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Paving Pathways: shaping the Public Health workforce through tertiary education

Paving Pathways: shaping the Public Health workforce through tertiary education Public health educational pathways in Australia have traditionally been the province of Universities, with the Master of Public Health (MPH) recognised as the flagship professional entry program. Public health education also occurs within the fellowship training of the Faculty of Public Health Medicine, but within Australia this remains confined to medical graduates. In recent years, however, we have seen a proliferation of undergraduate degrees as well as an increasing public health presence in the Vocational Education and Training (VET) sector. Following the 2007 Australian Federal election, the new Labour government brought with it a refreshing commit- ment to a more inclusive and strategic style of government. An important example of this was the 2020 visioning process that identified key issues of public health concern, including an acknowledgment that it was unacceptable to allocate less than 2% of the health budget towards disease prevention. This led to the recommendation for the establishment of a national preventive health agency (Australia: the healthiest country by 2020 National Preventa- tive Health Strategy, Prepared by the Preventative Health Taskforce 2009). The focus on disease prevention places a spotlight on the workforce that will be required to deliver the new investment in health prevention, and also on the role of public health education in developing and upskilling the workforce. It is therefore timely to reflect on trends, challenges and opportunities from a tertiary sector perspective. Is it more desirable to focus education efforts on selected lead issues such as the “obesity epidemic”, climate change, Indigenous health and so on, or on the underlying theory and skills that build a flexible workforce capable of responding to a range of health challenges? Or should we aspire to both? This paper presents some of the key discussion points from 2008 - 2009 of the Public Health Educational Pathways workshops and working group of the Australian Network of Public Health Institutions. We highlight some of the competing tensions in public health tertiary education, their impact on public health training programs, and the educational pathways that are needed to grow, shape and prepare the public health workforce for future challenges. Introduction institutions, often have different educational backgrounds The changing context for public health education and needs. They tend to fall into two distinct groups: There are important changes occurring in the tertiary edu- either they are training to deal with different public health cation landscape that provide a new context for discussion issues in their home countries when they return; or they on directions and challenges in public health tertiary edu- are focussed on using public health training as a vehicle to cation. There is continuing pressure on universities to be start new lives away from their home countries. less dependent on government funding, and associated Undoubtedly, competent international students add to pressures to increase the number of international fee-pay- the learning environment, particularly for local students ing places. International students, who make up a consid- interested in developing an international health under- erable proportion of public health students at some standing and skill set. However there is a real counter- balancing risk at the institutional level. Income-driven student recruitment policies can distract from the provi- * Correspondence: catherine.bennett@deakin.edu.au sion of education with a clear focus on what is in the School of Health and Social Development Deakin University, 221 Burwood best interests for public health in Australia. Highway, Burwood, Australia © 2010 Bennett 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. Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 2 of 9 http://www.anzhealthpolicy.com/content/7/1/2 Universities are also being encouraged to consider million per annum, an investment that no doubt restructuring teaching programs and to reduce the increased the capacity for member institutions to build length of postgraduate coursework award programs. and deliver public health education programs. It has yet Some are introducing articulated undergraduate - mas- to be seen what impact the closing of the PHERP initia- ters degrees where the higher degree is required for pro- tive after 2010 will have on post-graduate public health fessional registration; for instance psychology, education in Australia. occupational therapy and dietetics at La Trobe Univer- Prior to the 2005 PHERP Phase III Review, the Aus- sity. Others are moving all professional entry degrees to tralian Network of Academic Public Health Institutions graduate level, as seen for example with the introduction (ANAPHI) produced a monograph of case studies, of the Melbourne Model at The University of Mel- ‘Building Capacity to Improve Public Health in Austra- bourne. All these changes impose pressure on degrees lia: Case Studies of Academic Engagement [6]. The that have traditionally had a strong student base drawn monograph highlighted research, policy engagement and from undergraduate-trained health and allied health educational programs in Australia’s universities that had professionals, and command new thinking about public demonstrated how academic public health institutions health coursework and research educational pathways. have contributed to improving public health capacity in Health promotion and illness prevention are increas- Australia. Public health success stories included the ingly being recognised as vital to the wellbeing of the response to SARS, advances in Indigenous health and whole Australian population and essential for an eco- the prevention and management of chronic diseases. nomically sustainable health system, gaining traction, for The case studies highlighted the contribution of PHERP example through Australia’s 2020 summit resolutions funding and its impact on the growth in public health and recommendations. The 2020 resolutions and recom- capacity and improvements in the education of the pub- mendations together with the establishment of the lic health workforce, particularly through Master of Pub- National Preventive Health Agency reinforce the need lic Health programs. for a strong, capable public health workforce to deliver The National Health and Hospital Reform Commis- the promised intensified focus on prevention and health sion Report (2009), recommends adoption of a compe- promotion, and to characterise and address the major tency-based framework as part of broad teaching and determinants of ill health and poor health outcomes. learning curricula for all health professionals. Public Theprojected demographicshift towardsanageing health has yet to identify a role in this agenda, and it is population with decreasing number of young people also unclear what role public health will play in the expected to enter the health workforce over the next recommendation to establish a national clinical educa- decade [1] will challenge our ability to meet community tion and training agency. expectations of service delivery. Given the influence on The 2005 review of PHERP [7] also precipitated the public health outcomes of policies and actions emanat- establishment of minimum standards in public health ing outside of the health system [2,3] it is evident that competencies for graduates, aimed at MPH programs in public health education should be available and accessi- particular. Subsequent discussion has centred on public ble to professionals both within and outside the public health workforce needs, public health graduate compe- health sector, not just to those with a clinical back- tencies and the emerging definition and role of graduate ground or within traditional public health roles. We attributes [8]. The draft core competencies for MPH must therefore develop strategies to both increase public graduates were completed in August 2009 and at the health recruitment, and to both broaden and deepen time of writing are in the process of ratification by pub- public health knowledge and skills in the wider health lic health education providers across Australia. workforce. Major changes are also afoot internationally. The Subsequent to the 1986 Kerr-White recommendations MPH is generally considered to be an internationally [4] the Commonwealth actively supported public health transportable degree, but this might not continue to be education. A workforce survey [5] was completed in the the case. The Bologna Process [9,10] is a European mid-1990s and the Public Health Education and initiative designed to standardise certificated courses Research Program (PHERP) was introduced. Since its throughout the European Union (EU). As a part of this establishment, PHERP has provided ongoing support to process, Master of Public Health courses taught within five state-based university consortia, four national and the EU will soon be accredited. Registration of the pub- special focus centres and 41 innovation projects, as well lic health workforce will follow and hence will be sub- as several workforce development projects such as the ject to regulation [11]. Australia was one of four non- Masters of Applied Epidemiology program, a Biostatis- EU countries to be a signatory to the Bologna Agree- tics Collaboration, and a Public Health Registrars pro- ment, but has apparently not remained engaged in these gram. In 2001 the total program increased to $55 developments. The United States has taken a different Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 3 of 9 http://www.anzhealthpolicy.com/content/7/1/2 pathway [12] and has developed an accreditation process The state government-based training schemes in NSW linked to continuing professional development for the and Victoria have recently paired with universities in purposes of public health workforce regulation [13]. order to award a professional doctorate to those who successfully complete the specifically developed program Discussion (The University of New South Wales and Monash Uni- What is a public health professional? versity respectively). Given the breadth of the concepts Public Health graduates have taken a population health and skills covered in such training, as with the MPH, it perspective into a range of different employment set- will be a challenge to meet doctoral level competencies tings; from specialist public health research and practice, within such programs. Arguably, advanced educational to management and planning in health services, and programs are required to deliver high level knowledge clinical practice with a population orientation. The and skills, either as a specialised stream within a two- MPH and other specialist public health degrees build year Masters or three-year doctoral program, or as a capacity in, and strengthen, evidence-based public health ‘stand-alone’ degree. However, the public health work- practice. Public health education also brings an evi- force is to a large degree characterised by their breadth dence-based population health oriented approach to pol- of practice. This includes the wide span of contexts the icy making and management at all levels and in all practitioners work within, the disciplines they bridge sectors of public health and health service delivery. within their routine practice, and the multi-professional It differs from the clinical professions by focussing on teams they work within. Under this framework, the task what makes people sick and what keeps people well; of effectively assessing Doctoral or Masters level compe- that is, the determinants of health, and identifying tency standards solely against traditional discipline- which groups are vulnerable, and why this is the case. based benchmarks becomes problematic. Public health then designs, implements and evaluates The public health workforce is largely employed in programs to maximise opportunities for health and public sector and non-government organisations. Public reduce ill health. Public health education builds an health education programmes train the workforce in understanding of what health means; a vital ingredient health research and policy development. Curricula also for health policy, from the local agency through to gov- cover the implementation and evaluation of the out- ernment level. comes of biomedical research and of policy by way of Public health graduates therefore provide significant programme development. The theory and skills encom- enhancement to the public health and health services passed within public health training are therefore workforce. Yet, there remains substantial scope for increasingly being recognised as important for a wide further strengthening the values and perspective that range of health professionals. Until the 1980s, public public health training contributes. health comprised only a very small component of The practice of public health encompasses many disci- undergraduate medical and health sciences program plines, and best practice relies on practitioners and content. Widening recognition of the value of public researchers who have acquired interdisciplinary skills health perspectives for health care practice has driven a and perspectives. However, with the low priority tradi- significant shift, and there are now many examples tionally given to public health within the health sector, where public health is integrated into core undergradu- as well as the dominance of the medical paradigm in ate clinical health sciences training. Australia, relatively little attention has historically been In more recent times, some Universities have per- given to a consideration of the definition of public ceived a need to develop undergraduate programs for health professionals, and therefore the potential sources entry-level public health practitioners, firstly for Austra- and destinations of students, and their educational lian health promotion professionals, and more recently requirements. The (medical) faculties of Public Health with the introduction of undergraduate programmes Medicine in the United Kingdom, the USA and Austra- specifically for public health practitioners. There are lia, for example, have detailed the sets of competencies approximately 10 undergraduate public health programs their graduates are expected to have, as have the public offered in Australia [14]. In Queensland, health promo- health training schemes provided through State Health tion and public health professionals including epide- Departments in New South Wales and, to a lesser miologists are now recognised under the Health degree, in Victoria. The Victorian Consortium for Public Practitioner stream of the Queensland Health workforce. Health, together with the Australian Network of Public The Department of Health and Ageing have also pro- Health Institutions and Australian Government PHERP vided financial support to the vocational education and program, are currently engaged in public health training (VET) sector to develop training packages employer and graduate surveys to assess current work- at the Certificate and Diploma level in population force educational needs. health. Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 4 of 9 http://www.anzhealthpolicy.com/content/7/1/2 These certificate level and tertiary undergraduate pro- States and in the Asia Pacific Region, for example in grams have to meet the challenge of educating for a Vietnam and Thailand. In Australia, a range of under- professional group that is not well-defined because it graduate public health education programs exist, either does not have a clearly recognised professional identity. as ‘stand-alone’ Bachelor of Health Science or Bachelor It may be easier to provide education for selected public of Public Health awards or in combination with a wide health roles (for example programs to provide for the variety of other degrees such as nursing, development public health nutrition workforce in Queensland or studies and economics. The depth of learning and health promotion roles more widely across Australia) extent of skill development in the traditional public than for a ‘public health officer’; a term currently only health sciences of epidemiology, biostatistics, research used in New South Wales for their post-MPH-graduate methods and public health practice varies considerably trainees. within these degrees. Some place particular emphasis on Public health student profile a combination of these sciences in addition to studies in Whilst the MPH is globally recognised as the profes- health promotion and environmental health. sional entry degree in public health, it cannot, and Are these degrees preparing ‘beginning public health should not, be expected to deliver both a foundation in practitioners’? If so, what does this mean for the Master core public health skills and high-level specific skills of Public Health, once the traditional domain of training training in more than one skill or discipline area. This for the entry-level public health practitioner? And what disjunct will become even further pronounced as the is the repertoire of skills and competencies that an background of students becomes more diverse and undergraduate public health graduate brings to the increasingly removed from the traditional clinical feeder workplace? Or are undergraduate health science degrees pathways. Specialised award and non-award courses at that focus on public health and health promotion to be different academic levels are an essential consideration viewed, not as professional entry, but as part of a ‘liberal in a comprehensive public health capacity building plan. arts’ background emphasising breadth of topics and ana- These must also encompass pathways for continuing lytical and critical thinking but with a focus on the professional development, and research training health of populations? It is confusing for employers. opportunities. How will prospective employers differentiate between Alongside the introduction of more specialised pro- potentially divergent skills levels in graduates across grams, we are seeing a trend towards more students such varied training pathways? Will differences in train- embarking on public heath training earlier in their ing be consistent across educational institutions and career; either undertaking an undergraduate degree in States? Local understandings and skills required in Dar- public health, or commencing an MPH or specialist win may differ widely to those needed in Tasmania or public health degree soon after completion of their first urban Melbourne. degree. However many students in Australia still enter While there have been numerous projects mapping their public health training from the workforce, bringing competencies for public health and health promotion considerable work experience from within the health via professional associations and some State govern- sector, and continue to work whilst undertaking further ments in Australia and internationally, for example the study. Galway competencies for Health Promotion [15], these Universities need to respond to the challenges of are broadly defined and not necessarily embedded in the developing and delivering programs suitable for this distinctions between postgraduate and undergraduate increasingly diverse student group, and continue to levels. For example, the competency public health pro- accommodate the different needs of the full-time ject commissioned through the quality framework of employed students. For working students, access to pub- PHERP did not distinguish between these levels of edu- lic health education can be enhanced by employer sup- cation. The exercise of mapping curricula to such com- port (time off for study, contribution to study fees) and petency standards will ensure the public health sciences the flexible delivery modes on offer (including intensive are appropriately embedded across undergraduate and teaching blocks, distance education, on-line learning post graduate curricula, but the expectations for under- support and out-of-hours classes) and access to part graduates must be realistic. time programs. Academia and industry must therefore There is no doubt, on the other hand, that public work together to create the pathways that will rectify health career options should be made more visible to disincentives and encourage greater participation in undergraduate students, whether specialising in public further education by the public health workforce. health or not, and Universities need to work with the Undergraduate versus postgraduate education public health professions and workforce to build the The growth in undergraduate public health education in public profile of public health career pathways. Similarly, Australia parallels trends internationally in the United injection of core public health principles and concepts Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 5 of 9 http://www.anzhealthpolicy.com/content/7/1/2 into undergraduate programs should be widespread, [6]. This precipitated some debate on whether educa- including, but not restricted to, the health professional tional responses to future workforce needs should shift degrees. Achieving this remains a test for universities. to target capacity building in specialised skills for emer- The moves for registration of the public health work- ging health issues or focus on building a robust and force globally might also lead to a higher profile for responsive generalised workforce. The Review supports public health career paths, and this could potentially a shift in emphasis from university driven education to provide more leverage to introduce public health princi- a more collaborative planning process between govern- ples and practice into professional entry program ment sectors and universities. The intention was for curricula. specialised education to be resourced by a contestable Breadth versus depth PHERP process, but such a funding scheme did not A further tension exists between providing the requisite eventuate within PHERP Phase IV. breadth and depth in the understanding of health sys- However, previous PHERP innovation programs have tems and the place, language and perspectives of the funded curriculum initiatives including a range of dis- various health disciplines when preparing graduates to tance education resources which do hint at the possibi- be effective “judgement safe” public health practitioners. lity of national academic institution cooperation in Getting the balance right is the goal under the current further deepening and broadening public health research and final phase of PHERP funding where the desired and education in Australia. Encouragement of national graduates are defined as “having the necessary compe- initiatives that bring together the requisite critical mass tencies, including culturalcompetencies, forpublic of teachers and students for viable teaching programs health practice and research, commensurate with will foster specialist training and the sharing of limited national, state and regional public health workforce valuable resources (Indigenous Health educators for needs” [16]. example). A national Indigenous public health curricu- PHERP was initially introduced to boost Australia’s lum framework that sets the standards for Indigenous public health capacity. Building capacity might usefully health content and skills for all public health students18 be considered at three levels: and a discipline-based public health nutrition initiative 1. Generic skills in the public health workforce - for built on collegial activities and continuing education example information seeking and synthesis skills, project links with State health departments http://www.aphnac. management, critical appraisal skills, management and com/ are examples of potential templates for collabora- leadership. tions that could coalesce regional or discipline-based 2. Specialised skills in public health areas where there curriculum initiatives. is a nationally recognised deficit of highly skilled practi- Core public health skills that provide the platform of tioners/researchers - epidemiology, biostatistics, health transferrable knowledge and skills to meet surge capa- economics, environmental health and Indigenous health city demands are required to address both current and [6]. emerging national priorities and pandemics. These gen- 3. High profilespecificstrategic needs - specialist eric skills are appropriate to the range of emerging pub- skills, and a level of readiness; that is a pool of qualified lic health issues and interventions and, in general, practitioners that can be mobilised to meet surge capa- existing university departments of public health are able city needed in the event of sudden impacts - for exam- to respond to this with appropriate support. However, ple unexpected outbreaks such as SARS, pandemic flu the need to sustain a capacity to respond to current as and natural and manmade disasters. well as emerging priorities is as much dependant on a The acquisition of the necessary core public health flexible workforce allowing mobility in times of response skills and the need for specialisation and expertise to demand as it is on public health graduate attributes. allow graduates to operate independently in their area of The working environment of future public health interest is a challenge, particularly in those degrees that practitioners is unlikely to mirror that of the existing now seek to achieve this in less than two years full time workforce. Protection against public health challenges coursework. This is where other specialist degrees need such as new and emerging infections, terrorism or to be considered for their contribution in bringing extreme weather related events demands a strong and essential high level skills into the public health work- innovative workforce capable of rigorous surveillance force, and where there is a growing need for continuing and research. Educational institutions must therefore professional development, for example the Masters of focus on emerging trends, and incorporate these into Biostatistics program [17]. their programs. To this end, universities are increasingly The 2005 PHERP Review identified gaps in workforce emphasising lifelong learning skills as a key graduate capacity in areas of specialisation such as indigenous attribute, and graduates who take this ethos (and the health, epidemiology, health economics and biosecurity necessary skills) into the work place help to build a Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 6 of 9 http://www.anzhealthpolicy.com/content/7/1/2 learning-oriented public health workforce, able to deli- been driven by available expertise, ideological, ad-hoc or ver and maintain robust but flexible public health industry-driven factors. In the current environment of responses. health reform and the shift to a preventive agenda, the Australia’s future security is dependent on sustained demand for continuing professional development in investment in public health and support of regional as public health and related areas will face unprecedented well as local capacity to address infectious disease demands, and not just for the identified public health threats [5]. The summer of 2009 brought widespread workforce. flooding across parts north- and central-eastern Austra- The widespread inclusion of public health knowledge, lia, plus unprecedented bushfires and heatwaves across skills and values across multiple discipline areas will the south-eastern parts. The immediate health burden raise new challenges and opportunities for providers of was significant, and the recovery phase, to avert health public health education, and calls for more strategic and and social problems was protracted. This strained work- innovative approaches to up-skilling. The tertiary sector force resources, and the contemporaneous timing of needs to support a range of programs, both specialised these events hampered some aspects of workforce flex- and general, to meet the range of short course and pro- ibility, such as sharing of capacity between states. In fessional certificate educational needs, preferably within order to meet workforce demand, the small numbers of a flexible model that allows articulation with formal public health staff worked excess hours, a process that qualifications. lasted for weeks. The outbreak of ‘Swine Flu’ that imme- Continuing professional development training partner- diately followed further tested capacity in a strained ships also form an important knowledge exchange plat- workforce. The likelihood or timing of a recurrence of form between academia, government and industry. The such devastating events remains unknowable, but are interaction can ensure the contemporary relevance of predicted to increase in frequency and cause more the academic content and skills covered within short severe peaks in surge demand under a changing climate courses and filter back to inform public health award [19]. program curricula. These collaborations also expose the The prospect of exceeding response capacity, resulting workforce to academic training that may encourage in a system failure, is an unwanted outcome, reminding members of the workforce back into further education us of the importance of Australia having access to suffi- to extend their professional capacity. cient numbers of highly skilled and flexible public health Government investment in Public Health Training practitioners. However increased demand for public While Australian Government support for public health health skills is not restricted to calamitous events. The education through PHERP will cease after 2010, other creeping epidemics of obesity and diabetes promise to national governments are demonstrating decisive action significantly diminish future health of the Australian through public health workforce policy and planning population, and burden the acute heath system. Issues strategies. For example, the United States government such as ageing, substance abuse, sexual health and through ‘Healthy People 2010’ strategy has established more, all demand growing public health capacity to 14 Public Health Training Centres (PHTC). These Cen- achieve a healthy Australia for 2020 and beyond. tres are situated in Schools of Public Health and geogra- The role of continuing education phically distributed across the country to provide Pathways to boost workforce capacity include a constant competency-based courses for workforce development stream of new graduates and staff development via con- through a variety of delivery models. The PHTCs oper- tinuing education. The need for improved processes and ate as an academic and practice collaborative to pro- systems for human resource development have been mote workforce development [23]. identified as essential for enhanced workforce capacity Likewise, New Zealand’s national strategy for public [20] and new concepts and models that align health pol- health workforce development, Uru Kahikatea, has taken icy and workforce development are being developed and a systematic approach to address workforce develop- tested [21,22]. ment [24]. The objectives of the strategy include actions The success of such strategies will require funding, and targets for workforce policy and planning, public strategic policy alignment and effective partnerships health professional infrastructure, information, policy across sectors. Underpinning this is the requirement for and research, Maori and Pacific workforce development, an understanding of the imperative that meeting these supportive workplace cultures, public health career pro- emerging challenges demands access to a fully prepared motion and education and training (by developing gen- public health workforce. eric public health competencies to provide a common Continuing professional development in the public framework for professional development). The work health context has traditionally meant up-skilling the plan also includes actions and targets to improve the existing public health workforce, and in the main has wider health workforce skills and knowledge of health Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 7 of 9 http://www.anzhealthpolicy.com/content/7/1/2 promotion/public health, and to ensure that public academic sector be then, and who sets the agenda? health workforce is included in the wider health work- Whilst there is divided opinion on whether educational force information programs and planning. responses to future workforce needs should focus on Future policy and planning for continuing professional capacity building in emerging specialised skills sets or a development must be inclusive of research on-cost robust and responsive generalised workforce, there is no effectiveness for educational interventions. A recent sys- debate over the need for strong core skills sets across tematic analysis of the cost benefit of continuing profes- the public health sector. There is also agreement on the sional development in health found no empirical need to focus on building capacity in those core disci- evidence to demonstrate cost-benefit of any professional pline areas where we are currently experiencing a recog- development. The lack of a cost-benefit finding was nised capacity deficit (epidemiology, biostatistics, health attributed to the varying quality of the studies [25], economics, and environmental and Indigenous health). highlighting the need for future investment in quality However specialisation in targeted areas (biosecurity research into continuing professional development to responses etc.) will only be a worthy investment if built support evidence-based decision making for policy- on a solid theoretical foundation and skill base, and this makers and contribute to health outcomes for the is true at both individual public health practitioner and public. workforce levels. We in the tertiary sector must there- In Australia, the National Health Workforce Planning fore focus on providing both the underpinning training and Research Collaboration was established to provide as well as targeted programs addressing specialisation innovation and research to achieve health workforce gaps and emerging special skill needs. sustainability by 2020. The Collaboration aims to build Research higher degree training is a university enter- capacity in research by improving intellectual and meth- prise, andthisisanareathatwas notaddressedunder odological rigour in national health workforce planning, the PHERP agenda and urgently needs attention. Some and provide evidence to inform policy decision-making disciplines are considering strategies to encourage the about the health workforce. Regardless of the national development of more advanced skills in the workforce focus on prevention, this national body, as its predeces- (the Biostatistics Consortium of Australia) and to encou- sor planning body, the National Health Workforce Task- rage more exceptional students into a research higher force, has excluded the public health workforce from degree pathway [27]. However, this is an area that their deliberations and work plan [26]. requires more discussion amongst the public health pro- The Reform Commission has recommended a fession, both in terms of building supervision capacity National Health Promotion and Prevention Agency. It is and student project opportunities, and in raising the not clear at this stage where the governance and respon- profile of public health research careers. sibility for the public health workforce will be positioned The New Zealand Population Health Workforce Plan within these new arrangements, nor what links there includes strategies for training providers to strengthen might be to education and training institutions. public health skills of the primary care and nursing Meeting contemporary public health education workforce [27]. Even without such leverage or guidance, challenges many Universities have tried to develop their own solu- Public health education has traditionally been delivered tions, but with mixed success. By popular vote, this will by universities, the health profession, or as in-house be a future theme for an ANAPHI Teaching and Learn- training within the public health workplace. However, ing Forum, where representatives across the public initiatives at the TAFE and other registered training health professions and educational institutions come organisations that lead to accredited qualifications can- together to share strategies and jointly set the educa- not be ignored. For example, a Certificate IV in Popula- tional agenda for Australia. tion Health is now being offered through the Adelaide Western General Practice Network (AWGPN). There is Conclusions already precedent for TAFE awarded degrees (eg engi- To a certain extent, the emerging political agenda neering). With a shrinking national health workforce around health in Australia will influence the way public and increasing demands that will be placed upon it health education will evolve and develop to meet future under the Preventive Health agenda, alliances with this challenges. Greater collaboration across interest groups sector need to be considered together with possibilities and public health disciplines will facilitate and enhance for work-integrated learning and articulated pathways. the processes for setting future directions and will shape The key concern for public health is the health of our success in meeting current and future workforce populations. Bearing this in mind, what pathways in needs. The Population Health Congress coalition of the public health education and training best serve this four major public health professional associations, cause? What should our education priorities in the scheduled to meet every two to four years, will Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 8 of 9 http://www.anzhealthpolicy.com/content/7/1/2 inception to final draft, and assisted CB in the compilation of the final draft. strengthen the political voice for public health leader- EH contributed to discussions that shaped this paper and to the drafting of ship and advocacy. Similarly, the Australian Network of the final manuscript. PR contributed to the sections on the international Academic Public Health Institutions, or its post-PHERP public health training context, in particular the issues surrounding workforce accreditation. All authors read and approved the final draft. successor, will continue to play an important role as a focus for discussions on future educational opportu- Authors’ information nities, and meeting public health workforce training All authors are all members of the Australian Network of Public Health Institutions working party formed in 2006 to examine Public Health Quality needs. Agenda and Educational Pathways and are employed in Australian Schools/ There are significant challenges in determining how Departments of Public Health. CB was chair of this working party. we chart our way ahead in public health education. We Received: 30 July 2008 must not lose sight of the fact that much of what we Accepted: 3 January 2010 Published: 3 January 2010 do, particularly in engaging with stakeholders and responding to workforce needs, is exemplary, albeit out- References side a national or state framework. While this engage- 1. Senator Chris Evans, Minister for Immigration and Citizenship. Sustaining the boom - the role of skilled migration in the WA economy. Keynote ment remains ad hoc, there is no way forward for Address - John Curtin Institute of Public Policy. Perth: Government of nomenclature and enumeration. Whilst educationalists Australia. http://www.minister.immi.gov.au/media/speeches/2008/ce080717. in other discipline areas look to public health as a htm. 2. 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School of Health Sciences, University of Wollongong, 11. NHS Public Health Resource Unit. Skills for Health: NHS. An example: Australia. School of Public Health, Queensland University of Technology, Skills and career framework for Public Health in the UK. Oxford UK, Australia. School of Population Health, The University of Western Australia, 22nd June 2007. See document lodged in. http://www.idea.gov.uk/idk/ Australia. Public Health Association of Australia and National Centre for core/page.do?pageId=6856771. Epidemiology and Population Health, The Australian National University, 12. Public Health Accreditation Board. http://www.phaboard.org/. Australia. School of Health Sciences, La Trobe University, Australia. 13. American Public Health Association. http://www.apha.org/membergroups/ newsletters/sectionnewsletters/public_edu/winter08/ahep.htm. Authors’ contributions 14. Fleming M, Gould T: Educating the public health workforce: issues and CB led the development of the focus of the paper through her role as challenges. Aust N Z Health Policy 2008, 6(8):1-8. working group chair, drafted the manuscript, and was responsible for 15. Barry MM, Allegrante JP, Lamarre MC, Auld ME, Taub A: Core competencies coordinating author contributions in the preparation of the final manuscript. for health promotion and health education. Global Health Promo 2008, KL contributed to the shaping of the paper, and made significant 16(2):1757-9759. contribution to the sections on continuing education, and current policy/ 16. Department of Health and Ageing PHERP IV Program Objectives. http:// workforce development initiatives. HY contributed to the workshops and www.healthyactive.gov.au/internet/main/publishing.nsf/Content/ discussions that led to the formulation of this paper, and contributed to the 9527494BD339BD55CA256F190003CF8C/$File/pherp_report.pdf . drafting of this paper, and the text on undergraduate education in 17. Biostatistics Consortium of Australia. http://www.bca.edu.au/. particular. EP contributed to the initial concept of the paper; provided ideas 18. National Indigenous Public Health Curriculum Framework. http://www. for the section on the public health professional and undergraduate onemda.unimelb.edu.au/docs/IPH%20FINAL%20briefing%20paper.pdf . education and worked with KL on editing the penultimate draft. EG 19. Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, Friel S, Groce N, provided input at all stages of the discussions that shaped this paper from Johnson A, Kett M, Lee M, Levy C, Maslin M, McCoy S, McGuire B, Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 9 of 9 http://www.anzhealthpolicy.com/content/7/1/2 Montgomery H, Napier D, Pagel C, Patel J, Puppim de Oliveria JA, Redclift N, Rees H, Roger D, Scott J, Stephenson J, Twigg J, Wolff J, Patterson C: Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 2009, 373(9676):1693-733. 20. Buchan J: What difference does ("good”) HRH make?. Hum Resources Health 2004, 2:6. 21. Conway J, McMillan , Becker J: Implementing workforce development in health: A conceptual framework to guide and evaluate health service reform. Hum Resource Dev Int 2006, 9:129-139. 22. Lilley K, Stewart D: The Australian Preventative Agenda: What will this mean for workforce development?. Australia and New Zealand Health Policy 2009, 6:14. 23. US Department of Health & Human Service, Health resources and Services Administration. http://www.phf.org/link/index.htm. 24. Ministry of Health Te Uru Kahikatea: Public Health Workforce Development. http://www.publichealthworkforce.org.nz/. 25. Brown CA, Belfield CR, Field SJ: Cost effectiveness of continuing professional development in health care: a critical review of the evidence. BMJ 2002, 324:652-65. 26. National Health Workforce Taskforce: Australia’s Workforce On-Line. http://www.nhwt.gov.au/index.asp . 27. Rumbold A, Bennett CM: The epidemiology workforce: are we planning for the future. Aust N Z Health Policy 2009, 6:26. 28. Ministry of Health Te Uru Kahikatea: The Public Health Workforce Development Plan, Building a public health workforce for the 21st century2007-2016. http://www.publichealthworkforce.org.nz/reports– resources/ph-wd-reports–publications.aspx. doi:10.1186/1743-8462-7-2 Cite this article as: Bennett et al.: Paving Pathways: shaping the Public Health workforce through tertiary education. Australia and New Zealand Health Policy 2010 7:2. 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Paving Pathways: shaping the Public Health workforce through tertiary education

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Copyright © 2010 by Bennett et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Social Policy
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Abstract

Public health educational pathways in Australia have traditionally been the province of Universities, with the Master of Public Health (MPH) recognised as the flagship professional entry program. Public health education also occurs within the fellowship training of the Faculty of Public Health Medicine, but within Australia this remains confined to medical graduates. In recent years, however, we have seen a proliferation of undergraduate degrees as well as an increasing public health presence in the Vocational Education and Training (VET) sector. Following the 2007 Australian Federal election, the new Labour government brought with it a refreshing commit- ment to a more inclusive and strategic style of government. An important example of this was the 2020 visioning process that identified key issues of public health concern, including an acknowledgment that it was unacceptable to allocate less than 2% of the health budget towards disease prevention. This led to the recommendation for the establishment of a national preventive health agency (Australia: the healthiest country by 2020 National Preventa- tive Health Strategy, Prepared by the Preventative Health Taskforce 2009). The focus on disease prevention places a spotlight on the workforce that will be required to deliver the new investment in health prevention, and also on the role of public health education in developing and upskilling the workforce. It is therefore timely to reflect on trends, challenges and opportunities from a tertiary sector perspective. Is it more desirable to focus education efforts on selected lead issues such as the “obesity epidemic”, climate change, Indigenous health and so on, or on the underlying theory and skills that build a flexible workforce capable of responding to a range of health challenges? Or should we aspire to both? This paper presents some of the key discussion points from 2008 - 2009 of the Public Health Educational Pathways workshops and working group of the Australian Network of Public Health Institutions. We highlight some of the competing tensions in public health tertiary education, their impact on public health training programs, and the educational pathways that are needed to grow, shape and prepare the public health workforce for future challenges. Introduction institutions, often have different educational backgrounds The changing context for public health education and needs. They tend to fall into two distinct groups: There are important changes occurring in the tertiary edu- either they are training to deal with different public health cation landscape that provide a new context for discussion issues in their home countries when they return; or they on directions and challenges in public health tertiary edu- are focussed on using public health training as a vehicle to cation. There is continuing pressure on universities to be start new lives away from their home countries. less dependent on government funding, and associated Undoubtedly, competent international students add to pressures to increase the number of international fee-pay- the learning environment, particularly for local students ing places. International students, who make up a consid- interested in developing an international health under- erable proportion of public health students at some standing and skill set. However there is a real counter- balancing risk at the institutional level. Income-driven student recruitment policies can distract from the provi- * Correspondence: catherine.bennett@deakin.edu.au sion of education with a clear focus on what is in the School of Health and Social Development Deakin University, 221 Burwood best interests for public health in Australia. Highway, Burwood, Australia © 2010 Bennett 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. Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 2 of 9 http://www.anzhealthpolicy.com/content/7/1/2 Universities are also being encouraged to consider million per annum, an investment that no doubt restructuring teaching programs and to reduce the increased the capacity for member institutions to build length of postgraduate coursework award programs. and deliver public health education programs. It has yet Some are introducing articulated undergraduate - mas- to be seen what impact the closing of the PHERP initia- ters degrees where the higher degree is required for pro- tive after 2010 will have on post-graduate public health fessional registration; for instance psychology, education in Australia. occupational therapy and dietetics at La Trobe Univer- Prior to the 2005 PHERP Phase III Review, the Aus- sity. Others are moving all professional entry degrees to tralian Network of Academic Public Health Institutions graduate level, as seen for example with the introduction (ANAPHI) produced a monograph of case studies, of the Melbourne Model at The University of Mel- ‘Building Capacity to Improve Public Health in Austra- bourne. All these changes impose pressure on degrees lia: Case Studies of Academic Engagement [6]. The that have traditionally had a strong student base drawn monograph highlighted research, policy engagement and from undergraduate-trained health and allied health educational programs in Australia’s universities that had professionals, and command new thinking about public demonstrated how academic public health institutions health coursework and research educational pathways. have contributed to improving public health capacity in Health promotion and illness prevention are increas- Australia. Public health success stories included the ingly being recognised as vital to the wellbeing of the response to SARS, advances in Indigenous health and whole Australian population and essential for an eco- the prevention and management of chronic diseases. nomically sustainable health system, gaining traction, for The case studies highlighted the contribution of PHERP example through Australia’s 2020 summit resolutions funding and its impact on the growth in public health and recommendations. The 2020 resolutions and recom- capacity and improvements in the education of the pub- mendations together with the establishment of the lic health workforce, particularly through Master of Pub- National Preventive Health Agency reinforce the need lic Health programs. for a strong, capable public health workforce to deliver The National Health and Hospital Reform Commis- the promised intensified focus on prevention and health sion Report (2009), recommends adoption of a compe- promotion, and to characterise and address the major tency-based framework as part of broad teaching and determinants of ill health and poor health outcomes. learning curricula for all health professionals. Public Theprojected demographicshift towardsanageing health has yet to identify a role in this agenda, and it is population with decreasing number of young people also unclear what role public health will play in the expected to enter the health workforce over the next recommendation to establish a national clinical educa- decade [1] will challenge our ability to meet community tion and training agency. expectations of service delivery. Given the influence on The 2005 review of PHERP [7] also precipitated the public health outcomes of policies and actions emanat- establishment of minimum standards in public health ing outside of the health system [2,3] it is evident that competencies for graduates, aimed at MPH programs in public health education should be available and accessi- particular. Subsequent discussion has centred on public ble to professionals both within and outside the public health workforce needs, public health graduate compe- health sector, not just to those with a clinical back- tencies and the emerging definition and role of graduate ground or within traditional public health roles. We attributes [8]. The draft core competencies for MPH must therefore develop strategies to both increase public graduates were completed in August 2009 and at the health recruitment, and to both broaden and deepen time of writing are in the process of ratification by pub- public health knowledge and skills in the wider health lic health education providers across Australia. workforce. Major changes are also afoot internationally. The Subsequent to the 1986 Kerr-White recommendations MPH is generally considered to be an internationally [4] the Commonwealth actively supported public health transportable degree, but this might not continue to be education. A workforce survey [5] was completed in the the case. The Bologna Process [9,10] is a European mid-1990s and the Public Health Education and initiative designed to standardise certificated courses Research Program (PHERP) was introduced. Since its throughout the European Union (EU). As a part of this establishment, PHERP has provided ongoing support to process, Master of Public Health courses taught within five state-based university consortia, four national and the EU will soon be accredited. Registration of the pub- special focus centres and 41 innovation projects, as well lic health workforce will follow and hence will be sub- as several workforce development projects such as the ject to regulation [11]. Australia was one of four non- Masters of Applied Epidemiology program, a Biostatis- EU countries to be a signatory to the Bologna Agree- tics Collaboration, and a Public Health Registrars pro- ment, but has apparently not remained engaged in these gram. In 2001 the total program increased to $55 developments. The United States has taken a different Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 3 of 9 http://www.anzhealthpolicy.com/content/7/1/2 pathway [12] and has developed an accreditation process The state government-based training schemes in NSW linked to continuing professional development for the and Victoria have recently paired with universities in purposes of public health workforce regulation [13]. order to award a professional doctorate to those who successfully complete the specifically developed program Discussion (The University of New South Wales and Monash Uni- What is a public health professional? versity respectively). Given the breadth of the concepts Public Health graduates have taken a population health and skills covered in such training, as with the MPH, it perspective into a range of different employment set- will be a challenge to meet doctoral level competencies tings; from specialist public health research and practice, within such programs. Arguably, advanced educational to management and planning in health services, and programs are required to deliver high level knowledge clinical practice with a population orientation. The and skills, either as a specialised stream within a two- MPH and other specialist public health degrees build year Masters or three-year doctoral program, or as a capacity in, and strengthen, evidence-based public health ‘stand-alone’ degree. However, the public health work- practice. Public health education also brings an evi- force is to a large degree characterised by their breadth dence-based population health oriented approach to pol- of practice. This includes the wide span of contexts the icy making and management at all levels and in all practitioners work within, the disciplines they bridge sectors of public health and health service delivery. within their routine practice, and the multi-professional It differs from the clinical professions by focussing on teams they work within. Under this framework, the task what makes people sick and what keeps people well; of effectively assessing Doctoral or Masters level compe- that is, the determinants of health, and identifying tency standards solely against traditional discipline- which groups are vulnerable, and why this is the case. based benchmarks becomes problematic. Public health then designs, implements and evaluates The public health workforce is largely employed in programs to maximise opportunities for health and public sector and non-government organisations. Public reduce ill health. Public health education builds an health education programmes train the workforce in understanding of what health means; a vital ingredient health research and policy development. Curricula also for health policy, from the local agency through to gov- cover the implementation and evaluation of the out- ernment level. comes of biomedical research and of policy by way of Public health graduates therefore provide significant programme development. The theory and skills encom- enhancement to the public health and health services passed within public health training are therefore workforce. Yet, there remains substantial scope for increasingly being recognised as important for a wide further strengthening the values and perspective that range of health professionals. Until the 1980s, public public health training contributes. health comprised only a very small component of The practice of public health encompasses many disci- undergraduate medical and health sciences program plines, and best practice relies on practitioners and content. Widening recognition of the value of public researchers who have acquired interdisciplinary skills health perspectives for health care practice has driven a and perspectives. However, with the low priority tradi- significant shift, and there are now many examples tionally given to public health within the health sector, where public health is integrated into core undergradu- as well as the dominance of the medical paradigm in ate clinical health sciences training. Australia, relatively little attention has historically been In more recent times, some Universities have per- given to a consideration of the definition of public ceived a need to develop undergraduate programs for health professionals, and therefore the potential sources entry-level public health practitioners, firstly for Austra- and destinations of students, and their educational lian health promotion professionals, and more recently requirements. The (medical) faculties of Public Health with the introduction of undergraduate programmes Medicine in the United Kingdom, the USA and Austra- specifically for public health practitioners. There are lia, for example, have detailed the sets of competencies approximately 10 undergraduate public health programs their graduates are expected to have, as have the public offered in Australia [14]. In Queensland, health promo- health training schemes provided through State Health tion and public health professionals including epide- Departments in New South Wales and, to a lesser miologists are now recognised under the Health degree, in Victoria. The Victorian Consortium for Public Practitioner stream of the Queensland Health workforce. Health, together with the Australian Network of Public The Department of Health and Ageing have also pro- Health Institutions and Australian Government PHERP vided financial support to the vocational education and program, are currently engaged in public health training (VET) sector to develop training packages employer and graduate surveys to assess current work- at the Certificate and Diploma level in population force educational needs. health. Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 4 of 9 http://www.anzhealthpolicy.com/content/7/1/2 These certificate level and tertiary undergraduate pro- States and in the Asia Pacific Region, for example in grams have to meet the challenge of educating for a Vietnam and Thailand. In Australia, a range of under- professional group that is not well-defined because it graduate public health education programs exist, either does not have a clearly recognised professional identity. as ‘stand-alone’ Bachelor of Health Science or Bachelor It may be easier to provide education for selected public of Public Health awards or in combination with a wide health roles (for example programs to provide for the variety of other degrees such as nursing, development public health nutrition workforce in Queensland or studies and economics. The depth of learning and health promotion roles more widely across Australia) extent of skill development in the traditional public than for a ‘public health officer’; a term currently only health sciences of epidemiology, biostatistics, research used in New South Wales for their post-MPH-graduate methods and public health practice varies considerably trainees. within these degrees. Some place particular emphasis on Public health student profile a combination of these sciences in addition to studies in Whilst the MPH is globally recognised as the profes- health promotion and environmental health. sional entry degree in public health, it cannot, and Are these degrees preparing ‘beginning public health should not, be expected to deliver both a foundation in practitioners’? If so, what does this mean for the Master core public health skills and high-level specific skills of Public Health, once the traditional domain of training training in more than one skill or discipline area. This for the entry-level public health practitioner? And what disjunct will become even further pronounced as the is the repertoire of skills and competencies that an background of students becomes more diverse and undergraduate public health graduate brings to the increasingly removed from the traditional clinical feeder workplace? Or are undergraduate health science degrees pathways. Specialised award and non-award courses at that focus on public health and health promotion to be different academic levels are an essential consideration viewed, not as professional entry, but as part of a ‘liberal in a comprehensive public health capacity building plan. arts’ background emphasising breadth of topics and ana- These must also encompass pathways for continuing lytical and critical thinking but with a focus on the professional development, and research training health of populations? It is confusing for employers. opportunities. How will prospective employers differentiate between Alongside the introduction of more specialised pro- potentially divergent skills levels in graduates across grams, we are seeing a trend towards more students such varied training pathways? Will differences in train- embarking on public heath training earlier in their ing be consistent across educational institutions and career; either undertaking an undergraduate degree in States? Local understandings and skills required in Dar- public health, or commencing an MPH or specialist win may differ widely to those needed in Tasmania or public health degree soon after completion of their first urban Melbourne. degree. However many students in Australia still enter While there have been numerous projects mapping their public health training from the workforce, bringing competencies for public health and health promotion considerable work experience from within the health via professional associations and some State govern- sector, and continue to work whilst undertaking further ments in Australia and internationally, for example the study. Galway competencies for Health Promotion [15], these Universities need to respond to the challenges of are broadly defined and not necessarily embedded in the developing and delivering programs suitable for this distinctions between postgraduate and undergraduate increasingly diverse student group, and continue to levels. For example, the competency public health pro- accommodate the different needs of the full-time ject commissioned through the quality framework of employed students. For working students, access to pub- PHERP did not distinguish between these levels of edu- lic health education can be enhanced by employer sup- cation. The exercise of mapping curricula to such com- port (time off for study, contribution to study fees) and petency standards will ensure the public health sciences the flexible delivery modes on offer (including intensive are appropriately embedded across undergraduate and teaching blocks, distance education, on-line learning post graduate curricula, but the expectations for under- support and out-of-hours classes) and access to part graduates must be realistic. time programs. Academia and industry must therefore There is no doubt, on the other hand, that public work together to create the pathways that will rectify health career options should be made more visible to disincentives and encourage greater participation in undergraduate students, whether specialising in public further education by the public health workforce. health or not, and Universities need to work with the Undergraduate versus postgraduate education public health professions and workforce to build the The growth in undergraduate public health education in public profile of public health career pathways. Similarly, Australia parallels trends internationally in the United injection of core public health principles and concepts Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 5 of 9 http://www.anzhealthpolicy.com/content/7/1/2 into undergraduate programs should be widespread, [6]. This precipitated some debate on whether educa- including, but not restricted to, the health professional tional responses to future workforce needs should shift degrees. Achieving this remains a test for universities. to target capacity building in specialised skills for emer- The moves for registration of the public health work- ging health issues or focus on building a robust and force globally might also lead to a higher profile for responsive generalised workforce. The Review supports public health career paths, and this could potentially a shift in emphasis from university driven education to provide more leverage to introduce public health princi- a more collaborative planning process between govern- ples and practice into professional entry program ment sectors and universities. The intention was for curricula. specialised education to be resourced by a contestable Breadth versus depth PHERP process, but such a funding scheme did not A further tension exists between providing the requisite eventuate within PHERP Phase IV. breadth and depth in the understanding of health sys- However, previous PHERP innovation programs have tems and the place, language and perspectives of the funded curriculum initiatives including a range of dis- various health disciplines when preparing graduates to tance education resources which do hint at the possibi- be effective “judgement safe” public health practitioners. lity of national academic institution cooperation in Getting the balance right is the goal under the current further deepening and broadening public health research and final phase of PHERP funding where the desired and education in Australia. Encouragement of national graduates are defined as “having the necessary compe- initiatives that bring together the requisite critical mass tencies, including culturalcompetencies, forpublic of teachers and students for viable teaching programs health practice and research, commensurate with will foster specialist training and the sharing of limited national, state and regional public health workforce valuable resources (Indigenous Health educators for needs” [16]. example). A national Indigenous public health curricu- PHERP was initially introduced to boost Australia’s lum framework that sets the standards for Indigenous public health capacity. Building capacity might usefully health content and skills for all public health students18 be considered at three levels: and a discipline-based public health nutrition initiative 1. Generic skills in the public health workforce - for built on collegial activities and continuing education example information seeking and synthesis skills, project links with State health departments http://www.aphnac. management, critical appraisal skills, management and com/ are examples of potential templates for collabora- leadership. tions that could coalesce regional or discipline-based 2. Specialised skills in public health areas where there curriculum initiatives. is a nationally recognised deficit of highly skilled practi- Core public health skills that provide the platform of tioners/researchers - epidemiology, biostatistics, health transferrable knowledge and skills to meet surge capa- economics, environmental health and Indigenous health city demands are required to address both current and [6]. emerging national priorities and pandemics. These gen- 3. High profilespecificstrategic needs - specialist eric skills are appropriate to the range of emerging pub- skills, and a level of readiness; that is a pool of qualified lic health issues and interventions and, in general, practitioners that can be mobilised to meet surge capa- existing university departments of public health are able city needed in the event of sudden impacts - for exam- to respond to this with appropriate support. However, ple unexpected outbreaks such as SARS, pandemic flu the need to sustain a capacity to respond to current as and natural and manmade disasters. well as emerging priorities is as much dependant on a The acquisition of the necessary core public health flexible workforce allowing mobility in times of response skills and the need for specialisation and expertise to demand as it is on public health graduate attributes. allow graduates to operate independently in their area of The working environment of future public health interest is a challenge, particularly in those degrees that practitioners is unlikely to mirror that of the existing now seek to achieve this in less than two years full time workforce. Protection against public health challenges coursework. This is where other specialist degrees need such as new and emerging infections, terrorism or to be considered for their contribution in bringing extreme weather related events demands a strong and essential high level skills into the public health work- innovative workforce capable of rigorous surveillance force, and where there is a growing need for continuing and research. Educational institutions must therefore professional development, for example the Masters of focus on emerging trends, and incorporate these into Biostatistics program [17]. their programs. To this end, universities are increasingly The 2005 PHERP Review identified gaps in workforce emphasising lifelong learning skills as a key graduate capacity in areas of specialisation such as indigenous attribute, and graduates who take this ethos (and the health, epidemiology, health economics and biosecurity necessary skills) into the work place help to build a Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 6 of 9 http://www.anzhealthpolicy.com/content/7/1/2 learning-oriented public health workforce, able to deli- been driven by available expertise, ideological, ad-hoc or ver and maintain robust but flexible public health industry-driven factors. In the current environment of responses. health reform and the shift to a preventive agenda, the Australia’s future security is dependent on sustained demand for continuing professional development in investment in public health and support of regional as public health and related areas will face unprecedented well as local capacity to address infectious disease demands, and not just for the identified public health threats [5]. The summer of 2009 brought widespread workforce. flooding across parts north- and central-eastern Austra- The widespread inclusion of public health knowledge, lia, plus unprecedented bushfires and heatwaves across skills and values across multiple discipline areas will the south-eastern parts. The immediate health burden raise new challenges and opportunities for providers of was significant, and the recovery phase, to avert health public health education, and calls for more strategic and and social problems was protracted. This strained work- innovative approaches to up-skilling. The tertiary sector force resources, and the contemporaneous timing of needs to support a range of programs, both specialised these events hampered some aspects of workforce flex- and general, to meet the range of short course and pro- ibility, such as sharing of capacity between states. In fessional certificate educational needs, preferably within order to meet workforce demand, the small numbers of a flexible model that allows articulation with formal public health staff worked excess hours, a process that qualifications. lasted for weeks. The outbreak of ‘Swine Flu’ that imme- Continuing professional development training partner- diately followed further tested capacity in a strained ships also form an important knowledge exchange plat- workforce. The likelihood or timing of a recurrence of form between academia, government and industry. The such devastating events remains unknowable, but are interaction can ensure the contemporary relevance of predicted to increase in frequency and cause more the academic content and skills covered within short severe peaks in surge demand under a changing climate courses and filter back to inform public health award [19]. program curricula. These collaborations also expose the The prospect of exceeding response capacity, resulting workforce to academic training that may encourage in a system failure, is an unwanted outcome, reminding members of the workforce back into further education us of the importance of Australia having access to suffi- to extend their professional capacity. cient numbers of highly skilled and flexible public health Government investment in Public Health Training practitioners. However increased demand for public While Australian Government support for public health health skills is not restricted to calamitous events. The education through PHERP will cease after 2010, other creeping epidemics of obesity and diabetes promise to national governments are demonstrating decisive action significantly diminish future health of the Australian through public health workforce policy and planning population, and burden the acute heath system. Issues strategies. For example, the United States government such as ageing, substance abuse, sexual health and through ‘Healthy People 2010’ strategy has established more, all demand growing public health capacity to 14 Public Health Training Centres (PHTC). These Cen- achieve a healthy Australia for 2020 and beyond. tres are situated in Schools of Public Health and geogra- The role of continuing education phically distributed across the country to provide Pathways to boost workforce capacity include a constant competency-based courses for workforce development stream of new graduates and staff development via con- through a variety of delivery models. The PHTCs oper- tinuing education. The need for improved processes and ate as an academic and practice collaborative to pro- systems for human resource development have been mote workforce development [23]. identified as essential for enhanced workforce capacity Likewise, New Zealand’s national strategy for public [20] and new concepts and models that align health pol- health workforce development, Uru Kahikatea, has taken icy and workforce development are being developed and a systematic approach to address workforce develop- tested [21,22]. ment [24]. The objectives of the strategy include actions The success of such strategies will require funding, and targets for workforce policy and planning, public strategic policy alignment and effective partnerships health professional infrastructure, information, policy across sectors. Underpinning this is the requirement for and research, Maori and Pacific workforce development, an understanding of the imperative that meeting these supportive workplace cultures, public health career pro- emerging challenges demands access to a fully prepared motion and education and training (by developing gen- public health workforce. eric public health competencies to provide a common Continuing professional development in the public framework for professional development). The work health context has traditionally meant up-skilling the plan also includes actions and targets to improve the existing public health workforce, and in the main has wider health workforce skills and knowledge of health Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 7 of 9 http://www.anzhealthpolicy.com/content/7/1/2 promotion/public health, and to ensure that public academic sector be then, and who sets the agenda? health workforce is included in the wider health work- Whilst there is divided opinion on whether educational force information programs and planning. responses to future workforce needs should focus on Future policy and planning for continuing professional capacity building in emerging specialised skills sets or a development must be inclusive of research on-cost robust and responsive generalised workforce, there is no effectiveness for educational interventions. A recent sys- debate over the need for strong core skills sets across tematic analysis of the cost benefit of continuing profes- the public health sector. There is also agreement on the sional development in health found no empirical need to focus on building capacity in those core disci- evidence to demonstrate cost-benefit of any professional pline areas where we are currently experiencing a recog- development. The lack of a cost-benefit finding was nised capacity deficit (epidemiology, biostatistics, health attributed to the varying quality of the studies [25], economics, and environmental and Indigenous health). highlighting the need for future investment in quality However specialisation in targeted areas (biosecurity research into continuing professional development to responses etc.) will only be a worthy investment if built support evidence-based decision making for policy- on a solid theoretical foundation and skill base, and this makers and contribute to health outcomes for the is true at both individual public health practitioner and public. workforce levels. We in the tertiary sector must there- In Australia, the National Health Workforce Planning fore focus on providing both the underpinning training and Research Collaboration was established to provide as well as targeted programs addressing specialisation innovation and research to achieve health workforce gaps and emerging special skill needs. sustainability by 2020. The Collaboration aims to build Research higher degree training is a university enter- capacity in research by improving intellectual and meth- prise, andthisisanareathatwas notaddressedunder odological rigour in national health workforce planning, the PHERP agenda and urgently needs attention. Some and provide evidence to inform policy decision-making disciplines are considering strategies to encourage the about the health workforce. Regardless of the national development of more advanced skills in the workforce focus on prevention, this national body, as its predeces- (the Biostatistics Consortium of Australia) and to encou- sor planning body, the National Health Workforce Task- rage more exceptional students into a research higher force, has excluded the public health workforce from degree pathway [27]. However, this is an area that their deliberations and work plan [26]. requires more discussion amongst the public health pro- The Reform Commission has recommended a fession, both in terms of building supervision capacity National Health Promotion and Prevention Agency. It is and student project opportunities, and in raising the not clear at this stage where the governance and respon- profile of public health research careers. sibility for the public health workforce will be positioned The New Zealand Population Health Workforce Plan within these new arrangements, nor what links there includes strategies for training providers to strengthen might be to education and training institutions. public health skills of the primary care and nursing Meeting contemporary public health education workforce [27]. Even without such leverage or guidance, challenges many Universities have tried to develop their own solu- Public health education has traditionally been delivered tions, but with mixed success. By popular vote, this will by universities, the health profession, or as in-house be a future theme for an ANAPHI Teaching and Learn- training within the public health workplace. However, ing Forum, where representatives across the public initiatives at the TAFE and other registered training health professions and educational institutions come organisations that lead to accredited qualifications can- together to share strategies and jointly set the educa- not be ignored. For example, a Certificate IV in Popula- tional agenda for Australia. tion Health is now being offered through the Adelaide Western General Practice Network (AWGPN). There is Conclusions already precedent for TAFE awarded degrees (eg engi- To a certain extent, the emerging political agenda neering). With a shrinking national health workforce around health in Australia will influence the way public and increasing demands that will be placed upon it health education will evolve and develop to meet future under the Preventive Health agenda, alliances with this challenges. Greater collaboration across interest groups sector need to be considered together with possibilities and public health disciplines will facilitate and enhance for work-integrated learning and articulated pathways. the processes for setting future directions and will shape The key concern for public health is the health of our success in meeting current and future workforce populations. Bearing this in mind, what pathways in needs. The Population Health Congress coalition of the public health education and training best serve this four major public health professional associations, cause? What should our education priorities in the scheduled to meet every two to four years, will Bennett et al. Australia and New Zealand Health Policy 2010, 7:2 Page 8 of 9 http://www.anzhealthpolicy.com/content/7/1/2 inception to final draft, and assisted CB in the compilation of the final draft. strengthen the political voice for public health leader- EH contributed to discussions that shaped this paper and to the drafting of ship and advocacy. Similarly, the Australian Network of the final manuscript. PR contributed to the sections on the international Academic Public Health Institutions, or its post-PHERP public health training context, in particular the issues surrounding workforce accreditation. All authors read and approved the final draft. successor, will continue to play an important role as a focus for discussions on future educational opportu- Authors’ information nities, and meeting public health workforce training All authors are all members of the Australian Network of Public Health Institutions working party formed in 2006 to examine Public Health Quality needs. Agenda and Educational Pathways and are employed in Australian Schools/ There are significant challenges in determining how Departments of Public Health. CB was chair of this working party. we chart our way ahead in public health education. We Received: 30 July 2008 must not lose sight of the fact that much of what we Accepted: 3 January 2010 Published: 3 January 2010 do, particularly in engaging with stakeholders and responding to workforce needs, is exemplary, albeit out- References side a national or state framework. While this engage- 1. Senator Chris Evans, Minister for Immigration and Citizenship. Sustaining the boom - the role of skilled migration in the WA economy. Keynote ment remains ad hoc, there is no way forward for Address - John Curtin Institute of Public Policy. Perth: Government of nomenclature and enumeration. Whilst educationalists Australia. http://www.minister.immi.gov.au/media/speeches/2008/ce080717. in other discipline areas look to public health as a htm. 2. 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Australia and New Zealand Health Policy – Springer Journals

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