Building strong public health capacity across the US

For the first time in the history of the U.S. response to public health emergencies, Congress and the Biden administration have the opportunity to break the feast and famine cycle of public health funding. In addition to pumping billions of needed dollars to public health agencies across the country to respond to the immediate COVID-19 pandemic emergency, there is hope that rather than abandoning interest in public health in a post-emergency period, we will see serious investments that will rebuild our public health system, so we are better positioned for meeting the challenges of the next pandemic, as well as the ongoing challenges we face, especially with regard to health equity.

This is reflected in the $7.66 billion in the American Rescue Plan Act devoted to the public health workforce, some $3 billion of which will be allocated for longer-term investments. And it is reflected in the House Energy and Commerce’s portion of the Build Back Better Act allocating $7 billion in no-year money for public health workforce and infrastructure and Sen. Patty Murray’s (D-Wash.) Public Health Infrastructure Saves Lives Act.

Recognizing that we have underinvested in public health is the first step. But we must also acknowledge that “build back better” in the case of public health means building back differently. Even where health departments have been relatively well funded, the response to the pandemic was inadequate, and the underlying inequities in communities across the country resulted in the tragic disparate impact of the pandemic. This means we cannot simply rebuild the existing public health infrastructure. We need to think differently not just about how public health is funded, but how it is structured at all levels — federal, state and local.

We can find the path forward if we are guided by certain principles. First, we must address the tremendous variance in capacity in state and local health departments across the nation. Where you live shouldn’t determine how well government protects you from pandemics or other health threats. Second, public health needs to regain the trust of their residents by building stronger partnerships with community organizations and representatives to establish priorities, driven by sound data provided by public health to help shape the restructuring and focus of a modernized public health agency. Finally, and most importantly, this rebuilding effort must be driven by a focus on equity. This is the core mission of public health: to assure that all in the communities we serve can lead the healthiest lives possible.

How do we get from these principles to the practical reality of public health agencies that can translate them into practice? There is now a broad consensus in the field of public health that all communities must be served by a public health system that has certain foundational capabilities ranging from strong assessment and surveillance to emergency preparedness and response and community partnerships. These are now being integrated into revised accreditation standards being developed by the Public Health Accreditation Board (PHAB), and both the Energy and Commerce bill and the Murray bill link this new funding to accreditation.

Moving in this direction will not happen by chance. As these new funds flow, the federal government must be more assertive in its expectations of state and local public health agencies. We have learned, painfully, how the entire nation is placed at risk when we have health departments spread across the country that don’t have these foundational capabilities. Federal officials must hold grant recipients accountable for achieving measurable standards. This can be achieved through a four-step process:

1) States (and their localities) must provide a detailed assessment of their current capacity to deliver on foundational capabilities and their strategies for closing any gaps — whether through building new systems, hiring new workers or sharing services across jurisdictions. This has already been done in some states, such as Ohio.

The federal government should fund this assessment, and it should be a condition of further infrastructure and workforce funding. 

2) The federal government must assure that funding reaches all public health agencies — tribal, state and local. The traditional federal focus on states works in those places with centralized public health systems. Most of the country has a decentralized system; the money should follow the need.

3) The federal government should guarantee multi-year funding so that states and localities will have confidence that hiring new personnel will be sustainable. This is already implied in the American Rescue Plan Act and in the pending reconciliation bill, but Congress and federal agencies must sustain these investments.

4) Independent accountability should be built into this funding. With sufficient federal funding, state and local health departments should be expected to achieve Public Health Accreditation Board accreditation within a certain period of time, with technical assistance provided to help to achieve this goal. 

The U.S. will always have a decentralized public health system. But that doesn’t mean the federal government, as the largest funder of public health in the U.S., should not maximize its investment by assuring that all Americans are protected equally from public health threats. 

Jeffrey Levi, PhD, is professor of health policy and management at the George Washington University.