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?
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.
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
- 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
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:
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:
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
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
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
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:
CDC offers multiple resources for education and training, including:
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?
and Mortality Weekly Report
(MMWR) discusses the health of rural Americans, specifically how chronic diseases and
injuries affect rural populations compared to urban populations. According to the CDC’s coverage of leading
causes of death in rural America, 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
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
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.
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
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
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
Additional information may be available from these state-level organizations:
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
- 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
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%)
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.
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
Long lasting improvements in population health will require the coordinated efforts of rural healthcare
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
- 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) launched the Office of Rural Health (ORH) in the spring of 2023,
located in CDC's Public Health Infrastructure Center.
Previously, 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. 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
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.