How-To Guide

Public Health Workforce Strategies: the Ascendient Guide

Headshot of Brian Ackerman, partner at Ascendient

Brian Ackerman

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Every corner of the healthcare industry is struggling with workforce issues, but public health departments may be facing the biggest crisis of all. Here are a few strategies for both the near- and long term.

As I write this, the Covid-era public health emergency is scheduled to end in a few days – which is ironic because a new emergency for the public health workforce is just beginning to capture the interest of policymakers.

If you work in a public health department, look around your office and consider what would happen if half your colleagues disappeared in two years’ time. That’s the grim scenario envisioned by a recent study in Health Affairs. Based on trends from 2017 to 2021, the study predicts that 57% of the public health workforce will leave or retire by 2025. In actual numerical terms, the predictions look like this:

Projected departure numbers in the public health workforce

I don’t work often with statewide agencies, but in my 25-year career with Ascendient, I’ve advised local health departments (LHDs) from coast to coast, in cities big and small.

Hiring issues have been a concern in all of those engagements, but today I’m seeing unprecedented urgency as leaders struggle to provide essential public health services while navigating an ongoing workforce shortage. More and more, LHDs are asking Ascendient to evaluate organizational capacity, development, and design as they come to grips with the likelihood of permanently constrained staffing levels.

This kind of fundamental self-assessment can’t come fast enough because the staffing crisis is already taking shape. Nearly one in three public health employees say they are considering a move in the next year, according to research from the de Beaumont Foundation, which conducts a quadrennial survey of more than 100,000 workers across 143 public health agencies. Asked why they would consider leaving in the next year:

Top reasons for leaving, as cited by public health workers

When we assist health department leaders with strategic planning, most are thinking in three- to five-year cycles, but I worry that waiting for the next cycle may be too late to address the workforce crisis. When one third of your colleagues could be gone in 2024 and one half by 2025, it’s probably time to think about triage.

Near-Term Strategies for the Public Health Workforce

Retention is everything right now. Every time you manage to keep a team member on board, you’ll face one less recruiting nightmare in this extraordinarily tight job market. What can we do to prevent 25% to 50% attrition through 2025? I believe that is the existential question for LHD leadership.

Given the urgency and the short time frame, I look for solutions that are achievable within the LHD itself. If you need permission, buy-in, or budget from an outside party, that doesn’t qualify as a “near-term” solution.

For instance, looking back to the bulleted list of reasons for (potentially) leaving, it’s obvious that LHD leaders don’t have much latitude when it comes to pay. Departmental budgets are set largely by elected officials, which means that pay will never be lavish. With a median salary under $60,000 a year, public health employees have plenty of professional options that might promise equal pay with less stress.

Opportunity for advancement is another area where public health leaders may feel like their hands are tied. LHDs tend to have a fairly flat organizational structure, and there are only so many rungs on the career ladder.

The remaining issues – burnout, culture, and stress – are probably most amenable to management solutions. If you can reduce turnover by addressing those issues, you’ll be much better positioned for the turbulence ahead.

What to do right now? Invest in a job satisfaction survey.

Given the expectation of high turnover, I’d recommend surveying annually for the next few years – and hire an outside firm if you possibly can. Yes, there are costs involved, but you’ll still come out far ahead compared to recruiting and training new employees.

For starters, you’ll get better data because employees will be more comfortable sharing their true feelings. More importantly, outside experts can do the hard work of conducting follow-up conversations that probe the core findings of the survey – and translate those findings into action. I’ve had many clients say that the biggest value of the entire survey process is the insights that we generate with our follow-up work.

If you can’t afford consultants, look into DIY online tools such as SurveyMonkey or SurveyPlanet. Even if you don’t get the best possible data and insights, you’ll still be able to show employees that you’re trying to listen and respond to their needs.

Design your survey around the known drivers of turnover, and be sure that results can be stratified in multiple ways. For instance, younger workers may have different expectations for advancement compared to older workers, while front-line staff and administrative staff might part ways on cultural concerns.

Ask employees what they like, what they dislike, and what they’re planning for the future. You’ll need granular, actionable data that will help you craft a retention and recruitment plan with surgical accuracy.

Here are a few targeted approaches we might recommend to an Ascendient public health client, based on the results of an annual employee survey:


The pandemic changed the nature of work in most LHDs. From 2017 to 2021, the proportion of public health employees focused on communicable diseases tripled, going from 8% to 24%, while almost every other category of work showed sharp declines. Hardest hit were organizational competencies (such as IT, program evaluation, or admin support), environmental health, and communications.

That reshuffling left many team members stuck with work that didn’t match their training or interests, so it’s worth having some frank conversations about expectations vs. reality in workload. Once again, an outside firm can be a huge asset in leading those conversations.

(On a related note, public health agencies have seen sharp declines in administrative staff, which puts added pressure on professional staff. I broke out this topic in a separate blog post, entitled “A Supportive Solution for Public Health Burnout”.)


The Covid pandemic created unprecedented pressures for the public health workforce, and the effects are long-lasting. Some 56% of public health workers are suffering from pandemic-era PTSD, according to de Beaumont, and 22% describe their mental health as merely “fair” or “poor.” If that’s true for your team, consider acknowledging the problem and offering tailored solutions such as counseling or mini sabbaticals.


Does your public health agency deliver on its mission? Is your office a collaborative and professional place to work? Do your employees feel seen, appreciated, and equipped to succeed? All those questions get at the culture of your organization.

When asked about culture in the PH WINS survey, employees planning to leave within a year took a far dimmer view of their organization than employees who said they were planning to stay. If you’re not conducting regular surveys of your team – and using the results to build something better – then you are missing your best opportunity to mitigate the looming workforce crisis.

A chart showing organizational culture survey for responses for public health workers planning to leave their job vs those planning to stay

Longer-Term Strategies for the Public Health Workforce

Public Health 3.0 emphasizes innovative partnerships, upstream influences, more advocacy, and better funding mechanisms – all of which require buy-in from external stakeholders such as elected officials and health system CEOs. Even as you engage right now in strategic triage, it’s worth laying the groundwork for more lasting solutions.

Here are 3 trends to consider in your longer-term strategy:

1) Clinical detachment

Forgive the play on words, but I’m trying to make an important point that clinical roles are quickly disappearing in many health departments. According to a workforce study from NACCHO, 20% of LHDs reduced key clinical services in 2018, due largely to staffing shortages. RNs, typically the backbone of the public health workforce, have been disappearing for years, and I am certain that the pandemic exacerbated that trend as hospitals got caught up in a bidding war for nurses. Here's how NACCHO graphs the trend:

A chart showing the sharp decline of RNs in the public health workforce

I don’t see clinical roles coming back, for the most part. Every market will be slightly different, but the clear trend in Public Health 3.0 is for LHDs to focus more on the upstream drivers of health and less on delivery of safety net services. “A strong focus on clinical care may pull public health department resources downstream and impede fulfillment of PH3.0 principles,” NACCHO warns.

Rather than competing for scarce clinical workers, I think many LHDs will look at their local data and decide to work more closely with hospitals and community health centers on delivery efforts – an example that leads perfectly into the next trend …

2) Partnerships of all kinds

This is the topic that dominates discussions of Public Health 3.0 – and it’s a key factor in PHAB accreditation – but I don’t think it gets the kind of action that it deserves. Effectively addressing community-wide social drivers of health will never happen within the walls of a local health department. Budget cuts and workforce constraints may force us to look at creative partnerships, but really, it should be motivated by mission.

Community health assessments offer the perfect place to start. I’ve written before that health departments shouldn’t settle for just “checking the boxes,” but now more than ever, we should be using the process to build deep, strategic relationships all across the community. For example, try to include 20% more organizations in the CHA process or schedule a full day for specific, ambitious discussion topics such as, “What would it look like if we shared 3 FTEs?” or “How can we cross-train our teams to make them more engaged and effective?”

3) Departmental reorganization

From New York State (population 19.8 million) to Clinton County, Indiana (population 33,000) health departments of all sizes have been announcing reorganizations recently, and I think the trend will only gather steam in the coming years. A lot of this is inevitable: As you break public health out of its silo and integrate it more fully with other parts of the community, some job roles are bound to grow, contract, or become redundant.

Health departments in the future will probably be flatter and more permeable. Instead of a rigid hierarchy staffed with in-house specialists, we’ll see more flexible designs that encourage shifting and sharing among local health departments, state agencies, and community partners.

Smart reorganization could be a huge help in alleviating the workforce crisis – but the key word is “smart.” I would encourage public health leaders to take a proactive stance toward reorganization before elected leaders come up with a plan based primarily on saving money rather than strategic objectives.



There’s never been a better time to recognize the dedicated, mission-driven professionals who work in this sector. Despite extraordinary stress and upheaval brought on by the pandemic, 94% of public health staff believe their work is important and 93% say they try to give their best effort every day, according to the PH WINS survey. We can’t afford to lose people like that. The smart move is to focus urgently on retention while studying how your recruitment needs will change in the future.

The public health workforce crisis isn’t going away. Staffing issues will likely grow even more acute over the next three years, and secular changes over the longer term will lead to further turmoil and turnover. Public health leaders may not enjoy doing community health assessments or strategic planning, but both of those cycles offer the perfect opportunity to get in front of the coming changes while prioritizing efforts that will yield the greatest community impact.

Research by Patricia Dowbiggin, Ascendient strategy consultant

From strategy to workforce development to CHAs, the mission-driven consultants at Ascendient can provide expert guidance for local health departments of any size. Please contact us for more information.