摘要：Objectives. We examined state-specific administrative barriers to allocating 2009 H1N1 influenza public health emergency response (PHER) funds. Methods. We conducted a qualitative review of PHER grants management reports to identify and code barriers reported by states in allocating funds. Using linear regression, we examined the relationship between the percentage of funds allocated and each individual barrier and, separately, the cumulative effect of multiple barriers. Results. States reported 6 barrier types, including regulatory issues (n = 14, or 28%), contracting issues (n = 14, or 28%), purchasing issues (n = 6, or 12%), legislative issues (n = 5, or 10%), staffing issues (n = 5, or 10%), and issues transferring funds between state and local health departments (n = 4, or 8%). In multivariate models, having experienced a purchasing barrier was associated with a significant decrease in PHER allocation (B = −26.4; P = .018). Separately, the cumulative effect of having 3 barriers was associated with a decrease in PHER allocation (B = −16.0; P = .079). Conclusions. Purchasing barriers were associated with delayed use of PHER funds. Moreover, the cumulative effect of any 3 barriers hampered the allocation of funds. Understanding barriers to using funds can inform future funding guidance for improved efficiency of response efforts. In response to the detection of novel influenza A (H1N1) in a number of people in the United States in spring 2009, Congress appropriated the Public Health and Social Services Emergency Fund. 1 This funding supported public health emergency response (PHER) grants, which were awarded to 62 state and local public health agencies. Funds such as these can be established by Congress with the purpose of assisting federal, state, and local public health entities to prepare for and respond to a public health disaster or emergency. In this case, the funds were established in preparation for a potential H1N1 influenza pandemic, including planning for and conducting mass vaccination campaigns. Funds could also be used to hire additional employees as necessary, to assist in purchasing all essential supplies (e.g., vaccine, vaccine administration supplies, storage facilities), or to cover additional administrative costs associated with the response. As is common in disaster or emergency situations, Congress determines whether PHER funds are necessary for the specific public health disaster or emergency, and funds are distributed to states by the Centers for Disease Control and Prevention (CDC). Specifically, in this response, the CDC’s Division of State and Local Readiness distributed approximately $1.35 billion in PHER funds across the United States. (The CDC provides annual preparedness funding to state health departments through cooperative agreements. The terms of these agreements ensure that funds are used in specific ways and that consistent reports on the use of these funds are provided to the CDC by each state or entity at specified times. In the case of H1N1 response funding, a similar mechanism was used to disburse these PHER funds to the states.) Given the large amount of funds allocated to the states and the urgency with which those funds needed to be spent to protect the population from potential unnecessary illness and death, the capacity of states to efficiently allocate these types of emergency funds is an important issue. To benefit from the availability of PHER funds, states need to be able to effectively and efficiently use these funds to prepare for or respond to the public health event. During the H1N1 response, some state public health agencies experienced challenges in being able to use the PHER funds in a timely manner or in the ways in which they would have preferred (e.g., hiring temporary employees). 2 Because of differences in organizational structure, scope of activities, laws, and policies (e.g., protocols for formal declarations of emergencies), different states may experience different types of barriers to spending PHER funds. 2–7 For example, states differ in their policies of when to declare an emergency. 8 Such emergency declarations have the potential to determine exceptions to routine organizational processes such as protocols for spending approval, protocols for contracting with other agencies (i.e., external to public health or at varying levels within public health such as local health departments), the ability to fund or hire additional employees, or the ability to involve staff members who are not typically focused on emergency preparedness in the response activities. State public health agencies also vary by structure in terms of the centralization of decision-making as well as location and integration of the public health preparedness division within the organization. 3,7 In general, centralized states are more likely to make financial decisions at the state level than to contract with local public health departments to distribute funds to the local level, essentially allowing local decision-makers to determine how their funding is spent. 9 One might posit that centralized states may be able to easily move PHER funds from the state health department to local health departments during a response event because they do not have to individually contract with local health departments, which decentralized states typically have to do. In terms of the location of public health preparedness divisions within state health departments, those organizations that place preparedness just below the state health officer may experience emergency response differently (e.g., greater support or involvement from agency leadership) than do states that have the preparedness division farther down the organizational chart. In addition, states that have a relatively large emergency preparedness staff might be able to navigate the internal administrative barriers more efficiently than do those that have to pull in nonemergency preparedness staff to effectively manage the response. Nonemergency staff will ultimately continue having other duties, and in a prolonged response event, this may result in various challenges. Much of the efforts toward and research on improving public health preparedness, however, have focused on improving collaboration with and between external partners 10,11 and on preparing for specific types of events. 12–15 These efforts have been valuable and crucial to quickly bridging challenging gaps in public health preparedness and response planning, yet understanding the role of internal public health processes in emergency response situations is increasingly important and rarely examined. 16 Experiences during the H1N1 response have the potential to provide insightful illustrations of how internal organizational response processes can affect public health and its response to an emergency or disaster event. 2,17–19 State grant management reports, provided to the CDC during the H1N1 response, indicated that variation existed in how efficiently states were able to allocate PHER funds or move funds to local health departments. Although no prescribed amount of funds was supposed to be spent at the midyear point, some states had allocated as little as 10% of their PHER funds, and other states had allocated 93%. This variation begged the question of whether these differences were related to barriers in the state systems. Thus, we conducted this study to identify barriers to allocating PHER funds for use in state and local health departments. Not only is it important to understand what specific barriers were reported, it is crucial to understand the relationship between those barriers and the ability to allocate funds. Because the timely allocation of emergency response funds is of critical importance to an effective emergency response, findings from this study may inform decisions, procedures, and requirements for accepting and using future influenza or other urgently needed emergency response funds.
