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Using Grants as Incentives for Public Health Emergency Preparedness: A Double-Edged Sword?

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.  

By Nathan Myers and Elvis Asorwoe
September 19, 2014

The events surrounding the U.S. response to H1N1, as well as the recent international response to an outbreak of the Ebola virus, illustrates the importance of collaboration in preparing for a public health emergency. We will examine information from in-depth qualitative interviews conducted with two officials affiliated with the collaborative organization Indiana Hospital Preparedness District 5. One key theme from the interviews was although grant funding originating at the federal level, and then distributed to health organizations through the states, is essential to collaborative preparedness efforts it also creates barriers to operationalizing these efforts.

The District 5 organization was created under the auspices of the Hospital Preparedness Program (HPP), an initiative of the HHS Assistant Secretary for Preparedness and Response (ASPR). According to the HHS website, the mission of this federal program is to use grants to build up capacity for responding to a public health emergency in an integrated manner. District 5 includes Marion County (in which Indianapolis is located) as well as the surrounding counties. The hospital preparedness committee for District 5 works with 35 hospitals and many coalition partners, including local health departments. The ability of these different partners to collaborate is complicated by the fact that they receive grant funding from different sources. Grants to local health departments, for example, originate with the Centers for Disease Control and Prevention rather than the ASPR program.

As stated on the District 5 website, the organization serves as a repository for equipment and resources that can be distributed to hospitals in the area. Organizations within the district collaborate on efforts such as education, training and building relationships to maximize preparedness during a public health emergency. To get a better sense of the role of District 5 in building and maintaining collaborations, we interviewed two people: an official with District 5 who represents a hospital (henceforth referred to as the hospital representative) and another official affiliated with a local health department within the district (henceforth referred to as the LHD representative).

The hospital representative noted that the ASPR grant requirements have been revised to make evidence of coalition building a deliverable for the grant. For the hospitals, attendance at the monthly business meeting is required. Individual hospitals’ funding is tied to attendance at district meetings. The hospital representative noted that, while it is important that grant requirements continue to be met in order to maintain eligibility, in the last few years amounts awarded have decreased. While the members of District 5 have explored ways to keep the collaboration sustainable, the District currently lacks funding outside of the grant.

In addition to incentivizing more joint activity, grant funding has had positive impacts in a number of other areas as well. One such area is communications and logistics. Utilizing the ASPR grant funds, the district hospitals have subscribed to the Live Process system, a communication and information sharing tool. Hospitals have also obtained 800 MHz radios through the grant, as well as access to Web-based emergency operation center programs through the Department of Homeland Security.

Challenges to successful collaboration associated with grant funding include the fact that the capabilities hospitals, public health departments and other partners are supposed to address to receive grant funding are different, hindering their ability to engage in joint efforts. This is a problem seen operationally as well, at the county and the district level, with hospitals, public health departments and emergency management services having different protocols to follow in mass casualty events. One example where the absence of a common understanding of capabilities and protocols has hindered collaboration is in the area of integrating law enforcement into emergency planning. While the LPH representative stressed that law enforcement certainly understands their role in such events, he noted that the existing grant framework makes it difficult to provide law enforcement with incentives to participate in planning for public health emergencies with all the other things they have to manage.

The hospital representative noted increasing accountability requirements associated with grants as another challenge. Increasing amounts of time and effort are necessary for the required documentation and paperwork, putting strain on hospital employees and other coalition members who have full-time responsibilities in addition to preparedness duties. The hospital representative noted that, on the health department side, some of the health departments have dropped out of the grant programs because they were spending more effort and money to continue to receive the funding than they were actually receiving. It can also be difficult for hospitals to coordinate on providing evidence of grant deliverables because the guidelines for hospitals are not aligned with other coalition partners, such as local health departments.

The LPH official agreed that the work required to continue to receive grant funding was an issue for collaboration partners. He noted that while he is a county employee focused specifically on preparedness and paid from a recurring line-item in the budget, such a situation is very rare in Indiana. According to him, in public health, preparedness is an additional duty, not a primary occupation. This creates significant challenges for those charged with preparedness.

The lack of funding for public health emergency planning at the local government level as well as the hospital level makes these organizations (and other partners in preparedness planning) heavily reliant upon grants. As noted in the interviews, grants can be a double-edged sword in that they provide necessary funds for establishment of collaborative efforts yet also create disincentives for cooperation and spark conflict between organizations. According to the participants, much of the conflict stems from a lack of unified capabilities or responsibilities that all actors involved in public health emergency response should address. The idea that a stream-lined and consolidated version of the capabilities would greatly aid in the efficient fulfillment of grant requirements and help to foster collaboration was noted a number of times throughout these interviews.

Future research should explore this paradox of grant funding spurring the building of these relationships while also hindering the implementation of the products of these relationships. The need for a more comprehensive set of capabilities for public health emergency response should also be explored. More work is required to identify how the management of grant funding can be reformed to maximize incentives for collaboration and minimize disincentives for joint action.


Author: Nathan Myers earned a Ph.D. in Public Affairs at the University of Nevada, Las Vegas in 2009. His research interests include federal and state health policy, public health policy and administration, intergovernmental collaboration and bureaucratic politics and behavior.  Myers has previously published research on the effectiveness of state health care programs in Policy Studies Journal, Politics and Policy, California Journal of Politics and Policy, Administration and Society and the Journal of Health Politics, Policy and Law. He is currently an assistant professor of political science and public administration at Indiana State University and can be reached at [email protected] 

Author: Elvis Asorwoe is a Ph.D. student in public affairs and a teaching assistant in the Department of Public Administration at Florida International University. Asorwoe’s research interests include public policy, health care policy, e-governance and public sector management. Asorwoe worked in local government for 10 years in the Hohoe Municipal Assembly in Ghana. Asorwoe is also a consultant to the BUSAC Fund, a private sector support mechanism created and funded by DANIDA, with further support from the U.S. Agency for International Development, DFID and the European Union.

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