Since 2001, the US federal government has invested more than $9 billion to develop public health emergency preparedness (PHEP) and response capabilities in state and local health departments to prepare for large-scale emergencies.1 This investment has led to the development and testing of new emergency plans and procedures, purchasing of supplies and equipment, hiring of additional staff, and training of existing personnel to assume new roles and responsibilities when significant threats to public health occur. In addition, Congress granted funds through the 2009 Supplemental Appropriations Act for the Public Health and Social Services Emergency Fund to address specific emergencies. The Centers for Disease Control and Prevention (CDC) administered $1.4 billion to state and local health departments through the Public Health Emergency Response (PHER) grant to assist with influenza preparedness and response capacity during the 2009 H1N1 pandemic.2
In this context, a working group of representatives from federal, state, and local public health organizations was formed to jointly address challenges faced by state and local health departments in the administration of emergency preparedness (EP) funds granted by the Department of Health and Human Services. As a first task, the working group defined “administrative preparedness” as
the process of ensuring that fiscal and administrative authorities and practices that govern funding, procurement, contracting, hiring, and legal capabilities necessary to mitigate, respond, and recover from public health threats and emergencies can be accelerated, modified, streamlined, and accountably managed at all levels of government.
Once administrative preparedness was defined, the working group identified the need to investigate the barriers experienced by state and local public health officials in the administration of EP Department of Health and Human Services funds. This included the administration of annually appropriated preparedness funding, such as CDC's PHEP, the Assistant Secretary for Preparedness Response's Hospital Preparedness Program, and contingent emergency response funding, such as CDC's PHER grant.
A qualitative approach was employed to identify both barriers and practices from the field that state and local health departments face in the administration of EP funds. During March and April 2012, telephone interviews were conducted with 79 public health officials representing 13 state health departments and 36 local health departments across 14 states. These health departments represented states and counties with a high frequency of emergency declarations as reported by the Federal Emergency Management Agency and included different types of state and local governance (ie, local, state, mixed, or shared), jurisdiction (eg, city, town, county), and population size served by the agency.3 Public health officials were asked semistructured questions that focused on 5 domains of administrative preparedness derived from the definition given earlier: (1) accepting; (2) allocating; (3) spending; (4) monitoring; and (5) reporting (Figure). Interviewees reported on the administrative barriers encountered during the implementation of routine PHEP activities and emergency response activities.
The content analysis of the interview transcripts identified 755 informative statements describing barriers and practices from the field in the administration of EP funding. Most of the statements were related to challenges in allocation and spending efforts, indicating that these are areas of major administrative burden. The common challenges in the 5 domains of administrative preparedness are outlined below.
Accepting and Allocating
Respondents reported that the time frames and the complexity of the grant process were barriers to efficiently responding to a funding opportunity announcement. A time frame of less than 60 days is insufficient, especially for larger states with local governance where work plans from numerous local entities need to be incorporated prior to submission.
Some states reported that once the notice of award is received, they need to obtain legislative approval in order to use the funds, and that in some instances the legislative calendar may not be optimally aligned within the time frame that the funding is received. For many of the local health departments, a county or city commissioner or a board of supervisors is responsible for approving the funding before they can accept it from the state. Other local health departments must have their funds approved through a legislative process as well.
Wide variability was identified across state health departments in the criteria used to allocate PHEP funds. Across the 13 state health departments, 6 different allocation criteria were identified and used in various combinations (Table).
Since the inception of the PHEP program, population-based criteria have been used routinely to determine funding allocations; however, the decreasing funding levels have made it more difficult to use this as the only criterion to making such determinations. Some state health departments have adopted the use of the capability-based framework, whereas others have incorporated risk-based measures to allocate funding. The challenge that remains is establishing an agreed-upon methodology that reaches somewhere near consensus levels for allocation, whether with regard to locals, regions, or the central office, and acknowledges the wide variation in how states reach consensus support from the local health departments on that allocation methodology. At the moment, there are no clear standardized guidelines that can be used to aid states in the allocation of limited resources.
The analysis revealed common issues in hiring and procurement processes. Most state health officials said that they are limited in their ability to efficiently spend funds because of the time required to complete state-level procurement processes, further complicated by competitive bidding contract requirements within a 12-month grant cycle.
Health department officials also reported challenges in their hiring processes, specifically “hiring freezes” that have limited the ability of many health departments to increase or maintain their full-time employees and to hire certain types of professional positions. Other health departments reported facing difficulty in hiring qualified staff, given the uncertainty of funding past the 12-month cycle.
Respondents reported additional challenges pertaining to emergency response activities and the specific challenges that arise from the difference between declared and undeclared emergencies. For example, it was reported by some public health officials that guidance for spending is unclear, particularly when responding to a public health threat that is not a declared emergency. In those instances, state and local health departments may need to cover response costs without having clear guidance on reimbursement. Also, state officials reported that a disaster declaration signed by the governor needs to include numerous details and the necessary language in order to expedite the administrative response processes.
Monitoring and Reporting
The lack of a standardized, integrated monitoring system to collect data on an ongoing basis was consistently reported as a challenge at both the state and local levels. Many health departments reported the use of multiple systems for monitoring funds, including complicated Excel spreadsheets, Internet-based systems, and paper-dependent systems. This is a consequence of having to respond to many data requests from different authorities and the need to ensure redundancies should the primary reporting system be compromised. Considerable time and effort are devoted to collecting, coordinating, and analyzing the submission of data to these systems, creating additional administrative burden, especially during an emergency response.
Practices from the field
A selection of practices from the field that address some of the common administrative challenges reported by state and local health departments are listed as follows:
- The use of a host agency or fiscal intermediary responsible for administering the PHEP and PHER grants on behalf of the state or local health department was reported as an effective model for expediting administrative processes.
- The integration of a financial administrative person within the preparedness unit helped expedite administrative processes for both the PHEP and PHER funding streams. Having specific staff members dedicated to monitoring, reporting, and tracking administrative items was reported as an effective strategy to reduce administrative burden.
- Multiyear contracts with a clause specifying that contract execution is contingent on the availability of next year's funding have provided a solution for some health departments struggling with spending funds within a 12-month grant cycle and to bypass lengthy procurement processes.
- Some jurisdictions have adopted integrated monitoring and reporting systems that can be used at the state and local levels. The local health department can provide information to the state on an ongoing basis, making current information accessible at any time, thereby reducing or avoiding the need for the state to impose information requests within a short timeline.
This project highlighted barriers in the administration of EP funds and many promising practices from the field. The varying types of jurisdiction, governance structure, and population size of the health departments indicate that there may not be a best practice or one-size-fits-all approach. What clearly emerges from the interview analysis is that administrative barriers are limiting the capability of state and local public health officials to develop innovative approaches to improve preparedness outcomes. However, state and local health departments have expanded collaborative efforts to overcome such barriers. Some of the administrative challenges are structural and may be best addressed at the federal level, whereas others may be resolved at the state or local level. NACCHO and ASTHO are currently engaged in a collaborative process of developing solutions and recommendations across state and local health departments on how to decrease the barriers faced in the administration of EP funding.