10 strategies HHS could use to bolster its preparedness for public health emergencies

A May 2023 report from the Government Accountability Office reminded readers that “persistent, systemic problems” had prompted the agency to place the Health and Human Services Department’s coordination of public health emergencies on its high risk list of programs “in need of transformation.” 

According to GAO, 91 of its 155 recommendations to HHS “remain unimplemented.” These recommendations, highlighted as well in previous reports, include clarifying responsibilities within HHS, improved communications with such partners as state officials and the general public and enhanced data collection. That HHS programs have become more unwieldy and complex over time is apparent, but what GAO observes is a reflection of larger problems in how HHS has throughout the years been led and managed. 

Yet, there are ways to reinvigorate and enhance HHS’ organizational culture in ways that can improve its accountability to the public and bolster its preparedness to lead the nation during future public health challenges.

The total number of HHS employees actually is not that easy to find, but according to a document the department prepares in case of a government shutdown, in fiscal 2021 there were roughly 82,400 HHS employees including 17,315 in the Food and Drug Administration, 13,515 in the Centers for Disease Control and Prevention, 495 in the Substance Abuse and Mental Health Services Administration, 6,326 in the Centers for Medicare and Medicaid Services and 2,221 in the Health Resources and Services Administration. The fiscal 2024 update lists 88,731 HHS employees including 19,644 for FDA, 15,151 for CDC, 810 for SAMHSA, 6,546 for CMS, and 2,728 for HRSA. 

What in 2019 was a $1.214 trillion budget had by fiscal 2021, according to HHS’ budget in brief, become $1.37 trillion and was poised in fiscal 2024 to exceed $1.69 trillion. These numbers do not include changes in numbers or expenditures pertaining to grantees or contractors, such as those supporting FDA’s information technology systems.

As the number of employees and programs proliferates to support response to complex problems such as climate change or the COVID-19 pandemic, HHS has evolved little as an organization, continuing to experience the same types of difficulties its leaders and others described more than a generation ago.

What are some potential solutions that could make HHS a stronger, more cohesive, better managed department, one better prepared to lead during public health emergencies? Below are 10 strategies HHS could pursue to strengthen its leadership, commitment and effectiveness, both with respect to preparedness and in other programs.

• Conduct Joint Ongoing Strategic Planning: Working together on such activities could solidify partnerships among agencies as well as consistency of each agency’s plan with that of the overall department.

• Redevelop Reimagine HHS or a similar program: Reimagine HHS, launched in 2017, was intended to bolster employee engagement, collaboration and efficiency. While that program ended, HHS should consider a similar approach to support innovation and program improvement, with genuine opportunities for ground-level employee input.

• Appoint staff members as liaisons to other HHS Operating Divisions: By agreement, CDC and FDA appoint liaisons to one another to support interagency collaboration. While not a panacea or substitute for other efforts, this practice of appointing liaisons by one agency to another, if extended to other HHS agencies such as HRSA, SAMHSA, CMS and others, could over time solidify interagency collaboration on preparedness and other issues, building within each agency staff and leadership knowledgeable about how other agencies in the department work. 

• Clarify FDA’s standing within HHS: FDA’s former leaders, including its current commissioner, Robert Califf,  have expressed their view that the agency should be entirely independent of HHS. Other prominent former FDA officials disagree. It would be helpful both internally and externally to clarify FDA’s standing in HHS and its chain of command, including with respect to public health emergencies.

• Bolster Freedom of Information Act compliance: Transparency and accountability are key to maintaining public trust. FOIA helps ensure both. HHS should bolster its commitment to FOIA and proactively make information available even without a FOIA request in keeping with Justice Department guidance. FOIA can help ensure preparedness for future emergencies by making more information about agency operations available.

• More closely supervise political appointees: GAO has expressed concern about alleged political interference within HHS during the COVID-1 pandemic. Updating the Vacancies Reform Act, which governs Senate confirmation of permanent appointments to certain agency leadership positions and expanding its scope to additional positions may help. 

• Promote employee development and engagement: While some degree of attrition is to be expected, too much turnover is disruptive to employees and agencies. Recommendations made by a consulting firm to FDA concerning retention are broadly applicable to other HHS and government agencies as well.

• Share best practices and lessons learned across HHS: While some non-governmental organizations do occasionally share best practices as in human resources, there does not seem to be an organized effort within HHS to share best practices and lessons learned across the department or with other agencies and organizations. It would be great to change that by cataloging successful initiatives across HHS programs and agencies. Reports and lessons learned including about emergency preparedness, for instance, should be maintained and shared across the organization.

• Invest in employee and supervisor training and development: In 2010 the Merit Systems Protection Board observed the need for improved training and accountability for front-line/first-level supervisors. By these standards, HHS supervisor requirements seem fairly minimal. HHS as well wholly fails to articulate in its policies criteria by agencies for selection of supervisors. Doing so can ensure employees and supervisors are better prepared to deal with emergencies and other challenges. 

• Bolster teamwork and mutual respect:  At the height of the COVID-19 pandemic, more than 1,400 CDC employees signed a letter to the agency’s director stating their perceptions of bias within CDC. This letter arguably foreshadowed a need for change CDC now is attempting to address. The MSPB observed that as of 2021 nearly one-third of agency employees perceived such prohibited personnel practices as retaliation, discrimination or granting improper advantages in recruitment. There are warning signs in HHS, such as cases referred to the Office of Special Counsel and Equal Employment Opportunity Commission and public court filings, that HHS senior leadership should carefully scrutinize not necessarily because the claimants always are correct in their views but because at times these situations may reflect larger unresolved systemic problems.

Achieving these goals is not impossible for a department with HHS’ employees’ talents and capabilities. Other agencies and departments and non-governmental organizations may in part serve as models. Without such changes, even as HHS’ budget and employee numbers continue to grow, making the department appear to be more capable on paper, its actual real-world capabilities, including its preparedness for future emergencies, may atrophy.

Mitchell Berger has worked on public health and behavioral health programs at the federal and local levels and contributed to strategic planning and quality improvement activities. The opinions expressed are solely those of the author.