Politics, Risk, and Money: The Perils of Funding Public Health Preparedness (Part Two)
Overview
Even if we believe that we know what the right level of funding should be, there are practical difficulties to implementing an ideal system that need be addressed. One of the key challenges comes from coordination. Part of the problem is that public health preparedness is a multi-factorial process that usually involves many jurisdictions and agencies. Institutional barriers and general coordination problems can arise that make both funding and implementing a system challenging.
One of the key challenges to implementing and maintaining an effective level of preparedness is inter-agency coordination. There is often a lack of sufficient coordination between public health departments and other agencies responsible for responses to public health emergencies. In practice, unfortunately there is a great deal of systemic disharmony in the development of public health initiatives and emergency preparedness for public health emergencies. However, this dysfunction is not always recognized. If the essential relationships and general concordance between public health and preparedness were more widely recognized, more collaborative and coordinated funding decisions could be made. This would allow us to take advantage of synergies between different agencies and departments, avoiding repetitive systems and allowing for limited resources to be allocated more effectively.
Problems with coordination can be exacerbated for large-scale public health emergencies that span multiple jurisdictions since preparedness efforts of one community can affect outcomes for another. However, communities will most likely focus on their own needs, and may not recognize the “spillover” benefits to other communities. In addition, no area can be permitted to be isolated. Overlapping communities are resources are vital to public health preparedness and resilience to a public health emergency. Failure to recognize these issues could lead to too little investment in preparedness from an overall societal perspective. While as noted above, it is difficult to measure the effectiveness of preparedness activities, there is some evidence suggesting that targeted efforts to improve regional coordination across agencies can lead to enhanced preparedness.
There can also be spillovers across levels of government. Rural jurisdictions lack many of the resources to provide adequate preparedness on their own, making them more reliant on state or federal support. This means that cuts to federal funding can have significant adverse impact on preparedness in some areas, particularly poor and rural areas. If these cuts lead to inadequate preparation, individuals in these areas will be more likely to suffer in the event of a public health emergency due to the reduction in funding. These problems have become worse over the last decade, as increases in federal funding were met with decreases in state and local funding.
All this indicates that adequate investment in preparedness means more than just providing money for equipment and supplies. It also requires investment and commitment to ensure that the different agencies that are involved are able to work together and coordinate if a public health emergency occurs. This kind of coordination can be costly and time consuming, meaning that it will require financial commitment. But just as funding for preparedness has been declining, in the wake of the economic crisis government funding has become tighter for all agencies, especially in state and local government. As the budgets for non-preparedness activities tighten, administrators facing difficult choices will probably be more likely to focus on more immediate concerns and even less likely to prioritize preparing for a disaster. This could further undermine the ability of these local agencies and hospitals to effectively respond to a disaster if and when it occurs.
Summary of Issues in Emergency Preparedness Funding
The expenditure of public resources (rightly) requires justification about the appropriateness of the expenditure. In recent years, most public agencies have faced increasingly tight budgets and growing pressure to provide the maximum value for their expenditures. In the absence of hard data on the effectiveness of preparedness activities, it can be difficult to convince policymakers of the pressing need to invest in the appropriate resources. This means that alternative priorities such as investments education, health care or infrastructure will often seem like a more immediate problem. But a failure to invest adequately in emergency preparedness can have terrible consequences if and when a public health emergency does occur. In addition, failure to distribute allocated funds effectively can diminish the effectiveness of preparedness efforts. Broadly, additional research is needed to better understand how best to measure preparedness at the local, state, and federal level, and the best way to ensure that resources and capabilities are distributed to reduce redundancy and administrative barriers, and to ensure that no community is unprepared and isolated from the greater level of preparedness associated within the region, state or country when a public health emergency occurs.
The Association of State and Territorial Health Officers (ASTHO) and CDC recently completed a collaborative project to develop a National Health Security Preparedness Index (NHSPI). The new index combines different preparedness criteria into one composite set of measures that can be used to determine relative health preparedness capabilities over time. The NHSPI will also measure and help guide activities that support implementation of the National Health Security Strategy. According to the ASTHO website, this index is needed because “there is no standardized, national assessment of health emergency preparedness. State and local agencies have made significant investments in health emergency preparedness, yet levels of preparedness vary across the country.” The index will provide benchmarks of health emergency preparedness and allow communities to track their preparedness levels over time. The index will help identify useful practices that can be shared across jurisdictions. The index could also become a valuable tool in helping set the research agenda for developing a value based model for funding emergency preparedness and response
Although local health departments have primary responsibility for population health protection and public health emergency response, public funding has been declining for over three decades. The CDC and others have repeatedly identified deficiencies in public health infrastructure, workforce, and planning that compromise all-hazard readiness—systemic problems that remain unresolved today. Much of the blame for the current, suboptimal state of public health infrastructure, systems, and workforce has been attributed to the lasting effects of historic underfunding.
The decreasing funds available to health departments, hospitals, and communities, from all sources require a new strategy for public health preparedness, what can be termed the “new normal”. This means adjusting to less money, but maintaining a state of readiness that would be adequate under normal or emergency conditions. In order for health partners and their communities to survive this new normal in funding, there are several options which have shown promise in a variety of communities and states: regionalization, public-private partnerships, and resource sharing arrangements. Five criteria may be used to evaluate these three options. These criteria are critical components of public health readiness and are listed below:
1. Workforce capacity
2. Surge capacity
3. Laboratory capacity and capability
4. Mass patient care capability
5. Mass vaccination capability
Given that funding for public health preparedness efforts will likely continue to fall, communities will need to find creative ways to ensure local preparedness. Inherently, all disasters are inherently local and require a coordinated response at the lowest jurisdictional level, therefore, solutions for funding and support will need more and more to come directly from communities, not the federal government. Building on and maintaining strong local relationships is the way to effectively create public health response systems that can be sustained through variable levels of federal funding. In addition, some communities may need to find local ways to fund preparedness efforts in local taxes. While successful models do exist in some communities, it is unlikely that all communities across the U.S. will have local groups that are creative enough to create sustainable programs. Therefore, local, state, and federal government will continue to bear a significant responsibility to ensure that all communities in the U.S. are prepared for public health emergencies.
