Civic Engagement and Public Health Initiative

Civic Engagement and Public Health Initiative is sponsored by Centers for Disease Control and Prevention (CDC). Provides funding for nonprofit organizations to implement programs that promote civic engagement to improve public health outcomes.

## [](https://pmc. ncbi. nlm.

nih. gov/articles/PMC11757086/)Abstract In response to the COVID-19 pandemic, Congress passed the American Rescue Plan Act of 2021 (ARPA) that included a historic investment in the public health workforce. Charged with implementing this investment, the U.S. Centers for Disease Control and Prevention (CDC) launched the Public Health Infrastructure Grant (PHIG).

PHIG builds on CDC’s experience working with state, local, and territorial public health departments and represents a new approach to strengthening the public health workforce.

Specifically, PHIG incorporates features that allow these public health departments to prioritize and tailor the funding to meet their communities’ needs: 1) focus on workforce as core infrastructure, 2) streamlined programmatic and administrative requirements, 3) more equitable funding approach, and 4) enhanced support from national partners and CDC.

The goal is to optimize the unprecedented opportunity afforded by ARPA and lead to a stronger public health workforce and infrastructure across the United States. **Keywords:**funding, governmental public health workforce, public health infrastructure ## [](https://pmc. ncbi.

nlm. nih. gov/articles/PMC11757086/)Introduction The COVID-19 pandemic presented serious challenges to the public health workforce and system and galvanized efforts to further invest in them.

1–3 The American Rescue Plan Act of 2021 (ARPA) was one such investment. Through ARPA, Congress allocated unprecedented billions of dollars to award to state, local, and territorial health departments to support their public health workforce (ARPA, Sec 2501). Hundreds of millions more dollars were earmarked to support public health data modernization efforts (ARPA, Sec.

2404), among its many provisions. 4 These investments were historic in size and scale. The Centers for Disease Control and Prevention (CDC)’s response to this Congressional mandate was the development of the OE22–2203 Strengthening US Public Health Infrastructure, Workforce, and Data Systems grant (abbreviated to the Public Health Infrastructure Grant or PHIG for the remainder of this paper).

5 The purpose of this study is to describe PHIG’s design to a broader audience, because we believe PHIG represents a notable development in how CDC seeks to support the governmental public health workforce and infrastructure. In addition to its significant funding levels, PHIG blends features that allow these public health departments to prioritize and tailor the funding to meet their communities’ needs.

The goal is to optimize the unprecedented opportunity afforded by ARPA and accelerate the path toward a stronger public health workforce and infrastructure across the United States.

### The Public Health Infrastructure Grant: Origins and Overview The design of PHIG began during fall 2021 and included a series of 8 listening sessions with a wide range of public health partners to better understand their perspectives at this critical juncture of the pandemic.

With this input in mind and lessons of the COVID-19 pandemic still fresh, CDC staff approached the design of this funding mechanism with a desire to create a grant that could have lasting effects not only on recipient health departments but also on CDC’s approach to funding.

CDC sought to use the unique opportunity afforded by ARPA to better empower recipients to use funds to address each of their unique and most critical needs, capitalizing on both administrative and programmatic flexibility provided.

Four key features of the grant allowed for this enhanced flexibility including: (1) focus on workforce as core infrastructure, (2) streamlined programmatic and administrative requirements, (3) more equitable funding approach, and (4) enhanced support from public health national partners and CDC. The initial Notice of Funding Opportunity announcement was released on Grants.

gov on June 23, 2022, and the first Notices of Award were issued in November 2022. The basic design, funding sources, and recipients are summarized in Table 1. The program has a 5-year performance period and includes 2 components.

Component A was awarded to 107 jurisdictions, including states, big cities, counties, and territorial health departments or their bona fide agents. Funding from component A supports strategies regarding workforce (A1), which constituted most of the investment and focus; foundational capabilities (A2); and data modernization, which includes wide ranging data systems strengthening (A3).

6 Component B was awarded to 3 national partners to support strategies for providing training and technical assistance (T/TA) to component A recipients for A1, A2, and A3 strategies, evaluating the grant, and facilitating coordination and communication among all recipients.

These partners are the Association of State and Territorial Health Officials, the National Network of Public Health Institutes (NNPHI), and the Public Health Accreditation Board (PHAB), each of which works with numerous sub-partners. Relatively unique to PHIG is the fact that year 1 funding blended funding from various sources, and the time frames for funding availability varied.

For example, the ARPA funds are multiyear funds that are available for 5 years. The funds from the annual Public Health Infrastructure and Capacity appropriations are available for 1 year. Also, CDC awarded the funding for data modernization 6 months later than the workforce and foundational capabilities strategy funding to a subset of component A recipients (64/107).

### Four Features That Together Make the Public Health Infrastructure Grant Different #### Feature 1: Focus on workforce as core infrastructure The underlying theory of change is that this investment in workforce, alongside other improvements to each recipient’s public health infrastructure, will result in improved response to emergency health threats and public health outcomes more broadly (Figure 1).

Health equity and diversity, equity, inclusion, accessibility, and belonging were conceptualized as essential, crosscutting principles to be integrated across PHIG implementation, rather than called out as separate strategies. Several CDC programs have funded health departments to broadly build and implement core infrastructure, including developing the workforce, but for more focused purposes.

For example, for years, CDC’s Epidemiology and Laboratory Capacity program has supported this in relation to domestic infectious diseases; the Public Health Emergency Preparedness program has done so in relation to emergency response capacity.

8,9 More recently, OT21–2103 National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities (abbreviated as the COVID-19 health disparities grant below) and TO-23–001: Strengthening Public Health Systems and Services in Indian Country both explicitly seek to address the core infrastructure and workforce needs related to health equity and to American Indian and Alaska Native tribes, respectively.

10,11 However, PHIG goes farther, not only in its scale but also by including an even more explicit and comprehensive focus on workforce and infrastructure than most prior or current efforts. PHIG arguably allows recipients to address workforce and infrastructure weaknesses directly and in a more holistic way.

#### Feature 2: Streamlined programmatic and administrative requirements CDC layered this broad scope with streamlined grant requirements. This combination of features 1 and 2 provides recipients with powerful flexibility and thus enhanced agency. CDC’s experience with other highly flexible funding mechanisms, in particular CDC’s Preventive Health and Health Services (PHHS) Block Grant, paved the way for this approach.

12 The PHHS Block Grant is a community-driven grant that allows funded health departments to use the funds to address any of the objectives aligned to the Health People 2030 framework, including public health infrastructure.

The list of required activities for component A recipients in PHIG is highly focused: (1) to expand their workforce to some extent, given emphasis on this in authorizing legislation; (2) to support a high-level workforce director, to elevate cross cutting workforce strategy and implementation; and (3) to provide evaluation expertise for the grant, to ensure recipients’ capacity to monitor and evaluate work under PHIG.

State health departments also must allocate at least 40% of the workforce funding to local health departments not directly funded by the grant. Beyond that, recipients can direct the funding within each of the 3 strategy areas in ways that serve their needs best.

For its part, CDC is committed to supporting recipients’ unique needs and to streamlining and minimizing administrative and reporting requirements, to the extent feasible and allowable by law. CDC’s choice to use a grant mechanism rather than the more typical cooperative agreement mechanism for PHIG also affords recipients greater flexibility.

In general, the less prescriptive approach shown by the CDC in these requirements means that the recipients have more control to direct funding as needed in their unique jurisdictions. An additional benefit of flexibility is that it should make it easier for recipients to complement other federal, state, local, and other funding streams.

Some funding sources might be more restrictive due to Congressional directives, appropriations language, or limitations attached to their authorizing legislation. Flexible funding such as PHIG can enhance grantee abilities to optimize other funding sources; an example of leveraging this way is described in the context of CDC’s injury prevention funding.

13 This ability to direct and leverage PHIG funding according to recipient needs is clearly reflected in the breadth of activities being implemented across recipients, as evident in their work plans. We randomly selected 4 year-1 workplans from each eligibility category of component A recipients and summarized the work proposed (Table 2).

The random selections included a city (Milwaukee, WI), county (Wake County, NC), territory (US Virgin Islands or USVI), and state (Connecticut or CT) health department. For greater comparability, workforce and foundational capabilities information is provided. All 4 recipients are hiring a senior workforce director and an evaluator, as required.

Other hires reflect recipients’ needs and range from a clinic operations director (Milwaukee) to a process improvement director (USVI) and program coordinators for health equity partnerships (CT). Across these recipients, some hiring is under workforce (A1) and some is under foundational capabilities (A2).

Both Milwaukee and USVI planned to retain several staff funded through other means (eg, a graphic designer, a strategist, a program manager, and a fiscal coordinator), suggesting how PHIG complements other funding streams. Wake County chose to support and train existing staff over adding new hires, compared to the other recipients shown.

Some systems and policy changes represented include Milwaukee’s and Connecticut’s intention to revise job pay scales or review compensation levels (funded under A1 workforce) and USVI’s plans to upgrade their HR system (funded under A2 foundational capabilities).

Some activities are directed toward specific public health program areas, such as in USVI and Connecticut, which call out new investments in environmental health; most of the other activities across these recipients are crosscutting and foundational, intended to benefit staff across program areas (eg, workforce wellness programs) or to strengthen functions that serve many programs (eg, improved human resource recruitment and grants management).

These crosscutting functions can be difficult to support through more categorical or disease-specific funding. Together these examples demonstrate PHIG’s workforce and infrastructure focus and its flexibility in action.

#### Feature 3: More equitable funding approach This grant adopted the innovation made by the COVID-19 health disparities grant, which funded the largest number of state, territorial, and local public health department recipients (108) through a single grant in CDC’s history.

10 By including 49 city and county health departments, 8 freely associated states and territories, and all 50 US states, PHIG reduces steps and costs by awarding more funds directly to the local level rather than through the state first. Many of the local and territorial recipients have not been routinely funded by the CDC through its various other funding mechanisms (eg, El Paso, Texas; Mecklenburg County, NC).

This inclusivity as part of PHIG’s funding model further supports more local control and broader representation within the recipient community. The COVID-19 health disparities grant also led the way on incorporating measures of community vulnerability in the funding formula used to allocate funding, to help direct more funding to where needs were greatest.

The formula for PHIG was transparent to applicants and incorporated population size and the US Census Bureau’s Community Resilience Estimates to direct allocation amounts.

14 Finally, ARPA’s appropriations provisions provided CDC an unusual opportunity to obligate 5 years of funding for workforce up front, allowing recipients more certainty about funding levels throughout the grants’ period of performance and more time to plan and implement planned activities.

This feature provided them with a longer planning and implementation horizon than the annual funding that is more characteristic of discretionary federal funding and associated with increased administrative burden. As a result, PHIG recipients can pace spending according to their own plans, needs, and capacity during the 5-year period of performance. The exclusion of tribes as direct applicants to PHIG raised questions about equity.

However, because Congress provided significant, specific funding to tribes (managed by the Indian Health Service) through ARPA, tribes were not included as intended recipients of PHIG. To build on this complementary support provided by ARPA, PHIG recipients are strongly encouraged to collaborate with tribal nations and organizations in their jurisdictions.

#### Feature 4: Extensive support Despite a limited time frame for developing PHIG, CDC conducted 8 listening sessions with different public health partners at local, state, and national levels concerning their workforce needs. These sessions provided an additional source of information for designing the grant and reinforced decisions regarding flexibility.

Holding these sessions reflected CDC’s desire to manage PHIG differently and establish an expectation of high levels of engagement, inclusivity, and partnership from the start. Component B of PHIG supports national partners in providing T/TA to component A recipients, conducting grant evaluation, and facilitating communication among all partners.

PHIG is unusual in including this multi-partner support within the same funding mechanism as the group those national partners will serve (ie, component A recipients). This design accelerated the implementation of component B (eg, by the end of year 1, over 200 T/TA requests had already been made to, and addressed by, these partners).

Being within one Notice of Funding Opportunity (NOFO) and program also supports coordination and collaboration both within CDC and among component A and B recipients (eg, the national partners share reporting and other timelines with component A recipients and work with the same CDC team).

CDC also embedded flexibility and streamlined requirements in component B recipients’ strategies, giving them greater choices to support the wide variety of needs anticipated of component A recipients and to adapt quickly as implementation unfolds.

In the large funding amount and flexibility provided to component B recipients, CDC sought to strengthen public health partnerships nationally by empowering those national partners to play a larger service role in this grant than often is possible. It also moves CDC away from being both primary steward of the funding and primary T/TA provider; under PHIG, the T/TA role is shared.

The goal is to strengthen partnerships among these national public health partners, their numerous sub-recipients, and the health departments so that those partnerships can thrive outside the grant confines. Examples of work conducted by the national partners, from regional and national grantee convening to training and evaluation planning, can be found at their website, phinfrastructure. org.

15 The site also highlights success stories from health department recipients across the 3 strategies under component A. ## [](https://pmc. ncbi.

nlm. nih. gov/articles/PMC11757086/)Discussion It is worth reflecting on what PHIG could have looked like if CDC had adopted design features typical of many of its legacy funding mechanisms.

The NOFO could have been focused on workforce alone, in line with the original authorizing language of ARPA, rather than embedded within a larger framework of public health infrastructure and alongside other foundational public health organizational investments.

The funding could have been awarded with more requirements attached, with many specific strategies to deploy, steps to complete, and other tasks, rather than offering maximal flexibility. The recipient base could have included mainly states, with hopes that the benefits trickle down to local entities, rather than to the broader funding base PHIG has.

Support for implementation and T/TA could have been funded through multiple other grants or contracts that had to be developed or adapted for this purpose, or not funded at all, with CDC trying to fill that gap.

Instead, CDC used the historic opportunity born from the challenges of the COVID-19 response and provided by Congress through ARPA to create a grant that more fully prioritizes public health departments’ own needs and provides them more direct control, in hopes of accelerating change and strengthening services.

For both recipients and CDC, the grant may serve as a strong model for future funding and represent an efficient means of awarding future federal funding for public health workforce and infrastructure to state, local, and territorial health departments. Expectations for PHIG as both a potential model for funding and as a means for uplifting the governmental public health workforce and infrastructure are justifiably high.

However, they need to be tempered with realism. Implementation has just begun, and the extent of transformation, achievements, and challenges to come is unknown. PHIG is only a 5-year grant seeking to address workforce and infrastructure weaknesses that began decades before through a complex set of causes.

16–18 We also need to recognize that investments in governmental public health address only a part of the larger public health system in the United States, which involves nonprofit, academic, and other nongovernmental partners.

Although the funding amount is substantial, it falls short of what others have estimated that just state and local health departments need to provide a core package of comprehensive public health services in their communities, at approximately $4. 5 billion annually.

19 Moreover, substantial resources are being invested in grant evaluation through component B, but implementation and evaluation might occur too slowly or encounter challenges that hinder CDC and its partners from assessing success and (if warranted) making a strong case for continuation in time to sustain the investments made.

For example, longstanding policy and system barriers to hiring staff rapidly cannot be alleviated by a financial infusion alone. Also, PHIG’s flexibility represents an added challenge for program evaluation; when the programs being evaluated are so disparate, typical evaluation approaches need to be adapted.

20 Other potential risks include new public health challenges such as new outbreaks or other emergencies that could derail plans for more fundamental transformation. Success also relies on CDC and its partners committing significant energy to ongoing change after the COVID-19 pandemic, a period that exhausted the best of governmental public health leadership and staff.

21,22 The risks of not investing more in the public health workforce are high. Evidence of the need to strengthen the public health workforce had been building for years. 27–29 A recent analysis reported high levels of separation from governmental public health before and during the pandemic, indicating that without additional support, the public health workforce might weaken further.

30 The objective of PHIG and similar efforts is not only to prevent further loss or weakening but also to actively strengthen the governmental public health workforce. Recognizing the invaluable role that this workforce plays in public health and the need to support its growth and development is imperative at this juncture.

The approach used in PHIG is a step in the right direction toward building a public health workforce that can support the public health infrastructure needed to help safeguard the well-being of our communities. ## [](https://pmc. ncbi.

nlm. nih.

gov/articles/PMC11757086/)Acknowledgments Many thanks to Christina Chung, Christine Graaf, Yanelis Gonzales, Tamara Lamia, Stacey Mattison Jenkins, Karen Mumford, and various other staff in CDC’s National Center for State, Tribal, Local, and Territorial Infrastructure and Workforce for feedback on this paper and to all the people and recipients involved in the Public Health Infrastructure Grant who strive to make this unique initiative a success.

The findings and conclusions of this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The authors declare no conflicts of interest. ## [](https://pmc.

ncbi. nlm. nih.

gov/articles/PMC11757086/)References * 1.. Bipartisan Policy Center. _Public Health Forward: Modernizing the U.S. Public Health System_.

2021. https://bipartisanpolicy. org/download/?

file=/wp-content/uploads/2021/12/BPC_Public-Health-Forward_R01_WEB. pdf. Accessed July 3, 2023.

[Google Scholar] * 3.. The Commonwealth Fund. _Meeting America’s Public Health Challenge: Recommendations for Building a National Public Health System That Addresses Ongoing and Future Health Crises, Advances Equity, and Earns Trust_.

2022. https://www. commonwealthfund.

org/sites/default/files/2022-07/TCF-002%20National%20Public%20Heath%20System%20Report-r5-final. pdf. Accessed July 3, 2023.

[Google Scholar] * 4.. Congress t. _American Rescue Plan Act of 2021_.

US Congress; 2021. [Google Scholar] * 5.. Centers for Disease Control and Prevention.

_Public health infrastructure grant. Internet_. Centers for Disease Control and Prevention.

https://www. cdc. gov/infrastructure/phig/index.

html. Updated December 15, 2023. Accessed May 2, 2024.

[Google Scholar] * 6.. Centers for Disease Control and Prevention. _Data modernization initiative.

Internet_. Centers for Disease Control and Prevention. https://www.

cdc. gov/surveillance/data-modernization/index. html.

July 3, 2023. Updated April 7, 2023. [Google Scholar] * 7..

Public Health National Center for Innovation. _Transforming public health through the FPHS. Internet_.

Public Health National Center for Innovation. https://phnci. org/transformation/fphs.

June 30, 2023. [Google Scholar] * 8.. Centers for Disease Control and Prevention.

_Epidemiology and laboratory capacity (ELC). Internet_. Centers for Disease Control and Prevention.

https://www. cdc. gov/elc/index.

html. Updated April 3, 2020. Accessed February 15, 2024.

[Google Scholar] * 9.. Centers for Disease Control and Prevention. _Public health emergency preparedness program and guidance.

Internet_. Centers for Disease Control and Prevention. https://www.

cdc. gov/orr/readiness/phep/index. htm.

Updated February 2, 2024. Accessed February 15, 2024. [Google Scholar] * 10..

Centers for Disease Control and Prevention. _National initiative to address COVID-19 health disparities among populations at high-risk and underserved, including racial and ethnic minority populations and rural communities. Internet_.

Centers for Disease Control and Prevention. https://www. cdc.

gov/publichealthgateway/partnerships/COVID-19-Health-Disparities-OT21-2103. html. Updated September 1, 2023.

Accessed May 2, 2024. [Google Scholar] * 11.. Centers for Disease Control and Prevention.

_Strengthening public health systems and services in Indian country. Internet_. Centers for Disease Control and Prevention.

https://www. cdc. gov/tribal/cooperative-agreements/indian-country-services/nofo_overview.

html. Updated September 29, 2023. Accessed February 16, 2024.

[Google Scholar] * 12.. Centers for Disease Control and Prevention. _Preventive Health and Health Services (PHHS) block grant.

Internet_. Centers for Disease Control and Prevention. https://www.

cdc. gov/phhsblockgrant/index. htm.

Updated February 28, 2023. Accessed May 2, 2024. [Google Scholar] * 13..

Deokar, Dellapenna, DeFiore-Hyrmer, _et al. _ State injury programs’ response to the opioid epidemic: the role of CDC’s Core Violence and Injury Prevention Program. _J Public Health Manag Pract_.

2018;24(Suppl 1):S23–S31. doi: doi: 10. 1097/phh.

0000000000000704 . [DOI] [PMC free article] [PubMed] [Google Scholar] * 14.. United States Census Bureau.

_Measuring community resilience equitably. Internet_. United States Census Bureau.

https://www. census. gov/library/stories/2022/01/measuring-community-resilience-equitably.

html#:~:text=The%20Community%20Resilience%20Estimates%20provide%20an%20easily%20understood,estimates%20are%20based%20on%2010%20resilience-related%20risk%20factors. July 3, 2023. Updated June 12, 2023.

[Google Scholar] * 15.. _Public Health Infrastructure Grant National Partners_. PHIG partners.

Webpage. https://www. phinfrastructure.

org/. Accessed July 1, 2024. [Google Scholar] * 16..

DeSalvo, Wang, Harris, Auerbach, Koo, O’Carroll. Public Health 3. 0: a call to action for public health to meet the challenges of the 21st Century.

_Prev Chronic Dis_. 2017, Sep 7;14: E78. doi: doi: 10.

5888/pcd14. 170017 . [DOI] [PMC free article] [PubMed] [Google Scholar] * 17..

Institute of Medicine. _The Future of Public Health_. The National Academies Press; 1988.

[PubMed] [Google Scholar] * 18.. Institute of Medicine. _The Future of the Public’s Health in the 21st Century_.

National Academies Press (US); 2003. [Google Scholar] * 19.. Trust for America’s Health.

_The impact of chronic underfunding on America’s Public Health System: trends, risks, and recommendations, 2023. Internet_. Trust for America’s Health.

https://www. tfah. org/report-details/funding-2023/.

July 3, 2023. [Google Scholar] * 20.. Lamia, Lowry, McLees, Frazier, Young.

Improving outcome accountability of block grants: lessons learned from the preventive health and health services block grant evaluation. _Am J Eval_. 2020;42(2):185–200.

doi: doi: 10. 1177/1098214020904137 . [DOI] [PMC free article] [PubMed] [Google Scholar] * 21..

Hare Bork, Robins, Schaffer, Leider, Castrucci. workplace perceptions and experiences related to COVID-19 response efforts among public health workers—public health workforce interests and needs survey, United States. _MMWR Morb Mortal Wkly Rep_.

2022;71(29):920–924. doi: doi: 10. 15585/mmwr.

mm7129a3 . [DOI] [PMC free article] [PubMed] [Google Scholar] * 22.. Yeager.

The politicization of public health and the impact on health officials and the workforce: charting a path forward. _Am J Public Health_. 2022;112(5):734–735.

doi: doi: 10. 2105/AJPH. 2022.

306744 . [DOI] [PMC free article] [PubMed] [Google Scholar] * 23.. AmeriCorps.

_Public Health AmeriCorps. Internet_. Center for National Service.

https://americorps. gov/about/what-we-do/public-health-americorps. July 3, 2023.

[Google Scholar] * 24.. _HHS announces availability of nearly $48 million to increase the public health workforce in rural and tribal communities_. 2021.

https://public3. pagefreezer. com/browse/HHS.

gov/30-12-2021T15:27/https:/www. hhs. gov/about/news/2021/12/23/hhs-announces-availability-nearly-48-million-to-increase-public-health-workforce-rural-tribal-communities.

html. December 23, 2021. [Google Scholar] * 25..

_HHS announces $226. 5 million to launch Community Health Worker Training Program_. U.S. Department of Health and Human Services, 2022.

https://www. hhs. gov/about/news/2022/04/15/hhs-announces-226-million-launch-community-health-worker-training-program.

html. April 15, 2022. [Google Scholar] * 26..

Centers for Disease Control and Prevention. _CDC moving forward. Internet_.

Centers for Disease Control and Prevention. https://www. cdc.

gov/about/organization/cdc-moving-forward. html. Updated April 15, 2024.

Accessed May 2, 2024. [Google Scholar] * 27.. Carlin, Ensign, Person, Kittle, Meadows.

State of the public health workforce: trends and challenges leading up to the COVID-19 pandemic. _J Public Health Manag Pract_. 2021;27(1):92–93.

doi: doi: 10. 1097/PHH. 0000000000001294 .

[DOI] [PubMed] [Google Scholar] * 28.. Leider, Yeager, Kirkland, Krasna, Hare Bork, Resnick. The state of the US public health workforce: ongoing challenges and future directions.

_Annu Rev Public Health_. 2023; 44(1):323–341. doi: doi: 10.

1146/annurev-publhealth-071421-032830 . [DOI] [PubMed] [Google Scholar] * 29.. Leider, McCullough, Singh, _et al.

_ Staffing up and sustaining the public health workforce. _J Public Health Manag Pract_. 2023;29(3):E100–E107.

doi: doi: 10. 1097/PHH. 0000000000001614 .

[DOI] [PubMed] [Google Scholar] * 30.. Leider, Castrucci, Robins, _et al. _ The exodus of state and local public health employees: separations started before and continued throughout COVID-19.

_Health Aff (Millwood)_. 2023;42 (3):338–348. doi: doi: 10.

1377/hlthaff. 2022. 01251 .

[DOI] [PubMed] [Google Scholar]