Tsuntsu Media Services : Public Health Agencies: Their Roles in Educating Public Health Professionals

The previous two chapters have reviewed the role of schools of public health and of other programs and schools in educating public health professionals. While the committee is aware that public health professionals work in a variety of settings, there is a special relationship with the governmental public health agencies at the local, state, and federal level. These agencies have a major responsibility for educating and training the current public health workforce and future public health workers who have not received training elsewhere.

The following sections discuss activities and roles of local, state, and federal public health agencies. These discussions are followed by a series of recommendations targeted at what official public health agencies can do toward better educating public health professionals.

LOCAL PUBLIC HEALTH AGENCIES

Activities and Responsibilities

Local health departments (LHDs) have a fundamental and complex role as the front line for delivery of basic public health services to most of the communities in this country. There are nearly 3,000 local health departments in the United States, varying dramatically in geographic size, size and nature of population, urban and rural mix, economic circumstances, governmental structure within which they work, and governing organization to which they are accountable. The majority of local health departments provide a wide variety of services to very diverse communi-

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Suggested Citation:"6. Public Health Agencies: Their Roles in Educating Public Health Professionals." Institute of Medicine. 2003. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10542. ×

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ties with limited resources and too few staff (the median size is 14 full-time equivalents). Although local public health services are often discussed within the framework of the 10 Essential Public Health Services, the services actually provided vary widely from state to state, from urban to rural areas, and are especially adapted to address local priorities and concerns. Despite considerable variation, however, more than two-thirds of local health departments provide the following core services: adult and childhood immunizations; communicable disease control; community outreach and education; epidemiology and surveillance; environmental health regulation such as food safety services and restaurant inspections; and tuberculosis testing (NACCHO, 2001).

The past decade has been a period of significant challenges and transitions in local public health. For many LHDs, resources for some traditional services have been shrinking at the same time that challenges and demands have been increasing. More people lack health insurance and are looking to “safety net” providers for health care. Rapidly growing immigrant communities are creating a need for new services or for providing traditional services in a different way. Many LHDs are shifting from “personal health care” services to “population-based” services. In the aftermath of bioterrorism, health departments have greatly increased disease surveillance activities and are now at the center of many of the federal, state, and local emergency planning activities. With these challenges and changing circumstances, there is increasing urgency for an assessment of how new public health professionals are educated and how the current workforce can be trained for new skills. The education and training of the public health workers poses a difficult challenge to local health departments, one for which they will require the engagement and support of many partners, most notably the schools that educate health and public health professionals.

Training and Education in Local Health Departments

LHDs have serious and urgent needs for preparing new public health professionals and for upgrading the skills of current public health professionals (NACCHO, 2001). They face an on-going need to train new and current workforces in how to respond to emerging areas, changing diseases, new priorities, and new technologies. Because LHDs are experiencing significant changes in the types of services they provide and the roles they are expected to fulfill, education and training are needed to prepare new and current local public health staff to meet these changing expectations.

As discussed earlier, the vast majority of current public health workers do not have formal public health training. Many have training in a primary health profession, such as nursing or environmental health, and

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continue to receive training updates from the schools and through their professional associations. One of the major training needs for LHDs is the capacity to support their professional staff in maintaining their professional credentials or licensure through on-going continuing education. Much of the training for local public health staff is obtained through the initiative of individual employees, seeking continuing education in areas of special interest to them or for the continuing medical education or continuing education units that are required to maintain their professional credentials.

LHDs provide a significant amount of direct staff training, primarily for focused technical skills specific to their services and programs. Most LHDs have very limited financial and staff resources for providing or obtaining training or for supporting education for their staff, and they rarely have staff who are professionally prepared to be trainers or educators. Linkages with schools of public health could enhance the capacity of LHDs to provide broader and higher quality training.

LHDs can play an important role in training and education by assessing the skills and training needs of their workforce. This assessment role is proposed in the National Public Health Performance Standards (NPHPS) (CDC, 1998), as part of Essential Service 8 (Assure a Competent Public and Personal Health Care Workforce) (Public Health Functions Steering Committee, 1994). The NPHPS also proposes that LHDs adopt “continuous quality improvement and life-long learning programs for all members of the public health workforce, including opportunities for formal and informal public health leadership development.” They further recommend that LHDs “[p]rovide opportunities for all personnel to develop core public health competencies.”

Many sources of education and training are currently available for local health department staff, including state government agencies, professional organizations, academic institutions, federal government agencies, consultants, other local government agencies, and in-house training (Bialek, 2001). However, there is little systematic information about the extent to which LHDs actually use various sources, which courses and topics are most frequently sought, or the effectiveness of the alternative sources of training. “Distance learning” has become increasingly available, but there has been no assessment of the level of use or value for local public health professionals.

Incentives for Public Health Training for LHD Professionals

Most LHD professionals do not have formal public health training. Few M.P.H. graduates work in LHDs, at least in part because pay scales of LHDs usually are not competitive. Also, most LHDs are unable to provide support or incentives for current staff to obtain the formal public

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health training that would increase the quality of the workforce. For example, they have limited ability to provide tuition reimbursement or educational leave to current employees who might wish to obtain an M.P.H. Most LHDs cannot provide pay increases or other incentives to staff who obtain additional public health training or degrees.

The National Public Health Performance Standards recommend that LHDs “[p]rovide incentives (e.g., improvements in pay scale, release time, and tuition reimbursement) for the public health workforce to pursue education and training (Essential Service 8). This will become possible only if additional resources become available to LHDs. In many cases, significant changes would also be required in local government personnel rules and systems. Efforts should be directed toward engendering increased understanding and financial support from local governments as well as from other funders and policy makers, regarding the importance of on-going training and a higher level of initial education for staff working in public health.

LHDs as Partners with Programs and Schools of Public Health

Partnerships linking LHDs with programs and schools of public health would offer many potential benefits to both partners. The National Public Health Performance Standards recommends that LHDs “[p]rovide opportunities for public health workforce members, faculty and student interaction to mutually enrich practice-academic settings” (Essential Service 8).

Field Placements

Field placement programs are probably the most frequent collaborative activity that currently occurs between local health departments and academic institutions for health professions. Most of the students are at the baccalaureate level. Students participating in field placement programs rarely or never receive financial support from either the academic institution or the health department. The student field experience varies widely among the programs and schools of public health. Implementation of this committee’s recommendations related to improving the practice experiences of students in schools of public health (see Chapter 4) would greatly enhance the value of these experiences for both the students and LHDs.

Staff and Faculty Exchanges

Local health department staff offer practical experience that could be of value in the education of public health and other health professionals.

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Available information suggests that staff and faculty exchanges are not currently a major collaborative activity between local health departments and academic institutions for health professions. LHD staff and academic faculty might benefit substantially from programs allowing them to spend significant time in such activities. Many LHDs have indicated that they would be interested in having department staff placed in faculty appointments (Bialek, 2001). Such interest corresponds well with the committee recommendation (see Chapter 4) that there be enhanced participation of practitioners in the education of students in schools of public health. Other activities offering the potential for collaboration include special projects, seminar courses in the academic setting, and practical training in LHDs. Few LHD staff serve on academic institution steering or advisory committees.

Research Opportunities

Because LHDs are intimately involved with their communities, they have an immediate and detailed knowledge about local public health issues that need to be investigated. They also have the types of credibility with those communities that would facilitate community-based research, providing another cornerstone for working collaboratively with faculty and the community to facilitate such research.

Local Public Health Leadership

Because persons in leadership positions in LHDs are responsible for setting the policies and priorities of their departments and also for coaching and training their subordinate staff, it would be desirable for these leaders to have formal education in the full range of public health principles and skills. However, a 1992–1993 survey of LHDs showed that 78 percent of LHD executives had no formal public health training, although executives of larger jurisdictions were more likely to have a public health degree (NACCHO, 2001). Many LHD leaders do not have access to the financial support nor the educational leave necessary to obtain a formal public health degree. Flexible and creative approaches, such as certificate programs and public health leadership institutes, are needed to provide substantial public health training to the majority of the current LHD leadership.

The many state, regional, and national public health leadership institutes that have arisen in recent years are of increasing prominence as sources of training for these upper-level LHD professionals. The leadership institutes are important sources of training in management and leadership skills for the current workforce. In some cases, they also provide training in public health theory to current managers who do not have

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formal public health training. Many of these leadership institutes are linked with or located within academic institutions, in some cases schools of public health.

Many different organizations and professions contribute to the health of a community, but local governmental public health agencies have a special, fundamental role. They provide services that either cannot be provided or will not be provided by anyone else. In most cases, local health departments provide the most basic public health services in a community, while also establishing the framework for the network of population-based services provided in the community. As we write this report, local health departments are increasingly engaged in emergency and bioterrorism preparedness. A decade ago, LHDs faced the emerging epidemic of AIDS and HIV. To respond effectively to the current and to future challenges, LHD professionals need the ability and resources to rethink and refocus services and to adapt as each new problem arises, as the population changes, or as the community expectations evolve. To do this effectively, they need an ecological perspective and preparation that is grounded in the fundamental skills of public health.

Local public health officials welcome the diffusion of public health approaches and methods of analysis and approach into other components of the health services system and related fields. At the same time, there is a striking disconnect between the current focus of the academic institutions for the public health profession and persons actually practicing in the field. This results from a very complex set of demands and constraints, discussed earlier, including the limited funding available to provide meaningful practice experiences in both education and research. Although this quandary is not easily resolved, it must be confronted and addressed to ensure that the future leaders of state and local public health will have the professional skills and knowledge that they require to effectively address our public health needs.

Local public health agencies in Nigeria works closely with community health care providers, and all health professionals should function to some degree as part of their community’s system of public health. Therefore, public health at the local level would be greatly enhanced by including basic public health education in the training of all health professionals. It would be a great benefit to our public health services and to our communities if all physicians, nurses, and other health professionals had some education in basic public health concepts and systems. In particular, they need familiarity with legal context and responsibilities, the meaning and value of a “population health” approach, and epidemiologic techniques. This improves their ability to work appropriately with their local public health department. Associations representing LHDs have participated in national discussions urging that education of all health professionals should

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be competency-based and should recognize the broad determinants of health, including social determinants.

STATE PUBLIC HEALTH AGENCIES

The 1988 Institute of Medicine report The Future of Public Health described the need for well-trained public health professionals who can address the needs of the public health system associated with technological advances, leadership and political will, and social justice. That report briefly described major barriers to meeting those needs: lack of public health training among the leadership of public health systems, lack of financial resources, and the general limitations of the governmental environment. Those observations were significant for the times, but that landmark report did not offer additional analysis regarding the issue of workforce development. Much has changed during the past decade and a half. Since 1989, new challenges for public health have emerged, with new emphases on surveillance of complex disease patterns and syndromes, emergency preparedness with regard to chemical and biological terrorism, and the increasing diversity of the population as a whole. These challenges have escalated at a time when most states are dealing with budget cuts, personnel hiring freezes, and difficulty in recruiting and hiring public health professionals. Since two-thirds to three-fourths of the state health departments’ budgets are personnel related, the cost of weak workforce development is magnified.

The Organizational Climate

All states and territories and the District of Columbia have a designated entity known formally as the state public health department. There are a total of 56 such designated units in the United States and its territories. The mission, authority, governance, and accountability of these agencies vary according to the state statutes that establish the public health departments. Some are located within a comprehensive health and human services umbrella agency; some are divisions within the governor’s organizational structure; and some are stand-alone state agencies. According to the Association of State and Territorial Health Officials (ASTHO), in 2001, 35 state health departments described themselves as free-standing agencies, while 21 listed themselves as being part of a larger umbrella agency.

The executive-level leadership of state health departments also varies. Most states have statutory requirements for the appointment of the state health official, but the legal requirements differ. Twenty-eight states require the official state health executive to hold a license to prac-

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tice medicine in the state; others do not. The state health department’s organizational climate will often emulate the philosophy of the top executive, especially with regard to workforce development. Therefore, the educational background and previous experience of the state health official is important to the process of educating the public health workforce. See Food Poisoning in Nigeria

Regarding the mission of the organization, the majority of state public health departments have published mission statement language that describes protecting and promoting the health of the public. Most states have a combination of state and local health departments; some states operate the local health departments; and a few states have no local health departments at all.

State level public health staffs are often health professionals without public health degrees. Regarding governance, 34 state public health agencies have a state level board of health, while 22 state public health agencies do not. Seven state public health departments are designated as the official environmental health agency. Four state public health departments are the official mental health agency. Four state public health departments are the official Medicaid agency.

Recent emphasis on the development of state-level public health system performance measures offers an exceptional opportunity to articulate the unique role of state health departments within the overall public health system. The process of developing measures has challenged ASTHO, the Centers for Disease control and Prevention (CDC) and other partner organizations to delineate the basic public health functions that all states have in common, regardless of variations in organizational structures. Based on the set of essential public health services (see Box 6-1), performance measures enable states to take an enterprise-level view of key functions that must be in place to improve population-based health. The 10 Essential Public Health Services, by their nature, cut across categorical distinctions and allow for a more universal perspective on the principal state public health capacities and functions. The state health department’s role in any given state is to facilitate the implementation of the Essential Public Health Services, either by carrying them out directly or by indirectly supporting the efforts of the local public health agencies, and to articulate the needs of the public health workforce to federal partners.

Responsibility of the State Health Department

One of the 10 Essential Public Health Services specifically focuses on assuring a competent public health and personal care workforce, and state health departments have specific responsibilities in this area. Continuous improvement in the quality of services delivered to the citizens of a state includes an ongoing and systematic assessment. Public health act 2014

Tsuntsu Media Services

Friday 24 May 2019

Public Health Agencies: Their Roles in Educating Public Health Professionals

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