Building the US public-health workforce of the future

US public-health agencies have been fighting on the front line to protect Americans against COVID-19 for almost two years. To respond to the pandemic, public-health departments across the country have had to assume new and expanded responsibilities while continuing to deliver their core responsibilities and services as part of the public-health system.

As new COVID-19 variants hit the country and case rates surge, the rapid scale-up and shift in responsibilities continue to cause serious strain on the public-health system, which was already grappling with workers approaching retirement and staffing shortages before the pandemic (Exhibit 1). Over the past decade alone, the public-health workforce has shrunk by more than 15 percent.¹Brian C. Castrucci and Monica Valdes Lupi, “When we need them most, the number of public health workers continues to decline,” de Beaumont Foundation, May 19, 2020. Stagnant funding and cumbersome hiring processes have left departments struggling to attract the specialized and diverse talent they need to better reach, serve, and reflect their communities.²Yira Natalia Alfonso et al., “US public health neglected: Flat or declining spending left states ill equipped to respond to COVID-19,” Health Affairs, April 2021, Volume 40, Number 4, pp. 664–71.

1

As public-health departments face more attrition from pandemic-related burnout and resignations, such labor-market pressures are unlikely to abate. In May 2021, the US White House announced plans to invest $7.4 billion from the American Rescue Plan to recruit and train public-health workers.³“Fact sheet: Biden-Harris administration to invest $7 billion from American Rescue Plan to hire and train public health workers in response to COVID-19,” White House, May 13, 2021.

With that funding, state and local public-health departments have a unique opportunity to invest in the public-health workforce and build for the future. It is difficult in the throes of a COVID-19 surge to think about anything other than the acute pandemic response, but rebuilding the public-health workforce in parallel is critical to ensuring that health outcomes are on the path to improvement over the longer term. In this article, we outline six strategies that state and local public-health departments could consider to build the public-health workforce of the future (Exhibit 2).

2

Six strategies to consider for building the US public-health workforce of the future

While states and localities will need to tailor interventions to the unique needs of their constituents, each could consider focusing on six workforce development strategies.

1. Reassess capabilities and roles

By some estimates, the US public-health workforce will need to grow by 80 percent to provide a minimum set of health services in the country today.⁴Efforts to create national standards in the sector are under way, including a workforce calculator from the Center for State, Tribal, Local, and Territorial Support; the de Beaumont Foundation; and the Public Health National Center for Innovations (PHNCI) expected in summer 2022. For more, see “Staffing up: Workforce levels needed to provide basic public health services for all Americans,” de Beaumont Foundation and PHNCI, October 2021. Despite broad recognition of the current workforce shortages, there is no consensus on how optimal staffing should look in roles, capabilities, or jurisdiction size. Put another way, this is the first time in the current generation—and potentially in several—that the United States is having a societal conversation about the role of the public-health workforce as a part of the country’s necessary healthcare fabric and infrastructure.

The complexity of the US public-health infrastructure, which spans 50 state health departments, 2,800 local health departments, and 300 regional and district offices, complicates attempts to define future staffing needs.⁵ASTHO profile of state and territorial public health, volume 4, Association of State and Territorial Health Officials, 2017. Each locality has distinct mandates, programs, capabilities, governance structures, and operating models to serve its unique population.

In addition, much of public health has historically been funded through categorical (or vertical) financing streams for specific programs, disease areas, and initiatives, such as communicable-disease control and maternal and pediatric healthcare.⁶Institute of Medicine Committee on Public Health Strategies to Improve Health, For the Public’s Health: Investing in a Healthier Future, Washington, DC: National Academies Press, 2012. There has been little disease-agnostic funding for staffing in foundational areas such as communications, emergency preparedness, and executive management or for staffing to tackle new challenges, such as climate change. The injection of the American Rescue Plan and other funding offers states an opportunity to address needs in overall workforce shortages and to assess the capabilities required to meet those specific needs.

In one large US state, we conducted a systematic capacity and capabilities assessment of more than 50 local health jurisdictions. The results highlighted the variation in self-reported core technical competencies and exposed gaps in areas that have historically been underfunded, such as bioinformatics and health economics (Exhibit 3). They also showed sizable variations in capability and capacity among jurisdictions of different sizes, emphasizing the potential need to tailor workforce augmentation efforts.

3

Instead of a one-size-fits-all approach to staffing, state and local health departments can consider conducting a systematic assessment. They can identify the competencies needed in a future public-health system, assess current competencies and staffing levels, and create a plan to hire, train, and design the workforce for the future. And they can incorporate lessons learned during the COVID-19 pandemic, including the pros and cons of using temporary and contracted staff and transferring full-time employees among roles.

2. Share resources and engage partners

The COVID-19 pandemic has forced public-health systems to find talent creatively through internal transfers and rotations, temporary staffing, cross-jurisdictional collaboration, and engagement with partners and nongovernmental organizations. Public-health entities can use this moment in time to consider how to redefine their resourcing needs.

For example, states and jurisdictions can jointly examine which roles need to be local, regional, or remote. Public educators and direct clinical providers may need to be local, while laboratory technicians may be able to provide services regionally. Bioinformatic and data science professionals may be able to work remotely. And creative models of shared service can broaden access to top talent, especially in rural and hard-to-reach areas.

Public-health departments can also consider expanding their networks to partners with adjacent capabilities, especially for part-time, surge, and temporary staff. Healthcare providers, community-based organizations, academic institutions, private-sector businesses, and government partners have provided vital support during the COVID-19 pandemic.⁷For example, Homelessness and Health Response Group for Equity created a coalition with more than 100 members (including hospitals, federally qualified health centers, shelter operators, and housing advocates) to establish dedicated quarantine and isolation sites; the University of California, San Francisco, partnered with community organizations to test all residents of San Francisco’s mission district as well as Bolinas; North Carolina partnered with Medicaid programs to hire and train staff to augment local health department contact-tracing efforts; and Black pastors are promoting vaccine uptake in New York through hosting vaccination events and speaking out, targeting the 45 percent of Black adults who have not received a COVID-19-vaccine dose. For more, see Lloyd Michener et al., “Engaging with communities—lessons (re)learned from COVID-19,” Preventing Chronic Disease: Public Health Research, Practice, and Policy, July 2020, Volume 17; Liam Stack, “‘A safe space’: Black pastors promote vaccinations from the pulpit,” New York Times, October 13, 2021. For example, community-based organizations created safe spaces for quarantine and isolation, academic institutions built testing capacity, and faith-based organizations promoted vaccine uptake. States and localities can be creative about volunteer and surge staffing. Individuals can be trained, certified, and available on “warm standby” as a reserve corps for acute crises, and they can work as disease investigators, contact tracers, and public-health educators, as needed.

3. Overhaul the recruitment process

According to the US Bureau of Labor and Statistics, job resignation rates in the country hit a record high of 3 percent in November 2021, with more than 4.5 million people quitting their jobs. For public-health departments, the staffing challenges of the “Great Resignation” are exacerbated by common hiring challenges in the public sector, such as long recruitment timelines, complex and sometimes restrictive job descriptions, and compensation packages below industry standards.⁸The average public-health nurse salary was reported to be around $60,000 in August 2021, compared with the median registered-nurse salary of around $75,000. For more, see “Public health nurse salary guide,” NurseJournal, November 11, 2021.

Public-health departments can capitalize on the opportunity to rebrand by launching modernized and innovative recruitment platforms that attract prospective hires. Such efforts can be digitally enabled and analytically driven, tracking talent gaps to inform recruiting and reducing turnaround times. Departments do not have to build from scratch: they can borrow from platforms and approaches in other sectors.

With a renewed public focus on and appreciation for public health, agencies can broaden their talent pipelines and reach more diverse applicant pools. They can restructure job descriptions to emphasize capabilities over experience and offer remote- and hybrid-working practices. Public-health systems can also spark interest in potential candidates earlier in the pipeline. For example, organizations such as the Public Health Foundation’s HOSA-Future Health Professionals target secondary and postsecondary students, introducing them to public-health concepts at a preprofessional stage. Additional innovative recruitment efforts could include targeted programs, such as large-scale virtual and in-person job fairs, academic partnerships, rotational programs, internship programs, and community partnerships.

4. Invest in employees

A 2017 survey by the de Beaumont Foundation of public-health workers revealed that nearly half were planning to leave or retire within five years.⁹2017 national findings: Public Health Workforce Interests and Needs Survey, a joint report from Association of State and Territorial Health Officials, de Beaumont Foundation, and National Association of County and City Health Officials, January 2019. Employees cited inadequate pay, lack of advancement opportunities, the workplace environment, job satisfaction, and lack of support as their primary reasons. The COVID-19 pandemic seems to have only made matters worse. A more recent US Centers for Disease Control and Prevention survey revealed that 53 percent of workers had symptoms of at least one mental-health condition; 23 percent felt bullied, threatened, or harassed because of work; and 72 percent were overwhelmed by their workload or family–work balance.¹⁰Jonathan Bryant-Genevier et al., “Symptoms of depression, anxiety, post-traumatic stress disorder, and suicidal ideation among state, tribal, local, and territorial public health workers during the COVID-19 pandemic—United States, March–April 2021,” Morbidity and Mortality Weekly Report, July 2021, Volume 70.

Providing better support for public-health workers may require leadership and management teams to clearly define and actively cultivate their organizations’ culture, routinely reassess and address employees’ needs, and fund programs to contribute to a more sustainable working environment. In the immediate term, public-health systems can consider following some of their private-sector counterparts, offering extended sabbaticals, mental-health services, and additional at-home support (for example, childcare services) for their employees as they recover from the effects of the COVID-19 pandemic. Organizations can also invest in developing and advancing employees’ abilities. In a McKinsey Global Survey on future workforce needs, respondents often said that skill building, rather than hiring, is the most effective way to close skills gaps in the next five years. Capability-building programs can teach employees critical technical and strategic skills, such as bioinformatics, IT development, and healthcare economics.

Skill building can go beyond training courses. Organizations can foster a culture of learning and development that includes role modeling, apprenticeship, flexible training (including virtual and self-paced options), and incentives such as paid time off and stipends. Capability building can empower employees to pursue long-term careers in public health. Employers can help employees understand, from the start of their careers, how they can advance professionally and use the employers’ resources, mentorship programs, and rotational programs to do so.

5. Cultivate strong leaders

The COVID-19 pandemic has not only exacerbated the burden on frontline workers but also contributed to additional scrutiny of public-health leaders. They are challenged by more than 100 new laws that have implications for state and local public-health powers and face increased personal and public threats.¹¹Mike Baker and Danielle Ivory, “Why public health faces a crisis across the U.S.,” New York Times, October 18, 2021. Over the past 19 months, more than 500 public-health leaders have left their jobs, a significant loss of executive leadership and experience. As public-health departments look to rebuild for the future, they will need to replenish their leadership ranks.

That would likely require internal upskilling and external recruitment. In evaluating potential leadership candidates, public-health departments have an opportunity to build a cadre that reflects the diversity of the population they serve. That may require adjusting role descriptions to suit candidates based on their capabilities and competencies rather than specific educational qualifications or work experience.

States and jurisdictions can redouble their efforts to grow leaders internally. They can provide training opportunities for strategic management skills, such as change management, decision making, and consumer centricity. McKinsey surveys have found that just 28 percent of public-sector managers are qualified to support employees’ development and that fewer than 33 percent of leaders have been trained in change leadership.

6. Promote diversity, equity, and inclusion

The COVID-19 pandemic has highlighted long-standing inequities in public health: compared with White, non-Hispanic people, minorities have experienced more than one and a half times the case rate, three times the hospitalization rate, and two times the death rate.¹²“Risk for COVID-19 infection, hospitalization, and death by race/ethnicity,” US Centers for Disease Control and Prevention, November 2021. A January 2022 study by the Kaiser Family Foundation showed that COVID-19-vaccination uptake has followed suit, with racial and ethnic minorities experiencing substantially higher vaccine hesitancy.¹³Across 42 US states, 60 percent of White people, compared with 54 percent of Black people, had received at least one dose of COVID-19 vaccine as of January 2022. For more, see Nambi Ndugga et al., “Latest data on COVID-19 vaccinations by race/ethnicity,” Kaiser Family Foundation, November 2021. Those disparities underscore the importance of health equity, not just in outcomes but also in the diverse workforces serving communities.

One way for public-health departments to rebuild trust and serve the communities that need the most support is to foster more diversity in their workforces, which survey results indicate are roughly 80 percent women and 60 percent White workers today.¹⁴2017 national findings, January 2019. Possible initiatives include apprenticeship programs to recruit a diverse workforce, redefined minimum requirements for entry-level jobs, hiring from alternative pathways, and loan forgiveness and subsidy programs. Beyond hiring, public-health departments could also take initiatives to encourage an inclusive culture and require diversity, equity, and inclusion training for their workforces.

Investing today to prepare for tomorrow

The McKinsey Global Institute estimates that every $1 invested in healthcare improvements leads to a $2 to $4 economic return. Realizing this value will require states and localities to strengthen their public-health systems. Public-health departments can simultaneously build capacity and capabilities by investing in diversity and talent, creating opportunities for learning and development, and promoting a flexible, innovative, and inclusive environment. Modernization of the public-health workforce has been a “tomorrow problem” for many years. Tomorrow has arrived.