Brief State Actions to Bolster the Public Health Workforce

Public health is the science of protecting and improving the health of communities and is largely credited for longer life expectancies over the past century.

Public health initiatives addressing maternal and child health, safe and healthier foods, tobacco, and the spread of diseases like diphtheria, smallpox, tetanus, typhoid and tuberculosis, have resulted in the U.S. population living longer and healthier lives. The current nationwide shortage of public health workers poses a challenge for states around carrying out such services.

State Public Health Services

Every state has an agency responsible for providing public health services. The authority, organization and funding structure of public health agencies varies across the country. For example, a state public health agency may be an independent department or a component of a department with broader responsibilities. Some states have a centralized structure where local health departments are units of the state agency, others have a decentralized structure where local health departments are led locally, and some have a mixed or hybrid structure.

State and local public health agencies engage in a range of activities to promote public health, as outlined in the 10 Essential Public Health Services. Activities may include researching and assessing factors and needs that influence health, informing and educating people about health hazards and implementing policies and plans that improve health. Public health infrastructure, including maintaining a qualified and capable workforce, provides the foundation to provide these services.

Public Health Within the Health System

The fields of health care and public health are distinct yet important components of the overall health system. Health care is generally aimed at treating patients at the individual level and is generally grounded in private enterprise. Public health aims to identify population-level causes of morbidity and mortality and broader community health issues and is typically based in the public sector.

Both health care and public health are grappling with significant workforce shortages. With health care costs and spending on the rise, some states are examining population-based approaches to health care. Population-based health care acknowledges the importance of cross-sector collaboration, including with public health, in promoting the health of communities. The establishment of partnerships across health care and public health sectors can better address the needs of communities and improve health outcomes.

Public Health Workforce Challenges

The U.S. state and local public health workforce lost around 40,000 jobs between the 2009 Great Recession and the COVID-19 pandemic. It's estimated that nearly half of all employees in public health agencies left between 2017 and 2021. The greatest proportion were aged 35 and younger.

According to the Public Health Workforce Interests and Needs Survey, while most public health workers reported being satisfied with the work they do, pay and lack of opportunities for advancement were common causes of dissatisfaction. Employees also reported heavy workloads and chronic stress as reasons for leaving. The pandemic increased stress and worsened burnout among public health employees.

Additional public health workforce challenges include:

• Barriers to hiring may exist due to cumbersome government hiring systems or procedures. According to the report from Columbia University, it can take some government agencies an average of 204 days to complete merit-based hiring while the private sector process averages 12-49 days.
• The public sector often lacks the ability to offer competitive pay and hiring incentives and has difficulty competing with the private sector.
• Forty-three percent of public health staff work in science-related professions that require specialized training, such as nurses, epidemiologists and informatics staff, which can be difficult roles to fill.
• Students who obtain public health degrees often do not take jobs with governmental public health departments. According to the 2023 analysis, only 10% of undergraduates who received public health degrees in 2015-2018 reported working at government agencies.
• Large amounts of public health workers have left or plan to leave their agency in the near future, resulting in workforce deficits across state and local health departments.

State Actions

States may consider a variety of strategies to bolster the public health workforce, such as building or strengthening workforce pipelines, creating or improving recruitment incentives, creating workforce study commissions and reducing barriers to public sector employment.

Workforce Pipelines

Many states have passed legislation in recent years aimed at building various types of workforce pipelines. States can consider strategies such as training, upskilling and creating new career pathways to build a more robust public health workforce for the future. For example, the California 2024 budget act included $3.2 million for a Public Health Workforce Development and Engagement Program aimed at supporting worker upskilling to improve retention of the public health workforce. Minnesota enacted legislation to develop public health immersion experiences for students to introduce career pathways and improve diversity of the public health workforce.

Recruitment Incentives

States are exploring various incentives to entice workers into health-related professions through loan repayment programs, salary increases, tax credits and paid leave. Such incentives can help to attract workers into public health positions.

For example, Wyoming enacted legislation regarding compensation to state public health nursing employees so that when such compensation is increased, there will be corresponding increases in contract amounts for counties reflected in the health department's budget. Oklahoma recently amended its medical loan repayment program to include certified nurse practitioners who agree to practice in a community in the state approved by the state's Health Care Workforce and Training Commission.

Workforce Commissions

States have formed various types of commissions to study and make recommendations regarding workforce issues. State can consider such commissions for determining strategies to improve public health workforces. For example, Maryland enacted legislation in 2023 that established a Commission on Public Health to recommend improvements for delivering foundational public health services in the state including recommendations for improving the public health workforce.

Barriers to Public Employment

Many states struggle with filling public sector positions. NCSL's Public Sector Workforce Legislation Database features introduced legislation on various public workforce topics, including recruitment, retention, benefits, position requirements and more. At least 20 states enacted legislation related to public employees' position requirements or qualifications in 2024.

For example, Georgia required the Department of Administrative Services to "regularly assess … educational, experiential, and training requirements" for public job postings. Washington enacted legislation to identify and reduce unnecessary degree requirements in the civil service classification system.