National public health training program needs urgent funding

FEW events crystallise the value of Australia’s public health workforce more than a global pandemic. In light of ongoing outbreaks of COVID-19, lockdowns and a suboptimal vaccine rollout, the urgency of strengthening the national public health workforce is more pertinent than ever.

Public Health Physicians (PHP) have been integral to the pandemic response and many Chief Health Officers are PHPs. However, the impact of public health physicians (PHPs) is more far-reaching than leading responses to infectious disease outbreaks. PHPs are well positioned to tackle the greatest health challenges of our time, including climate change, unassuaged rates of non-communicable diseases, and widening health inequities.

Since the establishment of the Australasian Faculty of Public Health Medicine (AFPHM) within the Royal Australasian College of Physicians over 30 years ago, the PHP workforce undertakes a rigorously assessed postgraduate training pathway credentialed by the Australian Health Practitioner Regulation Agency (AHPRA) as a medical specialty. Yet PHP workforce shortages and geographic maldistribution have not been met with sustained investment, despite repeated recognition of PHP workforce capacity issues (and here) . Indeed, while acknowledging the complexities of estimating future PHP demand, the latest review of the Australian PHP workforce included an analysis of established practitioner to population ratio of 2.5 PHPs per 100 000 population. This is a relatively modest measure; comparatively, the UK Faculty for Public Health recommends three full-time equivalent PHPs per 100 000 population as a “feasible, desirable and affordable” benchmark for a world class public health system. Existing PHP workforce capacity data demonstrate that every jurisdiction, except the Northern Territory, the Australian Capital Territory and Queensland, falls well below these recommendations. Victoria is the worst affected with only 1.23 PHPs per 100 000 population. Importantly, this review did not consider contextual factors, such as socio-economic disadvantage, remoteness and quantified inequity, which may alter PHP workforce needs.

As public health medicine registrars, we note with interest a call for a National Public Health Training Program in the context of a broader review into the national public health workforce crisis. We recognise that public health is inherently multidisciplinary and that there is a need for structured vocational training pathways for non-medical public health practitioners. While we strongly welcome this national review and recognise the need for an evidence-informed approach for all public health disciplines, we believe urgent investment to meet the existing PHP workforce shortage should not be delayed. Expanded and sustained funding for trainee and early career fellow positions is needed to ensure the PHP pipeline can meet future public health challenges.

How can we rapidly upscale PHP workforce? We discuss three options available now that could be rapidly scaled up below.

AFPHM training

The AFPHM provides PHPs with an accredited national training pathway. AFPHM delivers a 3-year advanced training program for medical practitioners within the Royal Australasian College of Physicians. Three years of postgraduate clinical experience and a Master of Public Health or equivalent are required for entry.

A major limitation is the availability of securely funded training positions. This is distinctly unlike advanced training positions in other medical specialties. For instance, AFPHM receives less than 3% (30) of the 1000 specialist training program positions available each year through Commonwealth funding. Unlike other medical registrar positions, many accredited training positions are not consistently funded annually and there are clear jurisdictional differences in the availability of public health training opportunities. Victoria, for instance, has an extremely small number of accredited positions considering its population size. Furthermore, many positions are advertised haphazardly, separately from routine medical recruitment, making it difficult for prospective trainees to find positions to commence training.

Beyond calling for investment in more training positions, we hope to attract clinicians towards specialty training in public health medicine. About one-third of PHPs hold dual fellowships with other specialties. General practice, medical administration, and various physician subspecialties are common and there may be greater scope for recognition of prior learning for those who undertake AFPHM training after attaining fellowship in another field.

State-based programs

In New South Wales, there is a Public Health Training Program (PHTP) in which trainees undertake placements over a 3-year program in the NSW Ministry of Health and affiliated organisations, including research institutes, the Aboriginal Health and Medical Research Council of NSW, and Local Health Districts. Previously, the PHTP was university-affiliated towards attainment of a Doctorate in Applied Public Health and is fully accredited towards AFPHM training.

Queensland, South Australia, Victoria, Western Australia, and Tasmania have similarly structured AFPHM-accredited training positions networked within their health departments, such as the Victorian Public Health Medicine Training Scheme.

Public health medicine trainees are an important part of the immediately available surge-workforce to support public health emergency responses. The specific jurisdictional experience gained from working within departmental structures is a strength of these programs and serves an important role in deepening local capacity. In terms of urgently upscaling the PHP workforce, there is scope for state and territory governments to immediately invest in expanding training positions without waiting for a national review. For example, there are only two trainee positions in the Victorian public health medical training program per year.

The Master of Philosophy in Applied Epidemiology (MAE)

The National Centre for Epidemiology and Population Health at the Australian National University delivers a 22-month Master of Philosophy in Applied Epidemiology (MAE) program where trainees work within a health organisation, primarily departments of health or research institutes, towards their degree. Trainees apply to an annual intake and are matched to field placements, with 12–15 positions annually. It is a multidisciplinary program, and medical trainees may apply to the AFPHM to accredit their training.

The MAE is the Australian equivalent of the renowned US Centers for Disease Control and Prevention Epidemic Intelligence Service Program. With specific learning requirements that focus on outbreak investigation, surveillance systems and data analysis, the MAE delivers subspecialised epidemiological training. The MAE was previously funded through the Australian Government’s Public Health Education and Research Program, which ceased in 2009. Although sound epidemiological skills are relevant for PHPs, other AFPHM competencies may not be readily acquired. Leadership and management skills, policy development and communication are core to competent practice in public health medicine, as well as vital for effective outbreak response (here and here). For AFPHM trainees undertaking the MAE, they must still complete further accredited public health training and seek to attain other competencies, such as in community development, health promotion and qualitative research. Expansion of the MAE in isolation is therefore insufficient to address the PHP workforce shortage.

Implications for training and practice

Despite rigorous AFPHM accreditation standards, there is variability in supervisory support and learning experiences between accredited sites. There has not been a recent independent evaluation of trainee or supervisor perspectives of the AFPHM training and the small size of the Faculty and risk of re-identification may impose barriers to open disclosures about quality of training experiences. We therefore recognise the value of formal review of existing models through the National Cabinet’s proposed review, both to facilitate development of the proposed National Public Health Training Program and for improving trainee experiences. However, this should not delay addressing the urgent PHP workforce shortage.

Concerted investment by the Public Health Education and Research Program expanded opportunities for tertiary studies in public health, but graduates require vocational training programs to transition from student to specialist. The AFPHM advanced training program meets this need but is limited by inconsistent and unsustained funding for training and new fellow positions. The PHP workforce is unconventional in that it is significantly affected by controls on entry levels, such as availability of training positions.

Despite the pandemic uncovering PHP workforce shortages, national recommendations for the Commonwealth, states and territories to increase the number of PHP training positions, and a commitment by National Cabinet to invest in the PHP workforce, no jurisdiction has affirmed a long term investment in PHP training positions.

As a result of inconsistently available funding and employment within the public service, non-governmental organisations and universities, some public health registrar positions are not consistently remunerated across jurisdictions nor in accordance with jurisdictional medical officer employment agreements (here, here and here). This must be addressed if Australia seeks to attract the best medical candidates into challenging public health medical roles. With a female-dominated trainee workforce, employment conditions, leadership roles and parental leave are important considerations for gender equity in our profession.

Beyond building up the statutory health protection functions, investment in the PHP workforce will contribute to health reform, strategic analysis, policy, advocacy, health promotion, leadership and management capacity to address population health needs, particularly for populations that experience the greatest health inequities.

It is critical that PHP trainees receive appropriate support and vocational experiences to acquire the necessary breadth of skills, including opportunities to work within Aboriginal Community Controlled Health Services, in regional and remote areas, and equity-focused positions. Funding positions that will enable trainees to work in organisations that meet the breadth of public health medical practice is vital to ensure that future PHPs are sufficiently prepared to meet this century’s health challenges.

Conclusions

Rekindled discussions to invest in PHP training that recognise the urgent importance of addressing PHP workforce shortages and maldistribution are welcome. Yet, jurisdictional governments must immediately expand positions in their existing training programs and match funding to ensure appropriate medical officer remuneration. This investment will serve to attract prospective medical trainees to a fulfilling career in public health and build a sustainable PHP workforce that will contribute to the health and wellbeing of all Australians.

Dr Laksmi S Govindasamy is a public health registrar at Swinburne University of Technology and emergency registrar at Austin Health in Melbourne.

Dr Alyce N Wilson is a public health registrar and senior research fellow at the Burnet Institute.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.