The COVID-19 pandemic offers an unprecedented opportunity to examine federalism in action. To better understand the strengths and vulnerabilities of the U.S. intergovernmental responses, the National Academy of Public Administration (The Academy) developed a Working Group on the Intergovernmental Dimensions of the COVID-19 Pandemic in the Spring of 2021. They aimed to create actionable recommendations to facilitate the nation’s response to this pandemic and future events. After dedicating a year to this study, the Academy’s published their report, Intergovernmental Dimensions of the COVID-19 Responses and Consequences, in March 2022.

Since then, several other groups have published reports assessing government performance and opportunities for improvement. The Academy’s Center for Intergovernmental Partnerships (The Center) compared the Working Group’s report to three other reports to further examine this complex intergovernmental problem and potentially find common ground in their actionable recommendations:

• The United States Government Accountability Office (GAO)
• The National Academy of Sciences, Engineering, and Medicine (NASEM)
• Trust for America’s Health (TFAH)

In total, the four reports contain 56 actionable recommendations. The Center grouped them into four categories: testing for COVID-19, vaccine distribution, non-pharmaceutical interventions for infection risk reduction, and cross-cutting and over-arching issues. An analysis of the categories led to several themes for intergovernmental collaboration: 

1. Modernize public health data collection and sharing. 
2. Improve vaccine distribution. 
3. Improve government transparency and accountability to strengthen trust among stakeholders.
4. Improve procurement of Personal Protective Equipment (PPE) and supply chain.

Theme 1: Modernize Public Health Data Collection and Sharing.

Most acutely, in the early days of the pandemic, officials lacked data that would allow them to understand the spread and impact of COVID-19 within the United States. Several recommendations focus on addressing this issue. Federal, state, and local governments should coordinate with industry stakeholders to invest in a fully online, accessible, integrated public health data system. The system should be able to support reporting, monitoring, evaluation, and quality management of medical countermeasures. To ensure interoperability and coordination, the U.S. Department of Health and Human Services (HHS) should map the structure, technologies, and processes of the data systems needed to guide federal responses to COVID-19 in 2020. Then the U.S. Department of Labor (DOL) should ensure the new data systems include mechanisms that default to case assignment and prioritization consistent with established policies.

Theme 2: Improve Vaccine Distribution.

As vaccines became available, federal, state, and local governments did not have the infrastructure needed to distribute vaccines. HHS should enable local jurisdictions to lead efforts to reach higher-risk communities. Other vaccine-related HHS recommendations included maintaining a major vaccine acceptance public health program, assessing the needs of the U.S. Public Health Service (PHS) to support outbreak responses, establishing clear vaccination prioritization standards, and requiring all states to track vaccine distribution. Additionally, the HHS should recognize the critical function of the Public Health Emergency Medical Countermeasures Enterprise (PHEMCE) and reaffirm its mandate as the nation’s coordinating body for all aspects of medical countermeasures preparedness and response programs. The Center for Disease Control (CDC)  must encourage public health facilities and private laboratories to enhance laboratory surge testing capacity and asses the needs for goods and services to manufacture and develop diagnostic test kits in public health emergencies. Vaccine infrastructure improvements must also receive the support of policy makers, who should support investment in accelerating the development and distribution of medical countermeasures.

Theme 3: Improve government transparency and accountability to strengthen trust among stakeholders.

Mistrust of government and medical institutions and anti-vaccination disinformation campaigns dampened demand for vaccines. To reverse the situation, the HHS should invest in efforts to promote public trust in the government’s response to health emergencies. An Academy-sponsored expert panel could help develop recommendations on promoting transparency and accountability in intergovernmental public health responses. Similarly, Congress should create a COVID-19 Commission to review and address gaps in the pandemic response. Finally, recommendations urged the Office of the Assistant Secretary for Preparedness and Response to restructure PHEMCE to develop transparent and deliberative outreach practices and communication strategies across all levels of government, featuring clear authorities, roles, and responsibilities for private-sector partners, stakeholders, and the public.

Theme 4: Improve the procurement of Personal Protective Equipment (PPE) and the supply chain.

A “just-in-time” system for medical inventories can work well when the supply chain is functioning. It proved inadequate in the face of the massive disruption caused by the pandemic. HHS must work with relevant health sector stakeholder organizations to ensure the medical supply chain can provide enough PPE to hospitals and establish a working capital fund for the Strategic National Stockpile (SNS). Other recommendations urge HHS to collaborate with industry partners, government procurement organizations, supply chain industry leaders, and standards-setting bodies to promote and adopt blockchain standards for PPE manufacturers, distributors, and intermediaries. HHS should update its current policies and procedures for the SNS to document its procurement process and address payment integrity risks. Lastly, PHEMCE should conduct a root-cause assessment of lessons learned from COVID and previous public health emergencies specific to the SNS.

Common ground among these four major reports, conducted by distinct groups of experts and practitioners, bolsters their validity. These actionable recommendations chart a course forward, encouraging intergovernmental collaboration to identify obstacles, develop strategies to overcome them, and share innovative, promising practices.

Since the Center conducted this analysis, several other groups have assessed the intergovernmental pandemic response, contributed valuable insights, and provided recommendations in this space:

• The UCSF Institute for Global Health Sciences
• The Public Policy Center of the Conference Board
• The Kaiser Permanente
• The American Hospital Association
• The American Medical Association 

---

This post was written by Zamira Rodriguez, Research Associate of the National Academy of Public Administration’s Center for Intergovernmental Partnerships. She worked directly with several Academy Fellows to collect and analyze the reports which lead to this summary.