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The Hollowing Out of New York’s Public Health Workforce
By Molly Fleming, Senior Program Manager, NYSACHO and Sarah Ravenhall, Executive Director, NYSACHO
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The public health workforce in the United States has faced staffing shortages for over a decade, with one estimate by the Association of State and Territorial Health Officials (ASTHO) finding that the national public health workforce decreased by almost 10% between 2012 and 2019, while at the same time the United States population increased.1 New York State’s public health workforce has not been immune from this phenomenon, and these issues have only been further exacerbated by the COVID-19 pandemic.
New York’s local health departments (LHD) promote and protect the health of the populations living in each of New York’s 62 counties. They serve as the first line of defense against all new and potentially widespread public health crises. To assess whether the LHD workforce has been impacted by national shortages, the Region 2 Public Health Training Center (PHTC) collaborated with the New York State Association of County Health Officials (NYSACHO) to study the local health workforce for New York State.
The goals of the study were to quantify New York’s LHD workforce, assess how the workforce has changed since the COVID-19 pandemic began, and identify challenges to recruit and retain qualified public health workers in LHDs. NYSACHO and Region 2 PHTC developed the study questionnaire using validated questions from the National Association of City and County Health Officials (NACCHO) 2019 National Profile of Local Health Departments, to enable longitudinal comparison between 2019 and 2021.
The survey collected information on individuals and full-time equivalents (FTEs) employed, specific occupational titles, duration of vacancies, reasons for workforce reductions, barriers to hiring, and upcoming retirements. In late 2021, NYSACHO distributed the survey to leadership at all 58 of New York State’s LHDs, with 52 LHD’s (90%) responding.
Among its key determinations, this study found that New York State’s LHD workforce has seen a marked decline in the number of full-time staff employed since 2019. At first glance, the LHD workforce appears to have remained stagnant, with a slight increase in all FTEs employed (2%) since 2019. This alone would be alarming given that during this time, LHDs were responding to the largest public health threat in nearly a century.
However, when looking at the data broken down by employee type (full-time, part-time, contractual, and seasonal), this finding becomes even more worrying. Between 2019 and 2021, the full-time LHD workforce decreased by 26%, while contractual employees saw a huge increase, 12,210% (Figure 1). This large influx of contractual employees partly comes from COVID-19 funding provided by the state and federal governments for LHDs to hire contracted staff to assist with COVID-19 mitigation activities such as case-investigation, contact tracing, and vaccination. However, these employees are not permanent and when funding runs out, they will leave
LHDs with staffing shortfalls as they continue to fight COVID-19 and other existing and emerging public health issues, like Monkeypox and polio.
Additionally, LHDs have seen a marked increase in vacancy rates since 2019. Overall, LHDs reported a 20% average vacancy rate for their departments, compared to 12% in 2019. The positions with the highest vacancy rates included licensed practical or vocational nurses (39%), supervising public health nurses (26%), community health workers (24%), health educators (24%), and public health nurses (23%).
Respondents indicated that nursing positions, including public health nurses, were frequently vacant for more than a year. Public health physicians and health educators were the other positions that were most frequently reported to be vacant for long periods of time. Long vacancy periods leave LHDs without the full staffing required to be readily available to respond to emerging public health crises.
High vacancy rates also increase the risk of existing staff becoming overworked and suffering from burnout, leading to further turnover and vacancies. To read more about COVID’s Impact on the Mental Health of New York’s Public Health Workforce, see NYSAC Magazine’s summer 2022 issue.
Compounding the existing staff shortage, all LHD respondents, regardless of size, reported high impending retirements, with 990 FTEs (almost 10% of the current workforce) planning to retire within the next three years. Since the start of the pandemic, 31% of LHD leaders (Commissioners/Directors) have retired or left their departments. Each retirement equates to decades of institutional governmental public health knowledge leaving a department and the community it serves.
As to why LHDs struggle to hire qualified candidates, study respondents noted that salaries are too low to be competitive for positions such as nurses, public health physicians, office and administrative support staff, lab workers, epidemiologists, and others. Respondents also indicated that qualified candidates are hard to find for various roles including health educators, environmental sanitarians and technicians, and community health workers. Additionally, the hiring process for LHDs is too lengthy for candidates to endure due to various administrative hurdles, including civil service rules. LHD leaders have reported that during the hiring process, many candidates turn down job offers to accept positions within the private sector, local These findings complement existing evidence that has been accumulating for the last decade indicating the need for longterm investment in local public health infrastructure to bolster the workforce and ensure that local health departments are ready at a moment’s notice to activate emergency response efforts to protect their communities from health threats.
The 2022-23 New York State budget included a much-needed increase in base funding (known as Article 6 funding) for LHD operations. However, without a more proportional long-term investment in the LHD workforce, any gains made this year will not last. It is therefore imperative that federal, state, and local investments are made to bolster the local public health workforce and ensure the health of our communities. Emergency funding allocated to LHDs must be sustained, flexible, free of restrictions, and disease-agnostic to ensure LHDs can use it to meet the unique needs of the counties they serve.
With the arrival of new threats such Monkeypox, the return of formally defeated threats such as measles and polio, and the ever-present threats of childhood lead poisoning, opioid addiction, contaminated public water supplies, and now COVID-19, there is far too much at stake for the state to risk relying on understaffed public health infrastructure. New York State’s lawmakers must revisit this critical issue in the coming legislative year.
Please visit: https://www.nysacho.org/topic/state-budget-priorities to learn more about NYSACHO’s state budget priorities.
Acknowledgements: The project was supported by the Health Resources and Services Administration of the U.S. Department of Health and Human Services and the Region 2 Public Health Training Center. Thank you to those responsible for participating in this research. Isaac Michaels, Sylvia Pirani, Molly Fleming, Mayela M. Arana, Emily D’Angelo, Cristina Dyer-Drobnack, Margaret DiManno, Sarah Ravenhall and Christian T. Gloria
References: 1 Carlin M, Ensign K, Person C, Kittle A, Meadows K (2021). State of the Public Health Workforce: Trends and Challenges Leading up to the COVID-19 Pandemic. Journal of Public Health Management and Practice.
