Washington, DC, July 2, 2025 - The National Association of County and City Health Officials (NACCHO), the voice of over 3,300 local health departments across the country, released its 2024 Forces of Change Survey report that assesses changes in local health department capacity and activities driven by public health trends. The study explored key factors currently experienced by health departments at the county, city, and district level, including staffing and budget changes, health department governance, use of public health fellowship and training programs, the roles of public health nurses, program evaluation capacity, and activities that address the infectious disease consequences of substance use. 

The latest findings highlight critical trends and challenges faced by local health departments during a time of uncertainty in the local public health landscape. The Forces of Change Survey data show both point-in-time information, as well as longitudinal changes. The Survey results help explain the opportunities and challenges faced by local health departments. Key findings include:

Staffing and Budget Changes Over Time: The survey found that the number of local health departments losing staff through layoffs or attrition is continuing to rise, raising concerns about a shrinking public health safety net. In 2023, 19% of local health departments reported job losses—an increase from 14% in 2021 and 17% in 2022. The rate rises to nearly 40% among large local health departments. These reductions may reflect the winding down of temporary, contract-based pandemic staffing. Financial strain was also evident in the survey, with 17% of local health departments reporting budget cuts during fiscal year (FY) 2024, and 23% anticipating cuts in FY2025. While fewer departments ultimately saw FY2024 cuts than expected, the number forecasting FY2025 reductions increased over the prior year, indicating persistent uncertainty and vulnerability across the system.

Public Health Nursing: Nurses’ roles in local health departments are critical, and the report shows that their roles extend far beyond clinical and direct patient care. The top three areas of growth in the past five years were non-clinical: health promotion/protection, cross-sector collaboration and community engagement, and emergency preparedness. More than seven in 10 local health departments reported that nurses are involved in emergency preparedness and cross-sector collaboration functions, and more than four in 10 reported that nurses contribute to policy and advocacy work. The survey also reveals urban-rural differences, with more agencies serving rural jurisdictions reported having nurses working in WIC and substance use/tobacco prevention programs, while those serving urban jurisdictions reported having nurses working in refugee health programs.

Activities Targeting Infectious Disease Impacts of Substance Use: Local health departments remain critical entities in addressing the infectious disease impacts of substance use. In 2024, nearly 80% lead community education and outreach efforts, and over half distribute and train on naloxone use. Programs such as medications for opioid use disorder (MOUD) or safe supply programs are less common. In addition, 47% of local health departments reported having some role in decision-making related to opioid settlement fund spending, highlighting their potential influence in shaping local strategies to reduce overdose deaths and related harms.

Public Health Fellowship and Training Programs: Overall, few local health departments had individuals from training and fellowship programs assigned to their agency, which puts future workforce development at risk. Among those that did, the most frequently hosted programs were Public Health AmeriCorps and non-CDC fellowships, such as those sponsored by universities or state agencies. Barriers to hosting trainees were notable, with more than half of local health departments citing lack of supervisory capacity and one-third citing cost to support the trainee or lack of awareness of the programs. Nearly 70% noted insufficient funding to convert trainees into permanent staff, suggesting an ongoing gap between interest and capacity.

Evaluation Capacity: Local health departments are committed to evaluation, but they need greater resources and training to fully implement and sustain these efforts. In 2024, 84% of local health departments reported having programs with an evaluation component. While most incorporated evaluation into their work, nearly 60% reported challenges due to insufficient staff time or capacity. Among those conducting evaluations, 70% rely on internal staff or teams, underscoring the need for expanded resources and workforce development in this area to ensure local health departments can measure impact and improve performance.

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About the 2024 Forces of Change Survey  
For the 2024 survey, a total of 2,505 local health departments were included in the study population. Rhode Island was excluded from the study because the state health agency operates on behalf of local public health and has no sub-state units. A random sample of 1,200 local health departments were invited to complete the survey. NACCHO administered the survey from March to June 2024. Overall, the 2024 FOC survey had 667 local health departments respond, for a response rate of 56%. Deidentified data from the survey will be made publicly available through ICSPR’s data repository in late 2025. For access to prior years’ data and data use policies, please visit ICPSR. For more information about NACCHO’s FOC Survey, please visit www.naccho.org/forces.   

About NACCHO  
The National Association of County and City Health Officials (NACCHO) represents the over 3,300 local governmental health departments across the country. These city, county, metropolitan, district, and tribal departments work every day to protect and promote health and well-being for all people in their communities. For more information, visit www.naccho.org.