Australia and New Zealand Health
Policy
BioMed Central
Open Access
Commentary
The future of public health: the importance of workforce
Vivian Lin1, Rebecca Watson*2,3 and Brian Oldenburg3
Address: 1School of Public Health, La Trobe University, Bundoora, Australia, 2Australian Insitute of Health Policy Studies (AIHPS), Monash
University, Melbourne, Australia and 3School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
Email: Vivian Lin - v.lin@latrobe.edu.au; Rebecca Watson* - rebecca.watson@med.monash.edu.au;
Brian Oldenburg - brian.oldenburg@med.monash.edu.au
* Corresponding author
Published: 9 April 2009
Australia and New Zealand Health Policy 2009, 6:4
doi:10.1186/1743-8462-6-4
Received: 31 March 2009
Accepted: 9 April 2009
This article is available from: http://www.anzhealthpolicy.com/content/6/1/4
© 2009 Lin et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Health workforce has become a major concern and a significant health policy issue around the
world in recent years. With recent international and national initiatives and models being
developed and implemented in Australia and other countries, it is timely to understand the need
and the rationale for a better trained and educated public health workforce for the future. Much
more attention should also be given to evaluation and research in this field.
Through this thematic series on Workforce and Public Health, we have drawn on the diverse
nature of public health, workforce implications, education and training and national and
international case examples of ongoing improvements and issues in this sector.
Why a special call for articles on public health
workforce?
competencies for a number of health professions and the
piloting of new workforce models [4].
Health workforce has become a major concern and a
health policy issue around the world in recent years and it
was the focus for the World Health Report in 2006 [1].
Globally, increased concerns about the 'brain drain' of
health professionals from developing countries to more
developed countries led to the draft WHO code of practice
about human resources for health [2]. Within Australia,
the release of the Productivity Commission Report in
2005 [3] focused national attention on the significance
and importance of the current and future health workforce in this country. This culminated in the signing of an
inter- governmental agreement to move to a national registration system in Australia for a number of the health
professions in March 2008. This was followed by a more
recent appointment of a management committee for the
Australian Health Practitioner Regulation Agency which
will be established. Other important and related issues
being progressed nationally include the development of
However, all of these initiatives have been silent on issues
to do with what kind of workforce is required to improve
Australia's public health workforce and thereby, address
future public health issues and challenges, including
those challenges that are not currently known. With the
advent of a new Labor government in late 2007, which
has seen the establishment of a number of new commissions, committees and other working groups including –
the National Health and Hospital Reform Commission,
Preventative Health Taskforce, Primary Health Care Strategy, National Indigenous Health Equity Council, there
has been considerable discussion regarding an increased
emphasis on disease prevention and health promotion.
However, for such policy intent to be translated successfully into practice, this will rely on having a workforce that
has relevant and specialised knowledge and skills related
to the field of prevention and public health practice more
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Australia and New Zealand Health Policy 2009, 6:4
generally. Therefore, it is timely to examine what kind of
workforce will be required and to consider the related policy agendas that require attention.
What is the public health workforce?
If public health is defined as "the organized efforts of society to keep people healthy and prevent injury, illness and
premature death [5]", then the public health workforce
includes those professionals and other workers who are
engaged in these efforts. Such a definition immediately
leads to a range of challenging questions – How is it enumerated? What are the required qualifications? What is
the skill set? What does it actually do? These problems of
workforce definitions, and related issues of workforce
planning, have challenged all countries and were given
great salience during the SARS pandemic in 2003 [6].
Historically, the public health workforce has been seen as
1) those who are involved with public health and related
programs, typically in the public sector, and/or 2) those
that have some kind of specific training or degree in public health, such as a Master of Public Health (MPH) or a
qualification in a related discipline. However, it is also the
case that the majority of those who work in such areas do
not possess a formal qualification in public health [7].
While Australia's National Public Health Partnership [8]
defined several categories of public health workforce a
number of years ago – including those who are specialists,
those in the health sector who incorporate public health
practice into their normal clinical work or other roles, and
those in other sectors whose work contribute to the health
of the public it – is the MPH which has had the historical
and global recognition as the basic qualification for the
public health professional, with the DrPH and PhD as
research degrees. In more recent times, there has been an
increase in the number of specialist qualifications as the
number of career pathways into and beyond public health
have expanded. This has spawned the development of a
range of public health sub-specialties including epidemiology, biostatistics, health promotion, environmental
health, health economics, health policy, and health services management. The growth in postgraduate specialisation in public health has also been accompanied by the
commensurate development of undergraduate degrees in
public health and health promotion as well.
Policies affecting public health workforce
development in Australia
The growth of public health education in Australia has
been a product of purposeful government investment as
well as the result of broader policies in the health and education sectors. However, there are no currently coordinated efforts underway to address these issues for the
future [9].
http://www.anzhealthpolicy.com/content/6/1/4
The proliferation of public health education in Australia
has been a relatively recent phenomenon, after decades of
institutional stability (or stasis). The original School of
Public Health and Tropical Medicine was established by
the Commonwealth Institute of Health at the University
of Sydney in 1927. For much of the 20th century, Australians seeking an MPH qualification had to relocate to Sydney for 2 years to undertake this postgraduate training.
The 1988 Kerr White Report (the Bicentennial Review of
Public Health Education and Research) led to the establishment of Public Health Education and Research Program (PHERP) and the MPH became available in most
faculties of medicine around Australia by the early 1990s.
The subsequent Dawkins reforms in higher education (of
a 'national unified system') also led to the flourishing of
public health education in many new faculties of health
sciences in universities that did not have medical schools.
By the end of the 20th century and for the first time in Australia, MPH and other undergraduate and postgraduate
programs in public health and related fields, such as
health promotion, were established and built an identity
quite separate from the field of medicine.
In late 1993, the Commonwealth exercised its policy purchasing power by stipulating that PHERP funding would
be available to consortia of universities in each state, so
students could access the full range of public health disciplines. Further reforms in higher education, along with
the development of the National Competition Policy,
however, continued to reshape the landscape for universities. In the decade since the late 1990s, universities began
to shorten the length of MPH programs, offer more specialised postgraduate qualifications, introduce undergraduate qualifications in public health, as well as
professional doctorates (by research and by coursework)
in public health. International students grew in numbers
for the MPH as universities actively recruited for full-fee
paying students. These trends were reinforced, if not exacerbated, by the Commonwealth attempting to purchase
new "products" (i.e. so-called "PHERP Innovations")
through "top-slicing" of existing dollars for new projects
while the funding base was locked into historical patterns.
Concurrently, the states of NSW and Victoria began to
offer advanced practitioner training programs in public
health for those who had completed MPHs. These placement-based schemes generated a group of well-trained
public health professionals who have largely fast-tracked
into management and leadership roles. At the other end
of the workforce spectrum, with the growth of community-based health services, population health competencies were developed for the vocational education and
training (VET) sector as well [10]. These training programs
became available for such workforce categories as drug
and alcohol workers, Aboriginal health workers, home
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Australia and New Zealand Health Policy 2009, 6:4
care attendants. Finally, as a consequence of the PHERP
Review in 2005 [11] which placed the issue of the quality
of MPH education on the policy agenda, draft practicebased competencies are currently being finalised as part of
the proposed revision for MPH programs.
By 2008, there were at least 21 higher education institutions in Australia which were offering undergraduate and/
or postgraduate qualifications in public health, with 17
institutions receiving at least some funding through the
Commonwealth PHERP scheme.
Global expansion in workforce development in
public health
These Australian developments in public health workforce education are occurring as other countries are also
reviewing their policies and frameworks. The US Institute
of Medicine released a major report on the future of the
public health workforce in 2002 [12] and the US Association of Schools of Public Health jointly with their Council
for Public Health Education (the accreditation body for
schools of public health in US) have revised their competencies framework. The Public Health Agency of Canada
has released competencies for the public health workforce
[13] and there has been a rapid expansion of schools of
public health across the nation. While European schools
of public health are developing competencies [14] with a
view to educational harmonisation under the Bologna
Process, new schools are being developed in India, and
there is a national curriculum review process underway in
China, where there has been rapid expansion of new
schools of public health over the last five years.
At the same time, professional bodies have begun to introduce and or to debate the introduction of various kinds of
credentialing arrangements. The US has introduced exams
for voluntary credentialing. An international consensus
meeting on health promotion competency was held in
Galway, Ireland in 2008 [15]. The NZ and UK Faculties of
Public Medicine have established mutual recognition
arrangements. In Australia, the Faculty of Public Health
Medicine introduced an exam based on a competency
framework [16], while the Australian Epidemiology Association has debated credentialing, and the Australian
Health Promotion Association has been developing its
own competency framework [17]. In March 2009, the
Department of Human Services (Victoria) published a
report on competencies and the health sector and setting
standards across the health workforce and education principles [18]
Workforce planning and capacity development –
whose role?
The current situation in Australian is that health workforce policy – including the field of public health is –
http://www.anzhealthpolicy.com/content/6/1/4
effected through a combination of government purchasing from the health sector, and market-based education
from the education sector. In theory, public health programs exhibit all the characteristics of a public good, and
are dependent largely on government investment. As
such, it is reasonable that government should be purchasing public health education, in order to produce the workforce required. There is, however, little coordination
between the Commonwealth and the states/territories in
coordinating their investments, or in projecting workforce
requirements.
Beyond PHERP, the public health capabilities and capacity of the health workforce have also been improved
through other kinds of government investment (such as
through the recently established schools of rural health)
and through the efforts of the professional and academic
institutions (i.e. incorporating public health content and
skills into the curriculum of the clinical workforce). However, the effectiveness of including some public health
curriculum into undergraduate medical, nursing, and
health sciences education is largely unknown.
Unfortunately, there is little systematic information available about the outcomes and career trajectories of most
MPH students and other graduates. For example, it is not
known the extent to which such students are seeking
career change, or just upskilling. It is also not known the
extent to which graduates have proactively shifted into
working more full time in the field of public health, or are
merely using their public health knowledge and skills in
existing positions. Anecdotal information suggests that
'all of the above' are occurring, with the expansion of
employment opportunities in a wide range of relevant settings, including Divisions of General Practice, local government, non-government organisations. In 2004 a
survey was undertaken of 655 current and alumni MPH
students in Victoria. Most students agreed that the MPH
training was relevant to their jobs and prepared them for
public health positions. However, only 71 per cent of students thought that the MPH prepared them for practice,
while half of this number said that it prepared them for
research [19]. A series of ANAPHI case studies [20] suggested that PHERP-funded institutions have contributed
significantly to developing a workforce capable of
addressing such public health challenges as emerging diseases such as SARs, chronic disease, indigenous health
and socioeconomic health inequalities [21].
In the absence of a strong government role and leadership
in planning and purchasing in a 'public good' field like
public health, it becomes the role of the profession to create a market demand, or to reflect on how best to meet the
public interest and needs. The articles in this series demonstrate the efforts of the profession and the educators to
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Australia and New Zealand Health Policy 2009, 6:4
improve workforce capacity to work in disadvantaged
communities (Harris et al) and in low and middle income
countries (Patel & Phillips), to institute innovation in
education (Bullen & Neuwelt, for New Zealand) and
shape the pathways through education (Bennett et al),
and to undertake their own planning (Rumbold and Bennett, Fleming et al).
Such a market-based system provides for diversity, as well
as problems of sourcing needed expertise (Madden et al).
Yet, traditional workforce planning methods of deterministic projections have not been effective in addressing
workforce needs (Bolton & Segal). There have been
attempts to develop methods for estimating workforce
needs [22] as well as workforce planning models specifically for public health [7] – though neither has been sufficiently robust for broader adaptation and uptake.
Within the current policy context, there are some workforce needs which can be anticipated (Lilley & Stewart),
while the extent of new public health challenges such as
climate change may be less predictable (Ellis et al). In the
face of very uncertain futures, currently being impacted on
by the greatest global economic downturn to have
occurred in the last 50 years, the question for government
is how to ensure a sufficiently flexible and adaptive workforce, and how to provide sufficient incentives to academic institutions and the relevant professions to assure a
high standard and quality of education in the public interest and for a more capable public health workforce for the
future.
http://www.anzhealthpolicy.com/content/6/1/4
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Competing interests
The authors declare that they have no competing interests.
21.
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