A)
• Local Public Health Act: Related statutes
• Find a local health department or community health board
• Map: Current community health boards (PDF)
• Governance and organizational structures of Minnesota's community health boards (PDF)
• Local public health assessment and planning cycle
• SCHSAC (State Community Health Services Advisory Committee)
• Public Health is People: A History of the Minnesota Department of Health from 1949 to 1999
• Minnesota Local Public Health Association
• Healthy People 2030
• A call to action: Advancing health for all through social and economic change (PDF)
  Minnesota Health Improvement Partnership, April 2001
• NACCHO: Operational definition of a functional local health department