Public health has been succinctly defined as “what we do together as a society to ensure the conditions in which everyone can be healthy.”1 Front and center in this effort are leaders “partnering across multiple sectors and leveraging data and resources to address social, environmental, and economic conditions that affect health and health equity.”1 However, current financing structures compromise the ability of state health officials to fulfill their role as chief health strategists in this Public Health 3.0 model. State health officials know that factors broadly defined as the social determinants of health, such as safe and stable housing and nutritious food, are important to achieving and maintaining health. Yet these efforts are difficult to engage in, given that most of the funding within their agency budgets is targeted for specific programs or conditions.2
To address these issues, select public health agencies have started to combine funding from different sources to support public health efforts to achieve specific aims—a method known as braiding and layering funding. States have used these strategies to fund the Behavioral Risk Factor Surveillance System or to align disease or condition-specific programs around common risk or protective factors. In recognition of this growing practice, the Association of State and Territorial Health Officials (ASTHO), in partnership with the Center for State, Tribal, Local, and Territorial Support at the Centers for Disease Control and Prevention (CSTLTS, CDC), is working with states to advance these funding strategies into high-return areas where funding is needed the most. Building on the pioneering work of states that have forged a path, the pilot is focused on funding innovation in 2 areas: (1) activities addressing the social determinants of health and (2) developing needed infrastructure. At the end of the first year, it is clear the change associated with realizing this vision is significant but achievable. Braiding and layering funding demands the active engagement of leadership, a shared sense of purpose and vision, formalized communication and collaborative decision-making processes, well-established administrative procedures for cost allocation and reporting functions, and dedicated staff.
Figure 1 provides the contextual model for this work. The inverted pyramid in the figure shows that, within the bounds of traditional public health systems, current funding is most acute in the foundational capabilities domain on which programmatic areas and organizational competencies rest. Public health capabilities—traditionally referred to as infrastructure—have been defined as assessment/surveillance, policy development/support, communications, organizational administration, accountability and performance management, etc.3 These provide the necessary capacity to target programs and set priorities, data to inform decision making, and policy levers to effect change. In short, these areas provide the foundation for a fully functioning public health system.
Recently, the Public Health Leadership Forum engaged public health leaders, practitioners, stakeholders, and experts in finding solutions to transform public health systems and explicitly identified foundational capabilities as an area in need of finance reform. The Forum's white paper noted that “current best research indicates that an annual outlay of $32 per person is required to put in place the foundational health capabilities needed to promote health across the nation,” yet research shows that current investment is just $19 per person.2 These findings have been verified by other research, noting that “despite strong leadership and interested funders, widespread application and utilization of the foundational capabilities framework face a long road. One particularly challenging aspect of ensuring the standard array of foundational capabilities in every community is adequate funding.”4
The figure also shows that factors collectively referred to as the social determinants of health are relegated to the surrounding circle—areas on which current public health-funded efforts are often only indirectly targeted at best. As many as 40% of health outcomes have been attributed to such social and economic factors, including economic stability, educational attainment, access to food and housing, and employment status.5 In the absence of increased funding, braiding and layering funding strategies can help build a healthy foundation for public health and invest in the social determinants of health.
Transitioning to the Public Health 3.0 Funding Model Among States
Notwithstanding the challenges of siloed and insufficient funding, pioneering state health departments are evolving from a traditional public health funding model to a Public Health 3.0 funding model that uses braided and layered funds to focus interventions further upstream, including coordination and capacity building among community-level systems addressing social needs (midstream interventions) and enabling policy action to improve the social determinants of health (upstream interventions).6
Traditional public health funding model
As depicted in Figure 2, the traditional public health funding model includes siloed, categorical funds and reporting requirements that often determine both the organizational structure and work performed by the department. While most health departments establish a vision, strategies, and goals for improving population health in this model, they often do not engage in tactical planning nor do they establish operational mechanisms to ensure existing funding is used to support these aims. This can result in perpetuating funding siloes within state public health departments and communities resulting in a disjointed and uncoordinated approach that lacks a holistic view, creates inefficiencies, and produces significant gaps in addressing the social determinants of health. Further, funding siloes and limited coordination within this model overlook support for foundational capabilities and shared infrastructure necessary to address modern public health issues.
Public Health 3.0 funding model
Lacking changes in the federal funding structure for public health, the current Public Health 3.0 funding model shown in Figure 3 continues to receive siloed, condition-specific funds and reporting requirements. However, functioning as the Chief Health Strategist, public health department leadership collaboratively establishes a vision and goals and develops a governance and operational structure that will enable achievement of those goals. Collaboration occurs broadly, internally, and with cross-sector partners, and enables coordination of resources to meet a shared vision of improved health, addressing overlapping goals, common risk and protective factors, and populations. Funding from coordinated resources grows the foundational capabilities in the organization to reinforce the infrastructure necessary to serve as the Chief Health Strategist and support a collaborative approach to public health. Funding is coordinated, resulting in braided and/or layered funds to communities that support a collective impact model, and necessary infrastructure, with improving social determinants as a main goal. Reporting is coordinated and includes cross-cutting objectives as well as program-specific reporting necessary to respond to categorical cooperative agreements and grants.
Lessons Learned From Leading States
To further this vision, the idea for the CDC-funded pilot focused on braiding and layering funding was borne out of discussions among senior deputies—a peer group that the ASTHO convenes virtually and in-person. Hearing of the progress some of their peers made through this model, additional convenings and resources devoted to furthering knowledge and strategies in this area were requested. In response, the CSTLTS, the CDC provided funding for ASTHO staff to provide leadership development, assemble existing resources, and provide technical support. As a first step to learning about successful approaches and lessons learned, the ASTHO and the CDC convened a panel of 3 states that had successfully braided and layered funding. As part of their efforts, Colorado and Rhode Island addressed the social determinants of health while Washington State focused on building foundational capabilities:
- The Colorado Department of Public Health and Environment funds 46 communities that care across the state, empowering communities to develop, implement, and evaluate evidence-based prevention strategies to address youth substance abuse.
- The Rhode Island Department of Health funds Health Equity Zones (HEZs) to empower community collaboratives to eliminate health disparities through place-based strategies.
- Implementing the Foundational Public Health Services model, the Washington State Department of Health funds foundational capabilities, public health surveillance systems, and HIV prevention and care services.
From this initial meeting, it became clear that challenges with siloed funding existed at both the state and federal levels, and that 6 sequential steps (explained next) were needed to successfully address and overcome these barriers. States that jumped ahead without adequate planning or collaboration found it necessary to backtrack. Through this discussion with leading states, a model was developed that guided work undertaken with pilot states. And based on this sequential model, a roadmap for successful funding innovation was developed and attendant resources were assembled. During the first year, 2 states (Idaho and North Dakota) participated in the ASTHO facilitated Boundary Spanning Leadership workshops to help them employ practices that facilitate work across organizational silos and drive toward innovation and transformation. Developed by the Center for Creative Leadership (CCL), the approach focuses on 3 strategies: (1) managing boundaries, (2) forging common ground, and (3) discovering new frontiers.7 The pilot states convened stakeholders and developed implementation plans, specifying their approach within each of the following areas:
- Leadership: The first and perhaps most important step identified by experienced states consists of developing leadership buy-in and support, and empowering a cross-functional, high-level unit to lead this work within the agency. In order to overcome turf battles, entrenched interests, and inertia, all 3 states emphasized the critical importance of leading with the vision rather than the technical mechanics of combining funding streams. They emphasized the importance of leadership reaching out early and often to key internal and external stakeholders, including federal and state funders. Reflecting this advice, the first year of the pilot project was dedicated to planning within the pilot sites, and stakeholders were provided with the CCL's Boundary Spanning Leadership workshops developed to foster collaboration across boundaries intrinsic to cross-sector challenges.7
- Assessment and prioritization: With a vision in place, the functional mapping, strategizing and priority setting that needs to occur prior to project initiation can begin. During this step, explicit agreement on where and how innovation will be targeted is reached. Colorado mapped common risk and protective factors across programs, along with outcomes addressing social determinants of health and health equity. Rhode Island empowered communities to establish priorities and then identified relevant evidence-based practices and programs for communities to choose from.
- Methods: The identification of relevant funding streams is guided by the vision, purpose, and established priorities. This step also involves the development of cost allocation processes, along with standards of practice specifying the translation of work plans and budgets. In Rhode Island, the state mapped funding sources that could fund the priorities identified and evidence-based programs chosen by communities. HEZ budgets were built from these. Local HEZ managers must report on expenditures and outcomes, but the translation and mapping—or cost allocation back to identified federal, state, and foundation sources of funding, and attendant reporting—occurs solely at the state level. Both Rhode Island and Washington State developed standardized language specifying that a certain percentage of funding would be used for HEZs or public health capabilities and inserted it in all applications and proposals for identified funding sources.
- Management: Once implementation began, all 3 sites emphasized hands-on management with dedicated full-time equivalents focused on tracking expenditures and outcomes, and facilitating collaboration, communication, and problem-solving between programs and fiscal staff to apply cost-allocation and collaborative budgeting.
- Strategies: In the absence of established practice, the learning curve was steep for the pioneering sites who often “learned by doing.” This worked best in an open, collaborative environment where challenges and barriers were openly discussed, and solutions and strategies were arrived at in a collaborative manner and fed back into the implementation cycle. This environment was fostered through a sense of shared vision and mission, and frequent communication.
- Value: As with any new endeavor, the importance of evaluating results to show value back to funders and policymakers was emphasized. Sites made use of Healthy People 2020 objectives.8
Current federal and state funding structures and their guidance and interpretation pose significant challenges and obstacles to funding activities addressing the social determinants of health and the infrastructure needed to effectively support and inform public health systems. Nevertheless, states are beginning to make significant headway in these areas through funding innovation. The experience of leading states as well as those just beginning the journey underscores the significant degree of cultural and practice change that accompanies these efforts. Change of this magnitude demands the active engagement of leadership, a shared sense of purpose and vision, formalized communication and collaborative decision-making processes, well-established administrative procedures for cost allocation and reporting functions, and dedicated staff. There are no short cuts or easy solutions. Yet in the absence of new mandates or funding in these high-impact areas, the need for continued innovation is clear. Our infrastructure is woefully underfunded and existing funding is not properly targeted on addressing the causes of the conditions and diseases we face. In the absence of dedicated funding for these areas, we must press forward with funding innovation, following the path blazed by leading states.
Most states are adept at braiding and layering funding to achieve specific aims, such as funding for the Behavioral Risk Factor Surveillance System or aligning disease or condition-specific programs around common risk or protective factors. Now states are beginning to use these same strategies to move further upstream or to support needed cross-functional supports. Although challenges exist with taking braiding and layering to the next level, our shared history provides many examples of how time and again the public health field has learned and adapted, addressing daunting challenges and newly emerging threats in underresourced environments.
1. DeSalvo KB, Wang YC, Harris A, Auerbach J, Koo D, O'Carroll P. Public Health 3.0: a call to action for public health to meet the challenges of the 21st century. Prev Chronic Dis. 2017;14:170017.
2. DeSalvo K, Levi J, Hoagland B, Parekh A. Developing a Financing System to Support Public Health Infrastructure. Public Health Leadership Forum. https://www.resolve.ngo/docs/developing-a-financing-system-to-support-foundational-public-health-capabilities-final-draft-10.2.pdf
. Published October 2018. Accessed October 21, 2019.
3. The Public Health National Center for Innovations. Building a strong foundation of public health infrastructure. https://phnci.org/national-frameworks/fphs
4. Singh SR, Bekemeier B, Leider JP. Local health departments' spending on the foundational capabilities. J Public Health Manag Pract. 2019;26(1):52–56.
5. Booske BC, Athens JK, Kindig DA, Park H, Remington PL. Different Perspectives for Assigning Weights to Determinants of Health. University of Wisconsin Population Health Institute. https://www.countyhealthrankings.org/sites/default/files/differentPerspectivesForAssigningWeightsToDeterminantsOfHealth.pdf
. Published Feb-ruary 2010. Accessed October 21, 2019.
6. Castrucci B, Auerbach J. Meeting Individual Social Needs Falls Short of Addressing Social Determinants of Health. https://www.healthaffairs.org/do/10.1377/hblog20190115.234942/full/
Published January 16, 2019. Accessed November 18, 2019.
7. Leadership Institute Factsheet
. Center for Creative Leadership. Accessed October 21, 2019.
8. Healthy People 2020 Objectives. Healthy People 2020. https://www.healthypeople.gov/2020/topics-objectives
. Accessed October 21, 2019.