1. Carlin, Maggie MPH
  2. Ensign, Karl MPP
  3. Person, Cara J. PhD, MPH, CPH
  4. Kittle, Alannah MPH
  5. Meadows, Kristi MPH

Article Content

The public health workforce shapes our nation's health in myriad ways. Although often working behind the scenes, the COVID-19 pandemic has placed this critical workforce in the spotlight now more than ever. As state and territorial health agencies respond to new challenges in the COVID-19 era, it is important to assess the state of their workforce and reflect on trends over time.


One key data source to understand this workforce is the ASTHO Profile1-a longitudinal study of the governmental public health system across all US states; Washington, District of Columbia; US territories; and freely associated states. This study illustrates trends in state public health infrastructure over the past decade. The Profile collects data through a national survey of state public health agencies fielded most recently in 2019, offering a lens into the prepandemic public health workforce.


State Workforce Capacity

State health departments sustain critical public health services while remaining agile to emerging threats and population needs.2 In recent years, agencies have done so with a shrinking workforce. From 2012 to 2019, the state health workforce decreased by almost 10%, from 101 619 full-time equivalents (FTEs) to 91 540 FTEs. Since 2010, states experienced an average decrease of 10 FTE public health workers per 100 000 residents ([mu] = 50.86 in 2010; [mu] = 40.6 in 2019).1


This workforce decline was accompanied by a decrease in healthy agency funding over the same period. Expenditures by state public health agencies fell between 2010 and 2018, attributable to lower funding from federal and state sources.1 State public health agencies are also contending with other threats to their workforce capacity, with nearly half (47%) of state health department central office staff-themselves half (47%) of the total state public health workforce-reporting in 2017 that they were considering leaving their agency or planning to retire.1,3


Before the COVID-19 pandemic, this downward trend seemed set to continue. In 2019, state public health agencies reported more separations from their workforces that year ([mu] = 295.7 separations per agency) than recruitments for vacant positions ([mu] = 171.6 recruited positions per agency). These trends left state and territorial health agencies in a compromised position to effectively respond to the wide-scale public health emergency of the COVID-19 pandemic.4,5


Workforce Composition

The state public health workforce comprises a range of essential occupations, from public health nurses and laboratory workers to quality improvement specialists and informaticians. Representing more than a third of the workforce (35%) in 2019, administrative and business professionals play a crucial role in preparing for the administrative consequences of public health emergencies and sustaining the workforce itself. Many in this group are responsible for making and implementing decisions addressing workforce challenges.


In the years prior to the COVID-19 pandemic, the state public health workforce underwent significant shifts across specializations. Nationally, numbers of behavioral health professionals increased between 2012 and 2019 to make up a greater proportion of the workforce (11%) in 2019 as the public health system faced rising challenges such as the opioid crisis. Agencies also saw increases in epidemiological and statistical positions during the same period, though this group comprises just 5% of the state public health workforce.1,6 Epidemiologists and statisticians have been called on to play a leading role in the COVID-19 response along with laboratory and clinical occupations-2 groups that experienced little to no workforce growth in preceding years.1


Territorial Public Health Workforce

The public health workforce of the US territories and freely associated states-the insular areas-has seen similar trends but faces distinct challenges. Insular area public health agencies struggle to maintain a full public health and health care workforce due to a number of unique factors, including the sheer distance of Pacific jurisdictions from the mainland United States, the lack of basic infrastructure in remote island outposts, a lack of on-island educational opportunities, substantial emigration of professionals for better opportunities and higher salaries ("brain drain"), and underfunded health systems.7 All localities in each of the US-Affiliated Pacific Island jurisdictions are designated by HRSA as Health Professional Shortage Areas and Medically Underserved Areas/Populations.8


Given the challenges facing these jurisdictions and their proximity to skilled workers in countries such as the Philippines, Pacific jurisdictions frequently rely on foreign and guest workers for nursing and other specialized professions. Yet, when employed by territories, these non-US citizens must adhere to US visa and guest worker restrictions, requiring them to leave their posts at periodic intervals in the absence of specialized waivers.9


The ASTHO Profile found that the workforce in these areas decreased by 7.4% between 2016 ([mu] = 932 FTEs per agency) and 2019 ([mu] = 863 FTEs per agency). This segment of the public health workforce also has a higher proportion of clinical occupations and a higher average of FTEs per 100 000 population due to the integration of jurisdictional public health and health care systems in the Pacific.1


Recent and Upcoming Challenges

State and territorial health agencies continue to address a global pandemic and face near-constant decisions about staffing the response effort. Amid high turnover of state health officials,10 these agencies must now utilize or scale-up their existing workforces to implement key elements of the pandemic response such as establishing large-scale contact tracing operations and administering mass vaccination campaigns. With these scale-ups come crucial decisions on hiring, contracting, workforce training and development, and sustainability. To be truly effective, these efforts must be aligned at the state, national, and local levels.


The ASTHO Profile and other efforts will continue monitoring the workforce as a vital element of public health infrastructure. These and other data on the public health workforce will serve as context for the public health system's response to the COVID pandemic and as a baseline to monitor the impact of the pandemic on the public health workforce.




1. Association of State and Territorial Health Officials. ASTHO Profile of State and Territorial Public Health, Volume 5. Published 2020. Accessed October 14, 2020. [Context Link]


2. Association of State and Territorial Health Officials. Taking action: the activities of state health agencies from 2016-2019. Published 2020. Accessed October 14, 2020. [Context Link]


3. Bogaert K, Castrucci BC, Gould E, et al The Public Health Workforce Interests and Needs Survey (PH WINS 2017): an expanded perspective on the state health agency workforce. J Public Health Manag Pract. 2019;25:S16. [Context Link]


4. Maani N, Galea S. Covid-19 and underinvestment in the public health infrastructure of the United States. Milbank Q. 2020;98(2):250-259. [Context Link]


5. Hawkins D. Health agencies' funding cuts challenge coronavirus response. Washington Post. March 8, 2020. Accessed October 14, 2020. [Context Link]


6. Association of State and Territorial Health Officials. State health agency workforce by occupation. Published 2020. Accessed October 14, 2020. [Context Link]


7. Aitaoto N, Ichiho HM. Assessing the health care system of services for non-communicable diseases in the US-Affiliated Pacific Islands: a Pacific regional perspective. Hawaii J Med Public Health. 2013;72(5)(suppl 1):106-114. [Context Link]


8. Health Resources Services Administration. HPSA Find. Accessed October 14, 2020. [Context Link]


9. Torres R. Letter to Eugene Scalia, U.S. Secretary of Labor. Request for Temporary Labor Certifications. Washington, DC: US Department of Labor; 2020. [Context Link]


10. Weber L, Barry-Jester AM, Smith MR. Public Health Officials Face Wave of Threats, Pressure Amid Coronavirus Response. San Francisco, CA: Kaiser Health News and The Associated Press; 2020. Accessed October 14, 2020. [Context Link]