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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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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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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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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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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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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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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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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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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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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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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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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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
