The “Infrastructure” of Public Health Infrastructure

Posted on October 17, 2025 by Jason Orr

This entry is part 62 of 62 in the series Wide World of Public Health Systems

Public health infrastructure is often invoked in policy discussions, particularly during crises like pandemics or natural disasters, yet the term itself is rarely unpacked. When we talk about infrastructure, we may envision bridges, power grids, or broadband networks. However, in the context of governmental public health, infrastructure refers to the essential services and capabilities that support a health department’s ability to protect and improve community health, regardless of disease or health issue. One challenge for governmental public health agencies is the funding structure. Categorical grants—federal or state funds directed toward specific diseases or health risks—have historically dominated public health finance. These grants are narrow, programmatic, and outcome-focused, which can be effective for delivering disease-specific interventions but tend to underfund cross-cutting infrastructure. Infrastructure, by contrast, supports the ability to deliver all programs effectively. For instance, a well-functioning communications office helps inform the public regardless of whether the topic is COVID-19, air quality alerts, or vaccination campaigns.

As a metaphor, consider your house to represent a governmental public health system that aims to deliver the Foundational Public Health Services (FPHS); see Figure 1 as a visual example. Certain rooms or locations within your house serve visible purposes or functions, such as the kitchen for cooking or the bathroom for, well, bathing. In this metaphor, the rooms of the house represent the Foundational Areas (FAs), which are ‘categorical services’ and programmatic priorities directed at specific health issues (e.g., diabetes control, tobacco cessation). However, underlying those rooms is a common infrastructure, such as the foundation, framing, electrical wiring, and plumbing. Continuing the metaphor, this infrastructure represents the Foundational Capabilities (FCs), which are cross-cutting functions that, while often invisible to the public eye, are critical to ensuring that health departments can function efficiently, equitably, and responsively. This infrastructure includes critical cross-cutting functions like assessment and surveillance, organizational competencies (e.g., workforce, governance, IT, legal capabilities), and policy development and support. They represent the underlying system that makes any public health effort possible—whether the goal is reducing chronic disease, addressing maternal and child health, or responding to a new infectious threat.

Figure 1. Cutaway of a House That Depicts Infrastructure and Rooms

Source: Umar Shah (ID 393494454), https://www.dreamstime.com/isometric-illustration-modern-house-interior-showcasing-cutaway-view-multiple-rooms-visible-rooms-include-kitchen-image393494454

Despite increased awareness on the importance of public health, supporting and funding public health infrastructure remains a challenge. In many locations, health departments are not specifically directed nor funded to deliver high-quality FCs. Health departments often operate with minimal core staff, underinvestment in IT systems, and outdated approaches to data collection or analysis (if even available). These deficits hamper response to both everyday challenges and emergencies. Revisiting the earlier metaphor, you could create a structure that has walls and rooms, but skimping on materials may have consequences for reliable access to resources (e.g., electricity, water), structural integrity, or comfort which may impede effective use of the room. The same applies to governmental public health systems in which resources may be allocated toward categorical services via the FAs but the underlying infrastructure of the FCs are dysfunded or underfunded.¹

Several efforts have brought infrastructure to the forefront. Governmental public health services models and frameworks have evolved—notably from the 3 Core Functions (1988) to the 10 Essential Public Health Services (1994) to a “minimum package of public health services” (2012) which led to the FPHS framework (2014)²—spurring discourse, policy, and research with each evolution. The Public Health Accreditation Board’s (PHAB’s) health department accreditation process—awarded to more than 450 governmental health departments and reaching 90% of the U.S. population—directly incentivizes high-quality infrastructure by requiring documented performance on FC-related standards. Similarly, the Center for Disease Control and Prevention’s (CDC’s) Public Health Infrastructure Grant (PHIG) and the National Initiative to Address COVID-19 Health Disparities (commonly referred to as the ‘Health Equity’ grant) have allowed governments to redirect attention to long-term infrastructure building and invest in their workforce, data systems, and foundational capabilities without the constraints of categorical funding. Importantly, many of the FCs require only modest investments in time or resources to make substantial improvements; for example, adopting templates or example materials submitted by health departments for accreditation by PHAB (and later awarded) is an excellent low-resource activity.

Looking forward, the field of public health and its many disciplines must grapple with how to define, measure, and sustain public health infrastructure. Data modernization, workforce development, and quality improvement initiatives may each offer promising practices for infrastructure improvement. Moreover, modest but strategic investments in infrastructure can yield long-term benefits: a single epidemiologist shared with or embedded in a small rural health department may improve surveillance, grant writing, and program design across all services. Rather than being an abstraction, public health infrastructure, like a building’s infrastructure, is critically important: only visible when it breaks, but essential every day. Public health leaders, policymakers, and funders must continue to elevate infrastructure as a core priority. Without robust infrastructure (i.e., FCs), even the most innovative or well-funded population health interventions can falter. If we expect governmental public health to promote health equity, respond to new threats, and build community trust, then we must recognize that infrastructure is not a luxury but a core component of the system.

Notes

For a similar depiction of the Foundational Public Health Services, please see this brief video produced by the Public Health Accreditation Board: Foundational Public Health Services (FPHS).

References

Orr JM, Leider JP, Hogg-Graham R, et al. Contemporary Public Health Finance: Varied Definitions, Patterns, and Implications. Annu Rev Public Health. 2023. doi: 10.1146/annurev-publhealth-013023-111124.
Orr JM, Leider JP, Singh S, et al. Regarding Investment in a Healthier Future: Impact of the 2012 Institute of Medicine Finance Report. J Public Health Manag Pract. 2022;28(1):E316-E323. doi: 10.1097/PHH.0000000000001209.

About the Author

Jason Orr: Jason Orr is a Researcher with the Center for Public Health Systems. He is experienced in policy analysis, mixed-methods research, and systems design. He holds an MPH from Kansas State University and a PhD in systems engineering from Colorado State University. His interests include public health services frameworks, collaborative service delivery, and public health finance and workforce issues.