Weaving and Layering Funding: A Territorial Health Agency's Guide to Effective Health Financing

Abstract

Context: State and territorial health agencies can optimize programmatic funding through braiding and layering strategies. Implementation: The Commonwealth Healthcare Corporation, a territorial health agency located on the Pacific Island of Saipan, Commonwealth of the Northern Mariana Islands (CNMI), restructured its Non-Communicable Disease Bureau into 4 new units. Existing funding streams were braided and layered to support the restructuring. A shared vision of strengthening crosscutting connections to improve population health outcomes helped guide the restructuring process. Vision planning with leaders and funding partners, establishing buy-in within agency and external partners, and assessing immediate impacts were a few of the steps taken by the agency to ensure a successful restructuring. Impact: The immediate impact of the restructure has been positive. In both the CNMI and select states that have undertaken similar efforts, braiding and layering funding has facilitated more streamlined processes, coordinated approaches across programs and funding partners, and provided deeper levels of trust in partnerships. Although it is still too early to draw long-term assessments in the CNMI, the agency projects that coordinated funds will strengthen its foundational capabilities and promote a more community-centered, collaborative, and effective approach to public health. Restructuring the Non-Communicable Disease Bureau through braiding and layering funds gives the agency the flexibility it needs to more effectively address the social determinants of health and local population health priorities through a client-centered approach, ultimately improving health outcomes for the commonwealth. Lessons Learned and Implications: The agency experienced several challenges throughout the restructuring process that offer lessons learned for addressing effective health financing. For example, ample time is needed at the beginning of the braiding and layering process to establish policies and procedures for efficient accounting, documenting, and reporting. In addition, ongoing support and training opportunities for programmatic teams can smooth out the transition from siloed to braided and layered funding structures. These lessons, in addition to key elements mapped out by experienced state health agencies, can guide and prepare other agencies interested in implementing innovative funding mechanisms.

A Call to Increase Health Data Availability in US Territories—Not Too Small to Count

“…The 5 island areas are unincorporated territories under the purview of the US Constitution and US Congress. 1,2,6 However, US federal guidance is unclear surrounding territorial eligibility across federal health data systems. 2 For instance, whereas PR is included, Guam, CNMI, American Samoa, and USVI are not covered in the US Census Bureau's American Community Survey.…”

“…3,6 Local funding mechanisms (eg, tax collections) have shrunk amidst mass depopulation, 7 and federal funding streams have been limited in both volume (eg, territorial Medicaid funding caps) and structure (eg, earmarks for condition-specific programs). 6 This is augmented by a tradition of siloed federal grant funding mechanisms for public health programs that increase administrative burden and intervention costs for territorial health departments. 6 Recommendation 3: in November 2022, the 5 territories were awarded funding through the CDC's Strengthening US Public Health Infrastructure, Workforce, and Data systems grants.…”

“…6 This is augmented by a tradition of siloed federal grant funding mechanisms for public health programs that increase administrative burden and intervention costs for territorial health departments. 6 Recommendation 3: in November 2022, the 5 territories were awarded funding through the CDC's Strengthening US Public Health Infrastructure, Workforce, and Data systems grants. 5 This alone cannot close historic funding gaps.…”

“…The 5 island areas are unincorporated territories under the purview of the US Constitution and US Congress . However, US federal guidance is unclear surrounding territorial eligibility across federal health data systems .…”

“…Territorial health departments have historically operated under considerable financial constraints . Local funding mechanisms (eg, tax collections) have shrunk amidst mass depopulation, and federal funding streams have been limited in both volume (eg, territorial Medicaid funding caps) and structure (eg, earmarks for condition-specific programs) .…”