HHS and Jurisdictions Have Taken Some Steps to Address Challenging Workforce Gaps (GAO-25-107002)
Summary
A GAO report to congressional committees, GAO-25-107002, dated January 2025, on the public health workforce. It states that public health emergencies such as the COVID-19 pandemic and Hurricane Helene have highlighted the importance of a ready public health workforce. It describes the workforce's role in tracking disease outbreaks, monitoring water quality and communicating about health threats, and notes that nonfederal jurisdictions, including states, territories, Tribes and localities, have primary responsibility for public health. Its title states that HHS and jurisdictions have taken some steps to address challenging workforce gaps.
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United States Government Accountability Office
Report to Congressional Committees
PUBLIC HEALTH
January 2025
PREPAREDNESS
HHS and Jurisdictions
Have Taken Some
Steps to Address
Challenging
Workforce Gaps
GAO-25-107002
January 2025
PUBLIC HEALTH PREPAREDNESS
HHS and Jurisdictions Have Taken Some Steps to
Address Challenging Workforce Gaps
Highlights of GAO-25-107002, a report to
congressional committees
Why GAO Did This Study What GAO Found
Public health emergencies such as the The U.S. public health workforce serves a critical role protecting community
COVID-19 pandemic, Hurricane health, such as by tracking disease outbreaks, monitoring water quality, and
Helene, and other threats, have communicating with the public about health threats. Nonfederal jurisdictions
highlighted the importance of a public within the U.S. (states, territories, Tribes, and localities, such as counties and
health workforce that is ready to meet cities) have primary responsibility for public health in their geographic areas, and
the needs of its citizens. these jurisdictions employ most of the public health workforce—more than
The Consolidated Appropriations Act, 200,000 workers. The federal government, particularly the Department of Health
2023 includes a provision for GAO to and Human Services (HHS), supports these jurisdictions’ workforces and also
report on the public health workforce in employs its own public health workforce.
the United States. This report
GAO’s review found gaps between the existing public health workforce and the
describes, among other topics:
workforce needed. These gaps have existed across multiple occupations and
• gaps in the jurisdictional public jurisdictions and were exacerbated during public health emergencies. Gaps limit
health workforce and challenges to the ability of jurisdictions to conduct key public health functions, such as disease
recruitment and retention, and investigation and control, identification of hazards, and readiness to respond to
• steps HHS and selected emergencies.
jurisdictions have taken to address
jurisdictional recruitment and Examples of Gaps in the Public Health Workforce
retention challenges.
To address these objectives, GAO
reviewed 69 public health workforce
research studies and reports, and
interviewed HHS officials and officials
from 11 stakeholder organizations,
including national organizations
representing jurisdictions, public health
professionals, or educational
organizations; public health policy and
research organizations; and a national Challenges with recruiting and retaining workers contribute to public health
organization focused on public health workforce gaps. These challenges are difficult to solve and are likely to persist
practice and population health. over time, according to GAO’s review. For example, public health funding can be
GAO also interviewed officials in 11 restricted to limited time frames or specific activities, which makes it difficult to
jurisdictions, selected to obtain use the funding for hiring. In addition, jurisdictions faced challenges dealing with
variation in health department structure market competition for workers from other employers offering higher pay, better
(e.g., centralized vs. decentralized), job security, and more flexibility. Jurisdictions also can have cumbersome hiring
funding sources, and percent of processes based on state or local civil service requirements that are difficult to
population in rural areas. The selected change, and public health work can involve high workloads and stress.
jurisdictions included four states, one
territory, two tribal organizations, and HHS and selected jurisdictions have taken some steps to mitigate challenges.
four localities. For example:
• HHS has responded to funding challenges by offering jurisdictions greater
flexibility in using certain grant funds for workforce hiring and support.
• Selected jurisdictions have addressed the challenges of market competition,
cumbersome hiring processes, and stressful workplace environments by
View GAO-25-107002. For more information, offering financial incentives and improving hiring processes. For example,
contact Mary Denigan-Macauley at (202) 512- Maine increased pay for public health nurses and expedited hiring
7114 or deniganmacauleym@gao.gov.
processes, which helped the state fully meet its need.
United States Government Accountability Office
Contents
Letter 1
Background 5
Jurisdictions Face Multiple Workforce Gaps, and Recruitment and
Retention Challenges, Including Those Related to Market
Competition and Hiring Processes 10
Although Some Recruitment and Retention Challenges Are
Pervasive and Systemic, HHS and Selected Jurisdictions Have
Taken Some Steps to Mitigate Them 24
Agency Comments 33
Appendix I Examples of HHS Efforts to Identify and Address Gaps in Its Public
Health Workforce 34
Appendix II Methodology for Review of Studies and Reports 39
Appendix III GAO Contact and Staff Acknowledgements 42
Related GAO Products 43
Figure
Figure 1: Percent of City and County Health Departments Serving
Small, Medium, or Large Populations (N=2,512) 7
Page i GAO-25-107002 Public Health Preparedness
Abbreviations
ASPR Administration for Strategic Preparedness and Response
CDC Centers for Disease Control and Prevention
FTE full-time equivalent
HHS Department of Health and Human Services
HRSA Health Resources and Services Administration
IHS Indian Health Service
PHS Act Public Health Service Act
SAMHSA Substance Abuse and Mental Health Services
Administration
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Page ii GAO-25-107002 Public Health Preparedness
Letter
441 G St. N.W.
Washington, DC 20548
January 29, 2025
The Honorable Bill Cassidy, MD
Chair
The Honorable Bernard Sanders
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Brett Guthrie
Chairman
The Honorable Frank Pallone, Jr.
Ranking Member
Committee on Energy and Commerce
House of Representatives
The U.S. public health workforce serves a critical role protecting
community health, including by ensuring the nation prepares for,
responds to, and recovers from public health emergencies. During the
COVID-19 pandemic, for example, public health workers were on the
front lines, monitoring the number of cases and educating the public on
how best to limit the spread of the disease. In addition, public health
workers help to ensure basic health needs, such as clean drinking water,
even when the U.S. is not facing health emergencies.
Nonfederal jurisdictions within the U.S.—states, territories, Tribes, and
localities, such as counties and cities—have primary responsibility for
public health in the areas they serve. Most of the public health workforce
is employed by the more than 3,000 jurisdictional public health
departments across the country. A recent study funded by the Centers for
Disease Control and Prevention (CDC) estimated that, in 2022, the public
health workforce in state and local jurisdictions included a total of 239,000
individuals, with approximately 30 percent of that workforce at the state
level and 70 percent at the local level. 1 Jurisdictions employ a wide
variety of public health staff, such as nurses and community health
1The confidence interval for the estimate was 95 percent (227,963, 251,840). This study
did not include staff in tribal health departments. See Jonathon P. Leider et al., An
Enumeration of the Public Health Workforce in 2024 (Consortium for Workforce Research
in Public Health, 2024).
Page 1 GAO-25-107002 Public Health Preparedness
workers, and depend on them to deliver essential services, such as
vaccine administration.
The federal government, particularly the Department of Health and
Human Services (HHS), also has a role in supporting the jurisdictional
public health workforce. For example, HHS agencies assist jurisdictions
through funding and other resources to help support their operations, and
jurisdictions may request additional support from the federal government
when their public health capabilities become overwhelmed due to
disasters or other emergencies. 2 HHS and its component agencies, such
as CDC, also employ public health professionals such as epidemiologists,
though its public health workforce is smaller than the jurisdictional
workforce. 3
Public health leaders are concerned about gaps in the public health
workforce, and challenges hiring and retaining staff, due in part to
significant changes in the workforce over the past several years. Recent
research shows that the state and local public health workforce generally
declined in size following the recession of 2008–2009. 4 This decline
generally persisted over the next decade, even as other sectors of the
economy recovered, to varying degrees. 5 In response to the urgent needs
of the COVID-19 pandemic, many public health departments have
expanded their workforce, including by adding short-term employees.
2HHS provides funding to nonfederal entities such as jurisdictions through several
mechanisms including grants and cooperative agreements.
3For example, the CDC-funded study used 2012 federal employment data to identify
approximately 14,000 staff employed across CDC and HRSA. See Leider et al.,
Enumeration of the Public Health Workforce.
4For example, in 2019, the National Association of County and City Health Officials
reported that, since 2008, the estimated number of county and city public health
employees had decreased by 17 percent, as of 2019. See National Association of County
and City Health Officials, 2019 National Profile of Local Health Departments, (Washington,
D.C.: 2019).
Similarly, according to Jonathon P. Leider et al., the aftermath of the Great Recession saw
one-fifth of the public health workforce quit, retire, or get laid off. As such, the public health
workforce lost at least 40,000 jobs between 2010 and 2013. See Jonathon P. Leider et al.,
“The State of the US Public Health Workforce: Ongoing Challenges and Future
Directions,” Annual Review of Public Health 2023. 44:323–41.
https://doi.org/10.1146/annurev-publhealth-071421-032830.
5Evan Cunningham, “Great Recession, great recovery? Trends from the Current
Population Survey,” Monthly Labor Review, U.S. Bureau of Labor Statistics, April 2018,
https://doi.org/10.21916/mlr.2018.10.
Page 2 GAO-25-107002 Public Health Preparedness
The Consolidated Appropriations Act, 2023 includes a provision for us to
report on what is known about the public health workforce in the United
States. 6 This report describes:
1. gaps in the jurisdictional public health workforce and challenges to
recruitment and retention, and
2. steps HHS and selected jurisdictions have taken to address
jurisdictional recruitment and retention challenges.
In addition to these objectives, Appendix I includes examples of HHS
efforts to identify and address gaps in its federal public health workforce.
To describe gaps in the public health workforce and challenges to
recruitment and retention, we reviewed related studies and interviewed
officials or reviewed written documents from jurisdictions, HHS, and
stakeholder organizations. We focused this objective on public health
workforce gaps and challenges experienced by jurisdictions at the state,
territorial, tribal, and local levels.
Study identification and analysis. We identified studies through a
search of research databases, such as MEDLINE and ABI/INFORM.
Specifically, we searched for studies on the public health workforce,
public health workforce gaps, and challenges to recruitment and
retention, as well as for studies that analyzed survey data on the public
health workforce. Using these criteria, we identified 35 studies published
from January 2022 to April 2024 that were specifically related to public
health workforce, public health workforce gaps and challenges, or related
data. In addition to these articles, we also identified 34 other studies on
the public health workforce, including those published by national
stakeholders, research, and policy organizations such as the de
Beaumont Foundation, the Association of State and Territorial Health
Officials, and the Council of State and Territorial Epidemiologists, as well
as government agencies like the CDC and Health Resources and
Services Administration (HRSA). In total, we analyzed 69 studies and
reports, identified as described above, for information on the public health
workforce. See Appendix II for additional detail on our study review.
Jurisdictions. We interviewed officials with responsibilities for public
health at 11 jurisdictions—four states, one territory, two tribal
organizations, and four localities: California; Maine; Maryland; South
6Pub. L. No. 117-328, § 2221(b), 136 Stat. 4459, 5744 (2022).
Page 3 GAO-25-107002 Public Health Preparedness
Carolina; the U.S. Virgin Islands; Wabanaki Health and Wellness; the
California Rural Indian Health Board; Los Angeles County, California; the
city of Baltimore, Maryland; Garrett County, Maryland; and the city of
Portland, Maine. Where applicable, we also reviewed documents related
to jurisdictions’ public health workforce. We selected these state and
territorial jurisdictions to reflect variation in health department structure
(such as whether state health agencies and local health departments
were separate or combined), variation in sources of funding, and percent
of population residing in rural areas. We selected tribal organizations and
localities within the selected states. These interviews provided insights
into the specific workforce gaps and related challenges experienced at
each jurisdiction, and they are not generalizable to other jurisdictions. To
help ensure the accuracy of the facts and statements presented from our
interviews, we provided relevant excerpts of the draft report to the
jurisdictions we interviewed. We incorporated, as appropriate, their
technical comments.
HHS. We reviewed documents and interviewed officials from HHS
agencies or offices to understand the support they provide jurisdictions
with respect to the public health workforce. These supporting agencies
were the Administration for Strategic Preparedness and Response
(ASPR), CDC, HRSA, Indian Health Service (IHS), Substance Abuse and
Mental Health Services Administration (SAMSHA), and the Office of the
Assistant Secretary for Planning and Evaluation. We reviewed documents
and interviewed officials from these agencies and HHS’s Office of Human
Resources to understand HHS’s role supporting the jurisdictional
workforce, and gaps in HHS’s workforce and efforts to close those gaps.
Stakeholder organizations. We interviewed officials from 11 public
health stakeholder organizations we identified based on their knowledge
of, research on, and work with the public health workforce. We selected
three national stakeholder organizations that represent state, local,
territorial, or tribal health departments; two national stakeholder
organizations that represent public health professionals; one national
network of institutes focused on advancing public health practice and
population health; two policy and research institutes; one national public
health academic association; one national public health accreditation
Page 4 GAO-25-107002 Public Health Preparedness
organization; and, one national advisory committee. 7 These interviews
provided insights into workforce gaps and related challenges identified by
these organizations, and they are not generalizable to other entities.
To describe ways that HHS and selected jurisdictions have addressed
recruitment and retention challenges, we reviewed documents and
interviewed officials from the HHS agencies, selected jurisdictions, and
stakeholder organizations noted above. These sources identified actions
that HHS and selected jurisdictions took to address recruitment and
retention challenges. We categorized these actions and determined how
they compared to the specific challenges identified for our first objective,
but we did not assess HHS’s or jurisdictions’ planning efforts.
We conducted this performance audit from August 2023 to January 2025
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background
Public Health and Broadly speaking, public health work seeks to protect and improve the
Jurisdictions health of populations and communities by promoting healthy lifestyles,
researching disease and injury prevention, and detecting, preventing, and
responding to infectious diseases. The public health community also
seeks to reduce health disparities by promoting health care equity,
quality, and accessibility. 8 The United States has 59 state and territorial
7We interviewed representatives from the following stakeholder organizations: the
American Public Health Association, the Association of Schools and Programs of Public
Health, the Association of State and Territorial Health Officials, the de Beaumont
Foundation, the Council of State and Territorial Epidemiologists, the National Association
of County and City Health Officials, the National Indian Health Board, the National
Network of Public Health Institutes, the President’s Council of Advisors on Science and
Technology, the Public Health Accreditation Board, and the University of Minnesota
Center for Public Health Systems.
8Health disparities are preventable differences in the burden of disease, or in opportunities
to achieve optimal health experienced by socially disadvantaged racial, ethnic, and other
population groups. We have reported that various barriers such as discrimination,
economic instability, and lack of health care access can contribute to health disparities.
For more information, see, for example, GAO, Health Care Capsule: Racial and Ethnic
Health Disparities, GAO-21-105354 (Washington, D.C.: September 2021).
Page 5 GAO-25-107002 Public Health Preparedness
public health departments, and approximately 3,000 county, city, and
tribal health departments. 9 These jurisdictions provide essential public
health services, such as communicable disease control, chronic disease
and injury prevention, health inspections of businesses, maternal and
child health services, and facilitation of access to clinical health care
providers.
Jurisdictions vary in the public health services they provide depending on
the needs of their populations, the resources available to them, and the
availability of health care from other organizations. For example, a county
health department may provide certain clinical health services, such as
behavioral health care, if these services are not sufficiently available or
accessible through local health care providers. Likewise, jurisdictions
exhibit wide variation in how their health departments are organized and
operated—there is no standard for how they must be structured and thus,
wide variation exists across jurisdictions. For example, state public health
agencies may be part of larger state departments, or they may be stand-
alone state agencies. In addition, in some cases local jurisdictions, which
include counties or cities, are units of the state health department, while
in other cases they operate more independently. 10 Similar variation exists
in how jurisdictions are funded. 11 Jurisdictions vary in their funding
sources and amounts they receive. They may receive funds from a mix of
9See Mathematica, Surging the Public Health Workforce: Lessons Learned from the
COVID-19 Response at State, Tribal, Local, and Territorial Public Health Agencies, a
report prepared at the request of the Office of the Assistant Secretary for Planning and
Evaluation at the U.S. Department of Health and Human Services, September 2023.
See National Association of County and City Health Officials, 2022 National Profile of
Local Health Departments. (Washington, D.C., 2024).
https://www.naccho.org/resources/lhd-research/national-profile-of-local-health-department
s and Association of State and Territorial Health Officials. ASTHO Profile of State and
Territorial Public Health, Volume Six. (Arlington, Va.: 2023). As discussed earlier,
estimates in the 2024 enumeration study indicate that about 70 percent of public health
staff work in city and county public health departments, and the remainder in state and
territorial jurisdictions. This study did not include staff in tribal health departments. See
Leider et al., Enumeration of the Public Health Workforce.
10See National Association of County and City Health Officials, 2022 National Profile
(2024) and Association of State and Territorial Health Officials, ASTHO Profile (2023). For
more information on jurisdictions, see GAO, Public Health Preparedness: Building and
Maintaining Infrastructure beyond the COVID-19 Pandemic, GAO-24-105891
(Washington, D.C.: Nov. 7, 2023).
11Jonathon P. Leider et al., “How Much Do We Spend? Creating Historical Estimates of
Public Health Expenditures in the United States at the Federal, State, and Local Levels,
Annual Review of Public Health 2018. 39:471-87.
https://doi.org/10.1146/annurev-publhealth-040617-013455.
Page 6 GAO-25-107002 Public Health Preparedness
different federal or state grants, local property taxes, or other
organizations, such as foundations.
Jurisdictions also vary in the size of the population they serve. For
example, according to recent nationwide data, 62 percent of city and
county health departments serve small populations of less than 50,000
people, and these health departments serve approximately 9 percent of
the U.S. population. In contrast, only 6 percent of city and county health
departments serve populations of 500,000 people or more (see figure 1).
In total, however, the departments in these larger jurisdictions are
responsible for serving more than half the U.S. population.
Figure 1: Percent of City and County Health Departments Serving Small, Medium, or
Large Populations (N=2,512)
Public Health Workforce Jurisdictions employ public health workers in several broad areas, which
can overlap:
• Addressing public health issues. Some staff focus on directly
addressing public health issues, such as by monitoring disease
outbreaks and promoting wellness within a community. For example,
epidemiologists and laboratory staff detect and assess community-
level health threats, including diseases, genetic disorders, and
contaminants or toxins. Staff in these professions may also be
employed in other settings, such as academia or private research
facilities. For instance, in a hospital setting, laboratory staff might
conduct blood tests or pathology reviews of tissue samples on
individual patients.
• Providing clinical care to address public health needs.
Jurisdictional health departments also have staff, such as nurses or
Page 7 GAO-25-107002 Public Health Preparedness
physician assistants, who deliver clinical care services that are not
widely available or accessible from medical providers or that are
important for community health, such as vaccinations.
• Providing administrative and operational support. Certain staff are
responsible for the operation of public health departments, such as
human resource specialists responsible for hiring, or grants specialists
and contract managers responsible for managing funding sources.
Workforces in each of these areas may help prepare for and respond to
public health threats or emergencies, such as the COVID-19 pandemic
and Hurricane Helene. The following are examples of occupations in the
public health workforce and descriptions of the work they do:
• Public health nurses. Public health nurses work to prevent disease
and promote community health and safety. They may look at health
trends, identify health risk factors, and work to improve access to
health services.
• Epidemiologists. Epidemiologists use science, mathematics, and
statistics to collect and analyze data on public health, including
detecting and monitoring disease outbreaks and studying risk factors
and causes of disease.
• Health educators. Health educators provide education, resources,
programs, and services to improve community health and to share
information on health threats. These staff may also be referred to as
wellness coordinators, or outreach managers.
• Health inspectors. There are a variety of inspectors working in public
health departments, such as those that inspect restaurants for food
safety issues. In other cases, inspectors may focus on environmental
health issues, such as community water or air quality.
HHS Agencies Involved in HHS and its component agencies lead federal public health efforts,
Jurisdictional Public including efforts to support the jurisdictional public health workforce. HHS
agencies with significant involvement in supporting the public health
Health
workforce include the following:
• ASPR leads the nation’s medical and public health preparedness for,
response to, and recovery from disasters and public health
emergencies. ASPR collaborates with health care providers,
jurisdictions, community members, and other partners to improve
readiness and response capabilities.
Page 8 GAO-25-107002 Public Health Preparedness
• CDC’s responsibilities include helping strengthen jurisdictions’ public
health infrastructure—the people, services, and systems needed to
promote and protect health, including the public health workforce.
• HRSA supports jurisdictional public health needs through programs
focused on the nation’s highest-need communities, including
programs focused on the health workforce, such as scholarship and
loan repayment programs.
• IHS funds and provides medical and public health services, including
environmental engineering services and sanitation facilities, to
American Indians and Alaska Natives who are members or
descendants of federally recognized Tribes. 12 IHS also provides
support to students pursuing medical education to staff Indian health
programs.
• SAMHSA leads public health efforts to advance the behavioral health
of the nation and to promote mental health, prevent substance
misuse, and provide treatments and supports to foster recovery while
ensuring equitable access and better outcomes.
We previously reported on various aspects of HHS’s workforce planning,
and we have made various recommendations for improvements. For
example, in 2024 we recommended ways for ASPR to address ongoing
workforce planning problems and improve emergency response. 13 In
addition, workforce planning issues were part of the reason that we added
HHS’s leadership and coordination of public health emergencies to our
High-Risk list in 2022. 14
12Federally recognized Tribes and individuals who meet the applicable statutory and
regulatory definitions of “Indian” have a unique political status and are eligible for certain
federal programs, benefits, and services because of that status.
13See GAO, Public Health Preparedness: HHS Emergency Agency Needs to Strengthen
Workforce Planning, GAO-24-106108 (Washington, D.C.: Jan. 16, 2024). In that report,
we made four recommendations to improve ASPR’s workforce efforts. As of December 4,
2024, HHS had fully addressed one of the recommendations, partially addressed two, and
had not yet addressed one.
14See GAO, New High-Risk Designation: HHS and Public Health Emergencies appendix
in COVID-19: Significant Improvements Are Needed for Overseeing Relief Funds and
Leading Responses to Public Health Emergencies, GAO-22-105291 (Washington, D.C.:
Jan. 27, 2022) and High-Risk Series: Efforts Made to Achieve Progress Need to Be
Maintained and Expanded to Fully Address All Areas, GAO-23-106203 (Washington, D.C.:
Apr. 20, 2023).
Page 9 GAO-25-107002 Public Health Preparedness
Jurisdictions Face
Multiple Workforce
Gaps, and
Recruitment and
Retention
Challenges, Including
Those Related to
Market Competition
and Hiring Processes
Public Health Workforce Jurisdictions face widespread gaps in their existing workforce compared
Gaps Are Found in to the workforce needed to provide public health services, based on our
review of studies and interviews with selected jurisdictions and
Multiple Occupations and
stakeholder organizations. In particular, jurisdictions face gaps across
Skills, and Vary by multiple occupations and skills, with variation by location. Such public
Location health workforce gaps are exacerbated during public health emergencies,
according to our review, with some jurisdictions experiencing gaps in
multiple different occupations. HHS also faces gaps in its public health
workforce, and we include information on these HHS gaps in Appendix I.
Gaps Overall and across Overall, state and local public health departments across the country
Multiple Occupations would need 80,000 additional full-time equivalent (FTE) workers to deliver
certain public health services, according to a 2021 national study by the
de Beaumont Foundation, an 80 percent increase above existing staffing
levels for those services. 15 Specifically, the de Beaumont Foundation
study estimated that 54,000 additional FTEs were needed in local health
departments and 26,000 were needed in state health departments for
staff in multiple occupations to address such areas as chronic disease
and injury, and communicable disease.
15See de Beaumont Foundation, Protecting the Public’s Health: An Estimate of Staffing
Needed to Serve the Nation, October 2021. In this study, foundational public health
services represent capabilities needed to support basic public health protection and other
areas, such as chronic disease and injury prevention, to improve community health. The
estimates in this study were prepared prior to the COVID-19 pandemic and therefore do
not account for vacancies or hiring resulting from the pandemic. This estimate was based
on data from three state health departments and 170 local health departments in four
states prior to the COVID-19 pandemic. It does not represent workforce needs in U.S.
territories and freely associated states or Tribes.
Page 10 GAO-25-107002 Public Health Preparedness
Jurisdictions also faced gaps in multiple and varied occupations,
according to our review of studies and our interviews.
• Officials we interviewed from 10 of the 11 selected jurisdictions
indicated they had workforce gaps across multiple occupations. For
example, the Garrett County Department of Health in Maryland faced
gaps in nursing staff, social workers, behavioral health therapists,
epidemiologists, environmental health specialists, and clerical staff,
according to officials. Officials from South Carolina’s Department of
Public Health noted workforce gaps in nursing, nutritionists, laboratory
staff, and epidemiologists. Officials with the California Rural Indian
Health Board cited gaps with nursing, epidemiologists, and business
and financial operations staff.
• Officials we interviewed with the California Department of Public
Health reported high vacancy rates across multiple occupations in its
budgeted staff allocation for 2024, with the highest vacancy rates for
medical consultants (55 percent), public health medical officers (37
percent), public health microbiologists (30 percent), and nurse
consultants (22 percent). The department issued reports in 2021
estimating the need for 450 additional public health staff at the state
level and between 1,490 and 1,815 additional staff at local health
departments beyond budgeted staffing levels, to meet state public
health demands, an increase of between 10 and 12 percent. 16
• A 2022 study of 34 New York local health departments found they
also had gaps across multiple occupations including nursing,
community health workers, health educators and laboratory workers. 17
Vacancy rates were as high as 39 percent for licensed practical or
vocational nurses.
• A 2023 study of 72 local health departments in Minnesota found
vacancies in a variety of occupational categories for 2022. The most
frequently reported categories were public health nurses, public health
educators, and administrative staff positions. In addition, beyond
those vacancies, local health departments cited the need to create
16See California Department of Public Health, The Future Public Health System in
California: Workforce (Draft report, August 2021), and Initiative Deep Dives – Investments
and Capabilities Needed for the Future Public Health System (Draft report, September
2021).
17See Isaac Michaels et al., “Enumeration of the Public Health Workforce in New York
State: Workforce Changes in the Wake of COVID-19,” International Journal for
Environmental Research and Public Health, 19, 13592 (2022). The survey included 34
local health departments that reported information in both 2019 and 2021, out of a total of
58 health departments in the state.
Page 11 GAO-25-107002 Public Health Preparedness
additional positions for occupational categories such as health
planners, research analysts, and community health workers. 18
Gaps in Selected Occupations While jurisdictions face gaps in multiple and varied occupations, our
review of studies and our interviews highlighted particular gaps in three
types of occupations: nurses, epidemiologists, and operational support.
Officials we interviewed and documentation we reviewed, indicated that
public health emergencies, such as the COVID-19 pandemic, highlighted
these occupational gaps as they created new public health needs—such
as investigation and testing—and worsened gaps that existed before the
emergencies.
Nurses. Studies we reviewed of local health departments in Minnesota
(2022) and New York (2021) identified nursing as a particular and
substantial workforce gap. 19 Nurses were the second largest occupational
group in state and local health departments in 2019, according to one of
the studies. 20 In addition, data on the overall nursing workforce—not
limited to public health departments—indicate a large shortage of nurses
that is projected to continue over time. HRSA’s nursing workforce
projections indicate a projected shortage of 350,540 full-time equivalent
registered nurses in 2026 and a shortage of 358,170 in 2031. 21 In
addition, officials we interviewed from 8 of 11 jurisdictions told us they
experienced workforce gaps for public health nurses, including three
jurisdictions where officials identified nursing as one of their greatest
workforce needs.
Epidemiologists. State health departments need a total of 2,537
additional epidemiologists—about 44 percent more than current levels—
18See Harshada Karnik et al., “Staffing Local Health Departments in Minnesota—Needs,
Priorities, and Concerns,” Journal of Public Health Management and Practice, vol. 29, no.
4 (2023).
19See Karnik et al., “Staffing Local Health Departments in Minnesota” and Michaels et al.,
“Enumeration of the Public Health Workforce in New York State.”
20See Michaels et al., “Enumeration of the Public Health Workforce in New York State.”
21See U.S. Department of Health and Human Services, Health Resources and Services
Administration (HRSA), National Center for Health Workforce Analysis: Nurse Workforce
Projections 2021-2036, March 2024. Under these projections, the available workforce
would cover about 90 percent of the projected demand. The projections were generated
using historical data up to and including some data from 2021.The report notes that the
impact of the COVID-19 pandemic on the nursing workforce may only be partially
captured in the available data. These estimates were generated using HRSA’s Health
Workforce Simulation Model. The primary function of this model is to assess the adequacy
of the nation’s projected workforce supply to meet the demand.
Page 12 GAO-25-107002 Public Health Preparedness
to reach full capacity, according to a 2024 survey conducted by the
Council of State and Territorial Epidemiologists. 22 In addition, the survey
found that state health departments are also expected to lose a total of
more than 1,000 epidemiologists that had been supported with funding
related to the COVID-19 pandemic, making the need greater. Consistent
with this survey, officials we interviewed from 5 of 11 selected
jurisdictions said they experienced workforce gaps in epidemiologists. A
2016 survey of state and local health departments also found that state
health departments ranked epidemiologists as a “higher priority”
occupation than nine other occupation categories listed. 23
Operational support. Officials we interviewed from 7 of 11 selected
jurisdictions said they experienced key workforce gaps in operational
functions, such as human resources, grants management, financial
operations, and legal services. These occupations are not unique to
public health, but stakeholder officials told us that they are essential for
successful operation of public health departments. Financial and
operations support workers represented one of the four largest
occupational groups in state and local public health departments in 2019,
according to one study. 24
Our review of studies and our interviews found that jurisdictions’
experiences responding to the COVID-19 pandemic highlighted gaps in
key operational support occupations. The pandemic revealed that
jurisdictions did not have sufficient staff in human resources, finance, and
procurement, according to one study. 25 Four jurisdictions did not initially
have the necessary human resources staff to manage increased hiring
and three did not have enough grants management staff, when federal
emergency funding became available, according to our interviews and
review of documentation. An official with a stakeholder organization noted
that historically some jurisdictions had undervalued finance and
accounting functions but said that the importance of these positions
became clear during the COVID-19 pandemic, when they faced urgent
22See Council of State and Territorial Epidemiologists, 2024 Epidemiology Capacity
Assessment Report, (Atlanta, Georgia: October 2024).
23See Angela J. Beck et al., “State Health Agency and Local Health Department
Workforce: Identifying Top Development Needs,” AJPH, vol. 107, no. 9 (2017). Forty-one
of 46 state health departments (89 percent) responded to the survey; one did not report
workforce needs, leaving 40 state health agency responses for these analyses.
24See Leider et al., “An Enumeration of the Public Health Workforce, 2024.”
25See Mathematica, Surging the Public Health Workforce.
Page 13 GAO-25-107002 Public Health Preparedness
needs to manage increasingly complicated financial resources.
Specifically, the insufficient levels of human resources and accounting
staff before an emergency adversely affected the jurisdictions’ ability to
hire staff quickly, when necessary, for emergency response.
Skill Gaps in Informatics and Jurisdictions also face gaps in staff with knowledge of informatics,
Leadership leadership skills, and training in public health, according to studies and
interviews.
Informatics and data analysis skills. Our review of studies and our
interviews indicate that there are gaps in skills related to informatics and
data analysis in the public health workforce. 26
Recent studies indicate that informatics is one of the most significant
public health training needs, and can help public health departments
improve disease surveillance and better address public health needs and
disparities. A 2023 report for HHS by Mathematica, highlighted the
importance of informatics skills, especially for responding to public health
emergencies. 27 In addition, informatics skills were identified as a higher
priority workforce need by 72 percent of state health departments,
according to one study. 28 A national survey of 43,695 employees of state
and local health departments found that fewer than 5.5 percent of the
workforce at state public health departments and 2 percent of the
workforce at local public health departments identified as having specialty
expertise in informatics or information technology. 29
Similarly, officials with five of the jurisdictions we interviewed expressed a
need for personnel with informatics competencies. In addition, officials
with a national stakeholder organization told us there was a gap in the
26The Public Health Informatics Institute defines public health informatics as the science of
how to use data, information, and knowledge to improve human health and the delivery of
health care services.
27See Mathematica, Surging the Public Health Workforce.
28See Beck et al., “State Health Agency and Local Health Department Workforce.”
29See Timothy D. McFarlane et al., “Public Health Informatics in Local and State Health
Agencies: An Update from the Public Health Workforce Interests and Needs Survey,”
Journal of Public Health Management and Practice, vol. 25, no. 2 (2019). This study used
data from the Public Health Workforce Interests and Needs Survey, a nationally
representative survey of workers in state and local public health departments, first fielded
in 2014 and conducted periodically. This survey does not include tribal and territorial
health departments, nor does it include workforce in small health departments—those
serving fewer than 25,000 people or with fewer than 25 staff.
Page 14 GAO-25-107002 Public Health Preparedness
availability of people who understand informatics, and who can use
available data to identify community hazards and available assets to
address such hazards.
Leadership skills. A national survey of the public health workforce
identified gaps in leadership experience and knowledge within public
health departments. In particular, this survey found that 32.5 percent of
public health department supervisors and managers identified themselves
as having low skills in some areas they reported to be somewhat or very
important to their work. These included skills related to building cross-
sector partnerships and understanding social determinants of health. 30
According to officials we interviewed and documents we reviewed from
national stakeholder organizations, these skills represent key capabilities
needed by public health departments. For example, building cross-sector
partnerships can provide access to staff and resources that are not
available in a particular public health department, and an adequate
understanding of social determinants of health can help public health
departments to more effectively address the causes of health problems in
affected communities. These leadership skills gaps, such as those
relating to management skills or how government systems work, result in
part from high turnover among experienced management staff, according
to officials with three national stakeholder organizations we interviewed.
In addition to these skill gaps, most of the public health workforce—86
percent, according to a national survey—does not have a bachelor’s or
more advanced degree in public health. 31 Although such training is not
required for many public health occupations, studies have reported on its
30Casey P. Balio et al., “Rising to Meet the Moment: What Does the Public Health
Workforce Need to Modernize?” Journal of Public Health Management and Practice, vol.
29, no. 1 (2023). This study used data from the Public Health Workforce Interests and
Needs Survey, a nationally representative survey of workers in state and local public
health departments, first fielded in 2014 and conducted periodically. This survey does not
include tribal and territorial health departments, nor does it include workforce in small
health departments—those serving fewer than 25,000 people or with fewer than 25 staff.
31See Rachel Hare Bork et al., “Workplace Perceptions and Experiences Related to
COVID-19 Response Efforts Among Public Health Workers — Public Health Workforce
Interests and Needs Survey, United States, September 2021–January 2022,” Morbidity
and Mortality Weekly Report, vol. 71, no. 29 (2022). This survey does not include tribal
and territorial health departments, nor does it include workforce in small health
departments—those serving fewer than 25,000 people or with fewer than 25 staff.
Page 15 GAO-25-107002 Public Health Preparedness
benefits, such as preparing staff to engage in activities designed to
prevent health concerns, like foodborne illnesses. 32
Gaps in Rural Areas and Gaps in the public health workforce can be more severe in rural areas,
Regional Variation and can vary by region, based on our review.
Gaps in certain rural areas. Rural local public health departments have
fewer resources and provide fewer services compared with urban and
suburban health departments, according to studies on rural public
health. 33 Officials we spoke with in three state jurisdictions and a regional
tribal organization reported that workforce gaps were more common in
the rural areas they served.
Officials in one jurisdiction said, for example, that people with more
specialized skill sets tend to live in urban areas. In addition, rural areas
may face greater needs for clinical health services, due to hospital
closures or other workforce shortages in the availability of clinical care. 34
Therefore, in addition to staff with expertise in public health, rural public
health departments may need to hire clinical staff to provide needed
clinical services, such as prenatal and pediatric care.
Gaps and variation across regions. Two studies of the public health
workforce found regional variation in workforce supply, indicating that
some jurisdictions may have certain workforce gaps while others may not.
32See Gulzar H. Shah et al., “Ensuring Food Safety for Americans: The Role of Local
Health Departments,” International Journal of Environmental Research and Public Health,
19, 7344 (2022). https://doi.org/10.3390/ijerph19127344; and Laura C. Harrington and
Emily M. Mader, “Northeast Regional Center for Excellence in Vector-Borne Diseases’
Master of Science Training Program: a Curriculum to Support Future Capacity in Public
Health Entomology,” Journal of Medical Entomology, vol. 60, no. 5 (2023),
https://doi.org/10.1093/jme/tjad100.
33See Jenine K. Harris et al., “The Double Disparity Facing Rural Local Health
Departments,” Annual Review of Public Health, vol. 37, pp.167–84 (2016),
10.1146/annurev-publhealth-031914-122755. See also Jonathon Leider et al., “The State
of Rural Public Health: Enduring Needs in a New Decade,” AJPH, vol. 110, no. 9 (2020).
34GAO reported in 2018 that rural hospital closures more than doubled during 2013
through 2017 and that more rural hospitals closed than urban hospitals during these
years. See GAO, Rural Hospital Closures: Number and Characteristics of Affected
Hospitals and Contributing Factors, GAO-18-634 (Washington, D.C.: Aug. 29, 2018). GAO
also reported that residents affected by rural hospital closures had reduced access to
health care services. See GAO, Rural Hospital Closures: Affected Residents had Reduced
Access to Health Care Services, GAO-21-93 (Washington, D.C.: Dec. 2020).
Page 16 GAO-25-107002 Public Health Preparedness
• Nursing workforce projections by HRSA found that workforce supply
and shortages vary widely across states. While some states are
projected to have an adequate supply of nurses in 2036, others, such
as Georgia, California, and Washington, are projected to have
shortages, with one state projected to have a nursing shortage as
large as 29 percent. 35
• A 2024 study estimating the public health workforce in 2022 found
that the ratio of workers to population varied widely across 10
federally defined regional groups of states, ranging from an estimated
high of 97 state and local public health workers per 100,000
population for Region 1 (Connecticut, Maine, Massachusetts, New
Hampshire, Rhode Island, and Vermont) to an estimated low of 59 per
100,000 population for Region 6 (Arkansas, Louisiana, New Mexico,
Oklahoma, and Texas). 36
Gaps Exacerbated during Gaps found in the public health workforce may be exacerbated during
Public Health Emergencies public health emergencies as needs increase, especially when
accompanied by staff departures. The public health workforce declined 17
percent from 2008 to 2019, before the COVID-19 pandemic, according to
a 2019 nationwide survey of county and city health officials. 37 Gaps that
existed before an emergency arose—for example in emergency
preparedness and response—made it more difficult for jurisdictions to
increase the workforce when necessary for a public health emergency,
according to a 2023 report for HHS by Mathematica, and several
jurisdiction officials we interviewed. 38
35See U.S. Department of Health and Human Services, Health Resources and Services
Administration, National Center for Health Workforce Analysis: Nurse Workforce
Projections 2021-2036, March 2024.
36See Leider et al., “An Enumeration of the Public Health Workforce, 2024.”
37See National Association of County and City Health Officials, 2019 National Profile of
Local Health Departments (2019).
38See Mathematica, Surging the Public Health Workforce.
Page 17 GAO-25-107002 Public Health Preparedness
These gaps and other factors, such as public mistrust and criticism of
public health workers, increased stress among the workforce and
contributed to departures during and following the COVID-19 pandemic. 39
Recruitment and Retention Challenges with recruiting and retaining workers contribute to public
Challenges Related to health workforce gaps, according to our review of studies and interviews
with stakeholder organizations and jurisdictions. 40 Specific challenges
Funding Restrictions,
faced by jurisdictions include short-term and categorical funding
Market Competition, Hiring restrictions, market competition (including salary disparities),
Processes, and Work cumbersome hiring processes, and an unfavorable work environment.
Environment Contribute to
Workforce Gaps Short-term and categorical funding restrictions. Jurisdictions receive
a significant portion of their funding through awards from the federal
government, states, and other sources. The laws that appropriate this
funding may require the funds to be restricted to a short-term time frame,
or they may be restricted to specific categories of activities (known as
categorical funding)—for example, to address a particular disease (e.g.,
diabetes) or purpose (e.g., supporting laboratory capacity). However,
public health departments often seek to recruit and retain staff for longer
time periods, and staff with responsibility for addressing multiple diseases
and many purposes. Therefore, public health jurisdictions face challenges
using funding with these restrictions for recruiting and retaining their
workforce.
Our review identified the following challenges related to short-term
funding:
• One recent study funded by HHS reported that a lack of sustained,
longer-term public health funding was one of the most common
barriers to recruiting and retaining jurisdictional public health
39See Liliana Ventura et al., “Unprecedented Times: Experiences of Social Work and
Public Health Professionals during Times of Public Crises,” Social Work in Public Health,
vol. 38, no. 2 (2023); and Jonathon P. Leider et al., “The Exodus of State and Local Public
Health Employees: Separations Started before and Continued throughout COVID-19.”
Health Affairs, 2023;42(3):338-348. This study used data from the Public Health
Workforce Interests and Needs Survey, a nationally representative survey of workers in
state and local public health departments, first fielded in 2014 and conducted periodically.
This survey does not include tribal and territorial health departments, nor does it include
workforce in small health departments—those serving fewer than 25,000 people or with
fewer than 25 staff.
40In addition, this is consistent with GAO, Public Health Preparedness: Building and
Maintaining Infrastructure beyond the COVID-19 Pandemic, GAO-24-105891
(Washington, D.C.: November 7, 2023).
Page 18 GAO-25-107002 Public Health Preparedness
workers. 41 According to this study, short-term funding can lead to
cycles of hiring temporary workers who cannot be retained beyond
award periods. National stakeholder organizations and officials from
California Department of Public Health noted that these temporary
positions are not attractive to prospective workers looking for stable
employment.
• Officials at one local public health department explained that their
temporary positions have inferior employment benefits, which they
said may make the workers difficult to retain. A national stakeholder
organization and other jurisdictional officials further stated that
jurisdictions may make significant training investments for some
temporary workers, but then lose the benefits of these investments if
they cannot retain staff.
• Some jurisdictions may not be permitted to hire permanent public
health workers with short-term funding. An official at a national
stakeholder organization described one state in which programs must
have secured five years of funding to receive approval to hire
permanent positions, and the officials stated that such five-year
funding is rare in public health.
Our review identified that categorical funding may pose challenges for
jurisdictions seeking to hire staff to address local public health priorities or
staff to fill crosscutting positions. For example, we and HHS have
reported that jurisdictions were unable to use funding or staff hired with
COVID-19 response funding to conduct investigations or respond to other
emerging infections (e.g., hepatitis and mpox), even though communities
were experiencing outbreaks. 42 In addition, officials in the California
Department of Public Health told us that categorical restrictions on
funding use limits their department’s ability to adequately address
growing community needs.
Market competition. Jurisdictions faced challenges dealing with market
competition for public health workers from employers outside the
government offering higher pay, better job security and more flexibility,
our review of studies and our interviews found. Studies noted that this
market competition can be especially challenging because public health
41Mathematica, Surging the Public Health Workforce.
42See GAO, Public Health Preparedness: Mpox Response Highlights Need for HHS to
Address Recurring Challenges, GAO-24-106276 (Washington, D.C.: Apr. 1, 2024) and
Mathematica, Surging the Public Health Workforce.
Page 19 GAO-25-107002 Public Health Preparedness
jurisdictions compete for workers with private health care providers, who
generally can offer much higher salaries. For example:
• Several studies cited occupational pay disparities between the private
and public sectors. For example, state and local public sector pay was
about 10 to 47 percent less than in the private sector for 10 of the
occupations reviewed in one study involving data from 2021 and
2022. 43 These occupations included chief executives, epidemiologists,
computer and information systems managers, occupational health
and safety specialists and technicians, and emergency management
directors.
• Studies also found that, among jurisdictional workers who intend to
leave their positions, a large share cited pay as one of reasons for
considering leaving. One study showed that pay was the most
frequently cited reason for considering leaving (63%) among younger
jurisdictional public health workers, aged 35 or younger who were
considering leaving. 44
One study of employment data for 2015-2020 public health graduate
degree programs found that fewer were employed in government, than in
for-profit health care, or non-profit organizations. 45 Representatives we
interviewed from national stakeholder organizations told us health
departments generally cannot offer public health graduates salaries that
are competitive with salaries offered by private sector and some non-
profit organizations, and that it is therefore difficult for them to hire such
graduates.
43See Heather Krasna, Malvika Venkataraman, and Isabella Patino, “Salary Disparities in
Public Health Occupations: Analysis of Federal Data 2021-2022,” American Journal of
Public Health, vol. 114, no. 3 (March 2024): 329-339. doi.org/10.2105/AJPH.2023.307512.
44See Leider et al., “The Exodus of State and Local Public Health Employees.” This study
used data from the Public Health Workforce Interests and Needs Survey, a nationally
representative survey of workers in state and local public health departments, first fielded
in 2014 and conducted periodically. This survey does not include tribal and territorial
health departments, nor does it include workforce in small health departments—those
serving fewer than 25,000 people or with fewer than 25 staff.
45See Jonathon P. Leider et al., “Trends in Degree Conferrals, Degree-Associated Debt,
and Employment Outcomes Among Undergraduate Public Health Degree Graduates,
2001-2020,” American Journal of Public Health 113, 115-123 (2023).
Page 20 GAO-25-107002 Public Health Preparedness
Officials we interviewed from our selected jurisdictions also provided
examples of recruitment and retention challenges related to market
competition and pay. For example:
• Officials in two jurisdictions said that hiring and retaining nurses
during the COVID-19 pandemic became especially challenging, as
hospitals and other organizations were able to offer substantially
higher pay.
• Officials from the Los Angeles County Department of Public Health
told us that they have a hard time recruiting and retaining staff in
certain occupations, especially positions where there is large demand
and higher pay in the private sector. Officials said that employees may
work at the department long enough to be trained as registered
environmental health specialists, and then leave for higher paid
positions in private sector environmental or occupational health units.
• At the state level, the California Department of Public Health told us
that their most difficult retention challenges—for medical, scientific,
administrative, clerical, and laboratory staff—are due to competition
from both private and public sector organizations, including
competition from some California counties and the federal
government.
Cumbersome hiring processes. Our review of studies and interviews
with national stakeholder organizations and jurisdictions identified
restrictive or cumbersome hiring processes that may delay hiring and
hinder recruitment. This can result in applicants accepting other job offers
before a jurisdiction can complete the hiring process. Jurisdictions may
also not be able to fill vacated positions quickly, leading to workforce gaps
and loss of institutional knowledge. For example:
• One national stakeholder organization stated that jurisdictions have
different hiring process mandates, rules, and systems that can delay
hiring by 6 months and that prospective employees who need jobs are
typically not able to wait that long.
• Even when jurisdictions have funding available to hire staff, some
have not been able to fill some positions due to the length of time
needed for civil service hiring processes, according to an official from
a national stakeholder organization representing public health
jurisdictions. Similarly, our interviews with jurisdiction officials
indicated that many use civil service hiring processes that involve
lengthy applications, exams, and background checks.
Page 21 GAO-25-107002 Public Health Preparedness
• Another national stakeholder organization official said that not having
sufficient human resource and accounting capacity in jurisdictions
contributes to lengthy hiring processes.
• Officials at Maine’s Center for Disease Control and Prevention told us
that they paused hiring for multiple years for two key positions—a
data modernization director and a workforce director—to classify the
new positions through the state Bureau of Human Resources and
then obtain approval from the state Department of Administrative and
Financial Services.
• Some jurisdictions are required to use standardized job descriptions,
which officials noted also contributes to cumbersome processes,
according to our interviews. In particular, jurisdictions may be
restricted from updating and tailoring job descriptions to specific public
health roles. In these cases, jurisdictions may have to use job
descriptions that do not adequately explain the position being filled,
which may result in a candidate pool not aligned with the skill set
needed. For example, officials in California and Maryland told us that
they could only post jobs within rigid categories that do not match the
needs of the positions, such as an accountant position that used a job
description posting titled “Administrator 5.” According to officials from
two national stakeholder organizations we interviewed, revising these
job descriptions would be a long and challenging process, involving
multiple entities across the state governments.
• A 2022 study found that applicants seeking government public health
employment may struggle to identify and understand position
descriptions and required qualifications, for example, because of job
descriptions that do not clearly describe job responsibilities. 46
• Officials from two national stakeholder organizations also identified
that there are problems resulting from job descriptions not reflecting
what the actual job entails. One of these organizations told us that
inadequate job descriptions often lead to new employees quitting
shortly after being hired, if they discover that the actual responsibilities
of the job are different than they expected.
Unfavorable work environment. Our review of studies and our
interviews identified workload, stress, and burnout; a lack of advancement
opportunities; and a lack of remote work options as contributing to an
46See Rachel Locke et al., “Attracting New Talent to the Governmental Public Health
Workforce: Strategies for Improved Recruitment of Public Health Graduates,” Journal of
Public Health Management Practice, vol. 28(1) (2022): E235-E243.
Page 22 GAO-25-107002 Public Health Preparedness
unfavorable work environment for public health. These factors can hinder
recruitment and retention.
• Studies identified heavy workload, stress, and burnout as a reason for
employees leaving, or considering leaving, work in public health
departments. A 2023 study found that in 2021, more than 40 percent
of jurisdictional employees cited workload and burnout, and 37
percent cited stress as a reason for considering leaving their jobs. 47
For jurisdictional public health employees under the age of 50,
workload and burnout were cited by 46 percent and stress was cited
by 42 percent.
• Another study using the same data source found that, among those
ages 35 and younger with intent to leave their jurisdictional public
health employment, 44 percent cited overload and burnout and 39
percent cited stress as reasons for considering leaving. 48 The length
and intensity of the COVID-19 pandemic amplified stress and burnout
among public health workers, and made it difficult for jurisdictions to
retain staff, according to studies, stakeholders and jurisdictions.
• The same studies of jurisdictional public health workers found that
lack of advancement opportunities was among the most frequently
selected reasons for considering leaving governmental public health
service in 2021. Jurisdiction officials we interviewed said that
pathways for advancement may be especially limited among
specialized public health occupations.
• Two jurisdictions described how requirements to work in the office
every day have made recruitment and retention challenges more
difficult. An official from the California Rural Indian Health Board told
us that the organization experienced significant turnover when
employees wanted to remain remote following the end of the COVID-
19 pandemic. Similarly, officials at the Baltimore City Health
Department said that their organization has experienced recruitment
47Jonathon P. Leider et al., “Turnover, COVID-19, and Reasons for Leaving and Staying
within Governmental Public Health,”. Journal of Public Health Management Practice.
2023;29 (Suppl 1):S54-S63. doi:10.1097/PHH.0000000000001634. This study used data
from the Public Health Workforce Interests and Needs Survey, a national survey that does
not include tribal and territorial health agencies, or small health departments, those
serving fewer than 25,000 people or with fewer than 25 staff.
48Leider et al., “The Exodus of State and Local Public Health Employees.” This study used
data from the Public Health Workforce Interests and Needs Survey. This national survey
does not include tribal and territorial health departments, nor does it include workforce in
small health departments, those serving fewer than 25,000 people or with fewer than 25
staff.
Page 23 GAO-25-107002 Public Health Preparedness
and retention challenges because some positions that had been
remote began requiring an in-office presence. 49
Although Some
Recruitment and
Retention Challenges
Are Pervasive and
Systemic, HHS and
Selected Jurisdictions
Have Taken Some
Steps to Mitigate
Them
Systemic Factors Make Some of the challenges to recruitment and retention are pervasive and
Gaps and Recruitment systemic, making it difficult for HHS and jurisdictions to address gaps
fully. Key systemic factors relate to competition in the broader health care
and Retention Challenges
industry, jurisdictional employment requirements and decisions about
Difficult to Fully Address funding levels, and the historic pattern of public health funding structures,
according to our review of studies and our interviews with officials from
selected jurisdictions, and stakeholder organizations.
Broader health care industry competition. The challenge of market
competition, discussed earlier, is complicated to solve due to the
competitive advantages of other employers in the health care industry,
when compared with jurisdictions. Commercial health care delivery
systems, as well as health insurers and pharmaceutical companies, may
seek workers with the same skills valued by public health jurisdictions, but
have greater resources that allow them to offer higher salaries, according
to studies and national stakeholders. 50 Competition has been particularly
49See GAO work on telework, including GAO, Federal Telework: Key Practices That Can
Help Ensure the Success of Telework Programs, GAO-21-238T (Washington, D.C.: Nov.
18, 2020) and GAO, COVID-19: Federal Telework Increased During the Pandemic, but
More Reliable Data Are Needed to Support Oversight, GAO-22-104282 (Washington,
D.C.: Feb. 8, 2022).
50See Krasna et al., “Salary Disparities in Public Health Occupations,”; Margaret Tait et
al., “Federal Student Loan Debt in Public Health and the Opportunities for Loan
Repayment Programs,” Public Health Reports 1 – 7 (Association of Schools and
Programs of Public Health: 2024), DOI: 10. 1177/00333549231223712; and Leider et al.,
“The State of the US Public Health Workforce.”
Page 24 GAO-25-107002 Public Health Preparedness
acute for high-demand professions, such as nursing, physicians, and
epidemiologists, and during public health emergencies, such as COVID-
19 pandemic, according to officials we interviewed. In addition, one study
in our review noted a significant increase in hiring of candidates with
master’s-level public health training by pharmaceutical firms and health
insurance companies from March 2020 through October 2020—during
the COVID-19 pandemic—compared to a year earlier. 51
The challenge faced by jurisdictions in providing competitive salary and
benefit packages is further exacerbated by broader economic factors
such as rising education costs and related increasing student debt, and
the rising cost of living. These factors may influence employees to
maximize their salaries through private-sector employment, according to
our review of studies and our interviews with some stakeholders. Across
157 schools, the median loan for a master’s degree in public health,
based on combined data for academic years 2017-2018 and 2018-2019,
ranged from $8,185 to $100,000, according to one study. 52
Jurisdictional employment requirements. Jurisdictions—which have
primary responsibility and decision-making authority for their public health
services—may face challenges attempting to change cumbersome hiring
processes. In particular, they may be subject to state or local civil service
requirements that make it complicated to alter salary structures, job titles,
job descriptions, or recruitment processes to improve their effectiveness
in hiring public health workforce occupations, according to our review of
studies and our interviews. Some of these requirements were designed to
accommodate a broad range of civil service positions, thus making it
challenging to effectively target the hiring process to the public health
workforce. Longstanding civil service and merit-based requirements,
while intended to foster fairness, can result in cumbersome, slow hiring
processes, according to two studies in our review. 53
Jurisdictional funding levels. State and local governments vary widely
in how much funding they choose to provide for public health, according
to our review of studies and our interviews. Further, some jurisdictions
have fewer resources to address public health workforce challenges.
Funding may vary based on the total amount of resources available to a
51See Leider et al., “The State of the US Public Health Workforce.”
52Margaret Tait et al., “Federal Student Loan Debt in Public Health.”
53See Leider et al., “The State of the US Public Health Workforce.”
Page 25 GAO-25-107002 Public Health Preparedness
jurisdiction, and also based on the need to fund other key state or local
responsibilities, such as Medicaid and public education. 54 One study
found that per capita public health funding varied widely across states in
2021: among 45 states, per capita public health funding ranged from $7 in
Missouri to $159 in New Mexico. 55 Another study of 16 local health
departments in four states (Minnesota, Missouri, New York, and West
Virginia) found that their spending for core public health services ranged
from $1.10 to $26.19, per capita. 56
Public health funding structures. The challenges of short-term and
categorical funding, as described earlier, are related to the way that public
health has been funded over time. In 2012, the Institute of Medicine
issued a report that reviewed funding structures for public health and their
use in improving health outcomes. 57 Among other things, the report found
that:
• compartmentalized inflexible funding leaves many health departments
without financing for key priorities or for needed cross-cutting
capabilities, such as information systems and policy analysis; and
• funding from different levels of government is often uncoordinated and
has different rules for use.
These findings are consistent with the situation described by officials we
interviewed and other studies we reviewed. For example, a 2022 study
that reexamined the issues highlighted by the Institute of Medicine’s 2012
54Medicaid is the federal-state program that finances health care for qualifying for low-
income and medically needy individuals.
55See State Health Access Data Assistance Center, Exploring 2021 State Public Health
Funding Estimates Using State Health Compare (October 2022). This report calculates
state public health funding through analyses of state spending on public health for each
budget cycle using publicly available budget documents through state government
websites. Public health spending is defined in this study as including all health spending,
except for Medicaid, the Children’s Health Insurance Program, and other coverage
programs for low-income residents. The study notes that comparisons of public health
funding levels across states are difficult because of variation in how states allocate their
budgets and what details are provided.
56See Simone R. Singh et al., “Local Health Departments’ Spending on the Foundational
Capabilities,” Journal of Public Health Management and Practice, vol.26, no.1 (2020): 52-
56.
57See Institute of Medicine, For the Public’s Health: Investing in a Healthier Future.
(Washington, D.C.: The National Academies Press), 2012. https://doi.org/10.17226/13268.
Page 26 GAO-25-107002 Public Health Preparedness
report found no significant changes to funding structures that might
improve conditions. 58
HHS and Selected While the systemic factors make public health workforce challenges
Jurisdictions Use a Broad difficult to solve, HHS and the selected jurisdictions in our review have
taken a broad range of actions aimed at addressing the recruitment and
Range of Actions Aimed at
retention challenges that contribute to jurisdictions’ workforce gaps
Reducing Recruitment and according to our interviews with jurisdictions, stakeholder organizations,
Retention Challenges That and agencies. We grouped these actions into six broad areas: financial
Contribute to Workforce incentives, improved hiring processes, workplace environment
Gaps improvements, pathway expansion, funding flexibility, and special
resources for responding to disasters or public health emergencies. In
some cases, an action may be aimed at addressing more than one
recruitment and retention challenge, or multiple actions may address the
same challenge. (In addition to these actions aimed at reducing
jurisdictional public health workforce gaps, HHS also has taken action to
address public health workforce gaps in HHS agencies. Appendix I
includes examples of these actions.)
Financial incentives. HHS and selected jurisdictions have offered
financial incentives aimed at addressing the challenge of market
competition. Financial incentives include increased pay, recruitment
bonuses, competitive benefits, and student loan repayment or
forgiveness. Increased pay can be limited to certain mission critical or
hard-to-fill occupations, increasing the likelihood of recruiting and
retaining candidates to public health jobs that would otherwise be lower
paying. For example, officials in several jurisdictions described their
efforts to increase pay for nurses:
• The Baltimore City Health Department added pay incentives for new
public health nurses and provided bonuses to existing nurses.
• The South Carolina Department of Health worked to change the
state’s job classification system, which resulted in significant pay
increases for some nurses.
• Maine’s Center for Disease Control and Prevention received approval
to offer an additional 15 percent stipend after demonstrating the
difficulty of hiring public health nurses.
58See Jason M. Orr, et al., “Regarding Investment in a Healthier Future: Impact of the
2012 Institute of Medicine Finance Report,” Journal of Public Health Management and
Practice, vol. 28, no.1 (2022).
Page 27 GAO-25-107002 Public Health Preparedness
Jurisdictions may increase pay, for example, for positions that are
especially challenging to fill, as part of their regular budget processes. In
this way, they focus salary increases on occupations with large gaps
between jurisdiction and market pay. For example, according to officials,
the Maryland Department of Health requested that the state Department
of Budget and Management conduct a salary review for environmental
health professionals. When officials identified significantly lower pay at
the state level compared to Maryland counties, the state increased state
salaries for the environmental health classification.
Similarly, student loan repayment or forgiveness may improve recruitment
efforts by making it feasible for graduates with student loan debt to accept
lower paying positions in governmental public health departments.
Additionally, scholarship programs can provide incentives to pursue
training and careers in public health. For example, to improve recruitment
and retention outcomes, beginning in 2022, HRSA’s Public Health
Scholarship Program provided training scholarships specifically for public
health students. According to HRSA officials, in the program’s first year,
840 students received a total of $5,894,684 in scholarship funding. 59
Improved hiring processes. CDC helped jurisdictions address the
challenges of cumbersome hiring processes and market competition
through direct placement of CDC field staff to support public health
programs funded through CDC.
For example, the CDC Career Epidemiology Field Officer network
provides states and other jurisdictions with senior-level epidemiologists
directly, bypassing jurisdictional hiring processes. According to CDC
officials, CDC developed this program to strengthen the epidemiology
capacity to support emergency preparedness and response in state,
local, and territorial health departments, and to build a network among
health departments and CDC to aid in a coordinated response to public
health threats. CDC data indicate that as of December 2024, 51 field
officers had been placed in jurisdictions.
Officials with the Los Angeles County Department of Health created a
staff position to focus on recruiting outreach efforts to colleges and non-
profit organizations and on communicating with prospective job applicants
59Applicants are required to have a system for scholarship recipients to maintain or be
transferred into employment in public health upon completion of their training. See U.S.
Department of Health and Human Services, Health Resources and Services
Administration, https://www.hrsa.gov/grants/find-funding/HRSA-22-122.
Page 28 GAO-25-107002 Public Health Preparedness
through social media platforms such as Instagram and LinkedIn.
According to officials, this enhanced communication helped potential
applicants understand and navigate the county’s cumbersome hiring
process requirements. To address similar challenges, Maine’s Center for
Disease Control and Prevention expedited its application review process
for hiring public health nurses. Maine officials stated that their relatively
slow hiring process was placing them at a competitive disadvantage for
hiring, and they credited the initiative with enabling them to fully staff the
state’s public health nursing team.
Workplace environment improvements. HHS and selected jurisdictions
have taken action to improve the work environment in jurisdictions, such
as by providing greater workplace flexibility, addressing burnout and
heavy workloads, improving supervision and leadership, and providing
advancement opportunities, such as through training. In this way,
workplace environment improvements and expanded advancement
opportunities can help address challenges with market competition and
unfavorable work environments. Examples include the following:
• The flexibility of CDC’s Public Health Infrastructure Grant enabled the
Baltimore City Health Department to hire a Wellness and Culture
Manager to help improve well-being and stress levels among staff,
according to jurisdiction officials.
• South Carolina Department of Public Health officials credited their
telework policy with helping the Department recruit and retain
employees, while maintaining or improving productivity.
• The California Department of Public Health created the California
Public Health Workforce Career Ladder Funding Program, which, to
improve worker retention, provides grants to local jurisdictions and
reimbursement to state employees, and training opportunities and
professional development for existing public health workers, according
to documentation provided by officials.
• HRSA supports the Rural Public Health Workforce Training Network
Program, which provides assistance with training and job placement
services in rural and tribal communities. The program aims to expand
health services capacity by supporting public health job development,
training, and placement.
• CDC provides workforce development resources and training
programs through an online platform, CDC TRAIN. This platform is
available to jurisdictional public health professionals and others and
provides learning resources and training opportunities on a wide
Page 29 GAO-25-107002 Public Health Preparedness
variety of public health topics, according to agency officials. According
to agency documentation, the program provided free continuing
education through this platform to 232,000 unique health
professionals in fiscal year 2023.
Pathway expansion. HHS and selected jurisdictions implemented
actions to broaden interest in and exposure to governmental public health
employment, intended to help expand pathways into the public health
workforce. By expanding these pathways, agencies and jurisdictions aim
to address market competition for public health workers. For example, an
internship or fellowship program may encourage students or recent
graduates of public health-related degree programs to seek employment
at public health departments. Similarly, partnering with educational
institutions to expose students to public health may translate into greater
interest in governmental public health careers, according to interviews
and documents provided by agency and jurisdiction officials. Examples
include:
• CDC, through six fellowship programs, placed 409 full-time fellows in
jurisdictions in fiscal year 2023. These programs included the
Epidemic Intelligence Service, Laboratory Leadership Service, Public
Health Associates, Applied Epidemiology Fellows, Applied Public
Health Informatics Fellows, and Preventive Medicine Residents and
Fellows programs.
• HRSA’s Regional Public Health Training Centers Program seeks to
expand the public health workforce by coordinating field placements
for public health students. In addition to increasing the workforce,
according to an evaluation of the program, placing these students in
jurisdictions increased participants’ intent to work in such jurisdictions
in the future. 60 Officials reported that the program trained 1,107 public
health students across a 5-year period (academic years 2015-2020)
and that 41.9 percent of the students were from underrepresented
minority groups or from disadvantaged backgrounds.
• Officials with the Maryland Department of Health established a Public
Health Workforce Internship Program to provide a paid opportunity for
students to experience working in public health, and to help develop a
pipeline of potential employees.
60See Health Resources and Services Administration, (2022). Regional Public Health
Training Centers Program. U.S. Department of Health and Human Services.
https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/phtc-
outcome-report-2015-2020.pdf
Page 30 GAO-25-107002 Public Health Preparedness
Funding flexibility. Officials in selected jurisdictions told us that the
flexibility of CDC’s Public Health Infrastructure Grant helped to ease
recruitment and retention challenges. This grant provides flexible funding
and a longer-term grant period compared to other funding sources used
by jurisdictions that are short-term and categorical, according to
interviews. In 2022, this grant awarded $3 billion in funding for workforce
to 107 state, local, and territorial health departments. The funding will be
available to recipients until November 2027. Jurisdictions can use this
funding to address multiple or crosscutting public health infrastructure
needs, including staff salaries or training, without being limited to specific
activities or occupations. The grant’s five-year length may also help
jurisdictions hire and retain staff beyond typical, shorter-term grant
periods.
Examples of how jurisdictions we interviewed have used the Public
Health Infrastructure Grants include:
• Officials from the Los Angeles County Department of Public Health
and California Department of Public Health told us that Public Health
Infrastructure Grant funding allowed them to hire staff appropriate for
communities’ individual needs and workforce gaps.
• Officials from the Maine and California state public health
departments noted that lengthier grant periods, such as the 5-year
period of the Public Health Infrastructure Grant, helped them to obtain
approval from the state for hiring permanent, rather than temporary,
public health staff. In addition, according to officials, candidates are
more likely to consider employment when the position is funded for
more than a year or two.
Special resources for responding to disasters or public health
emergencies. HHS agencies and selected jurisdictions also provided
special resources to supplement the workforce for disasters or public
health emergencies. These resources are aimed to address challenges,
like market competition and slow hiring processes, that can be especially
difficult and exacerbate an already stressed workforce during
emergencies. Examples of special resources include the following:
• During a declared public health emergency, state or tribal
governments may request the temporary reassignment of personnel
in their respective public health departments or agencies whose
positions are funded under Public Health Service Act (PHS Act)
Page 31 GAO-25-107002 Public Health Preparedness
programs. 61 Each head of an HHS agency with programs funded
under the PHS Act may authorize requests for temporary
reassignment, with ASPR serving as an intermediary between
requesting state and tribal governments and the authorizing HHS
agency. During the COVID-19 pandemic, all 50 states requested
temporary reassignment of PHS Act funded personnel, according to
HHS officials.
• The National Disaster Medical System, established in 1984 and
overseen by HHS’s ASPR, provides workforce support for patient
care, patient movement, and fatality management during or after a
disaster or public health emergency, according to agency
documentation. 62
• ASPR also oversees the Medical Reserve Corps, a national network
of volunteers organized in local community-based groups to
strengthen public health and improve local preparedness, response,
and recovery capabilities, according to agency documentation.
Volunteers provided support during the COVID-19 pandemic, and
were, according to one study, especially useful to small public health
departments. 63
• Officials with the California Department of Public Health said that in
response to the COVID-19 pandemic, California created a state Public
Health Reserve Corp, which consists of trained teams that provide
emergency response for state emergencies. Officials said they used
the state’s Public Health Reserve Corp and staff reassignment during
emergencies, to meet the need, for example for personnel skilled in
epidemiology and information technology.
61Section 319(e) of the Public Health Service Act authorizes states and Tribes to request
the temporary reassignment of state, tribal, or local public health department or agency
personnel funded under programs authorized by the Act when the Secretary of the
Department of Health and Human Services has declared a public health emergency. 42.
U.S.C. § 247d(e). See
https://aspr.hhs.gov/legal/pahpa/section201/Pages/requesting-temporary-reassignment.as
px. Among other things, this Act authorizes the U.S. Public Health Service, which includes
the Office of the Surgeon General and all National Institutes of Health national research
institutes or centers.
62See GAO, Public Health Preparedness: HHS Should Take Actions to Ensure It Has an
Adequate Number of Effectively Trained Emergency Responders, GAO-20-525
(Washington, D.C.: June 18, 2020).
63See GAO, Public Health Preparedness: Information on the Use of Medical Reserve
Corps Volunteers during Emergencies, GAO-20-630 (Washington, D.C.: September 14,
2020).
Page 32 GAO-25-107002 Public Health Preparedness
• Jurisdictional officials we interviewed emphasized the value of CDC
staff who are placed to work directly in their jurisdictions’ public health
departments during outbreaks and emerging threats. In particular,
they cited CDC’s Career Epidemiology Field Officer network as helpful
to address their workforce gaps related to epidemiology. CDC also
provides workforce support to jurisdictions in other ways. For
example, CDC placed 115 fellowship participants in jurisdictions to
provide laboratory and other support during outbreaks and emergency
events in the 2023 fiscal year.
The public health workforce encompasses numerous jurisdictions within
the U.S., many of which face various persistent challenges in recruiting
and retaining public health workers. However, the HHS and jurisdictional
actions we have described, among others, have helped enable
jurisdictions to deal with the challenges, and helped begin to address
gaps in the public health workforce.
We provided a draft of this report to HHS for review and comment. HHS
Agency Comments provided technical comments, which we incorporated as appropriate.
We are sending copies of this report to the appropriate congressional
committees, as well as other interested parties. In addition, the report will
be available at no charge on the GAO website at http://www.gao.gov. If
your staff have any questions about this report, please contact me at
(202) 512-7114 or DeniganmacauleyM@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made key contributions to this
report are listed in appendix III.
Mary Denigan-Macauley
Director, Health Care
Page 33 GAO-25-107002 Public Health Preparedness
Appendix I: Examples of HHS Efforts to
Appendix I: Examples of HHS Efforts to
Identify and Address Gaps in Its Public Health
Identify and Address Gaps in Its Public
Workforce
Health Workforce
In addition to taking steps to address gaps within jurisdictions’ public
health workforce, agencies within the Department of Health and Human
Services (HHS) have identified and taken steps to address gaps within
the department’s own public health workforce in a variety of ways. This
appendix provides examples of agency efforts to identify and address
workforce gaps in staff and skills, based on agency documentation and
our interviews with HHS officials. We did not assess HHS’s workforce
planning, or that of its component agencies.
In general, HHS agencies identified gaps by monitoring workforce data
and surveying their employees to assess skill gaps. The agencies have
taken various steps to address these gaps, for example, by using
expedited hiring authorities, creating a new employee deployment
program for emergencies, and developing training resources, among
other efforts. According to HHS officials, these agency efforts are part of
implementing HHS’s Human Capital Operating Plan, which includes a
framework for HHS agencies to identify workforce staffing gaps and skill
gaps and to address these gaps through targeted recruitment and
retention activities. 1 Under this plan, the department provides resources
for identifying workforce gaps and for conducting recruitment activities,
with HHS’s Office of Human Resources working in coordination with HHS
agencies’ human resource offices and other agency officials.
The Administration for Strategic Preparedness and Response (ASPR)
Examples of ASPR leads the nation’s medical and public health preparedness for, response
Efforts to Identify and to, and recovery from disasters and public health emergencies. ASPR
became an operating division of HHS in 2022, and we previously reported
Address Workforce on ways to strengthen the agency’s workforce planning. 2 In March 2024,
Gaps ASPR awarded a contract to perform an agency-wide workforce
assessment, which is expected to be completed before the end of fiscal
year 2025. In addition, ASPR identified the need to recruit 38 additional
staff in human resources during 2024 and 2025. Officials told us they
have used a variety of social media in their recruitment activities, and they
have sought to establish an awareness of ASPR as a positive place to
1See the U.S. Department of Health and Human Services, Office of Human Resources,
Human Capital Operating Plan, FY 2022-2026.
2The Secretary of HHS elevated ASPR to an operating division in July 2022, which
resulted in additional program responsibilities. GAO, Public Health Preparedness: HHS
Emergency Agency Needs to Strengthen Workforce Planning, GAO-24-106108
(Washington, D.C.: Jan.16, 2024).
Page 34 GAO-25-107002 Public Health Preparedness
Appendix I: Examples of HHS Efforts to
Identify and Address Gaps in Its Public Health
Workforce
work because of its mission, work-life balance, and the recognition and
rewards provided to employees, among other things.
We also previously recommended actions to help ASPR ensure it has an
adequate number of effectively trained emergency responders within the
National Disaster Medical System. 3 ASPR identified a staffing gap in the
system through a 2023 assessment of the National Disaster Medical
System workforce. 4 In an effort to help address this gap, ASPR officials
told us that they continued to use a direct hire authority to hire new
intermittent employees. A direct hire authority allows federal agencies to
fill positions for which the Office of Personnel Management has
determined there is a critical hiring need or severe shortage of candidates
without regard to certain rating, ranking, and veterans’ preference
requirements.
In addition, ASPR officials told us that they have taken a range of steps to
attract candidates to the National Disaster Medical System, including
participation in networking and professional events, having teams conduct
personal outreach, and using social media to highlight the program’s
training and mission to a wider audience.
The Centers for Disease Control and Prevention (CDC) is responsible for
Examples of CDC protecting the public health of the nation through the prevention and
Efforts to Identify and control of diseases and other preventable conditions, and responding to
public health emergencies. The agency identified gaps in certain
Address Workforce occupations that it considers to be mission critical—essential for the
Gaps success of CDC programs—and addressed some of these gaps using
direct hire authorities, according to CDC officials. Examples of mission
critical occupations identified by the agency include data science,
information technology management, microbiology, chemistry, and
mathematical statistics.
According to CDC officials, the agency addressed gaps in some of these
occupations through direct hire authority for its Data Modernization
Initiative, authorizing hiring of up to 596 positions. The agency also hired
staff in these occupations through a government-wide direct hire authority
for science, technology, engineering, and mathematics positions,
3GAO-20-525.
4At a state’s request, the National Disaster Medical System provides personnel,
equipment, supplies, and a system of partner hospitals that work together with state and
local personnel to provide care during public health emergencies.
Page 35 GAO-25-107002 Public Health Preparedness
Appendix I: Examples of HHS Efforts to
Identify and Address Gaps in Its Public Health
Workforce
according to our review of documentation. In addition to direct hire
authorities, CDC officials indicated that the agency offers recruitment,
retention, and relocation incentives and offers “above the minimum pay”
to attract qualified talent, to the maximum extent possible. 5
CDC officials also told us that the agency initiated the CDC Career Ready
program in 2023 to conduct an agency-wide assessment of skills and
potential skill gaps in its existing workforce and to organize career
development and training. The program is overseen by a centralized
governing board and is supported by training resources and support
teams to facilitate workforce development across the agency.
Through the program, CDC identified specific gaps in the areas of
emergency preparedness and response, data analysis and interpretation,
and workforce development, among others. To address these gaps, CDC
plans to provide training and professional development opportunities and
ongoing skills assessment to existing CDC staff, officials told us. In
addition, through the program, CDC has developed analytical tools that
provide information about staffing levels and competencies to help CDC
identify recruitment targets.
CDC officials said that the agency established the CDC Ready
Responder program in 2022 to address gaps in its internal workforce that
responds to public health emergencies, and to help ensure that the
agency had appropriate, trained, and available staff needed during an
emergency. Beginning in 2020, the agency gathered data on the type and
number of positions needed during emergencies, and on the length of
time its staff spent deployed in those positions during emergency
responses to COVID-19 and other emergencies. Officials reported that
only a core group of certain staff volunteered to be deployed, with many
of them deployed multiple times, for different emergencies.
To expand the staff available for emergency response, CDC developed
the CDC Ready Responder program as a more structured approach to
preparing and deploying its workforce during emergencies, according to
officials. One aim of the program is to provide education for CDC staff on
5Federal agencies can use financial incentives in the form of compensation-based
flexibilities to help recruit and retain qualified personnel. According to the Office of
Personnel Management, federal agencies have broad discretionary authority to address
human capital challenges through the use of financial incentives such as recruitment,
relocation, and retention incentives. For example, an agency may pay a recruitment
incentive to a newly appointed employee if the agency has determined the position is
likely to be difficult to fill in the absence of an incentive.
Page 36 GAO-25-107002 Public Health Preparedness
Appendix I: Examples of HHS Efforts to
Identify and Address Gaps in Its Public Health
Workforce
what it means to serve during an emergency response at CDC, to ease
the uncertainty potential responders in its workforce may have about
joining such a response.
According to CDC officials, the program also includes expanded training,
planning, and deployment procedures for positions including
epidemiologists, laboratory workers, statisticians, health communicators,
and emergency management staff. CDC staff who participate are enrolled
into one or more cadres—groups of employees with specific knowledge,
skills, and experience that can fill certain roles in an emergency response.
As of April 2024, more than 2,500 CDC staff had enrolled in one or more
of 15 cadres in the CDC Ready Responder program, representing about
20 percent of CDC’s civil servant and Commissioned Corps workforce.
The Health Resources and Services Administration (HRSA) is
Examples of HRSA responsible for supporting health care in the nation’s highest-need
Efforts to Identify and communities. The agency has identified mission critical occupations
based on difficulties it has faced in hiring and retention, according to
Address Workforce officials. These mission critical occupations include public health analysts,
Gaps nurses, information technology specialists, acquisitions staff, medical
officers, health scientists, and human resource specialists.
HRSA officials stated that the agency has used direct hire authority for
some mission critical occupations and has taken other steps to address
workforce gaps. For example, the agency establishes hiring procedures
that can be used jointly by multiple offices, such as joint scheduling of
interviews with job candidates. To facilitate these procedures, the agency
shares a recruitment calendar with key recruiting time frames across
HRSA bureaus and offices. According to officials, this collaborative
approach streamlines the recruitment process and yields efficiency gains
by reducing the administrative burden on human resources staff, hiring
managers, and applicants.
HRSA also attends virtual and in-person recruitment fairs targeting
specific workforce groups, to improve their outreach to candidates,
according to officials. In addition, officials told us that the agency has
recruited graduates of the Peace Corps, who can be hired efficiently for
jobs otherwise restricted to federal employees. 6
6Peace Corps volunteers and employees may be granted non-competitive eligibility in
certain circumstances.
Page 37 GAO-25-107002 Public Health Preparedness
Appendix I: Examples of HHS Efforts to
Identify and Address Gaps in Its Public Health
Workforce
The Indian Health Service (IHS) funds and provides medical and public
Examples of IHS health services to American Indians and Alaska Natives, who are
Efforts to Identify and members or descendants of federally recognized Tribes. The agency has
identified gaps in multiple occupational areas, including for example
Address Workforce epidemiology, behavioral health, nursing, physician care, and laboratory
Gaps science, according to agency officials. They said that efforts to attract
staff in these occupations have included offering loan repayments,
increased leave, and premium pay. IHS has also piloted efforts to provide
housing subsidies and flexible work schedules.
IHS officials also said that the agency plans to complete a full
assessment of public health needs. In addition, IHS established a
National Public Health Council, which includes a subcommittee on
epidemiology and workforce development, according to our review of
documentation.
The Substance Abuse and Mental Health Services Administration
Examples of (SAMHSA) leads public health efforts to advance the behavioral health of
SAMHSA Efforts to the nation and to promote mental health, prevent substance misuse, and
provide treatments and supports to foster recovery. The agency identified
Identify and Address a gap in its workforce for grants disbursement and management after the
Workforce Gaps agency received increased appropriations in 2022 to support grants,
according to agency officials. SAMHSA applied for and received direct
hire authority to hire up to 149 positions including public health advisors,
grants management specialists, and social science analysts, according to
our review of documentation. SAMHSA also used other strategies to fill
critical positions, such as hiring staff through temporary 2-year
appointments, according to officials.
Page 38 GAO-25-107002 Public Health Preparedness
Appendix II: Methodology for Review of
Appendix II: Methodology for Review of
Studies and Reports
Studies and Reports
We identified and analyzed 69 studies (peer-reviewed literature) and
reports (governmental or other publications) on the public health
workforce that we determined were relevant to our work. Specifically, we
identified these studies and reports on the public health workforce for our
review in two ways, (1) by searching research databases for relevant
peer-reviewed studies, and (2) by considering studies and other reports
that were referred to us by officials we interviewed, or that we otherwise
identified during our work. We then analyzed each study or report to
identify common themes and illustrative examples on topics related to the
public health workforce.
Identifying studies by searching research databases. Based on our
research objectives, we searched research databases for peer-reviewed
literature on the public health workforce using the following search terms:
• public health workforce/workers/jobs/employees/staff/governmental
public health workforce plus needs, gaps, demand, supply, capacity,
OR challenges (hiring, recruitment, retention, training workforce
development, succession, pathway) and
• public health emergency/surge workforce plus needs, gaps, demand,
supply, capacity, OR challenges (hiring, recruitment, retention,
training workforce development, succession, pathway).
We also searched research databases for studies that included analysis
of data from key public health workforce surveys. Specific surveys
included:
• the Public Health Workforce Interests and Needs Survey administered
by the de Beaumont Foundation;
• the Profile Survey administered by the National Association of County
and City Health Officials;
• the Profile Survey administered by the Association of State and
Territorial Health Officials;
• the Epidemiology Capacity Assessment administered by the Council
of State and Territorial Epidemiologists; and,
• the Public Health Indian Country Capacity Scan administered by the
National Indian Health Board.
We searched various research databases, such as ABI/INFORM
Professional Advanced, APA PsycINFO, Coronavirus Research
Database, Embase, EMCare, Health & Medical Collection, Health
Page 39 GAO-25-107002 Public Health Preparedness
Appendix II: Methodology for Review of
Studies and Reports
Research Full Text Professional, MEDLINE, PAIS International, Publicly
Available Content Database (ProQuest), ProQuest Research ProQuest
Health & Medical Collection, ProQuest Health Research Full Text
Professional Library, ProQuest Sociology Collection, SCOPUS, ProQuest
SciTech Premium Collection, and Social SciSearch.
Searching these databases identified 280 studies published between
January 2022 and April 2024 that were potentially relevant for our work.
We reviewed the abstracts for each of these 280 studies, and selected 85
studies for full-text review. We selected studies that discussed the public
health workforce in the United States and included at least one of the
following:
1. information on public health workforce gaps or challenges with
recruiting, hiring, or retention;
2. contextual information about the public health workforce (e.g., size,
funding sources); or
3. an analysis of survey data from surveys of jurisdiction public health
departments or employees. These include surveys by the Association
of State and Territorial Health Officials, National Association of County
and City Health Officials, Council of State and Territorial
Epidemiologists, National Indian Health Board, Public Health Indian
Country Capacity Survey, and the de Beaumont Foundation Public
Health Workforce Interests and Needs Survey.
Using the same criteria, we then reviewed the full text of these 85 studies,
and we identified 35 studies for our analysis.
Identifying additional studies and reports. We also considered studies
and other reports—such as those from national stakeholders, research,
and policy organizations. These studies and reports were referred to us
by officials from the Department of Health and Human Services and other
agencies and stakeholders we interviewed, or that we otherwise
identified, for example, through stakeholder or agency websites and
citations in identified studies and reports. 1 Specifically, we reviewed the
1We interviewed representatives from the following U.S. Department of Health and Human
Services agencies and offices: the Assistant Secretary for Administration, Office of Human
Resources; Administration for Strategic Preparedness and Response; Centers for Disease
Control and Prevention; Health Resources and Services Administration; Substance Abuse
and Mental Health Services Administration; and the Indian Health Service.
Page 40 GAO-25-107002 Public Health Preparedness
Appendix II: Methodology for Review of
Studies and Reports
abstracts for 109 studies and reports referred to us by stakeholders, and
from this group we identified 12 studies for analysis that were not in our
literature search results. Additionally, we separately identified 22 studies
and reports for our analysis that were relevant to our objectives, for a total
of 34 additional studies and reports for analysis. To identify and select
these studies and reports, we used the same criteria that we used for our
search of research databases and selection of studies, with some
variation. For example, in several cases we selected studies or reports
from earlier than 2022, to obtain contextual information.
Analyzing studies and reports. We analyzed the 69 studies and
reports, described above, for information on the public health workforce.
Specifically, we analyzed these studies and reports to identify common
themes and illustrative examples on the following topics:
1. public health workforce gaps,
2. challenges with recruitment, hiring, and retention,
3. other challenges,
4. context about public health workforce, and
5. policy options and suggestions for addressing gaps and challenges.
In extracting information from these studies, we took into account any
methodological limitations of those studies that could affect the reliability
of that information.
We also interviewed representatives from the following stakeholder organizations: the
American Public Health Association, the Association of Schools and Programs of Public
Health, the Association of State and Territorial Health Officials, the de Beaumont
Foundation, the Council of State and Territorial Epidemiologists, the National Association
of County and City Health Officials, the National Indian Health Board, the National
Network of Public Health Institutes, the President’s Council of Advisors on Science and
Technology, the Public Health Accreditation Board, and the University of Minnesota
Center for Public Health Systems.
Page 41 GAO-25-107002 Public Health Preparedness
Appendix III: GAO Contact and Staff
Appendix III: GAO Contact and Staff
Acknowledgements
Acknowledgements
Mary Denigan-Macauley, (202) 512-7114 or
GAO Contact DeniganMacauleyM@gao.gov
In addition to the contact named above, Will Simerl (Assistant Director),
Staff Mary Giffin (Analyst-in Charge), Martha Elbaum Williamson, Kristeen
Acknowledgments McLain, Kimberly Perrault, and DeAndrea Porch made key contributions
to this report. Jennie Apter, Aditi Archer, Leia Dickerson, Steven Lozano,
Anna Maria Ortiz, Eric Peterson, Emily Wilson Schwark, Amber Sinclair,
Betty Ward-Zukerman, and Jennifer Whitworth also made important
contributions.
Page 42 GAO-25-107002 Public Health Preparedness
Related GAO Products
Related GAO Products
Public Health Preparedness: HHS Should Assess Jurisdictional Planning
for Isolation and Quarantine. GAO-24-106705. Washington, D.C.: July 25,
2024.
Public Health Preparedness: Mpox Response Highlights Need for HHS to
Address Recurring Challenges.GAO-24-106276. Washington, D.C.: April
18, 2024.
FEMA: Opportunities Exist to Address Mission Challenges and Increased
Workload. GAO-24-107351. Washington, D.C.: March 12, 2024.
Public Health Preparedness: HHS Emergency Agency Needs to
Strengthen Workforce Planning. GAO-24-106108. Washington, D.C.:
January 16, 2024.
Public Health Preparedness: Building and Maintaining Infrastructure
beyond the COVID-19 Pandemic. GAO-24-105891. Washington, D.C.:
November 7, 2023.
Public Health Preparedness: HHS Reserve Funding for Emergencies.
GAO-23-106102. Washington, D.C.: August 15, 2023.
Public Health: Leading Practices Could Help Guide HHS Reform Efforts
to Address Risk and Improve Preparedness. GAO-23-106872.
Washington, D.C.: June 7, 2023.
FEMA Disaster Workforce: Actions Needed to Improve Hiring Data and
Address Staffing Gaps. GAO-23-105663. Washington, D.C.: May 2, 2023.
Federal Workforce: OPM Advances Effort to Close Government-wide
Skills Gaps but Needs a Plan to Improve Its Own Capacity.
GAO-23-105528. Washington, D.C.: February 27, 2023.
FDA Workforce: Agency-Wide Workforce Planning Needed to Ensure
Medical Product Staff Meet Current and Future Needs. GAO-22-104791.
Washington, D.C.: January 14, 2022.
Federal Hiring: OPM Should Collect and Share COVID-19 Lessons
Learned to Inform Hiring during Future Emergencies. GAO-22-104297.
Washington, D.C.: October 25, 2021.
Page 43 GAO-25-107002 Public Health Preparedness
Related GAO Products
Public Health Preparedness: Information on the Use of Medical Reserve
Corps Volunteers during Emergencies. GAO-20-630. Washington, D.C.:
September 14, 2020.
Public Health Preparedness: HHS Should Take Actions to Ensure It Has
an Adequate Number of Effectively Trained Emergency Responders.
GAO-20-525. Washington, D.C.: June 18, 2020.
Disaster Response: HHS Should Address Deficiencies Highlighted by
Recent Hurricanes in the U.S. Virgin Islands and Puerto Rico.
GAO-19-592. Washington, D.C.: September 20, 2019.
Federal Workforce: Key Talent Management Strategies for Agencies to
Better Meet Their Missions. GAO-19-181. Washington, D.C.: March 28,
2019.
Page 44 GAO-25-107002 Public Health Preparedness
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