The Impact of Federal Public Health Funding on Sexually Transmitted Disease Outcomes

Federal public health funding is a major component of sexually transmitted disease (STD) prevention efforts in the United States. The Division of STD Prevention (DSTDP) at the Centers for Disease Control and Prevention allocates annual funds to 57 project areas across the country (50 states plus 7 distinct metropolitan areas). This funding helps achieve various division goals, which include reducing the incidence of STDs in the United States and decreasing health disparities in STDs. This paper estimates the impact of changes in funding on both of these outcomes from 1981 to 2016. Variation in project area funding comes from changes in the overall budget of DSTDP, as well as changes in how the division distributes funds among recipients. Between 2013 and 2014, funding became more targeted to areas with historically higher STD burdens. One empirical concern when estimating the impact of funding on incidence is that more funds will be targeted at areas with relatively larger expected increases in STD rates. To account for this, DSTDP rules governing funding allocations are used to develop an instrumental variable that strongly predicts funding levels but is unrelated to contemporaneous changes in reported STD rates. Specifically, DSTDP requires funding reductions to no exceed 5 percent annually and sets limits on the overall levels of gains and reductions. This induces variation in funding allocation that is based on historic funding rates and unrelated to current changes in incidence. Project areas may use funds to increase STD screening efforts, which may lead to more cases being detected even if true incidence remains unchanged. To account for this possibility, the paper focuses on gonorrhea in males, which is less likely to be asymptomatic than in females or for other common bacterial STDs. Because of this, men with gonorrhea generally seek out treatment, so identification of new cases is less dependent on STD screening efforts in their area. Preliminary results find that a one percent increase in funding decreases male gonorrhea rates by 0.96 percent. Further, findings estimate that the change in distribution of funds starting in 2014 led to 7.5 percent fewer reported cases over 2014-2016 than if the funding allocation had remained unchanged. Finally, the impact of funding on racial disparities in gonorrhea outcomes depends on whether an absolute or relative disparity measure is used. Findings suggest that targeting public health funds may lead to improved efficiency, and care must be taken when interpreting changes in health disparity.