Public Health

Unlike most states, Massachusetts primarily provides public health services on a municipal level rather than through a county or regional system. In fact, Massachusetts has more local health departments than any other U.S. state, even though it ranks 13th in the nation for population size and 44th in land mass.

Each local board of health is responsible for providing a comprehensive set of services defined by state laws and regulations. These boards are responsible for ensuring food safety, enforcing the state sanitary code, inspecting pools, food service establishments and summer camps, permitting all septic systems, preparing for public health emergencies, and responding to reportable communicable diseases.

As responsibilities increase, it becomes increasingly difficult for local board of health members, many of whom are volunteers, to adequately meet the statutory and regulatory requirements. The major benefit of regionalizing health services is better protection of the public’s health by employing trained professional staff who in turn limit a municipality’s legal liability exposure.

Regionalization has the potential to improve the way communities deliver public health services. Some of the primary benefits of establishing a shared services program include:

  • Ability to improve the scope and quality of services available to residents and achieve maximum impact with limited resources
  • Ability to afford more qualified, professional staff by pooling resources and expertise
  • Increased capacity to apply for grants and be more competitive in grant applications, bringing additional resources to their communities
  • Avoidance of municipal liability for health problems arising from unmet responsibilities
  • Empowerment of local boards of health to focus on administrative duties, such as policy making and guidance instead of service delivery and enforcement

Statutory Requirements

Local boards of health in Massachusetts are required by state statute (M.G.L. Chapter 111)and regulation to perform many essential duties to protect public health, including disease control, the promotion of sanitary living conditions, and protection of the environment from damage and pollution. Failure to perform these duties can expose residents to danger and a municipality to legal actions. See a comprehensive list of the laws and regulations relating to boards of health Manual of Laws and Regulations Relating to Boards of Health

Types of Agreements

Municipalities can regionalize or share health services using two different legal mechanisms in Massachusetts. Under M.G.L. Chapter 111, Sections 27A and B, cities and towns are authorized to share health agents and to form comprehensive health districts. These districts are separate legal entities that provide public health services to member communities.

Using the Commonwealth’s Inter-Municipal Agreement (IMA) Law, Massachusetts municipalities can opt to share some public health services without creating a comprehensive district, or to create a comprehensive shared department that is not a stand-alone district.

Extensive resources on regionalizing public health services are available in a Public Health District Planning Toolkit on the Boston University School of Public Health website. These draft IMAs, draft district bylaws, and tools for planning shared services.  See the Resources section below for this and other helpful information.


Toolkit for Shared Public Health Services Planning
Provided by the Boston University School of Public Health and the MA Public Health Regionalization Project’s Working Group.

Analysis of Regional Health District Statute (M.G.L. C.111, S.27A-C)
Provided by the Massachusetts Department of Revenue’s Technical Assistance Section.

Manual of Laws and Regulations Relating to Boards of Health
Provided by the Massachusetts Department of Public Health.

Shared Public Health in Massachusetts

There are more than 13 shared health service programs—established either through MGL Ch. 111, Sec. 27A-C or via Inter-municipal agreements—that serve 61 of the state’s 351 cities and towns. Shared public health programs in Massachusetts range in size from two to fifteen towns. Most of the shared health service programs include towns with fewer than 5,000 residents, and many include towns with fewer than 3,000 residents.

Comparison: Shared Public Health in Connecticut

The state of Connecticut has 20 formal health districts that include 109 of the state’s 169 towns.

They range in size from two towns to 17 towns, but most districts are quite large in terms of total population, amounting to around 100,000 residents per health district. There are few small towns with fewer than 5,000 residents that have not joined one of these larger districts. For example, the Torrington Area Health District serves 17 towns and one borough. Four of these towns have populations of fewer than 2,000 residents and five towns with populations between 2,000 and 5,000 residents.

Examples of Successful Municipal Agreements

Regional Health Districts (M.G.L. C.111, S.27A-C)

Quabbin Health District

The Quabbin Health District was established in 1980 to provide the communities of Belchertown, Ware and Pelham with the professional public health staff and services needed to create healthy communities. The district operates under a comprehensive district model, meaning all public health services are provided by one staff to all member towns.

Intermunicipal Agreements  (M.G.L. c.40, S.4A)

Northampton and Amherst are sharing a full-time health agent through an intermunicipal agreement. Under the agreement, Northampton pays the town of Amherst for half of the agent’s time, including benefits.

Melrose and Wakefield signed an intermunicipal agreement in 2009 to combine health department staff under the supervision of the Melrose Health Department Director. Reading later entered this partnership in 2011 with the Melrose Director assuming a supervisory and management role of Reading’s full-time health inspector, a part-time health inspector, a 30-hour a week nurse and a secretary.