Despite the limitations inherent to the data analyzed in the Yeager et al article, the findings represent a fertile and timely opportunity to examine the implications of this changing workforce. The pace of the changing health landscape is profoundly affecting the public health profession, its professionals, and the occupational setting.
The Profession
While the central tenets of public health professionals remain aligned with the core public health functions of assessment, policy development, and assurance,1 progress and setbacks in each core function are reshaping the scope of practice. For example, system-driven standards associated with the Patient-Centered Medical Homes framework,2 and the research stimulating promoting the ascertainment of the concept's effectiveness,3 increasingly requires that assessment activities go beyond mere patient-driven disease-specific health outcomes to more holistic community-based ascertainment of health. In this context, "health" deliberately integrates traditional health care and public health to represent population health. From a governmental public health perspective, this advancement is most pronounced in Federally Qualified Health Centers, where achieving improved patient-centered health outcomes requires technology- and research-driven assessment strategies supported by public, private, not-for-profit, and community partnerships. To date, the advancements in assessment are unfortunately not fully mirrored in the policy development and assurance functions. From a policy development aspect, the Affordable Care Act (ACA)4 has indeed significantly changed access to care for many; yet, persistent health disparities and inequities remain.5 The complex and changing stakeholder landscape impacts the ACA's implementation and consequently its effectiveness in assuring health services for those who are most vulnerable. Furthermore, assurance of health services is hampered by the decreasing financial and human assets of state and local health departments that must predominantly rely on disease-related federal resources, especially those in economically challenged states and territories.
Public Health Professionals
The September 11, 2001, events prominently demonstrated the importance of training and the role public health plays in each aspect of disaster management-from preparedness to recovery.6 The Centers for Disease Control and Prevention, supported by public organizations, academia, and professional associations, developed a national strategic plan for public health workforce development.7 The cornerstone of that plan is a strategic framework (Figure) linking 6 framing elements/questions.7 Differing degrees of change are occurring in each of the 6 areas. By far the most consequential change is in the composition of the public health workforce (element 1) driven by 2 linked forces: the growth in public health learning institutions, schools and especially programs in public health, and exponential expansion of undergraduate degrees (BSPH) at these academic institutions.8 While data from public health are not yet available, and in contrast to the Yeager et al findings, the current generation of professionals seems to put greater value on personal factors such as career development than on organizational factors including job security. Other important values include cultural and gender diversity, as well as the emphasis on contributing to globally relevant solutions. Pedagogically, significant curricular changes have been prominently driven by a more outcome assessment-driven accreditation process at the learner, program, and workplace setting. In turn, learner competencies at the master's level have evolved to emphasize skill-based learning early and throughout the curriculum (element 2). Virtual learning (element 3) in public health has expanded quantitatively and qualitatively to accommodate learner demand: many schools and programs of public health offer both synchronous and asynchronous learning opportunities, leading to certificates as well as degrees. The target audiences have evolved from exclusively mid-career professionals interested in formalizing their practice-based knowledge to a cadre of learners diverse in career stage, workplace setting, and geographic region. As a result of financial and human capital constraints, governmental public health is traditionally faced with the greatest challenges to incentivize lifelong learning (element 4). This is a concerning gap since, according to Yeager et al, 83% of the current governmental public health workforce does not hold a public health degree. While not exclusively targeting workforce development research, investment in Patient-Centered Outcome Research embeds a rigorous assessment of the public health workers' role in achieving improved health outcomes (element 5).3 Given the increasing recognition associated with the benefits not only of a systems approach but also of team-based health service delivery, dedicated research funding exclusively targeting public health workforce development is unlikely and may not yield the desired results (element 6). Instead, inclusion in health services research and other related systems-based science may represent a more sustainable approach to assuring a competent workforce.
The Occupational Setting
Governmental public health-federal, state, and local-remains an important occupational setting. The factors driving recruitment and retention are likely to differ from those currently employed, as reported by Yeager et al. Interprofessional education, initially championed by prominent professional associations in public health and medicine,9 has expanded to include most leading health professions including nursing, pharmacy, and dentistry.10 The transdisciplinary-prepared graduates seek a commensurately rich workplace in public health practice, policy, and research. For example, a growing number of students in medicine enroll in joint MD/MPH programs integrating "bedside and trench" practice. Geographically, public health professionals, especially those who benefited from study abroad programs during their education, seek to practice in lower- and middle-income countries where they hope to address dire health needs and make a greater difference.11
As an increasing number of state and local health departments become voluntarily accredited, performance standards emphasize the role a competent workforce plays in promoting community health and wellness. From disasters to disparities, public health professionals are employed in a variety of settings. Public health will be bolstered by embracing this diversity, provided we undertake rigorous and continuous assessment of workforce development benchmarks assuring professionals are capable of functioning in outcome-driven organizational settings.
REFERENCES