Salary Disparities in Public Health Occupations: Analysis of Federal Data, 2021‒2022

Abstract

Objectives. To assess salary differences between workers within key public health occupations in local or state government and workers in the same occupations in the private sector.

Methods. We used the US Department of Labor’s Occupational Employment and Wage Survey (OEWS). Referencing previous studies matching Standard Occupational Classification (SOC) codes with health department occupations, we selected 44 SOC codes. We contrasted median salaries in OEWS for workers in each occupation within state or local government with workers in the same occupations outside government.

Results. Thirty of 44 occupations paid at least 5% less in government than the private sector, with 10 occupations, primarily in management, computer, and scientific or research occupations paying between 20% and 46.9% less in government. Inspection and compliance roles, technicians, and certain clinicians had disparities of 10% to 19%. Six occupations, primarily in social work or counseling, paid 24% to 38.7% more in government.

Conclusions. To develop a sustainable public health workforce, health departments must consider adjusting their salaries if possible, market their strong benefits or public service mission, or use creative recruitment incentives such as student loan repayment programs for hard-to-fill roles. (Am J Public Health. 2024;114(3):329–339. https://doi.org/10.2105/AJPH.2023.307512)

The local, state, tribal, and territorial government public health departments (HDs)^1,2 in the United States serve as our nation’s frontline defense against disease but are severely understaffed,² with studies documenting workforce shortages, recruitment challenges, and pay inequity for key occupations such as epidemiologists^3,4 and public health nurses,^5–7 and labor market competition for public health degree graduates.⁸ While factors such as job satisfaction, public service motivation,⁹ flexible schedules, or benefits can attract candidates to apply for jobs, salary is known to be paramount in recruitment competition, including in public health.^3,8,10,11 According to the Public Health Workforce Interests and Needs Survey (PH WINS), three quarters of HD staff aged 35 years or younger quit between 2017 and 2021, and pay was the most commonly cited reason for considering leaving their role (63%).² Generally, salary is a key recruitment and retention factor; a national survey (not specific to public health) found that 56% of employees cite pay as a top reason to look for a new job, with 41% responding that they would leave for a 5% pay increase.¹² While several studies compare salaries between different occupations within HDs or ask PH WINS respondents if they are satisfied with their salary,¹³ fewer contrast salaries for the same occupations within government versus the private sector or ask directly about wage competition.

The American Rescue Plan Act’s Public Health Infrastructure Grant¹⁴ provides temporary public health workforce funding, but if salary levels are significantly lower in HDs as compared with competitor employers, recruitment may remain a challenge for HDs. One 2022 study found that the wage gap is so large that at least 1 local HD had to give their workforce funding back to the state because they were unable to fill positions.¹⁵

The Bureau of Labor Statistics (BLS) gathers data on salaries for each of the occupations for which there is a Standard Occupational Classification (SOC)¹⁶ code. SOC categories are used by BLS and other federal agencies to classify, enumerate, and study 867 detailed occupations. In addition, industries (i.e., types of employer organizations) are categorized with North American Industry Classification System (NAICS) codes.¹⁷ The BLS Occupational Employment and Wage Statistics (OEWS) program provides salary estimates for 830 occupations,¹⁸ including by NAICS industry, allowing comparisons of wages for the individuals working in the same occupation but different industries. Unfortunately, OEWS does not report salary details using the detailed NAICS code for Administration of Public Health Programs (923120),¹⁹ but does allow for salary comparisons between local and state government with nongovernment organizations.

Although SOC codes are an imperfect match with certain occupations in HDs,²⁰ there are new efforts to match public health occupations with SOC codes to improve workforce research. The public health workforce taxonomy established by the University of Michigan²¹ lists 73 occupations in the governmental public health workforce. These occupations, occasionally with slightly different nomenclature, are also used in PH WINS²² for respondents’ “job category.” Two recent studies matched these occupations with SOC codes.^8,23

Using the public health workforce taxonomy, as matched to SOC codes, as well as OEWS data, we asked whether there are salary differences between workers within key occupations in local or state government as compared with workers in the same occupations in other industries.

METHODS

We first used existing workforce taxonomies that matched public health occupations with SOC codes to identify SOC codes to prioritize and analyze, then we analyzed BLS salary data.

Taxonomy Matching and Inclusion/Exclusion Criteria

In a 2023 study, researchers matched the job titles of 26 516 PH WINS 2021 responders using the National Institute for Occupational Safety and Health Industry and Occupation Computerized Coding System.²³ They also referenced a study matching the University of Michigan public health workforce taxonomy with SOC codes, which also used machine learning to match 38 533 public health job postings to SOC codes.⁸ After generating a list of the key SOC codes for occupations in HDs, we prioritized occupations requiring specific training or credentialling (i.e., minimum of 1 to 2 years of training or an associate’s degree), that are relatively specific to HDs, and that constituted more than 0.5% of PH WINS responses or otherwise are a high priority in the HDs.

Occupations requiring relatively little preparation, such as custodians or administrative assistants, or that serve business support functions across many government agencies, such as accountants, customer service specialists, or human resources professionals, were excluded. We included certain PH WINS job categories known to have a poor SOC match such as disease intervention specialist, grants or contracts specialist, and population health specialist, but indicated the poor match, and excluded categories with no match such as implementation specialist and peer counselor. In addition, several PH WINS job categories matched to the same SOC code (e.g., deputy director, program manager, public health agency director); we selected the most-frequently matched SOC codes that could represent several HD job titles in this situation. We selected 44 SOC codes in all (Table 1 and Appendix A, available as a supplement to the online version of this article at https://ajph.org).

TABLE 1—

Standard Occupational Classification (SOC) Codes Included in Public Health Workforce Salary Analysis, With Code Used in Occupational Employment and Wage Survey (OEWS) if Different, and Estimated Job Category From the Public Health Workforce Interests and Needs Survey (PH WINS)

Standard Occupational Classification (SOC) Title	SOC Code (OEWS SOC if Different)a	PH WINS 2021 Job Category/Categories (Estimated)b
Chief Executives	11-1011	Department/Bureau Director
General and Operations Managers	11-1021	Department/Bureau Director; Program Director; Deputy Director; Public Health Agency Director; Quality Improvement Worker
Computer and Information Systems Managers	11-3021	Information Systems Manager/Information Technology Specialist
Medical and Health Services Managers	11-9111	Program Director; Department/Bureau Director; Public Health Program Manager; Deputy Director; Public Health Agency Director; Public Health Manager or Program Manager
Social and Community Services Managers	11-9151	Public Health Manager or Program Manager
Emergency Management Directors	11-9161	Emergency Preparedness/Management Worker
Managers, All Other	11-9199	Program Director; Department/Bureau Director; Deputy Director; Emergency Preparedness/Management Worker; Health Officer; Program Evaluator; Public Health Agency Director; Public Health Manager or Program Manager; Quality Improvement Worker; Grants or Contracts Specialist (poor match)
Compliance Officers	13-1041	Licensure/Regulation/Enforcement Worker
Management Analysts	13-1111	Program Evaluator
Computer & Information Research Scientists	15-1221	Public Health Informatics Specialist
Database Administrators	15-1242	Data or Research Analyst
Computer Occupations, All Other	15-1299	Information Systems Manager/Information Technology Specialist
Operations Research Analysts	15-2031	Policy Analyst; Data or Research Analyst
Environmental Engineers	17-2081	Engineer
Microbiologists	19-1022	Laboratory Scientist/Medical Technologist; Laboratory Technician; Laboratory Quality Control Worker
Epidemiologists	19-1041	Epidemiologist
Medical Scientists, Except Epidemiologists	19-1042	Laboratory Scientist/Medical Technologist
Chemists	19-2031	Laboratory Scientist/Medical Technologist; Laboratory Technician
Environmental Scientists and Specialists, Including Health	19-2041	Sanitarian or Inspector; Environmental Health Worker
Political Scientists	19-3094	Policy Analyst
Social Scientists and Related Workers	19-3099 (19-3000)a	Program Evaluator
Environmental Science and Protection Technicians, Including Health	19-4091 (19-4042)a	Sanitarian or Inspector; Environmental Health Worker
Social Science Research Assistants	19-4061	Data or Research Analyst
Life, Physical, and Social Science Technicians, All Other (includes Quality Control Analysts)	19-4099	Quality Improvement Worker
Occupational Health and Safety Specialists and Technicians	19-5010	Sanitarian or Inspector
Occupational Health and Safety Specialists	19-5011	Environmental Health Worker; Health Officer
Occupational Health and Safety Technicians	19-5012	Sanitarian or Inspector
Substance Abuse and Behavioral Disorder Counselors	21-1011 (21-1018)a	Behavioral Health Professional
Healthcare Social Workers	21-1022	Social Worker/Social Services Professional
Mental Health and Substance Abuse Social Workers	21-1023	Social Worker/Social Services Professional; Behavioral Health Professional
Health Education Specialists	21-1091	Health Educator; Health Navigator; Population Health Specialist (poor match)
Social and Human Service Assistants	21-1093	Social Worker/Social Services Professional; Community Health Worker
Community Health Workers	21-1094	Community Health Worker; Disease Intervention Specialist (poor match)
Public Relations Specialists	27-3031	Public Information Specialist
Dietitians and Nutritionists	29-1031	Nutritionist or Dietitian
Registered Nurses	29-1141	Registered Nurse - Public Health or Community Health Nurse; Other Nurse - Clinical Services; Registered Nurse - Unspecified
Nurse Practitioners	29-1171	Nurse Practitioner
Physicians, All Other (including Preventive Medicine Physicians)	29-1229	Public Health/Preventive Medicine Physician
Dental Hygienists	29-1292	Other Oral Health Professional
Clinical Laboratory Technologists and Technicians	29-2012 (29-2010)a	Laboratory Technician
Medical Records Specialists	29-2072	Medical/Vital Records Staff
Nursing Assistants	31-1131	Nursing and Home Health Aide
Dental Assistants	31-9091	Other Oral Health Professional
Statistical Assistants	43-9111	Data or Research Analyst

^a The OEWS from the US Department of Labor occasionally uses slightly different SOC code numbers for occupation titles that are matched to other SOC numbers in other settings. When the SOC codes are different in the usual use of SOC as compared with the code number in OEWS, both numbers are listed.

^b The “job categories” in PH WINS did not always match clearly with a specific SOC code, and in some cases the same PH WINS job category matched with more than 1 SOC code or vice versa. For certain occupations, the SOC match was especially uncertain; these cases are listed as “poor match.”

Salary Data Analysis

The OEWS program is a semiannual mail survey of nonfarm establishments and produces employment and wage estimates annually for approximately 830 SOCs, gathering data from every metropolitan and nonmetropolitan area in every state, across all surveyed industries, and from establishments of varying sizes. We used the May 2022 OEWS data, the most recent available.

OEWS also gathers data by industry (using NAICS codes). Although OEWS provides information on salary by occupation for 455 different industries including highly specific industries such as “Theater Companies and Dinner Theaters” (711110), the NAICS-based research “does not generally include government-owned establishments, even when their primary activity would be classified in industries covered by the economic census.”²⁴ A NAICS code for “Administration of Public Health Programs” exists (923120), but the OEWS data do not use this code. The NAICS codes most relevant to HDs include “State Government, excluding schools and hospitals” (999200), and “Local Government, excluding schools and hospitals” (999300). We compared median salaries in these 2 sectors with salaries in the private or nongovernment sector (defined, in this article, as all other sectors except for government, thus including both for-profit and nonprofit organizations). Because the data are reported in aggregate, statistical analysis of the salary data was not possible. We therefore used descriptive statistics.

RESULTS

Salaries were at least 5% lower in state government than the private sector for 31 occupations, and at least 5% higher for 10 occupations. In local government, salaries were at least 5% lower than private sector for 20 occupations and at least 5% higher for 10 occupations. For 1 occupation, salaries were at least 5% higher in state government than private industry, but lower for local government, and for 2 occupations the opposite was true (Table 2).

TABLE 2—

Salary Difference for Public Health Occupations From Occupational Employment and Wage Survey (OEWS) Median Annual Salaries, Private Sector Versus Local or State Government

SOC Title	SOC Code	Private Sector/ Nongovernment Median Annual Salary, $	Local Government, Excluding Schools and Hospitals, Median Annual Salary, $	State Government, Excluding Schools and Hospitals, Median Annual Salary, $	Salary Difference: Local Government/ Private Sector, $	Salary Difference: State Government/Private Sector, $	% Decrease/ Increase: Local/ Private	% Decrease/ Increase: State/ Private
Chief Executivesa	11-1011	209 810	111 380	129 540	−98 430	−80 270	−46.91	−38.26
General and Operations Managersb	11-1021	97 030	105 860	103 550	8 830	6 520	9.10	6.72
Computer and Information Systems Managersa	11-3021	166 070	126 930	117 690	−39 140	−48 380	−23.57	−29.13
Medical and Health Services Managersa	11-9111	103 940	103 510	94 640	−430	−9 300	−0.41	−8.95
Social and Community Service Managersb	11-9151	69 260	96 070	80 040	26 810	10 780	38.71	15.56
Emergency Management Directorsa	11-9161	100 210	75 160	66 750	−25 050	−33 460	−25.00	−33.39
Managers, All Othera	11-9199	130 330	103 580	87 820	−26 750	−42 510	−20.52	−32.62
Compliance Officersa	13-1041	69 990	64 000	59 700	−5 990	−10 290	−8.56	−14.70
Management Analystsa	13-1111	98 500	83 180	72 090	−15 320	−26 410	−15.55	−26.81
Computer and Information Research Scientistsa	15-1221	156 620	85 360	NA	−71 260	NA	−45.50
Database Administratorsa	15-1242	102 240	99 820	84 470	−2 420	−17 770	−2.37	−17.38
Computer Occupations, All Othera	15-1299	96 440	68 290	75 190	−28 150	−21 250	−29.19	−22.03
Operations Research Analystsa	15-2031	86 430	83 930	55 650	−2 500	−30 780	−2.89	−35.61
Environmental Engineersa	17-2081	96 320	95 370	87 710	−950	−8 610	−0.99	−8.94
Microbiologistsc	19-1022	80 890	83 440	63 500	2 550	−17 390	3.15	−21.50
Epidemiologistsa	19-1041	92 700	70 910	69 510	−21 790	−23 190	−23.51	−25.02
Medical Scientists, Except Epidemiologistsa	19-1042	102 210	86 770	86 300	−15 440	−15 910	−15.11	−15.57
Chemistsa	19-2031	80 010	76 640	62 930	−3 370	−17 080	−4.21	−21.35
Environmental Scientists and Specialists, Including Healtha	19-2041	76 870	76 300	70 080	−570	−6 790	−0.74	−8.83
Social Scientists and Related Workersa	19-3000	83 210	79 290	80 450	−3 920	−2 760	−4.71	−3.32
Political Scientistsa	19-3094	103 730	86 960	68 950	−16 770	−34 780	−16.17	−33.53
Environmental Science and Protection Technicians, Including Healthb	19-4042	46 710	58 710	50 590	12 000	3 880	25.69	8.31
Social Science Research Assistantsa	19-4061	51 490	48 960	41 540	−2 530	−9950	−4.91	−19.32
Life, Physical, and Social Science Technicians, All Otherc	19-4099	50 080	60 870	38 750	10 790	−11 330	21.55	−22.62
Occupational Health and Safety Specialists and Techniciansa	19-5010	75 050	67 720	64 310	−7 330	−10 740	−9.77	−14.31
Occupational Health and Safety Specialistsa	19-5011	78 650	73 030	65 150	−5 620	−13 500	−7.15	−17.16
Occupational Health and Safety Techniciansc	19-5012	58 240	61 450	53 850	3 210	−4 390	5.51	−7.54
Substance Abuse, Behavioral Disorder, and Mental Health Counselorsb	21-1018	48 820	62 050	51 110	13 230	2 290	27.10	4.69
Healthcare Social Workersa	21-1022	60 370	54 930	51 400	−5 440	−8 970	−9.01	−14.86
Mental Health and Substance Abuse Social Workersb	21-1023	49 170	61 280	60 250	12 110	11 080	24.63	22.53
Health Education Specialistsa	21-1091	58 860	55 490	55 190	−3 370	−3 670	−5.73	−6.24
Social and Human Service Assistantsb	21-1093	37 630	46 790	41 520	9 160	3 890	24.34	10.34
Community Health Workersb	21-1094	45 570	47 770	47 840	2 200	2 270	4.83	4.98
Public Relations Specialistsc	27-3031	67 160	69 270	62 940	2 110	−4 220	3.14	−6.28
Dietitians and Nutritionistsa	29-1031	66 630	60 320	57 450	−6 310	−9 180	−9.47	−13.78
Registered Nursesa	29-1141	80 970	79 590	77 610	−1 380	−3 360	−1.70	−4.15
Nurse Practitionersa	29-1171	121 520	116 900	102 820	−4 620	−18 700	−3.80	−15.39
Physicians, All Othera	29-1229	217 150	210 370	175 800	−6 780	−41 350	−3.12	−19.04
Dental Hygienistsa	29-1292	81 470	78 240	62 110	−3 230	−19 360	−3.96	−23.76
Clinical Laboratory Technologists and Techniciansa	29-2010	56 820	51 810	48 110	−5 010	−8 710	−8.82	−15.33
Medical Records Specialistsc	29-2072	46 770	44 370	49 650	−2 400	2 880	−5.13	6.16
Nursing Assistantsb	31-1131	35 640	37 400	37 330	1 760	1 690	4.94	4.74
Dental Assistantsc	31-9091	44 820	44 510	50 960	−310	6 140	−0.69	13.70
Statistical Assistantsc	43-9111	51 830	53 020	44 530	1 190	−7 300	2.30	−14.08

Note. NA = no data available; SOC = Standard Occupational Classification.

^a Pays less in government than private sector.

^b Pays more in government than private sector.

^c Higher salaries in state government than private sector and lower in local government than private sector, or vice versa.

Occupations with the severest salary disparities, with median annual salaries paying between 20% and up to 47% lower in either local or state government as compared with the private sector, included management, leadership, program management, program evaluation, and policy occupations. The largest salary disparities were for management occupations including “Chief Executives” (paying up to 46.9% less in government), “Operations Research Analysts” (‒35.6%), “Emergency Management Directors” (‒33.4%); “Managers, All Other” (‒32.6%), “Computer and Information System Managers” (‒29.1%), and “Management Analysts” (‒26.8%); computer and mathematics occupations including “Computer and Information Research Scientists” (‒45.5%) and “Computer Occupations, All Other” (‒29.2%); scientific, technical, and research occupations including “Political Scientists” (the SOC code for “Policy Analysts,” −33.5%), “Epidemiologists” (‒25%), and “Chemists” (i.e., laboratory scientists, −21.4%); and 1 clinical occupation, “Dental Hygienists” (‒23.8%).

Other inspection or compliance roles, scientific roles, technicians, and clinicians had moderate disparities in salary (paying 10%–19% less in either state or local government), including “Compliance Officers,” “Database Administrators,” “Medical Scientists, Except Epidemiologists,” “Social Science Research Assistants,” “Occupational Health and Safety Specialists,” “Healthcare Social Workers,” “Dieticians and Nutritionists,” “Nurse Practitioners,” “Physicians, All Other,” “Clinical Laboratory Technologists and Technicians,” and “Statistical Assistants.”

Some occupations had higher salaries in local and state government than in private industry. Those with the largest wage advantage in government were primarily in “Community and Social Service Occupations” or related human services roles, including “Social and Community Service Managers,” earning up to 38.7% more in government, as well as “Substance Use Counselors” (+27%) and “Mental Health Social Workers” (+24.6%). Certain technician roles paid more in government, such as “Environmental Science and Protection Technician” (+25.7%) and “Social Services Assistants” (+24.3%).

The BLS data show only a small wage gap for registered nurses (RNs), conflicting with other research showing a much larger disparity.⁷ Because there is no separate SOC code for public health nurses (PHNs), they are mixed in with RNs.²³ It is possible that RNs working in carceral facilities, state-funded long-term-care facilities, human services, or other government agencies besides HDs earn more than PHNs, skewing the median salaries higher than it would be if it pertained exclusively to PHNs.

We also assessed the proportion of workers in each occupation working in different NAICS industry groups to determine if wage differences might be explained by competition from certain industries (Appendix B, C, and D, available as supplements to the online version of this article at https://ajph.org).

According to OEWS, “Professional, Scientific, and Technical Services” (Sector 54), which includes consulting firms and research services, hired between 10% and 50% of several occupations with wage disparities, such as “Epidemiologists,” “Management Analysts,” “Social Scientists,” “Political Scientists,” “Occupational Health & Safety Specialists,” “Compliance Officers,” “Computer & Information Research Scientists,” “Computer and Information Systems Managers,” “Environmental Scientists and Specialists, Including Health,” and “Environmental Engineers.” “Health Care and Social Assistance” employed large numbers of “Epidemiologists,” “Social Scientists,” “Dietitians and Nutritionists,” “Compliance Officers,” “Dental Hygienists,” and “Emergency Management Directors.” “Manufacturing” and “Construction” hired large numbers of “Occupational Health & Safety Specialists,” and “Finance and Insurance” is a major employer of “Compliance Officers” and “Computer and Information Systems Managers.” The “Information” sector is a key employer of computer occupations.

For the occupations that pay more in government, competitor industries tended to be in “Health Care and Social Assistance” for “Social Services Managers,” “Mental Health Social Workers,” and “Healthcare Social Workers.” Looking in more detail at the “Health Care and Social Assistance” sector (NAICS 62), however, the subsectors within NAICS 62 that hire occupations that pay more in government tend to be substance abuse centers, nursing and residential care facilities, and social assistance (nonprofit) organizations, as opposed to large health care providers or hospitals. This is especially the case for “helping” professions such as social work or counseling. The top detailed NAICS Health Care and Social Assistance subsectors for occupations paying less in government include “Hospitals” hiring “Epidemiologists,” “Dietitians and Nutritionists,” and “Emergency Management Directors” and “Offices of Dentists” hiring “Dental Hygienists.” By contrast, the top detailed NAICS health care and social assistance subsectors for occupations paying more in government included “Ambulatory Health Care Services” and “Outpatient Mental Health and Substance Abuse Centers” hiring “Mental Health Social Workers” and “Nursing and Residential Care Facilities” and “Social Assistance” hiring “Social & Community Services Managers.”

DISCUSSION

Salary differences for many, but not all, occupations appear substantial, especially for technical, research, management, and leadership roles. Based on the limited federal data available, many public health occupations in local or state government appear to face serious wage competition, especially from the for-profit sector, particularly from professional, scientific, and technical services; finance and insurance; and information sectors, and from large health care organizations.

HDs have faced a decades-long workforce shortage.^1,2 While more research is needed to identify the impact of wage differences, it seems that the fact that between 20 and 31 of the identified occupations in this study pay at least 5% less in government—a differential that has been shown to entice workers to quit¹²—may have contributed to this shortage. Close attention should to be paid to whether the historic Public Health Infrastructure Grant investment, which recommended HDs to pay fair salaries to grant-funded hires, might result in long-term wage increases for permanent workers.¹⁴ And though more public health students might be graduating, labor market mismatches can still cause workforce shortages.^25–29

Wages and funding in the public sector are often set by factors unrelated to competition in the job market, including civil service pay scales, union-negotiated pay scales, local or state regulations, and the choices of elected officials.

Private-sector employers are not typically bound by these restrictions and can respond to a workforce shortage by increasing salaries, improving benefits, providing sign-on bonuses, and purchasing recruitment advertising or services. Within the private sector, for-profit corporations in particular generally have more revenue to invest in such efforts. SOC occupations with higher numbers of workers in industries comprising for-profit corporations, such as computer programmers, engineers, and scientists, may experience more labor market competition.^8,25,26 Meanwhile, occupations in which large numbers of workers are employed by small nonprofit organizations, such as social workers, may earn more in government. For certain technician occupations (“Environmental Science and Protection Technician” and “Social Services Assistants”), which require less credentialling and pay more in government, union-negotiated pay scales may cause government salaries to be higher.

Considering the potential recruitment challenges caused by salary disparities for certain occupations, several policy solutions might be considered.

Improvements in Federal Data

To improve federal data on the public health workforce, including for clearer salary information and workforce enumeration, BLS should be encouraged to use more detailed NAICS codes for OEWS if possible, including consistently using the specific NAICS code for public health services when surveying local and state governments,²³ and establish more-specific SOC codes for certain occupations like PHNs.^30,31

Improving Salaries

For those occupations with higher salaries in HDs, higher wages should be emphasized in recruitment marketing campaigns, whereas for those paying less, salary increases should be considered. Benchmarking salaries with competitor sectors is a standard procedure in human resources. It is also crucial for diversity and inclusion.^32–34 However, changing salary grades in government can be difficult, especially in jurisdictions where there are complex regulations, collective bargaining agreements, or political factors that make salary increases for government workers difficult.^11,35–37 State and local government wages have stagnated over the last 15 years.³⁸ Increasing salaries to recruit new hires can also cause wage compression with longer-serving or senior staff, or between union and nonunion employees, and, if budgets are stagnant, increasing wages for current staff means fewer new openings are available. Advocacy efforts at local, state, and federal levels would be needed to increase funding, improve HD salaries, and fill workforce gaps.³⁷ Because there are approximately 3000 local and state HDs, each with its own hiring regulations—some with civil service hiring laws embedded in their state constitutions—regulatory reforms to improve public-sector salaries are likely a long-term challenge.

If wage increases are possible, HDs could use local wage benchmarking and analysis of “hard-to-fill” vacancies to prioritize mission-critical occupations with large wage gaps for salary increases.

Recruitment Strategies in Absence of Higher Wages

Strategy 1: Benefits

If salaries cannot be increased in the short term, HDs may consider other strategies to attract candidates. While salary is crucial, job seekers also consider benefits, work‒life balance, schedule, and public service motivation. A survey of public health students found that “Job security (84.7%), competitive benefits (82.2%), identifying with the mission of the organization (82.2%), and opportunities for training/continuing education (80.6%)” were key motivators to work for government, though competitive salary was a detractor.³⁹

Even if salary is lower, government agencies often have certain advantages for job seekers that could serve as recruitment incentives if they are well-marketed to job seekers. Government may offer better retirement plans, with 86% of state and local government workers having access to defined benefit retirement plans (pensions), compared with 15% of private-sector workers, and with 68% of government staff receiving health care coverage compared with 47% in private sector.⁴⁰ In one study, employees who came to HDs from private industry were attracted by benefits and job security.⁴¹ The 2022 Global Benefits Attitudes survey found that 59% of respondents were willing to trade lower compensation for more generous retirement benefits and 46% for better health care plans.¹² However, the same survey found that 56% of employees cite pay as a top reason to look for a new job; only 29% listed retirement benefits as a reason to leave.

Using strong retirement benefits may not help as much with recruiting younger staff.⁴² When asked what they most want employers to focus on, individuals born from 1950 to 1980 mentioned retirement, but workers born 1981 or after listed other priorities.¹³

Some government agencies also provide overtime pay, which is not generally well-advertised to potential hires. Union membership is more than 5 times higher in government than the private sector, and the advantages of union protection can be marketed to job seekers.⁴³ Government agencies sometimes have better work‒life balance and more provide wellness benefits.⁴⁰ However, some data show that the value of benefits in government employers has declined over the years and that compensation lags behind the private sector even when including the value of benefits.³⁸

Strategy 2: Public service motivation

Many job seekers are motivated by the desire for meaningful work or public service. One study showed that participants were willing to be paid $17 300 to $22 639 less in average annual income to work in a more meaningful job.⁴⁴ However, careers in nonprofit organizations and other sectors are also highly meaningful, and relying on workers to take lower salaries in exchange for meaningful work, while noble in spirit, is neither equitable nor sustainable. With harassment caused by COVID-19, worker motivation to serve the public could be reduced.⁴⁵

Strategy 3: Recruitment marketing and onboarding

There are new efforts to improve the image of public health and attract job applicants to HDs,^46–51 and new initiatives to improve onboarding and employee wellness and to change structures that cause burnout may improve retention.^52–54

Strategy 4: Student loan repayment

For professions for which advanced education is required, student loan debt could force some job candidates to choose higher-paying jobs in other sectors.⁵⁵ Federal data show that for Master of Public Health graduates, median postgraduate earnings were $48 866, but loan debt was $52 263.⁴⁴ Considering the racial disparities in student loan debt,⁵⁶ comparably low salaries could create challenges for recruitment and retention of diverse candidates.

The Public Health Workforce Loan Repayment program, approved in the 2022 Omnibus Bill,⁵⁷ would provide student loan repayment for individuals with graduate degrees in public health, laboratory sciences, informatics, or statistics who choose to work in HDs for a period of 3 years. If funded, it could provide an incentive to candidates to work in HDs.

Limitations

Because BLS does not use the NAICS code for public health, for certain occupations, especially broad-based occupations like “senior executives,” there is a high chance that the majority of BLS data regarding local or state government is not specifically representative of HDs. Wages and costs of living are very different in different parts of the country, but geographic analysis was beyond the scope of this study.⁵⁸ Some HDs allow fully remote work, while others prohibit it. Further research is needed to assess the impact of remote work options—for example, to assess whether HDs that require in-person work, especially in locations with higher costs of living, might face compounded challenges from lower wages.

Because “public health nurse” is not a separate SOC code, it is hard to know which of the salaries pertain to a health care environment as opposed to public health. This may also be the case for social workers or counselors because there are likely to be more behavioral health staff working for human services agencies, as opposed to HDs. This is less likely to be the case for epidemiologists or health educators, who are more likely to work in HDs.

Certain jobs in a local or state government agency might require different responsibilities than in other sectors, which might result in different pay; further research such as an analysis of job postings may clarify this potential difference.

While benefits are often better in government than private industry, we did not include the cash value of benefits in this analysis.³⁸ Future research using PH WINS data to assess any links between respondents expressing a desire to quit and working in a comparably lower-paying occupation could clarify the impact of lower wages on retention.

Public Health Implications

If computer professionals earn up to $48 380 more outside government, we may ask who will implement new initiatives to modernize public health data infrastructure.¹⁴ When epidemiologists can earn $23 000 more and emergency management directors $33 460 more by quitting their jobs in HDs to work in private industry, we might wonder who will respond to the next pandemic or public health emergency. And with hundreds of senior HD leaders having quit, retired, or been fired during the pandemic,^2,45 we may ask how new leadership will be recruited when chief executives can nearly double their salaries and earn $98 430 more outside government.

Improving recruitment marketing, including focusing on benefits and meaningful work, combined with improved salaries or loan repayment, may help bolster the workforce, but stagnant funding and salaries will remain a barrier to public health.

Conclusions

To sustainably recruit and retain the diverse workforce that is needed to keep our nation healthy, we must consider salary disparities in health departments as an upstream determinant of public health.