Relationship to Existing APHA Policies
The following APHA policies are relevant to this newly proposed statement:
APHA policy statement 2003-4 – Protecting essential public health functions amidst state economic downturns
APHA Policy statement 2005-12 – Strengthening the Public Health Work Force to Address Current and Future Challenges
APHA policy statement 2009-11 – Public health’s critical role in health reform in the United States
APHA policy statement 201015 – Securing the Long-Term Sustainability of State and Local Health Departments
APHA policy statement 201119 – Increasing Efforts to Encourage Health Departments to Seek Accreditation
The nation’s public health workforce is not well defined. The Institute of Medicine’s 2003 report on public health professionals defines them as individuals educated in public health or a related discipline who are employed to improve health through a population focus. However, this definition does not capture the specifics of various public health workers or the various disciplines that are part of public health. The numbers and characteristics of the public health workforce are not well understood because we lack a common taxonomy for describing public health work and organized strategies for collecting information about where and how public health professionals provide essential services. As a result of demands for more effective and efficient population health services and relevant workforce policies, the public health profession must pursue avenues to develop increased knowledge about its workers, a common language to describe its work, and delineation of requirements that strengthen its capacity to do that work.
The public health workforce is the most important component of the nation’s public health infrastructure. Without a competent workforce, the public health system would lack capacity to assess and respond adequately and appropriately to population health needs and crises.
The public health workforce is composed of professionals representing many disciplines (e.g., nursing, medicine, biology, social work) as well as those trained specifically in public health. The Institute of Medicine’s 2003 report on public health professionals defines them as individuals educated in public health or a related discipline who are employed to improve health through a population focus. However, this definition does not capture the specifics of various public health workers and the disciplines that are part of public health. There is no clear definition of “the public health professional,” and job classifications for public health workers vary from setting to setting and often reveal little about job functions or the skills required. Despite several efforts, there is still a lack of specific data about the size, gender distribution, educational backgrounds, motivations, and geographic and programmatic distribution of public health workers that would help in making the most efficacious policy decisions about funding public health services and allocation of human and capital resources. The APHA issue brief on the Affordable Care Act’s public health workforce provisions notes that, “due to its diversity and range of settings, and the absence of funding for enumeration efforts, the exact size and composition of the public health workforce remains uncertain.”
In The Public Health Work Force: Enumeration 2000, the Health Resources and Services Administration (HRSA) noted that the size and composition of the public health workforce should be identified and should be tracked over time to develop appropriate plans for workforce development, recruitment, and retention. The report noted further that such an analysis “has not been realistic for the public health workforce as a whole, because there has been no systemic accumulation of the necessary information.”
An APHA policy approved in 2005 (Policy No. 2005-12: Strengthening the Public Health Work Force to Address Current and Future Challenges) recognized the lack of available information about the workforce. Two of its recommendations were that Congress provide adequate funding for a comprehensive national database of the public health workforce and provide adequate funding to make long-range projections for public health workforce needs and training at the state and local levels.
The lack of clear definitions and good data make it difficult to fully assess the sufficiency of the supply of qualified public health workers in relation to the demand for them, as well as the adequacy of their skills and competencies in relation to their roles and responsibilities.
Nevertheless, several strong attempts have been made to gauge the size (if not specific, descriptive characteristics) of the workforce, and current health services research is making strides in gathering workforce data through the use of harmonized surveys. Researchers in the Enumeration 2000 study estimated that, across the United States, almost 450,000 workers (excluding volunteers) were providing public health services through work performed in federal, state, tribal, local, private, and voluntary agencies. In more recent (but limited) research, the Association of State and Territorial Health Officials (ASTHO) estimated that 107,000 full-time-equivalent workers are employed in the nation’s state public health agencies. In addition, the National Association of County and City Health Officials (NACCHO) estimated that 190,000 staff work in more than 2,500 local health departments. While these 2 studies covered approximately 297,000 state and local government workers, they did not include estimates for federal, private, or voluntary public health workers. Data on those workforce sectors are particularly difficult to obtain. Researchers are hampered by a lack of discrete and consistent titles in the federal system and by the lack of organized systems for collecting information from private and voluntary organizations. The ASTHO and NACCHO figures suggest that the size of the state and local workforce has not increased noticeably since the Enumeration 2000 report despite newly emerging diseases, external threats (e.g., bioterrorism), and the growing need for enhanced chronic illness and preventive care services.
In a renewed effort to address the issues of enumeration and characterization of the workforce, the Centers for Disease Control and Prevention (CDC) and HRSA supported research conducted by centers of excellence at the University of Kentucky and the University of Michigan from 2008 through 2011. In a February 2012 joint report, the 2 centers put forth recommendations for developing a public health workforce surveillance system, suggested potential data sources, and delineated several action steps to effect a systematic way of enumerating and characterizing the workforce. One of the recommendations noted the need to develop a consensus definition of the public health workforce and adopt a common taxonomy to describe public health workers. The quest to fulfill that recommendation has been a long one. In a 1997 report, The Public Health Workforce: An Agenda for the 21st Century, the Public Health Functions Steering Committee recommended that the profession “develop a standard taxonomy based on the 10 essential public health services to qualitatively characterize the public health workforce. This classification scheme must be derived through collaboration and consensus of the entire public health community.” That group also recommended using the Standard Occupational Classification (SOC) system of the Bureau of Labor Statistics (BLS) to track personnel changes in the various workforce sectors (governmental, private, military, and voluntary).
Healthy People 2010 identified the public health workforce as one of the 3 essential components of the public health infrastructure. Also, development and adoption of public health workforce competencies by the Council on Linkages Between Academia and Public Health Practice requires knowledge about the workforce to determine how those competencies can best be identified and used. As the credentialing work of the National Board of Public Health Examiners (http://www.nbphe.org/) progresses, a more precise understanding of the type of work needed and who in the public health workforce is doing the work (as well as which competencies are being used) may be served well by a systematic effort to gather more precise occupational data. With respect to the work of the National Public Health Accreditation Board (http://www.phaboard.org/), a more consistent and precise enumeration and taxonomy of public health occupations may prove valuable in matching real operations and people with accreditation standards and positions. Finally, if there were no other reason to ensure a better understanding of public health occupations, the Affordable Care Act (http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf) presents an opportunity for the public health workforce to grow as the needs of the nation’s diverse population become better identified.
The public health profession must develop substantive, descriptive information about its workforce to ensure that it is providing the “minimum package of public health services” described in the Institute of Medicine report For the Public’s Health: Investing in a Healthier Future. Accurate data regarding the numbers of workers in particular areas of service at the local, state, and national levels can help guide decisions about resource. Better information will enable tracking the diversity of the public health workforce and can assist in addressing resource and workforce issues affecting health disparities in minority and disabled populations. For example, increased understanding about which types of workers can best address particular community population health needs might lead to deploying community health workers rather than certified health educators as the most appropriate resource. Conversely, use of certified health educators in particular population-based health programs may fit the demand for service more appropriately in other situations. Knowing who does what in public health, which occupational disciplines are available, and which are still needed are key elements of a stronger public health workforce and, ultimately, better service for the public. Community health workers and certified health educators are health occupations currently classified in the SOC system, and therefore their occupational taxonomy allows for such distinctions. Similar SOC classifications for other public health disciplines will greatly aid efforts to strengthen planning, resource allocation, and service delivery.
The Affordable Care Act provides for a national health care workforce commission; although this commission has not been funded, it could be an important national ally in helping with enumeration and a consistent taxonomy for the public health workforce. Public health must keep its issues in the forefront of this proposed commission’s work so that the essential services of public health continue, are better understood, and receive the funding required to maintain a vibrant public health system.
The urgency exists to better define the role the public health workforce plays in the nation’s health. A consensus-driven classification system and extensive dissemination of information about the workforce are needed, and the SOC system is a ready-made operational program for accomplishing these objectives. Understanding the makeup of the public health workforce is also essential as professional credentialing efforts mature and agency accreditation standards are refined.[14–16]
In addition to its importance in developing plans for serving expanding population needs, making professional operational distinctions, and accounting for and alleviating workforce shortages, enumeration with a consistent taxonomy can help to ensure equity in the diversity of the public health workforce by monitoring workforce distribution and the profiles of various disciplines. With better information about the workforce, the profession can advocate for an adequate supply of workers to address shortages affecting the delivery of essential services.
Proposed Recommendations Statement
To address the issues discussed above, recommendations include 3 overarching strategies and several specific actions.
Strategy 1: Development of professional consensus about a common taxonomy for public health. For the reasons detailed above, the public health profession must devote time and resources to developing a common taxonomy. This will require external resources as well as an organizing locus to bring stakeholders (e.g., federal agencies, philanthropic organizations, national public health professional associations, and academic institutions) together and to provide staff to develop specific products. Bringing the influence of a diverse set of stakeholders to public policy-making can be accomplished by having a major focus of attention on public health recognized by the White House as it implements the Affordable Care Act. Implementation of this legislation offers an opportunity to expand attention to public health issues, including workforce concerns. A White House event could be a rallying point for organizing the effort to develop a common taxonomy for public health occupations.
Strategy 2: Development of potential revisions to the SOC (e.g., including epidemiologists, physicians, nurses, physician assistants, social workers, health educators, and community health workers, among others) for presentation to the Bureau of Labor Statistics by 2018. Revisions to the SOC system will require long-term effort and commitment to ensure that suggested changes are identified in time to meet the next federal call for revisions anticipated in 2018. SOC defines the occupational categories to be used by the US Census Bureau for its decennial count. Although the SOC is operated within BLS, the policies and management related to it as a federal data system are regulated by the Office of Management and Budget (OMB). Therefore, 2 years before the census, OMB (along with BLS) asks for suggested revisions to the SOC in a Federal Register notice. It would be at this time that changes relevant to the public health workforce could be recommended. Thus, 2018 will be the next opportunity for public health stakeholders to recommend SOC revisions. With 2018 as a target date, the profession has about a 5-year time frame in which to build an internal consensus and develop relevant suggestions for occupational title classifications to be incorporated into the national reporting system.
The current SOC contains classifications for specific health care disciplines but few recognizing public health occupations. All federal agencies that publish occupational data for statistical purposes are required to use the SOC system and to promote a common language for categorizing and analyzing occupations. State and local governments are encouraged to use the system as well. Consistent definitions and reporting can provide much-needed data regarding the numbers, characteristics, and distribution of the public health workforce. Establishment of a specific public health group and public health workforce subgroups within the SOC could help BLS gather and analyze more substantive information about public health workers, and these classifications could serve as a major source for aggregate data on the public health workforce. Developing titles to suggest for a major SOC group, however, requires public health stakeholders working together to achieve a consensus about a common taxonomy for describing public health workers and their work. BLS officials are already involved in efforts to clarify descriptions of public health work and have expressed an interest and willingness to continue to work with the profession (personal communication, George Stamas, Bureau of Labor Statistics).
Strategy 3: Continued refinement and expansion of the harmonized surveys conducted by ASTHO and NACCHO. In parallel with the 2 strategies recommended above, continued support for the harmonized surveys employed by ASTHO and NACCHO is also recommended. Supplementing and expanding these efforts with surveys aimed at gathering information about federal, private, and voluntary agency workers would greatly enhance our knowledge of the workforce.
The recommended strategies present challenges for implementation by public health professionals. They will require dedicated workers, financial support, and input from multiple stakeholders. The profession needs to come together around common definitions of roles, functions, and titles and needs to convince OMB and BLS of the importance of adopting the recommended changes. Among various public health disciplines and geographic jurisdictions, there are likely to be differences about specific paths to follow to modify the SOC and perhaps disagreement over whether it is the best vehicle to provide discrete information about the workforce. Yet, it is currently the only national system available for conducting any type of workforce surveillance, and the public health workforce needs to be better represented in that system. Currently, governmental and nongovernmental public health stakeholders are working on development of a rational enumeration and taxonomy system for public health occupations (as noted above). Bringing public discourse and action to the level of coordinating public health worker recommendations for the 2018 SOC revisions will be an effort well worth the time.
- Key federal (e.g., CDC and HRSA) and private (e.g., the Robert Wood Johnson Foundation) funders to continue support for research to better characterize the nation’s public health workforce.
- Collaboration and consensus building among public health stakeholders led by key federal agencies (e.g., the Department of Health and Human Services, the Department of Labor, and OMB) toward development of a consistent taxonomy for describing public health occupations and functions.
- Public health stakeholders (e.g., national health professional associations, academic institutions, and philanthropic organizations) to coordinate efforts to meet the 2018 target for submitting recommendations for relevant revisions to the SOC system and to have suggested revisions ready to present when the Federal Register call is made.
- Congress to fund the national health care workforce commission authorized by the Affordable Care Act and to explicitly charge that commission with development of a separate, visible subgroup to address public health workforce issues.
- Public health stakeholders (e.g., national health professional associations, academic institutions, and philanthropic organizations) to work with key federal agencies (e.g., OMB, BLS, CDC, and HRSA) to advocate for a White House conference on public health that would examine national policies affecting state and local operations, with a particular emphasis on the public health workforce.
- Schools and programs of public health to develop common methods for tracking and documenting the career paths of their graduates to add to our knowledge about the distribution of public health services and workers.
- American Public Health Association. The Affordable Care Act’s public health workforce provisions: opportunities and challenges. Available at: http://www.apha.org/NR/rdonlyres/461D56BE-4A46-4C9F-9BA4-9535FE370DB7/0/APHAWorkforce2011_updated.pdf. Accessed December 17, 2013.
- US Department of Health and Human Services. The public health workforce: an agenda for the 21st century. Available at: http://www.health.gov/phfunctions/pubhlth.pdf. Accessed December 17, 2013.
- Health Resources and Services Administration. The public health work force: enumeration 2000. Available at: http://www.uic.edu/sph/prepare/courses/chsc400/resources/phworkforce2000.pdf. Accessed December 17, 2013.
- American Public Health Association. Policy No. 2005-12. Available at: http://www.apha.org/advocacy/policysearch/default.htm?id=1306. Accessed December 17, 2013.
- Moore J. Studying an ill-defined workforce: public health workforce research. J Public Health Manage Pract. 2009;15(6):S48–S53. Available at: http://journals.lww.com/jphmp/Fulltext/2009/11001/Perspectives_on_Public_Health_Workforce_Research.3.aspx. Accessed December 17, 2013.
- National Coordinating Center for Public Health Services and Systems Research. Data harmonization. Available at: http://www.publichealthsystems.org/data-harmonization.aspx. Accessed December 17, 2013.
- Association of State and Territorial Health Officials. ASTHO profile of state public health, volume 2. Available at: http://www.astho.org/profiles/. Accessed December 17, 2013.
- National Association of County and City Health Officials. 2010 national profile of local health departments. Available at: http://www.naccho.org/topics/infrastructure/profile/resources/2010report/. Accessed December 17, 2013.
- University of Michigan/Center of Excellence in Public Health Workforce Studies, University of Kentucky/Center of Excellence in Public Health Workforce Research and Policy. Strategies for enumerating the US governmental public health workforce. Available at: http://www.phf.org/resourcestools/Documents/Enumerating_the_Public_Health_Workforce_Final_Report_2012.pdf. Accessed December 17, 2013.
- US Department of Health and Human Services. Healthy People 2010: goal 23, public health infrastructure. Available at: http://www.healthypeople.gov/2010/document/HTML/Volume2/23PHI.htm. Accessed December 17, 2013.
- Council on Linkages Between Academia and Public Health Practice, Public Health Foundation. Core competencies for public health professionals. Available at: http://www.phf.org/programs/corecompetencies/Pages/About_the_CorePublicHealth_Competencies.aspx. Accessed December 17, 2013.
- Institute of Medicine. For the public’s health: investing in a healthier future. Available at: http://iom.edu/Reports/2012/For-the Publics-Health-Investing-in-a-Healthier-Future.aspx. Accessed December 17, 2013.
- Sumaya CV. Enumeration and composition of the public health workforce: challenges and strategies. Am J Public Health. 2012;102(3):469–474.
- Gebbie K, Goldstein BD, Gregorio DI, et al. The National Board of Public Health Examiners: credentialing public health graduates. Public Health Rep. 2007;122:435–440.
- National Board of Public Health Examiners. NBPHE home page. Available at: http://www.nbphe.org/. Accessed December 17, 2013.
- Public Health Accreditation Board. PHAB home page. Available at: http://www.phaboard.org/. Accessed December 17, 2013.
- Stamas G, Wiatrowski W. Use of Bureau of Labor Statistics data for characterizing the public health workforce. Available at: http://journals.lww.com/jphmp/Fulltext/2009/11001/Use_of_Bureau_of_Labor_Statistics_Data_for.13.aspx. Accessed December 17, 2013.
- US Department of Labor, Bureau of Labor Statistics. Standard Occupational Classification system manual. Available at: http://www.bls.gov/soc/socmanu.htm. Accessed December 17, 2013.
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