Funding and Accountability in Public Programs: Implications for Disease Intervention Specialists

“Public health agencies are held accountable in a variety of ways: directly to funders, heads of the executive branch, and boards of health where applicable, and indirectly to the communities they serve.”¹ “In addition to their own accountability for discharging their statutory duties and using federal, state, and local funding appropriately, public health agencies are stewards of a community's overall health and can play the role of monitors, conveners, or rapporteurs with respect to the performance and accomplishments of other stakeholders in the health system.”¹

TABLE 1.

Types of Accountabilities

Accountability Type	Function	Governmental Programs
Accountability for finances	Holding agencies responsible for using funds as defined by law, rules and standards.	HHS TAGGS—This system keeps track of all grants, cooperative agreements, and contracts issued by all parts of HHS, including the CDC, by state and by type of activity, such as research, health services, training, and technical assistance.
Accountability for fairness	Ensuring that agencies follow preestablished norms and values and are fair to employees, grantees, contractors, and citizens.	The Notice of Funding Opportunities (NOFO) issued by many federal agencies are available to the public through grants.gov, include a rationale for funding priorities and, describe the process to appeal decisions.
Accountability for use of power	Ensuring that government employees use the funding as intended and treat everyone fairly, and reduce the potential abuse or misuse of power by government employees.	The Freedom of Information Act allows citizens to request copies of printed or electronic government records. The Whistleblower Protection Act protects Federal employees and applicants for employment who lawfully disclose a violation of law, rule, or regulation; gross mismanagement; waste of funds; abuse of authority; or a substantial and specific danger to public health or safety.
Accountability for performance	Assuring that preestablished outcomes and programs' expectations are met.	Through the Healthy People Initiative CDC monitors improvement in population health by tracking progress in achieving national objectives.

This article will examine various elements and types of accountabilities and provide examples of governmental and nongovernmental accountability systems that are relevant to Centers for Disease Control and Prevention (CDC)-funded programs, including those supporting Disease Intervention Specialists (DIS).

DEFINITION OF ACCOUNTABILITY

Definitions of accountability usually vary depending on the field of knowledge defining it and the social, cultural, or institutional circumstances. The Merriam-Webster dictionary defines accountability as “an obligation or willingness to accept responsibility or to account for one's actions.” In general, “being accountable” is a quality or state of being where one either accepts or is obliged to accept responsibility for one's actions toward another. Thus, this definition assumes a relationship between two entities and involves taking responsibility for a particular action or goal. Accountability in politics has been defined as an “implicit or explicit expectation that one may be called on to justify one's beliefs and actions to others, and the extent to which a person's behaviors are observed and evaluated by others, with important rewards and punishments contingent upon those evaluations.”²

However, public accountability requires that the public sector demonstrate competence, reliability, and honesty while allowing the public to judge its trustworthiness in using public resources. “Trusted public officials are able to make flexible use of their skills, as well as their discretion and autonomy, to enhance their efficiency, responsiveness, and effectiveness.”³ This leads to a critical question; do we hold public employees accountable for program delivery or for the outcomes associated with it? Many agency administrators are usually accountable only when they are required to answer for their actions.⁴ However, public accountability can increase public trust and confidence in governmental programs, which could also result in increased support for the management of public programs. Likewise, trust and confidence in public programs increase as the government produces value through public services, laws, and regulations. Although the concept of the value of public programs has multiple facets, such as the program's strategic goals, understanding and delivering what the public wants, the political and authorizing environment, and what can be measured; it could be summarized in a very simple equation as the difference between the benefits provided and the resources and powers which citizens decide to give to their government.⁵

ELEMENTS OF ACCOUNTABILITY

Accountability in governmental programs is often associated with tracking funds, assuring legislative compliance, and providing administrative oversight. Governmental programs, typically do this by establishing and monitoring performance indicators. In recent years, the United States Government has developed new tools and resources to hold federal agencies and funding recipients accountable to legislators and society. Furthermore, philanthropic organizations have developed principles and methods of accountability for successful grant management. In the Principles of Accountability for International Philanthropy, a Joint Working Group of the Council on Foundations and the European Foundation Centre identified two fundamental questions that should be asked by every donor before issuing grants: to whom is the organization responsible as it makes grants, and how can funders ensure that their philanthropy is carried out in an accountable and responsible manner?

These questions ultimately led to defining seven elements of accountability to be considered for successful grant management in addition to the financial, legal, and administrative requirements. These elements are (1) integrity, (2) understanding, (3) respect, (4) responsiveness, (5) fairness, (6) cooperation and collaboration, and (7) effectiveness. Integrity requires aligning grants with the vision, mission, values, and core principles of the organization, but to be successful those who offer grants need to understand the context in which recipients operate, including staying aware of the political, economic, social, cultural, and technological environments. It is also important to respect and embrace cultural differences, human diversity, and recipient autonomy. To build trust and be responsive, donors need to be open and recognize the local needs and day-to-day realities of the recipient. Donors should also be fair and assure that demands are proportionate to the level, purpose, and nature of the support provided. For the long-term sustainability of the project, it is also important to cooperate and collaborate with a variety of local entities like nongovernmental organizations, businesses, and local governments. Finally, donors need to demonstrate the program's effectiveness and be able to describe how the funded program contributes to the achievement of the organization's mission as well as the advancement of the public good.⁶ When considering accountability for public programs, it is imperative to first identify the type of government in which the program is operating, as it is essential for preserving the integrity of the overall public program. In general, accountability is a characteristic of responsible and democratic forms of government.⁷ Although “lack of accountability” can create distrust of governmental institutions, accountability helps to reduce the discretionary powers of public officials, improves equitable access to public services, and documents what the public's return on investment is for paying their taxes and how effectively funds are spent.^7–11 The United States Government has prioritized accountability for the past 30 years and is including accountability as a function of leadership.

TYPES OF ACCOUNTABILITIES

Robert Behn describes four different types of accountabilities, accountability for finances, fairness, the use of power, and performance. The United States Government has traditionally created detailed, formal procedures to ensure that its agencies and employees are held accountable for finances and fairness. In the interest of improving performance, as required by law, front-line workers are asked to be more responsive to program requirements and performance, whereas middle managers are encouraged to be innovative, and public executives to be entrepreneurial.¹⁰ However, quantifying, and ranking performance for public health programs can be difficult and presents significant challenges as will be discussed further down.

Accountability for finances is the type most used by governmental agencies.¹⁰ One such example is the Health and Human Services (HHS) Tracking Accountability in Government Grants System (TAGGS).¹² This system keeps track of all grants, cooperative agreements, and contracts issued by all parts of HHS, including the CDC, by state and by types of activity, such as research, health services, training, and technical assistance. It also includes the abstracts of funding applications submitted to HHS agencies, for all approved grantees and contractors. There are plans to include performance measures, but that information is not currently available.

Next is Accountability for fairness. Health systems frequently claim to be fair and provide equitable services to the population when they set their priorities. Fairness has been defined as “the state, condition, or quality of being fair, or free from bias or injustice; evenhandedness,” and as “the quality of treating people equally or in a way that is right or reasonable.” Behn suggests that programs are fair only when they satisfy four conditions: the rationale for priority setting is publicly available; the rationale is considered appropriate by reasonable people; there is an avenue for appealing the rationale and related decisions; and, there is a clear process to ensure the first three conditions are met.¹⁰ This concept of fairness intersects with other principles important to public health, such as health equity and social justice.

An important question we should ask is why we need to worry about accountability in government. The natural response would be fear that public officials, including elected officials, appointed executives, or civil servants would abuse the power given to them. Power in this case refers to the ability, capability, or influence to accomplish an action or change the behavior of others. This brings us to Accountability for the use of power, the goal is to reduce the abuse or misuse of power by government employees, which is crucial for democratic societies.¹⁰ In the United States, the public can make government officials disclose what they've done through the US Freedom of Information Act, which allows nearly anyone to request copies of printed or electronic government records.¹³ Another tool to hold government officials accountable is the Whistleblower Protection Act. The Act protects Federal employees and applicants for employment who lawfully disclose a violation of law, rule, or regulation; gross mismanagement; waste of funds; abuse of authority; or a substantial and specific danger to public health or safety.¹⁴ Lastly is accountability for performance which has evolved significantly in the US Government over the past few years.¹⁰ In 1947, sociologist Max Weber suggested that a responsible bureaucrat needed to document his practice, but guard it against political interference. In those days, government archives were closed, and accountability was centered around private room discussions.¹⁵ By the end of the 20th century, accountability was associated with system-level responsibilities focused on increased access to data and documentation about public services. Recent advances in technology have made data and information more accessible to the public.¹⁵ Centers for Disease Control and Prevention monitors improvement in population health through the Healthy People Initiative. The Healthy People 2020 tracked 1318 objectives organized into 42 topic areas, including Sexually Transmitted Diseases.¹⁶

ACCOUNTABILITY OF GOVERNMENT BY GOVERNMENT

In 1986, Romzek and Dubnick⁴ stated that “public administration accountability involves the means by which public agencies and their workers manage the diverse expectations generated within and outside the organization.” Typically, public accountability relies upon some internal or external source of control that will define how much flexibility the agency will have in defining expectations generated from within or outside the organization. Therefore, accountability for public programs can take various forms based on where the authority comes from and how much flexibility the source of control exercises over the agency's decisions and operations. There are two forms of internal controls: the bureaucratic and the professional accountability systems. Bureaucratic accountability is characterized by an approach in which “the expectations of public administrators are managed through focusing attention on the priorities of those at the top of the bureaucratic hierarchy” and are based on stated rules and regulations.⁴ Professional accountability values the expertise that exists within the organization. In this system of control, professional associations and educational institutions may indirectly, through their members influence governmental agencies' actions. In contrast, legal and political accountability are based on external controls. Legal accountability can be based on policies and sanctions, and political accountability on the relationship between public officials and the public, elected officials, and special interest groups.⁴

Over the past 30 years and in response to a demand for increased controls, various US Government administrations have focused on initiatives to improve accountability by using data to develop evidence and to document the value provided by governmental programs. The 1993 Government Performance and Results Act (GPRA) required federal agencies to set goals, and performance measures, report progress, and evaluate findings to improve programs.¹⁷ The 2004 Program Assessment Rating Tool is required by the US Government to help programs determine the cause(s) for strong or weak performance, remedy deficiencies, make improvements, and achieve better results.¹⁸ The 2010 GPRA Modernization Act was built upon GPRA requirements and added a few additional features including the development of a centralized website to provide a comprehensive picture of government performance. It also aligned the agencies' strategic planning cycles to the presidential election cycles and administrative transitions.^19,20 In 2018, the Foundations for Evidence-based Policymaking Act emphasized collaboration and coordination to advance data and evidence-building functions.^21,22 Furthermore, in June 2021 the Office of Management and Budget (OMB) issued a memo advising heads of executive departments and agencies “to use evidence whenever possible to further both mission and operations, and to commit to building evidence where it is lacking, and to strategically plan and organize evidence-building, data management, and data access functions to ensure an integrated and direct connection to evidence needs.”²³

The current OMB focus is on outcomes, where agencies use all available evidence to improve programs and ultimately serve the American people more effectively. However, achieving population-level outcomes is complicated as it depends on too many diverse groups of people, governmental levels (federal, state, and local) their partners, and the private sector. In public health, governmental programs are only one of the many players in the health system that should be held accountable for or involved in improving health. Hence, accountability for population-level results in public health cannot be the responsibility of any one individual, organization, or level of government. The whole community, public and private sectors, must share responsibility for population health results.

Many governmental agencies are charged with holding public programs accountable. For example, the US Government Accountability Office provides Congress, agency executives, and the public with timely, fact-based, nonpartisan information that can be used to improve government and save taxpayer dollars.²⁴ The HHS Office of the Inspector General (OIG) is responsible for providing oversight to prevent inefficient and unlawful operations within the agency by identifying, auditing, and investigating fraud, waste, abuse, embezzlement, and mismanagement of any kind within the executive department.²⁵ In the November 2022 report, the OIG identified 6 top management and performance challenges faced by the HHS in its mission to enhance the health and well-being of all Americans. The first challenge identified was about safeguarding public health. It requires all relevant HHS agencies to strengthen their emergency preparedness and response capabilities. Centers for Disease Control and Prevention is responsible for addressing outbreaks and implementing appropriate, equitable, and immediate early interventions and prevention strategies, including support for case investigations and contract tracing.

ACCOUNTABILITY IN PUBLIC HEALTH PROGRAMS

The government-wide response to COVID-19 and mpox illustrate the complexities of assigning responsibility and holding accountable any agency, level of government or any of the multiple partners that collaborate with HHS. In 2011, the Institute of Medicine (IOM) committee concluded that there is “widespread recognition in public health that the government public health infrastructure generally “owns” neither the problems nor the solutions and thus needs to engage and collaborate with multiple stakeholders to find effective new ways to improve population health.”¹ The committee proposed measures and strategies to increase accountability of public health programs and to promote action by communities and other stakeholders. It also recommended changes in the processes, tools, and approaches used to gather information on health outcomes to assess the accountability of public health programs. Specifically, the IOM Committee recommended that “the Department of Health and Human Services work with relevant federal, state, and local public-sector and private-sector partners and stakeholders to “facilitate the development of a performance-measurement system that promotes accountability among governmental and private-sector organizations that have responsibilities for protecting and improving population health at local, state, and national levels.”¹ And, in response to this and other recommendations from program auditors and the public sector, HHS established a goal in the FY 2022–2026 Strategic Plan “to build trust, transparency, and accountability and encourage prudent use of resources.”²⁶

Accountability of Government by Nongovernmental Institutions

In a democracy, political accountability means that governmental decision makers must be answerable to the public for their actions.⁹ One mechanism that could be used to demonstrate accountability to the community as well as to policy makers and elected officials regarding the availability and quality of public health services is program accreditation.¹ In the United States, the Public Health Accreditation Board has developed standards and measures for public health practice for state and local health departments based on the ten essential public health services and the foundational public health services framework. Their mission is to advance and transform public health practice by promoting performance improvement, strong program infrastructure, and innovation.²⁷ Although accreditation is a useful tool to hold public health programs accountable, it also has some limitations, primarily because standardized measures usually focus on cross-cutting practices rather than specific evidence-based public health programs, policies, or interventions.¹ For example, DIS are public health professionals who conduct case investigations and contact tracing (CI/CT) to prevent and control infectious diseases. The 2022 Public Health Accreditation Standards and Measures include a measure (Measure 2.1.4 A) requiring documentation of protocols that outline a standardized approach for conducting timely, consistent, and thorough disease investigations but does not link this information to specific evidence that this approach improves population health outcomes for all infectious diseases.

Disease intervention is key to sexually transmitted disease (STD) prevention and control. Data from the CDC Division of STD Prevention indicates that most of the jurisdictions funded through Strengthening STD Prevention and Control for Health Departments (STD PCHD) are using a combination of federal, state, and local funding to hire DIS, and close to 40% of funded jurisdictions report that DIS are jointly hired by state and local jurisdictions. Additional measures are needed to improve accountability and trust in CI/CT programs and promote the judicious use of public resources. These measures should also be focused on improvement rather than blame or fault.

To successfully manage the implementation of DIS programs, CDC and state and local health departments must embrace the seven elements of accountability discussed previously. Division of STD Prevention already addresses the element of integrity of funded DIS activities in their 2022–2026 Strategic Plan which includes an objective to expand DIS capacity in programs and settings that serve communities and populations disproportionately impacted by STIs.²⁸ However, to address the remaining elements CDC needs to work with state and local partners to understand the political, social, and cultural context in which the STD programs operate and to assure that the program requirements are fair, reasonable, and not beyond the resources provided. Centers for Disease Control and Prevention also needs to collaborate with program directors and other subject matter experts to identify data elements that could improve the efficiency of the programs, for example by focusing resources on the areas that are most in need or populations who are often unreached by public health prevention efforts; and to develop innovative prevention models to expand coverage of DIS services, this could be through enhanced technological or patient-mediated approaches. Finally, to be responsive and respectful of the funded jurisdictions, CDC needs to be flexible and consider the local context, the specific needs of the community, and staff capacity. To accomplish this, CDC could organize national or regional listening sessions with funding recipients and their local partners.

CONCLUSION

Accountability is complex and difficult to monitor in federal programs when implemented through collaborative agreements with nongovernmental organizations or other levels of government. For example, the CDC provides funding to state, local and territorial health departments for STD prevention and control, including hiring and training DIS. Although there has been significant activity to improve accountability in these programs, few efforts have been undertaken to develop a measurement framework to document the population health impact of CI/CT funded by STD programs. Furthermore, holding these programs accountable for population health outcomes or achieving specific programmatic benchmarks may not be an easy undertaking because DIS hired with STD funds often support other public health programs such as HIV and viral hepatitis, and outbreak investigations for other infectious diseases like Zika, Ebola, COVID-19, and now mpox reducing the time and effort available for STI services. Besides, STD programs frequently need to combine funds from multiple sources to hire DIS. Despite these challenges, state and local STD programs need to evaluate the effectiveness of the services provided by DIS, and if necessary, reallocate resources. At a minimum, STD programs should keep track and report the number of partners that were located, notified, examined, tested and treated. Programs should also assess the speed and effectiveness in which services are delivered and the number of cases worked per unit cost.²⁹ Further discussions are needed to determine who should be held accountable, and to whom or to what program for the use of these CI/CT resources. What are the expectations for DIS services in terms of improved health outcomes and program impact? How will desired outcomes be measured; what are the targets and benchmarks for each performance measure, and who will be responsible for setting them? How are measures going to be documented and reported? And how program impact and accomplishments should be shared with the public. As a first step, CDC should work with funded jurisdictions to identify standard variables that could be used to assess inputs and calculate key CI/CT performance indicators at the national and jurisdictional levels and establish national and jurisdictional benchmarks. Furthermore, to promote accountability and transparency national and jurisdictional data should be shared with all funding recipients in a timely manner through grantee feedback reports. Programs that fail to meet the benchmarks should be required to develop and implement a program improvement plan. Challenges in accountability within STD prevention programs will remain until there is consensus on what accountability precisely means for STD programs and specifically for DIS work, and what tools and metrics are needed to hold programs and funding recipients accountable.