Health Affairs, 25, no. 4 (2006): 923-933 doi: 10.1377/hlthaff.25.4.923 © 2006 by Project HOPE	New Online   Senate Health Reform Bill   Rewarding Providers   Public Option Policy Brief   Health Reform & Abortion   Delivery System Reform

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Infrastructure

The Public Health Workforce, 2006: New Challenges

Abstract

 
Efforts to develop the public health workforce since 2001 have benefited from increased funding resulting from concerns over terrorism and other public health threats. This largesse has been accompanied by the need for greater accountability for results. The size, composition, and distribution of the public health workforce have long been policy concerns. Production and retention of public health workers remain important issues, although new dimensions of readiness are also taking center stage. We offer here policy recommendations in the areas of assessing the public health workforce and its needs, organizing development efforts around essential competencies for public health practice, credentialing workers, and accrediting agencies.

Heightened attention on emergency preparedness has led to increased interest in the employment, training, and uses of workers who are prepared to respond to emergencies, including those caused by humans. Beginning in 2002, funding for public health workforce preparedness and training increased dramatically. This influx of funding brought increased expectations for improvement and greater accountability for results. As a result, the public health system is challenged as never before to show that the vital signs of the public health infrastructure, including its workforce, are improving.

Despite increased attention and resources, major concerns remain as to the size, composition, distribution, skills, and performance of the public health workforce. Although convincing evidence is sometimes lacking, commonly cited concerns include (1) insufficient numbers of workers, especially for specific skilled public health occupational categories such as public health nurses and epidemiologists, related to public-sector budget restraints and competition with other sectors of the economy; (2) impending shortages of experienced workers who are approaching retirement age, without adequate replacements in the pipeline; (3) workers insufficiently prepared through education and training for the jobs they perform, relying too much on experience and on-the-job trial and error; and (4) inadequate workplace and work organization incentives that recognize and reward skill enhancement and demonstrated performance.

After a brief review of background material, we focus on four areas that are interwoven in current efforts to strengthen the workforce and then conclude with policy recommendations.

Background

Top Background Assessing The Public Health... Organizing Workforce Development... Credentialing Public Health... Accrediting Public Health... Policy Recommendations Conclusions NOTES

 
Framing documents. The 1988 IOM report on the future of public health highlighted the chasm between the practice of public health and the way in which it was taught in schools of public health; it called for collaboration to assure a work-force able to do what the nation needed.⁴ The Council on Linkages between Academia and Practice established a working agenda on a range of shared interests and in 2001 published core competencies, spanning eight content areas, for current and future public health workers.⁵

The attention to public health infrastructure stimulated by the national debate on health reform in 1993–94 led to the publication of Public Health in America, a statement of the mission and services encompassed within public health by the Public Health Functions Steering Committee (which includes the American Public Health Association [APHA], the Association of State and Territorial Health Officials [ASTHO], the National Association of County and City Health Officials [NACCHO], and the public health agencies of the U.S. Department of Health and Human Services [HHS]).⁶ This same steering committee wrote a report on the public health workforce in 1997.⁷ The 1997 report was the direct stimulus for HRSA’s enumeration of the workforce, published in 2000, which estimated that there were just under 500,000 public health workers in U.S. local, state, and federal agencies plus a limited number of partner organizations.⁸

Contributions of public health organizations. Assessing the adequacy of the public health workforce in 2006 in terms of its size, composition, and distribution is especially problematic in view of a lack of baseline information. Despite substantial differences in assumptions and data collection methods, comparisons between HRSA’s 1980 and 2000 studies fueled concerns that the number of public health workers was decreasing, at least in relation to the growth of the U.S. population.⁹ National public health organizations accepted this premise and supported policies intended to increase the number of public health workers. ASTHO published several reports on issues of aging and shortages within the public health workforce.¹⁰ NACCHO expanded its periodic survey of local public health agencies to include additional questions focusing on the workforce. National public health organizations also championed legislation that would authorize $235 million for a national program of scholarships and loan repayment programs for public health workers, to address current and projected shortages in specific occupational categories.¹¹

Investment of federal agencies. Federal agencies have invested in public health workforce development through grant programs such as HRSA’s Public Health Training Centers and the Centers for Disease Control and Prevention’s (CDC’s) Centers for Public Health Preparedness.¹² CDC bioterrorism grants to states and several large cities also support training and other public health work-force development activities. These grant programs, together providing more than $100 million, directly or indirectly encourage grantees to structure workforce development activities consistent with the reports described here. As a result of these developments, state and local public health agencies, together with their academic partners, face unprecedented opportunities to expand and strengthen the public health workforce. Several states have seized this opportunity to advance multifaceted strategic plans for public health workforce development, such as the New York State report to the state’s Public Health Council.¹³

Assessing The Public Health Workforce And Its Needs

Top Background Assessing The Public Health... Organizing Workforce Development... Credentialing Public Health... Accrediting Public Health... Policy Recommendations Conclusions NOTES

 
The numbers and federal funding. Despite concerns to the contrary, the number of governmental public health workers appears to have been increasing in recent decades, although a reversal of that trend may now be under way. Data on comparable categories derived from the 1980 and 2000 HRSA enumerations indicate that the number of public health professionals working for federal, state, and local public health agencies increased from 140,000 in 1980 to 260,000 in 2000.¹⁴ Data from the employment census of governmental agencies support this conclusion, showing that there has been a steady increase in full-time-equivalent (FTE) workers in governmental health agencies, including professional, technical, and administrative categories, over the past decade. In 2004 there were just over 550,000 FTE workers employed by federal, state, and local governmental health agencies (Exhibit 1). Based on information from HRSA’s 1980 and 2000 estimates and from employment census data, a steady increase in the number of public health workers is apparent through 2003 (Exhibit 2).

This finding illustrates how federal funding to states and localities for bioterrorism preparedness serves as a temptation to replace or supplant state and local support for public health with federal money, despite legal restrictions on federal appropriations. For example, in 2004 federal bioterrorism funds paid the salaries of 460 epidemiologists; among 390 epidemiologists working on bioterrorism and emergency response activities, 62 percent were funded by the federal government. The number of infectious disease epidemiologists did not increase between 2001 and 2004, but in 2004 nearly 20 percent were paid through federal bioterrorism funds.¹⁶ This scenario might also be true for several other public health occupational categories, such as laboratory workers and emergency response coordinators. It underscores the important role of the underlying financial health of state and local governments in determining the size of the public health workforce.

Information technology and administrative obstacles. Two additional modern forces affect the size of the public health workforce. The first is the expansion of information technology (IT) and the resulting change in worker productivity. Public health practice, by its very nature, is dependent on and driven by information. Improved IT tools and increased worker productivity mean that fewer workers are needed to support the work of administrators, professionals, and technical staff, although IT professionals must be added. This trend would tend to increase the proportion of professionals within the public health workforce, although its impact on overall size is unclear.

The second factor to affect public health workforce development is administrative and bureaucratic obstacles. State and local agencies face some of the most serious recruitment and retention problems, including slow hiring by governmental agencies; rigid civil service systems; hiring freezes; governmental budget crises; and the lack of career ladders, competitive salary structures, and other forms of recognition that value workers for their skill and performance.¹⁷

Organizing Workforce Development Around Competencies

Top Background Assessing The Public Health... Organizing Workforce Development... Credentialing Public Health... Accrediting Public Health... Policy Recommendations Conclusions NOTES

 
Core competencies. Establishing and promoting competencies to describe the expected knowledge, skills, and abilities of public health workers faces several challenges. These workers come from a variety of professional backgrounds, many of which have their own core competencies. For example, public health nurses are expected to meet a set of core competencies based on the essential public health services identified in the HHS Public Health in America statement, and health educators use a sophisticated competency framework for purposes of certification in that field. There are also competency formulations for epidemiologists, public health physicians, administrators, and several other professional occupations. This complexity accounts for the decade of debate and drafting needed by the Council on Linkages to develop the core competencies for public health professionals.

The national public health organizations endorsed and adopted these core competencies, which track to the essential public health services framework as the basis for assessing and improving the skills of public health workers. Core public health practice competencies serve as a useful benchmark for competency frameworks developed to serve state or local public health systems or to guide the development of more focused skills, such as in public health law, informatics, genomics, and emergency preparedness. Emergency response competencies for all public health workers are also available.

Competency-based training. The identification of core competencies demonstrates the support for competency-based training among practice organizations. A companion effort to identify a panel of core competencies for graduates of master of public health (MPH) programs is under development under the auspices of the Association of Schools of Public Health (ASPH).¹⁸ This panel contains discipline-specific competencies for behavioral sciences, health administration, epidemiology, biostatistics, environmental health, and public health biology as well as cross-cutting competencies in communication, informatics, cultural proficiency, ecological determinants of health, leadership, policy development, professionalism, program development and evaluation, and systems thinking.

Credentialing Public Health Workers

Top Background Assessing The Public Health... Organizing Workforce Development... Credentialing Public Health... Accrediting Public Health... Policy Recommendations Conclusions NOTES

 
Credentialing today. Health professions have taken various approaches to credentialing that include licensing (for physicians and nurses), certification (for health education specialists), and registration (for dietitians and sanitarians). They have also created a wide range of specialty certifications—credentials that identify those who have mastered some subset of knowledge and skills as demonstrated by a combination of study and examination.

This suggests that credentialing is already widely used for public health workers; examples include board-certified preventive medicine physicians, certified community health nurses and health education specialists, and certified and registered environmental health practitioners. Some licenses and many specialty credentials are renewed only if the worker completes required continuing education or even reexamination. Some certifications are open to members of only one discipline (for example, board certification as a medical specialist), while others are available to any clinician (Cardiac Life Support at two levels). The latter are usually narrower in scope than are those limited to an individual profession.

Challenges to credentialing. Public health faces particular challenges in this area because of its multidisciplinary nature. A strong public health team will comprise physicians, nurses, epidemiologists, environmental specialists, health educators, and community outreach workers. The full list of levels and types of public health workers represented in the job classifications of the Bureau of Labor Statistics (BLS) approaches 100. Of these, a sizable number already identify with a profession and must comply with some certification or other credentialing process. These professionals are educated as specialists in their primary discipline and often have little or no exposure to either the theory or the practice of public health prior to employment. A small proportion go on to earn the most common public health degree, the MPH, but reports have suggested that at least in leadership positions, only one in five incumbents have this training.¹⁹

Filling the credentialing gaps. The intent of any credential is to distinguish someone who is eligible for some status from others who are not. Identifying those who have demonstrated practice-relevant competencies at a specified level provides an incentive for workers to improve their skills. But there remains a need for credentials for those who would not fit into these specialty-specific credentials, such as public health physicians not certified in preventive medicine, or health educators who are not certified health education specialists. Since many, indeed most, workers will not be able to meet the specific requirements for specialty credentialing, such as the three-year residency for physicians or completion of a health education degree at the undergraduate or graduate level for certified health educators, a midlevel, public health–specific credential could be attractive to members of many public health disciplines.

A three-prong credentialing strategy emerged from the National Public Health Workforce Development Conference in early 2003, calling for recognition of public health competency at a basic or "Public Health 101" level and at a leadership level, as well as expansion of existing credentialing activities for public health disciplines to cover those not now included.²⁰ Both 2003 IOM reports on public health practice and education discussed the potential for a specific credential in public health, although the education group was more cautious.²¹ That panel suggested that a certification examination would make the most sense for the MPH graduate with no prior health experience, as a way to ensure minimum competence, similar to the licensing examinations in the classic health professions.

Accrediting Public Health Agencies

Top Background Assessing The Public Health... Organizing Workforce Development... Credentialing Public Health... Accrediting Public Health... Policy Recommendations Conclusions NOTES

 
Efforts under way. After several decades of debate and discussion, some form of a national program of voluntary accreditation of public health organizations now appears likely. With the key national public health practice organizations now in agreement, especially NACCHO and ASTHO, and with active support from the CDC and the Robert Wood Johnson Foundation (RWJF), a framework for a national accreditation program is likely to emerge in 2006.

Guiding this effort is a National Steering Committee and four work groups developing strategies and recommendations for the standards to be used, governance and financing of a national program, and its research and evaluation agenda. Contributing to this effort is a multistate collaborative funded by the RWJF that is examining the experience in five states (Illinois, Michigan, Missouri, North Carolina, and Washington) that now have some approach to public health agency accreditation.

Link between agency and worker preparedness. Although the eventual relationship of any national program accrediting public health organizations to efforts to credential individual public health workers is not yet clear, the possibilities are numerous and important. Both are based on standards, and if the basic concepts underlying those standards share the same conceptual framework, such as the essential public health services framework in the Public Health in America statement, they will serve to reinforce or even synergize each other. For workers to value credentials and the competencies upon which they are based, employers and health agencies must also find value in them and base decisions about hiring, promotion, salaries, and the like on a worker’s demonstration of those competencies. Improving workers’ ability to perform their functions competently relies on both worker training and work management strategies.²²

NACCHO’s program. An innovative NACCHO program, Public Health Ready, has already demonstrated the link between agency and worker preparedness. Public Health Ready recognizes public health agencies that meet standards for worker competency, agency preparedness plans, and regular exercises of those plans.²³ Workers can demonstrate preparedness competencies during those drills and simulations, furthering the ability of the agency to verify and document the preparedness levels of the organization and its staff. As this approach is deployed beyond several dozen pilot sites certified in 2004 and 2005, it could serve to focus public health workforce development efforts through its emphasis on the work, workers, and organizations that constitute the governmental public health enterprise.

Policy Recommendations

Top Background Assessing The Public Health... Organizing Workforce Development... Credentialing Public Health... Accrediting Public Health... Policy Recommendations Conclusions NOTES

 
Policy changes that truly strengthen the public health workforce will require action at all levels of government and the collaboration of multiple professional organizations. As a stimulus to the debate and action, we offer the following recommendations in assessment and development, credentialing, and accreditation.

Assessing and developing the public health workforce. Past trends and current market forces suggest that professional and administrative employment in public health is likely to grow over the next decade. Unfortunately, it will be difficult to measure the progress that has been made without deployment of a standard taxonomy for public health occupations and more comprehensive enumeration strategies and tools that provide better information on the key dimensions of the public health workforce, including its size and distribution in official agencies and private and voluntary organizations. Monitoring the interrelationships of size and composition of the workforce with expenditures, program activities, and health outcomes must be done at regular intervals using standardized definitions.

Competency-oriented job descriptions must become more widely used, not only to write position descriptions but also to evaluate workers’ performance and effectiveness. Core competencies and discipline- or activity-specific competencies can also guide orientation for new employees and training activities for the entire workforce. The use of competencies within public-sector personnel and human resources systems is growing but should not be allowed to take decades to develop.

Workforce planning and training in all public health settings must become an accepted portion of budgets and work plans. Managers and supervisors work with their employees to manage workers’ professional development and build skills for career advancement. However, experience demonstrates that training is the first budget to be cut. This practice may arise from the assumption on the part of policymakers and agency managers that many public health employees come to their jobs after completing considerable advanced training. However, they must understand that the emergence of new knowledge about health and how to protect it requires continuous education. Learning management systems within public health organizations can bring together information from worker assessments, annual performance appraisals, and completion of training courses to structure workplace management as well as education and training interventions. Further, workforce planning that accounts for turnover and retirements is essential information for the educational system if it is going to produce each needed new generation of workers.

Credentialing credentialing. Before any credentialing effort moves forward, the public health field must establish a credible system of documenting participation in continuing education. There is no common currency in the form of a public health continuing education unit (CEU) that assures quality and consistency of training activities nationally. Neither the CDC nor any of the national public health organizations has sought to serve in this capacity. A common currency that has credibility in the practice sector and is linked with organized workforce development strategies and credentialing programs would provide a considerable incentive for competency-based approaches to public health workforce development.

If public health is to develop credentialing, the process must focus more on public health practice competencies than on workers’ core disciplines. If that does not happen, then the only people likely to be credentialed are those with an MPH degree or graduates of other public health programs who are not otherwise credentialed in medicine, nursing, health education, dentistry, or any other field. Alternately, advocates for public health credentialing will have to make major changes in hiring practices or agency standards so that a new public health credential becomes a requirement for employment.

Accreditation of agencies. Accreditation of agencies or organizations in all other fields is possible because there is a common understanding of the unit to be accredited. There is no such clarity in public health. NACCHO’s "Operational Definition of a Local Public Health Agency Project" must be completed, and the definition must be agreed to by all major public health agencies as the essential first step.²⁴

Although state and national public health agencies should continue to be monitored for standards (or accredited) in specific areas such as laboratory performance, the building block of accrediting public health organizations will be the local agency—the place at which people meet public health. The National Public Health Performance Standards Program and the Mobilizing for Action through Planning and Partnerships (MAPP) process provide good beginnings for expected components.²⁵ Whatever process is established, accreditation requirements must include standards for workforce composition and competence.

Conclusions

Top Background Assessing The Public Health... Organizing Workforce Development... Credentialing Public Health... Accrediting Public Health... Policy Recommendations Conclusions NOTES

 
There is evidence that the size of the public health workforce has been increasing steadily at least through 2003. Since 2003, however, continuing federal bioterrorism grants for states and large cities in concert with reduced state and local budgets for public health agencies could supplant state and local funding. If federal bioterrorism funds decrease in future years, there could be a major reversal of a two-decade trend of increasing numbers of public health workers.

Past approaches to public health workforce development focused largely on a pipeline model, emphasizing production of future workers in various disciplines and occupations that could contribute to public health ends. Although pipeline strategies are necessary, they are not sufficient to meet the needs of the diverse public health workforce and must be supplemented through approaches that target public health workers where they are (meaning where they work).

The leadership of the public health community now realizes that an adequately prepared workforce does not simply materialize as wished for, that sustaining a drive toward high performance and improved health outcomes requires long-term workforce development, and that new approaches are necessary to move in the desired direction.

Editor's Notes

 
Kristine Gebbie (kmg24{at}columbia.edu) is the Elizabeth Standish Gill Associate Professor of Nursing at the Columbia University School of Nursing in New York City. Bernard Turnock is clinical professor of community health sciences, School of Public Health, University of Illinois at Chicago.

NOTES

Top Background Assessing The Public Health... Organizing Workforce Development... Credentialing Public Health... Accrediting Public Health... Policy Recommendations Conclusions NOTES

 

1. U.S. Department of Health and Human Services, Healthy People 2010: Understanding and Improving Health (Washington: DHHS, 2000).
2. Health Resources and Services Administration, The Public Health Workforce Enumeration 2000 (Washington: HRSA, 2000).
3. Institute of Medicine, The Future of the Public’s Health in the Twenty-first Century (Washington: National Academies Press, 2003); and IOM, Who Will Keep the Public Healthy? Educating Public Health Professionals for the Twenty-first Century (Washington: National Academies Press, 2003).
4. IOM, The Future of Public Health (Washington: National Academies Press, 1988).
5. Council on Linkages between Academia and Public Health Practice, "Core Competencies for Public Health Professionals," 11 April 2001, http://www.trainingfinder.org/competencies (accessed 12 April 2006).
6. Public Health Functions Steering Committee, DHHS, Public Health in America, 14 December 1999, http://www.health.gov/phfunctions/public.htm (accessed 12 April 2006).
7. Public Health Functions Steering Committee, DHHS, The Public Health Workforce: An Agenda for the Twenty-first Century, http://www.health.gov/phfunctions/pubhlth.pdf (accessed 11 May 2006).
8. HRSA, The Public Health Workforce Enumeration 2000.
9. HRSA, Public Health Personnel in the United States, 1980: Second Report to Congress (Washington: PHS, 1982).
10. Association of State and Territorial Health Officials, Council of State Governments, and National Association of State Personnel Executives, "State Public Health Employee Worker Shortage Report: A Civil Service Recruitment and Retention Crisis," 2004, http://www.astho.org/pubs/Workforce-Survey-Report-2.pdf (accessed 12 April 2006); and ASTHO, Strategies for Enumerating the Public Health Workforce, 2005, http://www.astho.org/pubs/WorkforceEnumerationReport.pdf (accessed 12 April 2006).
11. S. 2613, Public Health Preparedness Workforce Development Act of 2004.
12. HRSA, "Public Health Training Centers," http://bhpr.hrsa.gov/publichealth/phtc.htm (accessed 12 April 2006); and Centers for Disease Control and Prevention, "Centers for Public Health Preparedness (CPHP) Program," 2 December 2005, http://www.bt.cdc.gov/training/cphp (accessed 12 April 2006).
13. New York State Public Health Council, Strengthening New York’s Public Health System for the Twenty-first Century, http://www.health.state.ny.us/press/reports/century/index.htm (accessed 12 April 2006).
14. B.J. Turnock, Public Health: Career Choices That Make a Difference (Sudbury, Mass.: Jones and Bartlett, 2006).
15. U.S. Census Bureau, Federal, State, and Local Governments: Public Employment and Payroll Data, 28 December 2004, http://www.census.gov/govs/www/apes.html (accessed 12 April 2006).
16. Council of State and Territorial Epidemiologists, 2004 National Assessment of Epidemiologic Capacity: Findings and Recommendations, 2004, http://www.cste.org/Assessment/ECA/pdffiles/ECAfina105.pdf (accessed 12 April 2006).
17. H.H. Tilson and K.M. Gebbie, "Public Health Physicians: An Endangered Species," American Journal of Preventive Medicine 21, no. 3 (2001): 233–240.[CrossRef][Web of Science][Medline]
18. Association of Schools of Public Health, Master’s Degree in Public Health Core Competency Development Project, January 2006, http://www.asph.org/UserFiles/1.3FINAL.pdf (accessed 12 April 2006).
19. R.B. Gerzoff and T.B. Richards, "The Education of Local Health Department Top Executives," Journal of Public Health Management and Practice 3, no. 4 (1997): 50–56.
20. J.P. Cioffi et al., "Credentialing the Public Health Workforce: An Idea Whose Time Has Come," Journal of Public Health Management and Practice 9, no. 6 (2003): 451–458.[Medline]
21. IOM, The Future of the Public’s Health, and Who Will Keep the Public Healthy?
22. V.C. Kennedy and F.I. Moore, "A Systems Approach to Public Health Workforce Development," Journal of Public Health Management and Practice 7, no. 4 (2001): 17–22.[Medline]
23. National Association of County and City Health Officials, "Project Public Health Ready," 2006, http://www.naccho.org/topics/emergency/pphr.cfm (accessed 12 April 2006).
24. NACCHO, "Operational Definition of a Functional Local Health Department," http://www.naccho.org/topics/infrastructure/documents/OperationalDefinitionBrochure.pdf (accessed 1 June 2006).
25. NACCHO, "Mobilizing through Planning and Partnership (MAPP)," 2006, http://www.naccho.org/topics/infrastructure/MAPP.cfm (accessed 11 May 2006).

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