By Zuhaib Haleem, MPH, Amber Uskali, MPH, and Christina Welter, DrPH, MPH, University of Illinois Chicago School of Public Health: Policy, Practice and Prevention Research Center; Adam Forker, MPH, Executive Director DuPage County Health Department, Monica Hendrickson, MPH, PH Administrator Peoria City/County Health Department, Chris Hoff, Executive Director Lake County Health Department, Amanda Mehl, RN, MPH, PH Administrator Boone County Health Department, Molly Peters, B.S., L.E.H.P, PH Administrator Greene County Health Department, and Jeff Workman, Administrator Clay County Health Department (Illinois Association of Public Health Administrators)
The Role of SACCHOs and SALBOHs
Across states, there isn’t a single way local public health is organized, but there are some common patterns in how it functions. One of the clearest is this: when there’s a strong, formal way for local agencies to work together, things tend to run more smoothly. When there isn’t, the system still works, but it feels more fragmented than it needs to be.
That’s where State Associations of County and City Health Officials (SACCHOs) and State Associations of Local Boards of Health (SALBOHs) come in. They’re not always highly visible, and in some states, they barely exist. But where they are active, they tend to sit right in the middle of everything, connecting local health departments to one another, state agencies, and policymakers.
Insights from Illinois
In Illinois, that kind of structure is currently limited. The SACCHO’s role is nested within another organization and is led by one person on top of other responsibilities, and a previously active SALBOH has dissolved. That doesn’t mean coordination isn’t happening, but it does mean there isn’t a dedicated space for it.
In Spring, 2025, the Illinois Association of Public Health Administrators launched a workgroup of six local health department Executive Directors across the state and the University of Illinois-Chicago School of Public Health Policy, Practice and Prevention Research Center to explore benefits and approaches to a paid SACCHO and establishing a SALBOH. Over the course of the next few months, we connected with SACCHO and SALBOH leaders across 14 states to deepen our understanding of how these associations operate, with the aim of strengthening local public health in Illinois. What we saw in other states helps put that into perspective.
Coordination Without Duplication
One of the most consistent themes across interviews was how much these associations function as a central point of contact. Not in a formal way, but more so in that they become the place people go when they need to figure something out. That might be a policy question, a funding issue, or just trying to understand how other jurisdictions are handling the same challenge.
Without that kind of structure, local health departments often end up working in parallel rather than together. People described situations in which multiple agencies were developing similar tools or approaches without realizing it. The work still gets done, but there’s more duplication, and it takes longer to get to a shared understanding of what’s working.
Things look a bit different when an association has paid staff, including a full-time executive director, rather than a volunteer-led model. Instead of separate efforts, there’s a mechanism to bring information together, compare experiences, and move more quickly toward alignment. That doesn’t mean every jurisdiction does the same thing, but it does mean decisions are made with a clearer sense of what others are seeing.
A Collective Voice for Public Health
Advocacy came up in almost every conversation, but not in a theoretical way. It was usually described in terms of access and scale. Individual health departments can and do engage with legislators, but their reach is limited. Associations change that by pulling together shared priorities and presenting them collectively.
“…together, collectively, [we] have more power to get things done, to share resources so we’re not duplicating, to advocate for things, to make sure that [our] voice is heard…” – SACCHO Executive Director
In a few states, that collective approach has led to measurable outcomes: policy changes, increased funding, or movement on issues that had stalled for years. Medicaid expansion was one example that came up, along with environmental health efforts and smoke-free policies. The common thread wasn’t the specific issue, but the ability to show that the concern wasn’t isolated to one place.
At the same time, several people pointed out that associations not only amplify voices but also help filter and organize them. State agencies often don’t have the capacity to engage deeply with every local jurisdiction on every issue. Having a single group that can gather input, identify patterns, and communicate back in a structured way makes that process more manageable on both sides.
What the Pandemic Revealed
That role became more visible during the COVID-19 pandemic. In many states, associations shifted quickly into a coordination function. They collected feedback from local health departments, shared updates, and helped interpret rapidly changing guidance. In some cases, they met multiple times a week just to keep information flowing.
What stood out wasn’t just the frequency of communication, but how it was structured. Instead of dozens of separate conversations happening at once, there was a more organized exchange. Local concerns could be raised, compared, and brought forward with greater clarity. Information coming from the state could be distributed more consistently. It reduced some of the noise, even if it didn’t eliminate the uncertainty.
“There’s no major state decision that doesn’t come to us at this point… it’s been a long time since we’ve been blindsided with new information.” – SACCHO Executive Director
Workforce Development and Peer Learning
Outside of emergency response, a lot of the work is less visible but still important. Training and workforce support came up frequently. Associations often organize conferences, provide professional development, and create spaces for peer learning. For newer staff or board members, that can be one of the only places to get oriented to how the system works beyond their own jurisdiction.
Funding
Another piece is grant management. In several states, associations act as intermediaries, receiving grants and distributing them to local health departments. That arrangement can simplify things, especially for smaller agencies that don’t have the administrative capacity to manage large or complex funding streams on their own.
“We’ve been able to successfully advocate for funds in a lot of different areas… We were successfully able to advocate for more funding for the Local Public Health Grant.” – SACCHO Executive Director
Different Structures, Shared Functions
What’s notable is how different these associations look across states. Some are fully staffed organizations with multiple employees and significant budgets. Others operate with minimal staff or rely heavily on volunteer leadership. Legal structures vary as well, from 501(c)(3) nonprofits to 501(c)(6) associations, or arrangements where the association is housed within a larger organization.
Those differences matter, particularly when it comes to funding and advocacy. Some structures make it easier to receive grants. Others allow more flexibility in policy work. In a few cases, associations are exploring hybrid models to balance those needs. There isn’t a single approach that stands out as the best model. Most have evolved based on what was available at the time: funding opportunities, leadership capacity, or existing partnerships.
That also means sustainability can be a challenge. Several associations described periods when funding dropped off, or staffing was reduced, and the work had to be carried out by volunteers. In some cases, that led to scaling back activities. In others, it led to more creative approaches to maintaining operations.
Establishing Future SACCHOs and SALBOHs
For states thinking about building or rebuilding this kind of structure, those experiences are instructive. The starting point isn’t just deciding to create an association. It’s figuring out what functions are most needed and how they can be supported over time.
What comes through most clearly is that these associations don’t replace local health departments or state agencies. They sit in between, making it easier for both sides to do their work. When that layer is missing, the system still operates, but with more friction, more duplication, and fewer opportunities to act collectively.
Indeed, the Ethiopian proverb rings true: “When spiders unite, they can tie up a lion.” Public health can build its power and align its voice with stronger unity and resources through SACCHOs and SALBOHs.