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Public Health Preparedness: Building and Maintaining Infrastructure beyond the COVID-19 Pandemic

GAO-24-105891 Published: Nov 07, 2023. Publicly Released: Nov 07, 2023.
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Fast Facts

The COVID-19 pandemic demonstrated the need for strong public health infrastructure—including a skilled workforce and physical infrastructure—to prepare for and respond to threats.

The Centers for Disease Control and Prevention annually supports such infrastructure in states, localities, and territories through 2 programs. These jurisdictions also received billions of dollars in supplemental funding to respond to the pandemic.

But state officials and others involved in preparedness said the temporary nature of supplemental funds meant that infrastructure changes are mostly temporary. This could affect the nation's response to future threats.

Person wearing a mask, goggles, hairnet, and gloves working in a lab.

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What GAO Found

The COVID-19 pandemic demonstrated the importance of a strong public health infrastructure to prepare for and respond to threats, including a skilled workforce, and physical infrastructure, such as laboratories. The Department of Health and Human Services' (HHS) Centers for Disease Control and Prevention (CDC) annually supports public health infrastructure in jurisdictions—states, localities, and territories—through two key preparedness programs: (1) Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases and (2) Public Health Emergency Preparedness. The programs' award amounts to jurisdictions from annual appropriations totaled about $845 million on average per year from fiscal year 2019 through 2022. Separately, in fiscal years 2021 through 2023, using supplemental appropriations from the most recent COVID-19 relief law, CDC also provided jurisdictions with about $7.1 billion in awards to enhance infrastructure. Of this, $3.5 billion can be used over 5 years for a new longer-term infrastructure investment to help with future threats. Jurisdiction officials GAO spoke with cited important benefits of awards from both annual and supplemental appropriations, such as supporting epidemiology staff and purchasing supplies for laboratories.

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

  • Temporary public health funding. Officials from nearly all jurisdictions and stakeholder groups expressed concern about the pattern of increased federal funding for an emergency response, followed by a decrease in funding after that emergency ends. This pattern can make it hard for jurisdictions to invest in long-term sustainable efforts to prepare for future public health threats.
  • Varying levels of jurisdictional funding. Jurisdictions have primary responsibility to prepare for and respond to threats. However, there is variation in the amount of funding jurisdictions provide for preparedness and response. This affects the extent to which jurisdictions may need to rely on CDC awards for such purposes, according to two stakeholder groups.
  • Building a public health workforce. Jurisdictions' officials noted that because awards using COVID-19 supplemental appropriations were temporary, workforce increases were also largely temporary. Even for the new award that can be used over 5 years, officials from eight jurisdictions noted concerns about permanently increasing their workforces because of uncertainty of longer-term funding. Officials from six jurisdictions and five stakeholder groups also expressed concerns about the availability of a sufficient 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 was demonstrated during the COVID-19 pandemic. According to CDC officials, increased and ongoing investments in public health infrastructure are vital to the response to contain threats on a national level.

Why GAO Did This Study

CDC is the primary federal agency responsible for helping strengthen jurisdictions' public health infrastructure to aid emergency preparedness and response capabilities.

The CARES Act includes a provision for GAO to report on the federal response to the COVID-19 pandemic. This report (1) describes CDC awards to support jurisdictions' public health infrastructure for preparedness, and (2) examines challenges selected jurisdictions and stakeholder groups identified to building and maintaining such infrastructure.

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

GAO interviewed officials from a nongeneralizable sample of 12 jurisdictions—selected based on governance structure, funding received, and rurality. GAO also interviewed representatives from 10 stakeholder groups representing public health professionals and policy organizations, among others.

GAO provided a draft of this report to HHS 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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Disease controlDiseasesEmergency preparednessEmerging infectious diseasesHealth careInfectious diseasesLabor forcepandemicsPublic healthPublic health emergenciesPublic health servicesSupplemental appropriations