Improvements in the performance of local public health agencies.

Local health agencies in Iowa were surveyed in 1995 and 1997 to ascertain their performance in the areas of assessment, policy development, and assurance. Some improvements were noted in the assessment function. However, development of health plans and a policy agenda as well as evaluation of programs remain weak. Structural changes may be needed to increase the effectiveness of small, rural, public health agencies. Options discussed in this article include increases in funding, consolidation into districts, specialized training, a shift of responsibilities to the state level, and a merger with local hospitals.