Why So Little Transparency in Public Health Grant Spending?
By Christopher Williams
Founder, Public Health Liberation
The lack of transparency in public health federal grant funding poses a major threat to the viability of public health to meet challenges in health and data equity. Websites for federal grant agencies do not contain ready access to successful applications, grant reports, related tools, and datasets. While much of these data can be obtained through a Freedom of Information Act (FOIA) request, federal FOIA offices exercise considerable latitude to place limitations on public access. For example, I recently FOIA’ed to obtain the application for a $3.5 million funded federal grant application on LGBTQ+ mental health. The FOIA officer redacted 382 pages in full and only released 116 pages. The results provided the core of the grant activities, including consent forms and some assessments. The remaining 300-plus document was not released due to “trade secrets and commercial or financial information” and “information in personnel and medical files and similar files”. To gather data on any regular submitted reports to the agency or other pertinent information, I would need to submit a separate FOIA request. These practices that erect barriers to public data - the data that would be available under a FOIA request - is a hinderance to public health innovation.
The US Department of Health and Human Services (HHS) Office of Minority Health lists all active grants on its website here. The grants total in the tens of millions of dollars. Yet, no substantive information about the intervention is disclosed. The CDC grant funding dashboard shows basic information such as project name, funding agency, and grant amount. There is little else.
Why This Is a Problem
A colleague who worked in a local department of health provided insight into the effectiveness of public health spending. They were struck by the disconnect between the ambitious goals in the department’s federal application and poor program implementation, which often involved individuals with little formal public health training. The grant amount of $4 million was sizable. There was spending on activities that were not funded. There was development of materials that were not theory-driven and evidence-based. A key component of the application to develop a wide-ranging collaborative did not exist. Although the grant was nearing its original end date within six months, the program evaluation had not yet begun. Many of the community-based organizations (CBOs) were not spending their share of the budget despite being several years into the grant period. It is not clear to my colleague if those organizations knew about the availability of those funds.
This insight raises some doubts about the effectiveness in spending of public health dollars. How many more grants are similar to my colleague’s? Some estimate that adequate investment in public health requires $4.5 billion [1], but several reforms are needed. The first is that federal agencies should be more transparent about the grantee - its strengths, innovation, application, tools, and potential contribution to public health practice. The public would benefit from disclosure of the federal government’s risk assessment of grantees based on prior use of federal grants. This risk is used to determine the potential for fraud, waste, or abuse. This list is not published that I could find. My colleague shared that their department of health had an elevated risk that requires more regular reporting due to past performance.
The ability of local governments to effectively spend public health dollars provides insight into the Public Health macro-economy - meaning the performance at the local and state levels. The Public Health Economy is the analytical shift that Public Health Liberation believes is necessary for accelerating health equity, especially by income and race. Improving public health can only be achieved to the extent that the public health economy is well-understood. Poor-performing economies may require enhancements in the form of restructuring, re-training, or a greater federal role prior to receiving grant funds as not to waste public dollars. The general public and elected officials should also be interested in grant oversight because it may mean that a given city should make changes in recruitment and retention to attract talent with formal public health training.
