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The structure of public health agencies varies across counties and around the nation. Some are integrated into a single statewide structure, as is the case in South Carolina. In other parts of the country, local governments are obliged to establish local public health authorities that then work (with varying degrees of legal responsibility and budget support) with the state health authority. There are some states in which there is no identifiable local public health authority, with any services that exist coming from a single state agency that may have some regional offices.

While there is no absolute recipe for success, the Institute of Medicine’s 1988 report on public health suggested that we need, in any model, national leadership, state structure, and a local presence.