a

GAO

United States General Accounting Office

Report to the Director of the Centers for 

Disease Control and Prevention

January 2004 CENTERS FOR 

DISEASE CONTROL 

AND PREVENTION

Agency Leadership 

Taking Steps to 

Improve Management 

and Planning, but 

Challenges Remain

GAO-04-219
www.gao.gov/cgi-bin/getrpt?GAO-04-219.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Marjorie E. 

Kanof at (202) 512-7101. 

Highlights of GAO-04-219, a report to the 

Director of the Centers for Disease Control 

and Prevention 

January 2004

CENTERS FOR DISEASE CONTROL AND 

PREVENTION 

Agency Leadership Taking Steps to 

Improve Management and Planning, but 

Challenges Remain 

The management team in CDC’s top office—OD—is undergoing a structural 

change designed to provide a new approach to managing the agency’s public 

health work. Through this effort, CDC has taken steps that have merit. For 

example, OD established a Chief Operating Officer position with clear 

oversight authority for the agency’s operations units, such as financial 

management and information technology. However, a significant oversight 

weakness remains: there is no position or combination of positions on OD’s 

management team below the Director’s level to oversee the programs and 

activities of 11 centers that perform the bulk of the agency’s public health 

work. Only CDC’s Director has line authority for the centers, and the 

extraordinary demands on the Director’s time associated with public health 

emergencies and other external events make the practicality of this 

oversight arrangement uncertain. Another of OD’s structural initiatives was 

to align OD management team positions with broad mission “themes,” or 

goals, that cut across the centers’ institutional boundaries. The intent was to 

foster among the 11 independent centers a more integrated approach to 

performing the agency’s mission. This purpose may be difficult to realize, 

however, as connections between certain themes and associated OD 

positions are not sufficiently clear. 

OD has made improvements in its ability to oversee the agency’s response to 

public health emergencies—including the creation of an emergency 

preparedness and response office and the development of an emergency 

communication system—but concerns remain about OD’s oversight of 

nonemergency public health work. OD’s efforts to monitor the activities of 

the centers are not sufficiently systematic. For example, few formal systems 

are in place to track the status of centers’ operations and programmatic 

activities. Although OD has a process for center officials to elevate 

important issues of concern, the information flow under this process is 

largely center-driven, as the subjects discussed are typically raised at the 

discretion of the center officials. Similarly, OD’s efforts to foster 

coordination among the centers fall short of institutionalizing collaboration 

as standard agency practice. 

The planning tools that OD needs to set agency priorities and address human 

capital challenges are under development. In recent years, OD has operated 

without an up-to-date agencywide planning strategy with which to set 

mission priorities and unify the work of CDC’s various centers. In June 2003, 

OD initiated an agencywide strategic planning process. In a separate 

planning effort initiated in April 2003, CDC began working on a human 

capital plan for meeting the agency’s current and future staffing needs. This 

effort has been suspended while the strategic planning process gets under 

way, and no time frames have been established for resuming its 

development. At the same time, agency attrition and future limits on 

workforce growth suggest that agency leadership may be needed to ensure 

that workforce planning occurs expeditiously. 

The scope of work at the Centers 

for Disease Control and Prevention 

(CDC) has evolved since 1946 from 

a focus on communicable diseases, 

like malaria, to a wide and complex 

range of public health 

responsibilities. The agency’s 

Office of the Director (OD) faces 

considerable management 

challenges to ensure that during 

public health crises the agency’s 

nonemergency but important 

public health work continues 

apace. In 2002, the agency’s OD 

began taking steps aimed at 

organizational change. GAO has 

observed elsewhere that major 

change management initiatives can 

take at least 5 to 7 years. In this 

report, GAO examined the extent 

to which organizational changes 

have helped balance OD’s oversight 

of CDC’s emergent and ongoing 

public health responsibilities. 

Specifically, GAO examined OD’s 

(1) executive management 

structure, (2) approach to 

overseeing the agency’s work, and 

(3) approach to setting the agency’s 

priorities. 

GAO recommends that the CDC 

Director ensure OD’s oversight of 

the centers’ programmatic work at 

a level below the Director, improve 

OD’s monitoring of the centers’ 

operations and programmatic 

activities, and ensure that the 

agency’s strategic and human 

capital planning are coordinated 

and done expeditiously. CDC 

responded with a series of actions 

to address these recommendations. 
Page i GAO-04-219 CDC Management 

Letter 1

Results in Brief 3

Background 5

Despite the Merit of Some Changes, CDC’s Executive Structure Is 

Not Well Aligned to Oversee Centers’ Programmatic Work 10

OD Has Improved Oversight of Public Health Emergencies, but 

Concerns Remain about Oversight of Ongoing Agency Activities 18

Planning Tools That OD Needs to Manage Agency Priorities and 

Human Capital Challenges Are Not Yet Operational 23

Conclusions 28

Recommendations for Executive Action 29

Agency Comments 30

Appendix I Scope and Methodology 32 

Appendix II Comments from the Centers for Disease Control 

and Prevention 35 

Table 

Table 1: OD’s Organizational Themes and Corresponding OD 

Management Positions 17

Figures 

Figure 1: CDC’s Funding and FTE Growth from Fiscal Years 1946 

to 2003 6

Figure 2: Principal Locations of CDC Employees within the United 

States 8

Figure 3: CDC Organization Chart as of November 1, 2003 9

Figure 4: OD Management Team Below the Director as of 

November 1, 2003 12

Figure 5: Senior Officials Reporting to CDC’s Director as of 

November 1, 2003 15

Figure 6: Timeline of High-Profile Public Health Events and 

Emergencies Requiring CDC Response 16

Contents 
Page ii GAO-04-219 CDC Management 

Abbreviations 

ATSDR Agency for Toxic Substances and Disease Registry 

CDC Centers for Disease Control and Prevention 

COO Chief Operating Officer 

FTE full-time equivalent 

GPRA Government Performance and Results Act of 1993 

HHS Department of Health and Human Services 

NCEH National Center for Environmental Health 

OD Office of the Director 

OTPER Office of Terrorism Preparedness and Emergency Response 

SARS severe acute respiratory syndrome 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. It may be reproduced and distributed in its entirety without further 

permission from GAO. However, because this work may contain copyrighted images or 

other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately. 
Page 1 GAO-04-219 CDC Management 

January 30, 2004 

The Honorable Julie L. Gerberding, MD, MPH 

Director, Centers for Disease Control and Prevention 

Dear Dr. Gerberding: 

As the national focal point for conducting disease prevention and control 

efforts, the Centers for Disease Control and Prevention (CDC) is widely 

recognized for its work in investigating disease outbreaks as well as its 

health promotion programs. Since it was established in 1946, CDC’s scope 

of work has evolved from a narrow focus on malaria control and other 

communicable diseases to a wide and complex range of public health 

responsibilities. Today, CDC’s mission is “to promote health and quality of 

life by preventing and controlling disease, injury, and disability.” 

Establishing and maintaining balance within this broad mission is an 

ongoing challenge for agency management. CDC, an agency in the 

Department of Health and Human Services (HHS), has the lead federal role 

in responding to infectious disease outbreaks, such as severe acute 

respiratory syndrome (SARS), monkeypox, and the West Nile virus. The 

agency is also responsible for addressing nonemergency public health 

concerns, such as chronic diseases (including heart disease, cancer, and 

diabetes), childhood immunizations, and environmental and occupational 

health matters. 

CDC’s agency management responsibilities are considerable. In fiscal year 

2003, CDC managed a budget of almost $7 billion and its full-time 

equivalent (FTE) staff numbered more than 8,800. Most of the agency’s 

staff are distributed across 11 centers, which are located at multiple sites.1

The centers are responsible for working with the agency’s external 

partners—which include state, local, and international public health 

agencies, among others—to carry out a range of public health activities. In 

addition, CDC’s Director serves as the administrator of HHS’s Agency for 

Toxic Substances and Disease Registry (ATSDR), which focuses on 

environmental health-related issues. CDC’s top office, the Office of the 

Director (OD), has overall management responsibility for CDC and 

ATSDR. 

 1

“Centers” refers collectively to the agency’s centers, institute, and program offices. 

United States General Accounting Office

Washington, DC 20548 
Page 2 GAO-04-219 CDC Management 

Over the past few years, concerns have surfaced about aspects of the 

agency’s management, beginning with weaknesses identified in the 

financial management area. A 1999 study by the HHS’s Office of Inspector 

General stated that one of CDC’s centers failed to report the redirection of 

some of its funds—a problem that highlighted shortcomings in top 

management’s knowledge about center operations.2

 In 2000, we reported 

that CDC’s financial management capabilities had not kept pace with the 

agency’s expanded mission and increased funding and that financial 

management was not a high priority relative to the agency’s other 

functions.3

 That same year, after the public health community’s response 

to the first outbreak of the West Nile virus, we reported that public health 

preparedness could be improved, in part, through better communication 

among public health agencies, including CDC.4

 During the 2001 anthrax 

incidents, the agency garnered criticism for its slow release of important 

information. In 2002, we subsequently reported internal management 

control weaknesses with CDC’s oversight of the Select Agent Program, 

which is responsible for regulating the transfer of certain biological agents 

and toxins—such as anthrax—to appropriate laboratories.5

In the wake of the anthrax incidents and SARS outbreak, CDC has 

emerged as a key player in preparing the nation for public health 

emergencies. In 2002, the agency’s OD spearheaded a number of initiatives 

aimed at organizational change. Such change is necessarily a long-term 

undertaking, requiring leadership and commitment. Experience shows that 

successful major change management initiatives in large private and 

public sector organizations can often take at least 5 to 7 years. This length 

of time and the frequent turnover of political leadership in the federal 

government have often made it difficult to obtain the sustained and 

 2

U.S. Department of Health and Human Services, Office of Inspector General, Audit of 

Costs Charged to the Chronic Fatigue Syndrome Program at the Centers for Disease 

Control and Prevention, A-04-98-04226 (Washington, D.C.: May 10, 1999). 

3

U.S. General Accounting Office, Centers for Disease Control and Prevention: Independent 

Accountants Identify Financial Management Weaknesses, GAO-01-40 (Washington, D.C.: 

Nov. 15, 2000). 

4

U.S. General Accounting Office, West Nile Virus Outbreak: Lessons for Public Health 

Preparedness, GAO/HEHS-00-180 (Washington, D.C.: Sept. 11, 2000). 

5

U.S. General Accounting Office, Homeland Security: CDC’s Oversight of the Select Agent 

Program, GAO-03-315R (Washington, D.C.: Nov. 22, 2002). 
Page 3 GAO-04-219 CDC Management 

inspired attention to make needed changes.6 At this time, OD’s structural 

and management changes are relatively new. This report examines the 

extent to which these changes have helped balance OD’s oversight of the 

agency’s emergent and ongoing public health responsibilities. Specifically, 

it examines OD’s (1) executive management structure, (2) approach to 

overseeing the agency’s work, and (3) approach to setting the agency’s 

priorities. 

In performing our review, we interviewed CDC senior executives within 

OD. We also met with senior managers responsible for agency operations 

and selected senior managers in six of the agency’s centers and ATSDR. 

We analyzed pertinent agency documents and interviewed officials at state 

and local health departments, health-care-related associations, nonprofit 

organizations, private industry, and schools of public health. We 

performed our work from June 2002 through January 2004 in accordance 

with generally accepted government auditing standards. (See app. I for 

further detail.) 

The management team in CDC’s top office—OD—is undergoing a 

structural change designed to provide a new approach to managing the 

agency’s public health work. Through this effort, CDC has taken steps that 

have merit. For example, OD established a Chief Operating Officer (COO) 

position with clear oversight authority for the agency’s operations units, 

such as financial management and information technology. However, a 

significant oversight weakness remains: no similar position or 

combination of positions on OD’s management team below the Director’s 

level has been established to oversee the programs and activities of the 

centers, which perform the bulk of the agency’s public health work. Only 

CDC’s Director has line authority for the centers, and the extraordinary 

demands on the Director’s time associated with public health emergencies 

and other external events make the practicality of this oversight 

arrangement uncertain. Another of OD’s structural initiatives was to align 

OD management team positions with five broad mission “themes,” or 

goals, that cut across the institutional boundaries of the centers. The 

intent was to foster among CDC’s 11 independent centers a more 

integrated approach to performing the agency’s mission. This purpose may 

 6

U.S. General Accounting Office, Results-Oriented Cultures: Implementation Steps to 

Assist Mergers and Organizational Transformations, GAO-03-669 (Washington, D.C.: July 

2, 2003). 

Results in Brief 
Page 4 GAO-04-219 CDC Management 

be difficult to realize, however, as connections between certain themes 

and associated OD positions are not sufficiently clear. 

OD has made significant improvements in directing the agency’s response 

to public health emergencies, but concerns remain about OD’s oversight of 

nonemergency public health work. An emergency preparedness and 

response office was created in OD that, during the SARS outbreak, 

successfully coordinated the response efforts of CDC’s various centers 

and OD staff offices. OD’s communications office also developed an 

emergency communication system that facilitates coordination among 

specialists agencywide so that they can act in concert during public health 

emergencies. However, OD continues to face challenges in monitoring the 

agency’s ongoing programmatic activities. Historically, OD has operated in 

an environment in which—outside of routine management meetings—its 

communication with center management officials was largely informal and 

relied substantially on personal relationships. Currently, OD’s efforts to 

monitor the centers are still not sufficiently systematic. For example, few 

formal systems are in place to track the status of centers’ activities and 

develop strategies to mitigate adverse consequences in the event that 

some activities fall behind schedule. Although OD has a process for center 

officials to elevate important issues, the information flow under this 

process is largely center-driven, as the subjects discussed are typically 

raised at the discretion of the center officials. OD has not established its 

own criteria specifying the type of matters warranting management input 

or the time frames for reporting such matters. Similarly, OD’s efforts to 

foster coordination among the centers as a standard agency practice for 

nonemergency public health work fall short of institutionalizing such 

collaboration. 

The planning tools that OD needs to set agency priorities, including 

addressing human capital challenges, are under development. In recent 

years, OD has operated without an up-to-date agencywide planning 

strategy with which to set mission priorities and unify the work of CDC’s 

various centers. In June 2003, OD initiated an agencywide strategic 

planning process. In a separate planning effort initiated in April 2003, CDC 

began developing a human capital plan for meeting the agency’s current 

and future staffing needs. This effort has been suspended while the 

strategic planning process gets under way, and no time frames have been 

established for resuming its development. At the same time, agency 

attrition and future limits on workforce growth suggest that agency 

leadership may be needed to ensure that workforce planning occurs 

expeditiously. 
Page 5 GAO-04-219 CDC Management 

In light of OD’s management challenges, we are making several 

recommendations to the CDC Director. These include ensuring OD’s 

oversight of the centers’ programmatic work at a level below the Director, 

improving OD’s monitoring of the centers’ operations and programmatic 

activities, and ensuring that the agency’s strategic and human capital 

planning are coordinated and done expeditiously. In commenting on a 

draft of this report, CDC listed a series of actions it would take for each 

recommendation, such as evaluating OD’s oversight structure, instituting 

formal reporting requirements and tracking systems, and linking human 

capital planning and deployment with the agency’s strategic plan. 

CDC is one of the major operating components of HHS, which acts as the 

federal government’s principal agency for protecting the health of all 

Americans.7

 CDC serves as the national focal point for developing and 

applying disease prevention and control, environmental health, and health 

promotion and education activities designed to improve the health of 

Americans. CDC is also responsible for leading national efforts to detect, 

respond to, and prevent illnesses and injuries that result from the release 

of biological, chemical, or radiological agents. 

CDC was originally established in 1946 as the Communicable Disease 

Center with the mission to help state and local health officials in the fight 

against malaria, typhus, and other communicable diseases. Over the years, 

CDC’s mission and scope of work have continued to expand in concert 

with public health needs. Commensurate with its increased scope of work, 

CDC’s budget and staff have grown. In 1946, the agency had a budget of 

about $1 million and had over 360 FTEs. In fiscal year 2003, CDC managed 

a budget of almost $7 billion and had over 8,800 FTEs. (See fig. 1.) 

 7

In addition to CDC, there are seven Public Health Service Operating Divisions within HHS: 

Agency for Healthcare Research and Quality, Agency for Toxic Substances and Disease 

Registry, Food and Drug Administration, Health Resources and Services Administration, 

Indian Health Service, National Institutes of Health, and Substance Abuse and Mental 

Health Services Administration. 

Background 
Page 6 GAO-04-219 CDC Management 

Figure 1: CDC’s Funding and FTE Growth from Fiscal Years 1946 to 2003 

Note: GAO analysis of CDC data. 

a

We adjusted each of the budget numbers using a chain-type Gross Domestic Product Price Index 

and an estimate for 2003 provided by the Congressional Budget Office because fiscal year 2003 had 

not ended at the time these calculations were made. 

b

FTE data are for 1961. 

To achieve its mission, CDC relies on an array of external partners, 

including public health associations, state and local public health agencies, 

schools and universities, nonprofit and volunteer organizations, 

international health organizations, and others. CDC collaborates with 

these partners to monitor the public’s health, detect and investigate 

disease outbreaks, conduct research to enhance prevention, develop and 

advocate public health policies, implement prevention strategies, promote 

healthy behaviors, foster safe and healthful environments, and provide 

Source: CDC. 

Funding in 2003 dollars (thousands)a

1946 1950 1960b 1970 1980 1990 2000 2003

Fiscal year

FTEs

Funding (2003 dollars)

FTEs

3,122,297

$8,366 0

$1,000,000

$2,000,000

$3,000,000

$4,000,000

$5,000,000

$6,000,000

$7,000,000

$8,000,000

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

$48,002 $102,733 $165,510

$549,887

$1,466,956

$3,963,803

$6,989,132

$8,366
Page 7 GAO-04-219 CDC Management 

training. CDC provides varying levels of support to its partners through 

funding, technical assistance, information sharing, and personnel. In fiscal 

year 2002, CDC awarded 69 percent of its total budget to partners through 

financial assistance, such as cooperative agreements and grants.8 The 

majority of these funds—about 75 percent—were disbursed to state health 

departments. The remaining 25 percent of these funds were disbursed to 

various other public and private entities. 

CDC’s workforce consists of 170 job occupations including physicians, 

statisticians, epidemiologists, laboratory experts, behavioral scientists, 

and health communicators. Seventy-eight percent of CDC’s workforce 

consists of permanent civil service staff. U.S. Public Health Service 

Commissioned Corps employees account for 10 percent of the workforce, 

and temporary employees make up the remaining 12 percent.9

 Most of 

CDC’s staff are dispersed across over 30 locations in Atlanta, Georgia. 

CDC also has more than 2,000 employees at other locations in the United 

States. (See fig. 2.) Additional CDC staff are deployed to more than 37 

foreign countries, assigned to 47 state health departments, and dispersed 

to numerous local health agencies on both short- and long-term 

assignments. 

 8

A cooperative agreement is a financial assistance instrument for which the recipient 

receives money as well as programmatic collaboration in carrying out the contemplated 

project or activity. 

9

The U.S. Public Health Service Commissioned Corps is one of the seven Uniformed 

Services of the United States. 
Page 8 GAO-04-219 CDC Management 

Figure 2: Principal Locations of CDC Employees within the United States 

a

These CDC facilities are quarantine stations located at major international airports. CDC staff at 

these locations make and enforce regulations necessary to prevent the introduction, transmission, or 

spread of communicable diseases from foreign countries into the United States. There is also a 

quarantine station located at the international airport in Atlanta, the city where CDC is headquartered. 

CDC’s organization consists of OD and 11 centers. OD consists of the CDC 

Director’s office and 12 separate staff offices. (See fig. 3.) OD manages and 

directs the agency’s activities; provides overall direction to, and 

coordination of, its scientific and medical programs; and provides 

leadership, coordination, and assessment of administrative management 

activities. The individual OD staff offices are responsible for managing 

crosscutting scientific functions, such as global health and minority health, 

as well as support functions, including financial management, grants 

management, human capital, and information technology. 

Anchorage, 

AK

Chicago, 

IL Cincinnati,

OH 

Fort Collins,

CO

San 

Francisco, 

CA

Miami, 

FL

Hyattsville,

MD 

Atlanta, 

GA

(HQ)

Morgantown,

WV 

Pittsburgh,

PA 

Research 

Triangle Park, NC

Jamaica,

NYa

Los Angeles,

CA

Honolulu,

HI

Spokane, 

WA

Seattle, 

WA

Washington, DC

Source: CDC.

a

a

a

a

a

a

a
Page 9 GAO-04-219 CDC Management 

Figure 3: CDC Organization Chart as of November 1, 2003 

Each of CDC’s centers interacts with the agency’s external partners by 

providing various means of assistance, such as funding and training. Each 

center has an organizational structure that includes a director’s office, 

programmatic divisions, and branches, in most cases. The centers also 

have their own budgets, which they administer. Eight of the centers have 

Public Health Practice 

Program Office

CDC Washington 

Office

Office of Program 

Planning and 

Evaluation

Office of 

Communication

Office of Women's 

Health

Office of Health and 

Safety

Office of Equal 

Employment 

Opportunity

National Vaccine 

Program Office

National Immunization 

Program

National Center for 

Chronic Disease 

Prevention and 

Health Promotion

National Center 

for Environmental 

Health

National Center 

for Health 

Statistics

National Center 

for Infectious 

Diseases

Epidemiology Program 

Office

National Center 

for HIV, STD, and 

TB Prevention

National Institute 

for Occupational 

Safety and Health

Office of Global 

Health

National Center 

for Injury 

Prevention 

and Control

National Center on 

Birth Defects and 

Developmental 

Disabilities

Office of the Director 

and affiliated staff offices

Office of Science 

Policy and Technology 

Transfer

Office of Executive 

Secretariat

Office of Minority 

Health

Office of the Chief 

Operating Officer

Office of the Director

Source: CDC.
Page 10 GAO-04-219 CDC Management 

their own mission statements, and several have developed their own 

strategic plans. 

CDC also performs many of the administrative functions for ATSDR. The 

Director of CDC serves as the Administrator of ATSDR, which was 

established within the Public Health Service by the Comprehensive 

Environmental Response, Compensation, and Liability Act of 1980.10

ATSDR works to prevent exposures to hazardous wastes and 

environmental spills of hazardous substances. Headquartered in Atlanta, 

the agency has 10 regional offices and an office in Washington, D.C. It also 

has a multidisciplinary staff of about 400 employees. For many years, 

ATSDR has worked closely with CDC’s National Center for Environmental 

Health (NCEH), which is responsible for providing national leadership in 

preventing and controlling disease associated with environmental causes. 

To foster greater efficiency, NCEH and ATSDR signed a statement of 

intent in January 2003 to consolidate their administrative and management 

functions for financial savings. In August 2003, CDC’s OD announced 

HHS’s approval for a single director to lead both ATSDR and NCEH. Final 

approval of this consolidation effort was completed on December 16, 2003. 

The restructuring of the executive management team in CDC’s top office, 

despite certain merits, has shortcomings with respect to agency oversight. 

A positive OD change made in 2003 was the assignment of an OD official 

other than the agency’s Director to provide oversight authority for the 

agency’s operations units, such as financial management and information 

technology. However, no OD official, other than the Director, has explicit 

responsibility for overseeing the centers’ programmatic work. Another 

positive change made in 2003 was to align OD management team positions 

with broad agency mission themes that cut across individual programs and 

organizational units. However, despite the intention for the themes to 

foster collaboration among CDC’s 11 centers and with its external 

partners, clear connections between the management team’s deputy 

positions, the mission themes, and agency mission activities have not been 

made. 

 10Pub. L. No. 96-510, 94 Stat. 2767, 2778. (This act established the Superfund program to 

clean up highly contaminated hazardous waste sites.) 

Despite the Merit of 

Some Changes, CDC’s 

Executive Structure Is 

Not Well Aligned to 

Oversee Centers’ 

Programmatic Work 
Page 11 GAO-04-219 CDC Management 

In January 2003, as part of the agency’s transformation efforts, CDC’s 

Director announced an OD management team consisting of five senior 

officials, including a COO, two deputies, a senior advisor, and a Chief of 

Staff. A beneficial change in OD’s structure was the creation of a COO with 

clear oversight authority over the agency’s operations units, positioning 

OD to oversee these areas appropriately. However, no similar position or 

combination of positions has been established in OD to oversee the 

programs and activities of the centers, as no one below the Director on 

OD’s management team has direct line authority for the centers’ 

programmatic work. This also holds true for the three officials added to 

the OD management team as of fall 2003—the Director of the CDC 

Washington Office, the Senior Advisor to the Director, and the Associate 

Director for Terrorism Preparedness and Response. (See fig. 4.) 

OD’s Structure for 

Overseeing Centers’ 

Programmatic Work Raises 

Concerns 
Page 12 GAO-04-219 CDC Management 

Figure 4: OD Management Team Below the Director as of November 1, 2003 

Note: GAO analysis of CDC data. 

a

Staff reporting to the COO, who heads the office, include the Deputy COO, the Chief Information 

Officer, and the Chief Financial Officer. 

Source: CDC.

Deputy Director for 

Science and Public 

Health

Deputy Director for 

Public Health 

Service

Senior Advisor for 

Strategy and 

Innovation

Chief Operating 

Officer

Chief of Staff

Director,

Office of Global 

Health

Director,

Office of 

Minority Health

Director,

Office of

Women's Health

Director,

Office of 

Science Policy 

and Technology 

Transfer

Director,

Office of

Executive

Secretariat

Director,

Office of 

Program

Planning and

Evaluation

Staff of the

Office of the Chief

Operating Officera

Director,

Procurement 

and Grants 

Office

Director,

Facilities 

Planning and 

Management 

Office

Director,

Human 

Resources

Management 

Office

Director,

Information 

Resources

Management 

Office

Director,

Management 

Analysis and 

Services Office

Director,

Financial 

Management 

Office

Director,

Office of 

Security and 

Emergency

Preparedness

Director,

Office of Health 

and Safety

Director,

Office of Equal 

Employment 

Opportunity

Director, 

Office of 

Genomics and 

Disease 

Prevention

Director, 

CDC Washington 

Office

Senior Advisor to 

the Director

Associate Director 

for Terrorism 

Preparedness 

and Response

Staff of the CDC

Washington 

Officeb

Staff of the Office 

of Terrorism 

Preparedness 

and Responsec
Page 13 GAO-04-219 CDC Management 

b

Staff reporting to the Director of the CDC Washington Office include a deputy director. 

c

Staff reporting to the Associate Director for Terrorism Preparedness and Response include two 

deputy directors and an associate director. 

A look at the roles of OD’s management team highlights a structural 

weakness in oversight authority for the centers’ programmatic work. 

• COO. This official has oversight responsibility for the agency’s core 

business operations, including financial management, procurement and 

grants, human resources, and information technology, among others. 

CDC’s COO is consistent with a commonly agreed-upon governance 

principle that “a single point” within an agency should have the 

responsibility and authority for the agency’s management functions.11 It 

also parallels the experience of successful organizations that place this 

type of management position among the agency’s top leadership.12

• Deputy Director for Science and Public Health and Deputy Director for 

Public Health Service. These officials function largely as technical 

advisors, working with the centers on various issues but having no 

oversight responsibility for them. Five OD offices report directly to the 

Deputy Director for Science and Public Health. No offices report directly 

to the Deputy Director for Public Health Service. 

• The Senior Advisor for Strategy and Innovation. This advisor is 

responsible for the agency’s strategic planning efforts and, apart from the 

official’s own office staff, has no direct reports. 

• Chief of Staff. The Chief of Staff serves as a principal advisor and assistant 

to the Director and is responsible for OD’s day-to-day management. This 

responsibility includes routing to the appropriate OD or center official the 

agency’s incoming inquiries or requests from the Congress, the 

administration, and the public health community. Two OD offices report 

directly to the Chief of Staff—the Office of the Executive Secretariat13 and 

the Office of Program Planning and Evaluation.14

 11U.S. General Accounting Office, Highlights of a GAO Roundtable: The Chief Operating 

Officer Concept: A Potential Strategy to Address Federal Governance Challenges, 

GAO-03-192SP (Washington, D.C.: Oct. 4, 2002). 

12U.S. General Accounting Office, Results-Oriented Government: Shaping the Government 

to Meet 21st Century Challenges, GAO-03-1168T (Washington, D.C.: Sept. 17, 2003). 

13This office serves as the focal point for review and clearance of documents that require 

the signature of the Director and documents that require the signature of department 

officials. 

14This office performs numerous functions, including producing the agency’s annual 

performance reports. 
Page 14 GAO-04-219 CDC Management 

• Director, CDC Washington Office. This official manages the CDC 

Washington Office, which acts as a liaison between CDC and its 

Washington-based stakeholders, which include other agencies, 

associations, policymakers, and others interested in public health. 

• Senior Advisor to the Director. This advisor is responsible for providing 

research, analysis, outreach activities, and strategy formulation to meet 

the needs of the Director and, apart from the official’s own office staff, has 

no direct reports. 

• Associate Director for Terrorism Preparedness and Response. This 

official’s responsibilities include managing OD’s Office of Terrorism 

Preparedness and Emergency Response (OTPER) as well as CDC’s 

national bioterrorism program. 

As of November 1, 2003, a total of 20 officials, including the 11 center 

directors, reported to the CDC Director. (See fig. 5.) 
Page 15 GAO-04-219 CDC Management 

Figure 5: Senior Officials Reporting to CDC’s Director as of November 1, 2003 

Note: GAO analysis of CDC data. 

a

As of August 18, 2003, the Director of NCEH became a Senior Advisor within OD, and the Director of 

ATSDR became the head of the consolidated management and administrative structure for ATSDR 

and NCEH. 

b

Although this official reports to the CDC Director, the official is not a member of the OD management 

team. 

Whether this structural arrangement can support effective oversight of the 

agency’s programmatic work is uncertain, given the growth in the 

demands on the CDC Director’s time along with the likely change in 

directors over time. Since the first West Nile virus outbreak in 1999, CDC 

Office of the Director

Director,

Public Health

Practice Program

Office 

Director,

National Immunization

Program 

Director, 

National Center for 

Chronic Disease 

Prevention and 

Health Promotion 

Director,a

NCEH/ATSDR 

Director, 

National Center

for Health 

Statistics 

Director,

National Center

for Infectious

Diseases 

Director,

Epidemiology 

Program Office

Director,

National Center

for HIV, STD, and 

TB Prevention

Director,

National Institute

for Occupational

Safety and Health 

Director,

National Center

for Injury

Prevention and

Control 

Director,

National Center 

on Birth Defects 

and Developmental 

Disabilities

Director

Director,

CDC Washington Office

Director, 

Office of Communicationb

Source: CDC.

Associate Director for

Terrorism Preparedness

and Response

Deputy Director for 

Science and Public 

Health

Deputy Director for 

Public Health Service

Senior Advisor for 

Strategy and 

Innovation

Chief Operating 

Officer Chief of Staff

Senior Advisora
Page 16 GAO-04-219 CDC Management 

has responded to a steady stream of high-profile public health 

emergencies, including the anthrax incidents and the more recent 

outbreak of SARS. (See fig. 6.) Responding to these events has required 

the focused attention of the CDC Director. In addition, routine demands 

on the Director’s time—such as testifying before the Congress, 

coordinating with HHS officials, and meeting with other national and 

international public health officials—subtract from the time the Director 

has to oversee the centers, which perform the core of CDC’s mission work. 

Figure 6: Timeline of High-Profile Public Health Events and Emergencies Requiring CDC Response 

Note: GAO analysis of CDC data. 

The typical change in politically appointed agency heads every several 

years is another factor that makes center oversight solely by the Director a 

management vulnerability. CDC has had four directors, including the 

current one, since 1990. While there is nothing uncommon or irregular 

about such change, it is significant from a management perspective, as 

agency heads typically need time to acclimate to their new responsibilities 

and may not stay in office long enough to institutionalize management 

improvements. 

Despite the restructuring of OD to reflect agency mission themes, this 

effort falls short of its intention, owing to a lack of clarity and definition in 

the roles of the OD deputies. CDC’s Director established five mission 

themes, or goals—science, strategy, service, systems, and security. The 

intention was to acknowledge that shared goals cut across the agency’s 

diverse centers and that viewing the work in this way could foster 

collaboration. The new OD structure announced in January 2003 aligned 

executive management positions with each of the themes. (See table 1.) 

Unclear Roles and 

Responsibilities of OD 

Deputy Positions Slow 

Intention to Integrate 

Center Activities around 

Themes 
Page 17 GAO-04-219 CDC Management 

Table 1: OD’s Organizational Themes and Corresponding OD Management 

Positions 

Themes Positions 

Excellence in Science: Practice evidence-based 

science grounded in sound peer-reviewed 

research. 

Deputy Director for Science and 

Public Health 

Excellence in Service: Promote efficient service 

to meet the needs of partners and customers. 

Deputy Director for Public Health 

Service 

Excellence in Systems: Fine-tune and manage 

systems so that personnel, technology, 

infrastructure, and information are used efficiently 

to achieve results. 

Chief Operating Officer 

Excellence in Strategy: Ensure that strategies 

prepare agency for future challenges. 

Senior Advisor for Strategy and 

Innovation 

Excellence in Security: Ensure public health 

preparedness and support response efforts. 

Associate Director for Terrorism 

Preparedness and Responsea

Source: CDC. 

a

Although this position and its corresponding theme were also announced in January 2003, this 

official was not a member of the OD management team until October 2003. 

The distinction between the roles of the two deputy positions—Deputy 

Director for Science and Public Health and Deputy Director for Public 

Health Service—has not been clearly made. The role of the Deputy 

Director for Science and Public Health is to serve as OD’s contact point to 

the centers in areas including agency reports, guidelines and 

recommendations, and outbreak investigations. However, this deputy’s 

role is not distinct from that of the Deputy Director for Public Health 

Service, who serves as OD’s liaison to public health agencies and other 

external partners as well as OD’s contact point for certain scientific issues, 

including HIV policies, occupational safety and health policies, injury and 

violence prevention policies, and programs to address public health 

disparities. Addressing public health disparities, however, is the mission of 

CDC’s Office of Minority Health, which reports to the other deputy—the 

Deputy Director for Science and Public Health. Furthermore, some center 

officials said that regarding science-related issues involving CDC’s 

external partners, they were uncertain whether the primary point of 

contact should be the Deputy Director for Science and Public Health or 

the Deputy Director for Public Health Service. 
Page 18 GAO-04-219 CDC Management 

OD has implemented several changes in its approach to managing the 

agency’s response to public health emergencies, including the creation 

within OD of an emergency operations office that, during the SARS 

outbreak, successfully coordinated the response efforts of CDC’s various 

centers and staff offices. However, concerns remain about OD’s 

management of ongoing agency activities, as few systems are in place to 

provide top agency officials with essential oversight information or to 

foster collaboration among the centers. 

In recognition of past problems, OD initiated several structural and 

procedural changes that improved its ability to oversee the agency’s 

response to public health emergencies. Specifically, the 2001 anthrax 

incidents revealed weaknesses in the agency’s ability to coordinate 

internal response efforts and in its efforts to communicate with the 

nation’s public health agencies, medical communities, and other external 

partners—a problem that had also been identified during the response to 

the first West Nile virus outbreak in 1999. Agency officials and external 

partners recognized several problems that needed to be addressed: 

• A top OD official we spoke with noted that during the anthrax incidents, 

the agency leadership lacked formal protocols for making crisis 

management decisions. This official stated that over 100 staff attended 

internal information briefings; in this official’s view, the volume and 

diversity of information presented to agency management at these 

briefings resulted in “information overload” that impeded timely decision 

making. 

• An internal CDC document noted that as of October 2001, CDC was 

running four separate emergency operation centers, resulting in an 

uncoordinated command and control environment. Prior to September 11, 

2001, CDC operated two loosely connected emergency operations 

centers—one in NCEH and one in ATSDR.15 After the terrorist attacks on 

September 11, 2001, CDC established two additional emergency 

operations centers in the National Center for Infectious Diseases and the 

Public Health Practice Program Office. The internal document asserted 

that after the subsequent anthrax incidents, CDC’s multiple emergency 

 15At that time, infectious disease outbreaks were handled outside of the emergency 

operations centers. 

OD Has Improved 

Oversight of Public 

Health Emergencies, 

but Concerns Remain 

about Oversight of 

Ongoing Agency 

Activities 

OD Has Improved Its 

Ability to Oversee the 

Agency’s Response to 

Public Health Emergencies 
Page 19 GAO-04-219 CDC Management 

operation centers could not provide the agencywide coordinated effort 

needed to address a crisis. 

• A variety of external partners we spoke with criticized CDC’s response to 

the anthrax incidents for its failure to quickly communicate vital 

information to the public and to the health care workers responsible for 

diagnosing and treating suspected cases. Likewise, we recently reported 

that although CDC served as the focal point for communicating critical 

information during the response to the anthrax incidents, it experienced 

difficulty in managing the voluminous amounts of information coming into 

the agency and in communicating with public health officials, the media, 

and the public.16

• A top OD official contended that during the response to the anthrax 

incidents, the agency would have had difficulty responding to another 

public health emergency, since key personnel and resources drawn from 

the various centers and OD staff offices were consumed by this effort. 

In response to these weaknesses, CDC instituted several organizational 

changes. In August 2002, CDC created OTPER within OD to be headed by 

the Associate Director for Terrorism Preparedness and Response, who 

reports to the CDC Director. The office is responsible for coordinating 

agencywide preparedness and response efforts among the agency’s 

centers and its partners. Agency officials told us that the elevation of this 

responsibility to OD was necessary because of unsuccessful past efforts to 

ensure coordination among the centers. This office also has responsibility 

for specific aspects of information systems, training, planning, 

communications, and preparedness activities designed to facilitate the 

agency’s emergency response effectiveness. In addition, it provides 

financial and technical assistance for terrorism preparedness to state, 

local, and U.S. territorial health departments. In fiscal year 2002, OTPER 

disbursed about $1 billion in financial assistance to these partners. 

To improve the agency’s response effectiveness, OTPER developed 

management decision and information flow models, which outline who 

will be involved and how the emergency will be handled from strategic, 

operational, and tactical perspectives. According to the Associate Director 

for Terrorism Preparedness and Response, these models were used to 

manage the emergencies involving SARS, monkeypox, and potential 

terrorist acts associated with the war in Iraq. OTPER also drafted CDC’s 

national public health strategy for terrorism preparedness and response, 

 16U.S. General Accounting Office, Bioterrorism: Public Health Response to Anthrax 

Incidents of 2001, GAO-04-152 (Washington, D.C.: Oct. 15, 2003). 
Page 20 GAO-04-219 CDC Management 

including an internal management companion guide on implementation. 

CDC intends to distribute this document to the agency’s external partners. 

OTPER manages CDC’s recently constructed emergency operations 

center, where all aspects of the agency’s emergency response efforts are 

coordinated. This center is intended to provide a central command-andcontrol focal point and eliminate the need to coordinate efforts of multiple 

centers during emergencies. According to the Associate Director for 

Terrorism Preparedness and Response, the emergency operations center 

is operational around the clock and has a small number of dedicated staff. 

In times of emergency, subject matter and communication experts from 

the centers are temporarily detailed for 3 to 6 months as needed. For 

example, during the SARS response, individuals from the National Center 

for Infectious Diseases, the National Institute for Occupational Safety and 

Health, the Epidemiology Program Office, and the Global Health Office, 

among others, staffed the emergency operations center and returned to 

normal duties at predetermined intervals to mitigate any major impact on 

routine public health work. This logistical approach to staffing and 

resources was intended to enable CDC to respond to multiple public 

health emergencies, if needed. 

Within OD, the Office of Communication works with OTPER to facilitate 

external communications during public health emergencies. In August 

2002, this office established an emergency communication system to 

enhance CDC’s ability to disseminate timely and reliable information. This 

system consists of 10 teams that include agency staff from various units 

who can be called on to act in concert during public health emergencies. 

Each team has a particular focus—such as media relations, telephone 

hotline information, Web site updates, and clinician communication. In 

June 2003, CDC named an Emergency Communication System 

Coordinator to provide day-to-day oversight of the teams. 

Despite improvements to crisis management, OD faces challenges in 

managing its nonemergency public health work. Typically, the attention of 

OD’s top officials has been focused on emergent public health issues, such 

as infectious disease outbreaks, leaving little time for focusing on 

nonemergency public health work and agency operations. OD has also 

operated in an environment that until recently had not significantly 

evolved from the time when the agency was smaller and its focus was 

narrower; outside of routine management meetings, OD’s communication 

with the centers was largely informal and relied substantially on personal 

OD Faces Challenges in 

Overseeing Nonemergency 

Public Health Work 
Page 21 GAO-04-219 CDC Management 

relationships. As a result, the centers have operated with a high degree of 

independence and latitude in managing their operations. 

OD has few systems in place with which to track agency operations and 

programmatic activities. As of summer 2002, OD management officials 

received only limited management information regularly—monthly reports 

on budget obligations, a weekly legislative report, a weekly media 

relations report, and a weekly summary workforce report. Over the past 

year, OD has taken steps to obtain additional management information 

and has begun to track some aspects of center operations. 

• As of April 2003, a weekly summary report on congressional activities that 

supplements the weekly legislative report has been provided to OD 

management team officials. 

• In fall 2003, OD began compiling a weekly list of selected CDC 

publications, correspondence, and activities. 

• The COO began monitoring the centers’ travel and training expenditures 

on an ad hoc basis after conducting a benchmarking analysis on the 

centers’ fiscal year 2002 expenditures in these areas. Previously, scrutiny 

of these expenditures was at the discretion of center management. 

OD has not made similar efforts to monitor the agency’s programmatic 

work. Outside of routine management meetings with the centers, OD 

continues to lack formal reporting systems needed to track the status of 

the centers’ public health programs and develop strategies to mitigate 

adverse consequences in the event that some activities fall behind 

schedule. 

OD relies on its issues management process as one way to stay informed 

of the centers’ important but nonemergency issues.17 Historically, the 

center directors, accustomed to operating autonomously, had little 

precedent for raising issues for OD management input. In January 2003, 

OD instituted the issues management process, which, among other things, 

sought to encourage center officials to elevate significant matters that are 

not national emergencies but that warrant timely input from the agency’s 

senior managers. Under this process, a center official seeking management 

input on an issue of concern contacts OD’s Chief of Staff, who is 

responsible for coordinating agency input on the issue. The Chief of Staff 

identifies the appropriate senior officials for handling the concern and 

 17This process is also used to manage nonemergency issues received from external sources, 

such as the Congress, HHS, and the media. 

Few Tracking Systems Are in 

Place to Provide Management 

Oversight Information 
Page 22 GAO-04-219 CDC Management 

tracks actions taken until the matter is concluded. Emerging issues that 

centers have raised through this process include the agency’s HIV 

prevention initiatives, preparedness activities for the West Nile virus, and 

wild animal trade restrictions subsequent to the monkeypox outbreak. 

According to the Chief of Staff, the issues management process has 

provided an effective communication channel for the center directors, as it 

has enabled them to have regular contact with OD management and the 

CDC Director, as needed. As an effective OD oversight tool, however, the 

issues management process is incomplete. Under this process, OD has not 

established formal criteria—in the form of reporting requirements—that 

would instruct centers on what types of issues warrant management input 

and the time frames for reporting them. Instead, OD relies largely on the 

center directors’ discretion to determine which nonemergency public 

health issues are made known to the agency’s top management. In this 

regard, the issues management process remains essentially a bottom-up 

approach to obtaining information on CDC center activities. Coupled with 

a lack of management reporting systems, this approach places OD in a 

reactive rather than leadership position with respect to the centers and the 

public health work they manage. 

While OD has taken steps to improve the centers’ ability to effectively 

collaborate during emergencies, more needs to be done for collaboration 

on nonemergency public health work. The centers have historically not 

coordinated well on nonemergency public health issues common to 

multiple centers—a situation we reported on in February 1999.18 OD 

officials have also acknowledged that the centers operate as “silos,” 

characterizing the isolated manner in which these separate but related 

organizational components operate. 

OD has taken several steps to foster center collaboration on 

nonemergency public health work. Conceptually, OD’s emphasis on the 

five themes—science, service, systems, strategy, and security—is part of 

an approach to integrate the agency’s public health work across the 

centers’ respective missions and functions. In August 2003, OD announced 

the establishment of two governing bodies that encourage center 

collaboration—the Executive Leadership Team and the Management 

 18U.S. General Accounting Office, Emerging Infectious Diseases: Consensus on Needed 

Laboratory Capacity Could Strengthen Surveillance, GAO/HEHS-99-26 (Washington, D.C.: 

Feb. 5, 1999). 

OD Efforts to Foster 

Collaboration among Centers 

Are Incomplete 
Page 23 GAO-04-219 CDC Management 

Council. The Executive Leadership Team, which includes the OD 

management team and each of the center’s directors, meets biweekly and 

seeks to ensure that coordination occurs across centers and that the 

centers’ interests are not omitted when key decisions are being considered 

by the agency’s top officials. The Management Council, which also meets 

biweekly, focuses on crosscutting issues involving agency operations, 

such as information technology. The council is chaired by OD’s COO and 

is composed of staff office officials and representatives from each of the 

centers. In providing recommendations to the Executive Leadership Team 

on agency operations issues, such as the development of performance 

metrics and the consolidation of the agency’s information technology 

infrastructure, the council has the opportunity to foster more consistent 

management practices across the agency. 

OD officials acknowledged that along with these efforts to promote 

collaboration, additional initiatives are needed to ensure that collaboration 

among the centers becomes a standard agency practice. Such efforts by 

leading organizations to institutionalize collaboration include, for 

example, the design of cross-functional, or “matrixed,” teams; pay and 

other incentive programs linked to achieving mission goals; and 

performance agreements for senior executives that specify fostering 

collaboration across organizational boundaries.19

In recent years, CDC’s OD has operated without an up-to-date agencywide 

planning strategy with which to set agency mission priorities and unify the 

work of its various centers. In June 2003, OD initiated an agencywide 

strategic planning process. Shortly before this, in April 2003, OD began 

developing a human capital plan for current and future staffing priorities, 

but the plan has been put on hold until the agencywide planning strategy 

has been established. 

 19U.S. General Accounting Office, A Model of Strategic Human Capital Management, 

GAO-02-373SP (Washington, D.C.: Mar. 15, 2002), and Human Capital: Key Principles 

From Nine Private Sector Organizations, GAO/GGD-00-28 (Washington, D.C.: Jan. 31, 

2000). 

Planning Tools That 

OD Needs to Manage 

Agency Priorities and 

Human Capital 

Challenges Are Not 

Yet Operational 
Page 24 GAO-04-219 CDC Management 

CDC has a strategic plan that has not been updated since 1994. 

Consequently, this plan does not reflect the agency’s more recent 

challenges, such as preparing for terrorism-related events and 

implementing the civilian portion of the national smallpox vaccination 

campaign. In the absence of a current long-term strategy, OD has been 

establishing priorities within its diverse mission through the annual 

processes for developing the budget and updating goals for the agency’s 

annual performance report as required by the Government Performance 

and Results Act of 1993 (GPRA). This method for setting priorities is not 

effective for long-term planning, as its focus is on funding existing 

activities one year at a time rather than examining agency goals and 

performance from a broader perspective. 

CDC’s need for a comprehensive strategic plan is substantial, as OD must 

set priorities based on disease prevention and control objectives inherent 

in the agency’s mission as well as any additional public health priorities of 

HHS and the Congress. For example, in addition to addressing public 

health program priorities, such as obesity and diabetes, CDC must also 

address administration management priorities as directed by HHS.20

Moreover, the agency must keep a mission focus when coordinating with 

its external partners—largely, state, local, and international public health 

agencies. Although CDC relies heavily on these and other external 

partners to achieve its mission, a mutual understanding of the agency’s 

priorities may be lacking. For example, some of the state and local public 

health officials we spoke with were unable to articulate the agency’s top 

priorities aside from bioterrorism preparedness. CDC officials we spoke 

with similarly acknowledged the need to better communicate priorities to 

external partners. 

Many of the centers have their own mission statements and a few also 

have strategic plans to address individual center goals and priorities—a 

reflection of the centers’ independent focus. In the absence of an 

agencywide plan, however, OD lacks an effective management tool to 

ensure that the agency’s priorities are being addressed without undue 

overlap or duplication. In July 2003, participants in preliminary strategic 

planning discussions acknowledged poor cooperation across centers and 

the need for improvement in collaboration. 

 20The administration’s management priorities are specified in the President’s Management 

Agenda, which addresses executive branch management practices in the areas of human 

capital, competitive sourcing, financial performance, electronic government, and the 

integration of budget and performance. 

OD’s Priority-Setting 

Efforts Have Lacked a 

Long-Term Focus 
Page 25 GAO-04-219 CDC Management 

In June 2003, OD initiated an agencywide strategic planning process called 

the Futures Initiative, which is intended to involve all levels of staff and 

some of the agency’s partners in developing long-range goals and 

associated performance measures. The agency’s strategic planning efforts 

will be focused on 10 topics: the public health system, customers’ needs, 

research capacity, communication and information priorities, future 

resource needs, government partner relationships, measuring results, 

intra-agency coordination, programs and grants portfolio, and global 

health issues. In developing the strategy, OD intends to incorporate the 

agency’s mission and vision, the federal Healthy People 2010 goals, HHS’s 

strategic goals and objectives, and selected public health reports.21

However, at the time of our review, OD had not clearly linked the 10 topics 

and the agency’s five mission themes of science, strategy, service, systems, 

and security. 

To guide and manage the agency’s planning efforts, OD created a steering 

committee, which is led by the agency’s Director and consists of a small 

group of senior officials from OD and the centers. This committee makes 

recommendations to the Executive Leadership Team for decision making. 

Under the committee, four initial work groups, consisting of center 

representatives and some external partners, have been established to 

examine the following topics: customers and partners, health systems, 

health research, and global health. 

CDC’s overall strategic planning process has three phases. In the first 

phase, CDC will evaluate the agency’s overall direction and set priorities. 

In the second, it will examine the agency’s organizational structure and 

processes and their alignment with the strategic plan’s goals and begin 

implementation. The last phase will focus on measuring results and 

implementing the plan at all agency levels—both management and staff. 

OD plans to begin implementing the strategy in spring 2004. OD intends to 

communicate the results of the planning process internally to staff and 

externally to agency partners through CDC’s Web site and through a 

variety of meetings and different venues. 

According to the Senior Advisor for Strategy and Innovation, priority 

issues and programs identified through the strategic planning process will 

 21Healthy People 2010 is a national health promotion and disease prevention initiative that 

aims to improve the health of all Americans, eliminate disparities in health, and improve 

years and quality of life. These goals and objectives were launched by HHS and the Office 

of the Surgeon General. 

Strategic Planning Process 

Recently Initiated 
Page 26 GAO-04-219 CDC Management 

have goals, action plans, and outcome measures for tracking and 

accountability. This official also stated that the expected result is that the 

finished “strategy” will act as a framework for the individual centers to 

align with and will guide CDC’s priority setting, budget formulation, and 

annual development of GPRA goals. For OD to effectively lead the 

agency’s efforts in implementing its long-term strategy, it will be important 

to link the performance expectations of senior management to the 

agency’s organizational goals.22

OD has been operating without a comprehensive human capital plan with 

which to link workforce needs to agency priorities. The agency has several 

separate initiatives under way in response to administration directives 

regarding human capital management. However, in December 2002, HHS 

criticized these efforts as being overly focused on the centers and lacking 

an agencywide focus. In April 2003, OD began developing a 

comprehensive, long-term human capital plan. In July 2003, OD suspended 

the development of this plan until further progress could be made on the 

agency’s strategic planning process. As of November 2003, OD had not 

established a date when the human capital planning would resume nor 

determined how it would be coordinated with the agency’s strategic 

planning efforts. 

Furthermore, CDC is facing several human capital challenges that 

underscore the need for a strategy to address succession planning, which 

involves preparing for the loss of key staff and their associated skills. 

Leading organizations use succession planning and management as a tool 

that focuses on current and future workforce needs in order to meet their 

mission over the long term.23 Our analysis of CDC’s 2003 personnel data 

showed that—similar to the rest of the federal government—about 30 

percent of the agency’s workforce is eligible to retire within the next 5 

years. We also found that 33 percent of its senior managers and 

 22U.S. General Accounting Office, Results-Oriented Cultures: Using Balanced 

Expectations to Manage Senior Executive Performance, GAO-02-966 (Washington, D.C.: 

Sept. 27, 2002). 

23U.S. General Accounting Office, Human Capital: Insights for U.S. Agencies from Other 

Countries’ Succession Planning and Management Initiatives, GAO-03-914 (Washington, 

D.C.: Sept. 15, 2003). 

Human Capital Plan 

Initiated but Recently 

Suspended 
Page 27 GAO-04-219 CDC Management 

supervisors will be eligible for retirement within this time frame.24 Thus, 

within several years, the agency could potentially lose a key portion of its 

human capital that possesses both managerial and technical expertise.25

In addition, by the end of fiscal year 2005, CDC and other HHS agencies 

are expected to achieve a departmentwide 15 percent reduction in 

administrative management and support positions. HHS mandated that 

this reduction not result in the involuntary separations of employees and 

that affected resources be redirected to programmatic public health work. 

The implications for CDC are that within a 2-year time frame, CDC must 

redirect 573 administrative positions from support activities to frontline 

public health program activities. In some cases, this would involve 

redirecting administrative staff to program work. However, this will pose a 

challenge for CDC, as the agency does not maintain a repository of its 

employees’ skills, which is important to ensure appropriate employee 

placement. HHS has also directed each of its agencies to assume no 

growth in the number of FTEs beginning with the fiscal year 2005 budget 

formulation process and to include a 5 percent FTE reduction option in 

their budget submissions. 

OD has taken modest steps toward succession planning. For example, 

CDC participates in HHS’s program to train and mentor emerging leaders. 

CDC’s Director has also emphasized the importance of identifying future 

leaders within the agency and has made this issue a standing agenda item 

in routine management meetings with center officials. To forecast 

workforce needs, in August 2002, the agency produced a report of attrition 

for its offices and centers. Currently, CDC’s managers can access the most 

recent attrition data by querying a Web-based personnel information 

system. However, OD is limited in its ability to conduct targeted 

succession planning or promote greater retention, as it does not track 

certain key personnel information. For example, although resignations in 

calendar year 2002 accounted for a higher percentage of the agency’s 

attrition than retirement (30 percent compared with 20 percent),26 CDC 

 24Senior managers and supervisors were defined as positions at GS-14 or higher—or the 

equivalent thereof. However, these data did not include officials of the Public Health 

Service Commissioned Corps, who are eligible to retire at 20 years of service and who must 

retire after 30 years of service. 

25CDC’s personnel data show that staff who are eligible to retire tend to stay at the agency 

an average of about 3 years beyond their eligibility dates. 

26Other attrition was due to reasons such as death, termination of limited appointments, 

and separation. 
Page 28 GAO-04-219 CDC Management 

does not systematically document the reasons for resignations, either 

through standard “exit interviews” of employees who leave the agency or 

some other means.27 This lack of documentation limits OD’s ability to 

conduct comprehensive workforce planning, which includes strategies for 

retaining an organization’s workforce for meeting future needs.28

The considerable succession planning challenges that the agency faces 

argue for greater OD leadership over human capital planning. Such 

leadership would be consistent with the effective human capital planning 

actions of six federal agencies cited in our April 2003 report on this 

subject.29 The report noted, among other things, the importance of 

including human capital leaders in key agency decision making and the 

establishment and communication of a strategic vision by human capital 

leaders. Currently, CDC does not have, as envisioned in these reported 

best practices, a top-level leadership position focused on CDC’s human 

capital efforts. 

To better position CDC as it grows and evolves, OD has embarked on a 

number of changes to improve the agency’s management and planning 

efforts. While some of these changes have improved the agency’s ability to 

respond to recent public health emergencies, OD continues to face 

challenges in overseeing its ongoing, nonemergency public health work. 

First, a weakness in oversight of the centers exists, as only the CDC 

Director has line authority over them, and it is uncertain whether this 

arrangement provides for sufficient top management oversight of the 

centers’ programs and activities. In addition, the roles of OD’s two deputy 

directors lack the clarity needed for those seeking the appropriate OD 

points of contact. 

Second, OD lacks sufficiently systematic information to track agency 

operations or the centers’ core public health programs—placing agency 

 27OD officials told us that some OD offices and centers give employees the choice to 

participate in exit interviews. However, the offices and centers use different methods in 

conducting these interviews. 

28U.S. General Accounting Office, Human Capital: Key Principles for Effective Strategic 

Workforce Planning, GAO-04-39 (Washington, D.C.: Dec. 11, 2003). 

29U.S. General Accounting Office, Human Capital: Selected Agency Actions to Integrate 

Human Capital Approaches to Attain Mission Results, GAO-03-446 (Washington, D.C.: 

Apr. 11, 2003). 

Conclusions 
Page 29 GAO-04-219 CDC Management 

management in a reactive rather than leadership position. Despite efforts 

made to encourage a better information flow between OD and the centers, 

the reporting of important but nonemergency issues remains largely at the 

discretion of the centers. Furthermore, efforts to foster collaboration 

among centers for routine public health work have been made, but little 

has been done to institutionalize such collaboration and avoid undue 

overlap or duplication. 

Third, OD is taking steps to manage the agency strategically, but key 

planning tools are not fully in place. A recently announced strategic 

planning process is intended to identify and communicate the agency’s 

optimal structure, processes, and performance measures. A human capital 

plan was initiated in April 2003, but this effort has been postponed while 

the strategic planning process gets under way. As of November 2003, no 

time frames had been established for resuming the development of the 

human capital plan or coordinating it with the strategic planning process. 

The newness of the agency’s strategic planning process and stalled 

workforce planning efforts argue for greater leadership from OD to 

continue and coordinate both efforts. 

To improve OD’s management of CDC’s nonemergency mission priorities, 

we recommend that the CDC Director take the following three actions: 

• realign and clarify oversight responsibility for the centers’ programmatic 

work at a level below the Director, including clarifying the roles of OD’s 

deputy directors; 

• ensure that reporting requirements and tracking systems are developed for 

OD to routinely monitor the centers’ operations and programmatic 

activities; and 

• develop incentives to foster center collaboration as a standard agency 

practice. 

We also recommend that the CDC Director take the following two actions: 

• ensure that the agency’s new strategic planning process will involve CDC 

employees and external partners to identify agencywide priorities, align 

resources with these priorities, and facilitate the coordination of the 

centers’ mission-related activities and 

• ensure that the agency’s human capital planning efforts receive 

appropriate leadership attention, including resuming human capital 

planning, linking these efforts to the agency’s strategic plan, and linking 

senior executives’ performance contracts with the strategic plan. 

Recommendations for 

Executive Action 
Page 30 GAO-04-219 CDC Management 

In its written response to a draft of this report, CDC stated that it is 

committed to continuing the positive changes we highlighted in the report 

and agreed that challenges remain—especially for ensuring program 

accountability. CDC acknowledged that continued oversight from OD is 

critical to ensure high-quality management practices and scientific 

excellence. The agency further emphasized that it is in the early stages of a 

multiyear process of change. 

CDC stated that ensuring program accountability is a significant challenge 

that it takes most seriously as stewards of the public’s trust and funding. 

The agency agreed to evaluate our recommendation to realign and clarify 

oversight for the centers’ programmatic work at a level below the Director 

in light of the management changes the agency has already undertaken. 

CDC also stated that it is working to institute formal reporting 

requirements and tracking systems that monitor center activities with 

special emphasis on program outputs, outcomes, and impacts. In addition, 

CDC stated that it continues to seek ways to strengthen center 

collaboration. The agency also agreed with our recommendation regarding 

its strategic planning process and provided information on how it has 

involved both internal employees and external partners. CDC concurred 

that human capital planning is critically important and stated that it will 

link human capital planning and deployment to its strategic plan, and 

appropriately connect the performance contracts of its senior executives 

with the developing strategic plan. CDC also provided technical 

comments, which we incorporated as appropriate. CDC’s written 

comments are reprinted in appendix II. 

We are sending copies of this report to the Secretary of HHS. We will also 

provide copies to others upon request. In addition, the report will be 

available at no charge on GAO’s Web site at http://www.gao.gov. 

Agency Comments 
Page 31 GAO-04-219 CDC Management 

If you or your staff have any questions about this report, please call me at 

(202) 512-7101 or Bonnie Anderson at (404) 679-1900. Hannah Fein, 

Cywandra King, and Julianna Williams also made key contributions to this 

report. 

Sincerely yours, 

Marjorie E. Kanof 

Director, Health Care—Clinical Health Care Issues 
Appendix I: Scope and Methodology 

Page 32 GAO-04-219 CDC Management 

To assess the Centers for Disease Control and Prevention’s (CDC) 

executive management structure, we analyzed past and current 

organizational structures and reporting arrangements. We interviewed the 

agency’s Director about the basis of the management reorganization and 

the roles of the officials in the Office of the Director’s (OD) management 

team. We also interviewed the consultant who worked with agency 

management to help develop the new OD structure. To identify changes 

resulting from the reorganization, we spoke with past and current OD 

executive management officials to discuss their roles and responsibilities, 

and we reviewed the position descriptions for these officials. To ascertain 

the centers’ understanding of the roles of the OD management team, we 

interviewed management officials from the following six centers: National 

Center for Chronic Disease Prevention and Health Promotion; National 

Center for Environmental Health; National Center for Health Statistics; 

National Center for Infectious Diseases; National Center for HIV, STD, and 

TB Prevention; and Public Health Practice Program Office. We also 

interviewed management officials at the Agency for Toxic Substances and 

Disease Registry, which functions similarly to CDC’s centers. To assess the 

demands on the Director’s time, we identified high-profile public health 

events and emergencies since the first West Nile outbreak in 1999. We also 

analyzed the Director’s calendar for the 7-month period covering January 

1, 2003, through July 27, 2003.1

To evaluate OD’s approach to managing the agency’s response to public 

health emergencies, we looked at CDC’s emergency infrastructure and 

communication processes. To identify changes CDC implemented to 

improve its performance in this area, we interviewed senior management 

officials within OD, including the Associate Director for Terrorism 

Preparedness and Response. We reviewed documentation that included 

the agency’s decision models, its national public health strategy for 

terrorism preparedness and response, and information about the Office of 

Terrorism Preparedness and Emergency Response. We also reviewed 

documentation about the agency’s past emergency operations centers as 

well as the recently constructed operations center, including how it is 

staffed during times of emergency. To learn about CDC’s emergency 

communication system, we interviewed the Director of the Office of 

Communication and reviewed pertinent documentation on the various 

communication teams. We also spoke with some of CDC’s partners to 

 1

CDC officials told us that some items of a sensitive nature were removed from the 

calendar before it was given to us. 

Appendix I: Scope and Methodology 
Appendix I: Scope and Methodology 

Page 33 GAO-04-219 CDC Management 

obtain their views on how well the agency communicates during public 

health emergencies. 

To assess OD’s approach to managing routine agency operations, we met 

with OD executive management officials to determine the frequency and 

types of communications among them. We also met with management 

officials in six of the centers to discuss the frequency and type of 

communications between them and OD. To identify the type of 

management information OD received, we obtained copies of periodic 

management reports. We also obtained a list of all management meetings, 

including purpose, attendees, and frequency. We observed several 

management meetings, including an OD planning meeting, a senior staff 

meeting, and an issue briefing. We also attended agencywide staff 

meetings. In addition, we spoke with senior officials of the following OD 

staff offices: CDC Washington Office; Office of Communication; Financial 

Management Office; Procurement and Grants Office; Human Resources 

Management Office; Management Analysis and Services Office; and Office 

of Program, Planning, and Evaluation. We discussed with these officials 

the functions of their offices. We met with the Chief of Staff to discuss the 

issues management process, which the agency uses to manage issues 

requiring OD’s attention, and its use by agency officials. We obtained 

documentation of the corresponding issues tracking system as well as a 

list of issues that have been or are going through the process. To discuss 

how well the centers collaborate with one another, we met with 

management officials within OD to obtain their views and to identify steps 

taken by OD to improve the level of cooperation. We also obtained the 

views of some of the agency’s partners, who interact with multiple centers. 

To determine how CDC collaborates with its partners, we interviewed 

over 30 officials of state and local health departments, health-care-related 

associations, nonprofit organizations, private industry, schools of public 

health, and others, such as past CDC directors. We also interviewed the 

Deputy Director of Public Health Service to discuss how this official 

interacts with the agency’s partners. In addition, we reviewed relevant 

documentation, including an internal assessment of CDC’s customer 

service practices. 

To identify OD’s approach for setting the agency’s priorities, we 

interviewed senior management officials within OD and reviewed relevant 

documentation, including the agency’s 1994 strategic plan. In addition, we 

spoke with some of the agency’s partners to determine how CDC 

communicates its priorities to them. To learn about CDC’s recently 

implemented strategic planning approach, we interviewed CDC’s Senior 

Advisor for Strategy and Innovation and reviewed extensive 
Appendix I: Scope and Methodology 

Page 34 GAO-04-219 CDC Management 

documentation regarding this effort. We also attended agency meetings, 

which introduced the strategic planning process to both CDC staff and 

some of its advisors. We interviewed officials in CDC’s human resource 

office to discuss the agency’s workforce planning efforts. We also 

reviewed relevant documentation, including internal workforce planning 

reports, reports to the Department of Health and Human Services (HHS), 

feedback from HHS, and analyses performed by the agency’s contractor 

for the development of a human capital plan. We obtained and analyzed 

agency data on overall attrition and retirement eligibility. We also 

calculated retirement eligibility specifically for management-level staff. We 

discussed the limitations of the data with the appropriate CDC official and 

determined that the data were suitable for our use. Furthermore, we 

analyzed HHS directives that will potentially affect the size and 

composition of CDC’s workforce and discussed their implications with OD 

management officials. 
Appendix II: Comments from the Centers for 

Disease Control and Prevention 

Page 35 GAO-04-219 CDC Management 

Appendix II: Comments from the Centers for 

Disease Control and Prevention 
Appendix II: Comments from the Centers for 

Disease Control and Prevention 

Page 36 GAO-04-219 CDC Management 
Appendix II: Comments from the Centers for 

Disease Control and Prevention 

Page 37 GAO-04-219 CDC Management 
Appendix II: Comments from the Centers for 

Disease Control and Prevention 

Page 38 GAO-04-219 CDC Management 
Appendix II: Comments from the Centers for 

Disease Control and Prevention 

Page 39 GAO-04-219 CDC Management (290193) 
The General Accounting Office, the audit, evaluation and investigative arm of 

Congress, exists to support Congress in meeting its constitutional responsibilities 

and to help improve the performance and accountability of the federal 

government for the American people. GAO examines the use of public funds; 

evaluates federal programs and policies; and provides analyses, 

recommendations, and other assistance to help Congress make informed 

oversight, policy, and funding decisions. GAO’s commitment to good government 

is reflected in its core values of accountability, integrity, and reliability. 

The fastest and easiest way to obtain copies of GAO documents at no cost is 

through the Internet. GAO’s Web site (www.gao.gov) contains abstracts and fulltext files of current reports and testimony and an expanding archive of older 

products. The Web site features a search engine to help you locate documents 

using key words and phrases. You can print these documents in their entirety, 

including charts and other graphics. 

Each day, GAO issues a list of newly released reports, testimony, and 

correspondence. GAO posts this list, known as “Today’s Reports,” on its Web site 

daily. The list contains links to the full-text document files. To have GAO e-mail 

this list to you every afternoon, go to www.gao.gov and select “Subscribe to e-mail 

alerts” under the “Order GAO Products” heading. 

The first copy of each printed report is free. Additional copies are $2 each. A 

check or money order should be made out to the Superintendent of Documents. 

GAO also accepts VISA and Mastercard. Orders for 100 or more copies mailed to a 

single address are discounted 25 percent. Orders should be sent to: 

U.S. General Accounting Office 

441 G Street NW, Room LM 

Washington, D.C. 20548 

To order by Phone: Voice: (202) 512-6000 

TDD: (202) 512-2537 

Fax: (202) 512-6061 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm 

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470 

Jeff Nelligan, Managing Director, NelliganJ@gao.gov (202) 512-4800 

U.S. General Accounting Office, 441 G Street NW, Room 7149 

Washington, D.C. 20548 

GAO’s Mission 

Obtaining Copies of 

GAO Reports and 

Testimony 

Order by Mail or Phone 

To Report Fraud, 

Waste, and Abuse in 

Federal Programs 

Public Affairs