Enumeration and Composition of the Public Health Workforce: Challenges and Strategies

Abstract

The field of public health needs a comprehensive classification data system that provides a better assessment of the size and composition of its workforce. Such a data system is necessary for understanding the capacity, trend projections, and policy development critical to the future workforce.

Previous enumeration and composition studies on the public health workforce have been helpful, but the methodology used needs further improvements in standardization, specificity, data storage, and data availability. Resolving this issue should follow a consensus-based course of action that includes public and private stakeholders at the national, state, and local level.

This prime issue should be addressed now, particularly in the current environment of comprehensive health care reform.

THE FIELD OF PUBLIC HEALTH and its workforce have been persistently challenged by an unclear definition of boundaries of knowledge, expertise, and practice. These attributes lead to a corresponding lack of clarity of the public health workforce size (enumeration) and composition. Furthermore, other information on the public health workforce such as education and training, wages, turnover rates, and mobility across states is not regularly collected and available for comprehensive and comparative analysis and policy development.

Central to this issue is the lack of a consensus-based, comprehensive, standardized classification (taxonomic) data system that provides a relevant and validated characterization of the public health workforce.^1–4 Although there have been significant efforts to enumerate and garner a better characterization of the public health workforce, multiple gaps remain in specificity of the public health workforce and in the placement of this information in a suitable data repository for common use. Moreover, current circumstances—that is, alerts of workforce shortages in public health and other health professions (some based on limited estimated data), fears surrounding formidable rising health care costs, and recent passage by Congress of comprehensive health care reform initiatives—are provoking an escalating need to examine the public health apparatus and, in particular, the supply and needs or demands of the public health workforce.

I examine these challenges in developing a valid classification data system that could be a significant tool to understand, monitor, and provide direction to the workforce. An underlying purpose is to stimulate a sense of urgency and call for leadership to bring consensual action to bear in this matter.

SURVEYS AND STUDIES ON ENUMERATION AND COMPOSITION

Enumeration and composition of the public health workforce have been examined at the local, state, and national levels in several previous surveys and studies that used a variety of methodologies.² I briefly describe the analytical approaches, results, and limitations of data and interpretations from several representative contemporary studies and surveys.

The Public Health Workforce Enumeration 2000 study sponsored by the Health Resources and Services Administration (HRSA) and produced by the Center for Health Policy at the Columbia University School of Nursing is the most recent comprehensive best-estimate analysis of the workforce in the past 3 decades.⁵ The methodology included a secondary analysis of existing workforce reports, summaries, and information from principal health officials, public health academic institutions, other public health organizations, and federal agencies. The findings indicated a US public health workforce of 448 254 salaried positions, making a workforce-to-population ratio of 1 to 635. The breakdown of positions in this workforce consisted of the following: official/administrative (3.6%), professional (44.6%), technical (13.9%), and clerical/support (12.9%). It is striking and worrisome that a large portion, 25% of the estimated public health workforce, could not be assigned to a specific occupational category. Analyzed according to organizations or settings, the workforce included 13% local, 33% state, 19% federal, and 14% located in academic institutions or other sites. The study acknowledged long-standing problems with the inconsistencies, gaps, or nonspecificity in existing occupational classifications by specific job functions, job setting, and educational requirements. Significant problems also were noted with the lack of uniformity across organizations and states and the general lack of licensure or certification instruments in public health disciplines.

Two decades earlier, another national study⁶ reported an estimated public health workforce of 500 000, indicating a ratio of 219 workers per 100 000 population (or 1:456). Comparing these 2 national studies has limitations because of differences in the types of public health workers counted and comprehensiveness of the data, but these findings have been interpreted to indicate a significantly reduced US public health workforce per population in 2000 compared with that in 1980.⁷

Several surveys and studies of the public health workforce also have been conducted on an individual statewide basis, by regional or selected groups of states (often led by the Association of State and Territorial Health Officials),^8,9 by universities (often led by HRSA-supported Centers for Health Workforce Studies),^10–14 and by local health departments (often with their state or national health organization, the National Association of County and City Health Officials).^15–18 Some of these and other studies have focused on public health specialties such as epidemiologists, public health laboratory personnel, and public health physicians and nurses.^19–21

In a large-scale enumeration study, Kennedy et al.²² used a labor-intensive American Public Health Association methodology to enumerate public health personnel in Texas on the basis of a combination of public health–relevant work settings, work content, and positions.^23,24 The study consisted of 2 stages, 1 involving a survey of employers and organizations of population-based public health services and a second survey targeting the individual employees of these employers and organizations.

The Texas study and the other surveys and studies grouped by national, state, university, and local settings referenced earlier in this section provided a valuable understanding of major issues and trends within the workforce. These issues and trends included increased aging of personnel, inadequacies and variability in educational preparation, geographic maldistribution, and insufficiency in racial/ethnic diversity. Shortages also were noted in public health nurses, public health physicians, environmental scientists, health educators, epidemiologists, administrators, health analysts, and others. Nonetheless, major limitations exist in interpreting the data from these surveys and studies because of the variability across workforce settings, state and local health department relationships, range of services, and methodology.

RELATED INSTITUTIONALIZED DATABASES

A large civilian workforce data system, the Standard Occupational Classification System, is housed in the Bureau of Labor Statistics, a branch of the federal Department of Labor.²⁵ Oversight is provided by the US Office of Management and Budget. The data system was established so that comparable occupational data among federal agencies and private industry could be collected, stored, and analyzed, reflecting the current occupational structure in the United States. Regular classification revisions or adjustments of the Standard Occupational Classification System are tied to the decennial census. The system consists of a taxonomic scheme that focuses on title and functional roles and responsibilities but pays less attention to education and training characteristics. Its classification system is stratified into 4 groupings: major groups, minor groups, broad occupations, and detailed occupations.

To date, the public health workforce has had limited involvement with the Standard Occupational Classification System. Of the 840 detailed occupations currently in the Standard Occupational Classification System, an estimated 95 have health-related titles. However, the majority of those 95 are not public health–specific occupational titles. As an example, for the taxonomic structure of the “Physician” occupational title, one must go through the broader groups “Healthcare Practitioners and Technical Occupations,” followed by “Health Diagnosing and Treating Practitioners,” then “Physicians and Surgeons,” and finally “Specialties Within Physicians and Surgeons,” including “All Others.” The Standard Occupational Classification System has no taxonomic capability to identify a physician whose occupational effort and responsibility rest with public health (e.g., a physician who heads a health department or has occupational and environmental job functions in private industry). Similarly, for the taxonomic categories in nursing, the Standard Occupational Classification System does not classify “Registered Nurse” into a greater detailed occupational title that could identify a community health or public health nurse.

In 1998, a major review of the Standard Occupational Classification System led to the placement of 14 public health workforce–specific occupations (with well-defined roles and responsibilities) into the classification system.²⁶ However, in 2005 to 2006, another request to the Bureau of Labor Statistics by a group of 24 national public health organizations that sought to revise and expand further public health workforce elements failed.²⁷

Several other comprehensive occupational databases in various agencies within the federal government are closely related to or based on the construct of the Standard Occupational Classification System. (Actually, all major federal systems for collecting occupational data now use the system's taxonomy to compile data.) These federal databases^25,28–32 offer an array of occupational descriptors, crosswalks of related occupational titles in other organizations and industry, work settings, employment and wage estimates, and information on occupations and careers of interest to the public. These items potentially could be relevant to the development of a public health–oriented occupational classification data system.

FRAMEWORK FOR ENUMERATION AND COMPOSITION

Other researchers^1–4 and I believe that a systematic, comprehensive classification data system that more adequately enumerates and defines the composition of the public health workforce should be established. The data system should be consensus-based, standardized, easily accessible, and timely.

The uniqueness and unclear breadth of the public health workforce are vital characteristics that require critical attention and scrutiny as attempts are made to establish a comprehensive, standardized classification system of the workforce. A critical initial measure would be to develop specific definitions and boundaries related to occupational titles, work functions and responsibilities, work settings, and other pertinent characteristics that can serve as a substrate for the classification data system. This will necessitate significant discussion and debate and—most importantly—consensual decision making.

Yet public health and its workforce have common critical elements—“essential public health services,” “population focus,” “disease prevention/health promotion activities,” and “social determinants of health.”^4,33,34 These elements can provide the platform and parameters or boundaries of the public health identity. Other fields, such as mental health, that are also evaluating their workforce can have important interfacing aspects in titles and job functions that affect the breadth and inclusiveness determined by a future comprehensive public health classification system.³⁵

Several representative approaches to developing the classification data system for the public health workforce are summarized in Table 1. Despite current limited incorporation of public health–specific occupational titles in the Standard Occupational Classification System, this data system still may be relevant and adaptable to a public health workforce classification framework. This assumption could be valid if, for example, there is flexibility in adding extra detail beyond the existing “detailed occupation” group. This flexibility could allow for the extension of taxonomic categorization beyond the Standard Occupational Classification system's current 6-digit code, resulting in the incorporation of public health–specific occupational titles.

TABLE 1—

Representative Approaches to a Comprehensive Classification Database System for the Public Health Workforce

Approach	Features	Implications for Public Health Workforce
Integration with Standard Occupational Classification System methodology	Institutionalized database system	Need for determining specific occupational titles and functional roles, nonduplication with other workforces
	Taxonomy by very specific occupational titles and functional roles	Inclusion of disciplines and categories can be consensus-based process
	Reliance on decennial census	Potential modification of Standard Occupational Classification System's decimal methodology
	Ineligibility if below “minimal” size of occupational title category	Timeliness of data needs improvement
Integration with Standard Occupational Classification System plus other complementary surveys	Same features as for methodology	More comprehensive approach
	Use of broad survey or study followed by more specific subset survey of title and responsibilities linked to public health	Crosswalk capability to other industry databases (i.e., public health being an industry)
		Potential timeliness and coordination issues related to multiple surveys or databases
		Broadened scope and depth to public health workforce categories
Case studies, smaller surveys	Smaller settings	More detailed or ancillary information capability in focused workforce settings
	Discrete focus on geography, job patterns, salaries, education, and so forth
	Increased utility for organizations and associations
Credentialing system	Credentialing mechanisms through licensing, certification, registration, core competencies, or equivalent	Credentialing is expanding in the public health field
	Individual disciplines may require credentialing renewal	Limitation may be associated with the multidisciplinary nature of the public health workforce
	Specific data repository and its management may be included	Future formalized continuing education may be promoted by this approach
		Related efforts by recent accreditation mechanism for public health agencies

Alternatively, several complementary classification systems (likely in relation to the Standard Occupational Classification System) could be used, each providing additional relevant information that further extends the taxonomic structure and more detailed characteristics of public health–related occupational categories. Thus, information from an existing (or modifiable) institutionalized occupational data system as a first step could make a broad sweep of public health–related occupational categories. This information then could be “crosswalked” to a second (or third) survey data system, such as the “industry of public health,” to link with more detailed public health–specific items. Gebbie et al.²⁶ made use of this approach in a study enumerating public health nurses with information from the Bureau of Labor Statistics’ Occupational Employment Statistics, National Sample Survey of the Registered Nurse Population, and state or territory health officials’ databases. Case studies and surveys of smaller or focused settings (i.e., cities, regions, associations, or employer organizations) may be quite useful in detecting various patterns or characterizations of the public health workforce. This could include information on strengths, weaknesses, effect, salary levels, attrition rates, education and training, and retirement rates. Health professional groups with a formal credentialing system (license, certification, registration, or equivalent) in place are additional models for enumeration, definitions of workforce composition, and tracking mechanisms. An elaborate example of this has been established for the physician workforce (American Medical Association Physician Masterfile).³⁶ The public health field is moving progressively in the direction of increasing credentialing (or accreditation) mechanisms that in time could lead to a comprehensive classification system.³⁷

Other aspects related to the approaches in the development of a classification data system need to be taken into account. The methodology developed by the American Public Health Association^23,24 and used with adaptations in the study by Kennedy et al.²² may capture most of the public health workforce. However, it is quite labor intensive and still needs a formalized repository for data collection and management. Other entities such as the National Center for Health Statistics³⁸ or, perhaps, a nongovernmental organization should be explored for capabilities (and interest) in overseeing or participating in the development of a classification data system for the public health workforce and its components. Additionally, public health workforce categories that are duplicative or very similar to categories in other health or occupational fields or work settings should be avoided. The classification system should allow integration of local-state-national workforce information. It should facilitate use by researchers, health analysts, planners, policymakers, and others. For timeliness, it should not be confined to a decennial census or other data with long lag times.

DEVELOPING A CONSENSUS-BASED SYSTEM

Actions to bring about the development of a consensus-based public health workforce classification data system, possibly linked to an existing institutionalized database system, will likely require direct intervention from leadership at the US Department of Health and Human Services, if not higher. Partnerships and cooperative planning efforts between the US Department of Health and Human Services and other federal agencies, particularly the Department of Labor's Bureau of Labor Statistics, or organizations dealing with employment or occupational data systems are needed. Revisions to federal data collection agencies may require approval by the US Office of Management and Budget. Leaders from major governmental and nongovernmental public health–related organizations could be appointed to an ad hoc committee to the US Department of Health and Human Services, similar to the earlier Public Health Functions group.^4,34 This committee could provide expert technical assistance and be a liaison for consensus building with the public-private health sector community. Moreover, a national arbiter or organizational entity would be of major value in providing direction and monitoring of the public health (or broader health) workforce.

Health Care Reform Alignment

Recent progress toward workforce development and capacity building (including public health) is evidenced by the congressional approval of HR 3590 (Patient Protection and Affordable Care Act).³⁹ Included in this legislation is the establishment of a National Health Care Workforce Commission; National Center for Health Care Workforce Analysis; several health workforce development programs at the local, state, and national levels; and other programs targeting prevention and public health activities. The HRSA, in particular, and the Centers for Disease Control and Prevention should be the most relevant federal health agencies to assist with the operations of these proposed workforce-related national efforts.

Information Dissemination and Rationale Building

The importance of a refined characterization of public health and the purveyors of public health services, the public health workforce, must gain more attention from media, legislators, and the general public in understandable terms and data. The role of the public health workforce in disease prevention and health protection leading to improved productivity of employees, reduced absenteeism in schools, and a better quality of life must be better known.⁴⁰ Compelling arguments for the value of public health services to prevent or mitigate current and future health challenges of aging, chronic diseases, risky lifestyles, and natural disasters need to be disseminated effectively.

The public also should realize that compared with historical data, the more recent estimates indicate a shortage in the public health workforce. However, because of known limitations with both historical and current data, the development of a standardized classification system could more fully evaluate the ramifications of an estimated workforce shortage. The new classification system could bring greater validity to workforce enumerations, comparative analysis, and need-demand-supply constructs.

IMPLICATIONS AND CONCLUSIONS

Although a classification system and related workforce issues have appeared in print or been discussed over the years,^37,41 actions to address this enigma have been insufficient. The time for change is now, building on previous advances and the current impetus for support of workforce development, including the public health workforce. For example, workforce-focused research^42,43 is now assisted by the emergence of a new field, public health systems research (also referred to as public health services and systems research, public health delivery systems).^44–46 This research area is being supported in large part by the Robert Wood Johnson Foundation. Also, a growing movement exists to expand credentialing or accreditation mechanisms of public health disciplines,³⁷ health departments,⁴⁷ master of public health graduate students,⁴⁸ core competencies of public health practitioners,⁴⁹ and innovative educational opportunities in public health.⁵⁰ Two Centers of Excellence in Public Health Workforce based at the University of Michigan and University of Kentucky have been established with federal support from the HRSA and the Centers for Disease Control and Prevention. These centers have recently developed recommendations on the methodology to conduct effective public health workforce enumeration and are now actively collecting data. Healthy People 2010 has made its first mention of the need for an improved public health infrastructure, including the workforce.⁵¹ Furthermore, the stimulus bill (American Recovery and Reinvestment Act)⁵² and, even more recent, HR 3590³⁹ are ushering in other health reform initiatives that in part focus on public health and its workforce.

However, the reality is that the existing and proposed public health workforce initiatives could be erased or significantly limited in their effect because of ongoing major political tensions. It is incumbent on the public health community and friends to provide the necessary leadership in continuing to pursue a classification system, despite barriers, and in disseminating the evidence-based value of public health and its workforce. Furthermore, we must ensure that the public health workforce and essential public health services are well integrated and coordinated with the nation's health reform movement—starting with a consensus-based, comprehensive, classification data system that can better identify and monitor the nation's public health workforce.