ASPH Plicy Brief Cnfrnting the Public Health Wrkfrce Crisis EXECUTIVE SUMMARY The current public health wrkfrce is inadequate t meet the health needs f the U.S. and glbal ppulatin and wrsening wrker shrtages will reach crisis prprtins in the cming years. Fewer wrkers, drawing n diminished resurces t meet the needs f mre peple, mean Americans are likely t be at grave risk unless measures are taken immediately t rebuild the wrkfrce. In this paper, the Assciatin f Schls f Public Health (ASPH), which represents the 41 Cuncil n Educatin fr Public Health (CEPH) accredited schls f public health in Nrth America, ffers recmmendatins fr building a diverse public health wrkfrce prepared t meet future challenges. The Lming Wrkfrce Crisis By 2020, the natin will be facing a shrtfall f mre than 250,000 public health wrkers, accrding t ASPH estimates. Shrtages f public health physicians, public health nurses, epidemilgists, health care educatrs, and administratrs are anticipated. The public health wrkfrce is diminishing ver time even as the U.S. ppulatin increases. In 2000, the ttal wrkfrce was 448,000, r 50,000 less than in 1980. Mre than 100,000 gvernment public health wrkers apprximately ne-quarter f the current public sectr wrkfrce will be eligible t retire by 2012. Over the next 11 years, schls f public health wuld have t train three times the current number f graduates t meet prjected needs. Key Recmmendatins fr Actin Increase federal funding t supprt public health prfessinal educatin. Federal funds shuld be available t: Prvide financial supprt t students pursuing public health graduate training thrugh lan repayment and frgiveness prgrams, training and service bligatin grants, and fellwships. Strengthen practice experiences fr public health students. Prmte a mre diverse public health wrkfrce by ffering financial incentives and training pprtunities t underrepresented minrities and t students fcused n reducing racial and ethnic health disparities. December 2008 1
Build public health educatin capacity, enabling schls f public health t: Enrll and train mre graduate students. Develp cmpetencies and curriculum in emerging areas f public health practice. Expand jint degrees and ther pprtunities fr crss-disciplinary training. Significantly increase public health research training in ppulatin health, primary preventin, and cmmunitybased and public health systems. Expand undergraduate public health educatin. Develp pprtunities fr the public health wrkfrce t engage in lifelng learning thrugh shrt curses, certificate prgrams, distance learning, and ther pprtunities. Prvide grants t state health departments t prmte wrker training. Establish a U.S. Glbal Health Service t crdinate U.S. effrts t build a wrkfrce prepared t meet internatinal needs. Institutinalize a prcess fr peridic enumeratin f the public health wrkfrce in rder t identify current and future needs. Abut ASPH: These recmmendatins reflect the cnsensus f the Assciatin f Schls f Public Health (www.asph.rg), which represents the 41 Cuncil n Educatin fr Public Health (CEPH) accredited schls f public health in Nrth America. A critical natinal resurce, the natin s Schls f Public Health educate the next generatin f public health leaders; cnduct cutting-edge research; and translate knwledge int public health plicy and practice. They currently enrll 22,000 students, prduce mre than 7,300 graduates a year, and emply 9,600 faculty. ASPH is cmmitted t cllabrating with the public health practice cmmunity, gvernmental agencies, academic medicine, nn-prfit rganizatins, and business grups. This plicy paper is part f a series explring the natin s public health pririties. December 2008 2
ASPH Plicy Brief Cnfrnting the Public Health Wrkfrce Crisis Backgrund Dramatic public health advances in the 20 th century have helped t increase the average lifespan f U.S. residents by mre than 30 years and t imprve quality f life arund the wrld. Vaccinatins, cntrl f infectius diseases, safer wrkplaces, mtr vehicle safety, an imprved fd supply, strategies t prtect the health f mthers and babies, and the recgnitin f tbacc as a health hazard are amng the great public health achievements f the past century, accrding t the Centers fr Disease Cntrl and Preventin. 1 The public health wrkfrce has made all f this pssible thrugh practice, service, and research. 2 These multidisciplinary prfessinals: Include clinicians and health prgram administratrs, educatrs, planners, and plicy analysts, ccupatinal and envirnmental health specialists, and ecnmists, epidemilgists, and bistatisticians. Wrk in diverse public and private settings, including public health agencies at every level f gvernment, cmmunity-based service rganizatins, academic and research institutins, hspitals, health plans and medical grups, and private cmpanies. Serve many functins, including health surveillance and prtectin, wellness prmtin, planning and regulating, and rganizing, delivering, and evaluating health services. In an era f daunting public health challenges, when we face threats that knw n gegraphic bundaries, adequately trained U.S. public health wrkfrce must be prepared t: Cnfrnt emerging cmmunicable diseases (e.g., Ebla virus and avian influenza). Meet envirnmental challenges (e.g., fd insecurity and climate change). Tackle chrnic disease (e.g., the myriad health cnsequences f tbacc use and besity). Assist cmmunities in preparing fr emergencies (e.g., natural disasters and bilgical and chemical attacks). Advcate fr plicies designed t prmte health (e.g., increasing access t care and reducing health disparities). Prmte an emphasis n public educatin, and disease preventin and wellness. Cnduct research and build evidence fr interventins that wrk. December 2008 3
Given the increasing cmplexity f public health science, meeting these challenges means training many mre specialists in the many sub-disciplines f public health. As well, the availability and capacity f a glbal public health wrkfrce needs t be significantly expanded. Frecast While widely acknwledged, the extent f the public health wrkfrce shrtage remains imprecise, reflecting incnsistent enumeratin and the absence f a systematic effrt t assess natinal needs. 3,4,5 Nnetheless, it is clear that public health prfessinals have been frced t d mre with fewer peple, and that needs are grwing dramatically. In 2000, there were 50,000 fewer public health emplyees than in 1980. 6,7 Technlgical advances may t sme extent mitigate the impact f the decrease in the public health wrkfrce, but this trend clearly cannt cntinue withut drastically cmprmising the public s health. The wrkfrce rati in 1980 220 public health wrkers fr every 100,000 U.S. residents may underestimate the ideal, but it prvides a useful benchmark. 3 Given ppulatin increases, a ttal f 600,000 public health wrkers wuld have been necessary in 2000 t maintain the wrkfrce rati that existed tw decades earlier. Instead, we came up shrt by 150,000 peple. Ging frward, the gap is even mre alarming. In 2020, a public health wrkfrce f mre than 700,000 will be necessary t achieve the 220:100,000 rati. That creates a need fr sme 250,000 mre wrkers than are available tday. Public Health Wrkfrce t U.S. Ppulatin Ratis 8 Rati f the Public Health Wrkfrce Year U.S. Ppulatin t U.S. Ppulatin Public Health Wrkfrce 1980 226,542,199 220 per 100,000 500,000 6 2000 281,421,906 158 per 100,000 448,254 7 Prjected Need 2020 324,927,000 220 per 100,000 714,839 Many surces have dcumented current wrkfrce shrtfalls in specific fields: Mre than half the U.S. states respnding t a survey by the Assciatin f State and Territrial Health Officials reprted a lack f qualified emplyees t fill emergency preparedness needs. 9 The Institute f Medicine reprts a shrtage f 10,000 public health physicians, r twice the number nw in practice. 10 Other reprts have frecast shrtages amng public health nurses, epidemilgists, health care educatrs, and administratrs. December 2008 4
Mrever, there are demnstrated racial and ethnic disparities, and significant gegraphic gaps, in the public health wrkfrce. As the Sullivan Cmmissin n Diversity in the Healthcare Wrkfrce states: 11 Tday s physicians, nurses, and dentists have t little resemblance t the diverse ppulatins they serve, leaving many Americans feeling excluded by a system that seems distant and uncaring. The fact that the natin s health prfessins have nt kept pace with changing demgraphics may be an even greater cause f disparities in health access and utcmes than the persistent lack f health insurance fr tens f millins f Americans. Public health wrkfrce shrtages are even mre critical in much f the develping wrld. Fr example, sub-saharan Africa has 11% f the wrld s ppulatin and 24% f the glbal burden f disease yet it cmmands less than 1% f the wrld s health expenditures. 12 The Wrld Health Organizatin has said there is a majr mismatch between ppulatin needs and the available public health wrkfrce in terms f verall numbers, relevant training, practical cmpetencies, and sufficient diversity t serve all individuals and cmmunities. 13 Retirement. By 2012, mre than 100,000 U.S. public health wrkers in gvernment apprximately ne-quarter f an estimated 450,000-persn wrkfrce will be eligible t retire. Level Percent Eligible t Retire by 2012 Percent f Ttal Wrkfrce(6) Ttal Wrkfrce Number Eligible t Retire Federal 44 14 19 450,000 37,620 State 29 12, 15 33 450,000 43.065 Lcal 19 16 34 450,000 29,070 Ttal Eligible t Retire 109,755 The retirement status f public health prfessinals in the private sectr is unavailable. December 2008 5
The Respnse Recgnizing the urgency f the need, ASPH recmmends the fllwing measures t expand the public health wrkfrce: Increase federal funding fr public health educatin. Federal financial supprt fr public health prfessinal educatin has been steadily erding since 1980, and is wefully inadequate, accrding t the Institute f Medicine. 17 Public resurces can be used t: Attract students t public health graduate training and retain them as they pursue their degrees. Mechanisms include training grants, lan repayment and frgiveness prgrams, service bligatin grants, and fellwship prgrams. ASPH supprts passage f the Public Health Preparedness Wrkfrce Develpment Act, which wuld supprt educatinal lan repayment fr students pursuing a degree in public health in exchange fr service in a state, lcal, r tribal health department. 18 Imprve practice experiences fr public health students, which enhances their training while ffering a resurce t supprt the missin f health-related rganizatins. Opprtunities exist t increase bth the number and type f rganizatins that serve as sites fr practice rtatins. Prmte a mre diverse public health wrkfrce. Studies shw that increasing the number f health prfessinals frm racial and ethnic grups with pr health indicatrs will help t reduce health disparities. The Natinal Institutes f Health shuld establish a lan frgiveness prgram and ther financial incentives t attract underrepresented ppulatins t public health. The NIH Center fr Minrity Health and Health Disparities and ther funding agencies shuld create pprtunities fr pst-dctral studies and ther training targeted at minrities. Targeted financial supprt shuld be available t all public health graduate students wh fcus n disparities. Build capacity in schls f public health. Graduate educatin remains the gld-standard fr training public health prfessinals. Frty accredited schls f public health train ver 85 percent f public health graduates frm accredited schls and prgrams (mst f the rest graduate frm public health prgrams within ther schls, such as medical schls). T meet the predicted need fr an additinal 250,000 trained public health wrkers by 2020, schls f public health will need a threefld increase in the number f students they graduate ver the next 11 years. That means expanding capacity. Many public health schls nw lack the resurces t manage larger class sizes and states have cut their funds, frcing them t turn away qualified applicants. New federal resurces fr accredited public health schls are essential, as is enhanced student recruitment. A number f new schls f public health are being frmed, r are under cnsideratin. This will increase the public health wrkfrce, althugh new ventures are usually mre expensive n a per-student basis than adding capacity as a marginal cst t existing schl infrastructure. December 2008 6
Public health schls need funding t: Expand their capacity t enrll and train degree-seeking graduate students. Develp cmpetencies and curriculum in emerging areas f public health practice. Offer jint degrees and ther pprtunities fr crss-disciplinary training. Public health training can be cmbined with training in medicine, veterinary medicine, dentistry, nursing, law, business, public administratin, public plicy, and scial wrk, amng ther fields. The intercnnectedness f these fields is illustrated by the fact that 75% f emerging diseases are zntic (highlighting the link between veterinary medicine and public health). 19 Supprt fr greatly expanding HRSA training grants and graduate medical educatin are amng the mechanisms t increase the number f students wh pursue jint degrees. Expand undergraduate public health educatin in rder t intrduce mre students t the field. Prmte training f the public health wrkfrce thrugh shrt curses, certificate prgrams, distance learning, and ther pprtunities fr lifelng learning. Targeted prgrams are needed t meet the needs f credentialed public health prfessinals, undertrained and nncredentialed public health wrkers, and ther wrkers engaged in public health activities. Significantly increase public health research training in ppulatin health, primary preventin, and cmmunity-based and public health systems, amng ther areas. Particular emphasis shuld be placed n transdisciplinary research prgrams at the Agency fr Healthcare Research and Quality, the Centers fr Disease Cntrl and Preventin, and the Natinal Institutes f Health, which fund mst research training at schls f public health. Prvide grants t state health departments t prmte wrker training. At present, mst health departments have very limited training budgets, and federal funding in this arena has been waning. Grants t state health departments can be used t supprt wrking prfessinals wh wish t pursue MPH degrees, public health certificates, and ther training, and t prmte credentialing. Ensure that all primary, secndary, and pst-secndary schls ffer public health-related curricula. This is fundamental t giving all Americans a basic understanding f public health and the imprtance f preventin in health care. Create a U.S. Glbal Health Service. Given the crippling shrtages within the internatinal public health wrkfrce, the federal gvernment shuld establish a U.S. Glbal Health Service that wuld serve as an umbrella rganizatin fr a Glbal Health Service Crps, health wrkfrce needs assessment, fellwship and lan repayment prgrams, a twinning prgram, and an infrmatin clearinghuse. 20 These prgrams wuld be designed t strengthen the internatinal expertise f the U.S. public health wrkfrce, as well as t prepare wrkers frm ther cuntries t prvide public health services. Fund effrts t cllect data abut the public health wrkfrce. The federal Health Resurces and Services Administratin (HRSA) last cnducted an enumeratin f the public health wrkfrce in 2000; the enumeratin prir t that was cmpleted in 1980. 6,7 Public health needs a legislative mandate t cllect data regularly and t study wrkfrce issues under the guidance f a federal agency. December 2008 7
Better demgraphic data abut the wrkfrce wuld help t identify shrtages and surpluses, track trends ver time, and frecast future needs. Imprved public health enumeratin data wuld als be useful in guiding student decisinmaking abut which aspects f public health t pursue, ensuring a better balance between wrkfrce supply and demand. Effective public health depends n a wrkfrce f sufficient size and training t meet bth expected and unanticipated needs. A shrtage f crisis prprtins lms, and the pprtunity t address it shuld be seized nw. December 2008 8
References 1 Ten Great Public Health Achievements United States, 1900-1999. Mrbidity and Mrtality Weekly Reprt April 2, 1999:48 (12);241-3. 2 Health Sciences Cmmittee. Public Health Educatin and the University f Califrnia. Oakland, CA: University f Califrnia; 2004 3 Gebbie KM, Turnck BJ. The public health wrkfrce 2006: New challenges. Health Affairs 2006;25(4):923-933. 4 Institute f Medicine, Natinal Academy f Sciences. Wh will keep the public healthy? Educating Public Health Prfessinals fr the 21st Century. Washingtn, DC: Natinal Academy Press; 2003 5 Rahn DA, Wartman SA. Fr the health-care wrkfrce, a critical prgnsis. The Chrnicle f Higher Educatin 2007. 6 Health Resurces and Services Administratin. Public health persnnel in the United States 1980: Secnd reprt t Cngress. In: U.S. Department f Health and Human Services, editr. Washingtn, DC: U.S. Public Health Service; 1982. 7 Natinal Center fr Health Wrkfrce Infrmatin and Analysis, Center fr Health Plicy at the Clumbia University Schl f Nursing, Bureau f Health Prfessins. The Public Health Wrkfrce Enumeratin 2000. In: Health Resurces and Services Administratin, editr. Washingtn, DC: Health Resurces and Services Administratin; 2000. 8 U.S. Census Bureau 2008. 9 Assciatin f State and Territrial Health Officials. State Public Health Emplyee Wrker Shrtage Reprt: A Civil Service Recruitment and Retentin Crisis. Washingtn, DC; 2004. 10 Institute f Medicine, Natinal Academy f Sciences. Training physicians fr public health careers. Washingtn, DC; 2007. 11 Sullivan Cmmissin n Diversity in the Healthcare Wrkfrce. Missing Persns: Minrities in the Health Prfessins. Washingtn, DC; 2004. 12 Wrld Health Organizatin. Taking Stck: Health Wrker Shrtages and the Respnse t AIDS; 2006. 13 Wrld Health Organizatin. Wrking Tgether fr Health: Wrld Health Reprt 2006. Geneva, Switzerland; 2006. 14 Partnership fr Public Service. Hmeland Insecurity: Building the Expertise t Defend America frm Biterrrism. Washingtn, DC; 2003. 15 Assciatin f State and Territrial Health Officials. ASTHO 2007 State Public Health Survey. In. Washingtn, DC; 2007. 16 Natinal Assciatin f Cunty and City Health Officials. 2005 Natinal Prfile f Lcal Health Departments. Washingtn, DC; 2006. 17 Institute f Medicine, Natinal Academy f Sciences. The Future f Public's Health in the 21st Century. Washingtn, DC: Natinal Academy Press; 2003. 18 Unenacted bill: Public Health Preparedness Wrkfrce Develpment Act f 2008, S.1882 and Public Health Preparedness Wrkfrce Develpment Act f 2007, H.R. 5496, 110 th Cng. (2008). 19 Centers fr Public Health Preparedness. Centers fr Public Health Preparedness Cllabrative Grup Reprt n Veterinary Preparedness. Washingtn, DC: Assciatin f Schls f Public Health; 2006. 20 Institute f Medicine, Natinal Academy f Sciences. Healers Abrad: Americans Respnding t the Human Resurce Crisis in HIV/AIDS. Washingtn, DC; 2005. December 2008 9