Researchers say that money alone isn’t enough to overcome public health workforce woes

Indiana’s local public health departments are set to get millions more in funding, but will it be enough? (Getty Images)

After years of underfunding and understaffing, public health agencies in Indiana and across the country now have billions of dollars dedicated to addressing workforce shortages — but experts warn the funds aren’t enough to overcome long-standing, systemic barriers. 

Dr. Valerie Yeager, an Indiana University professor of health policy and management. (Photo from Indiana University)

“The message is not that public health has enough money, it’s that the money is cyclical and inconsistent. So it makes it very hard to use (the funds) to strengthen the workforce at times,” said Valerie Yeager, an Indiana University professor with a doctorate in public health. 

Yeager and co-author Heather Krasna, an associate dean of career services at the Columbia Mailman School of Public Health, recently published a commentary on public health workforce problems with Health Affairs.

The summarized research delves into hiring woes outside of low salaries, such as the lengthy bureaucratic process that can take up to 204 days to complete for federal public health jobs, cutting into positions that often have time-limited funding.

“If you’re given two years of funding and 200 of those days are (used for) recruitment, it’s hard to get approval to hire into a position that only has one year of funding,” Yeager said. 

The analysis comes as Indiana begins to study how counties spent the first year of grant dollars from the Health First Indiana fund — a new initiative that Yeager isn’t involved with but is following closely. The second year of funds, for the first time, will include all 92 counties after six holdout counties opted to join the 2025 cohort. 

Dollars coming to public health departments

The 2021 American Rescue Plan dedicated $7.66 billion to create 100,000 new public health jobs, shoring up beleaguered workforces across the nation’s 2,800 state and local health departments. 

According to an analysis from Columbia University researchers, the Indiana Department of Health has dedicated over half of its allotment, or $20.5 million, to grants for local public health departments to hire school liaisons to help with immunizations along with vision and hearing screenings. 

That wave of monies preceded the $225 million dedicated by the General Assembly in 2023 to public health departments in exchange for meeting a minimum of “core” services, such as maternal and child health, efforts or tobacco and vaping cessation. 

Eighty-six counties split $75 million in the first year while all 92 counties will receive a portion of the $150 million dedicated for 2025. 

Prior to the program, Indiana’s public health funding lagged behind nearly every other state and varied widely from county to county, partly due to Indiana’s reliance on local property taxes to fund the agencies. 

With the new funding, departments interviewed by the Indiana Capital Chronicle indicated that they used their dollars to hire new nurses or department positions — but Yeager said counties have other barriers to overcome. 

Notably, local public health departments can’t just hire someone at whatever salary they deem appropriate — usually the local board of health and county council have a say and give final approval. 

A diagram visualizing the hiring process for local public health departments. (From the Indiana University Bowen Center for Health Workforce Research & Policy)

“It complicates things because they may say, ‘We don’t think you need this position.’ They may not approve the position or they may require that the position be a contractor, which is going to make it harder to hire,” Yeager said.

While Indiana doesn’t have the same burdensome civil service requirements that other states do, any processing delay encourages applicants to give up and seek other employment. 

Becoming a contractor or intern might have fewer barriers, but also has fewer benefits, such as retirement contributions. Yeager advocated for easing the transition of such employees into full-time positions.

“We need to do a better job of being able to retain these individuals and make it easier for them to shift into a permanent position or a full-time employee position,” she said. “Because they learn a lot while they’re in their contract role, and then if we can’t retain them, they leave. And we lose their experience and their institutional knowledge goes with them.”

Interns can be challenging to transition, however, since young graduates aren’t usually able to wait months to secure employment. 

“If we’re not already putting them in the pipeline for the hiring process, there could be a gap between when they graduate and when they get a job offer, and that’s where we lose people. Because it’s hard for any graduate to go any length of time without income,” Yeager continued. “For as long as I’ve been in this field, that gap in how long it takes to get hired is where we lose people that are interested in contributing to the mission of public health work.”

Retention can also be difficult when employees don’t feel like they have opportunities for pay raises. And small staff sizes often mean each employee does the work of several people at once. 

Vigo County, for example, posted a position with its health department for a school liaison paying $37,822. It lists two-dozen responsibilities, including promoting student health, advising parents on vaccines and procuring emergency medicines for schools. Applicants must be certified medical assistants (CMAs) or have an equivalent degree and have three years of experience. 

But the listing, posted earlier this week, explicitly notes that the position is funded through Health First dollars, which the General Assembly has only funded through 2025. 

“The Vigo County Health Department makes every effort to ensure program sustainability but that is not guaranteed,” the post concludes. 

Improvements, but work remains

Still, Yeager did note areas of improvement. 

The historic COVID-19 pandemic brought attention to the oft-maligned profession, exposing the greater public to the importance of public health as a career and attracting more students to relevant degree paths. 

“(But) we aren’t doing a good job of bringing those newly trained people into the profession in a government setting — they primarily go to non-governmental organizations and other organizations that hire faster and can pay better,” Yeager said.

And there are many unknowns, Yeager added, including how long a localized, county-initiated hiring process takes compared to the federal process. 

“They often don’t get a lot of applications — maybe they’re in a rural setting and the person or the type of expertise that they’re looking for doesn’t live in that area and people don’t want to travel,” Yeager added. “… But what I’ve heard from many locals is that they’ll put a posting up and they’ll get no applications. So even if you got it up faster, that doesn’t help you get applicants.”

Yeager said she and some colleagues had wondered if offering a hybrid or remote option might help attract candidates, since workforce habits and preferences have shifted following COVID-19.

Research prior to the launch of Health First outlined current workforce opening across 93 health departments, who collectively had 180 open positions. Yeager isn’t involved with Health First.

“I don’t know what the status is or how many people are being recruited as a result of Health First Indiana,” Yeager said. “But hopefully we are able to get people into these roles and support these agencies in doing this really important work.”

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