Over the past 4 decades, there have been upward of 20 reports from US federal government agencies, associations, foundations, and others expressing concerns about the ability of the public health workforce to address the increasing number of current and emerging public health needs. Issues faced by public health departments and workers include preparedness and response to natural and unnatural threats, increasing numbers of individuals with chronic diseases, emerging infectious diseases, substance misuse associated with substances such as opioids, unintentional and intentional injuries, and overall community health. There have been calls for action over the 4 decades, but actions to address the needs of the public health workforce have been sparse. Since the launch of public health department accreditation, however, we are seeing concerted efforts of national organizations and federal, state, tribal, local, and territorial health departments to further identify and address workforce development needs.
A Little History
The US Department of Health & Human Services, Health Resources & Services Administration, reports in the early and mid-1980s indicated that we had little accurate information about the composition and skills of the public health workforce.1–5 While data were insufficient about public health workers, the 1988 Institute of Medicine report, “The Future of Public Health,” recommended that greater emphasis be placed on public health worker, managerial, and leadership skills and competence.6 Shortly following the Institute of Medicine report, the Health Resources & Services Administration funded the Johns Hopkins University School of Hygiene and Public Health in 1990 to convene the Public Health Faculty/Agency Forum, with goals that included (1) strengthening relationships between public health academicians and public health practitioners in public agencies; and (2) improving the teaching, training, and practice of public health.7 This forum, comprising national public health practice and academic leaders, led to the creation of one of the first bodies charged with taking action to directly address public health workforce development needs, the Council on Linkages Between Academia and Public Health Practice (Council).8 Council successes include development of a consensus set of competencies to guide public health education and training, the Core Competencies for Public Health Professionals (the current version was revised and approved by the Council in 2014), and advocating for requiring master of public health students attending accredited public health schools and programs to complete a practicum prior to graduation (practica remain a requirement today).9 , 10
While some important steps were taken to address public health workforce needs, the national focus remained on reports and recommendations. The Public Health Functions Steering Committee (convened by the US Department of Health & Human Services, Office of Disease Prevention and Health Promotion, and comprising national public health organizations and federal agencies), author of the Essential Public Health Services in 1995, addressed workforce as one of the services, “Assure a competent public health and personal health care workforce.”11 The steering committee then commissioned its subcommittee on workforce, training, and education to explore workforce composition, skills and competency needs, curriculum development, and distance training, resulting in the report, “The Public Health Workforce: An Agenda for the 21st Century.”12 Congress also was becoming concerned about the public health workforce and in 1999 charged US Department of Health & Human Services to report on the nation's public health infrastructure, including the workforce. The report, “Public Health's Infrastructure: Every Health Department Fully Prepared; Every Community Better Protected,” recommended that by 2010 “Each community will be served by a fully trained, culturally competent public health team, representing the optimal mix of professional disciplines.”13 Healthy People 2010 and 2020 followed suit with objectives specific to competencies for training, job descriptions, and performance evaluations, and addressed overall training needs.14 , 15 For the most part, the modus operandi remained studies, reports, and recommendations.
Important Steps Taken to Address Public Health Workforce Development
As training (on-site and distance) was increasingly being supported and developed by federal agencies, academic institutions, health departments, and other trainers, public health professionals were gaining access to training that could help enhance skills and competence. The Public Health Foundation (PHF) in 2000 launched TrainingFinder.org, an online course catalog containing hundreds of trainings from course providers around the United States, making it easier for public health professionals to find training. Soon, at the request of state health departments, PHF created and launched TRAIN.org, a public health learning network enabling public health professionals to find, access, take, and track training. Around the same time, the Association of State and Territorial Health Officials and the National Association of County & City Health Officials in their periodic profiles of health departments began documenting skill and competency needs and suggested that greater attention be paid to addressing workforce needs. We were beginning to witness more training and action. However, overall use of training remained relatively low.
The Impact of Public Health Department Accreditation on Workforce Development
What has truly “jump-started” public health workforce development has been health department accreditation, launched in 2011. The Public Health Accreditation Board (PHAB) created an entire domain of standards and measures specific to workforce development (Domain 8), with requirements such as health departments having to demonstrate use of nationally accepted competencies to assess and address agency competency needs, develop a comprehensive workforce development plan, and integrate competencies into job descriptions. Workforce development also was being addressed as agencies developed and used skills for quality improvement (QI) and performance management and implementation of QI plans (Domain 9). In fact, human resources and training needs were addressed throughout PHAB's initial set of standards and measures.16 In 2010, recognizing the technical assistance and training needs of health departments preparing for accreditation, the Centers for Disease Control and Prevention established the National Public Health Improvement Initiative “to infuse quality and performance improvement methods in health departments.”17 Between 2010 and 2014 (until Congress ended the program), the National Public Health Improvement Initiative provided funding and technical assistance to health departments in partnership with the American Public Health Association, the Association of State and Territorial Health Officials, the National Association of County & City Health Officials, the National Network of Public Health Institutes, and PHF. Public Health Accreditation Board Standards and Measures combined with National Public Health Improvement Initiative assistance led to a dramatic increase in workforce development efforts.
PHF's TRAIN Learning Network, with its 1.5 million registered users, has an abundance of data that help demonstrate the impact of health department accreditation. In the 8 years prior to accreditation, there were 75 552 governmental public health agency-registered users on TRAIN. Since accreditation's launch 7 years ago, this number has increased to more than 195 000. Course completions increased from 728 165 to 3.2 million (nearly 2.5 million course completions since the launch of accreditation). The number of courses addressing competencies from the Core Competencies for Public Health Professionals (referenced by PHAB in its standards and measures) doubled from 8323 to 16 560. Trainers also have been impacted by accreditation, with 767 courses mentioning accreditation in course titles or descriptions being added to TRAIN since 2011 (compared with 220 courses prelaunch).18 While the tremendous increase in public health workers taking and completing training cannot be fully attributed to health department accreditation, it is evident that accreditation has had a major impact.
The impact of accreditation on health department workforce development efforts also can be seen by the attention being paid to building skills, competence, and capabilities in QI and performance management. Prior to accreditation, PHF provided on-site services to fewer than 30 health departments. Since 2011, on-site QI and performance management assistance has been provided to more than 350 health departments, 30% of which have been accredited.19 Health departments also increasingly are assessing competency gaps and needs, integrating competencies into job descriptions, and developing competency-based workforce development plans.
Health departments have increased their workforce development activities since the launch of health department accreditation. Training efforts have moved beyond compliance training to training that focuses on QI, performance management, community assessment, and other crosscutting, noncategorical areas. This is contributing to greater organizational alignment across silos. The Public Health Accreditation Board's emphasis on QI and performance management created a cultural shift within many agencies, reinforcing continuous improvement, development of new skills and competencies, and overall organization-wide capacity building.
Increased attention to workforce development among health departments pursuing, achieving, and maintaining accreditation is not universal within and across agencies. Some staff still experience supervisors not providing time for training, and workforce development activities are not always seen as important to domains other than Domain 8. However, PHAB continues to “push the envelope” with Standards and Measures Version 1.5 by increasing attention to workforce development and its alignment with all domains. Unlike Version 1.0, Version 1.5 requires health departments to begin developing their workforce development plans much earlier in the accreditation preparation process. Based on observations of PHF's performance improvement experts in the field, we are seeing health departments initiate workforce development activities much earlier and integrate these with strategic plans, QI plans, and other agency-wide plans.
Health department accreditation has moved public health from only talking about workforce needs to taking action at all levels of government. As more health departments seek and become accredited, and as PHAB continues to add rigor to its standards and measures, progress will continue being made toward identifying and meeting workforce development needs throughout the United States.
1. US Department of Health & Human Services, Health Resources & Services Administration. Report on Public and Community Health Personnel. Washington, DC: Government Printing Office; 1980.
2. US Department of Health & Human Services, Health Resources & Services Administration. Public Health Personnel in the U.S. 1980. Washington, DC: Government Printing Office; 1982.
3. US Department of Health & Human Services, Health Resources & Services Administration. Report to the President and Congress on the Status of Health Personnel in the United States. Washington, DC: Government Printing Office; 1984.
4. US Department of Health & Human Services, Health Resources & Services Administration. Fifth Report on the Status of Health Personnel in the United States. Washington, DC: Government Printing Office; 1986.
5. US Department of Health & Human Services, Health Resources & Services Administration. Sixth Report on the Status of Health Personnel in the United States. Washington, DC: Government Printing Office; 1988.
6. Institute of Medicine. The Future of Public Health. Washington, DC: The National Academies Press; 1988.
7. Johns Hopkins University School of Hygiene and Public Health. Public Health Faculty/Agency Forum Report. Gainesville, Florida: University of Florida Press; 1991.
9. Council on Linkages Between Academia and Public Health Practice. Core competencies for public health professionals. http://www.phf.org/corecompetencies
. Accessed September 10, 2017.
11. US Department of Health & Human Services, Office of Disease Prevention and Health Promotion, Public Health Functions Steering Committee. Essential public health services. https://www.cdc.gov/nphpsp/essentialservices.html
. Accessed September 17, 2017.
12. US Department of Health & Human Services, Public Health Service. The Public Health Workforce: An Agenda for the 21st Century. Washington, DC: Public Health Functions Steering Committee; 1998.
13. US Department of Health & Human Services, Centers for Disease Control and Prevention. Public Health's Infrastructure: Every Health Department Fully Prepared; Every Community Better Protected. Report to Appropriations Committee of the United States Senate. Washington, DC: US Department of Health & Human Services, Centers for Disease Control and Prevention; 2000.
16. Public Health Accreditation Board. Standards and Measures, Version 1.0. Alexandria, VA: Public Health Accreditation Board; 2011.
18. Public Health Foundation. National TRAIN Learning Network Database. Washington, DC: Public Health Foundation; 2017.
19. Public Health Foundation. Performance Improvement Services Database. Washington, DC: Public Health Foundation; 2017.