Moving From Data to Action: Necessary Next Steps to a Better Governmental Public Health Workforce

We live in a time of unprecedented health transformation. Health disparities of all types (rural, age, race, and gender) are steady, if not increasing, and for the first time in US history, overall life expectancy is declining.1–5 Climate change,6–8 opioid misuse and addiction,9–11 integration of physical and behavioral health,12–15 and persistent rates of chronic disease are both contemporary and emerging public health problems. Tackling these problems from the governmental public health perspective requires a competent, adaptive, diverse, and engaged workforce. We cannot expect to achieve heath improvement in communities nationwide without strong public health agencies built on a foundation of well-trained and innovative public health practitioners. Building this foundation requires deliberate and thoughtful leadership, robust strategic thinking and implementation, and the resources needed to carry out public health's comprehensive mission. There were no nationally representative data on the governmental public health agency workforce before 2014. National data that were available were collected at the agency level. While these surveys provided valuable insights into staffing levels, budget changes, and other important topics, they did not capture the beliefs, attitudes, opinions, and experiences of individual public health workers. Efforts to survey individual members of the governmental public health workforce were limited by differences in data collection methods, time frames, and questionnaire content. The Public Health Workforce Interests and Needs Survey (PH WINS) was created to address the need for a single, national governmental public health workforce assessment.16 PH WINS comprises 2 waves of data collection with more than 70 000 responses from members of the governmental public health agency workforce. Due in part to PH WINS, governmental public health agency accreditation, and the Association of State and Territorial Health Officials (ASTHO) and National Association of County and City Health Officials (NACCHO) governmental public health agency profile data, we know more about the governmental public health agency workforce than in any previous time in history. However, it is taking this information and using it for workforce improvement that matters. Transformative action based on PH WINS results is needed if the public health practice community is to develop the governmental public health agency workforce this nation needs to maintain, if not increase, its health status. These next steps are described below. Step One. Develop National Governmental Public Health Agency Workforce Goals Without clear goals for the development of the governmental public health agency workforce, we lack clear direction. Thoughtful goals can help to bring order to a mixed bag of continuing education courses, awareness raising trainings, professional development workshops, on-line skills building, public health leadership development, and workforce competency assessment that characterizes governmental public health agency workforce development strategy today. Data from PH WINS can be used to develop system-wide workforce goals. It could be improving creativity and innovation, improving rates of retention, or specifically addressing identified training gaps. Regardless of the specific goal, it is alignment and action toward agreed upon goals that is most critical. The Public Health Accreditation Board (PHAB) could be a vehicle to establish these goals. As PHAB Standard 8.2 is currently stated, health departments need a workforce development plan and at least 2 examples of how it addresses gaps in capacity and capabilities.17 This standard could be developed to include explicit, specific national workforce development needs with a requirement to demonstrate progress in meeting these goals. This could be in addition to what is currently required providing a needed balance between national engagement and health department customization. Identifying and advancing specific national workforce development needs through PHAB brings consensus standards and some degree of uniformity and direction to workforce development efforts by moving multiple health departments in an aligned direction. Step Two. Define and Align the Resources Governmental public health agencies' primary resources are its people: unlike other industries where technology has made some positions redundant and where routine tasks have been automated, governmental public health continues to be a person-intensive industry. As such, when funding is cut for public health services, the primary impact is on the workforce. Data from PH WINS can help provide an understanding of where more people, and perhaps fewer, are needed to accomplish meaningful health improvement. Unfortunately, the current state of resource alignment in governmental public health is based more on grant portfolios and collective bargaining agreements than strategic workforce planning and resource allocation based on comprehensive and routine workforce assessments. Decades of categorical funding has created a highly specialized and knowledgeable public health workforce, but equally created significant variation in workforce preparedness reflecting funding differences by program area or public health crisis. Contemporary public health practice will be more successful if based upon cross-cutting skills and competencies rather than how to respond to specific diseases. The work of communicable disease control is a good example: public health professionals specifically trained to investigate STD/STIs are now being deployed to investigate other disease such as tuberculosis. Ebola funds were redirected to address Zika, another push to develop cross-cutting capabilities. Action to support workforce development activities in governmental public health agencies are primarily funded by categorical units within the Health Resources and Services Administration (Bureaus and Divisions) and the Centers for Disease Control and Prevention (Centers, Divisions, Institutes, and Offices). At a minimum, the annual investment in training for the governmental public health agency workforce across all federal funding streams and organizational units should be quantified by the Department of Health and Human Services to help identify where there is opportunity for connection and collaboration. Once the amount invested has been documented, these funds may be made more impactful if coordinated and directed by established workforce development goals. Taking this step will not be easy. Change in government rarely comes without a precipitating event. However, over the past decades, the public health crises facing the nation have included obesity, Ebola, natural and manmade disasters, gun violence, and opioids. There are others and more to come; challenges we have yet to even imagine. For each, we turn to our nation's state and local governmental public health agencies and expect that the workforce exists in these agencies to protect our nation from these problems. In the absence of aligned funding, we are allowing the skills in the governmental public health agency workforce to slowly erode. It may not be immediately noticeable, but there will come a crisis for which we are completely unprepared. Acting today to align funding for focused, thoughtful impact on the development of the governmental public health agency workforce is one possible path to avoiding continued fragmentation and inequity across workforce development programs. Step Three. Prioritize Governmental Public Health Agency Workforce Development While some call the public health practitioners the most essential element in our collective efforts to assure the public's health,18 where is the governmental public health agency workforce on our list of national priorities? Where is the development plan for the people who are on the frontlines of our public health battles? One can argue that these are mostly symbolic, but symbols are powerful in our culture. It may also bring attention to the needs of the governmental public health workforce, which are not prioritized or recognized outside of the public health community. The needs of the health care workforce are prioritized. The federal government provides more than $15 billion per year to support the graduate-level training of the nation's physicians.19 This commitment to fund the training of physicians in residency has existed since the inception of Medicare in 1965.19 If an ounce of prevention is worth a pound of cure, then the governmental public health workforce should receive approximately $980 million in federal support, but obviously the funds are not there. The attention is not there. In addition to training support, the Health Resources and Services Administration designates Health(care) Professional Shortage Areas and collects data on the health(care) workforce. Yet, there is little understanding of weakness in the nation's governmental public health system, and national data to inform planning, except for PH WINS, have been scarce. While these investments in healthcare training and safety net assessment may be necessary, it is indicative of a pattern of neglect of our governmental agency public health workforce. Step Four. Iteratively Assess, Evaluate, and Course Correct PH WINS data will be collected again in 2020. This ongoing commitment to collect these important data creates the opportunity to iteratively assess and evaluate coordinated efforts to improve the governmental public health agency workforce and, even more importantly, course correct. This will require the commitment and focus of the nation's governmental public health leadership and the leadership of the agencies and organizations supporting them. This ongoing engagement in a living, active workforce development strategy will be critical to improve health outcomes. Improvements in the nation's health ultimately will be realized through a trained and well prepared workforce that is supported to achieve these outcomes. When there is a natural disaster or outbreak, the success of mitigating the impact will be dictated by the strength of the governmental public health workforce. Yet, we prioritize other needs and opt to pay for expensive healthcare over prevention and interventions to address root causes that negatively impact our communities. The PH WINS provides data on the governmental public health agency workforce that was simply unavailable previously and was long overdue. However, information without action does not result in impact. There are immediate actions we can take to set national goals, quantify, and improve the impact of existing funding for governmental public health agency workforce development.

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