The COVID-19 pandemic magnified long-standing health disparities, showing that certain populations are at higher risk for effects of public health emergencies than others. The pandemic response also put demands on the nation's health departments and stretched their limited resources. In 2021, the Centers for Disease Control and Prevention launched the National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities (hereinafter, COVID-19 Health Disparities Grant) to reduce COVID-19 health disparities and advance health equity. Health departments in all 50 states, 50 localities, 5 territories, and 3 freely associated states were recipients of approximately $2.25 billion. This study explored the extent to which investments from the COVID-19 Health Disparities Grant, through the allocation of funds across 5 strategies, correspond to reported changes in recipient health departments' capacity to address the COVID-19 public health emergency and future emergencies as measured in the Health Department and Jurisdiction Capacity Survey in 2023. The survey measured capacity along 4 domains: workforce and human resources, interorganizational relationships, data and informational resources, and governance and planning. In total, 70 of 75 recipients who responded to the survey reported that they began with low capacity in at least 1 capacity domain and advanced their capacity during grant implementation. This study demonstrated the reported value of investments in health departments to build capacity and infrastructure to address health disparities and advance health equity to respond to future public health emergencies.

The flexibility federal block grants provide recipients poses challenges for evaluation. These challenges include aggregating data on wide-ranging activities grant recipients implement and the outcomes they achieve. In 2014, we began designing an evaluation to address the challenges of assessing outcomes and to improve outcome accountability for the Preventive Health and Health Services Block Grant. Through the use of evaluability assessment methodology, review of existing data and the literature, and key informant interviews, we developed a measurement framework to assess outcomes resulting from recipients’ ability to use grant funds to meet their locally prioritized needs. We argue our evaluation approach demonstrates that block grants, and other similarly flexible programs, can be evaluated through appropriately designed measures. Our efforts challenge the idea that flexibility presents an insurmountable barrier to evaluation and outcome accountability for federal block grants.