“We shape our buildings,” Winston Churchill once said, “and afterwards our buildings shape us.” The same could be said of an organization’s structure and its ongoing impact on members of the public, grantees, community organizations, employees, and many others. The Department of Health and Human Services’ (HHS’) performance during the Covid-19 pandemic was heavily scrutinized amidst the expiration of the public health emergency earlier this year. Even before the expiration the White House announced the resignation of the Center for Disease Control and Prevention’s (CDC’s) director. In this context, it is worth exploring HHS’s organizational structure as one reason why challenges may exist and persist during public health emergencies as Covid-19, Ebola, Avian Influenza (H1N1) and even the Opioid Crisis.
HHS’ current complicated organizational structure does not set the Department up for success, especially during crises. When he led in 1979 what was then the Department of Health, Education, and Welfare, Secretary Joseph A. Califano described overseeing 150,000 employees working on 271 health programs and supported by 298 advisory committees
More than 20 years later, a hypothetical HHS Secretary would oversee a department of “more than 60,000 employees, more than 300 programs, and a budget of more than $400 billion in 2001” according to Beryl Radin, herself a former HHS official. By 2023, the HHS Secretary manages a Department with a budget of $1.7 trillion, overseeing more than 80,000 employees and about 241 active advisory committees. It is little wonder that Donna Shalala, a former HHS Secretary, once observed that “[b]ecause of its size and complexity, HHS is one of the most difficult jobs in the world for a public official.”
In addition to Administration for Strategic Preparedness & Response, CDC, and Food and Drug Administration, among HHS’s 12 operating divisions and 15 separate offices the National Institutes of Health, Health Resources & Services Administration and others also have important emergency preparedness roles– as do many other federal Departments and Agencies. Operating throughout HHS as well is the US Public Health Service, with its more than 6000 uniformed Commissioned Corps members housed in various HHS agencies.
Periodically, there have been attempts to analyze HHS organization and recommend potential improvements. The Government Accountability Office has recently observed that HHS’s “structural characteristics” – such as the role of advisory committees, political appointees and Senate confirmation requirements for agency leaders – may impact their functioning. The same is true of how the various agencies and offices interact within HHS as a whole.
As the Covid-19 emergency recedes, at least in part, and before new emergencies make themselves felt, it may be worthwhile once again to take a careful, objective, and thorough look at HHS’ organizational structure, especially in relation to how the Department works internally and with other federal, state, local, tribal and territorial partners to support the nation’s public health emergency preparedness, mitigation and response. Such changes could strengthen the agency’s innovation and compliance posture.
Changes in HHS structure, along with well-funded and staffed partners at the state, local, tribal and territorial levels, may prove helpful for success during future public health emergencies and can help earn and maintain the public’s trust. As the authors of the Covid Resilience Ranking, observe: “[i]f there’s one lesson that the Covid era has made clear, it’s that societies with [a] strong component of trust and cohesion are in the best position to weather a crisis of this scale.” Further careful evaluation of HHS’ organizational structure and dynamics, is one step forward toward this goal.
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