The ‘Opportunity Cost’ of COVID-19: Measuring the Critical Public Health Work Lost During the Pandemic – JPHMP Direct

Data from the recent PH WINS shows very strong evidence of a substantial “opportunity cost” of COVID across every single public health program area, with potential negative health effects for communities across the nation.
“It was at times very long hours and most of my regular work was put on hold to assist with the clinics.” This public health practitioner’s perspective was highlighted by Yeager et al, who identified ‘strain on core responsibilities of public health’ as a key theme of the 2021 Public Health Workforce Interest and Needs Survey (PH WINS), findings which were published in a special supplement of JPHMP. This finding is critical yet is not entirely surprising. Since early in the COVID-19 pandemic, reports emerged of a strained public health system that was understaffed, underfunded and poorly positioned to mount a rapid response without having to make serious sacrifices.
Beyond this workforce toll, though, lies another important impact of putting core public health work on hold during the pandemic. Namely that core public health work was put on hold during the pandemic!
We recently published a study in the Journal of Public Health Management and Practice examining that critical system-level topic. We found very strong evidence of “lost work” across every single public health program area. We term this the ‘opportunity cost’ of COVID for public health practice, since time spent responding to the COVID-19 pandemic is, in large part, time that is not spent on other essential public health services such as environmental health or chronic disease. Since there is a fairly robust body of literature showing that public health department services lead to better public health outcomes, asking the public health workforce to pause its regular work and shift instead to other services could have negative health effects for communities across the nation.
What did the data show?
We found clear evidence suggesting a considerable public health opportunity cost to the public health workforce’s large and prolonged COVID-19 response.
This involved everyone.
Throughout 2020 and 2021, the workforce for every single public health service area reported spending more than 20% of its time on COVID-19 related activities. That is perhaps to be expected for, say, emergency preparedness or communicable disease workers. But that means that someone performing chronic disease prevention, or environmental health services, or maternal and child health, spent more than a day per week doing COVID work and not their regular work.
COVID’s opportunity cost in other areas was even more dramatic. Since April 2020, the communicable disease workforce has spent between 70-80% of its cumulative time on COVID-19 related work (see Figure 2). A disease investigator who in 2019 spent 5 days per week investigating non-COVID outbreaks would have only 1.5 days per week to perform non-COVID investigations in 2020 and 2021.
Why didn’t agencies re-assign existing workers or just hire more employees?
The public health system entered 2020 with an estimated workforce shortage of some 80,000 employees – and that’s before the pandemic struck. Re-allocating the existing workforce would simply be robbing Peter to pay Paul. So, many agencies used supplemental COVID-19 funds to hire additional staff for specific COVID-19 pandemic response work. That approach seemed to alleviate some of the strain on the public health workforce, but unfortunately additional hiring was a slow-release valve on a strained system. COVID-19 hiring began in early 2020 but continued throughout the entirety of 2020 and 2021 (see Figure 3). The median new employee wasn’t hired until the end of 2020, but by that point the US had recorded some 19 million COVID-19 cases and experienced 300,000 COVID-19 deaths, developed mass vaccination plans and priorities, administered nearly 3 million vaccination doses to adults, and deployed a wide range of non-pharmaceutical interventions aimed at flattening the curve or stopping the spread. As many of us know, hiring new staff and for new positions can be a long process for governmental public health agencies, one that may have seemed especially prolonged during the rapid and continued spread of the pandemic in 2020 and 2021.
How do we move forward and better prepare for the future?
The workforce responded to the COVID-19 pandemic by hiring new staff, reallocating or asking more of existing staff, and putting other public health practice work on hold. Large amounts of reallocation occurred across all programmatic areas of the public health workforce. At peak response levels the majority of the workforce was devoting more than a quarter of its workload to COVID-19 activities (see Figure 1). And this is where we see work lost and subsequent public health opportunity costs.
Large amounts of hiring were occurring at the same time the existing staff were being reallocated, which suggests that new hires were likely needed earlier to meet emergent workloads and that the workforce may have benefited from slack resources. Having slack resources means having the bandwidth to accommodate new tasks for evolving responsibilities and is associated with a host of positive workplace and health outcomes. The public health workforce did not have enough, or really any, slack resources prior to the COVID-19 pandemic. We believe that while additional hiring likely would still have been needed to meet the demand of the COVID-19 pandemic response, slack resources could have reduced or even prevented opportunity costs – some of which we are already starting to see with the emergence of vaccine preventable diseases.
Read: PH WINS 2021
The public health workforce has many lessons to take away from its response to the COVID-19 pandemic. Based on these findings, it is our recommendation that the governmental public health system build slack resources that would allow for faster surge responses to future public health crises. Ideally, surge responses should draw upon spare bandwidth at public health agencies, not simply demand that existing employees pause their ongoing work or work nights and weekends indefinitely. Additionally, we would encourage health departments to review their hiring practices and develop processes and procedures for rapid emergency response hiring.  
Read Our Article in the Journal of Public Health Management and Practice:
Learn More about the 2021 PH WINS Findings:
Mac McCullough, School of Public and Population Health, faculty/staff, outdoor portrait by Priscilla Grover
Mac McCullough, PhD, MPH, is associate professor in the School of Public and Population Health and serves as director of public health agency partnerships. His research involves examining investments in public health and social services and assessing how these investments improve population health. He led the creation of a data source to track spending on health and social services at the local level and has used these data to explore how community spending can influence health factors and outcomes. His teaching centers on finance, policy, and management in health care and public health.

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