This study provided a comprehensive analysis of the quantity, quality and equity of HRH allocation at the CDCs and identified several key issues. First, China's public health system is facing a shortage and turnover of HRH in CDCs. From 2005 to 2020, the number of CDC staff and health technicians decreased by 12,060 and 13,211 respectively. The public health workforce density of CDCs was consistently far below the standard of 1.75 per 10,000 residents. Although the number of CDC staff rose significantly in 2020, the shortage of CDC staff was 52,637 according to current Chinese standards. The Chinese government set a development goal of 250,000 CDC staff by 2025 in the “14th Five-Year Plan for National Health” [29]. The GM (1,1) model projections for the number of CDC staff and health technicians from 2021 to 2025 declined continuously. The GM (1,1) model projected that the number of CDC staff will be 185,176 in 2025, which is 64,824 less than the target. The public health workforce is not sufficient to meet the population's demand for public health services.
While the definition of the public health workforce is not entirely consistent in each country, the lack of a public health workforce is a common problem worldwide. For example, the public health workforce decreased by nearly 10% from 2012 to 2019 in the United States[25]. Low wages and a lack of long-term career opportunities are the main reasons for the decline in the global public health workforce [30], and China's public health workforce faces the same dilemma. In China, the CDCs are fully funded by the government budget, and the funding for CDCs is significantly lower than that for other health institutions [5]. The results in CDC staff being underpaid, which is not commensurate with the excessive workload. The technical title is not only a grade title to identify the business level and professional ability of HRH in CDCs but also a reflection of career advancement. The professionals with senior title increased by only 1.9% from 2005 to 2020. Furthermore, previous surveys of job willingness for Masters[31] and PhDs[32] in public health in China have also emphasized their reluctance to work in CDCs due to salary, career development, and lack of promotion opportunities. This is coupled with the low social recognition of CDC work and the lack of full awareness and respect for CDC staff[3]. These reasons combined have led to staff turnover and shortages, and directly affect the quality of HRH in CDCs.
The quality of CDC HRH has shown an aging trend, with 17.1% of staff over 55 years of age in 2020, and the lack of good articulation between the older, middle-aged and younger professional. CDCs have a low percentage of health technicians with high education levels and technical titles. CDCs are knowledge-intensive units in China. The academic qualifications and technical titles are concrete expressions of the quality of HRH and are fundamental to the development of CDCs. Young people are crucial to strengthen the capacity building of CDCs[33]. The current development in the number and structure of CDC HRH may lead to inefficient delivery of public health services and affect the quality development of public health system. Attracting and retaining CDC talent is the only way to reduce staff turnover, expand staff numbers and rationalize staffing structures, which are equally critical to enhancing the public health system.
Since the COVID-19 epidemic, China has gradually strengthened its public health system, establishing the National Bureau of Disease Prevention and Control in 2021 to reform China's prevention and control system[34]. The “14th Five-Year Plan for National Health” was released in 2022[29], which emphasized the need to substantially improve the capacity of public health services by 2025. Based on this, we suggest that more attention needs to be paid to the issue of public health workforce development. The Chinese government needs to focus on the current human resources situation in CDCs and retain public health workforce by enhancing the salary level of CDC HRH. The CDCs should focus on salary rationalization, improving career development opportunities and increasing the attractiveness of positions in CDCs. In addition, universities should be guided to expand enrollment and accelerate the construction of a high-level public health talent training system to provide the CDCs with sufficient high-quality talent.
Finally, it is worth noting that inequalities in the allocation of HRH in CDCs are also evident, with inequality between health technicians and CDC staff being similar. The Gini coefficient indicated that the equity of CDC HRH allocation by population outperformed that by geographical area from 2005 to 2020, which is the same as the results of studies on general practitioners[24] and traditional Chinese medicine[28]. Geographical area has long been neglected in the allocation of HRH. The aggregation degree made it clear that there are significant regional differences in CDC HRH, with differences mainly in the eastern and western regions. The equity of CDC HRH allocation is best in the eastern region by geographical area, with overconcentration of HRH in some provinces and cities (e.g., Shanghai, Beijing, Tianjin, etc.), yet the equity of allocation by population is worst in the eastern region. The eastern region accounts for only 11% of the geographical area but has 43% of the population. Cities in the eastern region, such as Shanghai and Beijing, are very attractive to people due to their good economic development and geographical location, resulting in an overly dense population. CDC HRH are unable to meet the health needs of the population in the eastern region.
The western region is characterized by 27% of the population and 71% of the area. The equity of CDC HRH in the sparsely populated western region is best allocated by population and worst by geographical area (mainly Inner Mongolia, Tibet and Qinghai and Xinjiang). Although the Chinese government has always favored talent policies for the western region[35], the economy of the western region is inferior to that of the central and eastern regions[19]. The western region has disadvantages in terms of resource inflow and talent introduction, and the economic and service radius are not fully taken into account when allocating HRH. Thus, the western region is still in a state of extreme inequity despite the gradual rise in geographical equity in the allocation of CDC HRH. In the central region, CDC HRH are relatively more equitable in terms of population and geographical area. However, it is noteworthy that the equity of the allocation of health technicians by population is declining in the central region. It is a distinct fact that regional differences in geographic location and economic development contribute to further inequalities in CDC HRH.
To ensure equitable access to public health services for residents in all regions, the Chinese government should fully consider factors such as service population, service radius and economic disparities when setting human resources standards for each region. Moreover, certain policies and talent support should be given to provinces and cities with weak CDC construction, a lack of HRH and less economically developed areas to promote the coordinated and balanced development of CDC HRH in all regions. CDCs in different regions can strengthen cooperation and learn from each other to improve the capacity of CDC staff and maximize the use of available HRH.
Our study has several limitations. The equity of allocation is limited to the number of HRH and does not reflect inequities in the quality of HRH. In addition, we chose to reflect the quality of HRH through the structure of health technicians and did not include changes in the structures of other technicians, management staff or logistics staff. Last, the GM (1,1) model used in this study is only able to predict based on the characteristics of the data itself but does not take into account social policies or emergencies. Future studies on forecasting and equity analysis of CDC HRH should be more comprehensive.