Significant gaps in the size, training, structure and credentialing of the public health workforce have been exposed as a result of the demands generated by the COVID-19 pandemic. This problem has been highlighted by the need to scale up to levels of activity never previously required by a communicable disease outbreak in Australia.
However, the demands on the nation’s public health workforce go beyond the management of a communicable disease outbreak alone. With the heavy and growing burden of preventable Non-Communicable Diseases (NCDs), workforce shortages are perhaps less urgent but just as real. Government capacity should be adjusted in line with this increasing threat and disease burden.
There is a broad scope of practice in public health, from epidemiologists and biostatisticians, through to contact tracers, community health promoters, transmissible disease experts, health economists, environmental health, nutrition and food safety workers, Aboriginal Health workers, nurses, physicians, policy analysts, policy makers and more. A clearly agreed definition of those to include and exclude remains difficult. One size will not fit all in terms of training needs, employment options and support. There will also be differing demands depending on the extent of workforce and skills shortages.
“Public health has traditionally sat in the back corners, but it really came to the forefront in a way it never has before. Dramatically so”
– Stephen Duckett, Grattan Institute 22 June 2020
Current best estimates suggest that about 80 percent of the public health workforce is employed by government, academia and the not-for-profit sector. What little data we have suggests that the rate of growth of public health professionals currently in the workforce is very low to zero. Certainly, the growth rate of the public health workforce is behind that of most other health professions, and indeed most other professions generally.
The pandemic has generated an extraordinary need for surge capacity in functions such as sample taking and testing, outbreak investigations, contact tracing, data analysis, targeted, efficient and effective public communications, highlighting the scale of the challenge facing governments and their agencies.
The 2017 Joint External Evaluation of Australia’s compliance with the International Health Regulations (JEE), addressed the issue of the public health workforce – “An Australian Government Health Workforce Strategy is currently being prepared, but it will not identify public health and its related workforce as an area that needs attention”.
To the best of our knowledge work is yet to commence on the three workforce recommendations in the JEE report or in our own National Action Plan for Health Security:
- “Use existing data sources, including relevant accreditation schemes, to define the public health workforce in order to conduct forward planning, recruitment of appropriate categories of staff (including toxicology and radiation specialists) and development of future credentialing schemes.
- Work with states and territories to ensure sustainable mechanisms for epidemiologists and other public health professionals at state, territory and local level.
- Develop a long-term strategy that uses current and new channels to increase the international experience of the public health workforce.”
PHAA has proposed a coordinated way forward to address these problems for the medium term, while offering some short-term options for consideration.
A major Strategic Review of the Public Health Workforce in Australia
Many issues underly the current gaps and problems relating to the public health workforce in Australia. Similar to other health and medical workforces, it is not a conventional workforce driven solely by supply and demand forces, but is significantly affected by controls on entry levels and numbers for training programs.
Any thorough review would need to establish the clearest possible understanding of the current public health workforce. Who are these people, how many are there, what do they do, what is their skill set and what’s missing?
“To bolster our public health team, firstly, we have gone from 37 to more than 1000 disease detectives doing that contact tracing on a daily basis, and this team is working 24 hours a day, seven days a week, on this important work”
– Victorian Health Minister Mikakos, Victorian Parliament, 18 June 2020
It also must engage with all the stakeholders to establish current and anticipated needs, and assess existing investment in staff, programs and training initiatives.
It is vital to examine the current training infrastructure including the capacity, throughput and standards of tertiary education and other providers, and competencies, accreditation, registration at the level of individuals, training providers and employing institutions.
Models from similar professional groups within Australia and public health workforce accreditation structures overseas should guide recommendations. Perhaps most importantly it should make clear recommendations relevant to all stakeholders aimed at improving the quantum and standard of the public health workforce in Australia for the medium and long term.
Alongside the review, there may also be an appetite for immediate action. Below are some options which are in no particular order of priority and are complementary rather than competing options. There will no doubt be many more options to consider.
Invest in or expand Public Health Officer Training or similar programs
A successful long-standing Public Health Officer Training Program in NSW has operated for 30 years and trained around 180 public health professionals. This three-year program is designed to meet the needs of public health program and service delivery at state government level through rotating trainees through a range of public health workplaces.
All trainees must have completed a Masters of Public Health at entry to training.The program has been evaluated and shown to perform strongly on measures including contribution to surge capacity need, and publications in peer reviewed literature.
NSW Health has also developed similar programs to address specialist areas within the public health workforce, including Aboriginal health and biostatistics, and has successfully increased capacity in NSW in both of those fields.
While not perfect, many believe this program in NSW better prepared that state for COVID-19.
Some other jurisdictions have had various forms of such a program, but on a smaller, less consistent basis. A national scheme through which states and territories acted together would allow economies of scale.
A more consistent commitment and investment from the Australian Government and from all states and territories is vitally important to systematically improve the capacity and skills of the public health workforce in Australia.
Revisit the Specialist Training Program to boost the number of Public Health Physician training positions
The current Specialist Training Program has supported over 1,000 medical specialist training program (STP) places around Australia. Fewer than 30 go to public health physician training through the Australasian Faculty of Public Health Medicine.
Now seems a logical time to substantially increase the number of STP positions for public health medicine around Australia, without having to increase the total number of positions funded.
Increase support for specialised field epidemiology training and capacity
The specialist Field Epidemiology Training Program in place (in the form of the Masters of Applied Epidemiology at the Australian National University), is established and successful.
Of the 231 graduates, 15 percent are Indigenous. Graduates have leading positions in health nationally and internationally.
The two-year Program could rapidly increase its capacity and student places and has direct relevance to communicable disease outbreak response. It places students in a relevant health organisation (for example, state health department, Commonwealth, and some NGOs) with intensive academic blocks to build expertise in the essential skills required to lead field epidemiology initiatives.
Increase training via placement in international programs
The expertise of Australia’s public health workforce would be increased by improving access to placements and real-world experience in communicable disease management via existing initiatives.
By supporting the cost of backfilling positions for the public sector public health workforce, the Australian Government could quickly increase the experience and expertise of Australians with skills to contribute to public health challenges outside Australia.
Various initiatives offer such experience, including the Centre for Indo-Pacific health security training expansion, the Global Outbreak Alert and Response Network and National Critical Care and Trauma Response Centre.
But these mostly do not meet the costs for staff to attend. For those unable to forgo income – especially in current circumstances – this is a significant barrier.
Reestablishment of the PHERP-like funding program
The Public Health Education and Research Program (PHERP), which operated from 1987 to 2010, included designated federal government funding for capacity-building in the public health workforce through higher education.
Reinstatement of this type of funding would focus on the education and training of the public health workforce by funding high quality postgraduate education, improving research infrastructure, and improving Australia’s biosecurity and pandemic preparedness.
A Public Health Employment Agency
COVID-19 highlighted the need for a surge workforce. The existing public health workforce could not be effectively mobilised on the scale required at a single location.
Establishing an entity to efficiently lead the identification, recording and, where necessary, recruitment and mobilising of the existing workforce is relevant to the National Cabinet’s 26 June announcement (see below).
The National Cabinet agreed on 26 June 2020 to a new plan for Australia’s Public Health Capacity and COVID-19. Under the plan developed by the AHPPC, six actions for state, territory and Commonwealth governments will improve long term sustainability of the public health workforce for the remainder of COVID‑19 and beyond by:
- strengthening a formal surge plan for the public health response workforce and review the ongoing structure of the public health units;
- progressing the national interoperable notifiable disease surveillance system (NINDSS) project and prioritise appropriate interfaces;
- establishing a national training program for surge workforce;
- better support the Communicable Disease Network of Australia (CDNA), including shared costs;
- prioritising enhancing the public health physician workforce capacity; and
- considering options for developing a formal public health workforce training program.”
Notwithstanding the current situation in Victoria, Australia has been relatively successful in managing the first wave of COVID-19.
The experience has nonetheless shown a significant problem with the national public health workforce, raising serious concerns about our capacity to deal with the present pandemic , future communicable disease outbreaks and other public health issues including NCDs.
Our experience with COVID-19 and other public health crises such as bushfires has highlighted the importance of a solid public health response.
Like investment in defence, investment in public health capacity is vitally important as a precaution.
Recent events suggest the likelihood of calling further on public health capacity is high, and may be needed sooner than we would plan or hope for.
Terry Slevin is the CEO of the Public Health Association of Australia, and is also Adjunct Professor in the School of Psychology at Curtin University and Adjunct Professor in the College of Health and Medicine at the Australian National University.