Public Health Preparedness: HHS and Jurisdictions Have Taken Some Steps to Address Challenging Workforce Gaps

What GAO Found

The U.S. public health workforce serves a critical role protecting community health, such as by tracking disease outbreaks, monitoring water quality, and communicating with the public about health threats. Nonfederal jurisdictions within the U.S. (states, territories, Tribes, and localities, such as counties and cities) have primary responsibility for public health in their geographic areas, and these jurisdictions employ most of the public health workforce—more than 200,000 workers. The federal government, particularly the Department of Health and Human Services (HHS), supports these jurisdictions' workforces and also employs its own public health workforce.

GAO's review found gaps between the existing public health workforce and the workforce needed. These gaps have existed across multiple occupations and jurisdictions and were exacerbated during public health emergencies. Gaps limit the ability of jurisdictions to conduct key public health functions, such as disease investigation and control, identification of hazards, and readiness to respond to emergencies.

Examples of Gaps in the Public Health Workforce

Challenges with recruiting and retaining workers contribute to public health workforce gaps. These challenges are difficult to solve and are likely to persist over time, according to GAO's review. For example, public health funding can be restricted to limited time frames or specific activities, which makes it difficult to use the funding for hiring. In addition, jurisdictions faced challenges dealing with market competition for workers from other employers offering higher pay, better job security, and more flexibility. Jurisdictions also can have cumbersome hiring processes based on state or local civil service requirements that are difficult to change, and public health work can involve high workloads and stress.

HHS and selected jurisdictions have taken some steps to mitigate challenges. For example:

• HHS has responded to funding challenges by offering jurisdictions greater flexibility in using certain grant funds for workforce hiring and support.
• Selected jurisdictions have addressed the challenges of market competition, cumbersome hiring processes, and stressful workplace environments by offering financial incentives and improving hiring processes. For example, Maine increased pay for public health nurses and expedited hiring processes, which helped the state fully meet its need.

Why GAO Did This Study

Public health emergencies such as the COVID-19 pandemic, Hurricane Helene, and other threats, have highlighted the importance of a public health workforce that is ready to meet the needs of its citizens.

The Consolidated Appropriations Act, 2023 includes a provision for GAO to report on the public health workforce in the United States. This report describes, among other topics:

• gaps in the jurisdictional public health workforce and challenges to recruitment and retention, and
• steps HHS and selected jurisdictions have taken to address jurisdictional recruitment and retention challenges.

To address these objectives, GAO reviewed 69 public health workforce research studies and reports, and interviewed HHS officials and officials from 11 stakeholder organizations, including national organizations representing jurisdictions, public health professionals, or educational organizations; public health policy and research organizations; and a national organization focused on public health practice and population health.

GAO also interviewed officials in 11 jurisdictions, selected to obtain variation in health department structure (e.g., centralized vs. decentralized), funding sources, and percent of population in rural areas. The selected jurisdictions included four states, one territory, two tribal organizations, and four localities.

For more information, contact Mary Denigan-Macauley at (202) 512-7114 or deniganmacauleym@gao.gov.