Most experts agree that the U.S. public health response to the COVID-19 pandemic was inadequate when compared to other wealthy countries. The U.S. had substantially higher per capita cumulative deaths and vast disparities in cases of COVID than other developed countries, and one of the key factors was the nation’s lackluster public health infrastructure. While there are many reasons for the flawed COVID-19 response, the underfunding of the U.S. public health system continues to emerge as one of the main factors — one with potentially lethal consequences for all Americans.

A new paper from the University of Minnesota School of Public Health (SPH) sheds new light on the complex system the U.S. relies on to pay for its public health infrastructure. In addition to analyzing the financing structure of our public health system, the paper also includes numerous recommendations for improving both the way public health is structured and paid for in the U.S.

Much of the confusion around public health funding in the U.S. stems from the fact that it’s funded by a complex web of public and private entities, including all levels of government, foundations, non-governmental organizations, and other funders. On top of this, many of these funding sources have differing, and sometimes competing, interests — leading to overlapping priorities and mixed messages shared with the public.

On top of these challenges, overall public health spending from all sources (apart from emergency infusions during the COVID-19 crisis) has trended downward over the past several decades, which further erodes our public health system’s ability to address basic needs. Ideally, government investment in the public’s health should exceed $32 per person annually, the paper notes, but current governmental funding is about two-thirds of that figure.

In addition to increased funding, the paper, published in the Annual Review of Public Health, includes specific recommendations to improve our public health structure and funding, including:

• Improving the data systems that monitor funding for public health departments in order to better track and measure public health financing.
• Increasing the autonomy of local public health agencies so they have more flexibility to respond to community priorities.
• Establishing a national framework for defining and measuring public health public health activities in order to better estimate funding levels for public health programs, systems, and infrastructure.

“The financing structures of the national public health enterprise are confusing at best, and fraught with competing priorities, inadequate expenditures, and intergovernmental arrangements that are so confusing that policy makers are often unsure what level of funding specific public priorities are receiving,” says SPH researcher and lead author Jason Orr. “The actions we recommend can address some of the challenges our public health system is facing, including simplifying funding, modernizing and standardizing public health data systems, and taking steps to ensure that public health investments are more equitable and sustainable.”