Libraries, universities and even zoos have national accreditation standards they must meet. But public health departments -- the very agencies that oversee disease outbreaks and the sanitation of restaurants and drinking water -- don't. 

There is, however, a movement to change that.

A national accreditation board for state and local public health departments was officially formed in 2011, but the process is currently voluntary. Since then, 96 agencies across the country (out of 2,615) have received accreditation, with an additional 253 in the process. If all 253 attain accreditation, that still only makes 13 percent.

Some states, like Illinois and New York, have started encouraging their local public health departments to get accredited. Ohio, though, is one of the first states to make it mandatory. A law passed in 2013 requires all local public health departments to get accreditation by 2020. If they don't, they'll lose state and federal funding.

“Our system of health departments is incredibly diverse," said Rick Hodges, director of the Ohio Department of Health. "So the legislature and state health department decided that accrediting our health departments was the most basic standard we could give to Ohioans to make sure they are safe."

A big chunk of the accreditation requirements are that departments have strategic plans for potential public health problems. This includes identifying the health issues within the particular community and how they could be better addressed, the presence of a 24/7 contact line and written protocols. 

The idea for a national public health accreditation board was born in 2005 when the Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson Foundation teamed up to create one. Kaye Bender, president of the Public Health Accreditation Board, said they recognized a void and filled it.

“I’ve worked in public health for more than 30 years, mostly in hospitals, so I was very surprised when I learned that public health departments didn’t have any sort of national accreditation process. When we looked into why not, the only thing we could find was political will. There just didn’t seem to be motivation there to get this practice standardized. We are lucky we had the backing of the CDC and Robert Wood Johnson Foundation."

  At the Oklahoma Department of Health, one of the first state departments to get accredited, the process forced them to review every policy and procedure.

“We found some policies were terribly outdated and needed to be thrown out and policies that were still appropriate but needed a bit of updating,” said Terry Cline, director of the Oklahoma Department of Health. “I don’t know when we would have ever addressed those things if we didn’t go through the accreditation process. In doing that, you learn quickly that you’re not as cutting edge as you think you are.”

But getting accredited isn’t easy.

Bender says it can take up to 18 months and be considered costly. Accreditation fees range from $12,720 to $95,400 -- depending on the number of people the department serves. Most local health departments serve less than 25,000 people and tend to have fewer financial and personnel resources than departments that are larger and/or state-run. The fees are mostly administrative, paying for a specialist, a site visit of peer review experts and support for re-accreditation, which must happen every five years.

Surveys show that limited staff, staff turnover and fees are the biggest barriers to national accreditation. 

In the meantime, at least a couple of other states have taken matters into their own hands. North Carolina has a statewide standard that local health departments have been held accountable to since 2005. And like Ohio, Florida requires its local departments to attain national accreditation. But the state's system is centralized, with all local offices working as branches of the state Department of Health, which was accredited in 2014.

In Ohio, some have complained about the cost, but Hodges is confident that all departments can meet the 2020 deadline. That's because a few smaller departments in less wealthy areas have already earned accreditation, which Hodges says should serve as proof that the rest of the state can comply.

“Becoming an accredited health department is not simply of measurement of service," he said. "It’s a matter of strategic planning -- really showing you can plan for anything," he said.

*This story has been updated with information about Florida and North Carolina's accreditation policies.