Transforming Public Health for the 21st Century: Bridging Theory to Practice is a blog series that will explore the challenges and opportunities faced by the public health sector and will introduce a roadmap for transformation. Sign up here to receive these summaries and more, and also follow KHI on Facebook, Twitter, LinkedIn, and Instagram. Learn more about the series on our archive page. Please feel free to share your feedback or suggestions with us by emailing info@khi.org.

Public health fills a vital niche in the U.S. health care system as the only discipline that emphasizes population-based primary prevention.¹ This approach is crucial because it addresses the root causes of health challenges and provides opportunities to solve problems rather than just manage their symptoms.²Local health departments are an essential component of the public health system because they foster closer relationships between public health professionals and local communities.³These close connections improve the effectiveness of public health programs by allowing community members to help identify, plan and implement interventions in line with their needs, strengths and desires.⁴

Plans for a national network of high-functioning local health departments date back to at least the 1940s, when the Commonwealth Fund’s Subcommittee on Local Health Units proposed the need for 1,200 local health departments nationwide, each serving at least 50,000 people.⁵ They advocated for the formation of multi-county health departments to build economies of scale in small jurisdictions by consolidating resources to improve public health performance.^5,6 This is important because national data show that public health department performance is substantially better above this threshold. However, today there are about 3,300 local health departments and about 60 percent serve populations less than 50,000 people.⁷

There are only about 250 multi-county health departments nationwide, and just two in Kansas. It isn’t clear why more counties haven’t joined together to form multi-county health departments.⁷ To gather in-depth insights on the benefits and challenges of leading a multi-county health department, we interviewed Becky Johnson, Administrator of the SEK Multi-County Health Department (SEKMCHD) in southeast Kansas. We hope these insights help illuminate why multi-county health departments might be a worthwhile strategy and how health department leadership differs in a multi-county jurisdiction.

Description of the SEK Multi-County Health Department

The SEKMCHD serves Allen, Anderson, Bourbon and Woodson counties in southeastern Kansas, covering a population of nearly 39,000 people. The department is staffed by 14 full-time and four contract employees who provide a range of public health services, include breastfeeding support, women’s health, maternal and child health home visits, immunizations and the Women, Infants, and Children (WIC) program. Additionally, the department conducts disease investigations, blood draws, physicals, tuberculosis (TB) tests, screenings and car seat safety checks. The SEKMCHD is also actively involved in community health needs assessments sponsored by local hospitals.

Benefits of Leading a Multi-County Health Department

In our conversations, Ms. Johnson discussed several benefits of leading a multi-county health department. We aimed to identify themes that differentiated the SEKMCHD from its single county peers that served similar communities. The themes that emerged focused on their board of health, staffing and services.

Board of Health

Volunteer Board Members

Ms. Johnson highlighted the unique composition of the board of health that oversees the SEKMCHD. In Kansas, single county health departments are typically governed by the board of county commissioners. In contrast, the SEKMCHD’s board of health includes one county commissioner, one consumer and one provider from each county, all of whom volunteer for these roles. Ms. Johnson thought that the volunteer nature of the board members led to better engagement than some single county health departments experience. She explained,

“Most of the board of health members are volunteers. So, they have an interest in these roles, rather than just being appointed. We have a lot of support from them. A lot of health departments don’t have that. I’ve seen many health department administrators and health officers leave because they don’t have the support like I do.”

Tangible Support

This support is evident in several tangible ways. Ms. Johnson noted that the members of her board of health support her when she presents to the county commissioners, and they provide her with greater freedom when it comes to pursuing grants or organizing the health department. She remarked,

“County commissioners have torn down administrators from other health departments. Ours haven’t done that in any of our four counties. I think it helps to have one of them on our board of health because they’re in our corner. They can explain to the other commissioners the needs and goals of the health department.”

Ms. Johnson also said that this support was important for continuity of leadership in her jurisdiction throughout the COVID-19 pandemic. She mentioned that the support of her board of health helped her persevere through the challenges of the pandemic, contrasting this with the experience of administrators and health officers from single county health departments, many of whom left their roles during the COVID-19 pandemic.⁸

Staffing

A Larger Number of Employees

The SEKMCHD benefits from having 14 full time and four contract employees, in contrast to many nearby single county health departments, most of which have six or fewer staff members.⁹ The benefits of a larger team include both cross training and coverage, as well as focus areas and subject matter expertise. Ms. Johnson explained that some nearby health departments may need to pause services when a staff member takes vacation or is on medical leave. But the SEKMCHD has sufficient capacity for continuity of operations in these instances. Ms. Johnson emphasized these advantages:

“We have people to cover, so that’s helpful. Some counties just have a nurse and a clerk, and the nurse is the administrator too.”

Additionally, a larger team allows the SEKMCHD to assign focus areas to staff members. This allows Ms. Johnson to delegate responsibility for programs across the staff, which frees her up to provide more overall leadership for the department.

Dedicated Administrative Staff

Additionally, Ms. Johnson highlighted the benefits of having dedicated administrative staff:

“I’m over all the counties, and we have an accountant that’s over all the counties, rather than having the county clerk or the county treasurer. Having that role is amazing and I think it is different than a lot of the smaller single-county health departments. It takes some of the pressure off me, instead of having to know everything about everything.”

This dedicated administrative support allows for delegation of tasks and more efficient and effective management.

Services

Comprehensive Service Offerings

The SEKMCHD stands out for offering select public health services that fit the needs of the communities they serve. Additionally, the department is actively engaged in two community health needs assessments in partnership with local hospitals. Ms. Johnson also said that she did not think the same level of services could be provided if they were organized as single county health departments in each jurisdiction.

Breastfeeding Support

One of the department’s exceptional programs is its breastfeeding support initiative. Ms. Johnson highlighted that one nurse is set to receive certification from the International Board of Lactation Consultant Examiners. This certification will help them contribute as members of the maternal-child health team, linking providers and community services. Regarding their breastfeeding work, Ms. Johnson said:

“We received a gold award for employee breast feeding support and we’re working on becoming a breastfeeding friendly health department through the Kansas Breastfeeding Coalition.”

Department of Transportation (DOT) Physicals

Ms. Johnson also described that they are planning to launch a new program to provide DOT physicals. DOT physicals ensure that people who drive commercial motor vehicles, such as large trucks and buses, are physically, mentally and emotionally fit as a requirement for this work.¹⁰ Ms. Johnson recognized that this service may be a need for their community due to the type of industry in their jurisdiction and a lack of existing providers. Additionally, Ms. Johnson stated that this might be a strategic opportunity to bring in a different population to their services, which might increase their public value. Ms. Johnson said:

“We are looking into starting DOT physicals because I don’t think there are many providers doing this in our counties and because there are a lot of people that work in industries that require this service. By providing this service, we could bring in a new population that we haven’t provided direct services to much in the past.”

By offering a full scope of public health services, working with community partners and bringing innovative programs to the area, the SEKMCHD demonstrates the advantages of its multi-county structure.

Challenges of Leading a Multi-County Health Department

In our conversations, Ms. Johnson also cited some challenges of leading a multi-county health department. These themes tended to focus on stakeholder engagement and not being able to access some county government support. We also discussed the potential for counties to separate from the multi-county health department relationship.

Stakeholder Engagement

Managing Multiple Stakeholders

Sufficiently engaging with all the relevant stakeholders across a four-county region was viewed as a challenge. Getting to know all the relevant stakeholders was demanding, given that there are four times as many stakeholders across the region. Ms. Johnson explained:

“I’ve met many people since I began working for SEKMCHD. Trying to keep track of who is who, that’s very difficult. But you have to figure out who knows who and ask for help when needed.”

Additionally, the increased number of stakeholders could create competing demands on Ms. Johnson ’s time, since she cannot be in multiple locations at once. She highlighted this issue with an example from the COVID-19 pandemic:

“During the COVID-19 pandemic, everyone wanted to talk to me, and everyone wanted me at their meeting, such as school board, city council, etc. But I couldn’t be everywhere at once.”

Engagement with County Commissioners

The SEKMCHD is well engaged with its Board of Health. However, Ms. Johnson noted that her engagement with the four boards of county commissioners was less frequent. She mentioned that she meets with each of them at least once a year, but wondered if other health departments had a closer relationship with their county commissioners. Regarding this, Ms. Johnson stated:

“If I had more time to go to the Board of County Commissioners meetings, maybe even quarterly, I could give them more frequent updates, share projects we’re working on and remind them of the services we provide.”

Having to engage with a greater number of stakeholders creates complexities and challenges for multi-county health departments. As Ms. Johnson said, “At times, it seems I am in the office more frequently than necessary. I would prefer to travel to our other offices and counties to better serve our communities as a whole.” This may highlight the need for leaders of multi-county health departments to develop strategies for community partner development across the broader region.

County Support

Ms. Johnson noted some differences in the support single-county health departments receive from their county government compared to the SEKMCHD. She listed the following examples.

Health Insurance: The SEKMCHD provides its own health insurance to employees. Ms. Johnson stated that while their health insurance is good, it might be better if they were part of a larger pool.
Facility Costs: The SEKMCHD must pay for all its own buildings, whereas single-county health departments might have these provided by the county government.
Access to County Services: The SEKMCHD must provide for its own services, such as maintenance or information technology (IT), which are often available to other county government departments.
Financial Contributions: Although the SEKMCHD has a higher operating budget than its single-county peers, the contribution from individual counties might be lower.

Multi-county health departments might not get the same level of support from the county governments that they serve. While this disadvantage might be offset by an overall greater level of resources, this might highlight additional opportunities to secure needed public health resources.

Counties Separating from the Multi-County Health Department

As a collaborative venture, I was interested in Ms. Johnson’s thoughts on the potential risk of counties separating from the SEKMCHD. She discussed that Linn County had separated from their relationship many years ago. But she also felt that she had a good rapport with the current counties and that she was not concerned that any would leave. She felt that the SEKMCHD provided good value for the money compared to some single county health department peers. Additionally, Ms. Johnson indicated that they would begin seeking input from the towns in the jurisdiction regarding the types of services they provide. By identifying the needs and desires of stakeholders in their jurisdiction they can improve their value proposition and maintain and improve buy-in.

Lessons Learned and Opportunities for Multi-County Health Departments

The insights from Ms. Johnson reveal some potential lessons learned and opportunities for advancing multi-county health departments as a strategy for improving public health systems. Some of these takeaways include:

Benefits Outweigh the Challenges: The benefits of a multi-county health department approach seem to outweigh the challenges in regions with small populations. Public health professionals’ benefit from having a larger team to support coverage and provide opportunities for focus areas, and the counties benefit from having access to at least the same level of services, if not greater, than they would receive under a single county health department system. Opportunities for economies of scale for administrative services as well as some population-based services, such as infectious disease control and community health promotion, may be possible as well.
Strategy for Stakeholder Engagement: All health departments and organizations in general need to engage their stakeholders and sell them on their value proposition. This is especially important for multi-county health departments because they experience the risk of counties separating from the multi-county health department structure, and because they have more stakeholders to engage. Multi-county health departments might benefit from developing a value proposition that distinguishes the value of the multi-county health department from a single county approach. Additionally, while the administrator or health officer will be ultimately responsible for stakeholder engagement, it may be worthwhile to assign a staff member with the responsibility of stakeholder engagement. Health education specialists may be especially useful in this role since they have specific training in community engagement.
Develop Support Systems: States pursuing a multi-county health department strategy may consider developing a support system to fill in gaps in basic infrastructure that single county health departments might receive from their county. For example, a statewide support system for employee benefits, information technology, maintenance, human resources and other basic infrastructure could be developed to support multi-county health departments. Statewide support systems like this could improve economies of scale for public health administration and support division of labor so that public health professionals can focus on their expertise of disease prevention and health promotion.

Multi-county health departments have been positioned as a strategy for improving public health performance and is a strategy worth further attention. Ms. Johnson’s insights show that a multi-county health department can benefit the public health workforce as well as the communities they serve. Her insights also show that leading a multi-county health department is different and specific strategies may be necessary for success.

References

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Cunningham M, Patel K, McCall T. 2022 National Profile of Local Health Departments. 2024. Accessed April 8, 2024, from https://www.naccho.org/resources/lhd-research/ national-profile-of-local-health-departments
Cain C, Hunt DC, Armstrong M, Collie-Akers VL, Ablah E. Reasons for Turnover of Kansas Public Health Officials during the COVID-19 Pandemic. Int J Environ Res Public Health. 2022;19(21). doi:10.3390/ijerph192114321
Kansas Public Health Collaborative. Interactive Maps. Accessed May 16, 2024, from https://kphcollaborative.org/interactive-maps/
WebMD. Department of Transportation (DOT) Physical Exam: An Overview. Accessed June 4, 2024, from https://www.webmd.com/a-to-z-guides/what-is-dot-physical

Beyond Borders: Benefits and Challenges of Leading a Multi-County Health Department

An Interview with Becky Johnson, Administrator of the SEK Multi-County Health Department