Public Health Finance and Infrastructure Support

Overview

The field of public health finance “examines the acquisition, utilization, and management of resources for the delivery of public health functions and the impact of these resources on population health and the public health system.”1 Public health professionals need to rely on public health financial management skills, build an understanding of the challenges they face, and learn about financing strategies that can be employed to support public health efforts and meet emerging needs.

Numerous organizations and nationally convened bodies have explored public health financing issues and offered frameworks and tools, including several initiatives supported by CDC’s Center for State, Tribal, Local, and Territorial Support (CSTLTS).

This page offers information and resources to help state, tribal, local, and territorial health departments strengthen awareness around funding public health practice and infrastructure.

National Resources and Frameworks

National reports and frameworks highlight a history of attention to public health finance and growing momentum for recommendations to achieve a public health system sufficiently funded to support healthy communities. Select examples include:

Foundational Public Health Services: The Foundational Public Health Services (FPHS) framework, which describes foundational capabilities and foundational areas for governmental public health, was revised in 2022. Originally developed in in 2013 to support and advance conversations around public health financing, the framework addresses a need to further define a minimum package of services for which costs could be estimated. The FPHS framework has become the foundation for several costing methodologies, and many states have used the framework in their financing efforts. Links to various state-based initiatives can be found on the Public Health National Center for Innovations (PHNCI) website.

For the Public’s Health: Investing in a Healthier Future (2012): This Institute of Medicine (IOM) report examines public health funding and provides actionable recommendations for public health agencies and other partners. Some recommendations include developing a research infrastructure for establishing the value of public health, enabling greater state and local expenditure flexibility, and establishing a minimum package of public health services framework for costing (which developed into the FPHS). Progress toward meeting the recommendations in the 2012 IOM report and insight on the future of public health financing are summarized in Characterizing the Impact of the 2012 Institute of Medicine Report on Public Health Finance: A Final Report, developed by PHNCI.

Public Health Forward: Modernizing the US Public Health System: This 2021 report, released by the Bipartisan Policy Center, provides a framework for practical and prioritized actions to modernize the public health system at the state, territorial, and local levels where critical decisions are made regarding the administration and allocation of federal funds. Actions are recommended in six core areas: laws and governance, community engagement, partnerships, workforce, data and information technology, and financing. In November 2022, the de Beaumont Foundation released Implementation Guidance, providing 10 interactive case studies that share real-world experiences and lessons learned by state and local health departments that have already put them into practice.

Podcast—Financing the Future of Public Health: This 2021 Association of State and Territorial Health Officials (ASTHO) Public Health Review podcast episode discusses how states can move from a reactive approach of ad hoc crisis funding to a proactive investment in nimble, cross-cutting systems. Field insights address the short- and long-term needs that public health departments must consider as they invest in the next generation of public health infrastructure.

Lights, Camera, Action—The Future of Public Health National Summit Series: Speakers at this 2022 virtual event highlighted the connection between law, governance, and finance in public health and discussed tools, strategies, and information for strengthening public health finance. The recording, slides, and supplemental reading materials are available at the Summit 3: Strengthening Public Health Law, Governance, and Finance to Support a Modern System.

Innovative Financing Strategies

Braiding and Blending Funds to Support Community Health Improvement [PDF – 367 KB]Many health departments are using innovative methods to address challenges in supporting public health infrastructure. These methods may help health departments identify ways to collaborate with new funding partners, access non-traditional funding streams, or make funding go further by bringing separate funding streams together.

Braiding and Layering Funding

Braiding funding is defined as weaving together funding from multiple sources to support a single initiative in a way that each funding source remains distinguishable.

Layering funding— sometimes referred to as “blending”—is combining different funding streams into a single, indistinguishable, pool to address a specific need.

General information about the use of braiding and layering funding in state and local governmental agencies—including definitions, benefits, challenges, and examples—can be found in both the Association of Government Accountants report, Blended and Braided Funding: A Guide for Policy Makers and Practitioners, and the Trust for America’s Health compendium Braiding and Blending Funds to Support Community Health Improvement.

ASTHO, with CDC support, has explored the use of braiding and layering funding for population-level impact. Multiple ASTHO reports are available to aid health departments in understanding opportunities to braid and layer funding to address social determinants of health (i.e., supportive housing and food insecurity) and the prevention of adverse childhood experiences.

Financing Innovations Used by Local Health Departments
The National Association of County and City Health Officials (NACCHO), supported by CDC CSTLTS, created a Public Health Finance site with a series of snapshots exploring the benefits and barriers of various innovative funding strategies being used by local health departments. Strategies include

Along with each strategy, you can find field examples from local health departments across the country. You can also view recordings of the Public Health Innovative Funding Mechanisms Webinar Series, which explores the snapshots in more detail.

Understanding Funding Flow and Investments

Understanding how funding reaches health departments and is spent can help demonstrate the impact of financial investments on population health.

CDC Grant Funding Profiles: This site provides interactive data and summaries of CDC cooperative agreement and grant funding to recipients in US states, territories, freely associated states, and the District of Columbia. Data and summaries are provided annually after close-out of each fiscal year (FY), starting with FY2010.

Exploring Funding Streams and Administrative Requirements: NACCHO, supported by CDC, worked with consultants to explore how federal cooperative agreement funds made their way to three local health departments (rural [PDF – 1.3 MB], Midwest semi-urban [PDF – 1.1 MB], and large urban [PDF – 692 KB]). Each case study analyzes data from key informant interviews and cooperative agreement and contract documentation. Findings distinguish federal requirements from requirements added by pass-through entities and identify factors that can help or hinder achieving cooperative agreement goals. Summaries of each case study can be found on the NACCHO Public Health Finance page.

Uniform Chart of Accounts: The Uniform Chart of Accounts (UCOA) project, led by the University of Washington School of Nursing Public Health Activities and Services Tracking, provides a standardized format for tracking state and local public health revenue and expenditures. The UCOA allows budget and financial staff to crosswalk their fiscal data with standard categories and submit them for inclusion in a dashboard to facilitate comparisons with other participating health departments and better understand public health finance.

Staffing Up: Determining Public Health Workforce Levels Needed to Serve the Nation: Through this initiative, PHNCI, in partnership with the de Beaumont Foundation, modeled existing expenditure and staffing data from local and state health departments to develop a national estimate of 80,000 more full-time-equivalent (FTE) positions needed to provide basic community services. With additional support from CDC CSTLTS, the Staffing Up project has developed a Public Health Workforce Calculator to allow health departments to determine the total number of FTE staff needed to provide the Foundational Public Health Services.

E-Learning and Training

Finance-Related Core Competencies and Strategic Skills: The Core Competencies for Public Health Professionals [PDF – 659 KB], updated in 2021, include competencies relevant for public health finance in Domain 7: Management and Finance Skills. Public Health Strategic Skills also include resource management, which address financial management.

  • The TRAIN Learning Network provides e-learning offerings that can be searched and filtered using competencies from the Core Competencies’ Management and Finance Skills domain or other relevant key words.
  • The Public Health Learning Navigator provides training from Public Health Training Centers and can be searched using filters such as “finance” or “resource management.”

Federal Grants Management Training Series: This CDC Foundation offering is a self-paced, 6-hour training series to help public health organizations understand roles and responsibilities in successful management of federal grants and cooperative agreements.

On-Demand eLearning to build financial knowledge [PDF – 161 KB]: With support from CDC, NACCHO maintains a periodically updated list of eLearning courses and programs designed to build financial and resource management knowledge and skills for local health officers, program directors, budget and financial staff, and other staff in leadership positions in local public health departments.

Building Expertise in Administration & Management (BEAM): The University of Miami, in partnership with the de Beaumont Foundation, offers this Building Expertise in Administration & Management online certificate program. This self-paced, 15-20-hour program was developed to advance public health professionals’ budget and financial management skills.

1 Honoré PA, Amy BW. Public health finance: fundamental theories, concepts, and definitions. Journal of Public Health Management and Practice. 2007;13(2):89–92.