The Price of Dedication: An Analysis of Wage Trajectories in State and Local Public Health From 2017 to 2024

Abstract

Context:

Salary plays a crucial role in recruiting and retaining employees in public health; however, information about trends in compensation is limited.

Objective:

To analyze trends in earnings among state and local governmental public health workers between 2017 and 2024.

Methods:

Data used are from the Public Health Workforce Interests and Needs Survey for the years 2017, 2021, and 2024. The analytic sample comprised 34 379 full-time permanent employees with complete salary data in 2017, 32 862 in 2021, and 45 241 in 2024, representing state health agency (SHA) and local health department (LHD) public health workers in each respective year. We performed a multi-cross-sectional analysis using descriptive and bivariate analyses and interval-based regression techniques to explore relationships between annualized earnings and key individual and agency-level characteristics.

Results:

Earning patterns in 2024 were largely consistent with historical patterns. Individual and agency-level characteristics continued to play a significant role in shaping salary. Higher salaries remained associated with higher supervisory status, longer tenure, higher educational attainment, salaried (versus hourly) employment, union/bargaining unit representation, and employment setting within SHAs versus LHDs. Between 2017 and 2024, annual earnings for full-time permanent employees increased from $57 817 in 2017 to $73 299 in 2024, representing a 27% average increase of $15 482. However, when adjusted for inflation, annual wages showed no real growth, indicating that earnings remained largely stable in terms of purchasing power during this timeframe. Subgroups that experienced declines in inflation-adjusted salaries between 2017 and 2024 include executives, employees with longer tenures, employees with doctoral degrees, and employees with public health degrees versus degrees in other fields.

Conclusions:

The continued decline in inflation-adjusted earnings for certain groups and persistent gender and racial pay gaps indicate that without targeted interventions, public health agencies may face challenges in retaining experienced professionals, attracting new talent, and ensuring workforce stability.

Introduction

The public health workforce continues to face persistent challenges related to recruitment and retention.1-7 These challenges have significant implications for the effectiveness and resilience of the public health system, especially during public health emergencies when a stable and skilled workforce is most critical. Despite efforts to strengthen governmental public health capabilities, particularly through strategies aimed at strengthening the workforce, many agencies continue to face high turnover rates and difficulties filling essential roles.1,8-11

Dissatisfaction with pay is a central factor driving these workforce challenges. Public health professionals frequently cite pay dissatisfaction as a key consideration in their intention to leave their current position.4-6,12-18 Additionally, public health leaders have reported that salaries are a significant barrier to recruiting new employees.19-21 Specifically, a 2021 study found that the lack of competitive salaries – often due to civil service guidelines or rules and sometimes union negotiations – was one of the biggest factors that deterred public health graduates from seeking work in governmental public health.22

This issue is especially pronounced when comparing salaries in governmental public health to those in other sectors. A study using 2022-2023 data found that over half of governmental public health occupations analyzed paid their employees significantly less than the private sector. Occupations with the largest pay differences included Chief Executives, Computer Systems Analysts, Healthcare Social Workers, Registered Nurses, and other critical roles.23 Notably, nurses made roughly 44% less and IT staff made roughly 50% less in governmental public health than in the private sector.23 These findings align with a related study that used data from the 2017 Public Health Workforce Interests and Needs Survey (PH WINS). It identified a pay gap between state health agency (SHA) employees and their respective state averages for individuals in nursing and epidemiology.24 These pay gaps created a competitive disadvantage for public health agencies, leading to an ongoing struggle to recruit and retain talent with more lucrative salaries elsewhere. As a result, practitioners and scholars have emphasized that enhancing the public health workforce will require improving pay.25,26

Data from PH WINS provides an opportunity to examine the salaries of governmental public health employees and explore earning trajectories over time. Specifically, this study aims to examine the levels of and trends in salaries among state and local governmental public health workers between 2017 and 2024, thus building on prior work in the field.27,28 By analyzing recent trends in compensation, this study aims to assess the degree to which there has been progress in improving pay among governmental public health employees. Findings from this study will be of interest to public health leaders and individuals tasked with leading workforce recruitment and retention initiatives at both the state and local levels.

Methods

Data and Sample

Data used in the analyses for this study came from the PH WINS. It was developed by the de Beaumont Foundation and the Association of State and Territorial Health Officials to understand the interests and needs of the state and local government public health workforce in the United States, and was fielded in 2014, 2017, 2021, and 2024. This study drew on data from PH WINS for the years 2017, 2021, and 2024. Data from 2014 were excluded due to differences in sampling.

In 2017, PH WINS was distributed to 102 305 public health workers across 47 SHAs and 612 local health departments (LHDs) in 47 states, yielding 47 604 responses and a 48% response rate.29 The 2021 survey expanded its reach, targeting 137 446 individuals in 47 SHAs and 744 LHDs across 48 states, with 44 732 employees completing the survey for a 35% response rate.30 Building on this expansion, the 2024 cycle further increased its scope, reaching 159 627 workers in 48 SHAs and 1178 LHDs across 49 states, resulting in 56 595 responses and a 37% response rate.31

In PH WINS, LHDs were categorized based on staff size and population served: small LHDs were defined as agencies with fewer than 25 employees or serving populations under 25 000; medium LHDs had more than 25 employees and served populations between 25 000 and 250 000; and large LHDs had more than 25 employees and served populations exceeding 250 000. For the purpose of this study, employees of small LHDs were excluded due to the lack of nationally representative samples of small LHDs in both 2017 and 2021, rendering cross-year comparisons incompatible. This resulted in the exclusion of 2540 observations in 2017, 1803 observations in 2021, and 2584 observations in 2024.The study sample was further restricted to full-time permanent employees with complete salary data. Individuals who selected “Other” as their job position were excluded due to insufficient sample sizes for meaningful analysis. The final analytic sample comprised 34 379 employees in 2017, 32 862 in 2021, and 45 241 in 2024, representing full-time permanent state and local government public health workers in each respective year.

Measures

This study analyzed trends in annual earnings among full-time permanent public health employees in state and local governments over time. For this purpose, an annualized earnings estimate was constructed for each respondent in each survey year, aligning with the approaches employed in previous work.27,28 Respondents who earned a salary were asked to indicate their annual earnings in $10 000 interval options beginning at $25 000 and ending at $145 000. For the purpose of this study, respondents with annual salaries lower than $25 000 and greater than $145 000 were excluded from the analyses. For respondents who were paid on an hourly basis, hourly wages were converted to annual earnings using the assumption that full-time employees work 2000 hours per year. For the descriptive and bivariate analyses, earning intervals were converted into a point estimate equal to the mid-point of the respective wage interval. To allow for comparability of earnings over time, earnings from 2017 and 2021 were adjusted to 2024 dollars (ie, inflation adjusted) using the Consumer Price Index developed by the US Bureau of Labor Statistics.

In line with prior work, independent variables of interest for this study included both individual and agency-level characteristics.27,28 Individual employee characteristics selected for the analyses included supervisory status, tenure in public health, gender, race/ethnicity, educational attainment, job classification, paid salary or hourly wage, and representation by a union/bargaining unit.

Supervisory status was defined as non-supervisor, supervisor, manager, or executive. Tenure was defined in intervals (0-5, 6-10, 11-15, 16-20, 21+ years) representing a respondent’s time in public health practice. Gender was defined as women versus all others. Race/ethnicity was defined as white versus person of color. Educational attainment was defined as highest degree attained (no college degree, associate’s degree, bachelor’s degree, master’s degree, doctoral degree) and whether the degree was in public health or another field. Job classification was defined as administrative and leadership; clinical, behavioral, and social services; and public health sciences (for more detail on the job types included in each of the of the 3 job classifications, see Supplemental Digital Content Appendix Table 1, available at http://links.lww.com/JPHMP/B573).

Agency characteristics included agency setting, defined by whether the respondent worked in a SHA central office (SHA-CO), large LHD, or medium LHD, and geographic region using Department of Health and Human Services (HHS) Regions.

Analytical Strategy

Descriptive and bivariate analysis was conducted to describe annualized earnings of state and local public health employees in 2024 and explore trends in earnings between 2017 and 2024. Given previous work suggesting systematic differences in earnings related to both individual and agency-level characteristics, interval regression analysis was conducted to examine factors associated with annualized earnings in 2024.27,28 Balanced repeated replication weights were used to correctly calculate variance estimates, given the complex sampling design.

Results

Earning Patterns in 2024

Bivariate Findings. In 2024, both mean and median annualized earnings among full-time permanent public health employees fell into the $65 000 to $75 000 range (Table 1). However, annual salaries varied considerably. Almost 16 percent of the public health workforce made more than $105 000 a year, while over one-quarter made less than $55 000.

TABLE 1.

Annualized Earnings Among State and Local Public Health Practitioners, 2024

Annualized earnings	Estimate	95% confidence interval
<$25 000a	0.3%	0.2-0.3
$25 000-$35 000	3.3%	3.1-3.5
$35 001-$45 000	10.0%	9.6-10.4
$45 001-$55 000	13.1%	12.8-13.4
$55 001-$65 000	14.6%	14.2-15.0
$65 001-$75 000	14.3%	13.8-14.8
$75 001-$85 000	11.8%	11.4-12.2
$85 001-$95 000	9.0%	8.8-9.3
$95 001-$105 000	7.8%	7.5-8.2
$105 001-$115 000	5.3%	5.0-5.7
$115 001-$125 000	3.6%	3.4-3.8
$125 001-$135 000	2.1%	1.9-2.3
$135 001-$145 000	1.5%	1.4-1.7
>$145 000a	3.3%	3.1-3.6
Supervisory status
Nonsupervisor	$66 735	$66 304-$67 166
Supervisor	$83 010	$82 252-$83 768
Manager	$98 489	$97 653-$99 324
Executive	$110 212	$108 547-$111 878
Tenure in public health, years
0-5	$65 787	$65 202-$66 373
6-10	$75 254	$74 454-$76 055
11-15	$78 764	$77 476-$90 052
16-20	$79 955	$79 350-$80 560
	$82 599	$81 911-$83 287
Gender
Female	$72 161	$71 735-$72 587
All other	$77 438	$76 463-$78 412
Race/ethnicity
White	$74 455	$74 011-$74 898
Person of color	$71 510	$70 640-$72 379
Highest level of educational attainment
No college degree	$52 345	$51 843-$52 484
Associate’s degree	$61 066	$60 297-$61 835
Bachelor’s degree	$73 650	$73 163-$74 137
Master’s degree	$84 427	$83 554-$85 300
Doctoral degree	$99 673	$98 305-$101 041
Public health degree
Yes	$79 548	$78 567-$80 529
No	$71 575	$71 166-$71 984
Position type
Administrative staff and leadership	$68 761	$67 909-$69 613
Clinical, behavioral, and social services	$73 714	$72 983-$74 445
Public health sciences	$75 958	$75 440-$76 475
Paid as salary vs hourly
Salary	$78 302	$77 744-$78 859
Hourly	$66 020	$65 585-$66 455
Part of union/collective bargaining
Yes	$79 339	$78 843-$79 835
No	$69 800	$69 207-$70 394
Agency type
SHA Central Office	$80 395	$79 973-$80 817
Large LHD	$73 372	$72 653-$74 091
Medium LHD	$63 721	$63 161-$64 281
HHS region
Regions 1 and 2	$81 495	$79 767-$83 223
Region 3	$73 080	$72 079-$74 081
Region 4	$61 931	$61 335-$62 506
Region 5	$72 335	$71 709-$72 961
Region 6	$62 228	$61 762-$62 695
Region 7	$62 028	$61 023-$63 032
Region 8	$74 491	$73 562-$75 419
Region 9	$83 731	$82 555-$84 908
Region 10	$85 169	$83 643-$86 696

Notes: This table shows bivariate comparisons of annualized earnings for full-time permanent staff in state and local public health agencies. The point estimates are approximated by converting responses in equidistant intervals to dollars.

Abbreviations: SHA, State Health Agency; LHD, local health department; HHS, Department of Health and Human Services.

^aRespondents with annualized earnings of less than $25 000 and more than $145 000 were excluded from all analyses.

As in previous years, meaningful differences in earnings were found across both individual employee characteristics and the characteristics of the agency for which the employee worked.27,28 Nationally, nonsupervisory staff earned an average of about $67 000 in 2024. Supervisory staff, which included supervisors, managers, and executives, reported substantially greater earnings than nonsupervisory staff. On average, supervisors earned approximately $83 000 in 2024, whereas managers and executives reported average earnings of $98 000 and $110 000, respectively. Tenure in public health was directly associated with annual earnings. Employees who had worked in public health the longest (>20 years) reported average annual salaries of almost $83 000 while those who worked in public health for 0 to 5 years reported average salaries of less than $66 000. Women earned $72 000 on average compared to $77 000 for all others. White employees earned $74 000 on average, while employees of color earned $72 000.

Education and position type also mattered for annual earnings. Employees with a doctoral degree as their highest level of education earned almost $100 000 on average, compared with average annual salaries of $52 000 for employees without a college degree, $61 000 for employees with an associate’s degree, $74 000 for employees with a bachelor’s degree, and $84 000 for employees with a master’s degree. Employees with a degree in public health earned on average almost $80 000 a year while employees without a degree in public health earned an average of less than $72 000. Degrees in areas other than public health included degrees in medicine, pharmacy, nursing, social work, business, law, public administration, among others.

The type of role that employees had also impacted their annual salaries. Staff in public health sciences earned almost $76 000 on average compared to $69 000 for staff in administration and leadership roles and $74 000 for staff in clinical, behavioral, and social services. Employees who are paid annual salaries earned $78 000 on average compared to $66 000 for employees paid hourly wages. Employees represented by unions earned $79 000 on average while those not represented by unions averaged $70 000 in annual salaries.

Finally, agency types and geographic location mattered greatly. Employees in SHA central offices earned an average of $80 000 per year, while employees in large and medium LHDs earned $73 000 and $64 000, respectively. Average annual salaries were highest in HHS Region 10 ($85 000) and lowest in HHS Regions 4, 6, and 7 ($62 000).

Multivariate Findings. Interval regression results revealed that employees with higher supervisory status earned significantly higher annual salaries (Supplemental Digital Content Appendix Table 2, available at http://links.lww.com/JPHMP/B574). Compared with employees without supervisory roles, supervisors earned approximately $11 600 more on average, managers earned approximately $24 500 more, and executives earned approximately $38 400 more, all else equal. Tenure in public health was also associated with significantly higher earnings. Compared to employees with 0 to 5 years of tenure, employees with more than 20 years earned $11 200 more per year. Women earned on average $1500 less per year than all others and being a person of color was associated with earning $2600 less than white employees, all else equal. Higher educational attainment was also associated with significantly higher earnings, yet having a public health degree was associated with $3500 less in annual earnings compared to a degree in another area, all else equal. Employees in clinical, behavioral, and social services roles earned $8000 more than employees in administrative and leadership roles. Employees with salaried employment and union (bargaining unit) positions had significantly higher annual salaries as did employees who worked in SHA-COs. There were also noticeable regional associations in average annual earnings.

Trends in Earnings Between 2017 and 2024

Annual earnings for full-time permanent public health employees rose from $57 817 in 2017 to $64 280 in 2021, and further to $73 299 in 2024 (Supplemental Digital Content Appendix Table 3, available at http://links.lww.com/JPHMP/B575). This represents an average increase of $15 482, or 27%, over the period from 2017 to 2024. However, when adjusted for inflation, annual wages showed a small decline (−$994, or −1%), indicating that earnings in public health remained largely stable in terms of purchasing power during this timeframe.

A closer examination of trends in earnings showed that all subgroups of public health employees examined in this study experienced significant growth in nominal salaries and wages (Figure 1 and Supplemental Digital Content Appendix Table 3, available at http://links.lww.com/JPHMP/B575). However, when adjusted for inflation, the findings are more complex. While most subgroups saw stagnant wages, several subgroups experienced declines in inflation-adjusted earnings between 2017 and 2024.

FIGURE 1.

Changes in Nominal and Inflation-Adjusted Annual Earnings among State and Local Public Health Practitioners, 2017-2024.

Notes: All changes in nominal annual earnings are statistically significant at P < .05. * indicates subgroups for which inflation-adjusted annual earnings are statistically significant at P < .05.

Abbreviations: LHD, local health department; SHA, state health agency.

While employees in non-supervisory roles, supervisors, and managers maintained relatively stable annual wages, executives reported a statistically significant decline of approximately $12 000 (−10%) in inflation-adjusted annual earnings between 2017 and 2024. Tenure in public health also played a role with employees with 6 to 15 years reporting significantly higher inflation-adjusted wages in 2024 than 2017 than employees with less than 6 years or more than 15 years of tenure. Women’s inflation-adjusted annual salaries remained unchanged during the 2017 to 2024 period, yet the salaries of all other genders decreased by a statistically significant $4700 (−6%). Likewise, white employees experienced a statistically significant average decline of almost $1700 (−3%) in annual earnings, whereas earnings for employees of color remained stable.

Employees with doctoral degrees and those with a degree in public health faced significant average decreases in inflation-adjusted annual salaries of $8400 (−8%) and $7500 (−9%), respectively compared to other degree holders. Job classification was another factor that played a role in the trajectory of annual earnings. Salaries for employees in administrative and leadership roles as well as clinical, behavioral, and social services remained relatively flat, while those in public health science roles experienced a statistically significant decline of $3200 (−4%).

Earnings Trajectories in State Versus Local Health Departments

Salary trajectories differed noticeably between state and local health departments. Employees in SHAs saw an average increase of $1200 (2%) in their inflation-adjusted annual salaries between 2017 and 2024, whereas annual salaries for employees in LHDs remained essentially flat.

Further analysis of trends in inflation-adjusted annual salaries, categorized by employees’ supervisory status, revealed that executives faced statistically significant declines in earnings across all 3 settings (Figure 2). The only subgroup that saw significant increases in earnings comprised employees in non-supervisory roles within SHAs.

FIGURE 2.

Changes in Inflation-Adjusted Annual Earnings among State and Local Public Health Practitioners, by Supervisory Status and Setting, 2017-2024.

Notes: * indicates subgroups for which inflation-adjusted annual earnings are statistically significant at P < .05.

Abbreviations: LHD, local health department; SHA, state health agency.

An analysis of trends in inflation-adjusted annual earnings based on employees’ tenure in public health practice indicated that statistically significant salary increases were observed only among employees in SHAs with less than 16 years of tenure and those in medium-sized LHDs with 6 to 15 years of tenure (Figure 3). For employees in large LHDs and those with 16 or more years of tenure, annual earnings largely remained stagnant, regardless of their setting.

FIGURE 3.

Changes in Inflation-Adjusted Annual Earnings among State and Local Public Health Practitioners, by Tenure in Public Health and Setting, 2017-2024.

Notes: * indicates subgroups for which inflation-adjusted annual earnings are statistically significant at P < .05.

Abbreviations: LHD, local health department; SHA, state health agency.

Irrespective of setting, reductions in inflation-adjusted earnings were concentrated among employees with advanced degrees, most prominently doctoral degrees (Figure 4). All other subgroups of employees experienced stagnant salaries with the exception of employees in SHA-COs who saw small increases in average inflation-adjusted annual earnings between 2017 and 2024.

FIGURE 4.

Changes in Inflation-Adjusted Annual Earnings among State and Local Public Health Practitioners, by Degree and Setting, 2017-2024.

Notes: * indicates subgroups for which inflation-adjusted annual earnings are statistically significant at P < .05.

Abbreviations: LHD, local health department; SHA, state health agency.

Further analysis of trends in inflation-adjusted annual salaries based on employees’ educational attainment – bachelor’s, master’s, or doctoral degree – reveals that employees with degrees in public health faced declines in inflation-adjusted annual salaries regardless of work setting (Supplemental Digital Content Appendix Figure, available at http://links.lww.com/JPHMP/B572). Employees holding doctoral degrees faced the most significant decreases, a trend that was observed among individuals with doctoral degrees in both public health and other fields of study. The only groups that experienced statistically significant salary increases were those with non-public health bachelor’s degrees working in SHA central offices.

Discussion

The public health workforce faces persistent recruitment and retention challenges.1-7 A key driver of these challenges is dissatisfaction with pay, frequently cited by public health professionals as a reason for considering leaving their positions and as a barrier to hiring prospective employees.4-6,12-22 Governmental public health salaries often lag behind those in the private sector, especially in critical roles such as nursing, IT, and executive leadership, creating a competitive disadvantage.23,24 Improving compensation has been widely recognized as an essential pathway to strengthen the workforce.25,26 This study uses data from the 2017, 2021, and 2024 PH WINS surveys to provide new insights about salary characteristics and trends among governmental public health workers from 2017 to 2024.

Between 2017 and 2024, the US economic landscape underwent significant transformations, primarily driven by the COVID-19 pandemic, which led to record-high inflation. Overall, salaries for state and local governmental public health workers have generally increased throughout the study period; however, they have not consistently kept pace with inflation, which is consistent with other US workers.32 In fact, starting in 2021, US workers saw declines in their real wages or the purchasing power of their wages. Real wages only began to increase again in 2023.33 Similar to our findings for public health workers, estimates show that between 2017 and 2024, real wages for US workers overall increased by less than 2%.34 For public health workers, the finding that inflation-adjusted wages remained largely the same throughout the COVID-19 pandemic is a particular conundrum as the COVID-19 pandemic response resulted in never before seen financial investments in public health, supporting the federal, state and local governmental responses. Many LHDs experienced significant inflows of funding during the pandemic, which in addition to hiring additional staff and investments in technology infrastructure does not seem to have translated into higher salaries.

Moreover, study findings indicate that there are variations in how the wages of the public health workforce have been changing. More specifically, individuals with public health degrees earned less in 2024 than in 2017 after adjusting for inflation. Additionally, executives, long-tenured employees, and those holding doctoral degrees reported decreases in inflation-adjusted salaries. These patterns have the potential to negatively impact retention within public health agencies. This is particularly worrisome given the role of individuals with public health degrees as they often provide crucial skills and competencies.35,36 While this finding warrants further investigation to understand what factors are influencing these outcomes, it might be that there is a surplus of people earning public health degrees, increasing supply and consequently pushing wages down. Findings from this study also indicate that public health workforce earnings are largely consistent with historical patterns.27,28 Individual and agency-level characteristics continue to play a significant role in shaping salary. In bivariate analyses, higher salaries remain associated with higher supervisory status, longer tenure in public health practice, higher levels of educational attainment, salaried (versus hourly) employment, union/bargaining unit representation, and employment setting within SHA-CO versus LHDs. One notable finding is that the salary increase between those with very few years of experience compared to those with over 20 years of experience is relatively small, which might point to wage compression issues with younger and less experienced workers being paid relatively more or wage increases being so small that added years of experience do very little to garner any salary increase.

Persistent disparities in salary by gender and race continue to raise concerns about pay equity within the governmental public health workforce. Between 2017 and 2024, women’s inflation-adjusted earnings remained constant while earnings for all others declined by approximately $4700. Despite this, women who represent the majority of the public health workforce continue to earn less than other genders.27,28 The inflation-adjusted earnings of white employees declined by an average of $1700 during this period, while earnings for employees of color remained stable. Still, racial disparities in pay also persist, with employees of color continuing to earn less on average than white employees.27,28 These contrasting trends suggest a potential shift in pay equity, although further examination is necessary to determine whether these changes reflect meaningful progress.

Salary trajectories were found to vary significantly by setting. Employees in SHA-COs experienced modest increases in salary, whereas those in LHDs, especially within large LHDs, often saw declines. Salary trajectories may be shaped by how governmental public health agencies manage staffing and compensation amid ongoing financial pressures. Both SHAs and LHDs face fiscal constraints that can impact their ability to offer competitive salaries, particularly in comparison to the private sector.25,37,38 These financial limitations may reduce their flexibility to adjust salaries in response to inflation or market competition. As such, efforts to address compensation challenges must be tailored to the specific fiscal and organizational contexts of different governmental public health settings. Some health departments are using periodic market salary assessments to inform considerations on salary adjustments as feasible for agency budgets.39

Union representation was found to be associated with financial benefits for public health employees. In 2024, unionized workers earned an average annual salary of $79 000, compared to $70 000 for their non-unionized counterparts. This pay differential illustrates the potential that unions create in reducing wage disparities and advocating for more competitive compensation packages. Unionized environments have also been shown to offer additional benefits beyond salary, such as higher benefit standards, working hours limits, and workplace hazards protections.40 As public health agencies seek to strengthen workforce recruitment and retention, expanding or supporting union representation may be an important strategy to ensure fair compensation.

The findings from PH WINS 2024 provide an updated view of compensation within governmental public health. Before adjusting for inflation, the bivariate analyses show that salaries and wages increased from 2017 to 2024. During this period, however, inflation has fluctuated in the United States, peaking in 2022, painting a different picture of inflation-adjusted wage growth over time. The continued decline in inflation-adjusted earnings for certain groups and persistent gender and racial pay gaps signal that, without targeted interventions, public health agencies may struggle to retain experienced professionals and attract new talent. Additionally, the variations in salary trajectories across different public health settings highlight the need for tailored approaches to compensation, particularly in organizations with more constrained budgets. To ensure workforce stability, future strategies must focus on equitable pay structures, greater support for advanced credentials, and enhanced union representation where applicable.

Limitations

This study has several limitations that must be considered when interpreting the findings. First, the earnings data are self-reported, which likely includes some inaccuracies resulting from not recalling exact earnings, rounding of answers, or intentionally misreporting earnings due to social desirability bias. Additionally, questions about earnings often have higher non-response rates because of their sensitive nature. To improve response rates, PH WINS uses income intervals rather than exact figures. While interval data are less precise, the equidistant scales and large sample size of PH WINS allowed for conversion of intervals to dollar estimates for easier interpretation.

A second limitation is that PH WINS collects information only on earnings from salary or wages, excluding fringe benefits and potential overtime. Since both benefit packages and overtime can vary significantly across agencies, the absence of this information prevented us from conducting a comprehensive analysis of total compensation for state and local public health employees during the study period.

Third, unlike prior work,27 this study utilized de-identified data, meaning the analyses did not adjust salary and wage information to account for variations in the cost of living across different US communities. In a perfect world, wages need to be adjusted for the cost of living to allow for an apples-to-apples comparison. Without such an adjustment, earnings might appear higher or lower than they actually are in terms of purchasing power and comparisons might be misleading.

Forth, due to data limitations, this study excluded wage data from small LHDs. Small LHDs differ from medium and large LHDs on a number of key characteristics and often serve rural and underserved communities. In many states, a large percentage of LHDs meet the definition of a small LHD so the findings presented in this study might not apply to these agencies and states. Future work is needed to explore wage trajectories in small agencies to explore how wages have changed for employees in these agencies and compare trends across jurisdiction sizes. Finally, PH WINS is a cross-sectional survey, which limits its ability to track changes in earnings over time at the individual level and requires aggregate comparisons across years. Consequently, trend analyses are restricted to descriptive and bivariate examinations, preventing insights into earnings trajectories or longitudinal patterns. A more complete analysis would include longitudinal data to capture variations in individual employees’ compensation over time.

Implications for Policy & Practice

• Integrating inflation forecasts into budget planning: Public health agencies should advocate for multi-year funding models that anticipate inflationary pressures, ensuring that compensation remains sustainable over time.

• Conducting regular compensation benchmarking: Comparing public health salaries to those in healthcare, academia, and the nonprofit sector provides an evidence base for salary adjustments and helps maintain competitiveness.

• Establishing transparent salary structures: Pay scales that include inflation-indexed baselines and stepwise increases promote equity, predictability, and morale within the workforce.

• Using workforce data to support policy change: Turnover rates, recruitment delays, and staffing gaps should be systematically tracked and used to inform budget requests and legislative advocacy.

• Supporting collective workforce advocacy: Departments can benefit from engaging in or facilitating collective bargaining processes, which are associated with more consistent and inflation-responsive compensation policies.