What role do county commissioners play in the creation and operation of local public health agencies?

North Carolina law requires counties to provide public health services to their residents. County commissioners take several actions to ensure that this happens:

• Selection of agency type: Commissioners are key players in the selection of the type of local public health agency. In all counties, the commissioners may choose to operate a county health department or jointly resolve with the local board of health to join a district health department or form a public health authority. If the county meets a certain population threshold (currently 425,000),[1] the commissioners may choose to operate a consolidated human services agency, in which public health, mental health, and social services are provided by a single agency.
• Appointment of board: County commissioners make appointments to the local public health board. The board of county commissioners appoints all the members of a county board of health, a single-county public health authority board, or a consolidated human services board. The boards of district health departments or multi-county public health authorities are appointed somewhat differently: the board of county commissioners of each participating county appoints one county commissioner to the health board, and then those commissioners appoint all the remaining members. Finally, in counties that meet a population threshold (presently 425,000), the county commissioners may serve as the local board of health.
• Approval of budget or budget request: County commissioners approve the budgets of local public health agencies that are county departments. If the county participates in a public health authority or district health department, the commissioners may be involved in approving budget requests or providing funding to the agency but it is not required.