Describe the places of employment of the public health workforce, how the workforce is trained, and who is licensed or certified.
◄ ◄
◄
The Public Health Workforce
Matthew L. Boulton, MD, MPH • Edward L. Baker, MD, MPH • Angela J. Beck, PhD, MPH
LEARNING OBJECTIVES
Upon completion of this chapter, the reader will be
able to:
1. Identify professions comprising the public health
workforce and describe efforts to determine the public
health workforce size and composition.
2. Describe the places of employment of the public health
workforce, how the workforce is trained, and who is
licensed or certified.
3. Describe the efforts underway to ensure and measure
the impact of public health workforce development,
including leadership development.
4. Describe the essential public health services delivered
by the public health workforce.
5. Define leadership and be able to distinguish leadership
and management.
6. Understand theories of leadership practice a_nd
the related behaviors needed to practice effective
leadership.
7. Understand the needs for leadership development at
various career stages.
KEY TERMS
certification
competencies
enumeration
leadership
licensure
management
multidisciplinary teams
voluntary health organizations
workforce
workforce capacity
307
308
INTRODUCTION
. l forefront of the
Public health is increasmgly at t 1e d re-emergent
national and global response to new anf d adly infechealth
threats ranging from ~utbreak:ho in ~he obesity
tious diseases, to the explosive gro~ . . and vioepidemic,
to disturbing increases m mff1urt~ public
lence makm. g the nee d fo r a l1 1· ghly e ec 1ve f that
health system as vital as ever. Perhaps no part O
public health system is as important as th~ pheo~t1~
who work within it as members of the pubhc ea .
workforce. A well-trained and competent workforce is
essential to the practice of public health and. the successful
delivery of essential public health services. The
professionals and other workers who comprise the
public health workforce share a common awareness
of and commitment to improving health through a
population focus. These workers are uniquely diverse
in terms of the education, skills, and experience they
bring to the field, especially relative to other health
professions. However, unlike other health professions,
the public health workforce has actually become
smaller over the last two decades. At the same time the
variety of occupations comprising that workforce has
diversified and includes new positions such as health
informatics specialists, public health geneticists, and
emergency preparedness professionals which mostly
did not exist just a decade ago. The opportunities for
public health worker training and education have also
grown dramatically as schools and programs of public
health have undergone an unprecedented expansion.
This has been accompanied by a rapid development
of continuing education and other training, often using
distance modalities, offered through national networks
of federally funded workforce centers. These
efforts are creating an increasingly professionalized
workforce that has been reinforced and strengthened
through complementary initiatives aimed at development
of competency-based education and training
worker certification, and accreditation of public health
agencies.
Despite these exciting developments, many contemporary
c?allenges confront attempts to fully characterize
the pubhc health workforce-there is still too little known
about how many workers it contains, the disciplines they
represent, wh~re they d~liver services and how effective
they are at domg so, their demographic composition, the
reasons they enter and leave the workforce, and how th
adapt to unstable funding impacting their job security a~~
future caree~ prospects. And, we continue to wrestle with
the appropnate _benchmarks that define the ideal mix of
educ~tlon, expenence, and diversity needed to produce an
effecnve workfor~e an? how that mix contributes to overall
workforce capacity. F_mally, there is a clear need for more
research on the pubhc health workforce to address these
PART FOUR
ON OF PUBLIC HEALTH SERVICES
pROViSI
l ensure that, ultimately, we hav
. and to a so . h kill . e
many questions f eople with the ng t s s m the right
the right nu~ber ~ Pe to improve and protect the public’s
t the nght um
place a . .
health. ludes with an extensive discussion
The chapter cone ctice of leadership consists of speof
Jeaders~ip. ~~ r~ead to the realization of a shared
cific behaviors :
1
~ plementation of core strategies and
vision through t e imerational reality of specific tactics
I. tion to op . . ·
the app ica t” e of leadership consists of specific
f the prac 1c .
There ore, . h 1 d to the realizat10n of a shared vih
. s whic ea .
be avior h . plementation of core strategies and
sion thr~ug~ t ~~:perational reality of specific tactics.
the apphcatihon . s has developed regarding the skills
A oft eone
range a ct· leadership; one of the most compelneeded
for eue ive · · l d h’
. ublic health practice IS servant ea ers 1p. As
lmg for P 1 leadership development needs to change
leaders evo ve, h” d I
d b ddressed by formal leaders Ip eve opment
an can ea h’ · I
programs. In public health, leaders I•p • IS cendtr ad to a· ddressing
the challenges and opportumties nee e to improve
and protect the public’s health.
PUBLIC HEALTH WORKERS
The effective delivery of public health services is dependent
upon the availability of a skilled, competent
workforce (the population employed in a specified
occupation). A key challenge for governmental and
nongovernmental public health organizations is to
employ the appropriate number of workers who possess
the requisite skills which can be used where and
when they are needed.1 The public health workforce
c~mpri~es a_ highly varied group of professions. The
wide diversity of skills, education, and experiential
~ack~rounds that public health workers bring to the
field ~s a strength given the multitude of factors that
contribute to population health· however it also ere·
ates cha.l l.e n ges · ‘ . ‘ . lil accurately determimno the size,
composition 1• b f . 0 bl’
h I h ‘ 0 unction, and expertise of pu ic
eabtl. whorkers, both individually and collectively. The
pu ic ealth w kf
ways, wi. th a f or orce has been defined in many
the comm i°cus on population health serving as
Accord. on e ement to define a public health worker.
lie heal~~gp:~r:~:i~nstit~t~ of Medicine (IOM) , a pu?health
or a 1 n~l is a person educated in pubhc
re ated dis · 1· ·
prove health th cip me who is employed to 101·
~mportance of t~ough a_ population focus.”2 Given the
mg and protect” e p~bhc health workforce in promot·
to understand ~~~ ; health of populations, it is ke)’
ployed and what k”ll any Workers are currently et11·
gaps in Workfor s 1 s they possess as well as where
d . ce cap · . ‘ .
an retain the . h ac1ty exist and how to recruH
health settings. ng t types of Workers in all public
CHAI”‘ I t:K IO I Ht: PUBLIC HE
ALTH VvOR
KFORCE
WORKPLACE SETTIN
public health workers Gs
f
. b . . can be£
0 10 settmgs m both bl’ 0 unct in .
h
• pu 1c and a Wide
of t ese settmgs may not b private variety
as places where public h
1
e traditionally s~tors. Some
services carried out theree~! s~rvices are ~el:racterized
to the public’s health non th e important co v~red, but
· d · e eless AI h ntnbuti
summa~1ze m this chapter e · t ough the _ons
of public health workers mploy substantial settings
. , not all w k numbe
these settmgs are necessa .1 or ers em I rs
workforce. n Y part of the p u b~li co yheedal tinh
Governmental Public H ealth
The core public health workf
l
. orce is
ernm. enta settmgs ‘ includ’m g 5 9 st et mployed in g ovpubhc
heal~h agencies, nearly 3 0 a e and territorial
partments (mcluding tribal a : OO local health dedes
that contribute to a pubY~n~ies), and federal agenthe
Department of Health icd :;1th
mission such as
vironmental Protection Ao an uman Services, En-
. l oency, and D
Agncu ture, among others W’th’ epartment of
government, public health ~o k
1
m all three levels of
. f r ers are found · ‘d
vari.e ty o programs that focus on areas such m a w1 e
environmental protection c00. . , 1’ d sa1ce ty h ealth a· s energy,
(.m clud.m oo Medicaid) ‘ 1· mmum.z at1. ons’, controlm osfu irnafneccenous
dis.e ases, maternal and child health , mentaI h ealth
occupat10nal health and safety, substance abuse i
health , traffic safety, sexually transmitted infec,tir;:~:
~elfare, and zoning. Many of these programs, orig~
mally developed as part of a department or board of
?ealth, have since been relocated or combined as policy
makers shift preferences for relating programs and
people. For example, pesticide control programs now
housed in agriculture were once part of health departments,
and the function of assuring access to care for
the poor encompassed by Medicaid may have been a
part of the jurisdiction of a board of health. The IOM
described an ideal state health agency that encompasses
all of these programs. :1 However, no such agency exists,
nor is one likely to appear. Consequently, public health
professionals must work collaboratively across program
and agency lines and among public and private and
voluntary partners.
Nongovernmental Public Health
f d in a range of set-
Public health workers can be o~nhealth agencies. For
tings beyond governmental pu~l~~ . dual schools (pub~
xample, school distric~s ao<l
1
~
0
1
v~any public health
he, private, and parochial) em~ s~hool-aged children.
nurses to assure the he_a~th ~nd environmental health
They may also have nutntion_ . t wi’de level to assure
· t a d1str1c –
professionals working a
309
the healthf I Inde, pendeun tn Wesast and safet y o f sc h ool meal programs
tri c• t s also em lo er, sew. er ‘ or waste management dis-·
that standard: fo; ~~1ti’,1c :ealth professionals to assure
In addition I ic ealth protection are met.
(an industry co~ v~ _untary health organizations
fund raising for hns;;hg organizations that engage in
cation, and patiente: :related research, health edufor
public health w ekrv1ces) represent another setting
a speci.a l case of or 1e rs • The Am en·c an Red Cross is
h eal t h and care-g·a v. o untIa ry. a gency, gi.v en the public
ivmg ro e 1t pl d •
response in coord’ . ays urmg emergency
. mat1on with I I officials. It also prov· d ?ca ‘ state, and national
ti~n in many localittesesf~:tens1ve public health educash1p
of HIV/ AIDS ‘ . example, through sponsororganizations
wit/:es~ent10n trai?ing. Other voluntary
elude the A • rong pubhc health presence inCancer
_mencan Lung Association, the American
the S?c1ety, _the American Heart Association, and
th American Diabetes Association. Although each of
ese ~mploys public health personnel, they also use
extensive. networks of volunteers’ some of whom are
also fu~l-t1me public health workers in other agencies
For th~ir. volu~teers who are not public health workers:
~he trammg given for volunteer tasks results in expandmg_
the public health knowledge within communities.
To Illus~ate, few communities would be as strict in control
of mdoor tobacco smoke today were it not for the
thousands of public health volunteers workino through
voluntary associations. Local communities ltlso often
have nonprofit groups with public health and human
services missions who provide important outreach to
the population through health education, health advocacy,
and other public health efforts.
Hospitals and Healthcare Organizations
Many hospitals and health care organizations (including
staff-model and other health maintenance organizations)
employ public health professionals. Many of
the administrators of personal health care services have
earned graduate degrees in administration from programs
housed in schools of public health, and may have
developed a population focus on their work. Among the
most common public health workers in these settings
are health educators, outreach workers, and epidemiologists.
A large institutional system may have its own
sanitarians, environmental engineers, and occupational
health staff as well. Further, many localities expect that
the clinical portion of public health services, such as
immunizations or home-based education and outreach,
will be housed with other care services, and not solely
in the public health agency, and often are inc?rp?1:ate1d
seamlessly into daily practices such as a pediatncrnn s
ongoing care. Conversely, it should be remem~ered,
however, that just providing a health-related service or
PROVISION OF PUBLIC HEALTH SERVl():s
PART FOUR i;;
310
activity outside the walls of a hospital does not mak~ it
a public health activitv. The test for whether something
should be considerei part of public health is the pr~sence
of a focus on a population group or commumt!
and on a preventive strategy or a preventable outcoi~e.
As public health and health care organizations continue
to implement mandates of the Patient Protection and
Affordable Care Act of 2010 (ACA),5 some of the job
tasks of public health workers and hospital workers
may become more integrated and shared across worker
settings.
cal health departments? Enumerations
state n1ul_ lo unt the number of workers ernpl tuct.
( t dies to co · · 0 ies s u d t f agencies or orgamzations) have bY e·d
in a defined se tohe U.S. public health workforce s·een
con ducte o. n te i’ts size. More recent ef f orts esti”‘ ince
Occupational Health
For workforce and other strategic considerations, occupational
health is a subspecialty of public health practice
that may take workers into almost any other field as
a part of the organization’s infrastructure. These public
health professionals include physicians (some board certified
in occupational medicine by the American Board
of Preventive Medicine), nurses, epidemiologists, and industrial
hygienists, and are involved primarily with protection
of workers from hazardous working conditions.
Some also develop workplace-based health promotion
programs or even broader health programs for workers
and their families. Workers concerned about their
health and safety may also employ public health expertise
through unions or professional associations. For
example, occupational health advocates on the staff of
the American Nurses Association were leading activists
in supporting legislation protecting health care workers
from occupational exposure to blood-borne pathogens.
WORKER ENUMERATION
1908 to est1ma •11ated
ublic health workers per 10?,000 population in
220 p while a national enumeration_ study conducted
1. 98200,0 0 y1. e lded a total of approxim. ately 450 ,O oo 10 t· nally equivalent to a ratio of 158 pub\’ workers na 10 • 1 . 7 1c
k s per 100,000 popu at1on. These stud
health wor er f ” bl’ h ·
. d d’fferent definitions or pu ic ealth Worker”
1es use 1 d 11 t· ak’
d•ff t methods for ata co ec ion, m mg trend
and 1 eren . . 1 Th
. s over time d1fficu t. e most recent enu
comparison . 14 . 1 d .
merat.i on st udy , conducted m 20 , m· e u he s workers in
l l t te and federal health agencies w o are respono’bcla
‘ fs a th’e delivery of essent·i aI pub l1’ c h ea1t h services, s1 e or . . h d .
which is a narrower defimt10n_ t an use m previous
stu d1. es. In this study, approxim.a tely 291,000 pub- 1
.
lie health workers in 14 occupat10na categories were
enu merated using survey data collected by multiple 8 • organizations (see Table 18-1), eqmva1 ~ nt to a rate of
92/100,000 population. Half of the pubhc health workforce
worked in local health departments, which is not
surprising given that the majority of public health services
are provided at the local level; 30 percent worked
in state health departments and 20 percent at federal
health agencies. Additional detail on the recent trends
in governmental workforce data is provided in Chapter
8 (for state health departments) and Chapter 9 (for
local health departments). Enumeration studies provide
valuable information for assessing the size of the workforce,
but usually provide limited information on other
characteristics of the workforce, such as demographics,
Unlike for other health professions such as physicians
and nurses, the U.S. government does not employ a system
for continuously collecting data to count or characterize
the public health workforce. The U.S. Bureau of
Labor Statistics (BLS) produces employment and wage
estimates annually for over 800 professions. 6 Although
public health workers are included in these estimates,
most cannot be counted because they are grouped
within broader health care professions categories that
lack sufficient precision to specifically determine who is
a public health worker. As a result, public health professional
organizations and public health systems researchers
undertake national surveys and studies in an attempt
to collect information on different segments of the
workforce. Most studies are conducted with state and
local health departments because these agencies are easily
identifiable, have a clear public health mission, and
are often willing to participate in such research activities.
Among the most basic of research questions studied
is How many public health workers are employed ‘in
education and training background, and job function
because most data are collected from the organization,
rather than from individual workers.
Public Health Occupations
The occupational categories listed in Table 18-1 represent
the primary professions of public health workers.
The occupational diversity of the workforce is apparen~.
~everal disciplines, each with their own skills and
trammg requirements, work in multidisciplinary teains
t~ contribute to the overall delivery of public health services
· Ad mi·m ·s trat1·v e and clerical personnel, who in~Y
not have a degree in public health but support public
hhealth program activities in local state and federal
ealth. de partments, represent almo’s t 20 p’ ecr cent ofth e
;
0 ~~-fo~e. The largest proportions of workers trained in
(;6 ic ealth service delivery are public health nurses
ers (~ercent), followed by environmental health work-
0th percent), _and public health managers (6 percent).
er occupations w·th f l boratory workers b .1 ewer workers include ~ ‘ pu he health physicians, behav1ora
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
rJ\BLE 18-1 Public Health Workforce Occ .
upat,ons and Enumeration Estimates, 2014
occupation
Administrative/
Clerical
personnel
Public Health
Nurses
Environmental
Health Worker
Public Health
Manager
Laboratory
Worker
Public Health
Physician
Behavioral
Health
Professional
Job Description
Staff who work in bus· f·
d . . mess, inance, auditing, management,
~n accountin~; trained at a professional level in their
f1ehld of expertise before entry into public health · staff
w. o p.e rform support work ·1 n areas of busi.n ess a’ nd
financial operations; and staff who perform nontechnical
supf=’.ort wo_rk in all areas of management and program
adm1n1strat1on.
Wor~ers who plan, develop, implement, and evaluate
nursing and public h_ealth interventions for persons, families,
and_ f?0 Pu!at1o~s. at nsk for illness or disability. This includes
pos1~1ons 1dent1f1ed at the registered nurse (RN) level,
and include~ graduates of diploma and associate degree
programs with the RN license.
Staff who plan, develop, implement, and evaluate standards
and systems to improve the quality of the physical
environment as it affects health; manage environmental
health programs; perform research on environmental health
problems; and promote public awareness of the need to
prevent and eliminate environmental health hazards.
Health service managers, administrators, and public health
directors overseeing the operations of the agency or of
a department or division, including the senior agency
executive, regardless of education or licensing.
Staff who plan, design, and implement laboratory
procedures to identify and quantify agents in the
environment that might be hazardous to human health,
biologic agents believed to be involved in the e~iolo_gy of
diseases among animals or humans (e .g., bacteria, viruses,
or parasites), or other physical, chemical, and biologic
hazards; and laboratory technicians who plan, perform, and
I te laboratory analyses and procedures not elsewhere
eva ua . d ‘ I
classified, including performing routine tests 1n a me 1ca
laboratory for use in disease diagnosis and trea~ment;
prepari·n g v accines, biologics, and serums for disea. se
preven t’1 0n; preparing tissue samples for pathologists or
taking blood samples; and executing laboratory tests (e.g .,
urinalysis and blood counts).
Physicians who identify persons or groups at risk for illness
or d ‘1 sa b1T1 t y an d who develop ‘. implement, and evaluate
programs or · terventions designed to prevent, treat, or r in . . . . h risks· might provide direct medical services
ame ,orate sue , . • d ‘ I
. h’ h text of such programs, 1nclud1ng me 1ca
Wit In t e con r d . I’ d d d tor of osteopathy genera 1sts an spec1a 1sts,
octor an oc . • I h ·
f h have training in public hea t or preventive
some o w om
medicine.
h vide psychological support and assess,
Worke.r s w o pdr om onitor provision of communi·t y servi·c es f or
coo.r dinate, aI’n ts Includes soc1·a I work ers.
patients or c ,en ·
35,000
29,191
13,300
10,100
2,000
2,100
4,000
1: <
311
1 •
II I,
1· ,
I
,, 1
14,559 6,085 55,644
12,286 5,793 47,270
4,618 5,920 23,838
3,296 4,998 18,394
5,699 5,685 13,384
791 6,700 9,591
1,839 895 6,734
PART FOUR PROVISION OF PUBLIC HEALTH St1:1
“Vl~~S
TABLE lS-l (Continued)
Workers who design, organize, implement, communicate,
evaluate, and provide advice regarding the effect of
educational programs and strategies designed to support
and modify health-related behaviors of persons, families,
organizations, and communities.
Nutritionist
Epidemiologist
Emergency
Preparedness
Staff
Public Health
Dental Worker
Public Health
Informatics
Specialist
Public
Information
Specialist
Staff who plan, develop, implement, and evaluate programs
or scientific studies to promote and maintain optimum
health through improved nutrition; collaborate with
p~o~rams that have nutrition components; might involve
clm,cal practice as a dietitian.
Staff who investigate, describe, and analyze the distribution
and determinants of disease, disability, and other health
outcomes and develop the means for disease prevention
and control; investigate, describe, and analyze the efficacy
of programs and interventions.
Workers whose regular duties involve preparing for
(e.g., developing plans, procedures, and training programs)
and managing the public health response to all-hazards events.
Staff who plan, develop, implement, and evaluate dental
health programs to promote and maintain the public’s
optimum oral health, including public health dentists
who can provide comprehensive dental care and dental
hygienists who can provide limited dental services under
professional supervision.
Workers who systematically apply information and
computer science and technology to public health practice,
research, and learning (e.g., public health information
systems specialists or public health informaticists).
Staff who represent public health topics to the media and
public, act as a spokesperson for public health agencies,
engage in promoting or creating goodwill for public health
organizations by writing or selecting favorable publicity
material and releasing it through different communications
media, or prepare and arrange displays, make speeches,
and perform related publicity efforts.
Other or
Uncategorized
Worker
Public health workers in occupations not listed in the
previous categories; workers who cannot be placed in a
category due to missing data
TOTAL
6,715
5,000 1,276 223 6.499
1,800 2,476 4,276
2,900 810 3,710
2,600 356 443 3,399
2,100 729 2,829
2,100 174 2,274
30,200 35,960 20,271 86,431
147,491 86,411 57,056 290,988 ==————– SOURCE: Beck, A.J. and Boulton, M.L.
h 1th professionals, health educators, nutritionists,
e~demiologists emergency preparedness staff, public
ep1 ‘ . . f . . . l
health dental workers, pubhc health _m ormat1cs ~pecia –
1· sts, an d publi· c information specialists. Approxunately
30 percent of the workforce in this study was repre·
sented by an undesignated occupation or was unas·
signed to a category due to underreporting of workforce
information. This further supports the need for n1ore
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
stan dardized metho. dologies for collecting workforce 1· 11-
ation on a national level.
forrn
public health workers who are often excluded from
st public health workforce enumeration studies are
rn’:nrnunity health workers, individuals who conduct
co treach for medical personnel or health organizations
ou . h
irnplement programs m t e community that pro-
:ote, maintain, and improve individual and community
health . 6 Community health workers, sometimes
called lay he~lth workers or ?romotoras, depending on
the community, are a growmg segment of the public
health work_forc_e; they may_ be volunteer or paid, are
found workmg m any pubhc health setting, and generally
do not have a formal educational background
in public heal~h, but are trained to help deliver public
health services to the population. The BLS recently
began collecting data on this segment of the workforce
and estimated that 45 ,800 community health workers
were employed in the United States in 2013, excluding
self-employed and volunteer workers for which
enumeration estimates are unavailable. The number of
employed, paid workers in this discipline is similar to
the number of public health nurses enumerated in oovemmental
public health settings. This diverse grou; of
public health workers could soon represent the largest
group of public health workers in the United States.
Workforce Taxonon-1y
One method for improving the quality of data related
to enumeration and other workforce characteristics is
to develop a common system for classifying workers.
A public health workforce taxonomy was developed
in 2014 by several public health professional groups
and federal agencies providing a framework for worker
classification that could lead to a much clearer picture
regarding workplace settings, type of employment, job
tasks, funding sources for workers, educational background
, licensure and certification , and worker demographics.
9 The taxonomy’s occupational categories,
which include far more than the 14 occupations used
in the most recent enumeration study, provide more
specificity on the types of disciplines represented in the
~ublic health workforce (see Table 18-2). Broadly, pubhe
health occupations can be grouped into four main
categories: management and leadership; professional
and scientific; technical and outreach; and support services.
The workforce taxonomy provides a mechanism
for standardizing the classification of public health occupations
across different workforce surveys, which has
been a persistent challenge for workforce researchers,
~ermitting more valid comparisons while also provid~
ng a framework for ensuring collection of a set of minimum
data elements on all workers in the public health
Workforce.
313
TRENDS IN PROFESSIONALIZATION
The field of public health has been aptly described
as a “loose confederation of professions” because t~e
breadth of skills and experience needed by pubhc
health workers requires highly diverse back~round_s
representing many different disciplines. Histoncally, it
was commonplace for workers in health d~part~ents,
for example, to be primarily trained on the Job w~th no
public health degree and little or no formal educat10n or
even training in public health. However, that began to
change with the IOM’s 1988 report, The Future of Public
Health, which prominently acknowledged th~ need
for significant changes in the training and educat10n of
the national public health workforce, including acces_s
to more educational offerings. That need was dramatically
highlighted and reinforced in the follow-on 2003
IOM report, Who Will Keep the Public Healthy in the
21st Century?, which recommended that the CDC and
Health Resources and Services Administration (HRSA)
“periodically assess the preparedness of the public
health workforce, to document the training necessary to
meet basic competency expectations and to advise on
the funding necessary to provide such training.” These
ongoing efforts to further develop the skills and competence
of the existing public health workforce have increased
substantially since 2000, with greater emphasis
on certification and licensure of public health workers,
and accreditation of governmental public health departments.
Although it may have been true at one time that
public health workers learned most skills on the job and
that any worker in the health department could perform
almost any job task in a pinch, even without any training
or education in that area, that is rapidly becoming
an outmoded perspective and no longer true nor feasible
in the modern public health workforce. As several
enumeration and other workforce studies have revealed
the public health workforce is becomino increasinol~
professionalized as workers are charged
0
with carryhi~
out more complex, specialized, and technical tasks tha~
c~ll for an appropriate level of educational and profess10nal
background training. This has been driven, in
part, b! the enormous changes occurring in health informat10n
technology with the advent of advanced webbased
com?1′:1nicab~e disease surveillance systems, ever
more sophisticated immunization information systems
the ?evelo~ment of large and complex health registries:
the tncreastng use of electronic health records and th
need_ to u~ilize “big data” to improve health, all ,of whic~
r~qmre high levels of technical and professional expertise.
For example, a 2002 national study found that
over 40 percent of epidemiologists in state health depa~
tme?ts lacked any education or formal training in
ep1dem~ology;10 similarly a state health department reported
m 2006 that over 60 percent of their workforce
I 1
………
l I ,
I I
I I
314 PART FOUR PROVISION OF PUBLIC HEALTH SERVICES
TABLE 18-2 A Taxonomy for the Public Health Workforce
1.4. Management and Leadership
1.4.1. Public Health Agency Director
1.4.2. Health Officer
1.4.3. Department or Bureau Director
(subagency level)
1.4.4. Deputy Director
1.4.5. Program Director
1.4.6. Public Health Manager or Program Manager
1.4. 7. Other Management and leadership
1.4. 7. 1 . Coordinators
1.4.7.2. Administrators
1.5. Professional and Scientific
1.5.1. Behavioral Health Professional
1.5. 1.1 . Behavioral Counselor
1.5.2. Emergency Preparedness Worker
1.5.3. Environmentalist
1.5.3.1 . Sanitarian or Inspector
1.5.3.2. Engineer
1.5.3.3. Technician
1.5.4. Epidemiologist
1.5.5. Health Educator
1.5.6. Information Systems Manager
1.5.6.1. Public Health Informatics Specialist
1.5.6.2. Other Informatics Specialist
1.5.6.3. Information Technology Specialist
1.5.7. Laboratory Worker
1.5. 7. 1. Aide or Assistant
1.5.7.2. Technician
1.5.7.3. Scientist or Medical Technologist
1.5.8. Nurse
1.5.8.1. Registered Nurse Unspecified
1 .5.8.1.1. Public Health or
Community Health Nurse
1 .5.8.1.2. Other Registered Nurse
(Clinical Services)
1.5.8.2. licensed Practical or Vocational
Nurse
1.5. 9. Nutritionist or dietitian
1.2.
1.3.
1.5
1 _ 1.1. Oral Health Professional
1.1 .1.1. Public Health Dentist
1.1.1 .2. Other Oral Health Professional
1.1.2. Physician
1.1.2.1. Public Health or Preventive
Medicine Physician
1.1.2.2. Other Physician
1.1.3. Medical Examiner
1.1.4. Physician Assistant
1.1.5. Public Information Specialist
1.1.6. Social Worker
1.1 .6.1 . Social Services Counselor
1. 1. 7. Statistician
1.1.8. Veterinarian
1.1.8.1. Public Health Veterinarian
1.1.8.2. Other Veterinarian
1.1. 9. Other Professional and Scientific
1.1.1 O. Student Professional and Scientific
Technical and Outreach
1.2.1 . Animal Control Worker
1.2.2. Community Health Worker
1.2.3. Home Health Worker
1.2.4. Other Technical and Outreach
Support Services
1.3.1 . Clerical Personnel
1.3.1.1 . Administrative Assistant
1.3.1 .2. Secretary
1.3.2. Business Support
1.3.2.1. Accountant or Fiscal
1.3.2.2. Facilities or Operations
1.3.2.2.1. Custodian
1.3.2.2.2. Other Facilities or
Operations Worker
1.3.2.3. Grants or Contracts Specialist
1.3.2.4. Human Resources Personnel
1.3.2.5. Attorney or Legal Counsel
1.3.3. Other business support services
Other
SOURCE: Boulton, M.L. , Beck, A.J., Coronado, F., Merrill, J., Friedman, C. et al.
Jacked a college degree of any type. 11 However, just a
decade later a repeat of the national epidemiology assessment
revealed over 60 percent of epidemiologists
working in health departments possessed a public
health or epidemiology degree and almost 90 percent
had received at least some formal training in epidemiology
(although this may constitute just a single epidemiology
course12). The Jack of formal training within the
workforce resulted in workers who were cross-trained to
fulfill many types of duties: a public health nurse may
have also performed duties of an epidemiologist, such
as outbreak investigation; a health educator may have
also assisted with health facility inspection. Although
the public health professionals continue to work in
multidisciplinary teams (work groups composed of
or combining several usually separate fields of expertise)
and are cross-trained to some extent, public health
disciplines have become much more specialized as t~e
number of accredited schools and programs of public
health have increased in the United States (Figure 18-1).
PUBLIC HEALTH EDUCATION
The first U.S. school of public health was founded in
1916 but the process of formally accrediting these
schools did not begin until the 1940s; two decades
later, the first program of public health (outside of~
school of public health) was accredited. The number 0
schools and programs grew steadily until the 2000S nt
◄
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE 315
70 en
E e en 60
£ 50
“O
C ca en 40
0 ——
0 ~ 30 u —– 50
(/) – 0 20
.! E 10
:::I z
0
—— – – – 31
0 —- 5 — 17
9 13
6 6 5 7
1940s 1950s 1960s 1970s 1980s 1990s 2000s 2010s
Decade
\ D Programs D Schools \
FIGURE 18-1 The Growth of Schools and Programs of Public Health in the United States, 1940s-201 Os
which point a dramatic and rapid expansion occurred
(see Figure 18-1). The increased availability of public
health degree programs at the graduate level and, more
recently, at the undergraduate level, in on-campus and
distance learning formats has greatly improved the accessibility
of public h ealth education. Not all public
health graduates choose to work in public health practice;
however, it seems reasonable to expect increases
in the percentage of public health workers with formal
public health education in future years.
The academic core of a public health Master’s (MPH)
degree program, which is the most common type of public
health degree, includes courses in the following five
areas: biostatistics, epidemiology, environmental health
sciences, health services administration/policy, and social
and behavioral sciences, described in Table 18-3. All
schools and programs of public health accredited by the
Council on Education for Public Health (CEPH), the main
national accrediting body, are required to offer courses
in these areas; many also offer courses in areas such as
global public health, health information/informatics, public
health genetics, health disparities, and maternal and
child health, among other specialty areas. Some of these
areas have more recently been developed into formal degree
offerings; in particular global public health, public
health preparedness, and health information technology
are offered as MPH concentrations through a number of
schools and programs of public health.
TABLE 18-3 Knowledge Areas of the Core Academic Components of Accredited Master of Public Health Programs
Biostatistics
Epidemiology
Environmental Health Sciences
Health Services Administration
Social and Behavioral Sciences
………
SOUR.c E: C-oun-cil on Educatt. on for p u blic Health
l
Collection, storage, retrieval, analysis, and interpretation of health data;
design and analysis_ o’. health-related _surveys and experiments; and concepts
and practice of stat1st1cal data analysis
Distributions and determinants of d isease, disabilit ies and death in human
populations; the c~aracteristics and dynamics of human populations; and the
natural history of d isease and the biolog ic basis of health
Environmental factors including biolog ical , physical, and chemical factors that
affect the health of a community
Plann ing, organization, ad1;1 inistration , management, evaluation, and policy
analysis of health and public health programs
Concepts and methods of social and behavioral sciences relevant to the
identification and solution of publ ic health problems
I
316
Continuing Education
Beyond educatin_g students for future work in public
health, substantial resources have been invested by
schools of public health and other public health organizations
to train current public health workers.
The !OM reported that schools of public health have
a responsibility to ensure that appropriate, quality
education and training are available to public health
professionals, other members of the public health
workforce, and health professionals who participate in
public health activities. 2 As a result, federally funded
training centers were developed at schools of public
health across the country to train the existing public
health workforce in foundational public health skills.
A large national network of Public Health Training
Centers (funded by the HRSA) and CDC-funded Preparedness
and Response Learning Centers have offered
trainings using distance learning and a variety
of other modalities to offer instruction which is provided
by public health professionals and faculty covering
a diverse array of public health topics ranging
from short courses related to the five academic core
areas of public health, to emergency preparedness and
response. These trainings tend to be more applied in
nature in order to provide knowledge and skills that
the public health worker can integrate into his or her
daily job tasks immediately and often provide continuing
education credit to meet certification or licensure
requirements.
Licensure and Certification
In keeping with trends of greater professionalization
and training of the public health workforce, there has
been a concurrent increase in the requirement for and
monitoring of worker licensure and certification.
There are several methods for verifying that workers
are adequately trained and capable of performing the
duties required by their positions. Some health professionals
are required to obtain a state license by passing
an examination in order to practice their profession. Examples
common among public health workers include
M.D. licenses for physicians, R.N. licenses for nurses,
R.S. licenses for sanitarians, and R.D. licenses for dietitians.
Maintaining licensure generally requires the
worker to complete training courses to achieve a minimum
number of continuing education credits within
specific time intervals and then report those credits periodically
to a state licensing board. Licensure may be
an effec.tive way to ensure workers continue to hone and
maintain their skills; however, only a minority of the
overall public health workforce is eligible for licensure,
as there is no license for most disciplines within the
public health workforce.
◄
PART FOUR PROVISION OF PUBLIC HEALTH SERVICES
Worker certification is another common method f
encouraging workforce development. Unlike licensu~r
certification is usually voluntary, ~!though_ some Pub:
lie health organizations _and a_ge?c1es m~y mdividual!y
require worker certification. Su~ilar to hcen_sure, Workers
achieve certification by pass!~g a~ ex~mmation and
maintain certification by part1c1patmg m continuin
education opportunities. _Ther~ are many examples 0~
public health worker cert1ficat10n; however, a cenification
open to public health workers of all educational
backgrounds and disciplines does not yet exist. Perhaps
the closest example of a uniform certification for public
health workers is the Cert!fied in Public Heal~h (CPH)
credential. In 2005, a Nat10nal Board of Pubhc Health
Examiners, comprising representatives from academic
and practice organizations,. was _formed to develop and
administer a voluntary cert1ficauon exam for graduates
of public health schools and programs. The CPH is intended
to distinguish public health workers who have
“mastered knowledge and skills relevant to contemporary
public health.”13 Eligibility for certification was
expanded in 2013 to include public health professionals
who have taken core public health courses at an accredited
institution and have relevant job experience or
other education. The CPH is the field’s only certification
for which all public health disciplines are eligible.
Other examples of certification in public health are
discipline specific. Physicians and nurses may achieve
board certification in public health through a combination
of completing clinical or preventive medicine
residency programs, successfully passing board examinations,
and enrolling in other advanced training
or fellowship programs. Workers with a degree and/
or substantial experience in health education are eligible
to sit for a Certified Health Education Specialist
(CHES) exam, which is also offered at a Master’s level
for advanced health educators. Finally, public health
laboratory workers are eligible for a variety of generalist
and specialist certifications within their field.
WORKFORCE COMPETENCIES
Public health education and training, whether provided
by a school of public health or through a training
center’s online offerings, is increasingly being guided
by the development of competencies. Competencies
form the cornerstone of efforts by schools and pro·
grams of public health, governmental public health
agencies, and many public health professional groups
to more systematically ensure that public health work·
ers are equipped with the appropriate level of skills
and knowledge to competently and effectively carry out
their work.
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
public health workforce competencies are the
foundational_ knowledge, ski!ls , and abilities necessary
for pubhc_ health profe~s10nals to efficiently and
ffectively deliver the services deemed essential to
;ublic h~alth . Competencies the~selves should be
action-oriented and clearly describable, observable,
and measurable. The CDC, IOM, and the Association
of Schools and Programs of Public Health (ASPPH)
have all strongly endorsed competency development
in order to strengthen the public health workforce.
Competencies improve the workforce by providing a
framework for developing educational and training
programs, delin_ea:ing worker roles and responsibilities
, and perm1ttmg a means for assessing worker
performance and organizational capacity. The first
public health workforce competencies were developed
in the 1980s; more recently many national public
health worker specialty groups including the Council
of State and Territorial Epidemiologists (CSTE) , the
Association of Public Health Laboratorians, the Quad
Council of Public Health Nursing Organizations, the
TABLE 18-4 Public Health Workforce Competency Sets
317
National Commission for Health Education Credentialing,
and the CDC, among others, have develope_d
comprehensive worker competencies specific to their
profession (see Tobie 18-4). 14-18 These practitioner and
profession-specific competencies are complemented by
more general public health competencies such as the
Core Competencies for Public Health Professionals d~veloped
by the Council on Linkages Between Academ~a
and Public Health Practice-developed for all public
health workers19-and the more academically oriented
public health core competencies for MPH students enrolled
in academic degree programs, developed by the
ASPPH Education Committee. For educational accreditation
, CEPH requires academic programs to clearly
identify the competencies expected of their graduates
and to indicate how course-specific learning objectives
will lead to the acquisition of these competencies.
2° Competencies are further addressed in detail in
Appendix B.
A common basis for many of these public health
worker competencies is the 10 Essential Services of Public
Competency,~~:~ Lead Organization -·=• ‘ -· ·~ ·’ · · – –~ ., Date’· Notes ·
Bioterrorism and Emergency Readiness: Columbia University School of Nursing 2002
Competencies for All Public Health Center for Health Policy & Centers for
Workers Disease Control and Prevention
Applied Epidemiology Competencies Council of State and Territorial 2006 Three tiers: Beginner,
Epidemiologists Midlevel, and Senior
Epidemiologist
Master’s Degree in Public Health Core Association of Schools of Publ ic Health 2006
Competency Development Project (v. 2.3)
Competencies for Public Health Centers for Disease Control and Prevention & 2009
lnformaticians University of Washington Center for Public
Health Informatics
Areas of Responsib ility, Competencies, National Commission for Health Education 2010
and Subcompetencies for Health Credentialing, Inc.
Education Speciali sts
Ouad Council Competencies for Public Quad Council of Public Health Nursing 2011
Health Nurses Organizations
Guidel ines for Biosafety Laboratory Centers for Disease Control and Prevention 2011
Competency
Competency Guidelines for Publ ic Health Centers for Disease Control and Prevention & 2014
Laboratory Professionals Association of Publ ic Health Laboratories
Core Competencies for Pub lic Health The Council on Linkages Between Academia 2014 (This is the newest
Professionals and Public Health Practice version)
/’ I I’
I’ I
• I
I
318
Health (ESPH) (Tobie 18-5), described earlier in this text?
ook (see, e.g., Chapters 1, 2, and 11). First formulated
m_ 1994 by the Public Health Functions Steering Com’.~
ttee, these 10 key services summarize the major activities
of ~he workforce in carrying out the responsibilities
of pubhc health and form the core from which necessary
worker knowledge, skills, and abilities are derived. For
example, the CSTE Applied Epidemiology Competencies
and the six national capacity assessments based on those
competencies focus on them largely in the context of carrying
out just four ESPH which are perceived to have a
significant epidemiological focus: ESPH 1 (Monitoring),
2 (Investigate), 9 (Evaluate), and 10 (Research).
PUBLIC HEALTH WORKFORCE
CAPACITY
There have been an increasing number of researchers,
practitioners, and policy makers acknowledging the
need to identify factors that contribute to workforce
capacity, or the ability of the public health workforce
to perform the necessary tasks to effectively deliver the
essential public health services. Deficiencies in organizational
capacity have been theorized to negatively impact
TABLE 18-5 The 10 Essential Public Health Services
1. Monitor health status to identify community health
problems.
2. Diagnose and investigate health problems and
health hazards in the community.
3. Inform, educate, and empower people about health
issues.
4. Mobilize community partnerships to identify and
solve health problems.
5. Develop policies and plans that support individual
and community health efforts.
6. Enforce laws and regulations that protect health and
ensure safety.
7. Link people to needed personal health services, and
assure the provision of health care when otherwise
unavailable.
8. Assure a competent public health and personal
health care workforce.
9. Evaluate effectiveness, accessibility, and quality of
personal- and population-based health services.
1 O. Research for new insights and innovative solutions to
health problems.
SOURCE: Centers for Disease Control and Prevention
PART FOUR PROVISION OF PUBLIC HEALTH SERV1ces
the ability to sustain public health programs and i
ventions 21 -22 an d work fo rce capac1• t y contri.b utesn te.r –
nificantly to the overall capacity of an organizatio sig.
deliver services. ~~ny f actors can contn’b u te to Wno rtko.
force capacity. Ind1v1dual factors such as educational
training background , J.O b experi.e nce, an d J. o b satisfactain d
may play a role, as well as organizational factors such on
whether the organization suppor.t s c.o ntinu. ing educati· oans
for employees. Workforce capacity 1s an ~mportant concept
that needs further research to determme how it m
h t t . . ay
be enhanced and to w at ex en orgamzational performance
may be improved as a result. Consensus amon
public health systems and services researchers and publi~
health practitioners as to how and what to measure in order
to most accurately assess workforce capacity remains
elusive although interest in this area continues to grow.
Public Health Department
Accreditation
Accreditation is the process by which health department
performance is assessed against a set of nationally recognized,
practice-focused and evidence-based standards
that are continually developed and revised. Ultimately,
the goal of the national accreditation program is to improve
and protect the health of the public by advancing
the quality and performance of tribal, state, local,
and territorial health departments while also increasing
value and accountability to public health stakeholders.
The Public Health Accreditation Board (PHAB), a
nonprofit entity charged with developing accreditation
standards and measures as well as evaluating health departments’
abilities to achieve them, strongly supports
development of the nation’s governmental public health
workforce. In addition to the various standards and
measures that detail tasks and responsibilities expected
of public health workers, there are also accreditation criteria
that focus on ensuring that a sufficient number of
workers are staffing health departments, and that those
workers are well-qualified. PHAB encourages the development
of a competent workforce by requiring health
departments to regularly assess staff competencies and
address gaps through training opportunities. 23-24 The
PHAB standards and measures include a domain focused
on maintaining a competent public health workforce.
The two standards within this domain require
health departments to: encourage the development of
a sufficient number of qualified public health workers;
and, ensure a competent workforce through assess·
me_nt_ of staff competencies, the provision of individu~
t~ammg and professional development, and the pr~vi·
s1on of a supportive work environment. 24 Accreditation
measur~s such as these promote the development of _a
well-tramed workforce that can effectively deliver public
health services in health departments.
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
WORKFORCE RESEARCH
Research on the public health workforce is typically inJuded
under the broader umbrella of public health sere.
es and systems research (PHSSR) which is defined as
VlCfi eld of study t h at exami.n es t h e organization, finance,
and delivery of public health services in communities
:nd the impact of these service~ on public health.
In the last few years especially, numerous national
workgroups have been convened, meetings held, and papers
written on public health workforce research needs.
Recently, a number of central themes have been developed
to guide the public health workforce research agenda25
and public health workforce has been specifically identified
as one of the four main thematic areas of PHSSR in
a 2012 journal supplement (as shown in Tobie 18-6).2<>
The progress in the conduct of research on these themes
varies and, for example, while the evidence base on public
health worker enumeration and competency development
have both rapidly advanced, in contrast we have
made very little headway in examining issues around (the
Jack of) workforce diversity and disparities, or in addressing
the clear lack of diversity in the current public health
workforce, especially in leadership positions. Nonetheless,
these themes provide a research roadmap that hopefully
will establish a basis for guiding future efforts to develop
a competent, sustainable, and diverse public health workforce
through evidence-based training, career and leadership
development, and strategic workforce planning to
improve population health outcomes.
LEADERSHIP
Leadership is the “process of persuasion or example by
which an individual influences a group to act toward a
common goal.”27 In this definition emphasis is placed
on the processes associated with the practice of leadership
(rather than the personality of the leader)• It
then follows that effective leadership is characterized by
TABLE 18-6 Public Health Workforce Research
Priority Areas
Worker enumeration
Demand, supply, and shortages
Diversity and disparities
Recruitment and retention
Workforce competencies
Educational methods and curricula
SOlJR.CE: Consortium from Altarum Institute, CDC: th~ Robert
Wood Johnson Foundation, and the National C00rdmat1ng Center
for Public Health Services and Systems Research
319
adherence to certain behaviors which can contribute to
improved performance by “followers” and to increased
organizational effectiveness.
In this section, some of the theoretical resea_rch
on leadership practice will be reviewed with a parti_cular
emphasis on applicabilit~ to publ_ic heal~h pract1
::~
Since an emphasis on practice and 1mprovn1:g lea~
ship behaviors flows from that research, a d1scuss10n
of various programs desigi:ied to enh_ance p~blic healt~
leadership development will be provided. Fmall~, som
guiding principles and best practices will be delmeated
as a guide for future leader development.
Leadership versus Management
The processes of leadership and manage~e~t ar~ different.
The process of leadership has been d1stmgm~hed
from the process of management by the aphons~:
“leadership is doing the right thing, management 1s
doing things right.”28 Perhaps the most useful framework
for distinguishing the two processes came from
Kotter. 29 In his formulation, management is designed
to provide order and consistency; leadership is designed
to provide change and movement. To accomplish these
goals, management consists of planning and budgeting,
organizing and staffing, and controlling and problem
solving. Leadership is about providing direction, aligning
people, and motivating and inspiring. 29
Another approach to distinguishing the practices
of management and leadership30 focused on the role
of leaders as providing a compelling vision and core
strategies while management involved translating strategies
into operational reality using specific tactics. In
this formulation, a vision should be “something you can
see”-a visualizable mental picture that is easily communicated
to others. Strategies provide the logic and limited
details for how the vision can be achieved. In public
health, programs are created to operationalize the strategies
and apply concrete tactical solutions to problems.
Theories of Leadership Practice
The commonly used statement that “leaders are born
and not made” derives from a trait perspective toward
leadership.27 As a result of this emphasis, early research
on leadership practice focused on the personal attributes
of effective leaders, leading to the erroneous view
that a basic set of unique traits could be delineated and,
as a result, aspiring leaders should be assessed with respect
to those ideal traits. Selection for leadership positions
then utilized an assessment and matching process.
In the mid-twentieth century, this point of view
was called into question as an era of leadership development
began. Since the trait theory of leadership provides
a very static view of what a leader is and should
I
320
be, ~ystematic development of leadership skills and be~
aviors was devalued. Once this static view was called
mto question, the research field expanded to consider
a range of theoretical foundations that led into formal
approaches to developing leaders.
The Skills Approach
Seminal research31 •32 in the mid- to late-twentieth century
created a useful framework for the elucidation of
the skills needed for effective leadership. Katz’s 1955
paper considered the skills needed at various levels
of an organization. At the supervisory level, technical
and human skills are needed to a greater degree than
con~~ptual skills. As one moves “up” into a managerial
position, ~II ~h~ee skill areas take on equal importance.
Once_ an m~1vidual reaches a top leadership position,
techmcal skill becomes less important while human and
conceptual skills are paramount.
. Mui:nfo_r~ went further by focusing on the relationship
of md1V1dual attributes and competencies as they
relat~ to leadership outcomes, such as effective problem
solvmg and enhanced performance. 32 In his formulation,
there are four key individual attributes:
► General Cognitive Ability
► Crystallized Cognitive Ability
► Motivation
► Personality
These attributes contribute to specific leadership
competencies:
► Problem-solving skills-especially when dealing
with novel and ill-defined problems
► Social Judgment skills-the capacity to understand
people and social systems
► Knowledge-the accumulation of information
needed to apply skills to a particular situation,
along with the ability to mentally structure and
communicate that knowledge
This skills-based framework has fostered the use of a
range of educational approaches designed to enhance
creative problem solving, conflict resolution, listening,
and teamwork. 27
The Situational Approach
Building upon the skills approach, research then evolved
to consider ways in which leadership styles should be
adapted to different situations, particularly as they relate
to the developmental level of the follower. 33 This approach
takes into account the degree to which leaders should focus
energy and attention on tasks versus the development
of relationships. For example, in situations where the “follower”
is less developed, a directive is called for; whereas,
more developed followers can be supported or delegated
to. A central challenge of this approach lies in the ability
PART FOUR PROVISION OF PUBLIC HEALTH SERViqs
of the leader to correctly assess the developmental le
hi /h ve 1o r another person and to adapt s er style according! y.
Transformational Leadership
A more popular, recent theory of leadership practi· .
transformational lea de rs h1. p, wh 1′ c h .ts contrasted wce· ihs
transactional leadership. As described by Burns :J.1, t It . . ‘ ransformational
leadership taps the motives of followers
establishes an interactt.o n be tween Ie a de rs and followaenrds
toward achieveme.n t of .a common goal. In contrast , tr~” nsactional
leadership rehes on the exchange of some ty
of contingent reward from the leader in order to elicitpc
behavior on the part of t_h e 1c 0I I ower:’ lo Tr ~nsformationaal
leadership is seen as evoking a more endunng level of motivation
and a level of performance beyond expectations
Kouzes and Posner36 articulated a set of five fund~mental
practices which p~ovide strategies for practicing
transformational leadership:
► Model the Way
► Inspire a Shared Vision
► Challenge the Process
► Enable Others to Act
► Encourage the Heart
This practice-oriented approach emphasizes that certain
behaviors can lead to better organizational outcomes
and can be learned by the developing leader.
Servant Leadership
Robert Greenleaf in his classic book, Servant Leadership,37
articulated a view of leadership that has resonated for
many:
Servant leadership begins with the natural feeling
that one wants to serve, to serve first … . The
best test is: do those served grow as persons and
will the least privileged in society benefit. 37
Servant leadership behaviors can then be described as
including listening, showing empathy and awareness,
committing to the growth of others, and building com·
munity. 38 Within the context of public health practice,
the servant leadership philosophy has had particular
resonance as a foundation for various approaches to
the development of public health leaders.
Leadership Development
in Public Health
As theories of leadership evolved and an emphasis on developing
leaders increased, organized programs were created
to develop public health leaders beginning in 1990,
The National Public Health Leadership Institute
Following the IOM report on The Future of Public
Health, 3 the CDC, under the leadership of Director
j
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
or. William Roper, c~n~mitted to an extensive effort
to strengthen the pub~ic mfrastructure in 1990. Within
this conte~’t, leadership de~elopment_was identified as
top priority and the National Pubhc Health Leader-
31 •p Institute (PHLI) was formed in 1991. The mission
s1f1 the PHLI was to provi’ d e top pub h. e health leaders 0 ‘th a high-quality development opportunity in which
M .
they were exposed to new perspectives related to the
ractice of leadership within the public health system.
i’he pHLI program was initially designed and managed
by a team of California public health leaders; the proaram
was later managed out of the University of North
0 Carolina.
Over the 20 years of its existence (1991-2011),
the Public Health Leadership Institute included nearly
1,000 scholars in top public health leadership positions,
including a former U.S. Surgeon General, top
CDC and other federal health agency leaders, numerous
state and local health directors, the National Association
of County and City Health Officials (NACCHO)
and Association of State and Territorial Health Officials
(ASTHO) presidents, the current Food and Drug Administration
commissioner, the CEO of CARE, a senior
vice president of a major health foundation, presidents
and executive directors of the American Public Health
Association, Association of Schools of Public Health,
Public Health Foundation, Association of Public Health
Laboratories, deans and professors in schools of public
health, and leaders in many other major health
organizations. 39
An evaluation40,41 of the impact of the PHLI prooram
revealed that 81 percent of PHLI graduates de:
eloped a better understanding of leadership principles
and practices; 73 percent developed ne~ o~ better
leadership skills and behaviors, such as skills m leading
collaborations and managing teams; 82 percent developed
an enhanced awareness of their own personal
leadership behaviors through the use o~ 360 de~re~
assessment, team interaction, and executive coachi?g,
55 percent developed a professional knowle~ge-shar~ng
network focusing on public health leadership practice,
which continued for many years after gradu~t.wn; and
19 percent obtained new or higher level positions as a
result of PHLI participation. PHLI grad_u~tes also led
the creation of new policies and laws gmdmg the practice
of public health such as increasing cigarette taxes,
developing a state trauma registry system, and passage
of a smoke-free workplace act. Finally, gra_duates
increased funding for public health programs mcludi.
n g legislation providing $ 1. 9 mi·1 1·i on for loca.l pu.b –
11.c health departments and an ·m creas e in funding for
school nurses. was the
Another benefit of the PHLI prof~ H alth
creation of an alumni network, the u hic e h
Le adership Society (PHLS), w hi. c h broug t toget er
321
PHLI alumni and alumni of other similar prog~am~ to
enhance lifelong learning. An important contnbutwn
of the PHLS was the creation of a Public Health Code
of Ethics,42 which is discussed in greater detail in
Chapter 5.
The National Public Health Leadership
Development Network
In 1994 the National Public Health Leadership Network
(le’d by the Saint Louis University College for
Public Health and Social Justice) was formed to share
information and to develop collaboration across the
growing number of state, regional, and national public
health leadership institutes. The network of leade_rship
institutes ultimately expanded through academ~c
and practice collaboration among schools of pubhc
health and state public health departmen~s, ~esulting
in the establishment of 1~ state~ba~ed mst1tutes,
10 regional institutes, 6 national mst1tutes, and 3
international institutes. As a result, 4 7 states plus the
District of Columbia and Puerto Rico had access to
a state, regional, or national public health leadershi_P
program. These programs graduated over 6,000 pubbc
health practitioners from across the world. A full report
on these public health leadership programs can be accessed
through http://www.heartlandcenters.slu.edu.
Furthermore, the network created a competency
set which guided the design and development of public
health leadership institutes for over a decade. -i-3
The National Leadership Academy
for the Public’s Health
The National Leadership Academy for the Public’s
Health (NLAPH) began in 2011 to provide training to
four-person multisector teams from across the country
to advance their leadership skills and to achieve health
equity in their communities. The program, managed by
the Public Health Institute in Oakland, California, uses
an experiential learning process that includes webinars,
a multiday retreat, coaching, peer networking, and an
applied population health project.
In its first year, NLAPH was successful in advancing
participants’ leadership skills, strengthening team functioning,
increasing intersectoral collaboration, and helping
teams make progress on their community health
improvement project. Through 2014, 69 teams from 33
states along with two national teams have participated
in the NLAPH pmgram.
Schools of Public Health and Academic
Public Health Programs
Some schools of public health and academic public
health programs have included courses in the curriculum
related to leadership theory and practice. Often ,
I
322
graduate public health students may have access to
leadership development experiences through business
schools within their own university. Some schools (e.g.,
University of North Carolina at Chapel Hill, University
of Illinois at Chicago, and Harvard) have developed
doctoral programs in public health leading to DrPH
degrees that focus on leadership practice and provide
opportunities to develop leadership skills as part of a
fom1al degree program.
In 2009, the Association of Schools of Public
Health developed a set of competencies for DrPH
programs which included specific leadership competencies
to develop the ability to create and communicate
a shared vision for a positive future; inspire trust
and motivate others; and use evidence-based strategies
to enhance essential public health services. (More information
can be found at http://www.aspph.org by
searching “DrPH Model.”) Graduates of such DrPH
programs are expected to acquire the following leadership
skills:
► Communicate an organization’s mission, shared
vision, and values to stakeholders.
► Develop teams for implementing health initiatives.
► Collaborate with diverse groups.
► Influence others to achieve high standards of
performance and accountability.
► Guide organizational decision making and planning
based on internal and external environmental
research.
► Prepare professional plans incorporating lifelong
learning, mentoring, and continued career progression
strategies.
► Create a shared vision.
► Develop capacity-building strategies at the individual,
organizational, and community level.
> Demonstrate a commitment to personal and
professional values.
These competencies now provide a basis for curriculum
development and course creation in schools of public
health and academic public health programs.
Lea~ership Development Programs Sponsored by
National Public Health Organizations
PRovisioN OF PUBLIC HEALTH SERVicl:’. .. l· PART FOUR Q
. h lth directors in a mentoring relationshi’
with new ea d J h d p.
d
. f m the Robert Woo o nson an de Beau
Fun mg ro · l ·
mont Fo un d a ti·ons has been essentla to support the se
programs.
Leadership Development Needs at Stages
of Career Development
As leaders develop, they may evolve through a series
of stages in which devel?pmental needs differ.44 The
emerging leader (sometimes refe~red ~o as a “rising
star”) needs to be identifie? an~ assisted m developing a
personal awareness of their umque talents and abilities.
Further these emerging leaders benefit from exposure
to lead~rship concepts and theories ~as noted above)
and involvement in a formal mentormg relationship.
Emerging leaders should seek out a mentor, rather than
hoping one will come along.
At a later stage, often when a young leader enters a
full-time job situation, needs evolve as she/he enters the
stage of the “early leader.” In this stage, technical skills
are often central in public health occupations (e.g., epidemiology);
however, leadership development must
also advance skills in adaptive change. At this stage, formal
360 degree assessments are useful along with participation
in formal leadership development programs
of the type noted above. Peer networks are also of great
value as ways to share lessons learned and promote lifelong
learning.
As leaders progress to becoming established leaders,
they will continue to benefit from activities noted
at earlier developmental stages and should take note
of the need for ongoing peer-to-peer interaction with a
struc~red approach to formal executive coaching. Often,
established leaders fail to commit to leadership develop·
~~°:t as the? _bec~me saddled with increasing responsi·
bihties. Pa~c1pat10n in some type of formal development
program swted to their needs can offset the tendency to
procr~stinate with regard to ongoing leadership learning.
Fmally, as leaders enter the emeritus stage of their ca·
reers, they may be uniquely qualified to serve as coaches
and m_ent?r~ to those at early career stages. In this way,
these mdividuals may pass on the wisdom of experi·
ence tha.t goes b eyon d fo rmal courses or programs ·in
leadership.
Both ASTHO (http://www.astho.org) and NACCHO
(~ttp://www.naccho.org) have sponsored programs designed
to enhance leadership skills in directors of state
or local health departments. ASTHO has also created
a leadership development experience designed for senior
deputies. Each of these programs relies on a competency-
based format and a cohort model in which
peer learning and network development is enhanced.
The NACCHO program-the “Survive and Thrive
Program”-pairs experienced local health directors
PROFILES IN PUBLIC HEALTH
LEADERSHIP
Many of the princi 1 exemplified d .
1
. P es and practices noted above arc
Two example:
1
(f;:~he work of public health lea~ersd
here) are useful . many hundreds not describe
practice of publicm h p roviding 1 f the 1 h concrete examp es o .
Exhibit 18-1. eat leadership, as shown beloW 111
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
tXlllBIT 18-1 Leadership Profiles
f c•j=• § liii) # ;l =!M: ~
As Director of the Massachusetts Commission of Public
Health, John Auerbach led efforts to capture and codify
the role of public health in the Massachusetts Health Reform
effort that has served as a national model for health
system change. In an article titled: “Lessons From the
Front Line: The Massachusetts Experience of the Role
of Public Health in Health Care Reform,” 45 he stated five
key principles that enabled public health contributions to
landmark health policy change:
1. Get a Seat at the Table
2. Take an Open Minded and Critical Look at What Public
Health Does Now
As Director of the Kane County (Illinois) Health
Department, Paul Kuehnert was faced with a daunting
challenge during the Great Recession of 2008. Budget
cuts prompted an in-depth reassessment of the role
of the public health agency that ultimately led to the
transfer of personal health services out of the health
agency into three federally qualified health centers and
SUMMARY
The public health workforce comprises a diverse group
of health professionals who are uniquely varied in terms
of the education, skills, and experience they bring to the
job, although all share a common awareness of and commitment
to improving health through a population fo~s.
Over the last decade the public health workforce, unhke
?ther health professions, has grown smaller while also
increasing in occupational diversity to encompass n_ew
fields such as health informatics, public health genetics,
~nd emergency preparedness. The opportunities for public
health training and education have never been greater
as the number of programs and schools of publ~c health
have rapidly expanded along with more o~tions for
continuing education. The result is an increasmgly p~ofessionalized
public health workforce that has been further
~trengthened by enhancements to co~pe~ency-basecl
t~ainings, worker certification, and accred1tatJOn °_f pu~hc
health agencies. Despite these advanc~s, too httle 18
known about the number and type of pubhc healt~ workers
and the reasons they enter and leave ~he workfo~ce. ,
. A key concept related to workfare~ is that of lea~ership,
defined as the “process of persuaswn or example by
Wh1· ch an m. d1. v1. dual i. nfluences a gr oup to act tow. ard. a
cornrnon goal.” Leadership is essential to the reahzat10n
323
3. Defend the Traditional Public Health Approach When
Called For
4. Keep on the Lookout for Opportunities
5. Envision a Better Model and Take Steps to Make It
Real
These principles, which were instrumental in leading
the Massachusetts Health Reform effort, reflect the
leadership attributes described in this section and are
broadly applicable to other public health challenges and
opportunities.
a reduction in the agency workforce by 50 percent.46
This case study exemplifies the practice of front line
leadership within a public health agency (in addressing
major organizational changes) as well as leadership outside
the agency (to navigate major political challenges
related to accomplishing unprecedented organizational
change).
of a shared vision, and a number of theories have been
developed regarding the skills required for effective leadership,
although “servant leadership” is an especially
compelling model. Outstanding leadership for the public
health workforce will be needed to successfully address
the challenges and opportunities to improve and
protect the public’s health in the twenty-first century.
REVIEW QUESTIONS
1. What are some of the professions that comprise
the public health workforce and what do they share
in common’?
2. What are some of the key trends in public health
worker professionalization ‘?
3. What are competencies and why are they valuable’?
What are some of the public health professions
which have developed profession-specific
competencies’?
4 . How does the practice of leadership differ from the
practice of management’?
5. What are the key feahires of servant leadership’?
6. What do “early leaders” need to enhance their own
leadership skill development’?
