A county legislative authority is charged with establishing either a county health department or a health district to assure the public's health. Local health departments and health districts can take various forms and include a single county health department or district, a combined city and county health department, or a health district of several counties.

Each local public health jurisdiction is governed by a local board of health (Board). Board membership requirements for home rule charter and noncharter counties must include county commissioners or representatives from the county legislative authority and unelected members from the following three categories that must be approved by a majority vote of the board of county commissioners:

• public health practitioners, employees of health care facilities, and health care providers;
• consumers of public health, which includes residents who have self-identified as having faced significant health inequities or as having lived experiences with public health-related programs; and
• other community stakeholders, persons representing various organizations, including active, reserve, or retired armed services members, community-based or nonprofit organizations that work with populations experiencing health inequities in the county; the business community; or the environmental public health regulated community.

If the number of Board members selected from these three categories is evenly divisible by three, there must be an equal number of members selected from each of the three categories. If there are one or two members over the nearest multiple of three, those members may be selected from any of the three categories. If the Board demonstrates it attempted to recruit members from all three categories and was unable to do so, the Board may select members only from the other two categories. There may be no more than one member selected from one type of background or position.

If a federally recognized Indian tribe holds reservation, trust lands, or has usual and accustomed areas within the county, or if a 501(c)(3) organization registered in Washington that serves American Indian and Alaska Native people and provides services within the county, the Board must include a tribal representative selected by the American Indian Health Commission.

The legislative authority or board of county commissioners may, at its discretion, adopt an ordinance expanding the size and composition of a Board to include additional members, including elected officials from cities and towns and persons other than elected officials as members, so long as the number of members from the three categories and tribal members is equal to the number of elected officials on the Board.

Each county has a Board that is coextensive with the county, unless the county has opted to create a health district (district) on its own or in conjunction with one or more other counties.  A single-county or multi-county district board of health operates in a similar manner and has a similar governing and membership structure to a Board.

If a federally recognized Indian tribe holds reservation or trust lands, or if an Urban Indian Organization (organization) recognized by the Indian Health Service and registered as a 501(c)(3) organization in Washington that serves American Indian and Alaska Native people providing services within the county, the Board must allow a tribal representative from each tribe and each organization.

The tribal representative must be selected by the tribe or organization, and the county must notify the American Indian Health Commission. 

If a tribal representative is added to a Board, the county commissioners or county legislative authority must modify the membership of the Board:

• in compliance with timelines established by the State Board of Health in rule, once the rules go into effect; and
• until the rules go into effect, within 60 days of receipt of notice of the selection of a tribal representative.

The State Board of Health must adopt rules establishing timelines for modifying the membership of a Board as required by statute.  The rules must go into effect no later than one year after the effective date of the bill.