Innovations and Hiring Improvements to Address Public Health Workforce Recruitment

Abstract

Objectives:

This study engaged state and local health agency employees involved in the hiring process to examine the impact of hiring laws and civil service requirements on recruitment processes. Additionally, we identified innovative approaches to improve recruitment.

Design:

Key informant cross-sectional qualitative study.

Setting:

State and local U.S. governmental public health agencies.

Participants:

Health department hiring managers, human resources/workforce development directors and assistant directors, program managers, deputy commissioners, and other HR representatives.

Main Outcome Measures:

Experiences and perceptions of public health hiring approaches, processes, and civil service requirements.

Results:

Three themes emerged as solutions and innovations for public health agency recruitment: marketing strategies, organizational workforce development changes, and applicant experience improvements. Marketing strategies to improve recruitment included the expanded use of job wrapping and social media platforms. Organizational workforce development for recruitment and retention initiatives included paid fellowship programs, salary comparisons and market adjustments, expanded benefits, and the enhanced role of HR teams. Discussion of civil service requirements and hiring laws revealed that organizational and governance factors, such as hiring authority, were perceived as more consequential to effective recruitment than specific components of the law.

Conclusions:

Organizations should improve inefficient recruitment and hiring processes and systems where possible. Much of this is achievable through quality improvement initiatives rather than legal or regulatory changes. However, tracking the hiring process to identify inefficiencies is essential, as barriers likely differ across agencies and states. Finding ways to shorten the applicant review timeframe and improve communication with applicants throughout the hiring process may yield more successful recruitment efforts. Lastly, Public Health Infrastructure Grant (PHIG) funding and programming have led to recruitment innovations. Flexibility to adapt recruitment approaches to changing workforce and labor market dynamics is needed for an adequate workforce with the capacity to address foundational needs and public health challenges.

Introduction

Recruitment and retention have remained ongoing challenges for the public health workforce for decades.1-3 Health departments struggle to attract and retain workers due to a wide range of long-standing barriers, including insufficient funding,4,5 unclear public health position advertisements,6,7 and protracted hiring processes with complex administrative requirements.8,9 Such challenges not only limit the ability to fill critical positions but also contribute to workforce shortages, which, in turn, increase worker burden and burnout.10,11 Addressing these issues requires a deeper understanding of the systemic factors that hinder efficient recruitment and retention.

One significant public health recruitment obstacle is the lengthy and inefficient hiring process. Unlike the private sector, where hiring can take as little as 12-49 days, the average time to hire for merit-based government positions is 204 days.12,13 Such delays make it challenging for health departments to compete for strong candidates, and the protracted hiring process often leads to candidate attrition. Even when applicants have a strong desire to work in a health department, they often cannot wait long periods without employment. Several factors contribute to these prolonged hiring timelines, including the need for multiple levels of approval to establish and post job openings, burdensome application processes, and rigid hiring requirements, such as mandatory civil service exams in some states.4-9,12,14-16 Even when positions are successfully filled, historically low salaries and limited career advancement opportunities make retention a persistent issue, particularly within smaller health departments where financial resources are often more constrained.17,18 Studies indicate that more than half of state and local health department positions offer significantly lower salaries than equivalent roles in the private sector,19-21 deterring many applicants from seeking government positions and leading to high turnover rates as current employees leave for better-paying private sector positions. Beyond hiring timelines and compensation, governance structures also play a role in recruitment and retention challenges. Delays in hiring decisions are often exacerbated in health departments where hiring is managed by other state agencies, such as a Department of Management and Budget.21 This external agency oversight can also result in confusion for potential employees regarding the hiring process, as well as more complex and inefficient applicant reviews.

These ongoing challenges to recruitment and retention were brought to light during the urgent staffing needs and accelerated workforce attrition experienced during the COVID-19 pandemic. In response to the resulting public health capacity deficiencies, policymakers mobilized new resources to support efforts aimed at improving the public health system.22 In 2023, the Centers for Disease Control and Prevention (CDC) provided flexible new funding through the Public Health Infrastructure Grant (PHIG) to strengthen the workforce, ensure the provision of foundational capabilities, and support data modernization in public health agencies. A total of 107 health departments and three national public health partners received this funding.23 At the time of the PHIG funding, estimates indicated that 80 000 additional workers were needed to ensure the provision of foundational public health services.24 In the context of this shortage, and even prior to the COVID-19 pandemic, employees reported fatigue and stress resulting from existing workforce shortages and increasing workloads.8,9,25,26 These burdens were exacerbated during the pandemic, with lengthy recruitment processes and failed hiring efforts further contributing to reports of burnout.27-31 In an analysis of employee responses from 96 state and local health departments that participated in the Public Health Workforce Interests and Needs Survey (PH WINS) in both 2017 and 2021, researchers found employee turnover rates of about 50% by the end of 2021.17 Furthermore, a subanalysis of 2017 PH WINS survey responses for staff under 35 years old and/or staff with less than 5 years of experience at the department revealed turnover rates of nearly 75% by the end of 2021.17 These findings align with general workforce studies suggesting that workers from younger generations tend to change jobs more frequently than those from older generations.32,33 Given the ongoing recruitment challenges, the typically abbreviated tenures of younger generations, and persistent retention issues in public health agencies—particularly following the pandemic—it is crucial to understand the current state of hiring experiences in public health agencies, as well as explore innovations to improve workforce recruitment and retention.

The study employed qualitative research methods to explore the experiences of state and local public health agency employees involved in the hiring process, specifically to understand the role of hiring laws and civil service requirements, as well as to identify innovative approaches to addressing ongoing workforce challenges. Staff involved in state and local governmental public health hiring were interviewed between December 2023 and August 2024, providing timely insights into recruitment innovations and some of the ways that agencies can address challenges to recruitment and retention overall. Findings from this study provide examples that other governmental public health agencies may consider in addressing their own hiring challenges.

Methods

Sample

This study utilizes cross-sectional data collected through qualitative interviews. Governmental public health employees were interviewed from local and state health departments. A semi-structured interview guide was used to direct the conversation, focusing on topics related to hiring processes, assessing applicants, and advertising vacancies. Follow-up questions were used as needed. Questions included, “Can you provide an overview of the basic hiring process in your agency?” and “Tell me about the development of hiring qualification standards in your agency.” See Table 1 for the full interview guide. Interview questions were developed based on existing literature regarding civil service laws and factors related to recruitment and retention. Additionally, the authors have extensive experience studying recruitment and retention of the workforce, and thus, their expertise informed the interview guide.

TABLE 1.

Interview Guide Questions

Topic	Interview questions
Role	What is your current role at the Health Department?
Hiring	Overall Process: Can you briefly describe the recruitment/hiring process in your agency (if possible) and walk us through your role in the recruitment/hiring process?
	Filling Vacancies: What are your biggest challenges in recruiting to fill vacancies?
	Are specific positions more difficult to fill? Why? (Probe: salary concerns, lack of local expertise in the workforce, few applications, etc.) Do you have any workarounds or options for situations where salary is the reason you cannot fill a vacancy?
	Workforce Assessment: Does your organization assess whether staffing levels or the current number of existing positions are appropriate? How frequently does this assessment occur? What criteria are examined? (Probe: current workloads, health outcomes such as health equity, and other factors.)
	Are there policies that infringe on your ability to change the number of staff in specific roles? Does your health official encourage or direct you to conduct this kind of staffing assessment?
	Position Approval: Could you describe the approval process for positions? Is this the same for all positions, or does it vary? If it does, how? Who oversees this process?
	Position Creation and Determination (i.e., job description, classification, etc.): What is the process for position creation and classification?
	Is this the same for all positions, or does it vary? If it does vary, how? (e.g., are contract positions handled differently?)
	Recruitment: Can you share your current approach and strategies for recruitment (e.g., outreach, marketing, communication, etc.)?
	Is recruiting for remote positions different from recruiting for in-person or hybrid positions, and if so, how? Does your organization have any recruitment programs or partnerships with universities to aid in recruitment? (e.g., student employees working part-time while they study to gain work experience and meet minimum requirements?) Do you currently implement any targeted diversity initiatives in your recruitment process? Are there any other innovations to support recruitment? What is the role of public health institutes in workforce recruitment? Are there any risks to hiring contractors? (Probe: pay discrepancies/morale issues.)
	Interview and Selection Process: Could you describe your current interview and selection process?
	Do you have standard interview protocols? Is this decentralized (i.e., can you ask your own questions), or is there a standardized approach that must be followed? Are writing samples required, and/or are there other exercises or work that applicants must complete? Do you have control over candidate selection, or is this decision made through HR? Are there any preferred categories or applicant pools that are prioritized for specific positions?
	Decision/Offer: How does the offer process work once you’ve identified a candidate you wish to move forward with?
	Who oversees the final hiring decisions? Do you have any input in this? Is this oversight consistent across all types of positions?
	Pre-employment: What steps are required as part of the pre-employment process once an offer has been made (e.g., background checks, reference checks, etc.)?
	Who oversees this? Do you have any role in this process, and if so, how?
	Onboarding and Training: What is the typical onboarding and training process at your agency?
	Is there a centralized process at the agency level? Are there any onboarding processes that are specific to a given position?
Data Metrics/Tracking	Are you currently collecting any data metrics on recruitment and/or retention?
	If so, what metrics are being collected, and by whom? How is the data currently being tracked?
	Do you have career ladders or career development plans for employees?
Civil Service System	What are your experiences with the civil service system in your state? (e.g., how does it impact hiring practices?)
	Are there specific ways in which the civil service system impacts processes? Are there any issues with state merit-based requirements in terms of recruitment? Has your state revised these laws or systems in recent years? If so, please describe. Are there any differences, from your perspective, in terms of recruitment success since those changes?
Other	What do you think could be helpful in improving the hiring process? If you had a magic wand, what changes would you wish for?
	Is there anything else you would like to share?

Interview recruitment

The recruitment process was supported by the Association of State and Territorial Health Officials’ (ASTHO) workforce committee, as well as through the research team’s existing connections with governmental public health agencies. Additionally, snowball sampling was employed to recruit additional individuals involved in hiring and retention at other public health agencies. Interview participants included individuals involved in various aspects of recruitment and workforce development. Individuals holding different roles in hiring were intentionally recruited to garner a range of perspectives on hiring processes. As such, interviewees held a range of positions, including members of the agency’s Human Resources (HR) team focused on hiring staff for the agency overall; hiring managers who primarily hold programmatic roles in the agency and are involved in the hiring process only when filling open positions within their program; and workforce development staff who typically have no direct roles in the hiring process.

Analysis

Interviews were conducted by at least two members of the research team via Zoom and recorded with permission. Interviews averaged 45 minutes. Once the interviews were completed, transcripts and recordings were downloaded, manually reviewed, and cleaned for accuracy. The interview transcripts were then analyzed thematically using an inductive approach. Following the initial review of the transcripts, the authorship team employed an inductive process to generate a list of recurring ideas and topics that emerged. Based on these, a coding protocol was developed, including a list of themes and explanations. Using the protocol, two members of the research team (ERM and VAY) reviewed each of the transcripts again, assigning themes to the transcripts. We met to discuss the coding. Any identified discrepancies were then discussed among the entire authorship team and resolved through consensus, ensuring consistency in the assigned themes. This study was deemed exempt by the institutional review boards of both Indiana University and Johns Hopkins University.

Results

Participant demographic information

A total of 28 interviews with key informants were conducted across 10 agencies (7 state agencies and 3 local health departments). Table 2 presents the characteristics of the agencies represented as well as the characteristics of the participants. Agencies and individuals represented both urban and rural areas across all four regions of the United States. In terms of organizational structure, agencies were primarily in decentralized states, although one agency had shared governance. A total of 21 state and 7 local health department representatives were interviewed. The positions and roles of participants included directors of HR/workforce development/talent management, hiring managers, recruitment, retention, and engagement team members, as well as nonspecific HR team members. The majority of participants were women (n = 23, 82.1%), which aligns with the demographics of the overall workforce in public health.

TABLE 2.

Agency and Participant Demographics

Characteristics of agencies represented (n = 10)	N (%)
Agency type
State health departments	7 (70.0%)
Local health departments	3 (30.0%)
Agency organizational structure
Centralized	0 (0%)
Decentralized	9 (90.0%)
Shared	1 (10.0%)
Regions represented
Northeast	3 (30.0%)
Midwest	1 (10.0%)
South	3 (30.0%)
West	3 (30.0%)
Agency receives public health infrastructure grant (PHIG) funding
Yes	9 (90.0%)
PHIG funding unknown*	1 (10.0%)
Characteristics of participants (n = 28)
Participant role
Nonspecific human resources team member	11 (39.3%)
Director of human resources, workforce development, and talent management	6 (21.4%)
Hiring manager (e.g., program director/program manager)	4 (14.3%)
Deputy/operations administrator	4 (14.3%)
Recruitment, retention, and engagement team member	3 (10.7%)
Fellow	1 (3.6%)
Participant setting
State health department	21 (75.0%)
Local health department	7 (25.0%)
Participant sex
Women	22 (78.6%)
Men/other	6 (21.4%)

^*Note: The participants were not directly asked whether their agency received PHIG funding; however, several agencies mentioned their PHIG funding in their responses. One agency is listed as “PHIG funding unknown.”

Key findings

Findings from this study are divided into two general categories: (1) solutions or innovations for recruitment and retention, and (2) the role of hiring laws in recruitment. Solutions or innovations for recruitment and retention include activities that were identified as new initiatives by interviewees and were self-reported during the interviews to have successfully advanced the agency’s recruitment and retention efforts (Table 3). The role of hiring laws in recruitment was shared by interviewees as an ongoing challenge that offers opportunities for change (Table 4).

TABLE 3.

Solutions and/or Innovations for Recruitment and Retention

Theme and specific examples	Explanation and example quotes
Marketing Innovations	Participants discussed marketing-specific innovations that allowed them to improve recruitment practices.
Virtual Career Fair License	Obtaining and utilizing virtual career fair licenses to increase visibility and reach, particularly with students and recent graduates.
	“We were able to purchase licensing for virtual career fairs. That’s really helped cast a broad net, I would say, from a town acquisition sourcing mentality. And one instance we’ve used that is we had our oral health oral health team have hold booths, and we broadcast it out that we were holding an event where they could come and learn about the Department of Health, learn about being a dentist and or any other opportunities we may have on our oral health services team.”
Social Media	The use of social media platforms (e.g. Instagram, X (formerly Twitter)) to increase visibility and research when recruiting.
	“We have been able to use things like Facebook, Instagram, all kinds of different paid sponsored ads that we hadn’t before.”
External Online Job Platform	Posting job vacancies on job websites such as Indeed, LinkedIn, etc. to improve visibility and reach when recruiting.
	“Some of the things we’ve been able to do with the additional federal funding was access to LinkedIn Recruiter and that’s been wildly helpful for our outreach efforts. We’ve kind of really structured that around more private, or, you know, private industry recruiting strategies and some of the processes there and that’s been very helpful.”
Strategic Networks	Participants discussed networking with individuals in the healthcare sector who are nearing retirement, mitigating challenges with insurance, as a means to recruit.
	“What we have seen more success in is going to those individuals who have owned their private dentist practice for 35 years, and they’re ready to retire. Instead of retiring, they come and work for us and go back to direct patient care without having the issues of overhead, you know, insurance, all that kind of stuff. They can go back to that the reason why they went to school, and we’ve hired a lot of physicians and dentists that way, and that that’s been a success for us.”
Job Wrapping	Participants used the term “job wrapping” to describe a process by which jobs can be captured from the employer’s website and automatically posted to the online job boards where the employer wants to advertise them.
	“So we’re trying to job wrap as many different places as we can just to try to increase visibility, and over the past couple of years, I’ve had several different people in the department tell me that the number of applicants that we are seeing has increased exponentially as we’ve tried to implement some of those different things.”
Organizational Changes for Recruitment and Retention	Participants discussed changes within departments to increase and/or promote recruitment and retention of the workforce.
Use of Contract Staff	Participants discussed the use of contract staff as a means to fill positions more quickly, given the sometimes lengthy hiring processes for permanent hires.
	“..we have a certain amount of designated positions per the legislature…and those are our, you know, full time positions. And then in previous years we have had some liberty to also hire contractual employees or temporary employees of various types.”
Paid Fellowships	Participants discussed paid fellowships as a means for recruiting employees who may then transition into permanent positions.
	“So there are a number of our fellows that end up getting hired into full-time positions…they’re pretty quickly transitioning into being full-time employees. That’s essentially the job they were doing as a fellow. If they’re happy with the fellow, they have the budget to hire that fellow at the end of the fellowship, and then they convert over to a full-time hire.”
Pay for Performance Program	Participants described programs where participants, through an annual evaluation process, have the opportunity to increase their salary based on how they’ve performed in their positions over the previous year.
	“We also have pay for performance, which is an annual employee evaluation program.. So that’s another opportunity for employees to have really a direct impact on their salary, and that’s something that we’ve really tried to put a lot of focus on – those programs to where employees can directly affect the salary that they’re receiving with us.”
Salary Comparisons and Market Adjustments	The use of market research on salary to inform introductory salary ranges and raises, as well as gauge what other sectors are offering so that public health departments can remain competitive in the job market.
	“A project that was implemented from our state Department of Human Resources ..they got an external consultant company to come in and take a look at our job descriptions and try to match those the best they could to public sector positions, to try to bring our salaries more competitive to the public sector.. But they really tried to take a look at our benefits packages and different things like that, to really try to make us more competitive against the private sector folks.”
Expanded Benefits	Offering expanded benefits (e.g., education, certifications) to improve recruitment and retention of employees.
	“We’ve expanded our educational support policy, so we are providing two courses a semester for staff that’s going back to school for any type of educational degree. We’re also giving them one day off a week, up to 40 days a year for classes, homework, exams, whatever they need throughout that process, and at the completion of that they may be eligible for a 5% increase for their salary on top of their salary. We also have a continuing education program where we’re trying to cover continuing education credits that’s required for healthcare professionals such as physicians and RNs, but then that same policy will also cover initial certification. So if we have a disease intervention specialist who’s doing investigations and they want to become certified in public health, will also cover that exam and that certification fee for that person as well, on top of a prep course, if they need any books, a practice test, and then also give them a day to go take that exam. So we’re really, really trying to focus and empower our staff to really utilize the resources that we’ve got to make available to them.”
Rethinking HR to Include Workforce Development/Talent	Comments about public health departments reconsidering the scope of HR involvement to include developing the workforce and talent to improve retention.
	“But kind of prior to the pandemic, I think there was, you know, a department of HR that tended to be more focused on sort of the administrative side of sort of hiring, firing, benefits, and so on. And I feel like it’s been a new approach completely for the department to have somebody [like this group] thinking more about workforce development and talent management.”
Applicant Experience Improvement	Participants discussed changes made to job postings to increase the clarity of job positions and increase applicant interest.
Transparency in Pay	Clearer indication of salary or salary range on the job posting itself.
	“So when we post the job salary range is posted, so we have that level of transparency…we are able to narrow the range to a more realistic range, and we did that with a recent posting that we did in my team.”
Clearer Job Descriptions and Titles	The use of clearer language regarding job titles and their respective descriptions to increase applicant interest and applicant assessment of job position fit.
	“..having more specific job descriptions for the position or for the role versus the job type, like the position title, I guess I should say… I think the main the more descriptive job descriptions, making the job descriptions more specific.”

TABLE 4.

The Role of Hiring Laws in Recruitment

Theme(s)	Description and Example Quote(s)
Civil Service Exams	The general lack of clarification as to what the law means and how they are implemented varies, with most not being an “exam” at all, but rather a check of skills/ minimum qualifications.
Civil Service Exam Requirements	Participants discussed redundant, unspecific, and/or time-consuming exam requirements for applicants that may deter them from applying or completing the application.
	“So, for most of our classifications, candidates can take an online exam and then they get placed on a certification list. It’s a self-certifying list… they’re self-certifying minimum qualifications, and that’s why we have to verify on the back end of some of our exams again depending on the classification – if it’s one that’s used by all State Departments or just ours, it might be one that we administer. Not to make it even more complicated, but depending on which classification the exam process itself can look a little different because we might even have to have subject matter experts review and score those applications for a few of our classifications. Some may require some of those nuances, and maybe it’s a classification we don’t use frequently. There are some classifications where maybe we have less than 5 employees in it, so we might offer the exam just on an annual basis or twice a year, and then that becomes a challenge when all of a sudden there’s vacancies, and there’s a need, and then we need to align the vacancy, and job post dates somewhat with the exam administration process.”
Organizational and Governance Factors	Participants described that the organizational authority and hiring responsibilities are often more impactful on recruitment practices than specific components in the law.
Hiring Authority/ Systems	Participants discussed the rigidness of hiring systems that govern the hiring processes, lengthening the hiring processes.
	“There are three levels of approval above our Deputy Secretary for Public Health Services. One is the Budget and Management Office, the other is within the Operations Unit, which is lateral to The Office of Human Resources, and they also need to sign off on the position creation and then the State Department of Budget and Management also needs to sign off on position creation.”
Budget Approval	Approval of budgets for existing and new positions was a barrier to recruiting, as this often extended the process but could also create a challenge relating to the salary offered.
	“..it goes to the budget office for budget approval. If you are a hiring manager in a program, it would go to your program director or your leadership for their approval, or whatever the appointing authority, your designated kind of appointing authority person would be.”
Position Creation Processes	The process of creating new positions has lengthened the hiring process as multiple entities would often need to approve the creation.
	“There’s more work upfront because we have to determine whether or not the classification that they’ve proposed is appropriate, and so it might take more back and forth the program, looking at the duties, making recommendations. Possibly, if we don’t think it’s the appropriate classification. We go back and forth for more edits and discussions, and sometimes there are reorganizations. So if there are new positions a group of new positions. We commonly have reorganization requests, and so those packages take months to work on. There’s a lot of pre-work with the program.”
Applicant Review and Ranking/Prioritization Systems	The methods used by health departments when scoring and ranking applicants (e.g., skills, educational requirements).
	“..we would get a registry from our human resource person…once you got that registry, you would rank the however many – the top 15 to 20 – just depending on say ‘Yes, this person qualifies for an interview based on the job description and the skill set’. Then you would give that scoring back to human resources and they would give you the finalized registry of those qualified individuals with their name and their contact information and then from there we would set up interviews.”
Organizational Process Changes	Participants described automating processes, streamlined application review processes, communicating hiring timelines with applicants, and updating application portals.
Onboarding	Participants described the onboarding processes for new hires within their health departments (e.g., resources, mentorships).
	“The onboarding process can be a month or two months. I spoke to a local health department, their HR only runs the onboarding training once a month. So if you get a hiring offer right after that training, you may have to wait another month to do your onboarding.”
	“I think one thing that I really like about the county is that we use Microsoft 365 and so there’s a SharePoint Hub that our quality improvement specialists put together about a year ago and it has basically like two parts to it. One is like everything for the hiring manager, and then the other is for the person and everything is outlined what they need to do within their 1st day, their 1st week, their 1st month, their 1st 6 months. and it has all the tools and all the resources and everything that they need in order to be successful. If there’s any training videos that they have to watch, or if they have problems with their computer, we have a department immunization policy, and it has that policy link.”

Solutions or innovations for recruitment and retention

Three themes emerged as solutions and innovations for recruitment: marketing strategies, organizational changes for recruitment and retention, and applicant experience improvements. Marketing strategies involved various approaches implemented by health departments to improve recruitment efforts, such as utilizing social media platforms like Instagram, Facebook, and X (formerly Twitter), as these platforms offered a greater reach for job postings and an opportunity for health departments to highlight the value of working for their agency alongside the job posting. Participants described virtual career fair licenses as another means for health departments to broaden their reach, particularly with students and recent graduates. Furthermore, strategic networking with individuals in healthcare nearing the age of retirement, primarily those working in the private sector, was another strategy utilized by some health departments to fill hard-to-hire roles. For example, one participant shared how recruiting dentists who are nearing retirement to work a limited number of days in health department clinics or mobile outreach clinics enabled the provider to continue seeing patients without the additional administrative and other burdens that come with running their own practice. Participants also talked about “job wrapping,” which entails job listings being automatically captured from the employer’s website and simultaneously posted to selected external job boards where the employer wants to advertise open positions. This automated job posting process was perceived as ensuring real-time listings and updates across platforms without creating additional work for HR. In the same vein, participants discussed options other than job wrapping to creatively utilize external online job platforms such as LinkedIn Recruiter, Indeed, and others to increase the reach, attractiveness, and visibility of their job listings. The increased flexibility that agencies have when posting positions to external platforms (versus more stringent language guidelines in the formal position descriptions on department HR websites) enables the online platform postings to be more compelling to potential applicants via a range of approaches, including intentional usage of plain language descriptions, visuals, testimonials from current employees, and modified job titles that clarify job responsibilities and purpose.

Findings within the theme of organizational workforce development consisted of innovations to advance workforce recruitment and retention. Some health departments implemented paid fellowship programs as a way to increase the attractiveness of governmental public health employment and to more easily transition high-performing fellows into permanent positions after the conclusion of the fellowship. Others pursued contractual hiring, given the quicker timeline and greater flexibility in advertising contractual positions, along with fewer associated administrative hiring burdens. Salary comparisons and market adjustments were also used to compare the salaries offered by private sector employers with those of public health departments and to inform decisions on setting levels of compensation. Expanded benefits were another avenue that some health departments explored as a way to increase recruitment and retention, namely offering educational reimbursement that covers courses, continuing education, and certifications. Pay-for-performance programs were also implemented for some positions to incentivize and retain employees. Another strategy was to rethink HR to include workforce development and talent, thus expanding HR’s role beyond the traditional functions of recruitment, hiring, and benefits administration.

The third theme was applicant experience improvements, which included sub-themes relating to how health departments modified aspects of the application process to boost recruitment efforts, including making applicant portals more user-friendly and updating job postings to make them more compelling to desirable candidates. In particular, interviewees emphasized improved transparency in pay as a noteworthy and positive change made to job postings, whereas postings traditionally listed wide salary ranges or had no indication of compensation. Some hiring committees also made an effort to informally discuss salary early in the interview process based on the candidate’s experience and qualifications. These early informal conversations helped prevent situations where, at the end of the search process, the offered salary fell short of the candidate’s needs—potentially resulting in a failed hiring search if other candidates were no longer available. Additionally, clearer job descriptions and titles were indicated as an important change to job postings to improve clarity regarding what the position is, the responsibilities expected of a hire, and the purpose of the work. Participants also discussed the necessity of regular communication with candidates throughout the hiring process to be more transparent about the timeline and their application status.

The role of hiring laws in recruitment

Several themes emerged regarding hiring laws and their role in recruitment. These included civil service exams, organizational factors, and organizational process changes. Many state laws stipulate civil service exam requirements; however, the general lack of clarity in the laws means that the implementation and/or interpretation of these exams vary across states and positions, further complicating the hiring processes. Additionally, we found that in at least one state, while the term “exam” is included in the application process, for some positions, HR does not require any type of formal exam in their hiring process but instead uses other mechanisms to ensure that applicants possess the skills needed to perform the required job tasks (e.g., self-assessments or hiring committees reviewing education and prior work experiences). In contrast, we found that in at least one other state, a traditional exam remains a crucial step in obtaining hiring approval for a candidate. In that state, applicants are encouraged to take the exam and score high enough to be placed on a hiring eligibility list before applying to open positions. Although an applicant can technically apply to a position without taking the exam, they will not be cleared for hiring—even if prioritized by the hiring committee—because they have either not taken the exam or have not scored high enough. While technically individuals can apply without first taking the exam, the posted exam requirement likely deters some applicants from starting the process altogether and complicates and lengthens the process for those who do submit applications.

In discussions about the role of hiring laws, organizational and governance factors, such as hiring authority and systems, were perceived as more consequential to effective recruitment than specific components of the law. One example is cumbersome, outdated application platforms. If state health department HR leaders want to modernize the application platform to improve applicant experiences, the authority to do this often exists at the state personnel agency level. This means that the health department HR does not have influence over application portal changes or the way jobs are posted. Hiring authority determinations are typically written into state regulations, which would likely need legislative approval to resolve any identified challenges. Participants also described challenges and delays in obtaining required budget approvals for both new and existing positions. The position creation process, in particular, often requires additional layers of approval, which may constrain an agency’s ability to use existing funds during their available funding period. Also of note are the multi-step applicant review and ranking/prioritization systems utilized by HR and hiring committees that add additional layers to the hiring process and may limit the number of qualified applicants eligible for consideration. For example, a centralized hiring agency or agency HR team may conduct the first review of applicants and then provide a ranked list of qualified applicants to the hiring program manager or committee; yet, once the program managers or hiring committees receive the HR list of potential candidates for a more thorough review, they may determine that the candidates selected by HR do not, in fact, have the required experience or content expertise. In this type of situation, depending on the organizational rules, it can result in the program manager or hiring committee going through a longer applicant list to screen applicants again themselves to identify potential candidates. Alternatively, in some agencies, the program manager or hiring committee may need to submit additional requests and approvals to HR for permission to revisit the full pool of candidates. These multi-step processes lengthen the hiring timeline and may mean that, by the time candidates are finally contacted, they have already accepted another job. Additionally, stringent requirements regarding interview panels and processes can contribute to scheduling delays and the need for multiple rounds of interviews. All of these barriers can lengthen hiring times and increase the number of failed recruitments. As a result, an entire recruitment process must be started again, which can be demoralizing and an additional burden to all involved in the process.

Lastly, participants discussed opportunities for organizational process changes to reduce the time required to hire new staff and get them started in their new roles. In one agency, they shared that new hires have to wait for the next onboarding training provided by the state personnel agency. Thus, depending on the timing of the offer and the availability of the training, the selected candidate may have to wait weeks to start their new position, prolonging the additional burden on the existing workforce. To address this challenge, it may be beneficial for onboarding processes to be automated and supported by standardized resources for all new staff. A standardized onboarding process would ensure consistency across all new hires while also reducing wait times to start positions.

Discussion

Given the current shifts in fiscal, employment, technological, and political landscapes, coupled with ongoing and emerging public health threats, it is hard to predict future trends and needs in the public health workforce. However, what is certain is that flexibility in adapting recruitment approaches to the changing dynamics will be critical to ensuring an adequate workforce with the capacity to address foundational needs and new public health challenges. The solutions and innovations discussed in this study thus provide an opportunity to consider how such adaptations to current processes can be implemented to meet changing needs and dynamics.

Among our key findings, we identified recruitment innovations using new technologies such as job wrapping, the use of online platforms where candidates are likely to search for work, and adapting job descriptions for clarity and ease of understanding regarding the work that will be expected. Such innovations offer practical avenues for agencies experiencing challenges in reaching potential candidates and simultaneously address the restrictions related to posting language and labels in formal hiring systems. As technology continues to advance and artificial intelligence (AI) becomes more embedded into recruitment practices, these new technologies should be used to make processes more efficient and user-friendly, while also targeting applicants who are a good fit for open positions.

Developing formal pathways to hire fellows and other long-term but temporary employees provides an additional opportunity for the successful recruitment of new and already vetted employees and offers a solution to the lengthy processes involved in establishing new positions, as well as the limitations on using shorter-term (ie, one or two-year) grant funds for new full-time, permanent positions. Additionally, baby boomers retiring from their careers may create opportunities for new public health employees in their second careers. As noted in our findings, newly retired healthcare providers could potentially expand recruitment avenues for hard-to-fill public health positions by offering more flexibility and reducing administrative burdens. Furthermore, our findings indicate that innovations such as pay-for-performance, expanded benefits, and education reimbursement may support employee retention by incentivizing workers and making governmental public health employment more appealing.

In considering the findings concerning hiring laws, where feasible, organizations should make improvements to processes and systems that are inefficient. Much of this can be achieved through quality improvement initiatives rather than legal or regulatory changes, but an essential step is tracking the hiring process and working to understand where inefficiencies exist, as our findings indicate that these likely differ across agencies and states. Finding ways to shorten the time to review applicants and improve communication with applicants throughout the hiring process may result in more successful recruitment efforts. A few states have instituted civil service rule changes that include removing ranked hiring lists to facilitate flexibility for hiring managers.34 Simplifying the applicant review process may also be less time-consuming and burdensome for the staff involved in recruitment. Staff spoke of many failed job searches, which required additional recruitment processes. More successful recruitment would allow staff to spend less time recruiting and more time on their other responsibilities. While civil service/merit requirements were not commonly identified as the specific reasons for slow hiring processes, the lack of clarity in explaining when exams are required and what an exam entails may deter some candidates from applying for government positions that mention civil service exams. Previous studies have documented that a number of states have moved toward more at-will employment positions (employees can be terminated at any time for any reason) and, as such, underscore the need for attention to changing dynamics that may impact the labor market, recruitment practices, and approaches for public health agencies.34-36

The solutions and innovations shared in this study offer perceived successful practices to advance current recruitment efforts, as well as models for adjusting and updating recruitment practices to meet ongoing needs and changing expectations of job seekers. In general, the findings presented in this study highlight some of the early achievements and the importance of the PHIG efforts, which had been underway for a year or more at the time of this study’s interviews. In fact, respondents shared that they had used PHIG funding to facilitate some of the innovations highlighted in our findings, including costs associated with fee-based job wrapping services and features of online hiring platforms, expanding HR team roles such as creating talent management and workforce development positions, and funding paid fellowship programs. However, as health departments are often constrained by a patchwork of limited funds, we found that the PHIG funds were frequently braided together with other funding mechanisms to support innovative programming.

Limitations

Interviewees held diverse roles within their agencies, offering a broad range of perspectives shaped by different experiences. However, this meant that interviewees were not informed by the same experiences, and some of the participants were relatively new in their roles, which may have limited their familiarity with existing or planned workforce strategies and innovations. Additionally, since participants in this study were exclusively hiring personnel, the findings do not address the experiences and perspectives of applicants and new hires. Future research should examine the experiences of applicants. It is also worth noting that evolving job market conditions, including changes in labor demand and hiring practices, may have contributed to varying levels of knowledge about workforce development and recruitment strategies. Although we worked to ensure the representation of different governmental public health agencies in the sample (eg, centralized/decentralized/shared governance, region of agency, etc.), generalizability remains a limitation. Lastly, while the qualitative approach and limited sample size do not facilitate the systematic analysis of the relationship between themes and organizational/participant characteristics, future research may explore these themes further.

Implications for Policy & Practice

• PHIG funding and programming have led to recruitment innovations.

• Flexibility in adapting recruitment approaches to changing workforce and labor market dynamics is critical to ensuring an adequate workforce with the capacity to address foundational needs and public health challenges.

• The solutions and innovations discussed in this study provide an opportunity to consider how such adaptations to current processes can be implemented to meet changing needs and dynamics.

• Implementing pay-for-performance models, expanding benefits, and providing education reimbursement may help address compensation challenges.