Construcción del componente ExSmartGoTo

The WHO has laid out the structural components pertinent to having a strong health system.¹² These include adequate numbers of workers with appropriate competencies, functional support systems, and an enabling environment. The U.S. public health workforce has been examined over the past half century by the Institute of Medicine, the federal government, and a variety of other public and private institutions. The challenges to achieving the goals of a well-trained workforce of adequate size and appropriate expertise and conducive work set-tings have been relatively persistent over the past decade. They have become even more prominent due to recent trends in health care, public health, educa-tion, the economy, and social demographics.

Shortages

The U.S. public health system faces a severe shortage in the number of workers available due to retirement and problems related to retention and recruitment.

Retirement of the baby boom generation is one factor. Public health, like other health professions, will see the retirement of an estimated 20 percent or more of the total workforce by 2020. An analysis by ASPH in 2007–2008 estimated a shortfall of as many as 250,000 master’s-level public health practitioners by 2020, with up to 100,000 government public health employees eligible to retire as of 2012.¹³ This retirement trend will not only reduce the number of people working in public health but also substantially change the mix of senior man-agers with experience and more junior staff with less experience but perhaps a greater propensity for the use of technology. Hence, the change in the com-position of the workforce may result in changes in operations and practices.

In addition, the economic downturn in the United States between 2008 and 2011 affected many state and local public health departments. NACCHO reported that more than half the local health departments throughout the na-tion experienced job losses between 2008 and 2010, with a total of 29,000 jobs

cut.¹⁴ Similarly, ASTHO reported that 89 percent of state health agencies ex-perienced workforce reductions from 2008 through early 2011, with a total of 14,700 lost jobs.¹⁵ Although these functions might be taken over by other workers or accomplished by work redesign in the short term, the dramatic de-crease in the public health workforce means fewer workers available to meet the increased demands placed on the public health system by the ACA of 2010 and other recent environmental trends.

Recruiting workers into the field of public health is also challenging. Pub-lic health is poorly understood as a field, let alone a career. Initiatives such as the “This Is Public Health” campaign and fellowship programs run by the Cen-ters for Disease Control and Prevention (CDC) strive to recruit young people into the field early in their educational careers. A sobering fact is that while many students are incurring increasingly large financial debts in pursuit of a formal education,¹⁶ salaries in many facets of public health, particularly gov-ernment and nonprofit positions, are less than those paid for comparable po-sitions in other fields or other careers in health care.

Alignment of needs and skills

The Global Independent Commission on Education of Health Professionals for the 21st Century advocates a systems approach, starting with a determination of what functions need to be performed to address the problems of the health care delivery system and then shaping professional education accordingly.¹⁷ As noted earlier, the current approach to training the public health workforce is a combination of no training, discipline-specific clinical training with public health as an add-on, and topic-specific continuing education responding to the latest crisis or trend. Only a relatively small percentage of the public health workforce has any core training specifically related to public health.

Ideally, the goal is to match the needs of the health system with the skills of those who are trained to work in it. Education for public health has be-come competency driven, which raises several questions: Which competen-cies apply? To which workers? For what purposes? If workers can demonstrate

“competence,” does this have a direct impact on the health of the public or the performance of the public health system? As workers retire or change posi-tions, what are the implications for continuing education? How does educa-tion of the workforce relate to the public health needs of the community?

The multiple sets of competencies pertinent to health professionals com-plicate the responses to these questions. A 2011 cataloging of such competen-cies found no fewer than fifteen sets of them, including those for clinicians of various disciplines, health care administrators and policy analysts, ethicists,

emergency responders, environmental health specialists, and health educa-tors, among others.¹⁸ In addition, there are competencies for formal univer-sity programs and other competencies for those already employed in a public health setting.

The importance of lifelong continuing education is also apparent. As the older generation of workers retires, their replacements or those advancing to new positions may need different job skills. As the public health environment changes due to technology, globalization, advances in science, or the emer-gence of new diseases, updated knowledge and commensurate skills will be necessary, even if personnel have a solid foundation of basic competencies.

New perspectives continue to inform education and expectations about workers’ knowledge and skills. A trend toward systems thinking and the non-stop advancement of a broad range of technologies warrant a consideration of how educational competencies relate to future job needs. For example, in the twenty years between 1990 and 2010, computer technology and the science of informatics completely changed how surveillance—one of the core public health functions—is conducted. Mapping of the outbreak and spread of disease has changed dramatically: Whereas physicians were once required to report in-dividual patients with contagious diseases, now highly sophisticated geograph-ic information systems track outbreaks in multiple dimensions. In the past, communication involved telephone calls from laboratories to public health experts, but today, social media alerts reach hundreds of laypeople instanta-neously, and, conversely, hundreds of laypeople alert national media and health agencies with frontline information during emergencies. Preparing the public health workforce to manage such drastic changes and to employ emerging tech-nology requires ongoing education and personnel change management.

Interprofessional collaboration

Collaboration among professionals from different disciplines has been touted by past generations and periodically experiences a revival in popularity; then it wanes as the practical challenges of implementation set in. Since 2010, inter-professional collaboration has once again come to the forefront.¹¹ Recognition of the multiple factors that affect disease prevention, chronic disease manage-ment, and health promotion has combined with ACA-related changes in the health care delivery system to emphasize that the creation of healthy commu-nities and healthy individuals cannot be achieved by individuals acting alone.

Public health professionals have typically taken a broad perspective, and now seems to be an appropriate time to take an interdisciplinary approach to pre-vention and population health.

Global health

The globalization of the world’s economies has led to the realization that no country can stand alone. Public health calamities such as SARS, avian flu, and the ongoing challenges of HIV/AIDS have reinforced the notion that “public health is global health.”¹⁹ Immigration continues to expand the diversity of the U.S. population.²⁰ All these forces mean that the public health workforce must be cognizant of the impact of global health on day-to-day tasks, whether in the Badlands of South Dakota or on the beaches of Florida.

The Global Independent Commission on Education of Health Professionals for the 21st Century emphasizes the need for a global perspective when it comes to educating and deploying public health professionals.¹⁷ Universities and public health institutions across the country have not yet responded to this challenge, but their programs are likely to evolve as it becomes increasingly clear how a di-verse environment affects the daily tasks of all public health workers—from the receptionist who needs to be multilingual to the physician who needs to pro-mote vaccinations within the context of a recent immigrant’s culture.

A few schools of public health have established specific training pro-grams in global health. Others have taken the approach of globalizing the en-tire curriculum—that is, infusing global awareness and global relevancy into all courses and all degree programs. These are still in the minority, howev-er. A set of global health competencies was recently developed by more than 380 health care practitioners from around the world, both in academia and in practice. These competencies include the main domains or content areas in which public health practitioners specializing in global health should be profi-cient, including capacity strengthening, collaboration and partnering, ethical and professional practice, health equity and social justice, program manage-ment, sociocultural and political awareness, and strategic analysis.

Cultural competence and health literacy

One of the most common manifestations of globalization is the need for cul-tural sensitivity and culcul-tural competence. For example, in one large county in California, residents spoke 109 languages, and the county printed all materials in the 18 most common languages. Public health practitioners who are trying to influence behaviors must be aware of their constituents’ social and behav-ioral foundations if they are going to be successful in promoting change. Na-tional standards on culturally and linguistically appropriate services (CLAS) are frequently used as a reference point for health care practitioners.²¹ The CLAS standards are targeted at health care organizations, but they can also be

used to make individual clinical practices more culturally and linguistically accessible. The fourteen standards are organized around three main themes:

culturally competent care (standards 1–3), language access services (standards 4–7), and organizational supports for cultural competence (standards 8–14).

According to the U.S. Department of Health and Human Services (DHHS) Office of Minority Health, “The principles and activities of culturally and lin-guistically appropriate services should be integrated throughout an organiza-tion and undertaken in partnership with the communities being served.”²¹ By inference, public health professionals must be knowledgeable about cultural competence in order to implement this mandate.

The current focus on health literacy is yet another manifestation of the need to create messages that can be understood and acted on by individuals, families, and communities. Health literacy is defined as the degree to which in-dividuals have the capacity to obtain, process, and understand the basic health information needed to make appropriate health decisions and utilize the ser-vices required to prevent or treat illness. The HRSA and CDC have both ac-knowledged the importance of health literacy to health care and public health professionals and have created tools to promote health literacy.^{22, 23}

Teaching technologies and innovations

Scientific knowledge, biomedical and communications technologies, and in-novations of all types have drastically changed public health from milk wag-ons delivering supplies for newborns to highly sophisticated jobs employing advanced technology to facilitate access and learning. Public health informat-ics has evolved as its own field of specialization, with competencies and sup-port from professional associations.²⁴ Geographic information systems are now widely utilized to conduct disease surveillance and have been incorporated into classroom education. Distance learning and online educational options are so prevalent that there are more students enrolled online on any given day than sit-ting in classrooms. In brief, as the work of public health is increasingly facilitated by technology, those pursuing careers in public health—whether new students earning their first degrees or workforce veterans continuing their education—

are enmeshed in technology as an integral part of their daily jobs. Similarly, ed-ucational institutions are evolving to offer education maximized by technology.

A strong, well-trained workforce is vital if a nation is to have a stellar public health system. Numerous challenges must be overcome to achieve this goal.

Currently, the public health workforce in the United States is like a bright-ly colored Rubik’s cube that can be organized and viewed from different

perspectives for different purposes. The tasks of identifying, enumerating, and characterizing the full workforce have yet to be accomplished, despite repeat-ed attempts to do so. The issues that impact the workforce are many and can be dealt with most effectively if policies and programs are based on data and a consensus about future demand and supply.

The ACA of 2010 includes a number of provisions pertaining to the public health workforce. Some are aimed directly at resolving the issues mentioned here. Others are designed to implement the act’s provisions to increase access to care but also have considerable implications for the public health workforce.

Funding for many elements of the ACA was not forthcoming in 2011 or 2012 due to the nation’s budget deficit. Which provisions are eventually funded and implemented over the first several years of the ACA’s rollout will affect how and to what degree each of the above issues is addressed at the national level.

In the meantime, local governments, nonprofit organizations, and for-profit companies must all work together to ensure a public health workforce that is adequate in size, appropriately trained, and motivated by a positive working environment.

Appendix: Entities Representing Public Health Disciplines or Functions

Association (ANA) 3.1 million registered nurses http://nursingworld.org/

American Public Health

Association (APHA) More than 30,000 individual public health professionals

Health Centers (AAHC) More than 100 academic

health centers nationwide http://www.aahcdc.org/

Medical Colleges (AAMC) 134 accredited U.S. and 17 accredited Canadian medical

Public Health (ASPH) 49 CEPH-accredited graduate schools of public

59 state and territorial health

officials http://www.astho.org

Appendix: Entities Representing Public Health Disciplines or Functions, continued is the national leader in developing and applying care services for people who are uninsured, isolated, or a master’s degree from an accredited school of public

Notes

The author would like to acknowledge the contributions of Kristin Dolinski, Elizabeth Weist, Jamie DiGiacomo, John McElligott, and Harrison Spencer, MD, MPH.

1. U.S. DHHS, Centers for Disease Control and Prevention. Healthy People 2020.

http://www.cdc.gov/healthypeople2020. Accessed July 25, 2011.

2. Gebbie K, Rosenstock L, Hernandez L, eds. Who Will Keep the Public Healthy?

Educating Public Health Professionals for the 21st Century. Washington, DC: National Academies Press; 2003.

Appendix: Entities Representing Public Health Disciplines or Functions, continued

Association Description Website

National Network of Public

Health Institutes (NNPHI) National membership network committed to

(WHO) Collects data on countries

throughout the world, including health and health workforce statistics

http://www.who.org

Source: Compiled by the Association of Schools of Public Health, 2011. Current as of July 2011;

information may change without notice.

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Accessed July 28, 2011.

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http://www.ASPH.org/document.cfm?page=200. Accessed July 29, 2011.

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Interprofessional Education Collaborative; 2011. https://www.aamc.org/download/

186750/data/core_competencies.pdf. Accessed August 9, 2011.

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healthsystems/2007.3. Accessed August 14, 2011.

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jobloss. Accessed August 14, 2011.

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96, 1999–2000, 2003–04, and 2007–08 National Postsecondary Student Aid Study. Web table 3. Washington, DC: U.S. Department of Education; September 2010. http://www .nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2010180. Accessed July 6, 2011.

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2010;376:1234–1258.

18. Association of Schools of Public Health. Internal analysis of competency sets.

June 2011.

19. Friend L, Bentley M, Buekens P, Burke D, Frenk J, Klag M, Spencer H. Global health is public health. Lancet. 2010;375:536–537.

20. Hobb, F, Stoops N. Demographic Trends in the 20th Century. U.S. Bureau of the Census, CENSR-4. Washington, DC: U.S. Department of Commerce; November 2002:71–114. http://www.census.gov/publications. Accessed August 11, 2011.

21. U.S. DHHS, Office of Minority Health. National Standards on Culturally and Linguistically Appropriate Services. http://www.minorityhealth.hhs.gov/templates/

browse.aspx?lvl=2&lvlid=15. Accessed August 11, 2011.

22. U.S. DHHS, Health Resources and Services Administration. About Health Lit-eracy. http://www.hrsa.gov/publichealth/healthliteracy/healthlitabout.html. Accessed August 11, 2011.

23. U.S. DHHS, Centers for Disease Control and Prevention. CDC Health Literacy for Public Health Professionals, On-Line Training. http://www.cdc.gov/

healthcommunication/. Accessed August 11, 2011.

24. U.S. DHHS, Centers for Disease Control and Prevention. Competencies for Public Health Informaticians, 2009. http://www.cdc.gov/InformaticsCompetencies/.

Accessed August 14, 2011.

The Role of Community-Oriented