Maine's Public Health System

Maine Public Health Association’s (MPHA) Public Health Infrastructure Member Section, with endorsement by the MPHA board and staff, has prepared this overview of Maine’s governmental public health system. The website’s purpose is to provide a brief orientation to public health and explain the history and current state of Maine’s governmental public health system, including its structure, operation, and funding. We provide an overview of Maine’s statutes and regulations, including who has what authority and responsibility to protect and improve public health. We also provide a  vision  for modernizing and innovating Maine’s governmental public health system so that all people in Maine have a fair, just, and equitable opportunity to achieve optimal health.

This website is intended to educate and inform anyone who is interested in, studying, or working in public health or a related field about the history and current state of Maine’s governmental public health system. It will be updated should there be changes to statute or legislation.

Public health promotes and protects the health of people and the communities where they live, learn, work and play  (American Public Health Association) .

Public health practitioners focus on the health of populations, rather than individuals, and achieve better health through organized partnerships with other health-oriented entities. These entities need to work together in a strategic and coordinated way to achieve short- and long-term results to protect and improve population health. Typically, governmental agencies coordinate these efforts. Other non-governmental sector partners may include healthcare, public safety, housing, transportation, land use planning, education, media, environmental health, philanthropy, community economic development, social services, and civic organizations.

In seeking to improve health outcomes and reduce health disparities, public health practitioners aim to improve determinants of health. These are factors in the environments in which people are born, live, work, play, worship, and age that affect a wide range of health and quality of life outcomes (such as water safety, economic opportunity, education quality, and other factors). Focusing on these determinants is widely supported by  research  showing that our zip code is a stronger predictor of our health status than our genetic code.

This “public health system” can be described as a network of these entities with differing roles, relationships, and interactions. All these entities contribute to the public’s health and well-being throughout the community. According to the  National Association of County and City Health Officials , public health systems are commonly defined as “all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction.” 

 For every $1 spent on evidence-based disease prevention programs we save $5.65 in health spending and get back $7.50 in economic output. 

While the public health system includes many different partners, some public health activities involve enforcement of laws, rules, and regulations, requiring governmental oversight. The authority to issue public health orders, establish fees and penalties, or otherwise enforce public health laws is limited to governmental public health agencies. This authority is conveyed in the United States and State of Maine Constitutions, as well as in the responsibilities set by Maine’s laws and regulations.

While some national resources and laws affect public health, most of the authority for public health activities resides at the state-level. Each state determines the state and local public health department authority for hiring, budgeting, and setting priorities.

In some states, such as Maine, the state public health agency is part of a larger “umbrella” health and human services department, whereas in others, it is a standalone department with cabinet-level leadership.

As separate nations, federally-recognized tribes may establish their own public health agencies, and partner with state and local public health entities for resources or technical services as they choose.

The Maine Center for Disease Control and Prevention (Maine CDC) is the state’s public health agency. Originally formed in 1888, it is now part of the Department of Health and Human Services (DHHS). Thus, the Maine CDC Director reports to the Commissioner of DHHS. The Maine State Legislature’s Joint Standing Committee on Health and Human Services has jurisdiction over matters concerning public health and health services. As such, the Committee may require reports and request other information from Maine CDC and Maine DHHS. 

In 2005, a state-initiated Public Health Workgroup (PHWG) was created to “implement a statewide community-based public health infrastructure that works hand in hand with the personal health care system.” In their  2007 report , the PHWG addresses the “Legislature’s charges and describes the public health infrastructure, administered through eight districts, that includes Local Health Officers, Comprehensive Community Health Coalitions, district offices of Maine CDC, District Coordinating Councils, and a Statewide Coordinating Council. The system, for the first time, links and coordinates local, sub-state, and state public health activities using existing resources more efficiently. This system also includes representation from and links to the state and county emergency preparedness system.”

The  Statewide Coordinating Council  (SCC), established in statute, is designed to be a representative, statewide body of public health stakeholders formed for collaborative public health planning and coordination. The SCC serves in an advisory capacity to Maine CDC, assisting in planning for and coordinating of the essential public health services to be provided to each public health district (see map  below ) and across Maine. 

In 2016, Maine CDC became accredited by the national  Public Health Accreditation Board .

Funding

Over time, Maine CDC has built its capacity for delivering public health services primarily by receiving federal grants, including block grants and competitive grant awards, as well as via the  Master Settlement Agreement , rather than other state funds. In general, total state financial support for public health is difficult to determine because the state’s budget is organized by funding source (e.g.,  Fund for a Healthy Maine ), not by department. Maine CDC’s budget requests are reviewed by DHHS, and the Governor’s Office before ultimately being considered by the Maine Legislature. Philanthropic awards to non-governmental public health partners are also leveraged to conduct public health work.

Historically, most local services have been provided by contracts with community organizations, such as community action programs, health care organizations, other non-profits, and municipalities. In the late 1980s, Maine CDC (then called the Bureau of Health) facilitated the development of community-based, healthy community coalitions. These coalitions were called for in Maine’s Healthy People 2000. In late 2001, a statewide system of community health coalitions called  Healthy Maine Partnerships  (HMPs) were formed to address tobacco, physical activity and nutrition; and, later, substance use prevention. The HMPs were formalized in  statute  in 2009 and served all municipalities in official hospital service areas. 

Regional Funding

Since 2008, the Maine CDC has consistently funded each district’s liaison position. State funding for DCC activities has varied over time, but currently DCCs do not receive any state funds. 

Early versions of community coalitions were funded with federal funding via Maine CDC and the Office of Substance Abuse. Upon receipt of the Master Settlement Agreement monies in 2000 (see above), state leaders agreed to dedicate the funds to tobacco prevention and control as well as other public health activities. Concurrently, Maine CDC braided a large heart health grant to use the statewide coalitions to also address physical activity and nutrition. The HMPs were supported by both the Fund for a Healthy Maine and federal grants obtained by the State until the initiative was discontinued in 2015. Community coalitions continue, funded with a combination of time-limited and project-specific philanthropic grants, federal grants, and State sub-contracts. 

The oldest part of Maine’s public health infrastructure is the establishment of  Local Health Officer s (LHOs). In 1885, the state legislature allowed municipalities to establish independent, local  Boards of Health  (BoH), which served in an advisory capacity to the LHO. Experiences in Maine during the pandemic influenza of 1918 resulted in several statutory changes. As part of these changes, the LHOs and BoHs came under the direct supervision of the Commissioner of the Maine Department of Health – now the Department of Health and Human Services. 

Today, LHOs are appointed by the officers of their municipality. The LHO works with Maine CDC District Liaisons, public health nurses, other LHOs, code enforcement officers, public safety officials, environmental health officials, and other regional and local public health professionals to protect community health. Each municipality is required by statute to designate an LHO; if one is not named, then either the municipality’s manager, first selectperson or chair of its council serves as the LHO. 

Maine law provides the legal duties of an LHO. LHOs generally have these primary job roles: overall health resource to the community; investigator, mediator, and/or problem-solver in the resolution of complaints; reports to and informs the Board of Selectman/City Council on the community's public health status; and reports to Maine CDC, on any perceived local public health threats.

Unlike most states, Maine does not have a full network of county or municipal health departments. There are two municipalities (Portland and Bangor) with their own independent health departments, which deliver a wide variety of public health services and are overseen by their city councils. Some municipalities may have a “health department” by hiring staff for specific programs – such as a school nurse or LHO – or may have a local Board of Health; but only Portland and Bangor have recognized city health departments. 

To modernize, innovate, and strengthen Maine’s public health infrastructure there needs to be: 

1. A sustained commitment to ensuring that all people in Maine have a fair, just, and equitable opportunity to achieve optimal health and to benefit from essential public health services.
2. Strategic and sustained coordination of Maine’s policies and assets to protect and improve health and reduce health disparities at the state systems level, with an emphasis on public health infrastructure and workforce development. 
3. Support for a regional approach to address public health, where local governments and community organizations are engaged and collaborate.
4. A balance between accountability for the use of state and federal funds and shared local and state ownership of decision-making.
5. Comprehensive emergency preparedness planning and resources for all regions and municipalities throughout the state to aid in the preparation for future public health emergencies.
6. A commitment to continue to innovate and advance public health practice and workforce development.

APHA's  "That's Public Health" Series 

The American Public Health Association has put together a  series  explaining public health. Check out a few of these videos and click on the link for more!

To learn more about how Maine CDC is structured, and which services and programs it offers, please visit the Maine CDC’s  About Us  and  Office and Divisions  webpages. The Maine DHHS  About Us  webpage offers similar information about how Maine DHHS is structured. A directory of LHO’s can be found  here .

Please note: As we describe, there are many partners in a functioning public health system, including hospitals, non-profit organizations, universities, and public safety. This overview does not capture those entities or their relationships to the governmental system. Subsequent briefs will expand on those partnerships and their influence on public health in Maine.