The COVID-19 pandemic has shown that the local public health system in Massachusetts is not adequately structured, staffed, or financed to meet large scale public health challenges. This action plan will accelerate improvements in the Massachusetts local health system, so that it is better prepared to meet future challenges. This proposal is based on the consensus findings and recommendation of the Special Commission on Local and Regional Health, including those now in statute as Chapter 72 of the Acts of 2020, An Act Relative to Strengthening the Local and Regional Public Health System (also known as the State Action for Public Health Excellence, or SAPHE, Act), signed by Governor Baker on April 29, 2020.

Local Public Health During COVID-19

Massachusetts local health departments have been on the front lines of our state’s response to the COVID-19 crisis, leading critical response efforts including:

• investigating suspected cases, making testing recommendations, tracing contacts, and recommending and enforcing quarantine and isolation;
• enforcing essential business orders & re-opening guidance and providing input to businesses on safe operating procedures; and
• coordinating with town officials, first responders, businesses and residents, and serving as a communications hub between local residents and state officials.

The Problem

The challenges our decentralized structure of 351 separate boards of health/local health departments face lead to inequities in public health protections across municipalities, but they also put the entire state at risk. Because viruses do not respect municipal borders, the extreme variability of protections provided across municipal health departments increases danger and harm to all communities.  Examples of challenges include:

• Lack of Funding and Staff: Because the state does not provide any categorical funding, local health departments compete with many other important local needs for scarce municipal funds. There are no minimum staffing requirements or mandatory training or credentials for local health officials, which contributes further to wide variability across municipalities.
• Lack of Access to Public Health Nursing: Many municipalities have no Public Health Nurse on staff, leaving them unprepared to conduct the core local public health nursing response functions for COVID-19, including contact tracing.
• Inconsistent Use of Massachusetts Virtual Epidemiologic Network (MAVEN): Prior to the pandemic, too many municipalities did not regularly use MAVEN, the state’s mandatory communicable disease surveillance program, used for case investigation, surveillance and contact tracing. In these towns, communicable diseases like COVID-19, measles, and Hepatitis A can spread unchecked, putting the larger community at risk.
• Inconsistent Enforcement: With hundreds of local health agents and board of health members interpreting business guidance and other state orders, interpretation and enforcement is not consistent across municipalities, leading to variable protections and uneven playing fields for businesses.
• Incomplete and Inconsistent Data Collection and Reporting: Health departments are responsible for a tremendous amount of data collection and reporting, which form the basis of sound decision making at the state and local level. However, there are neither incentives nor penalties from DPH for to reporting data or failure to report data, and much of the data that is reported is never tracked or reported by DPH. As a result, data on local public health activities and outcomes is incomplete and inconsistent.
• Unaddressed Health Inequities: Data suggest that Black and Latinx residents have contracted COVID-19 at a significantly higher rate than White residents. A system that relies solely on municipal funding for health departments too often results in weaker protections in housing, food, and water safety for residents of lower income communities and communities of color, putting their health at higher risk.

Proposal to Transform the Massachusetts Local Public Health System
Now is the time to move rapidly to transform our local public health system to adequately protect public health and safety during the remainder of the COVID-19 crisis and for future threats to public health. The goals for a stronger system have already been outlined in the consensus recommendations of the Special Commission on Local and Regional Health. In order to accelerate progress toward these goals, the state should move quickly to:

1. Adopt Universal Minimum Public Health Standards. The state should adopt a minimum set of public health standards, based on the Special Commission recommendations, to ensure that every resident benefits from a core set of public health protections. The need for this has never been more clear: no community is safe when some municipalities lack sufficient capabilities to control the spread of COVID-19 or other diseases. System improvements must be designed to improve equity for residents with low incomes and people of color that have been disproportionately impacted by COVID-19 and many other health conditions. Achieving these goals will require:

• Expanding Services through Cross-Jurisdictional Sharing: While some municipalities

may be able to meet new standards independently, many will need to increase cross-jurisdictional sharing to effectively and efficiently improve the quality of services. Municipalities should retain the ability choose for themselves whether to adopt such arrangements, and if so, with which surrounding communities.

• Ensuring a Qualified Workforce: All residents should be served by full-time, salaried, credentialed health agents and public health nurses. Minimum standards should include staffing and credentialing requirements consistent with the Special Commission recommendations and the SAPHE Act.

2. Establish Sustainable State Funding. To support these improvements, the state must establish direct funding for local public health to supplement ongoing local funding. Funding to local health departments should be allocated using a formula that includes population, total permit numbers, and sociodemographic data. This will account for variations among municipalities, such as communities with small populations but high tourism, municipalities with high levels of rental or substandard housing, and municipalities with large numbers of residents not on municipal water and sewer. This will also increase equity by investing in the local public health protections as a social determinant of health – that is, providing more funding to communities with residents who traditionally bear an inequitable burden of ill health and have less access to housing, wealth, education, and social capital. The funding formula should also incentivize sharing of services across municipalities, a system that is proven to lead to better public health outcomes in Massachusetts.