Public Health Workforce Shortages Imperil Nation's Health

Originally published as HSC Research Brief No. 4 by the Center for Studying Health System Change (HSC), April 16, 2008. HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

After the September 11 terrorist attacks, interest in America's public health system spiked, particularly around emergency preparedness. Significant federal funding flowed to state and local agencies to strengthen their capabilities. But the spotlight on the public health infrastructure faded quickly, and public awareness of the escalating threats to basic services like disease surveillance remained low. Local health departments faced a growing workforce crisis as they struggled to recruit, train, and retain qualified workers, according to a study by the Center for Studying Health System Change.

A Crisis Hidden in Plain Sight

Less than 3 percent of the more than $2 trillion spent annually on U.S. health care went to government public health programs. Given this chronic underinvestment, it was hardly surprising that substantial shortages of key public health workers plagued local communities and threatened essential services. Without enough skilled workers, public health agencies were struggling to meet core responsibilities: preventing the spread of disease, protecting against environmental hazards, reducing injuries, promoting healthy behaviors, and responding to disasters.

The National Association of County and City Health Officials reported that local health departments had the greatest difficulty recruiting public health nurses, epidemiologists, and environmental health scientists. To examine the extent of these shortages, their causes, and strategies to address them, the HSC study used a community-based approach with interviews of public health officials and other knowledgeable respondents in six communities: Cleveland; Greenville, South Carolina; Indianapolis; Little Rock, Arkansas; Orange County, California; and Phoenix.

Factors Driving the Shortages

Several converging factors fueled the workforce shortage. Inadequate funding left agencies unable to offer competitive salaries and benefits, putting them at a disadvantage against private-sector employers and clinical health care organizations competing for the same pool of trained professionals. An exodus of retiring workers was draining institutional knowledge and leadership capacity. The supply of newly trained public health workers was insufficient to replace those leaving. And public health as a career choice lacked the appeal and visibility needed to attract the next generation of professionals.

Community Responses

Local public health agencies had pursued a range of strategies to address the crisis: improving workforce monitoring and planning, developing targeted recruitment and retention programs, investing in professional development and training, and strengthening partnerships with academic institutions that trained public health professionals. However, progress remained limited. Budget constraints undermined many of these efforts, and the fundamental challenge of making public health careers financially competitive with private-sector alternatives persisted across all six communities studied.

Implications

Without additional support to address workforce issues -- including meaningful investment in recruiting the next generation of public health leaders -- local public health agencies were unlikely to succeed in meeting growing community needs. The consequences extended well beyond the agencies themselves: weakened public health capacity meant diminished ability to detect and respond to disease outbreaks, environmental threats, and public health emergencies. The study concluded that the public's health was potentially at risk unless policy makers and the public recognized the severity of the workforce crisis and committed resources to address it.

Sources and Further Reading

Draper, Debra A., Robert E. Hurley, and Johanna Lauer, HSC Research Brief No. 4, April 2008. | National Association of County and City Health Officials workforce surveys. | Health Resources and Services Administration, 2005 public health workforce study. | Institute of Medicine, The Future of Public Health, 1988.