ARPA’s public health workforce provisions prompted initial work on PHIG, but in early phases of grant development, CDC adopted a broader infrastructure framework, with workforce at the core. For the governmental sector, this infrastructure framework is most clearly articulated in the 8 foundational capabilities within the Foundational Public Health Services.⁷ This includes assessment and surveillance, community partnership development, equity, organizational competencies, policy, performance management, emergency preparedness response, and communications. What underlies all of these functions, systems, and services is the public health workforce. PHIG centers around the governmental workforce as its primary focus and as the primary means to realizing these foundational capabilities. In this way, PHIG differs from many other CDC funding opportunities, which are disease, condition, or population specific. Accordingly, under each strategy, the scope of activities allowed is wide, to ensure the effects can reach the foundations of the public health infrastructure. For example, supporting the workforce includes not only hiring but also retention, professional development, engagement, workforce wellness, and strengthening relevant workforce systems.

The underlying theory of change is that this investment in workforce, alongside other improvements to each recipient’s public health infrastructure, will result in improved response to emergency health threats and public health outcomes more broadly (Figure 1). Health equity and diversity, equity, inclusion, accessibility, and belonging were conceptualized as essential, crosscutting principles to be integrated across PHIG implementation, rather than called out as separate strategies.

Several CDC programs have funded health departments to broadly build and implement core infrastructure, including developing the workforce, but for more focused purposes. For example, for years, CDC’s Epidemiology and Laboratory Capacity program has supported this in relation to domestic infectious diseases; the Public Health Emergency Preparedness program has done so in relation to emergency response capacity.^8,9 More recently, OT21–2103 National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities (abbreviated as the COVID-19 health disparities grant below) and TO-23–001: Strengthening Public Health Systems and Services in Indian Country both explicitly seek to address the core infrastructure and workforce needs related to health equity and to American Indian and Alaska Native tribes, respectively.^10,11 However, PHIG goes farther, not only in its scale but also by including an even more explicit and comprehensive focus on workforce and infrastructure than most prior or current efforts. PHIG arguably allows recipients to address workforce and infrastructure weaknesses directly and in a more holistic way.

CDC layered this broad scope with streamlined grant requirements. This combination of features 1 and 2 provides recipients with powerful flexibility and thus enhanced agency. CDC’s experience with other highly flexible funding mechanisms, in particular CDC’s Preventive Health and Health Services (PHHS) Block Grant, paved the way for this approach.¹² The PHHS Block Grant is a community-driven grant that allows funded health departments to use the funds to address any of the objectives aligned to the Health People 2030 framework, including public health infrastructure.

The list of required activities for component A recipients in PHIG is highly focused: (1) to expand their workforce to some extent, given emphasis on this in authorizing legislation; (2) to support a high-level workforce director, to elevate cross cutting workforce strategy and implementation; and (3) to provide evaluation expertise for the grant, to ensure recipients’ capacity to monitor and evaluate work under PHIG. State health departments also must allocate at least 40% of the workforce funding to local health departments not directly funded by the grant. Beyond that, recipients can direct the funding within each of the 3 strategy areas in ways that serve their needs best. For its part, CDC is committed to supporting recipients’ unique needs and to streamlining and minimizing administrative and reporting requirements, to the extent feasible and allowable by law. CDC’s choice to use a grant mechanism rather than the more typical cooperative agreement mechanism for PHIG also affords recipients greater flexibility. In general, the less prescriptive approach shown by the CDC in these requirements means that the recipients have more control to direct funding as needed in their unique jurisdictions.

An additional benefit of flexibility is that it should make it easier for recipients to complement other federal, state, local, and other funding streams. Some funding sources might be more restrictive due to Congressional directives, appropriations language, or limitations attached to their authorizing legislation. Flexible funding such as PHIG can enhance grantee abilities to optimize other funding sources; an example of leveraging this way is described in the context of CDC’s injury prevention funding.¹³

This ability to direct and leverage PHIG funding according to recipient needs is clearly reflected in the breadth of activities being implemented across recipients, as evident in their work plans. We randomly selected 4 year-1 workplans from each eligibility category of component A recipients and summarized the work proposed (Table 2). The random selections included a city (Milwaukee, WI), county (Wake County, NC), territory (US Virgin Islands or USVI), and state (Connecticut or CT) health department. For greater comparability, workforce and foundational capabilities information is provided.

All 4 recipients are hiring a senior workforce director and an evaluator, as required. Other hires reflect recipients’ needs and range from a clinic operations director (Milwaukee) to a process improvement director (USVI) and program coordinators for health equity partnerships (CT). Across these recipients, some hiring is under workforce (A1) and some is under foundational capabilities (A2). Both Milwaukee and USVI planned to retain several staff funded through other means (eg, a graphic designer, a strategist, a program manager, and a fiscal coordinator), suggesting how PHIG complements other funding streams. Wake County chose to support and train existing staff over adding new hires, compared to the other recipients shown. Some systems and policy changes represented include Milwaukee’s and Connecticut’s intention to revise job pay scales or review compensation levels (funded under A1 workforce) and USVI’s plans to upgrade their HR system (funded under A2 foundational capabilities). Some activities are directed toward specific public health program areas, such as in USVI and Connecticut, which call out new investments in environmental health; most of the other activities across these recipients are crosscutting and foundational, intended to benefit staff across program areas (eg, workforce wellness programs) or to strengthen functions that serve many programs (eg, improved human resource recruitment and grants management). These crosscutting functions can be difficult to support through more categorical or disease-specific funding. Together these examples demonstrate PHIG’s workforce and infrastructure focus and its flexibility in action.

This grant adopted the innovation made by the COVID-19 health disparities grant, which funded the largest number of state, territorial, and local public health department recipients (108) through a single grant in CDC’s history.¹⁰ By including 49 city and county health departments, 8 freely associated states and territories, and all 50 US states, PHIG reduces steps and costs by awarding more funds directly to the local level rather than through the state first. Many of the local and territorial recipients have not been routinely funded by the CDC through its various other funding mechanisms (eg, El Paso, Texas; Mecklenburg County, NC). This inclusivity as part of PHIG’s funding model further supports more local control and broader representation within the recipient community.

The COVID-19 health disparities grant also led the way on incorporating measures of community vulnerability in the funding formula used to allocate funding, to help direct more funding to where needs were greatest. The formula for PHIG was transparent to applicants and incorporated population size and the US Census Bureau’s Community Resilience Estimates to direct allocation amounts.¹⁴ Finally, ARPA’s appropriations provisions provided CDC an unusual opportunity to obligate 5 years of funding for workforce up front, allowing recipients more certainty about funding levels throughout the grants’ period of performance and more time to plan and implement planned activities. This feature provided them with a longer planning and implementation horizon than the annual funding that is more characteristic of discretionary federal funding and associated with increased administrative burden. As a result, PHIG recipients can pace spending according to their own plans, needs, and capacity during the 5-year period of performance.

The exclusion of tribes as direct applicants to PHIG raised questions about equity. However, because Congress provided significant, specific funding to tribes (managed by the Indian Health Service) through ARPA, tribes were not included as intended recipients of PHIG. To build on this complementary support provided by ARPA, PHIG recipients are strongly encouraged to collaborate with tribal nations and organizations in their jurisdictions.

Despite a limited time frame for developing PHIG, CDC conducted 8 listening sessions with different public health partners at local, state, and national levels concerning their workforce needs. These sessions provided an additional source of information for designing the grant and reinforced decisions regarding flexibility. Holding these sessions reflected CDC’s desire to manage PHIG differently and establish an expectation of high levels of engagement, inclusivity, and partnership from the start.

Component B of PHIG supports national partners in providing T/TA to component A recipients, conducting grant evaluation, and facilitating communication among all partners. PHIG is unusual in including this multi-partner support within the same funding mechanism as the group those national partners will serve (ie, component A recipients). This design accelerated the implementation of component B (eg, by the end of year 1, over 200 T/TA requests had already been made to, and addressed by, these partners). Being within one Notice of Funding Opportunity (NOFO) and program also supports coordination and collaboration both within CDC and among component A and B recipients (eg, the national partners share reporting and other timelines with component A recipients and work with the same CDC team).

CDC also embedded flexibility and streamlined requirements in component B recipients’ strategies, giving them greater choices to support the wide variety of needs anticipated of component A recipients and to adapt quickly as implementation unfolds. In the large funding amount and flexibility provided to component B recipients, CDC sought to strengthen public health partnerships nationally by empowering those national partners to play a larger service role in this grant than often is possible. It also moves CDC away from being both primary steward of the funding and primary T/TA provider; under PHIG, the T/TA role is shared. The goal is to strengthen partnerships among these national public health partners, their numerous sub-recipients, and the health departments so that those partnerships can thrive outside the grant confines. Examples of work conducted by the national partners, from regional and national grantee convening to training and evaluation planning, can be found at their website, phinfrastructure.org.¹⁵ The site also highlights success stories from health department recipients across the 3 strategies under component A.