Sustainability of the Growth of the Local Public Health Workforce During the COVID-19 Pandemic, 2019–2022

Abstract

Objectives. To explore whether and how the local health department (LHD) workforce shifted during the COVID-19 pandemic given the large influx of supplemental funding to public health.

Methods. We used data from the National Association of County and City Health Officials National Profile of Local Health Departments, the main source of comprehensive data collected from LHDs across the United States. Total numbers of employees, total numbers of full-time equivalents (FTEs), and employee types (full time, part time, contractual, and seasonal) were used to estimate the total LHD workforce in 2022, changes in the LHD workforce from 2019 to 2022, and changes in the LHD workforce from 2019 to 2022 by employee type.

Results. In 2022, the estimated LHD workforce consisted of 182 100 employees or 163 200 FTEs. Between 2019 and 2022, there was a 19% increase in the total LHD workforce, but the size of the workforce varied according to jurisdiction size and rurality. The largest increase was among contract workers (175%), whereas the full-time workforce grew by approximately 7%, indicating that the permanent workforce was predominantly unchanged.

Conclusions. With the surge in temporary and contract workers in 2022, there are concerns regarding the sustainability of the LHD workforce. Without continued strategic and sustained funding across jurisdiction types, the workforce may be in jeopardy. (Am J Public Health. 2025;115(8):1271–1277. https://doi.org/10.2105/AJPH.2025.308096)

Underinvestment in state and local public health in the United States after the Great Recession of 2008 has been well documented,¹ as has its contemporary effects on the governmental public health workforce.² A recent analysis of survey data from state and local public health departments nationwide indicated that the combined labor force of these agencies declined by 16% between 2008 and 2019.³ Employee turnover and churn remain common in this sector; in the 2021 Public Health Workforce and Needs Survey, more than half of respondents indicated plans to retire, change positions, or leave the workforce within the following year.⁴

Although funding to state and local public health has been stagnant and not commensurate with population growth,⁵ the overall quantity of funds is not the only factor negatively affecting the workforce’s readiness to address population health threats. Federal funding streams and hiring mechanisms in governmental public health tend to be highly vertical,^6,7 directed to specific diseases and program categories rather than to foundational public health services. State- and local-level funding streams have historically varied widely in their flexibility as well as their quantity.⁸ Vertically oriented funding mechanisms frequently restrict staff scope of work, thus limiting agencies’ flexibility to adapt to changing needs.

This trend toward workforce reductions in the context of ongoing verticality left many state and local health departments inadequately prepared for the COVID-19 pandemic. Recognizing the need for increased epidemiology, surveillance, laboratory, clinical, infection prevention, and communications capacity in communities across the United States, the federal government allotted surge funding to be distributed to state and local health departments through legislative activity in 2020 and 2021.

Early in March 2020, the Coronavirus Preparedness and Response Supplemental Appropriations Act⁹ authorized the US Department of Health and Human Services to distribute $950 million rapidly to state and local health departments for response activities, including workforce scale-up. This was followed in late March 2020 by the Coronavirus Aid, Relief, and Economic Security Act,¹⁰ which authorized additional funding for state and local workforce support; in April 2020 by the Paycheck Protection Program and Health Care Enhancement Act,¹¹ which released funds from the Public Health Social Services Emergency Fund for pandemic response activities; and in December 2020 by the Coronavirus Response and Relief Supplemental Appropriations Act.¹² In March 2021, the American Rescue Plan Act¹³ allocated an additional $4.4 billion for workforce support in states and localities.

Measuring the impact of this legislative support on the local public health workforce during the COVID-19 pandemic is challenging because of the complex nature of the funding streams and the different pathways by which funds were allotted to localities (i.e., directly or via state pass throughs). Similar challenges exist in enumerating the workforce impact of programs supported by philanthropies, foundations, and other private funding sources.¹⁴ One analysis of data from the 2021 Public Health Workforce Interests and Needs Survey, fielded in September 2021 through January 2022, indicated that most pandemic-associated surge hiring had occurred before March 2021.^14,15

Overall, as of 2019, the National Association of County and City Health Officials (NACCHO) estimated that the local public health workforce consisted of 153 000 employees or 136 000 full-time equivalents (FTEs), as compared with the 2008 total of 184 000 employees or 162 000 FTEs.¹⁶ In addition, before the COVID-19 pandemic, it was estimated that LHDs require approximately 54 000 more FTEs to provide the core foundational public health services.³ There are no reliable estimates of the local governmental public health workforce during the pandemic.

Although it is difficult to understand the true effect of supplemental funding on the local governmental workforce, it is possible to observe how workforce trends have shifted from before the pandemic to indirectly gauge its importance. Therefore, our objectives in this study were to describe the overall local public health workforce in 2022 during the pandemic and characterize any shifts from 2019, including possible increases in the workforce. To address these objectives, we used the NACCHO National Profile of Local Health Departments study to examine LHD workforce data in the context of pandemic legislative trends and expand on different workforce indicators to showcase trends beyond NACCHO’s previous survey work.

METHODS

The triennial National Profile of Local Health Departments is the only nationally representative survey of LHDs across the United States; it provides the most reliable estimates of LHD workforce, infrastructure, practice, services, and capacity. The survey questionnaire was developed and revised through consultation with internal and external subject matter experts including academics, public health officials, and members of government and nonprofit organizations. For the purposes of the survey, an LHD is defined as an administrative or service unit of local or state government that is concerned with health and carries some responsibility for the health of a jurisdiction smaller than the state.

The survey has been fielded every 3 years since 1989 to describe how LHD staffing, governance, funding, and activities have varied across the United States over time. It is administered to LHDs identified for surveying purposes (without duplicating US residents served); it typically includes 2 module questionnaires to survey LHDs on additional topics at random as a means of reducing survey fatigue while providing further vital information on public health infrastructure and practices. Modules are sampled via nationally representative random stratified sampling (according to population size served).

Between June and September 2022, the survey was distributed online via Qualtrics to a total of 2512 LHDs; 942 LHDs responded (37.5% response rate). Rhode Island was excluded from the study because the state has no LHDs. Additional details regarding the 2022 survey and its methodology can be found elsewhere.¹⁷ Here we reference 2019 survey data to assess longitudinal trends in the workforce. The same methodology was used for fielding and analyzing the 2 separate 2019 and 2022 surveys. A total of 2459 LHDs were included in the 2019 study population, with a final response rate of 60.8%.¹⁶

Workforce Measures

For each responding agency, the research organization used the US Census Bureau classification system to compile information on jurisdiction size (defined in terms of population served, categorized as small [less than 50 000], medium [50 000–499 999], or large [500 000 or above]) and rurality (urban/rural status). LHDs were classified as urban or rural on the basis of whether the majority of the people they served were from urban settings (i.e., departments serving more than a 50% urban population were classified as urban).

In this study, we focused on 2 survey workforce items requested from all LHD respondents: the numbers of individuals and FTEs currently working and the numbers in specific job categories (full time, part time, contractual, and seasonal). Because data on these items were gathered separately, individual responses for job categories may not sum to the total.

Data Analysis

Analyses were conducted in Stata 18 (StataCorp LP, College Station, TX) via poststratification weighting; a 7-category measure of LHD size based on population served (less than 25 000, 25 000–49 999, 50 000–99 999, 100 000–249 999, 250 000–499 999, 500 000–999 999, 1 000 000 or more) was used to adjust for nonresponses. Results obtained in this manner can be interpreted as national estimates for the survey year based on the size of the population served. We initially calculated descriptive statistics across workforce items, specifically total numbers of employees and FTEs overall and within each job category, to obtain national LHD workforce estimates. Cross tabulations with the 3-category size of jurisdiction measure and the location measure based on rurality (urban or rural) were also calculated for 2022. Workforce trends from 2019 to 2022 were based on calculations of the weighted workforce totals (employees and FTEs) for each of the 2 data sets separately.

RESULTS

Table 1 outlines the LHD workforce in terms of employees and FTEs according to size of population served and rurality. In 2022, the total estimated LHD workforce in the United States consisted of 182 100 employees (95% confidence interval [CI] = 160 200, 204 100) or 163 200 FTEs (95% CI = 144 600, 181 800). LHDs serving larger populations tended to have a larger total workforce (96 100 employees vs 63 900 for medium and 22 100 for small LHDs). Furthermore, the total workforce across urban LHDs consisted of 153 400 employees or 138 100 FTEs, much larger than the workforce across rural LHDs (28 700 employees or 25 100 FTEs).

TABLE 1—

Size and Rurality Breakdowns of the Local Public Health Department Workforce: United States, 2022

	Total Employees, No. (95% CI)	Total FTEs, No. (95% CI)
Overall	182 100 (160 200, 204 100)	163 200 (144 600, 181 800)
Size
Small	22 100 (20 500, 23 700)	19 000 (17 500, 20 500)
Medium	63 900 (57 600, 70 300)	55 100 (49 800, 60 500)
Large	96 100 (75 100, 117 100)	89 000 (71 200, 106 800)
Rurality
Rural	28 700 (25 700, 31 800)	25 100 (22 400, 27 800)
Urban	153 400 (131 500, 175 400)	138 100 (119 500, 156 600)

Note. FTE = full-time equivalent; CI = confidence interval. Data are weighted and rounded to the nearest hundreds. Sample sizes were 929 (employees) and 924 (FTEs).

Figure 1 illustrates trends in the overall LHD workforce from 2019 to 2022. Over this period, the LHD workforce expanded by approximately 19% to 20% for employees and FTEs. Before this upward trend, the LHD workforce had been steadily declining since 2008.¹⁷ Further examination of these trends by jurisdiction size showed that there was limited to no increase in the total workforce between 2019 and 2022 among small LHDs, as compared with an upward trend for both total employees and FTEs among large LHDs.

FIGURE 1—

Local Public Health Workforce for (a) All Local Health Departments (LHDs), (b) Small LHDs Only, (c) Medium LHDs Only, and (d) Large LHDs Only: United States, 2019–2022

Note. The 95% confidence intervals for employee and full-time equivalent (FTE) estimates are provided for each survey year, rounded to the nearest hundreds. Lines represent changes in the weighted total number of employees or FTE estimates from the 2019 to 2022 surveys. Sample sizes were 1467 (employees) and 1468 (FTEs) for 2019 and 929 (employees) and 924 (FTEs) for 2022; however, the data were weighted for each year to allow national estimates. There is a different y-axis for all LHDs to account for total numbers and 95% confidence intervals.

Table 2 provides an overview of the LHD workforce across 4 job categories: full time, part time, contractual, and seasonal. Overall, in 2022, the LHD workforce primarily consisted of full-time employees (137 500), followed by contractual employees (22 000). As expected, LHDs serving larger jurisdictions tended to have greater numbers of employees across the 4 categories. In addition, the total estimate for employees among urban LHDs was much greater across all job categories than the estimate among rural LHDs.

TABLE 2—

Local Public Health Department Employees Across Job Categories With Size and Rurality Breakdowns: United States, 2022

	Full Time, No.	Part Time, No.	Contractual, No.	Seasonal, No.
Overall	137 500	14 700	22 000	3 400
Size
Small	17 400	3 000	1 400	100
Medium	49 500	5 900	4 900	1 300
Large	70 500	5 900	15 700	1 900
Rurality
Rural	22 900	3 300	2 200	100
Urban	114 600	11 400	19 800	3 300

Note. Data are weighted and rounded to the nearest hundreds. Sample sizes were 892 (full time), 882 (part time), 882 (contractual), and 885 (seasonal).

An examination of job categories within the LHD workforce across time showed that the greatest relative difference was in contractual employees between 2019 and 2022 (a 175% increase; Table 3). The number of part-time employees declined from 2019 to 2022, whereas full-time employees increased by 7% between these years. The permanent workforce declined or saw modest gains, and the largest increases were among temporary and contract staff positions added after the introduction of emergency supplemental COVID-19 funding. In addition, workforce gains were not universal across jurisdiction sizes; instead, the increases in workforce job types seen were within medium and large LHDs as opposed to small LHDs. Specifically, across jurisdiction sizes, small LHDs saw practically no growth or even workforce declines.

TABLE 3—

Local Public Health Department Job Categories by Department Size: United States, 2019–2022

	Full Time	Part Time	Contractual	Seasonal
Overall
2019, no.	128 500	17 600	8 000	2 300
2022, no.	137 500	14 700	22 000	3 400
Difference, %	7	−16	175	48
Small LHDs
2019, no.	17 000	4 300	1 400	200
2022, no.	17 400	3 000	1 400	100
Difference, %	2	−30	0	−50
Medium LHDs
2019, no.	46 500	5 600	2 200	600
2022, no.	49 500	5 900	4 900	1 300
Difference, %	6	5	123	117
Large LHDs
2019, no.	65 100	7 700	4 500	1 400
2022, no.	70 500	5 900	15 700	1 900
Difference, %	8	−23	249	36

Note. LHD = local health department. Data are weighted for each year separately and rounded to nearest hundreds. Sample sizes for 2019 were 1092 (full time), 1087 (part time), 1090 (contractual), and 1088 (seasonal). Sample sizes for 2022 were 892 (full time), 882 (part time), 882 (contractual), and 885 (seasonal).

Contract employees increased by 123% and 249% in medium and large LHDs, respectively, with no change observed among small LHDs. The same general trend was observed among full-time and seasonal employees, with larger increases among medium and large LHDs than among small LHDs. For example, there was a 36% increase in the total seasonal workforce for large LHDs, in contrast to a 50% decline among small LHDs. The total number of part-time employees declined overall; however, medium LHDs exhibited a slight increase of 5%, as compared with a 30% decrease among small LHDs and a 23% decrease among large LHDs.

DISCUSSION

The local public health workforce steadily declined from 2008 to 2019. During the COVID-19 pandemic, emergency funds allocated to public health agencies for the response likely led to the 19% increase in the total LHD workforce. Gains in staffing were primarily observed among medium and large jurisdictions, and most of this increase occurred among contractual (175% increase) and seasonal (48% increase) workers; the part-time workforce shrank, and the full-time workforce grew marginally by 7%.

Public Health and Policy Implications

A larger public health workforce after decades of decline is at first glance a welcome sign given that the workforce has been insufficient thus far to deliver necessary core and fundamental services across the country.¹⁸ There are important implications and considerations in relation to our findings. First, gains between 2019 and 2022 were largely among contractual and seasonal workers in medium and large health departments; the workforce in small local health departments remained relatively stable or decreased. Previous work has shown that LHD hiring faced challenges in filling workforce gaps during the COVID-19 response ranging from external funding restrictions to a lack of authorizations for new staff positions.¹⁹

Our findings appear to indicate that LHDs were able to flex around these many limitations by bringing in temporary, contractual, and seasonal labor in response to the explosive needs driven by the COVID-19 response. Because contractual workers may not be able to transition to full-time positions or programmatic areas in need outside of COVID-19 given the expiration of pandemic supplemental funding in 2024, it is possible that the workforce will decline again. Also, despite this growth since 2019 in the local public health workforce, it falls far short of the workforce needed to provide infrastructure and public health services, estimated to be 80 000 or more FTEs.¹⁸

In addition, these gains occurred after an influx of funding to public health that will soon expire.²⁰ Without unrestricted and disease-agnostic funding, it is not possible to sustain staffing levels specifically aimed at the COVID-19-related emergency response. Although the need for a larger local public health workforce to meet the demands of the nation’s public has been suggested by previous research, it cannot be sustained through COVID-19-specific continuing or expiring funds from the federal government. One reason that disease-agnostic funding is likely necessary is that small and rural jurisdictions, which experienced almost no workforce growth during COVID-19, also face higher rates of threats to public health such as heart disease, stroke, cancer, accidental injuries, suicide, and COVID-19.^21,22

Although medium and large jurisdictions may have experienced increases in staffing during the pandemic, there remain threats to public health that COVID-19 emergency funding was not intended to address. Nearly 80% of LHDs in 2020 reported having to reassign staff from existing roles, departments, and duties to respond to the pandemic.²³ In addition, many jurisdictions reported both anecdotally and through nationally representative data collection that other critical activities that may reduce the impact of future public health crises (e.g., data modernization) either were on hold or involved no plans for implementation.²⁴ Funding a right-sized, permanent, and appropriately staffed local public health workforce that can meet the need for essential services must also include consideration of existing threats and the needs of jurisdictions that are typically not supported through emergency funding.

The Public Health Infrastructure Grant (awarded in December 2022)^25,26 may provide temporary mitigation of some of the losses in staffing in the absence of future growth. This funding mechanism provides disease-agnostic funding to state health departments and a variety of LHDs, both directly and indirectly, for recruitment, retention, support, and workforce training²⁵; these funds may include support for the transition of temporary workers to full-time positions before they are removed from the LHD workforce. But only 21% of the $3 billion in workforce funding is allocated for staff hiring and recruitment,²⁷ and there is no indication that this funding will be renewed in perpetuity (or past 2027²⁵) to support the future workforce long term. Future research should evaluate whether the Public Health Infrastructure Grant helps to sustain the public health workforce (including aspects such as the transition of temporary and contract positions to full-time positions) after the COVID-19 pandemic.

Finally, other incentives to support the natural growth of the local public health workforce are still likely necessary. For example, the Public Health Workforce Loan Repayment Plan included in the Consolidated Appropriations Act, which passed Congress with bipartisan support in 2022, would provide recent graduates who earned degrees in fields such as public health, epidemiology, data systems, informatics, and statistics with student loan repayments of up to $50 000 per year for 3 years of service. However, this plan has not yet been funded to implement the program. Programs such as this are just one recruitment and retention tool LHDs could use to build a stronger and larger workforce. Overall, without appropriate funding to grow and sustain the local public health workforce long term, the United States may be unprepared to respond to future public health emergencies.

Limitations

This study is not without limitations. For example, the data were self-reported by LHDs and could not be independently verified by NACCHO. For a variety of reasons, in addition to survey nonresponse, LHDs may have provided incomplete workforce information; to account for differential nonresponse among jurisdictions of different sizes, we used poststratification weighting based on jurisdiction size to produce national estimates of the LHD workforce. Although poststratification weighting helps minimize the effects of differential nonresponse, response rates for national surveys across public health were low during the COVID-19 pandemic (including the National Profile of Local Health Departments); therefore, such biases are still possible limitations of our study.

In addition, caution should be taken when attempting to sum individual categories of position types or FTEs to estimate the workforce; the survey collected total estimates from LHDs and subsequently individual category estimates (without summing them) because although these categories were defined for respondents, there was the potential for nonmutual exclusivity between categories (for example, workers on a contract may have been working full time at the agency during their contract). These data have been collected consistently over several iterations of the survey so that within-category changes and trends can be monitored, along with changes among the full workforce.

Conclusion

The growth of the local public health workforce since 2019 is potentially promising with respect to supporting consistent and sufficient delivery of public health services in the United States; however, such gains have primarily been driven by medium and large jurisdictions. In addition, there have been large relative increases in seasonal and contract staffing. Without sustained and disease-agnostic funding in future years, these increases are likely temporary. Moreover, the declines in the public health workforce that began in 2008 and continued until 2019 will likely occur again or future growth will not occur, especially in jurisdictions that did not exhibit workforce growth during this increased period of public health funding.