From the Chief Medical Officer: Braiding and Layering Funding Amplifies Public Health Impact

July 03, 2024 | Marcus Plescia

At ASTHO’s Policy Summit in 2023, state and territorial health officials engaged leadership of CDC’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) in a discussion about funding constraints across the Centers’ divisions. I was particularly interested in this conversation because of my own experience earlier in my career as the chronic disease director at the North Carolina Division of Public Health, where we attempted to integrate the state’s chronic disease programs to build leadership, surveillance, and epidemiologic capacity.

The division gained support from NCCDPHP leadership to explore opportunities to better integrate disease-specific funding lines to meet states’ needs. CDC selected North Carolina as one of four state participants—along with Colorado, Massachusetts, and Wisconsin—for a pilot project, in pursuit of determining policy, management, and procedural practices to better integrate state chronic disease programs. The overall experience and results led CDC to develop a combined five-year funding opportunity that allowed states to blend staff roles and offer more comprehensive options for state outcome objectives and program deliverables.

Since then, many states and territories have successfully obtained more flexibility in how they use CDC categorical funding. Braiding and layering, or strategically integrating multiple funding streams from various sources to support comprehensive public health initiatives, has emerged as a descriptive term for these efforts. In public health, where every dollar can help save lives and serve communities, the pursuit of innovative and efficient funding strategies is strategic. As a transformative funding approach, braiding and layering allows state health departments to leverage diverse funding sources and amplify their impact, which has been particularly instrumental in addressing social determinants of health (SDOH) and multi-sector prevention efforts.

Understanding Braiding and Layering

Braiding and layering refers to coordinating two or more funds to achieve a shared goal:

• Braiding weaves together funds from different sources to support complementary activities or a common purpose. Each funding stream is typically still required to be tracked and reported on individually, though the individual reporting measures may be rolled up across all funding streams to show collective impact across funders.
• Layering (formerly known as “blending”) stacks or pools multiple funding streams together to maximize resources for a specific program or intervention; the present term describes the intricacies and nuances of these complex financial arrangements more accurately. Typically, the funder must approve layering, and officials managing layered funds are required to report on a single set of requirements or measures rather than report each source separately.

By intertwining funds from federal, state, local, and private sources, state health departments can create a more robust financial foundation that empowers them to tackle complex health challenges holistically. Effective braiding and layering strategies also further the importance of defining shared goals between multiple program areas and divisions. Unlike traditional funding models that operate in silos, braiding and layering fosters collaboration, flexibility, and synergy among different funding streams allowing state health officials to fulfill their emerging role as chief health strategists.

Integrating Social Determinants of Health to Advance Health Equity

Through braiding and layering, state health departments have directed resources towards interventions that address SDOH, such as affordable housing initiatives, access to nutritious food, transportation services, and community development projects. By targeting the root causes of health inequities, this approach not only improves health outcomes but also fosters resilience and empowerment within communities.

Rhode Island has been a leader in this area—it has drawn from a variety of categorical funding to support the work of its health equity zones, which are designed to support a community-driven approach to health equity and SDOH. Early in my tenure at ASTHO, we engaged a number of states in a learning collaborative focused on adapting the health equity zone approach, informing resources on braiding and layering funds on many of the SDOH—e.g., access to care, food insecurity (retail and access), housing for individuals living with substance use disorders, and housing for older adults and persons with disabilities. Many states have adopted a braided funding approach to community health challenges; for example, the Arizona Department of Health Services braided state and federal funding to launch a 24/7 service that coordinates medical transfers between critical access and Indian Health Service hospitals, which has grown to include over 230 hospitals and supported the transfers of over 10,000 patients.

Leading Change in Public Health Funding

The integration of braiding and layering within state health departments represents a paradigm shift in public health funding. By embracing this approach, health officials can unlock new opportunities to address complex health challenges, promote health equity, and build resilient communities. As we navigate an ever-evolving landscape of health disparities, social determinants, and uncertain financial times, it is vital that we provide perspective and leadership on current public health funding mechanisms.

My experience, in North Carolina and in more recent conversations, is that CDC leadership is willing to support these flexible approaches to using categorical funding. The emphasis on addressing “syndemic conditions” in the National Center for HIV, Viral Hepatitis, STD, and TB Prevention is a recent example. However, the long-held tradition of categorical funding from Congress, the power of disease-specific advocacy groups, and the personal experience and passion that public health staff often bring to certain conditions like cancer and HIV are challenges to braiding and layering. States have used several strategies to overcome these barriers, including articulating clear objectives for funding and program changes, engaging programmatic staff in these change efforts, and focusing on crosscutting approaches like policy change and health systems collaboration.

Ultimately creative approaches like these require leadership to encourage program and administrative staff to take advantage of federal funding flexibilities and move beyond traditional disease-specific programming.