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Can a Public Health Department Perform Well Without a Strong Workforce?

Bender, Kaye PhD, RN, FAAN

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Journal of Public Health Management and Practice: March/April 2019 - Volume 25 - Issue - p S13-S15
doi: 10.1097/PHH.0000000000000951
  • Open

Success is no longer about changing strategies more often but having the agility to execute multiple strategies concurrently. And success requires CEOs to develop the right leadership capabilities, workforce skills, and corporate cultures to support digital transformation.

Pierre Nanterme1

Some Things Change; Some Do Not

I recall discussing the needs of the public health workforce years ago when I was just a new part of that group. The discussions in those days centered around enumeration of the workforce; discrepancies between public health salaries and those in the private sectors; defining competencies and the associated education and training; and seeking strategies that would alter retention despite the low salaries. In the ensuing decades, some of the issues remain the same (salary discrepancies and turnover) but others have been systematically addressed by the various iterations of competencies and the widespread use of online learning modalities. Compared with my early years as a member of the public health workforce, the attention to those issues have much improved.2–4 However, some of the same issues prevail, as noted by the 2002 quote by Gebbie et al, which could still be said today—“Without a competent workforce, a public health agency is as useless as a new hospital with no health care workers.”2(p57)

The first Journal of Public Health Management & Practice supplement focused on the Public Health Workforce Interest Needs Survey (PH WINS 2014) contained several articles on how a better understanding of the feedback directly from the workforce can provide invaluable guidance to public health departments on improving their performance. Today's public health practice environment poses some new challenges to ensuring a solid, competent, and well-prepared workforce in the governmental public health environment. The changing nature of public health practice; the need for new and sharper skills in the use of data for decision making; in understanding and working with communities in meaningful and sustainable ways; and in basing their work on a solid understanding of the multiple determinants of health, leading to new and innovative ways to work with and across various sectors.

Unfortunately, in my early days, there were supervisors and managers who practiced as though the needs of the public health workforce were issues that individuals within the workforce had to solve. But there were many others who saw the potential and the need to mentor and strengthen the workforce so that their health departments would be better and stronger. Those future-looking mentors did not accept a common belief that because governmental salaries are lower than similar salaries in the private sector, the workers that are recruited either cannot or will not stay in their roles long enough to make a difference. They believed that all public health workers need to be given the opportunity to be creative, to offer suggestions for innovation, and to be actively engaged in ensuring that the health department is the best health department it can be. And they did that with little data to inform their workforce development strategies. Now that the country has a valid survey of public health workforce interests and needs, today's supervisors and managers have the tools upon which to provide the best workforce development opportunities they can. And, in doing so, they will strengthen their health department's overall performance.

What We Have Learned From Accreditation

Accreditation standards and measures (version 1.5) require health departments to demonstrate capacity to Maintain a Competent Public Health Workforce (Domain 8). There are 2 standards and a few associated measures for this domain.

  • Standard 8.1: Encourage the Development of a Sufficient Number of Qualified Public Health Workers. These measures are associated with the health department's support for and engagement in developing a pipeline of new public health workers.
  • Standard 8.2: Ensure a Competent Workforce Through Assessment of Staff Competencies, the Provision of Individual Training and Professional Development, and the Provision of a Supportive Work Environment.5

In general, health departments have performed well on the measures associated with this requirement. Data extracted from the Public Health Accreditation Board's (PHAB's) information system revealed that health departments perform quite well on most of the measures. However, some health departments have been required to do additional work either in an action plan or on their annual reports, postaccreditation, on their workforce development plan. In addition, performance on a measure that requires state health departments to provide technical assistance to Tribal or local health departments reveals some weaknesses.6 While PHAB acknowledges that attention to the needs of the workforce are much more challenging in tight fiscal times, the accreditation requirements support the concepts that a health department cannot function well without a well-prepared, well-supported workforce.

Since PH WINS data are now available to participating health departments, PHAB received questions about whether participation in the PH WINS would count for accreditation. PHAB is a strong supporter of PH WINS collecting data on the interests and needs of the public health workforce. There are 2 places in Domain 8: Measure 8.2.1 and Measure 8.2.3, where PH WINS data/reports might apply. Also, for Measure 8.2.1 (Workforce Development Plan), it is sufficient to use aggregate data about the needs, gaps, etc, as the basis for the plan, if the data are specific to the health department. So, for those state health departments that participate in PH WINS and get their state-specific report back, it most definitely can be used to inform the development of their workforce development plan. PHAB does not dictate how a health department gets the information (needs assessment/gap analyses) from its staff, so they certainly can use their own surveys. However, with PH WINS already done for them, it seems like a win-win for them to use it to inform their plan. Regarding Measure 8.2.3: Individuals who participate in the PH WINS may print their responses to the training needs assessment portion of the survey and share that information with their supervisor when mapping out personal training needs. If the supervisor or health department uses it for its professional/career development, then it can be used as an example for this measure.7

Thinking Ahead

Despite the attention that accreditation places on workforce development, research on the association between accreditation and employee satisfaction is still unclear. While some reports have indicated a correlation between accreditation and employee satisfaction, others have found little alignment. Could it be that all health departments are working so diligently on workforce development that the accreditation standards and measures are not rigorous enough to measure the gaps? PH WINS data would suggest that there are gaps between what employee needs and interests are and what health departments provide. Since accreditation's foundational focus is based on performance improvement, attending to the health department's performance regarding its workforce appropriately aligns with other aspects of health department performance improvement required by the standards and measures.

As PHAB works on version 2.0 of the accreditation standards and measures (planned for public vetting in early 2020), there are some potential opportunities for accreditation to serve as a vehicle for strengthening health department performance as it relates to supporting their workforce. Some of the ideas that have been shared with PHAB so far include the following:

  • Could the workforce development plan include analysis of the workforce interest and needs (through a survey such as PH WINS) and specific goals and objectives for addressing the identified gaps? In keeping with its philosophy about not telling health department how to accomplish the work required by the standards and measures, health departments would have the opportunity to develop the plan that works best for them?
  • Might accredited health departments' annual reports require follow-up reporting on the impact of the goals and objectives described in the workforce development plan?
  • Is there a strong evidence base for public health workforce strategies to address the gaps identified by a survey such as PH WINS? If not, how can PHAB's National Center for Innovations (PHNCI) be engaged to explore the development, replication, and testing of same?
  • Have we as a public health field adequately explored exemplars in public health academic/practice collaborations aimed at strengthening the connection between formal public health education and governmental public health practice?

Public health department performance is only as strong as its workforce. High-performing health departments know and demonstrate that the use of valid data can lead to good decision making in other aspects of public health. The same can apply to the management of our valuable workforce.


1. Famous quotes by Chief Executive Pierre Nanterme. Accessed August 10, 2018.
2. Gebbie K, Merrill J, Tilson H. The public health workforce. Health Aff. 2002;21(6):57–67. Accessed August 10, 2018.
3. Tilson H, Gebbie K. The public health workforce. Ann Rev Public Health. 2004;25:341–356. Accessed August 20, 2018.
4. Institute of Medicine. Who Will Keep the Public Healthy? A Consensus Study Report by the Board on Health Promotion and Disease Prevention. Washington, DC: National Academies Press; 2003. Accessed August 10, 2018.
5. Public Health Accreditation Board. Standards and measures for initial accreditation. Updated 2015. Accessed August 15, 2018.
6. Public Health Accreditation Board. Internal Data Analysis. Alexandria, VA: Public Health Accreditation Board; 2018.
7. Public Health Accreditation Board. e-Newsletter. 2017;(69). Accessed August 10, 2018.
© 2019 The Author. Published by Wolters Kluwer Health, Inc.