Staffing Up and Sustaining the Public Health Workforce : Journal of Public Health Management and Practice

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Staffing Up and Sustaining the Public Health Workforce

Leider, Jonathon P. PhD; McCullough, J. Mac PhD, MPH; Singh, Simone Rauscher PhD; Sieger, Annie BS; Robins, Moriah MPH; Fisher, Jessica Solomon MCP; Kuehnert, Paul DNP, RN, FAAN; Castrucci, Brian C. DrPH, MA

Author Information
Journal of Public Health Management and Practice: October 11, 2022 - Volume - Issue - 10.1097/PHH.0000000000001614
doi: 10.1097/PHH.0000000000001614

Abstract

In the decade since the Great Recession, the state and local governmental public health workforce in the United States has declined substantially.1,2 While governmental public health agencies employed close to 250 000 full-time equivalent (FTE) positions in 2008, continued state and local public health funding reductions forced agencies to reduce their staffing levels by 15% to 20% over the following decade (Figure 1).3–5 This retrenchment occurred despite a 4.3% annual average rise in national health care expenditures and annual average overall economic growth of 3.3% during the past decade.6

F1
FIGURE 1:
Size of State and Local Governmental Public Health Workforce by YearaAbbreviations: Local, local and regional health departments; SHA CO, state health agency central office.aAuthor analysis of data from the Association of State and Territorial Health Officials and the National Association of County and City Health Officials. Workforce rounded to the nearest thousand.

Even before the COVID-19 pandemic, many state and local health agencies operated with minimally sufficient levels of staff to address health needs and protect and promote health in the communities they serve.7 The additional demands on public health agencies brought on by the COVID-19 pandemic increased awareness of critical gaps in public health funding and staffing among public health practitioners and policy makers as well as the general public.8 While the US government estimates public health spending doubled from 2020 to 2021, significant concerns remain about the long-term viability of the workforce.9,10

A strong public health infrastructure is essential to ensuring that communities are capable of delivering core public health functions and creating an environment in which all community residents can live healthy lives.11 Yet, because of continued job losses in state and local public health departments, communities across the country have been losing critical prevention and health promotion services and the staff who deliver them.12 As communities lose public health workers, they lose capacity for monitoring community health status, protecting against environmental hazards, reducing injuries, promoting healthy behaviors, and tracking and responding to disease outbreaks and other public health emergencies. Reductions to the public health workforce may pose a threat to the public's health.

Recognizing the potential threats to the nation's health stemming from an inadequate public health workforce, in 2012, the Institute of Medicine (IOM; now known as the National Academy of Medicine [NAM]) called for substantial additional investment in the nation's public health system.13 During the COVID-19 pandemic, the Biden Administration has called for 100 000 additional public health staff,14 though these additional positions were largely meant to be in temporary support of COVID-19 response and recovery. Ensuing discussions about the level of resources needed to ensure comprehensive public health protections, however, have to date been limited by a lack of data on the current state of the public health infrastructure. While others have shown a 15% to 20% reduction in current versus historic public health staffing levels,1–3 there are currently no national estimates of the size of the public health workforce necessary to adequately respond to public health needs prior to the COVID-19 pandemic. So while there may be agreement that the governmental public health agency workforce is underfunded and understaffed, it is unclear what adequate staffing (or funding) would be. A clearer picture and national estimate of the size of the public health workforce gap may help with ongoing efforts to fully staff public health agencies to meet the nation's public health needs.

In 2020, the de Beaumont Foundation partnered with the Public Health National Center for Innovations (PHNCI) at the Public Health Accreditation Board on a new workforce initiative, “Staffing Up: Determining Public Health Workforce Levels Needed to Serve the Nation” (“Staffing Up”). The goal of the initiative was to develop a national estimate of staffing needed to support elements of the implementation of a minimum package of public health services, known as the Foundational Public Health Services (FPHS), in communities across the United States.

In this article, we describe the processes used and the analyses conducted by the Staffing Up project. Specifically, the purpose of our work was to calculate (a) current public health workforce staffing levels in state and local public health departments, (b) the public health workforce needed to fully implement the Foundational Capabilities (FCs) and Foundational Areas (FAs) components of the FPHS model, and (c) the gap in the size of the public health workforce at the state and local levels.

Methods

We describe our project's overall approach, definitions, major assumptions, and analyses. Because of the complex nature of the project and the multitude of analytic decisions needed to achieve the project's objectives, a 10-member research advisory team consisting of expert public health systems researchers provided input on the project's methods and quantitative approaches throughout the course of the project. A 28-member steering committee consisting of local, state, and Tribal public health practitioners, federal agency stakeholders, and national public health policy makers and advocates provided overall project guidance and direction. See Supplemental Digital Content STEERING COMMITTEE ORGANIZATI-ONS (available at https://links.lww.com/JPHMP/B36).

Our analyses focused on the public health workforce employed at state health agencies (SHAs) and local health departments (LHDs) in the 50 US states. Because of data availability, territorial and Tribal health jurisdictions were not included in these analyses. Our analyses were grounded in the FPHS model,15 which represents an evolution of the “minimum package” of public health services model posited in the 2012 IOM report.13 The FPHS model includes 5 FAs and 8 FCs.15

The FPHS model classifies public health activity into core public health activity and expanded activity. Core activities (ie, Foundational Capabilities and Areas, hereafter FCs and FAs) are those that “should be present everywhere for the [public] health system to work anywhere,” while the expanded activities are those that exist to meet additional community need or satisfy state or local priorities.15 The goal of Staffing Up was to estimate public health workforce capacity and needs related to core public health system obligations in the FCs and FAs. States or communities that engage in activities beyond the FCs and FAs may have greater workforce needs than presented here.

Data sources

Estimates of workforce needs created through the Staffing Up project were generated using 4 primary data sources. Data on the current SHA workforce came from the 2019 Association of State and Territorial Health Officials' (ASTHO's) Profile of State and Territorial Public Health.16 Data on the current LHD workforce came from the 2019 National Association of County and City Health Officials (NACCHO) National Profile of Local Health Departments.17 Additional state and local workforce data were obtained from the 2017 Public Health Workforce Interests and Needs Survey (PH WINS).18 Data on the size of the current public health workforce (“current workforce”) and the size of the public health workforce that would be needed to fully implement the FCs and FAs (“full implementation workforce”) were obtained from SHAs and LHDs located in 4 states that have completed public health modernization work as part of the PHNCI's 21st-Century (21C) Learning Community.19 All data were collected prior to the COVID-19 pandemic and represent a snapshot of the prepandemic public health workforce.

Local health department workforce calculations

To estimate the national public health workforce gap, we first used existing data to directly calculate the current size of the workforce performing core public health activity in the United States. We then used self-reported estimates of the number of FTEs needed to “fully implement” core FPHS. Additional detail regarding self-reported data collection processes is available in the Supplemental Digital Content Appendix (available at https://links.lww.com/JPHMP/B37). These full implementation expenditure and staffing estimates were obtained from LHDs in four 21C states (Colorado, Ohio, Oregon, and Washington). Each of these 4 states underwent extensive public health modernization activities, as detailed elsewhere.19–21 These agencies reported their current expenditures and current FTE staffing for each FC and FA included in the FPHS model. To ensure consistency across jurisdictions, we limited to “core” or “below-the-line” work for each FC and FA.22 LHDs use a wide variety of staffing models to perform public health services—permanent employment, temporary staffing, contract labor, etc. Since public health agency budgets tend to be weighted toward personnel, agency-level FTE and expenditure data were combined to obtain a more valid estimate of the size of the public health workforce than the raw number of employees at a given LHD. We compiled LHD current and full implementation self-reports from the 21C states and harmonized activity definitions across jurisdictions to generate a final analytic sample for 168 LHDs. Data included estimates of current spending and current FTEs and full implementation spending and FTEs for each LHD overall and for each FC and FA at each LHD.

Data from the four 21C states were collected between 2016 and 2018, prior to the onset of the COVID-19 pandemic. Spending estimates were converted to constant 2018 dollars to account for inflation. We also adjusted for purchasing power differentials through a cost-of-living measure for each county LHDs served.23

Model determination

We used current and full implementation data obtained from one hundred sixty-eight 21C state LHDs to generate a predictive model of the gap between current and full implementation staffing for the public health workforce.

Candidate current versus full implementation staffing models included predictions associated with linear regression, as well as curve-fitting models (linear, quadratic, cubic, and power models) (see Supplemental Digital Content Appendix Figure 1, available at https://links.lww.com/JPHMP/B37). We examined several candidate model designs that accounted for items such as public health service mix, rurality, measures of community need, and other community characteristics (see Supplemental Digital Content Appendix Methods, available at https://links.lww.com/JPHMP/B37, “Model Estimation Approach,” and Supplemental Digital Content Appendix Figure 2, available at https://links.lww.com/JPHMP/B37). Calculations were conducted for each FPHS FC and FA. We group many of the FCs into a single category for parsimony, due to some statistical instability around smaller category estimates, and conceptually since it may have been challenging to differentiate some FCs when estimating full implementation scenarios. A locally weighted power model regressing full implementation FTEs on population size alone proved the most predictive and performed the best across a variety of model-fitting exercises. To assess whether the model was overfit, the generalized approach for curve fitting the 21C data was checked against available NACCHO data (which includes total FTEs but does not collect FTEs by core vs expanded service). Stata was used to conduct microsimulation, and macrosimulation strategies with a Monte Carlo design were to assess variability in total estimates through strength of assumptions. To estimate the current FTEs that provide FCs and FAs, we applied the ratio of core FTE to expanded service FTE from the 21C data to national estimates. For both current and full implementation, estimates were calculated by FC and FA and population size served by the LHD (<25 000; 25 000-49 999; 50 000-99 999; 100 000-249 999; 250 000-499 999; 500 000+). Additional methodological detail, including specific approaches tested for the state portion of the estimate, is provided in the Supplemental Digital Content Appendix (available at https://links.lww.com/JPHMP/B37). All analyses were performed using Excel and Stata/MP version 15.1

F2
FIGURE 2:
Current Versus Full Implementation Staffing Levels for State Health Agencies and Local Health Departments, Both Overall and by Size of Population ServedAbbreviation: FTE, full-time equivalent.

Results

Results from “21C states” completing cost estimation of Foundational Areas and Capabilities

Among the 168 LHDs constituting the analytic sample, 156 departments reported needing more staff to fully implement the FPHS in their jurisdiction (Figure 2; and Supplemental Digital Content Appendix Figure 4, available at https://links.lww.com/JPHMP/B37). LHDs reported needing an average of 34 additional FTEs per 100 000 population (median: 20 additional FTEs per 100 000 population; IQR = 9-44 additional FTEs per 100 000 population). This finding differed by population size, with agencies serving fewer than 25 000 persons needing an average of 73 more FTEs per 100 000 population (median: 60 additional FTEs) while jurisdictions serving populations of 200 000 to 499 999 needed an average of 11 more FTEs per 100 000 (median: 9.5 additional FTEs).

Substantial variation in additional staffing needs was observed across the FAs and FCs. For Assessment/Surveillance, LHDs reported having 2.2 FTEs per 100 000 population on median (IQR = 1.1-4.1) and needing 4.4 FTEs per 100 000 (IQR = 2.6-8.5). For Emergency Preparedness and Response, current staffing was reported at 2.1 (IQR = 0.9-4.1) and needed staffing was 3.0 (IQR = 1.6-7.7). For the other Capabilities, agencies reported “current” staffing of 9.2 FTEs per 100 000 (IQR = 5.3-16.1) and 17.3 (IQR = 9.8-31.1) FTEs per 100 000 needed for full implementation. For the FAs, LHDs reported having 4.3 FTEs per 100 000 population on median for Communicable Disease Control (IQR = 2.4-7.4) but needing 7.8 FTEs (IQR = 4.4-14.3). Chronic Disease and Injury Prevention was 3.0 (IQR = 0.75-4.7) current and 4.8 full FTEs (IQR = 2.1-11.6); Environmental Health was 6.9 current (IQR = 4.1-10.6) and 10.2 full FTEs (IQR = 7.5-17.4); Maternal Child Health was 1.9 current (IQR = 0.8-5.2) and 4.2 full FTEs (IQR = 2.1-11.7); and Access/Linkage was 0.72 current (IQR = 0.23-1.88) and 2.2 full FTEs (IQR = 0.77-6.6).

National results

Extrapolating workforce patterns from 21C states for which data were available to other states without available full implementation staffing data nationwide, we calculated that LHDs and SHA central offices (COs) employ 30 FTEs per 100 000 population to deliver the core FPHS. To achieve full implementation of core below-the-line public health capabilities, LHDs and SHA COs would need a total of 55 FTEs per 100 000 population. At LHDs, there are currently 20 FTEs per 100 000 population whereas full implementation would require 40 FTEs per 100 000 population. At SHA COs, there are currently 10 FTEs per 100 000 population whereas full implementation staffing would require 15 FTEs per 100 000 population.

The current versus full implementation staffing gap varied by size of population served by an LHD (Figure 2). LHDs serving populations of less than 25 000 saw relatively larger staffing gaps in terms of FTEs per population—current staffing of 35 FTEs versus projected full implementation staffing of 110 FTEs per 100 000 population. LHDs serving populations of greater than 500 000 saw relatively smaller staffing gaps in terms of FTEs per population—current staffing of 20 FTEs versus projected full implementation staffing of 30 FTEs per 100 000 population. In general, our results showed that the larger the jurisdiction size served, the smaller the number of both current and full implementation FTEs per 100 000.

Given substantial variation in observed current to full implementation FTEs needed across LHDs, microsimulation modeling was conducted at the agency level and macrosimulation at the LHD group level (by population size). While overall the LHD totals for new FTEs needed to fully implement varied approximately ±6% in microsimulation models for results within the 2.5 percentile to 97.5 percentile and ±12% in the more conservative macrosimulation model, more substantial variation in simulation outcomes was observed for individual FAs and FCs. In the microsimulation models for the LHD component of the estimate, Assessment ranged by ±11% from the median, Emergency Preparedness at ±12%, remaining capabilities at ±7%, Communicable Disease Control at ±8%, Chronic at ±9%, Environmental Health at ±19%, Maternal Child Health at ±9%, and Access/Linkage at ±9%. The state component of the estimate varied substantially in simulation modeling, ±17% in microsimulation models (see Supplemental Digital Content Appendix Figure 3, available at https://links.lww.com/JPHMP/B37).

F3
FIGURE 3:
Additional Staffing Needed to Fully Implement Core Foundational Public Health Services

The number of new FTEs needed varied across the 8 foundational services examined, though all areas were found to need additional FTEs to reach full implementation (Figure 3; see Supplemental Digital Content Appendix Table 1, available at https://links.lww.com/JPHMP/B37). The number of new FTEs needed ranged from 4500 additional FTEs (3500 local plus 1000 state) for access/linkage to 13 000 additional FTEs (8000 local plus 5000 state) for chronic disease and injury.

Discussion

The Health Resources and Services Administration uses health professional shortage area designations and medically underserved area/population designations to identify shortages of critical medical care providers and provide necessary resources to reduce disparities in access.24 While this is a common practice for the medical workforce, the number of governmental public health agency staff necessary to provide basic, minimum public health services has previously been unclear, so it has not been possible to identify similar shortage areas in the public health workforce. Following the September 11 terrorist attacks, public health staffing and funding increased. But those increases have proven to be only temporary, with declines in the public health workforce observed following the Great Recession and since.1,11 Given the role that public health departments play in emergency preparedness and response, each reduction in subsequent budget cycles may increase risks to our nation's health. The COVID-19 pandemic revealed an existing workforce starved for the resources and capacity necessary to provide minimum public health services let alone adequately respond to a nationwide public health crisis.2

Based on this analysis, local and state health departments need to hire a minimum of 80 000 more FTEs—an increase of nearly 80%—to provide the minimum set of public health services to the nation. Additional research to further refine estimates of the workforce gap could help confirm or refine estimates presented here. Additional data from a larger set of public health agencies representing additional regions of the country, different public health governance structures, and a larger number of agencies of all jurisdiction sizes may be especially important.

Our findings point to 2 important policy questions—how to recruit and fill this workforce shortage and how to pay for it. While solutions for both of these are beyond the scope of this analysis, we consider both as follows:

Recruiting and sustaining a fully staffed public health workforce may entail collaboration between public health educators and practitioners. New opportunities could include working with undergraduate or graduate public health schools and programs to promote a pipeline of public health graduates into public health practice. Additional outreach beyond schools or programs of public health may also be needed to fully staff a diverse and skilled workforce able to implement the FPHS model.

Our study quantified the size of the public health workforce gap under “normal” public health operations in a post–COVID-19 environment. We did not examine the potential additional workforce gap that may have arisen due to additional public health system responsibilities associated with the COVID-19 pandemic response. Likewise, this study did not estimate the financial cost to close the public health staffing gap; however, the cost of these additional staff would very likely pale in comparison with the estimated $16 trillion in estimated cumulative economic costs of the COVID-10 pandemic.25 This increase in staffing would provide the foundational infrastructure upon which additional staff could be added to respond to future public health emergencies.

The Build Back Better Act (BBB) as passed by the US House of Representatives in November 2021 contained Section 31001. That section would have provided multiyear funding to support core public health infrastructure for state, territorial, local, and Tribal health departments.26 The legislation defined core public health infrastructure utilizing the language and definitions of the Foundational Capabilities and services. Despite the inability of the US Senate to pass BBB in 2021, the process has familiarized federal policy makers with the foundational public health capabilities and services.

Despite the failure to enact BBB and provide more sustainable funding for public health infrastructure, the Biden Administration has already made significant investments in governmental public health. The American Rescue Plan Act of 2021 (ARPA)27 provided $3 billion specifically allocated to “create a new grant program that will facilitate federal investment in the people and expertise needed at the state and local levels to expand, train, and modernize the public health workforce for the future.”28 While building a robust public health system is impossible without sustainable funding sources, the experience of many states in the 21C Public Health Learning Community has shown that assessment of state-based public health systems against the foundational public health capabilities and services and the identification of gaps can be leveraged into effective advocacy for sustained state funding for public health.29 Deploying the ARPA funds to address gaps in Foundational Capabilities and services by hiring additional staff needed even on a short-term basis can help health departments demonstrate short-term impacts and bolster advocacy efforts for sustainable public health funding.

The decision to be made is whether the boom-and-bust cycle of public health funding continues or if the necessary resources are invested to ensure state and local public health agencies have adequate staffing, which is especially important considering that public health funding is often categorically limited through block grants or other restrictive funding streams. There is a need to develop a sustainable long-term funding model for the public health workforce. The need has been clearly understood, but these data provide the necessary target. Much like DeSalvo et al30 set a target of $4.5 billion of new, permanent resources to fully support core public health foundation capabilities, the present study sets a complementary target for the size of state and local governmental public health workforce necessary to provide the minimum set of public health services. Our findings relative to this workforce target suggest a sizable workforce gap in the governmental public health workforce as currently staffed.

As allocated funding is implemented and the direction for the nation's public health system discussed, workforce staffing estimates should be a continually revisited target until it is met. Regardless of the financial investments made into public health infrastructure or improvements in other areas, for example, laboratory technology or data modernization, much of the work of ensuring the public's health is performed largely by trained public health workers and managers. Until there is an adequately and permanently staffed public health workforce to accompany an adequate public health infrastructure, the nation will remain vulnerable to emerging and present threats to our health.

Limitations

This analysis has a number of limitations. Data driving the national estimates are derived from a sample of only 168 LHDs and 3 SHAs across 4 states. While outliers were identified and removed for purposes of national estimates, remaining agencies may not be generalizable to all LHDs and SHAs in the United States, as the 4 states included are decentralized and largely located in the mountain/Pacific portion of the country (see Supplemental Digital Content Appendix Methods: Generalizability, available at https://links.lww.com/JPHMP/B37, and Supplemental Digital Content Appendix Figures 5-9, available at https://links.lww.com/JPHMP/B37, for how these items were assessed and addressed). Moreover, the data used were obtained prior to the COVID-19 pandemic. While Staffing Up did not aim to estimate the surge capability needed to respond to a once-in-a-generation disaster like COVID-19, it may be the case that cost estimation post–COVID-19 would yield different results. Future analyses using these findings as a baseline might be able to estimate peri- or post–COVID-19 workforce gaps, given updated workforce size estimates following ongoing public health hiring. A number of assumptions were made in the modeling process, especially regarding the proportion of the workforce focuses on core (FCs and FAs) FPHS versus expanded services, how the state component of the estimate relates to the local, and how FTE needs of very large jurisdictions do or do not experience diseconomies of scale or scope. Different assumptions yield modestly different results, as shown in the microsimulation models (see Supplemental Digital Content Appendix Figure 3, available at https://links.lww.com/JPHMP/B37), though the direction and overall magnitude of the findings persist across various model assumptions and specifications.

Conclusions

The response to COVID-19 has wrought historic investments in public health workforce, though the legislative intent behind these investments highlights their temporary, response-oriented nature. As the United States moves into a COVID-19 recovery period, one logical line of inquiry is what a post–COVID-19 governmental public health system ought to look like and what resources are needed to make that happen. The work presented in this article represents a first national estimate of FTE needs to ensure residents of the United States receive the minimum of public health protections they should expect.

Implications for Policy & Practice

  • Between the onset of the Great Recession and the start of COVID-19 the governmental public health workforce was reduced 15% to 20%.
  • In 2020, a national effort was made to determine how many FTEs were needed to deliver the core Foundational Public Health Services as part of the Staffing Up project.
  • At least 80 000 FTE at the state and local level were needed, before COVID-19, to deliver the FPHS.

References

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Keywords:

public health workforce; staffing; workforce estimation

Supplemental Digital Content

© 2022 The Authors. Published by Wolters Kluwer Health, Inc.