By Joshua Franzel, Paula Sanford, Jessica Johnston, Eva Travers, Cory Fleming, and Andrea Fox

Globally, there is an increasing focus by local governments to incorporate health considerations into all aspects of their programs, policies, and operations. This is the case in a variety of environments, including those for which the organization with the primary public health responsibility exists outside of the general local government structure.

There are many reasons for this evolving alignment. From global and national perspectives, there has been an emphasis on better coordination by international development funders, national governments, and efforts geared toward the Millennium Development Goals and Sustainable Development Goals.

More locally, given public budget uncertainties and increases in service demands, local governments continue to look for ways to offer a wide-ranging portfolio of services in a cost-efficient manner, against the backdrop of increased devolution of responsibilities and the focus on overall local quality of life by residents, businesses, and regional stakeholders.

Also, economically, the focus on health in all local services highlights the continued connection between a population’s health and gains in knowledge and capital production,2 reductions in lost output due to non-communicable diseases,3 and ability to develop a dynamic, locally based labor force.

Communities around the world are experiencing major population growth as people move from rural areas to urban centers. According to the United Nations World Urbanization Prospects: The 2014 Revision Highlights, in 1950, 30 percent of the world’s population lived in an urban environment. By 2050, this proportion is projected to increase to 66 percent.

As urban centers go through this transformation today, it is informative to briefly look back on the urbanization of North American and Western European cities between 1890 and 1920. During this time frame, according to the U.S. Census, the United States went from having 35 percent of its overall population living in urban areas to 51 percent.

Given the increased urban populations of this time, water and sanitation networks were built out to reduce the spread of disease and provide dependable access to water—key components to maintaining public health and sustaining an adequate quality of life. It was at this time that urban reform movements were occurring, including those that emphasized professional city management, with the intent of effectively and equitably providing local services.

With advances in public health knowledge, by the mid-1900s, the profession of public health was well established and, in many jurisdictions, separate governance and funding structures were established to begin or continue to provide core local public health services such as disease and environmental health surveillance, immunizations, and vital health records, among many others. These are the core public health goals offered at the local (and state) levels, often segmented from general local government services.

As urbanization continues, much of it in developing economies, many of those responsible for the administration of local programs and infrastructure assets are reassessing how these services can be structured, not only to achieve direct aims, but also to support the broader development of healthier communities.

ICMA Research Examines Global Efforts

ICMA recently published the report Improving Quality of Life: The Effect of Aligning Local Service Delivery and Public Health Goals4 that examines the role of local governments from around the world to support public health.5 The content offered in this section comes from this report. Because many of the services local governments provide are similar—planning, water, and roads–officials can learn not only from nearby jurisdictions, but also from those across an ocean.

The research also considered how local governments are collaborating to advance public health and the outcomes of those partnerships. Through better appreciation of the successes, challenges, and innovations local governments face when providing services, perhaps community health gains can be realized.

When thinking about local service delivery and public health on a global scale, the importance of governmental structure becomes quite evident. For it is the roles, responsibilities, and resource options that the national, state, and provincial governments assign to local governments that enable the latter to impact public health.

Australia, for example, has a strong state governmental structure, leaving local governments with far less authority to manage services as compared to cities and counties in the United States. Australian states, not local governments, provide public safety services, so Australian cities have less influence on some aspects of public health.

In Great Britain, local governments provide a complete cadre of local services. Yet they are also subject to following national policies in many service areas and rely heavily on national transfers. This level of dependence will naturally impact how services are provided and their outcomes.

In India, local governments have substantial authority over how several services can be provided, some of which are even designated in the country’s constitution, but may lack resources and management capacity from which to address such public health needs as clean water and sanitation.

These countries provide an interesting contrast to the United States, where, through home rule authority and tradition, local governments generally have more autonomy to implement a variety of services, but must pay for those services through own-source revenues.

Toward Greater Collaboration

Authority and organizational structures can also serve to enable or hinder collaboration between general-purpose local governments and public health departments. Improving coordination and collaboration between public health and local government was an objective when the United Kingdom’s National Health Service transferred responsibility for public health to local county councils in 2013.

Funding for health care comes from the national government. Local health and well-being boards allocate funding based on their respective community’s health needs and priorities and national policy direction.

An important component of this devolution is that the boards can assign funding to programs apart from treatment, as long as a strong link can be shown between the program and the improving community health outreach programs to promote physical activity.

This flexibility provides opportunities for local health teams to work and coordinate with other county departments or local districts within a county and to develop collaborative arrangements.

In contrast, provincial governments in Canada fund and develop policy direction for health care. As a result, public health collaborations involving cities are typically initiated by the higher level of government.

Likewise, cities needing expertise in health policy may seek assistance from the private sector, including hiring an adviser to help integrate health components into a comprehensive plan since that expertise may not be available within the government.

Collaboration between public health departments and local governments in the United States is as varied as the public health systems themselves; public health began through a combination of local initiatives and states directing local governments—primarily counties—to collect public health data.

As a result, public health is funded and managed through various models across the country. Twenty-eight percent of states provide public health services directly while in 37 percent of states, local or regional health departments provide this service.6

In 35 percent of states, local governments and their state government share responsibility for funding public health services. To the degree the city or county manager oversees the health department, collaboration between that department and another general government service should be easier.

Core Health Challenges

Beyond prevention of such chronic diseases as diabetes and hypertension that are often caused by obesity and lack of physical activity, localities also have other core health challenges to help solve. Local governments in England, for example, are working to reduce the problem of inadequate housing. The country has the oldest housing stock in Europe and in 2014, one in five homes were classified as “nondecent.”7

In Australia, cities are working to address climate change as this country is expected to face extreme drought, sea level rise for coastal communities, and intense rainfall and storms. Responses include reducing carbon emissions and promoting solar energy, stormwater investments, expanding tree canopy, and public education.

In lower-income countries and those with emerging economies like India, cities continue to struggle to supply safe drinking water to residents, particularly in quickly urbanizing areas. These urbanizing cities are also facing alarmingly high incidents of traffic fatalities as infrastructure is inadequate to accommodate the ever increasing number of cars, pedestrians, and cyclists.

Even with these variations in public health priorities, solutions and local programs are transferrable across jurisdictions. To improve traffic safety in developing countries, advocates are recommending local governments adopt a “safe system” approach to street design.

Safe systems include several of the components applied to the “complete streets” concept that promotes such physical activity as traffic-calming measures and networks for bicycles, sidewalks, and mixed-used development. When local governments in different countries have similar health concerns, like obesity in children, public education and outreach programs could be successfully transplanted.

Across the U.S., parks and recreation departments are partnering with health departments and pediatricians to offer “park prescriptions” to highlight the need for physical activity for overweight or obese children. The pediatrician gives the parent or guardian a “prescription” to encourage the child to exercise at a local park or participate in a public sport program.8

The park and recreation department may also offer scholarships for low-income children. This outreach effort could be adopted in other countries like England or Canada where physical inactivity is also a problem.

Collecting Public Health Data

In order to improve outcomes, officials are beginning to fully appreciate how important it is to analyze the impact that local government services and programs have on public health, as well as to adopt evidence-based solutions to public health problems. One analytical tool growing in importance is the health impact assessment (HIA), which involves applying both quantitative and qualitative components to best understand the impact a policy or program will have on public health.

HIAs have been used in Europe and Australia for several years and more than 400 have been completed in the United States. Common examples for undertaking an HIA are altering public transit routes and fares, park development, comprehensive planning, and freeway expansions.9

The basis for effective analysis and evidence is data. Without quality data, it is difficult to fully understand the health impact of public policies or health interventions. Unfortunately, public health data can be resource-intensive to gather.

In the U.S., public health data is usually collected at the county level or for larger cities, which makes analysis for a neighborhood or small city challenging. To promote evidence-based decision making, Australia has undertaken a massive data synthetization effort with the Australian Urban Research Infrastructure Network (AURIN).10 This online portal integrates more than 1,000 databases from 35 data sources for health, infrastructure, transportation, energy, and water.

The WHO Health Economic Assessment Tool (HEAT) is another online tool for European countries to conduct economic analysis of the health benefits from walking or bicycling.11 HEAT results can be used to better understand the economic impact from different kinds of infrastructure investments. These innovative analysis tools demonstrate effective ways data can be used to inform local officials and improve health outcomes.

Local government services, from public safety to water, sanitation, planning, parks, infrastructure and transit, all impact public health. Through the sharing of ideas, officials can improve the quality of life for their community and their neighbors around the world.

ICMA Enhances Service Delivery

In many local governments, the responsibility for community public health is experienced through the provision of services. Effectively run waste management, stormwater, and drinking water systems are critical to the health of a community, and essential elements in a city that residents want to call home.

Globally, ICMA has worked to increase the capabilities of local governments to effectively deliver services. Here are examples:

Water resource management in Shimla, India. Located in the Western Himalayas, Shimla, India, plays a critical role in the water and natural resource management of the region. Beyond the local and regional importance of this area, the Himalayan mountain range provides water to 40 percent of the world population, making it a focal point of climate change and water resource management.

Through ICMA’s USAID-funded CityLinks ( program, Shimla, India, and Boulder, Colorado, are partnering to help Shimla address water resource management constraints in light of future climate change impacts.

In addition to the challenges of adapting to climate change, Shimla is facing a rapid increase in its population that has put further stress on the water sector. Shimla, currently, cannot deliver water to municipal customers on a 24/7 basis, and the water that has been delivered has had levels of contamination that resulted in hepatitis and jaundice outbreaks.

To address the nexus of health, water, and climate change, Boulder has been working with Shimla to:

  • Develop a water conservation outreach campaign.
  • Address water loss and consider water conservation as equally important to water storage.
  • Make water quality a central focus addressing good housekeeping, security, and technology investments.
  • Focus on climate adaptation strategies.

Boulder will prepare a full report to complement work done in conjunction with the Urban Climate Change Research Network ( that addresses future climate impacts on Shimla’s water sector.

These reports will be used by the Municipal Corporation in Shimla to help justify future investments, along with policy and planning decisions to protect water resources from contamination and impacts of climate change.

Waste management and recycling in Kakheti and Adjara, Georgia. For the past two years, ICMA has been providing technical assistance to the government of Georgia in designing adequate waste management and recycling systems in the Kakheti and Adjara regions through the USAID-funded Waste Management Technologies in Regions project12 (WMTR).

Designed as a CityLinks associate award, WMTR has also been focusing its work on increasing public awareness of services offered by the local government and promoting best practices for waste disposal to minimize waste and its negative impacts on environment and public health.

Georgia has 65 uncontrolled landfills that fail to comply with international standards, not including numerous rural dumpsites along rivers and residential areas. Current landfill management practices offer no methane capture or waste-based energy production resulting in greenhouse gas emissions into the atmosphere.

WMTR is tackling the problems of waste and pollution on several levels, working with the communities, private sector representatives, municipalities, as well as at the ministry level.

Examples of WMTR’s recent collaborations with the Ministry of Environment and Natural Resources Protection of Georgia include drafting bylaws on the construction, operation, closure, and after-care of landfills; as well on the collection and treatment of municipal waste.

The new legislation establishes procedures and sets the requirements for the mandatory effective collection services at all municipal waste generators. It is aimed at minimizing the impact on the environment and the risks to human health related to the effects of waste on local surface water, groundwater, soil and air, including global environmental effects through mitigation of climate change-related emissions.

ICMA is also working with Georgian municipalities to establish an appropriate fee for waste collection and disposal services to ensure a financially sustainable system, through WMTR-designed city-to-city partnerships. At present, under WMTR Telavi, Georgia, and Catawba County, North Carolina, collaboration activity, WMTR is implementing an optimization of waste collection routing.

Working with schools and local communities, the program is educating the public on the effective and appropriate waste systems and practices for composting; recycling; and disposal of medical, hazardous, and construction waste.

Administrative efficiencies in local health departments. Working with the Center for Sharing Public Health Services (CSPHS) at the Kansas Health Institute, in 2014, ICMA conducted a national study of the types of shared services arrangements for administrative services that exist among local government public health offices.13

Findings from the study’s national survey showed: 64 percent of public health agencies share administrative functions with another agency; 67 percent that share services were able to realize new efficiencies as a result of their shared arrangement, for example, having a greater pool of knowledge; 88 percent would recommend a shared services arrangement to other local governments; and of those not sharing, the main reason given is that they haven’t considered it.

The study also included three case studies that illustrated the use of these shared administrative service agreements:

  • Prowers County Public Health and Environment and Kiowa County Public Health, Colorado. An interjurisdictional contract between two counties, wherein one county provides administrative services for both.
  • Eastern Highlands Health District, Connecticut. A regional public health district formed by 10 towns, the largest of which provides many administrative services through a long-term agreement.
  • Pennyrile District Health Department, Kentucky. A five-county district that provides all administration and program services.
Endnotes and Resources
5 This report includes a review of existing research, a series of expert interviews, and analysis of global examples.
6 Hyde, J. and S. Shortell, “The Structure and Organization of Local and State Public Health Agencies in the U.S., A Systematic Review,” American Journal of Preventative Medicine, 2012 (42:5S1): S29–S41.
7 Department for Communities and Local Government, English Housing Survey: Headline Report 2014 to 2015 (February 2016).
8 National Recreation and Parks Association, Parks Build Healthy Communities: Success Stories (Ashburn, VA: National Recreation and Parks Association).
9 Interview with Anna Ricklin, American Planning Association, on February 11, 2016.
10 For more information, go to:
11 For more information, go to:
12 For more information, go to:


Joshua Franzel is president/chief executive officer, Center for State and Local Government Excellence, Washington, D.C. ( Paula Sanford is public service and outreach faculty member, Carl Vinson Institute of Government, University of Georgia, Athens, Georgia ( Jessica Johnston is senior program manager, ICMA, Washington, D.C. ( Eva Travers is senior program manager, ICMA ( Cory Felming is senior technical specialist and program director, ICMA ( Andrea Fox is deputy director, Global Programs, ICMA (


Report Issued in 2016

This article reflects content that was offered during ICMA’s World Bank/International Monetary Fund Civil Society Policy Forum session, ‘‘Local Governments and Public Health: Coordinating to Improve Quality of Life and Achieve Sustainable Community and Economic Growth,” held on April 13, 2016, in Washington, D.C.

In June 2016, ICMA released the research report Improving Quality of Life: The Effect of Aligning Local Service Delivery and Public Health Goals that can be found at

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