State and Island health agencies can learn from the Commonwealth of the Northern Mariana Islands’ journey to restructure its Non-Communicable Disease Bureau to promote local ownership and facilitate braided and layered funding strategies.

Categorical funding limitations are the elephant in the room of governmental public health. Strong evidence, great ideas, and motivated staff are not sufficient to improve clients’ access to services and ensure programs improve population health. A health agency must also obtain, manage, and maintain funding that is flexible enough and of sufficient volume to deliver the right activities at the right time. In the article “Weaving and Layering Funding: A Territorial Health Agency’s Guide to Effective Health Financing,” we describe how one jurisdiction successfully shifted its financing strategies and organizational structures to reduce siloed, inefficient workflows and better address community health priorities.

The Commonwealth of the Northern Mariana Islands (CNMI) is a US territory located 3,226 miles west of Hawaii. The primary source of public health programming and acute care in CNMI is the Commonwealth Healthcare Corporation (CHCC), which serves CNMI’s 57,000 residents through one hospital, several outpatient clinics, a dialysis unit, behavioral health services, and all governmental public health programming. Between 2016 and 2021, CHCC restructured its Non-Communicable Disease Bureau to address community chronic disease priorities more efficiently and effectively through braided and layered funding.

Braiding and layering funding is a process through which categorical funding streams are brought together to support mutually beneficial activities. In the traditional model, categorical funding streams support separate activities, even when focused on the same client. The braiding and layering approach allows agencies to be more responsive to local population priorities and to ensure programming reflects population needs while meeting funder requirements.

Before restructuring, the CHCC NCD Bureau had four program areas. These divisions reflected the available funding streams: the Tobacco Prevention and Control Program, Diabetes Prevention and Control Program, Comprehensive Cancer Control Program, and Breast and Cervical Screening Program. The programs targeted some of CNMI’s top health priorities—preventing and reducing NCDs—but were hindered by often duplicative and inefficient workflows. Programs would often implement similar activities and approaches without leveraging complementary programs within the Bureau, even though many targeted the same population of high-risk individuals in the CNMI. CHCC sought to braid and layer these programs and their funding sources to better address the root causes and social determinants of health affecting chronic disease across the commonwealth.

CNMI’s restructure had three phrases. From 2016-2019, CHCC prioritized vision planning and establishing buy-in from agency leadership, community partners, funders, and agency staff. This included several staff retreats to build trust and promote collaboration across previously siloed programs. From 2019-2020, CHCC planned for the restructure by assessing NCD Bureau strategies and organizational structures, and mapping funder requirements to program functions. From 2020-2021, CHCC began implementation, with regular feedback from staff and leadership (eg, human resources and grants management), guided by updated strategic plans.

The newly restructured NCD Bureau has four crosscutting units organized by function rather than grant type: the Healthy Communities Unit, focused on primary prevention, policy, systems, and environmental change; the Surveillance and Evaluation Unit, focused on qualitative and quantitative data collection, monitoring, and reporting; the Health Management Unit, focused on secondary prevention; and the Health Promotions and Community Relations Unit, focused on multimedia development, comprehensive outreach, and community partnerships. Each unit incorporates funding from multiple chronic disease funding sources and carries out deliverables benefiting crosscutting chronic disease efforts, including tobacco, diabetes, and cancer control/prevention. Units are accountable to grant-specific activities, metrics, and reporting requirements, which are regularly reviewed by unit leadership. Each unit also meets with funders annually to affirm that crosscutting structures will support grant-specific requirements, emphasizing how grant funding can be more impactful in the new, more efficient structure. All grant applications from CHCC now include standard language regarding crosscutting organizational structures.

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Although it will take several years for CHCC to fully evaluate the impact of its new structures and financing strategies, preliminary data indicate these changes have improved program operations and reach, as well as prompted a more cohesive Bureau. CHCC is confident this funding and organizational approach will allow the agency to more efficiently and effectively respond to its community’s top health priorities. CHCC encourages other agencies to consider braiding and layering funding strategies as they seek to leverage categorical funding opportunities toward sustainable health system development. CNMI also highlights three tips to help jurisdictions carry out an organizational restructure and implement braided and layered funding: (1) communicate early, consistently, and transparently to promote widespread commitment to the restructure; (2) allocate additional time, staff, and infrastructure to facilitate the transition; and (3) offer ongoing training to help staff adjust to and best operate in braided and layered environments.

To learn more about the CNMI CHCC’s journey with braided and layered funding, check out our article, “Weaving and Layering Funding: A Territorial Health Agency’s Guide to Effective Health Financing,” published in the July/August issue of JPHMP.

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Alex Wheatley is the Assistant Director, Island Support, at the Association of State and Territorial Health Officials (ASTHO). Her work seeks to advance health equity for the territories and freely associated states through legislative and administrative policy change. She is a graduate of Princeton University (BA, MPA).

Karl Ensign is Vice President for Island Support at ASTHO. As a member of the executive team, he strategizes with ASTHO’s programs and activities to ensure their relevance to island members in the Pacific and the Atlantic. ASTHO is the only non-profit organization dedicated to advancing state and territorial public health.

Amber Mendiola is the Administrator for the Non-Communicable Disease Bureau, at the Commonwealth Healthcare Corporation. She is the designated liaison for the state/local led chronic disease prevention and control programs and services. Amber oversaw and coordinated the organizational restructure of the NCD Bureau

Sharon Gilmartin is the Deputy Director of the Safe States Alliance, a nonprofit and membership organization whose mission is to strengthen the practice of injury and violence prevention. Sharon oversees the organization’s programmatic portfolio, partnering with state and local health departments, hospitals, and other practitioners to advance equitable strategies for prevention.

Casierra Cruz is the Health Equity Strategist for the Pacific Region under the OT21-2103 Health Disparities Program. She is passionate about working with communities to develop sustainable solutions to improve health outcomes. She also serves as a Faculty Instructor in the School of Health at the University of Guam.

Michael Fraser, PhD, MS, CAE, FCPP, is the chief executive officer at ASTHO.