Public health preparedness: Building and maintaining infrastructure after the COVID-19 pandemic

Public health preparedness: Building and maintaining infrastructure after the COVID-19 pandemic

What Gao found

The COVID-19 pandemic has demonstrated the importance of having a strong public health infrastructure to prepare for and respond to threats, including a skilled workforce and physical infrastructure, such as laboratories. The Centers for Disease Control and Prevention (CDC) of the Department of Health and Human Services (HHS) annually supports public health infrastructure in jurisdictions—states, localities, and territories—through two major preparedness programs: (1) Epidemiology and Laboratory Capacity for the Prevention and Control of Emerging Infectious Diseases and ( 2) Public health emergency preparedness. Program grant amounts to jurisdictions from annual appropriations averaged about $845 million annually from fiscal years 2019 through 2022. Separately, in fiscal years 2021 through 2023, using supplemental appropriations from the most recent coronavirus relief law, the Centers provided Disease Control also awarded jurisdictions about $7.1 billion in awards to enhance infrastructure. Of this amount, $3.5 billion could be used over 5 years for new long-term investment in infrastructure to help address future threats. Judiciary officials spoke with GAO about the important benefits of awards from annual and supplemental appropriations, such as supporting epidemiology staff and purchasing supplies for laboratories.

Selected jurisdictions and stakeholder groups have identified several challenges in building and maintaining infrastructure to be adequately prepared to address public health threats. These challenges include the following areas:

  • Interim funding for public health. Officials from nearly all jurisdictions and stakeholder groups have expressed concern about the pattern of increased federal funding for emergency response, followed by a decrease in funding after the emergency ends. This pattern can make it difficult for jurisdictions to invest in long-term, sustainable efforts to prepare for future public health threats.
  • Varying levels of judicial funding. Judicial authorities have primary responsibility for preparing for and responding to threats. However, there is variation in the amount of funding that jurisdictions provide for preparedness and response. This impacts the extent to which jurisdictions may need to rely on CDC awards for these purposes, according to two stakeholder groups.
  • Building the public health workforce. Jurisdiction officials noted that because the grants using the COVID-19 supplemental credits were temporary, the workforce increases were also largely temporary. Even for the new bonus that can be used over 5 years, officials from eight jurisdictions cited concerns about permanently increasing their workforce due to uncertainty about long-term financing. Officials from six jurisdictions and five stakeholder groups also expressed concerns about the availability of an adequate public health workforce, due to burnout and other factors.

Jurisdictions are key partners in preparing for and responding to public health threats. The infrastructure challenges they face can impact how quickly and effectively CDC and other response partners are able to contain these threats, as demonstrated during the COVID-19 pandemic. According to CDC officials, increased and continued investments in public health infrastructure are vital to respond to and contain threats at the national level.

Why did the Government Accountability Office undertake this study?

The Center for Disease Control (CDC) is the primary federal agency responsible for helping strengthen public health infrastructure in jurisdictions to assist in emergency preparedness and response capabilities.

The CARES Act includes a provision that enables the Government Accountability Office to report on the federal response to the COVID-19 pandemic. This report (1) describes CDC awards to support public health infrastructure in jurisdictions for preparedness, and (2) examines the challenges selected jurisdictions and specific stakeholder groups face to build and maintain this infrastructure.

GAO analyzed CDC data on awards made to jurisdictions using annual appropriations and some supplemental appropriations made in response to the pandemic. Specifically, GAO analyzed annual award data from fiscal year 2018 (the year GAO last reported award data) through 2022 (the most recent data available at the time of GAO’s review). GAO also analyzed data on awards using appropriations from the recently enacted COVID-19 relief law – the American Rescue Plan Act of 2021.

GAO interviewed officials from a non-generalizable sample of 12 jurisdictions—selected on the basis of governance structure, funding received, and rural character. GAO also interviewed representatives from 10 stakeholder groups representing public health professionals and policy organizations, among others.

GAO submitted a draft of this report to the Department of Health and Human Services for review and comment. HHS provided technical comments, which GAO incorporated as appropriate.

For more information, contact Mary Denigan Macauley at (202) 512-7114 or

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