Flu-shot clinics; restaurant inspections; checkups for low-income mothers, infectious-disease contingency plans.
For the last 70 years, Pennsylvania has been encouraging counties to create health departments to provide such services, calling local agencies the best way to promote the health of state residents.
Democrats who are trying to gain council seats in traditionally Republican Delaware County for the first time in more than a generation are attempting to make an issue of the fact that the county doesn't have one, citing a recent study that rated Pennsylvania poorly for the well-being of African American and Latino youth.
Delaware is the only one among Philadelphia's collar counties without its own health department, but if it did decide to form one, it would be in the minority statewide. Despite state-grant incentives, only six of the 67 counties have health departments.
In effect Pennsylvania has regionalized public-health services in much of the state, stepping in to lead when communities do not have their own departments – similar to how the state provides police coverage for some towns.
Marianne Grace, the county's executive director, contends that establishing a department might be more trouble than it is worth. "Do we want to create something where we'll be relying more on the state [for funding]?" she said, noting the state's recent budgeting struggles.
The county does have a health advisory board, a Department of Intercommunity Health, which can make referrals, and specific health task forces, she said.
Unlike New Jersey, Pennsylvania does not mandate the creation of local health departments. Since the state fills in, many counties don't see the need to pay to establish new government agencies.
The counties that do have health departments – Bucks, Chester, Montgomery, Philadelphia, Allegheny, and Erie Counties — say local officials can better tailor health services to their communities' specific needs. These county departments and municipal ones in Allentown, Bethlehem, Wilkes-Barre, and York cover about 40 percent of the state's population.
Deciding on local control is more than just looking at population size, said Laura Hanen, interim executive director of the National Association of County and City Health Officials.
"It has to make sense based on the assets you have in your community," she said.
More than three-quarters of the 2,533 departments that the association surveyed last year are locally controlled. Some are outposts of state agencies. Some states, such as Pennsylvania, Maryland, and Virginia, have a mix.
In 2010 Delaware County paid Johns Hopkins University to look for gaps in its health services. The study recommended the county hire someone to coordinate public-health initiatives, increase funding for public health, and create a centralized system to distribute health information, which the county has done, Grace said. Johns Hopkins did not, she noted, recommend that the county create a health department.
"Whenever this question comes up," said John McBlain, a County Council member, "it really becomes a matter of form over substance."
In New Jersey, every town must be served by a local health department. Local boards of health can decide to form municipal departments, join with neighbors to form regional departments, or use a county department. New Jersey's diversity in population and geography means what works in one part of the state may not work in another, said Shereen Semple, director of the Office of Local Public Health at the New Jersey Department of Health.
Erie County is the least-populous Pennsylvania county that has a local department. It provides vaccines to many of the estimated 600 refugees who arrive each year, and coordinates programs to help expectant mothers stop smoking. About 20 percent of pregnant women smoke, and the program has helped save money on prenatal and postpartum care, said Melissa Lyon, director of the county's health department.
"We're very proud of the services we offer," said Lyon, whose department has an annual budget of $6.7 million. For every $1 the county spends, the return on investment for the county is $3.43, she said.
Around the time Delaware County commissioned its health study, Lehigh and Northampton Counties discussed forming a joint health department, another option for counties that the state encourages and one that local officials politicized. After more than two years of talking, officials abandoned the idea, which lays dormant just as it did after similar discussions in the late 1980s.
"We all work on tough budgets," said Tom Muller, Lehigh County executive. "We have difficulty trying to keep taxes down."
In 1968, Delaware County residents voted down the creation of a health department. That's the same year Chester County voters created theirs. When the issue came up again, voters in Chester County again voted in 1976 to keep their health department, which has a budget now of $10 million. The cost to the county after grants and fees is $1 million — $1.95 per resident, said Jeanne Casner, the county's health director.
Bucks County's health department formed after voters passed a referendum in 1953.
"Any county with a reasonable population — even if it's a small health department, it's worth the time and money to create it," said David Damsker, head of the Bucks County department. "I think that's still always going to be better than dealing with people who don't know your county."