Care for the caretakers: Building the global public health workforce

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Health workforces face persistent challenges, including understaffing, underfunding, and underappreciation, that affect many roles in both public health and healthcare delivery. The unrelenting nature and global scale of the COVID-19 pandemic have exacerbated these difficulties. Public health systems have rapidly scaled up their operations to respond, including issuing clear and timely guidance based on science, expanding testing operations, pursuing sequencing, expanding disease investigation infrastructure, and swiftly and equitably distributing vaccines—all while maintaining baseline services and contending with waves of new variants, evolving scientific findings, and worldwide pandemic fatigue.1

As the world begins to shift from fighting COVID-19 on a day-to-day basis to living with endemic COVID-19, public health systems are wrestling with where and how to rebuild their workforce and talent pipelines.2Pandemic to endemic: How the world can learn to live with COVID-19,” McKinsey, October 18, 2021. The to-do list can feel endless, and available resources are limited. But governments could consider capitalizing on the renewed attention and resources being devoted to the broader health ecosystem, which includes both healthcare delivery and public health at the central and local levels.3 By thinking holistically across this ecosystem,4 government leaders could rebuild their workforces to effectively serve constituents for decades to come. This article examines the workforce shortages of today and defines a short list of potential initiatives that jurisdictions around the world may wish to pursue to start rebuilding.

Defining the health workforce

Governmental public health is charged with a broad mandate: health promotion, health protection, and disease prevention. While there is substantial variation in how public health systems around the world fulfill this mission—from the infrastructure in place to the services provided—they all rely on diverse and robust workforces to get the job done. This includes the central public health system, which focuses on countrywide or statewide efforts; local public health systems, which are responsible for core public health and often a subset of healthcare delivery services; and traditional healthcare delivery systems, which employ clinically trained professionals for patient-level services (Exhibit 1). While governments have often focused on one subsegment at a time, they may want to take a holistic view when building for the future by defining a potential workforce strategy for health professionals that caters to the needs of—and capitalizes on the synergies between—individual entities within the health ecosystem.

Public health systems are uniquely positioned to holistically rebuild the workforce of health professionals.

While these entities may have distinct governance structures, compensation models, and job descriptions, the ecosystem is interconnected, with a shared talent pool and an overlapping set of critical roles (Exhibit 2). Each is facing acute workforce shortages, and any solution that focuses on only one entity may negatively affect others. Given their overarching responsibility to all constituents and their view across public bodies, public health system leaders are optimally positioned to play a proactive role in defining and developing the talent pool needed to transform workforces across the entire health ecosystem, furthering all entities’ unified mission of saving lives and improving livelihoods.

Roles and responsibilities often overlap across the health-professional ecosystem.

Public health system leaders are optimally positioned to play a proactive role in defining and developing the talent pool needed to transform workforces across the entire health ecosystem.

Understanding public health workforce shortages

Definitions of public health vary by geography, making it difficult to quantify the full extent of global workforce shortages. Reports from workers and employers reveal, however, that shortages across the ecosystem are acute. These shortages existed prior to the pandemic, with a recent Lancet report finding that, globally, the health workforce (including physicians, nurses and midwives, dentistry personnel, and pharmaceutical personnel) fell short by approximately 43 million in 2019.5 The pandemic exemplified how shortages can be further exacerbated across all levels of care in times of crisis:

The shortage is likely to increase due to supply-side constraints and evolving demand. Moreover, trends indicate that supply shortages could continue to worsen. For example, a McKinsey survey conducted in November 2021 revealed that 32 percent of surveyed registered nurses indicated that they were likely to leave their current position of providing direct patient care within one year, a 10 percent increase from ten months prior.8Surveyed nurses consider leaving direct patient care at elevated rates,” McKinsey, February 17, 2022. These capacity constraints will likely be compounded by rising demand for health services due to an aging population,9 increasing emphasis on prevention, and evolving health priorities, including an expanded focus on behavioral health and the need to continually address new pathogens.

The root causes of workforce shortages differ by region, country, state, and locality but often include insufficient education pipelines, long recruitment timelines, and compensation gaps between the public and private sectors. In preparing for the future, each public health system will have a unique set of circumstances to be holistically assessed, including its needs, constraints, and processes for attracting, developing, and retaining workers.

Four shifts that public health systems can consider implementing today to prepare for tomorrow

Although the challenge is daunting, our experience suggests that four specific shifts could help governments rebuild central public health workforces and support the rebuilding of local public health and healthcare delivery workforces (Exhibit 3). These strategies will likely need to be tailored to each public health system but may serve as starting points.

Four sets of critical shifts can help governments rebuild the public health workforce.

Supporting and retaining the current workforce by equally emphasizing mission and people

The Great Attrition continues to challenge all industries, with more than 52 percent of Gen Z and millennials worldwide reporting that they are likely to consider changing employers this year.10 Public health leaders could commit to creating an environment that meets the expectations of the present-day workforce, focusing simultaneously on employee well-being and on fulfilling the public health system’s mission.

Meeting expectations of the modern worker. Public health systems will be asked to respond to demands for new ways of working. At the organization level, this may mean creating an operating model that is fast, nimble, and frictionless—and flattening the historically hierarchical public-sector bureaucracy.11Organizing for the future: Nine keys to becoming a future-ready company,” McKinsey, January 11, 2021. In addition, given the uncertainty of the past two years, employees are seeking clear statements of employer expectations. A recent McKinsey survey showed that organizations with well-articulated policies for the future workplace have seen a rise in employee well-being and productivity. For example, organizations that have clearly stated postpandemic work arrangements have seen a threefold increase in feelings of inclusion and an almost fivefold increase in feelings of individual productivity.12The future of the workplace: Embracing change and fostering connectivity,” blog entry by Marino MugayarBaldocchi, Bill Schaninger, and Kartik Sharma, McKinsey, June 21, 2021.

At the individual level, workers are prioritizing career development more than ever, with recent global survey results indicating that 43 percent of respondents across industries see career advancement opportunities as a top priority. That said, few were satisfied with the opportunities provided by their current employer.13 Providing a culture of development can have substantial effects on retention. For example, when a sales organization implemented a mentorship program that focused on frontline career pathing, it saw a double-digit increase in employee retention.14When the grass is truly greener: How companies are retaining frontline talent,” blog entry by Matt Fenton, Neel Gandhi, and Taylor Lauricella, McKinsey, January 31, 2022. Public health systems could restructure career pathways to support advancement, train future leaders, and allow lateral movement for staff members who wish to explore a variety of roles within public health, perhaps through rotational programs.15‘Great Attrition’ or ‘Great Attraction’? The choice is yours,” McKinsey Quarterly, September 8, 2021.

Within the health ecosystem specifically, employee expectations are compounded by a need to recover from burnout caused by the pandemic. A McKinsey survey of registered nurses indicated that among those reporting a likelihood to leave direct patient care, top factors influencing their decision included insufficient staffing levels, a feeling of being ignored or unsupported at work, and the emotional toll of the job.16Surveyed nurses consider leaving,” February 17, 2022.

Broadly, prospective employees also increasingly seek work that is mission-oriented, with 71 percent of LinkedIn members surveyed believing job purpose is as important as compensation or status.17 Public health system leaders may wish to capitalize on this sentiment by promoting their mission of transforming public health and promising a meaningful career that makes a real difference in people’s lives.18

Launching tailored retention efforts. Given the breadth of roles within the public health system, the challenges faced by workers vary widely. As such, public health system leaders can consider building analytically backed systems to identify needs and tailor retention initiatives to subsegments of the workforce. For example, initiatives that effectively address burnout among frontline local public health educators may differ from those needed to support centralized, hospital-based public health nurses or regional data analysts who continue to work remotely. Governments could play an active role in helping employees recover from the pandemic through new expanded paid leave or vacation time policies, behavioral health and recovery-focused programs, and enhanced benefits, among other measures.19 Public health systems can follow private-sector counterparts that have launched a variety of initiatives focused on mental wellness to support their workforces throughout the pandemic. For example, the Mount Sinai Health System in New York City launched a Center for Stress, Resilience, and Personal Growth, which continues to sponsor resilience workshops, individual behavioral healthcare services, and mental health self-screening services.20Rebuilding clinician mental health and well-being after COVID-19,” McKinsey, December 15, 2020. Customizing retention efforts could create an environment that entices workers to build careers in public health and could actively demonstrate the commitment of public health leaders to the well-being of their staff.

Public health leaders could commit to creating an environment that meets the expectations of the present-day workforce, focusing on employee well-being and on fulfilling the public health system’s mission.

Building for evolving capability needs by strategically hiring and training

As global health priorities continue to evolve and as new challenges arise due to factors such as climate change and entrenched health inequities, public health system leaders can consider reassessing the roles needed within the workforce.21 These changes will likely require public health entities to hire or train for fundamentally new types of competencies.22 Our global experience with workforce development, including partnering with a UN agency that set capability and capacity targets to fuel growth and achieve sustainable development goals, has demonstrated the importance of clearly understanding needs and setting targets when building for the future.

Assessing capability needs. The past two years have highlighted a new set of roles and capabilities that will likely be required by public health systems worldwide. Examples include those within the Global Epidemic Response and Mobilization (GERM) team proposed by Bill Gates, which includes roles in epidemiology, communications, genetics, data systems diplomacy, rapid response, logistics, computer modeling, and more.23 While many of these topics have historically been core to public health, others are new roles for which the public health ecosystem will actively need to recruit or train, including the following:

  • Health IT and analytics specialists. Modernizing IT, data science, and informatics to improve public health capabilities in disease monitoring and forecasting will be critical in informing health priorities, policies, and actions. There has been a substantial increase in both demand for, and supply of, data in public health, resulting from the proliferation of new digital health technologies, growing reporting requirements related to disease surveillance, and public expectations regarding transparency and open data (for example, in epidemiological modeling or in race and ethnic data). Innovations in advanced analytics have led to increased opportunities to drive insights, such as using syndromic surveillance techniques to predict outbreaks or analyzing environmental and social data to predict risks of lead poisoning. Finally, the federal government has introduced legislation to modernize data and increase interoperability (for example, the Strengthening U.S. Public Health Infrastructure, Workforce, and Data Systems grants from the from Centers for Disease Control and Prevention [CDC]; or Epidemiology and Laboratory Capacity [ELC] funding).24 As the future of public health becomes more data-driven, it will be key to build IT and data capacity and skills across public health systems, including engineering capacity (for example, data engineering and cloud native engineering); data translation capacity (for instance, data science and clinical informatics); and other capacities (such as agile, design thinking and vendor management). Furthermore, building data literacy skills in those acting as public health decision makers—from policy makers to local implementing partners—will also be a priority.
  • Behavioral-health professionals. The pandemic has exacerbated the existing worldwide mental health crisis. For example, the global prevalence of anxiety and depression increased by 25 percent in the first year of the pandemic.25 The United States alone is expected to have 510,000 vacancies in the skilled and semiskilled mental health workforce by 2026.26 Public health systems could help fill this dire need by hiring professionals, creating training programs, and building partnerships with community organizations, academic institutions, and others.
  • Climate change specialists. WHO asserts that the single largest threat to humanity’s health is climate change, predicting that between 2030 and 2050, approximately 250,000 additional people will die per year from malnutrition, malaria, diarrhea, and heat stress exacerbated by climate change.27 Public health systems could help by building a workforce that is able to research and address the effects of climate change on health.
  • Communications experts. As scientific guidelines evolved during the pandemic, the importance of accurate, timely, and accessible public health communications became widely apparent. Meanwhile, only 51 percent of countries in the Organisation for Economic Co-operation and Development (OECD) in 2020 reported trust in their governments.28 To help boost trust, public health systems can consider communications capabilities to successfully tell the story of public health’s societal value, both in stable times and when the next health crisis strikes.

Determining optimal avenues for filling gaps. According to a McKinsey Global Survey on future workforce needs, recruitment is not the only (nor the most effective, necessarily) way to fill gaps—especially in tight labor markets or where public-sector hiring is a challenge.29Beyond hiring: How companies are reskilling to address talent gaps,” McKinsey, February 12, 2020. Beyond hiring, public health system leaders can consider the following opportunities:

  • Outsource or automate. In addition to hiring externally, public health system leaders can pursue opportunities to outsource or automate specific services and upskill current staff. Skill building can emphasize core strategic and technical competencies (such as in bioinformatics or IT) and critical management skills (such as change management, decision making, and consumer centricity).
  • Resource sharing. Public health system leaders can evaluate resource-sharing opportunities. Although certain roles, such as health educators, require a substantial local presence, others, such as data analysts, may be effectively filled in a regional or central staffing model. This approach can be especially beneficial in rural communities and for roles that are hard to staff, such as nurses.
  • Creative service delivery. Creative service delivery models, including rotational staffing and virtual care, can allow public health systems to reach a much broader constituency, as can models that have gained traction in recent years but have yet to fully scale, including those that employ professionalized community health workers. Governments can also build staffing partnerships with public- and private-sector organizations outside of the public health system. This may include temporary or contracted staff and rapid-response teams—all of which were used temporarily during the pandemic.

To boost trust, public health systems can consider communications capabilities to successfully tell the story of public health’s societal value.

Innovating to flexibly extend the workforce by proactively scaling up

The COVID-19 pandemic highlighted the need for public health systems to quickly respond when a new threat arises. This response should neither overburden existing employees nor reduce a system’s ability to continue delivering core services. Public health system leaders can proactively plan and implement infrastructure to effectively expand their workforces when a crisis strikes.30The future of Emergency Operation Centers: Six shifts to consider from COVID-19,” McKinsey, July 1, 2021.

Building central and local reserves on ‘warm standby.’ Public health systems can build infrastructure to marshal extra resources at a moment’s notice. For highly specialized roles, national or international organizations could train staff centrally and deploy them around the globe as needed. This model is used today by the CDC’s Global Rapid Response Team, which has more than 50 staff members who can be deployed within 24 to 48 hours. For less specialized roles, public health systems could offer frequent and widely accessible training to build up local reserves—made up of volunteers, private-sector partners, and others—that are on “warm standby.” This approach proved successful when the United States deployed the National Guard during the pandemic and when Japan mobilized more than 160,000 volunteers to respond to the 2011 Tōhoku earthquake.31Creating this infrastructure could enable public health systems to augment their workforces during emergencies while controlling full-time labor costs.

Instituting flexible policies. Public health system leaders can reassess policies and regulations to optimize staff members’ productivity. This may include a focus on reassessing how and when providers are credentialed. Governments may consider where they can increase the flexibility of who can perform each set of services they administer. By allowing providers to practice at the top of their license and extending privileges across borders, governments may be able to substantially increase workforce capacity in both times of steady state and times of crisis. Similarly, public health systems can rethink how services can be delivered, including staffing ratios, virtual care guidelines, and so on.32 While some policy changes may make sense during ordinary times, others may be appropriate only in times of extreme need. The latter may include temporarily suspending licensing restrictions to allow providers to practice across borders; adjusting regulations to expand the responsibilities of individuals, such as authorizing pharmacists to prescribe critical medications and expediting formal education requirements; or simplifying license renewal processes to bring potential workers out of retirement.33 To enable a nimble response, public health system leaders can consider setting emergency thresholds—for example, when medical needs exceed immediately available resources or when incidence rates exceed a predetermined level—that immediately trigger policy changes.

Creating robust talent pipelines that are streamlined and user-friendly

As demands on public health systems continue to increase, public health system leaders may need to creatively expand their approaches to sourcing talent.

Growing partnership networks. Public health systems can build from the events of the COVID-19 pandemic to broaden talent pipelines through strengthened relationships with community-based organizations, academic institutions, private-sector businesses, and government partners. Our experience has shown that partnerships can be used to great effect. For example, as part of a digital transformation, one ministry of immigration in a G-20 country established more than 15 partnerships to attract tech talent, which helped funnel approximately 100 candidates through its pipeline.34 Separately, through efforts with some African and European countries, public unemployment agencies are partnering with private-sector businesses and academic institutions to train individuals in high-demand capabilities and arrange internships. These programs not only decrease unemployment rates but also ensure that training is fit for purpose. Partnership networks can also help diversify the workforce, potentially targeting community-based organizations in rural areas, creating exchange programs within academic institutions, or launching tailored recruitment plans for specific subsegments of the population.

Modernizing recruitment functions. Outdated, cumbersome recruitment processes could be transformed into streamlined, user-friendly systems to maximize application completion and yield. While the employment landscape varies widely around the world, all public health system leaders can reassess their hiring processes by mapping the user journey of potential candidates and recruitment staff. Our experience has shown the benefits of streamlining processes, clearly defining roles across the system, implementing new technology, building HR capabilities, and implementing modern performance management systems. For example, a federal agency in the United States has seen a reduction in time to hire by up to 75 percent, as well as significant capacity expansion.35

Other potential initiatives include simplifying job qualifications to emphasize required capabilities rather than relying exclusively on prior experience, centralizing public health job listings, ensuring reasonable application turnaround times, creating long-term job security, providing competitive compensation packages, and offering remote or hybrid work models. Where feasible, public health systems may also consider leveraging analytically backed digital labor platforms to increase efficiency and reduce human biases throughout the recruitment process.36Managing talent in a digital age,” McKinsey Quarterly, March 1, 2016.

Next steps

Although the work ahead isn’t easy, following the COVID-19 pandemic, public health systems can play a pivotal role in building a better future for societies and communities at large. While the above initiatives will likely propel jurisdictions forward in their quests to recover and rebuild, public health system leaders could concurrently ensure that they have a long-term, systemwide, strategic plan to develop and maintain their workforces. This approach could include defining the future vision for health, deciding which entities are best equipped to deliver each service, assessing the set of capabilities needed across relevant sites of care, determining future workforce needs by role type, and defining the public health system’s role in meeting demand.

If properly redesigned and implemented, the full ecosystem—including the central public health system, local public health systems, and global healthcare delivery systems—could be improved for generations to come. Public health system leaders will likely need to strategically source, proactively develop, and creatively retain talent that is well equipped to face the next set of challenges, whether serving communities around the world under normal circumstances or quickly mobilizing to confront the next life-threatening health crisis.

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