Rural Public Health Agencies
Rural public health agencies work to protect and improve the health of rural populations by:
- Preventing injuries and the spread of disease
- Protecting rural populations against environmental hazards
- Promoting and encouraging positive health behaviors
- Responding to disasters
- Assuring the quality and accessibility of services
Rural public health agencies encounter many challenges while trying to meet the unique and diverse needs of rural Americans, including:
- Workforce recruitment and retention
- Workforce education and training
- Information technology
Public health agencies work to address chronic disease and health disparities within the populations they serve. To learn more about the differences in health status for rural residents, see RHIhub's Rural Health Disparities topic guide. RHIhub's Chronic Disease in Rural America topic guide details how specific health conditions affect rural populations and provides additional resources and funding opportunities to improve chronic disease conditions in rural populations.
Frequently Asked Questions
- What infrastructure and governance exists in rural areas for public health agencies?
- What public health services are provided in rural areas?
- How can public health agencies respond to emergencies and disasters in rural areas?
- Where is information on local governmental public health agencies located?
- What education and training opportunities are available related to rural public health?
- What challenges and opportunities do rural public health agencies face?
- To what extent do rural public health agencies struggle to maintain an adequate workforce?
- Where can I find public health datasets or information particular to my region or state?
- How can my public health department become accredited and what is the process?
- How can rural public health professionals network and connect with their peers?
- How can rural healthcare providers and public health departments work together to improve population health in their communities?
- What federal agencies focus on public health in rural areas?
- Is there funding for public health programs in rural communities?
What infrastructure and governance exists in rural areas for public health agencies?
CDC defines the public health system as:
“all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction.”
Delivering essential public health services in rural areas requires a coordinated, collaborative effort from multiple stakeholders involved in the public health system.
Rural public health infrastructure varies from community to community. The National Association of County and City Health Officials (NACCHO) report, 2019 National Profile of Local Health Departments, describes local health department (LHD) governance, infrastructure, funding, leadership, workforce, programs, practice, and more. The report analyzes survey data from 2,459 LHDs from every state except Rhode Island, which does not have a sub-state level public health unit. Areas without LHDs are not represented in the NACCHO national profile report. The report reveals the following about small and rural LHD infrastructure:
- 50% of top executives at rural LHDs have graduate degrees, compared to 76% of top executives at urban LHDs.
- 33% of top executives at rural LHDs have degrees in nursing, compared to 16% of top executives at urban LHDs. Urban top executives are more likely to have degrees in public health and medicine.
According to the 2020 article, Funding and Service Delivery in Rural and Urban Local US Health Departments in 2010 and 2016, both large rural LHDs and small rural LHDs relied more heavily on state and federal funding sources compared to urban LHDs. While urban LHDs had a higher proportion of revenue from non-clinical fees and fines, large rural and small rural LHDs had more funds from clinical funding sources, such as Medicare/Medicaid, private insurance, and personal patient fees. Funding sources can impact key public health functions within a community, including a health department’s ability to effectively address local needs and priorities.
NACCHO's 2019 National Profile of Local Health Departments classifies LHD governance into 4 categories:
- Local or decentralized – all LHDs in a state are units of local government
- State or centralized – all LHDs in a state are units of state government
- Shared – all LHDs in a state are governed by both state and local authorities
- Mixed – LHDs in a state have more than one governance type
In areas that lack a local public health presence, state health departments are responsible for local public health services. A November 2017 report, ASTHO Profile of State and Territorial Public Health, Volume 4, illustrates the number of LHDs and identifies if there is a regional health department in each state (Figure 1.2). The report also includes a flow chart describing state and local health department governance classification (Figure 1.3).
A 2015 report, State and Local Public Health: An Overview of Regulatory Authority, from the Public Health Law Center discusses how local boards of health, whose members are appointed or elected, serve as the administrative body for LHDs. The Public Health Law Center report details how the role, legal authority, and regulatory powers of local boards of health vary by jurisdiction. In 2012, the National Association of Local Boards of Health (NALBOH) identified 6 key governance functions of local boards of health:
- Policy development
- Resource stewardship
- Legal authority
- Partner engagement
- Continuous improvement
To find more information related to the history of rural health, including the roles of public health and healthcare, see the 2021 report, Rural Public Health and Health Care: A Scan of Field Practice and Trends.
What public health services are provided in rural areas?
LHDs provide a variety of programs and services. Each locality is different. Clinical programs and services may include:
- Screening for diseases/conditions
- Treatment for communicable diseases
- Maternal and child health services
- Other clinical services, such as school-based clinics, oral health services, home healthcare, and correctional health services
Population-based programs and services may include:
- Epidemiology and surveillance
- Primary prevention
- Regulation, inspection, and/or licensing
- Environmental health services
- Other services, such as vital records, outreach and enrollment for medical insurance, and collection of unwanted or expired pharmaceuticals
NACCHO's 2019 National Profile of Local Health Departments report identified programs and services that were more likely to be provided at rural LHDs:
- Childhood immunizations
- Adult immunizations
- Tuberculosis treatment
- Maternal and child health surveillance
- Women, Infants, and Children (WIC)
- HIV/AIDS screening and treatment
- Other STD screening and treatment
- High blood pressure screening
- Body Mass Index (BMI) screening
- Early and periodic screening, diagnosis, and treatment of health problems
- School health
- Prenatal care
- Well-child clinic
- Home healthcare
Funding and Service Delivery in Rural and Urban Local US Health Departments in 2010 and 2016 found rural LHDs are more likely to provide specific clinical services and remain part of the healthcare delivery safety net, while urban LHDs are more likely to provide specific population-based services. Rural communities without LHDs are more likely to have fewer public health services available. State public health agencies, rural hospitals, rural clinics, private practice physicians, and community groups may provide some public health services to communities without LHDs. To learn more about access to healthcare in rural areas, see RHIhub's Healthcare Access in Rural Communities topic guide.
Some services may be provided on a regional basis either by state health departments, multiple local governments, or independent LHDs sharing staff and resources between jurisdictions. A November 2017 Center for State and Local Government Excellence report, Staff Sharing Arrangements for Local Public Health, describes how sharing public health staff between jurisdictions can fill gaps, provide public health services that otherwise might not be economical, and allow rural public health departments to qualify for grant funding.
To review models of a public health staff sharing agreement, see RHIhub's Model & Innovations:
- Genesee and Orleans County Cross Jurisdictional Sharing Project (GO Health)
- San Luis Valley Public Health Partnership
Public health agencies differ in their approach to interacting with tribal jurisdictions and organizations. According to the 2022 article Best of ARM, Evaluating Engagement in Multisector Community Health Networks: The Case of Tribal Organizations, 72% of public health networks located near AI/AN healthcare facilities lack engagement with tribal organizations.
The National Indian Health Board (NIHB) provides information on tribal public health. It actively works to encourage healthy behaviors, prevent injury and disease, and develop health policy. NIHB also helps deliver necessary resources and infrastructure to tribal governments and American Indian/Alaskan Native populations.
How can public health agencies respond to emergencies and disasters in rural areas?
Emergencies and disasters can have a disproportionate impact on under-resourced and rural communities due to healthcare facility closures and delayed response times from emergency medical services, according to the 2022 National Preparedness Report. The report discusses public health and healthcare system capacity and suggests ways to invest in preparedness strategies, connect systems, and address inequities.
Public health agencies play a key role in emergency preparedness and response. Some roles include:
- Coordinating planning and response efforts across partners in the community
- Communicating with state government officials
- Infectious disease surveillance, contact-tracing, immunizations, and other mitigation efforts
- Communicating to the public about threats as well as resources available for community members
A 2022 webinar, Preparing your Organization for Disaster: A Guide to Rural Resilience provides strategies on how rural public health agencies can prepare for potential disasters. For more information, see our topic guide on Rural Emergency Preparedness and Response and our Rural Emergency Preparedness and Response Toolkit.
Where is information on local governmental public health agencies located?
Information on local governmental public health agencies can be found on their online sites through web searches, by contacting municipal and county government offices, or by searching the NACCHO Directory of Local Health Departments. The agency may serve the city and/or the county and may be referred to as a health department, board of health, health district, or public health agency.
If a community does not have a local governmental public health agency, the corresponding state or territorial health department can assist in locating an agency or organization that may be providing public health services in a community.
What education and training opportunities are available related to rural public health?
Public Health Schools and Programs
Programs with a specific emphasis or focus area can be found by searching by degree programs from Council on Education for Public Health (CEPH) accredited institutions. CEPH is the accrediting body for schools and programs of public health. CEPH maintains a list of accredited public health schools and programs.
The Association of Schools & Programs of Public Health (ASPPH) also has a searchable database of member institutions' degree programs by area of study. ASPPH is a national organization representing schools and programs of public health that are accredited by CEPH.
Some schools of public health, such as the East Tennessee State University (ETSU) College of Public Health, offer rural training tracks and certificate programs. Many of the HRSA-funded Rural Health Research Centers are also located within schools of public health and offer student research and training opportunities through assistantship programs.
Training and Continuing Education
The Public Health Foundation (PHF) coordinates the TRAIN Learning Network, comprising state and federal affiliates that provide education, training, and resources to professionals at little or no cost. Available courses can be searched by rural, course format, date, selected public health competencies and capabilities, and more.
The American Public Health Association (APHA) offers continuing education programs for public health professionals online and in-person at their annual meeting. APHA is a national, professional organization for public health professionals and works to promote and improve the health of all communities. APHA-affiliated state and regional public health associations may provide education, training, and resources within their respective states.
NACCHO University has online trainings and educational webinars and offers continuing education programs at NACCHO's 3 conferences:
NACCHO also offers training, workforce development, and performance improvement opportunities, including:
- Workforce Resource Center
- Roadmap to Ready: A Training and Mentoring Program for New Preparedness Coordinators
- Adaptive Leadership and Change Management
CDC offers multiple resources for education and training, including:
- CDC Learning Connection
- Public Health Associate Program
- Public Health Informatics Fellowship Program
- E-learning Institute Fellowship
The Bureau of Health Workforce (BHW), within HRSA, funds the Regional Public Health Training Centers (Regional PHTC) program to improve the public health system by strengthening the technical, scientific, managerial, and leadership competencies of the public health workforce through education, training, and consultation services. There are 10 regional PHTCs throughout the U.S. Each PHTC focuses on a specific topic, including:
- Public health preparedness
- Health disparities, health equity, and social determinants of health
- Health informatics and health information technology
- Infectious disease
- Environmental public health
- Behavioral health
- Nutrition, physical activity, and obesity
- Violence and injury prevention
What challenges and opportunities do rural public health agencies face?
CDC's Morbidity and Mortality Weekly Report (MMWR) Rural Health Series discusses the health of rural Americans, specifically how chronic diseases and injuries affect rural populations compared to urban populations. According to a CDC press release, rural residents tend to be older and sicker than their urban counterparts, which increases the burden on rural public health agencies and rural healthcare systems.
A 2012 NORC Walsh Center for Rural Health Analysis report, Establishing and Maintaining Public Health Infrastructure in Rural Communities, describes funding, public health jurisdictional issues, and the lack of support from community members and elected officials as common barriers rural public health agencies encounter when establishing or expanding public health infrastructure and services. The 2022 publication A Playbook for New Rural Healthcare Partnership Models of Investment recommends that public health agencies partner with the community development sector to leverage resources and build healthier communities.
Rural public health agencies encounter many challenges related to workforce and infrastructure. A 2015 AcademyHealth report, Rural Public Health Systems: Challenges and Opportunities for Improving Population Health, describes rural public health departments as having less capacity to perform core public health functions and provide essential public health services. The report highlights the need for a tribal and rural public health research agenda:
“While the body of research specific to local public health systems is growing, a very small proportion of the evidence focuses on rural health departments — which comprise approximately 60 percent of all LHDs. Noticeably absent are studies specific to Tribal public health; the Tribal population accounts for a major segment of rural communities.”
Despite the many challenges faced by rural public health agencies, the AcademyHealth report identified accreditation, evidence-based policies and practices that inform continuous quality improvement processes, and multi-jurisdictional partnerships as opportunities that exist for LHDs to improve healthcare services and delivery.
Rural communities can also capitalize on their strengths to improve population health and equity. According to a NORC Walsh Center for Rural Health Analysis report, Exploring Strategies to Improve Health and Equity in Rural Communities, public health agencies can leverage individual, organizational, community, and cultural assets to address rural health challenges. Additionally, the report features recommendations for using existing networks, partnerships, and anchor institutions to collectively respond to problems facing rural communities. Another potential strategy to help rural communities leverage resources is to collaborate with public health departments in other communities. The 2018 article Cross-Jurisdictional Resource Sharing in Local Health Departments: Implications for Services, Quality, and Cost analyzes the potential benefits related to service quality, resource access, and effectiveness of resource usage when small LHDs utilize cross-jurisdictional sharing.
A single rural healthcare provider or public health department cannot address all aspects of a patient's health. A 2014 Commonwealth Center for Governance Studies, Inc. report, Improving Community Health through Hospital – Public Health Collaboration, examined 12 partnerships between hospitals, public health departments, and community organizations working to improve the health of their communities. The study identified successful examples of organizational models, partnership management, and sources and levels of financial support. Through collaborative efforts and community health partnerships, rural healthcare providers and public health departments can work together to address the clinical, social, economic, and environmental factors that influence patient health.
State and federal agencies have the ability to reduce health disparities by implementing changes to improve social determinants of health (SDOH). ASTHO's resource, entitled State Approaches for Addressing Rural Social Determinants of Health, includes state and federal considerations for addressing SDOH to promote positive rural health outcomes. The document discusses factors related to rural health disparities, with information on transportation, broadband, income, and educational attainment. For more information on SDOH in rural areas, see the Social Determinants of Health for Rural People topic guide.
The Center for Sharing Public Health Services serves as the national resource on cross-jurisdictional sharing. The center maintains a cross-jurisdictional sharing resource library with a section specifically for rural and small jurisdictions.
To what extent do rural public health agencies struggle to maintain an adequate workforce?
A 2016 National Rural Health Association policy brief, Rural Public Health, describes some of the challenges rural public health agencies face, including workforce recruitment, retention, education, and training.
NACCHO's 2019 National Profile of Local Health Departments reports:
- A 17% decrease in the number of LHD employees from 2008-2019
- Only 18% of LHD full-time equivalents (FTEs) serve rural populations
NACCHO's 2020 Forces of Change survey found that small LHDs, serving fewer than 50,000 individuals, reported gaining more jobs than they lost in 2020. Of the small LHDs, 16% reported a smaller budget in the current fiscal year and 20% of small LHDs anticipated having smaller budgets in the next fiscal year. Budget cuts affect a small LHD's ability to recruit and hire public health professionals, but they also affect the continued training and education of current employees, which could influence employee retention.
Healthy People 2030 identifies multiple objectives to ensure public health agencies have necessary public health infrastructure. Objectives include improving the public health workforce by increasing the number of public health agencies that use Core Competencies for Public Health Professionals in their continuing education programs. Healthy People 2030 also recommends expanding public health pipeline programs that include service and experiential opportunities.
The BHW also funds the Center for Workforce Research in Public Health (CWORPH), a consortium of 6 schools that supports public health workforce development. East Tennessee State University (ETSU) is included as a partner within CWORPH to conduct rural-focused studies and provide rural context and narrative across CWORPH work.
Where can I find public health datasets or information particular to my region or state?
Numerous public health datasets are available, but accessing local data for rural communities can be a challenge due to small numbers and insufficient sampling. This challenge is particularly problematic for survey-based datasets. RHIhub's Finding Statistics and Data Related to Rural Health topic guide discusses challenges and limitations of various data sources related to rural areas.
These CDC tools and databases are particularly useful to rural public health:
- Behavioral Risk Factor Surveillance System (BRFSS) is a telephone survey that collects data on health-related risk behaviors, chronic health conditions, and the use of preventive services.
- National Center for Health Statistics (NCHS) provides statistical information about the health of U.S. residents. Data is collected from birth and death records, medical records, interview surveys, and through direct physical exams and laboratory tests. Additionally, the NCHS Data Visualization Gallery provides interactive visuals illustrating trends in injury mortality, drug poisoning mortality, teen birth, and more. Each visual contains national-, state-, and county-level trends by age, sex, race, and ethnicity.
- Web-based Injury Statistics Query and Reporting System (WISQARS) is a database housing fatal and nonfatal injury, violent death, and cost of injury data.
- Wide-ranging Online Data for Epidemiologic Research (WONDER) manages multiple sets of public-use data for U.S. births, deaths, cancer diagnoses, tuberculosis cases, vaccinations, environmental exposures, population estimates, and other topics. Tables, maps, charts, and summary statistics are just a few features available to analyze the data.
Many state health departments offer health data resources or access to datasets and information. Local state or territorial health departments can provide more information.
RHIhub's State Guides, U.S. Territories and Commonwealths, and State-by-State Resources for Rural Health are starting points for reports, data, and resources on a wide range of topics for public health professionals. Additional county-level and rural-specific data on public health topics are included in Finding Statistics and Data Related to Rural Health and Data Sources and Tools Relevant to Rural Health.
Additional information may be available from these state-level organizations:
- State and Regional Public Health Associations
- State Offices of Rural Health and State Rural Health Associations
The National Health Security Preparedness Index and Trust for America's Health Ready or Not? 2017 report include state-by-state assessments of readiness for public health threats including natural disasters, infectious diseases, and man-made threats.
How can a public health department become accredited and what is the process?
The Public Health Accreditation Board (PHAB) evaluates the performance of a public health department against a set of nationally recognized practice and evidence-based standards. PHAB accreditation is a voluntary program to improve and protect the health of the public by increasing the quality and performance of tribal, state, local, and territorial public health governmental entities.
Public health departments interested in becoming accredited need to determine their eligibility and follow a seven-step process:
- Document Selection and Submission
- Review (Site Visit)
- Accreditation Decision
- Additional Reporting and Annual Reports
PHAB accreditation has a five tier graduated fee schedule based on the size of the population the public health department serves. Public health departments serving populations of 100,000 persons or fewer are classified as Category 1. As the population served by the public health department increases, so does the fee schedule. The cost of accreditation can be prohibitive or raise concerns for rural public health departments. PHAB can work with local public health departments to create an individualized payment plan.
It's Possible: Voluntary Accreditation for Rural Public Health Departments, a 2019 Rural Monitor article, describes the public health department accreditation process and provides tips and suggestions for rural public health departments seeking accreditation. Another 2019 Rural Monitor article, Understanding Rural Health Departments: Do They Have Unique Accreditation Needs?, discusses factors such as governance and organizational size that influence the ability of rural local health departments to achieve voluntary accreditation.
A 2018 article published in the Journal of Public Health Management and Practice, Public Health Agency Accreditation Among Rural Local Health Departments: Influencers and Barriers, found that significantly fewer LHDs located in rural (4.1%) or micropolitan (8.9%) areas were seeking accreditation compared to LHDs in urban areas (87.0%). The top three barriers rural LHDs reported to pursuing PHAB accreditation are:
- Time and effort required for accreditation application exceeds the benefits (88.0%)
- Fees for accreditation are too high (83.2%)
- Accreditation standards exceed the capacity of the LHD (50.5%)
NACCHO's Accreditation Support Initiatives (ASIs) provide funding and technical assistance to LHDs preparing for accreditation through PHAB. NACCHO's Project Public Health Ready (PPHR) program is a criteria-based training and recognition program that assesses the capacity and capability of LHDs to plan for, respond to, and recover from public health emergencies. PPHR can help LHDs prepare for PHAB accreditation.
How can rural public health professionals network and connect with their peers?
There are several ways to connect with peers interested in rural public health issues. One option would be to join the National Rural Health Association (NRHA) Public Health Constituency Group. The Public Health Constituency Group represents members interested in community-level policy development and advocacy to promote and improve access to healthcare services and a community's overall health status. Membership in NRHA is required to become a member of the interest group.
The Rural Health Section at NACCHO is another option. The Rural Health Section includes NACCHO members and partners working together across programmatic areas to develop a high-level strategy for advocacy, goal attainment, structural system requirements, resources, and approaches to improve rural health. NACCHO's Rural and Frontier Health programs also have community building initiatives aimed at connecting local public health leaders with similar needs and interests.
Another way to connect with like-minded peers is through the APHA Rural and Frontier Health Committee. Interested parties can contact the co-chair of the group, Cody Mullen, at firstname.lastname@example.org.
How can rural healthcare providers and public health departments work together to improve population health in their communities?
Long lasting improvements in population health will require the coordinated efforts of rural healthcare providers and public health departments. The Institute of Medicine (IOM) Committee on the Integration of Primary Care and Public Health 2012 report, Primary Care and Public Health: Exploring Integration to Improve Population Health, identified 5 principles that are essential for integration of primary care and public health:
- A shared goal of population health improvement
- Community engagement
- Aligned leadership
- Sharing and collaborative use of data and analysis
The IOM committee identified 3 strategies for successful primary care and public health integration efforts:
- Working together on specific health issues identified as an area of concern by the community
- Working with multiple groups and organizations to provide community health services
- Sharing and using data
In 2016, the National Quality Network developed a step-by-step community action guide, Improving Population Health by Working with Communities: Action Guide 3.0, that describes how to bring multiple community groups together, including rural healthcare providers and public health departments. The community action guide presents 10 key elements that communities, healthcare providers, and public health departments can use to identify and design initiatives that improve population health.
Rural healthcare providers and public health departments can also work together to perform a community needs assessment to understand the needs and resources in their community. For additional information on conducting community needs assessments, types of assessments, or Community Health Needs Assessments (CHNAs) requirements, see the Conducting Rural Health Research, Needs Assessment, and Program Evaluation topic guide.
Partnerships among public health, healthcare, and other community partners are essential for leveraging scarce resources to address community health challenges. NACCHO supports Mobilizing for Action through Planning and Partnerships (MAPP), a planning process to assist communities in identifying, addressing, and improving health concerns. MAPP works to address community health concerns through the application of strategic thinking that allows communities to prioritize public health issues and identify resources to address them. MAPP integrates data collected through community health assessments (CHAs) and Community Health Improvement Plans (CHIPs) to prioritize issues and develop community-wide action plans.
NACCHO's Toolbox is a collection of free tools and resources for public health. Planning guidance, tools, and templates specific to rural public health and their partners can be found by searching ”rural“ in the toolbox.
What federal agencies focus on public health in rural areas?
The Centers for Disease Control and Prevention (CDC) does not have a centralized rural office; however, the Office of the Associate Director for Policy and Strategy (OADPS) coordinates rural-relevant policy and programmatic efforts across the agency. In 2017, the agency published a series of articles centered on rural health in the Morbidity and Mortality Weekly Report (MMWR), CDC's flagship scientific journal. They have published a number of other rural-focused MMWR articles as well. Additionally, to help communicate what works to improve rural health, the CDC Center for Surveillance, Epidemiology, and Laboratory Services (CSELS), in collaboration with OADPS, created a section of the CDC website dedicated to rural health. Another CDC website, POLARIS, provides rural health policy briefs, featuring information and examples of policy options to address public health issues.
The Federal Office of Rural Health Policy (FORHP), located within the Health Resources and Services Administration (HRSA), is the federal office charged with promoting health and access to quality healthcare for rural residents. FORHP directs activities, policy work, and funding to rural healthcare issues. FORHP works to increase access to care and improve the delivery of healthcare services through multiple programs.
Other federal agencies also have programs that support public health in rural areas. The U.S. Department of Agriculture (USDA), through its Rural Development mission area, provides financial resources and support for rural communities, residents, and businesses. Rural Development funds water and waste disposal programs; community facilities, such as healthcare facilities, public safety services, and local food systems; and other programs that build infrastructure and address social determinants of health. USDA also funds local public health activities that promote food security within rural communities, such as Women, Infants, and Children (WIC) and the Supplemental Nutrition Assistance Program (SNAP), among others.
The U.S. Environmental Protection Agency (EPA) works to protect human health and the environment. Programs include ensuring clean air, land, and water in rural and urban areas.
The Office of National Drug Control Policy (ONDCP) coordinates national efforts to address substance use disorder (SUD) and oversee drug policy.
While not federal agencies, federal regional commissions and authorities, such as the Delta Regional Authority, Appalachian Regional Commission, and the Denali Commission are quasi-governmental partnerships between federal and the state governments of each region. While primarily economic development entities, they may fund health-focused initiatives to improve conditions in local communities, such as addressing the social determinants of health.
Is there funding for public health programs in rural communities?
At RHIhub we maintain a list of federal, state, and foundation funding opportunities for public health. Interested public health stakeholders can contact us at 800.270.1898 or email@example.com to request a list of funding opportunities specific to local projects and communities.
Last Reviewed: 1/11/2023