Managing Director & Senior Partner
From the first weeks of the COVID-19 pandemic, the US public health system has been waiting for a moment of calm—a chance to reflect and plan for the future. Three years later, the public health workforce is still under stress, and calm reflection may be elusive for quite a while longer. Nonetheless, this is the time to learn and plan.
The pandemic demonstrated the immense capabilities that the US public health system can bring to bear. It also revealed some severe shortfalls in the system’s ability to manage major and enduring crises. Leaders in the field know that more challenges are coming. These could include not just future pandemics and health crises but new chronic diseases and experimental treatments. There will also be challenges related to social determinants of health, equitable access to care, the health impact of climate change, and the lingering effects of COVID-19. It’s important to spend the time now to revitalize the public health system and rebuild its capabilities.
One starting point is people. COVID stretched the public health workforce to the breaking point. In early 2022, in a survey of state and local government public health staff members conducted by the de Beaumont Foundation and the Association of State and Territorial Health Officials, 32% of respondents said they were considering leaving the profession in the next year. More than 40% of this group cited COVID-19 as a major reason.
Finding and attracting the next generation of talent is just one essential task. The public health system also must continue to develop the skills of its current and future practitioners, particularly as it suffers a loss of experience and institutional memory through attrition. The pandemic accelerated the pace of innovation in public health practice, and even the most expert agency practitioners have not fully kept their skills and capabilities on the cutting edge. Moreover, many public health professionals have not had formal training in some of today’s most critical competencies: epidemiology, data and analytics, policy development, community partnership, and management.
The greatest shortfalls are in the skills of public health strategy and execution:
Based on our experience working shoulder-to-shoulder with public health leaders, the authors believe it will take advances across each of these four domains to bring the workforce up to speed—and to take full advantage of lessons learned during the first global pandemic of the modern era.
During the pandemic, public health entities were hampered by disparate, incomplete data. Information was cobbled together from many sources. Public health practitioners were faced with making critical decisions and setting guidance with only a partial view of the picture. Of course, this reflected the novelty and ever-changing nature of the virus. No one had a complete understanding of its transmission or effects, urgency compounded the chaos, and officials’ messages were further muddied by active disinformation.
To design and implement public health interventions (PHIs), practitioners had to aggregate multiple sources of disparate data. They had to look beyond case rates and hospitalizations to include data on various groups and behaviors, and adjust their decisions on the fly to reflect changing circumstances. Integrated data and appropriate analytic tools were not available at scale. Widespread testing and contact tracing were not yet in place, nor was the tracking of clinical outcomes. Hospital systems were overwhelmed and unable to generate easily usable data. Moreover, as the number of data sources increased, so did the burden of managing and analyzing their input, especially when coordinated across a wide range of private and public organizations.
Consider the challenge of launching PHIs that would uphold equity. During those early months, people from underserved groups suffered disproportionately due to exposure, insufficient access to care, financial loss, and school shutdowns. But most health data systems could not accurately break down hospitalization and death information by race until months after the pandemic began. It was thus difficult to estimate how PHIs developed in response to the virus affected different groups—or to adjust interventions to achieve greater health equity.
This lack of comprehensive data, together with the urgency of the pandemic, challenged traditional public health decision-making. Practitioners were accustomed to leveraging “hard” skills in epidemiology, analytics, and rigorous frameworks together with harmonized data to make strong recommendations. The evolving crisis required them to rely on “soft” skills—judgment and engagement—to cobble together imperfect data, perform quick and thoughtful analyses with what was available, and make actionable recommendations. As they assembled data from sources such as traditional registries, primary research, and local hospital systems, many public health professionals had to rapidly assess the credibility of that data. They then had to make decisions and take action based on a minimally sufficient level of evidence and confidence. This unfamiliar way of working contradicted many of the practices and principles they were accustomed to.
Public health leaders should regard this experience as a dress rehearsal for crises to come. As they modernize the public health data infrastructure and invest in informatics and digital tools, they also need to equip practitioners with more of the complementary “soft” skills: identifying, evaluating, and managing disparate data for decision-making and clearly communicating recommendations and considerations—especially when under pressure. This will better equip them to support rapid, informed intervention.
COVID-19 demonstrated that public health practitioners could navigate to unprecedented solutions, particularly when they understood and worked across the complexities of the current system. This meant building partnerships and combining resources across public-sector agencies at the federal, state, and local levels as well as private and non-profit entities.
For example, some states rapidly built early testing, tracing, and wraparound support models by marshalling resources from across this complex landscape. People organized a new arrangement of alliances with hospitals, clinics, labs, and the resources needed for contact tracing, quality improvement, and support through quarantine. Where public health officials insisted on primarily using existing public health laboratories and resources, test and trace efforts moved more slowly.
The skills involved in mapping the landscape include exploring, networking, evaluating, and tracking available resources—both personnel and funding—that can be deployed at the right time. This also includes knowing the limitations of local public health resources, the potential capabilities of non-governmental partners, and the relationships between them.
This combination of formal management and informal networking prowess has traditionally been learned through years on the job. Now, it should be broadly scaled to build networks that outlast COVID-19. Public health leaders should form relationships with partners across the public health value chain—relationships that can be activated quickly when the next crisis hits. Moreover, leaders have an opportunity to actively involve these partners in emergency planning and ongoing public health operations. By cultivating and maintaining their networks, public health officials can more rapidly stand up joint efforts at any time.
In December 2020, the US public health system demonstrated its ability to set direction and take action. Multiple COVID-19 vaccines had been developed, but supplies were limited and it wasn’t clear when the first doses would be authorized by the FDA. Additional ambiguities included the relative priority of initial recipients, supply chain logistics that supported ultra-cold storage requirements, and vaccine administration details. And yet, everyone expected the fastest vaccine roll-out in history.
The pandemic forced public health leaders to quickly set direction and manage programs in the face of imperfect information. Public health officials and policymakers applied structures such as the “evidence-to-decision” framework to translate available evidence and unknowns into workable vaccine recommendations.
Future crises will similarly call on public health practitioners to demonstrate their leadership and management skills. Under high-stakes circumstances, they must be able to efficiently project-manage programs, whether driven directly by public health systems or by partners. As practitioners improve their ability to manage timelines and risks, they will make more efficient use of finite resources. They will learn to manage constraints and trade-offs—related to funding, people, and other resources—and to find alternatives when necessary.
The average public health practitioner should not be responsible for developing or expertly using complex frameworks for every-day decisions. However, being able to document the knowns, unknowns, assumptions, evidence, and recommended actions for a public health program or policy is essential. This is where “mapping the landscape” helps. An understanding of the location of resources from across the public health system can help people use them creatively, reconciling perceived trade-offs among programs. For example, projects can involve public health trainees and local hospital systems, instead of choosing one or the other.
By March 2020, it was already evident that COVID-19 was not affecting communities evenly. Public health interventions, including quarantine and isolation procedures, would impact some groups more than others. Overnight, practitioners became the public face of pandemic response: the on-point people who coordinated across government agencies, hospital associations, special interest groups, and private businesses. They compiled a map of the public and private health landscape, all while trying to understand and communicate with their communities and inform elected leadership.
In retrospect, this too was an issue of underdeveloped capabilities. To effectively engage stakeholders and the community, public health practitioners learn to communicate with a broad range of people, from hospital CEOs, agency heads, and health experts to anxious or skeptical individuals. They must be effective advisors to decision-makers who have not had scientific training. They must collaborate with a wide variety of people and constituencies, including outside associations and advocates, and must have the diplomatic skills needed to understand and appreciate all their points of view, while also focusing on equity.
Communicating to the public requires a great deal of skill in any situation. In a rapidly evolving health crisis, the available information is incomplete and ever-changing. While explaining data or setting direction, leaders must speak clearly, explaining “what we know, what we don’t know, what we’re doing now, and why,” in a way that people understand. The communicators must prepare people to expect the unexpected, while also conveying confidence and helping people make informed choices about, for example, whether they should send their children to school. Future public health practitioners should be trained and equipped with an array of stakeholder communication tools now, to help promote and improve health every day—and to respond to challenges when the time comes.
All of these capabilities reinforce one another. Those who gather information and process it skillfully are better equipped to set direction and take action. Mapping and navigating the landscape—the relationships among public health organizations, health care providers, political leaders, and other stakeholders—leads to more effective communications. And in communicating to the public, practitioners gain a more complete sense of the challenges people face, enhancing their ability to gather meaningful information. The data becomes less biased, leading to more equitable mitigation and care.
Nobody knows how long this current period of uncertainty and upset in health care will last—or if it will ever feel like the right time to step back and reform the system. But the longer such actions are delayed, the more costly and difficult it will be to create and implement the necessary reforms.
To revitalize the public health workforce, a number of action steps can be taken by state, local, and federal agencies. These represent opportunities for public health organizations to give people the capabilities and support they need in this new working environment. Here are the steps to take:
Even as the pandemic wanes, improvements will continue to be made in public health infrastructure, data, policies, and more. But longer-lasting impact will only be realized if these improvements are supported by advancement of the current and future public health workforce. Our collective experience with COVID-19 has stretched and challenged public health, but also demonstrated the impressive capabilities and skills of public health practitioners. If leaders can recognize and celebrate their people, and reinvent their culture to build on these advances, they can create the more nimble, impactful, and sustainable US public health system that our country needs.
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